Every finding on record at Fairfield Senior Living & Rehabilitation LLC

Based on interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 (R1) of 3 residents reviewed for medication administration in the sample of 6. This failure resulted in R1 not receiving his seizure medication as ordered for 5 days resulting in R1 experiencing a seizure that lasted 10 minutes and an emergency department visit.This past non-compliance occurred between 04/07/2026 and 04/13/2026.Findings Include:R1's admission Record documented an admission date to the facility of 03/14/2024 with diagnoses including chronic obstructive pulmonary disease, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, type 2 diabetes mellitus, alcoholic cirrhosis of liver, chronic pancreatitis, hypothyroidism, hyperlipidemia, and epilepsy.R1's MDS (Minimum Data Set) dated 03/13/2026 documented R1 had a BIMS (Brief Interview for Mental Status) score of 12 indicating R1 has moderate cognitive impairment.R1's Order Summary Report with a print date of 04/23/2026 documented an order for R1 to receive Lacosamide 200 mg by mouth two times a day with an order date of 05/24/2025.R1's MAR (Medication Administration Record) dated 04/01/2026 - 04/30/2026 documented on 04/07/2026 in the box for 0800 A.M. the number 6 and the box for 8:00 P.M. the number 5. On 04/08/2026 at 0800 A.M. a 6 was documented in the box and the box for 8:00 P.M. a 5 was documented. On 04/09/2026 the box for 8:00 P.M. has a 5 documented. On 04/10/2026 the box for 0800A.M. has a 6 documented and the box for 8:00 P.M. has a 6 documented. On 04/11/2026 the box for 0800 A.M. has a 6 documented and the box for 8:00 P.M. has a 7 documented in it. The Chart Codes documented on the MAR indicates 5 is Hold/See Progress Note, 6 is Other-See Progress Note, and 7 is absent from facility or Partial Administration.R1's Progress Notes dated 04/07/2026 document the following:9:57 A.M.: lacosamide 200 mg by mouth twice daily was out of stock. Notified provider and will monitor. Hard prescription was sent to pharmacy for refill and V7 (Nurse Practitioner) aware. 10:04 A.M.: R1's power of attorney was notified related to out of stock medication. 7:28 P.M.: Lacosamide 200 mg by mouth two times a day not in stock. R1's Progress Notes dated 04/08/2026 document the following:7:31 A.M.: Lacosamide 200 mg by mouth two times a day awaiting delivery.7:35 P.M.: lacosamide 200 mg by mouth two times a day awaiting medication supply. R1's Progress Note dated 04/09/2026 documents the following:7:09 P.M.: Lacosamide 200 mg by mouth two times a day awaiting from pharmacy. R1's Progress Notes dated 04/10/2026 document the following:7:55 A.M.: Lacosamide 200 mg by mouth two times a day none in stock. 7:19 P.M.: Lacosamide 200 mg by mouth two times a day, provider to send new prescription. Currently awaiting arrival. R1's Progress Notes dated 04/11/2026 document the following:7:33 A.M.: Lacosamide 200 mg by mouth two times a day not available.5:31 P.M.: R1 observed to be having a seizure in the dining room. Seizure activity lasted approximately 10 minutes. Provider was called and a new order was obtained to send R1 to the local emergency department. R1 was sent on gurney to local hospital emergency department.11:56 P.M.: R1 returned to the facility with an order to give Lacosamide. R1's records from the local hospital document an arrival date and time of 4/11/26 at 5:54 P.M. documents a diagnosis of Epileptic seizure related to external causes, not intractable, with status epilepticus. Under Assessment at 5:58 PM it documents R1 came to the Emergency Department from the facility after having a 10 minute seizure. Under the same section at 7:46 P.M. documents that R1 has seizure activity observed with left sided twitching and tremors. Seizure activity lasted approximately 12 minutes. At 10:11 P.M. documents the nurse was reviewing R1's chart and medication administration record provided by the facility, it appears R1 has not been given Lacosamide since 4/9/26 at 7:02 A.M. This medication is ordered for 200mg to be given 2 times per day, but has not been given in over 48 hours. Under Administered Medications documents R1 was given Ativan 2mg and Keppra 2000 mg intravenously. R1 discharged back to nursing facility, instructed to administer the dose of Lacosamide tonight.On 04/22/2026 at 1:22 P.M., V1 (Community Liaison) stated R1's medication not getting sent to the facility had to do with V7's (Nurse Practitioner) DEA (Drug Enforcement Administration) number. V1 stated she is not sure what the exact problem was, but that was the reason R1's medication was not at the facility.On 04/22/2026 at 1:40 P.M., V7 (Nurse Practitioner) stated when the facility made her aware that R1's script for lacosamide needed renewed, she immediately sent one. V7 stated she thought the script went through but it did not. V7 stated she had her company look into why she was not able to electronically prescribe medications, and it was discovered that V7's DEA number expiration date was put in the system wrong. V7 stated the system was printing the script instead of electronically sending it to the pharmacy. V7 stated she was notified that the facility needed a new prescription for the medication but was not notified that the facility did not have the medication in stock. V7 stated if she had been made aware that the medication was not in the facility, she could have verbally approved the prescription with the pharmacy, or another practitioner from the company could have written the prescription. V7 stated it would have been addressed sooner if she had known that the facility was out of the medication. V7 stated that R1 not getting his medication could have contributed to R1 having a seizure, but R1 has other complex problems that could have caused issues.On 04/22/2026 at 2:17 P.M. R1 stated he does not remember having a seizure or having to go to the emergency department. R1 stated he was not made aware that the facility was without one of his medications.On 04/22/2026 at 4:12 P.M. V1 (Community Liaison) stated she has spoken to a representative from the pharmacy and from now on when the pharmacy receives an order and it gets kicked back to the pharmacy and will not go through, the pharmacy will email the corporate staff. V1 stated she believes this will help in not having to wait for days for the providers to send a new prescription to the pharmacy.On 04/23/2026 at 10:52 A.M. V8 (Licensed Practical Nurse) stated he called the pharmacy to see why R1 did not have his medication. V8 stated the pharmacy told him that they needed a new prescription from V7 (Nurse Practitioner). V8 stated he called V7 and informed her that there was a new prescription needed for R1's medication. V7 stated the only new order that was given to him by V7 was to monitor R1.On 04/23/2026 at 11:23 A.M. V9 (Pharmacy) stated facility sent refill request to the pharmacy. V9 stated once they received the request, they knew the medication would require a new prescription. V9 stated the pharmacy then sent a notification to V7 (Nurse Practitioner) that they needed a new prescription. V9 stated the order was then saved in the pharmacy system as pending so the staff would know to follow up on it. V9 stated pharmacy staff called V7 several times to get the new prescription. V9 stated V7 would tell pharmacy staff that it was sent. V9 stated the pharmacy checked on their end to make sure there was not a problem with the pharmacies computer system. V9 stated the pharmacy attempted to get a verbal prescription because it was acceptable with this type of medication, but was told by the receptionist no, because the providers were not responding to requests timely. V9 stated V7 and V7's office was notified several times by phone and fax that they were needing this prescription.On 04/23/2026 at 12:22 P.M. V2 (Director of Nursing) stated the facility nurses sent in a request to refill R1's lacosamide. V2 stated her understanding after investigating the situation, V7 (Nurse Practitioner) was having trouble with her DEA number and that is why the prescription was not going through when she attempted to send it to the pharmacy. V2 stated the day that V8 (Licensed Practical Nurse) reached out to V7, was the first day that R1 missed his dose. V2 stated it was her understanding that the receptionist at V7's office told V8 that the message would be sent to V7. V2 stated V7 did not give any new orders to any of the nurses besides monitoring of R1. V2 stated she called the pharmacy on 04/10/2026 because the medication was still not in the facility. V2 stated the pharmacy let her know that they needed a new prescription and the pharmacy had reached out multiple times to the provider to get the prescription. V2 stated on 04/11/2026 when the medication was still not in the facility, she messaged V7 directly. V2 stated V7 told her she is confused why the prescription is not going through because she had sent it to the pharmacy a couple times. V2 stated she did not go to the Medical Director because every time the facility called her she made it sound as if the situation was fixed. V2 stated she felt like she attempted every way possible to get the medication for R1.R1's Incident Report titled Medication Error dated 4/7/26 documented a Root Cause of Invalid DEA number from provider to pharmacy. Under Intervention documents R1's medication was delivered to the facility on 4/11/26 and the issue has been resolved.On 04/24/2026 at 2:23 P.M. V1 stated the investigation showed there was an issue with the provider's DEA number. All nurses have been educated, if they put in an order for a refill and the medication does not arrive, the nurse is to notify the V1 immediately and the Medical Director. V1 stated the corporate team will be notified too, that way they can follow up with the medication to ensure timely delivery. V1 stated V2 was educated about proper notification of the Medical Director. V1 stated during the investigation it was discovered that when the facility calls the provider and they speak to the Nurse Practitioner (NP), the message does not go the to the Medical Director. V1 stated V2 was educated to make sure that the NP and the Medical Director are both notified. V1 said the facility had a QA (Quality Assurance) meeting on 04/13/2026. The medication error was discussed. It was determined that the providers company put in the wrong expiration date for V7's DEA number, which caused V7's controlled substance prescriptions to not go through. V1 said the facility has asked the pharmacy to add this medication to the backup / emergency medication box. To prevent another reoccurrence, the facility put into place that V2 will monitor medication reorder and delivery 5 times a week for 3 weeks and V2 will monitor medication carts one time a week for 3 weeks to ensure medication supply is adequate and reorder has been completed at appropriate time.The facility policy titled Medication Refill Request Policy (revised April 2007) documented the facility in conjunction with the provider and pharmacy shall ensure resident medications are readily available as possible.Prior to the survey date, the facility took the following actions to correct the non-compliance:A Quality Assurance and Performance Improvement (QAPI) meeting was held on 04/13/2026. The incident was reviewed and identification of others at risk was discussed. In attendance were V1 (Community Liaison), V2 (Director of Nursing) and V17 (Medical Director).Interventions put into place to reduce the risk of recurrence: reeducation of nursing facility personnel over notification to pharmacy and V2 if medication does not arrive at expected date completed by 04/13/2026.Monitoring / Effectiveness: V2 will use QA tool to monitor medication reorder and delivery five times a week for three weeks. V2 will review medication carts one time a week to ensure medication supply is adequate and reorder has been completed at appropriate time to ensure ordered medications remain in stock. V2 will notify V17 immediately if there is an identified prescription issue or refill issue. Any issues found will be addressed immediately and in QA meeting.

Based on interview and record review the facility failed to implement appropriate interventions and supervision required to prevent an elopement for 1 (R2) of 3 residents reviewed for accidents in the sample of 6.The Findings Include:R2's admission Record documents an admission date to the facility of 12/01/2023 with diagnoses including Alzheimer's Disease, unspecified dementia, type 2 diabetes mellitus, chronic kidney disease, insomnia, and conductive hearing loss. R2's MDS (Minimum Data Set) with a date of 02/13/2026 documented Section C0100- Should Brief Interview for Mental Status be conducted? 0 was coded indicating that R2 is rarely / never understood and the assessment should not be completed. Section E-Behaviors documents under Wandering-Presence and Frequency documents the behavior was not exhibited. Section GG of the same MDS documents that R2 is independent for sit to lying, lying to sitting, sit to stand, walk 10 feet, walk 50 feet with two turns and walk 150 feet.R2's current Care Plan has a focus area of impaired cognitive function / dementia / Alzheimer's Disease, I often wander around throughout the facility with an initiation date of 12/18/24. Documented interventions include: are keep my routine consistent and provide a homelike environment with initiation dates of 12/18/24. A focus area with an initiated date of 04/03/2026 documents risk of elopement for R2 due to potential confusion and misidentification as a visitor. Interventions listed include post R2's photograph with notice at all facility exit doors, as approved by power of attorney with an initiation date of 4/3/26.An Elopement Risk assessment dated [DATE] documents that R2 is mobile with or without assistive device and R2 wanders. Risk factors with a check mark next to them include Alzheimer's / Dementia, Active Mental Illness, and psychotropic medication changes in the past three months. An Elopement Risk assessment dated [DATE] documents that R2 is mobile with or without assistive device and R2 wanders. Risk factors with a check mark next to them include Alzheimer's / Dementia, psychotropic medication changes in the past three months, resident stated they are leaving the facility, and resident appearance is that of a visitor. An Elopement Risk assessment dated [DATE] documents that R2 is mobile with or without assistive device, has one or more attempts to leave the facility, and wanders. Risk factors with a check mark next to them include Alzheimer's / Dementia, psychotropic medication changes in the past three months, resident stated they are leaving the facility, and resident appearance is that of a visitor.A document titled Elopement with a date of 04/02/2026 documented V11 (Hospital Employee) received a call from V14 (Community Member) at 1:06 P.M. that R2 was walking and out of the facility. V11 went to where R2 was with V14, asked him to get in the golf cart, and brought R2 back to the facility. R2 was last seen at approximately 1:05 P.M. by the nurse's station. Interventions put in place to prevent recurrence document a picture of R2 was placed at doors with permission of power of attorney, message sent out to families to be aware of surroundings when exiting / entering the building. Environmental assessment completed of doors, doors were functioning properly. R2 was assessed with no injuries, R2 never left facility property and V14 had visualization of R2 the entire time.On 04/22/2026 at 9:40 A.M. there is a sign observed posted on the entrance door with a picture of R2 on it. The sign states For the safety of our residents, please ensure the door closes securely behind you and that only your party exits with you. If you see the resident pictured below, who may appear to be a visitor, please do not allow him to exit with you. Thank you for your cooperation. A second sign states: Notice To ensure the safety of our residents please ensure that the door closes behind you. Please do not allow residents or anyone you don't know to exit the facility. If you have questions, please speak to the Administrator or Director of Nursing.On 04/22/2026 at 12:03 P.M., V3 (Licensed Practical Nurse) stated that R2 got out of the building on 04/02/2026. V3 stated that R2 is having an increase in behaviors and exit seeking before his elopement. V3 stated she last saw R2 right before she went to lunch on 04/02/2026 around 1:05 P.M. at the nurse's station. On 04/23/2026 at 10:52 A.M., V8 (Licensed Practical Nurse) stated R2 was out of the facility. V8 stated he was told R1 was out by trees and two hospital staff brought him back in. V8 stated once he was back in management took over and he did not do anything with it. On 04/23/2026 at 1:13 P.M., V10 (Family Member) stated R2 got out of the facility on 04/02/2026. V10 stated she gave the facility permission to post R2's picture so he does not get out again. V10 stated she is ok with them posting his picture. V10 stated the way she understood it, R2 was out walking by the road and a hospital employee's wife saw R2 and called her husband. V10 stated she thinks it was maintenance staff that got R2 in the side by side and brought him back to the facility. V10 stated R2 was not injured. V10 stated she came to the facility that day because it was R2's birthday. V10 stated when she got to the facility that is when she was made aware that R2 had gotten out of the facility. On 04/23/2026 at 1:58 P.M. V11 (Hospital Employee) stated V14 (Community Member) was delivering cards to the hospital and the nursing facility. V11 stated V14 was leaving the hospital / facility in her car, and she saw R2 walk out of the sun room door and head south. V11 stated V14 knows R2 from the community and followed R2. V11 stated V14 approached R2 and called V11 to come assist. V11 stated himself and V12 (Hospital Employee) got in the gator and drove around to the south grassy area of the hospital grounds where R2 was with V14. V11 stated R2 was headed towards a local restaurant in the grassy area of the property. V11 stated that R2 was about 25 yards form the road. V11 stated R2 was not wanting to redirect and he knew there was other staff on the golf cart. V11 contacted V15 (Hospital Employee) and V16 (Hospital Employee) to come assist. V11 stated once V15 and V16 got there, R2 was willing to go with them to the facility. V11 stated V12 and V13 took the gator to the facility to tell them and V11 rode with R2 in the golf cart. V11 stated R2 was in socks and did not have shoes on. V11 stated he believes that it was overcast that day. V11 stated he knows R2 well as they use to go to church together. V11 stated it was maybe 15 minutes from the time his wife called him until R2 was back in the facility. On 04/23/2026 at 2:15 P.M., V12 (Hospital Employee) stated he was there when V14 called V11 because R2 had gotten out of the facility. V12 stated he got in the gator with V11 and went to assist with R2. V12 stated when they got to the grassy area of the hospital grounds R2 was with V14. V12 stated once R2 was on the golf cart with V11, himself and V13 got on the gator and went to the facility. V12 stated he entered the building and asked a lady in the office if their alarms were working because R2 was outside. V12 stated the staff at the facility did not know that R2 was out of the building. V12 stated he does not remember what R2 was wearing that day. V12 stated the facility staff walked out with him and V11 had already had R2 back to the door. V12 stated as soon as R2 was back in the building he left.On 04/23/2026 at 2:20 P.M., V13 (Hospital Employee) stated he heard on the radio and came to help V11 and V12. V13 stated once R2 was in the golf cart he went with V12 to the facility to see if they knew he was out. V13 stated the facility was not aware that R2 was out of the facility. V13 stated that R2 had socks on, no shoes but did not remember what type of clothes he had on. V13 stated that R2 was on a mission to go to a local restaurant. On 04/23/2026 at 2:32 P.M., V1 (Community Liaison) stated R2's picture is on the door because he has been exit seeking. V1 stated it is her understanding that V14 occasionally volunteers at the facility and was with R2 the entire time. V1 stated V14 saw R2 exit and followed him. V1 stated that R2's wife gave the facility permission to post his picture on the doors. V1 stated the family has been offered to move R2 to a more secure facility and they refused. V1 stated during the investigation it was determined that a visitor went out that door right before R2 went out. V1 stated the door must have been green still, which allowed R2 to exit without the alarm going off. V1 stated the door alarms were checked immediately, and all alarms were functioning appropriately. V1 stated she did not consider it an elopement because R2 was still on the facility property. V1 stated R2 was assessed, and he was not harmed in any way.On 04/23/2026 at 3:05 P.M., V2 (Director of Nursing) stated R2 does wander around the facility. V2 stated that R2 will go up to a door and if it doesn't immediately open he will move on to the next. V2 stated that staff are often 1-1 with R2 because he is always in and out of other residents' rooms.On 04/24/2026 at 9:45 A.M., V14 (Community Member) stated she was leaving the facility and left through the main entrance. V14 stated she was parked at the north end of the parking lot. V14 stated she had been at the facility delivering easter cards to the residents. V14 stated when she got in her car and pulled out she saw R2 at the exit door of the sun room and no one else around. V14 stated R2 was observed being in socks and not having shoes on. V14 stated she realized it was R2 and started following him. V14 stated she watched him walk south in the grass and through the parking lot so she parked her car and got out. V14 stated she started saying R2's name really loud to get his attention. V14 stated she called V11 to bring the golf cart to help get R2 back in. V14 stated she didn't go back in the facility because she was afraid it would have taken too long and R2 would have been in the road. V14 stated that V11 and V12 came and was finally able to convince R2 to get on the golf cart and go back to the facility.

Based on interview and record review the facility failed to document and report a fall for 1 (R1) of 3 residents reviewed for accidents in the sample of 4.The past noncompliance occurred between [DATE] and [DATE].The Findings Include:R1's admission record dated [DATE] documented that R1 was admitted to the facility on [DATE] with diagnoses that include Parkinson's Disease without Dyskinesia, depression, sleep apnea, benign prostatic hyperplasia, essential hypertension, hypothyroidism, hyperlipidemia, and unspecified dementia.R1's MDS (Minimum Data Set) quarterly assessment dated [DATE] documented R1 has a BIMS (Brief Interview for Mental Status) score of 08 indicating R1 has moderate cognitive impairment. R1's Care Plan documents a focus area of Fall Risk - at risk for falls related to unsteady gait, interventions include: [DATE]- offer to assist resident bed when appears to be tired,[DATE] - all regular socks removed from room, gripper socks to be used as resident complies, [DATE] - bolster mattress will be added to bed as tactile reminder of bed perimeter, [DATE] - busy box to be offered to resident when he is up since resident likes to work / fix things, [DATE] - use 2 wheel walked when up, observe for safe ambulation's, Re-educate on safe walked use as needed, call light within reach, may use wheelchair as needed, and observe for unsafe actions and intervene.An Illinois Department of Public Health report form documents incident date: [DATE] documented R1 was observed on the floor in his bedroom and the resident was in no pain and had no complaints of discomfort. Resident later had complaints of pain; nurse received an order for an x-ray that revealed a subcapital right femoral neck fracture. Physician ordered to send R1 to the local hospital for evaluation and treatment. At the time of the incident, the call light was within easy reach and eyesight yet not activated. The resident was wearing appropriate footwear, and the room was free from clutter or spills. During interview with the resident, he was unable to state what happened. A bolster mattress to be applied to bed to aid in positioning and as a tactile reminder of bed perimeter, and resident to be offered a busy box when up, since resident was working on his wheelchair when he was noted in the floor.R1's Nurse's Note, documented as a late entry date of [DATE] at 5:23 P.M. documented a date of [DATE] timed 5:45 A.M. authored by V4 (Registered Nurse), documented during first morning medication pass coming from rose hall to begin giving medications to daisy hall, (R1) was seen sitting in the side of the bed with wheelchair lifted resting on (R1's) leg working on the front wheels of the wheelchair. (R1) verbalized no needs, no distress, or pain was verbalized. CNA's that came to get (R1) dressed observed (R1) sitting upright in the middle of the room (on the floor) with the wheelchair pulled over to him and leaned over working on the wheelchair. They proceed getting (R1) ready for the day and resident was assisted to the restroom and then back to the recliner.R1's Nurse's Note dated [DATE] timed 11:15 A.M. authored by V5 (Licensed Practical Nurse), documented call out to physician on call service related to complaints of severe pain to right hip with new order received for X-ray. V3 (Family Member) aware.R1's Nurse's Note dated [DATE] timed 6:26 P.M. authored by V15 (Registered Nurse) documented x-ray results received and physician notified. New order to send to emergency room for evaluation and treatment. V3 notified of results and new orders. V2 (Director of Nursing) notified of x-ray results.R1's x-ray report dated [DATE] documented under section titled Impression subcapital right femoral neck fracture with varus angulation and proximal displacement.R1's Neuro Check assessment in the Electronic Health Record documents a date and time of evaluation of [DATE] at 5:50 (am) and a Lock Date of [DATE], documents R1 was alert, pupils were reactive, hand grasps were equal, and R1 could move all extremities.On [DATE] at 1:48 P.M. V4 (Registered Nurse) stated she was the nurse caring for R1 the morning of [DATE]. V4 stated she was passing the early am medications somewhere around 5 am and R1 was observed sitting on the edge of his bed tinkering with his wheelchair. V4 stated this was a normal behavior for R1. V4 stated she did not see R1 fall or see R1 on the floor. V4 stated the staff working said that it occurred. V4 stated she assessed him, and he had no complaints of pain. V4 stated she does not consider R1's behavior of sitting on the floor a fall. V4 stated she knows there is no behavior care plan for R1 sitting on the floor. V4 stated I guess they are considering him sitting in the floor a fall. V4 stated she did not do a fall assessment or an incident report because she did not consider it a fall. V4 stated when she was leaving around 6:30 A.M. on [DATE] R1 was going to the dining room and was not having any pain. V4 stated she does not know the time that R1 was on the floor. V4 stated that the cna's got him up and put him in bed without notifying her. V4 stated the cna's told me after the fact that it happened. V4 stated that is why she did an assessment when she went in to give R1 his morning medications. V4 stated it is her expectation that the cna's tell her immediately so she can do an assessment on the resident before they move him. V4 stated that R1 was known to be in the floor working on chairs, doors etc. V4 stated after V2 discussed the fall with her and educated her, she went back and completed a nurse note and neuro check on what she observed on [DATE].On [DATE] at 10:00 A.M. V12 (Certified Nurse Assistant) stated her and another aide were doing a bed check between 12:00 A.M. and 1:00 A.M on [DATE]. V12 stated that when they got to R1's room he was sitting in the floor fixing his wheelchair. V12 stated she got V4, and V4 came and assessed R1. V12 stated her and another aide got R1 up, took him to the bathroom to change his clothes and placed him in bed. V12 stated she provided care for R1 at 4:00 A.M. and he was in bed and had no complaints.On [DATE] at 1:57 P.M. V11 (Certified Nurse Assistant) stated she was working the night that R1 was in the floor. V11 stated somewhere around 4:00 A.M., she went into R1's room with V12 (Certified Nurse Assistant) and observed R1 on the floor. V11 stated she stayed with R1 while V12 went to get V4. V11 stated that R1 was on the floor and was not moved until V4 assessed R1. V11 stated after V4 assessed R1, Her and V12 got R1 up with a gait belt and took him to the bathroom. V11 stated that R1 was his normal self and there was no indications of pain or that there was a problem. V11 stated after taking R1 to the bathroom, he was placed in his bed to rest. V11 stated R1 had no complaints of pain at the time.On [DATE] at 1:55 P.M. V5 (Licensed Practical Nurse) stated he was the oncoming nurse on [DATE]. V5 stated his shift started at 6:00 A.M. V5 stated R1 took his medications that morning and did not appear to be in pain. V5 stated there are days that R1 needed more help than other days. V5 stated on that day, R1 needed more assistance to get out of bed, but with R1's dementia that was not abnormal. V5 stated later in the morning before lunch, staff came and told him that R1 was having more pain than normal and there was something wrong. V5 stated that he did an assessment and could tell that R1 was having pain in his hip area. V5 stated that is when he called the physician and got an order for x-rays. V5 stated that visually R1 was not rotated but upon assessment of his hips and trying to move them he would have severe pain. V5 stated the x-ray results came back after V5 left for the day. V5 stated the cna's notified him of the change in R1 after breakfast. V5 stated when he was placed in bed after breakfast, he required more assistance than he normally would. V5 stated he did an assessment and started making phone calls immediately. V5 stated R1 would have pain he could not be specific as to where it was. V5 said that R1 could not communicate, for example, that my left foot hurts when I stand on it but he could say my left foot hurts. V5 said R1 could not give specific details about pain.On [DATE] at 2:40 P.M. V9 (Certified Nurse Assistant) stated on [DATE] she went to get R1 up for breakfast. V9 stated R1 was his normal self. V9 stated R1 was stiff and tired that morning. V9 stated she had been told by the night shift staff that R1 had been up most of the night. V9 stated she took R1 to the dining room for breakfast. V9 stated after breakfast she placed R1 in his bed to rest. V9 stated she went to get R1up for lunch and R1 was complaining of pain like he had never complained before. V9 stated that she went and immediately told V5 that there was an issue with R1.On [DATE] at 9:13 A.M. V10 (Certified Nurse Assistant) stated she came in at 05:00 A.M. on [DATE]. V10 stated the off going night shift had told her R1 had been up most of the night and R1 finally went to sleep around 3:00 A.M. V10 stated when R1 was up for breakfast he appeared tired and more stiff than normal. V10 stated some days R1 would need minimal assist but on days where he had been up all night, R1 would need more assist. V10 stated she thought since R1 had been up all night he was just tired. V10 stated when he was laid down after breakfast, and was rolling him, that is when R1 complained of pain. V10 stated she went and got V5 (Licensed Practical Nurse) and asked him to look at R1 because something was wrong. V10 stated that V5 immediately came and assessed R1.On [DATE] at 1:03 P.M. V2 (Director of Nursing) stated R1's fall was not initially treated as a fall. V2 stated It should have been treated as a fall because R1 was not care planned to have behaviors of sitting on the floor. V2 stated that R1 has had several falls and each time a new intervention is put into place. V2 stated she was not sure if R1 was out of bed the morning of [DATE]. V2 stated V5 (Licensed Practical Nurse) observed the changes in R1 and did an assessment. V2 stated that V5 called the doctor and received orders for an x-ray. V2 stated she was coming in the night of [DATE] to help with the medication pass so she was out the facility and immediately started investigating what caused the fracture to R1. V2 stated through her investigation it was determined that R1 was sitting on the edge of the bed during early morning medication pass. Sometime after that, R1 was observed sitting in the middle of the floor in his room. V2 stated that V4 (Registered Nurse) was called and asked what had happened the prior night. V2 stated V4 said R1 did not have a fall but was observed sitting in the floor. V2 stated that V4 did not consider this a fall and did not complete a fall incident report or notify anyone of the event. V2 stated that V4 had been educated on this matter and now knows that any time a resident has a change in plane, it is considered a fall. V2 stated that R1 did not come back, he was admitted on Hospice at the hospital and died on the skilled care unit. V2 stated her expectation is if the resident is on the floor, it is to be counted as a fall. V2 stated V4 should have completed neuro checks per the policy. V2 stated when V4 was educated on what a fall was, she went back and completed a neuro check because V4 told V2 that she had assessed R1.On [DATE] at 12:48 P.M. V1 (Administrator) stated the situation with R1 was immediately investigated once he was made aware of the fracture. V1 stated that V4(Registered Nurse) kept saying that R1 never had a fall. V1 stated he was never aware of R1 having behaviors of being in the floor. V1 stated that V4 has been educated on what a fall is, and the fall policy on proper notifications. On [DATE] at 8:37 A.M. V16 (Nurse Practitioner) stated if a resident has a fall, no obvious injuries and the resident is not complaining of pain, then she would not send them for treatment at the emergency department. V16 stated that when V5 (Licensed Practical Nurse) called about R1, she was not told that the resident had any falls or any real reason for the pain. V16 stated when V15 (Registered Nurse) called with the x-ray results she was told after further investigation it was noted that R1 had been observed on the floor during the previous night. V16 stated if she would have been notified immediately, she would not have sent R1 for an evaluation if R1 was not complaining of any pain. V16 stated as soon as V5 was made aware of the pain, she was notified, and she ordered x-rays immediately. V16 stated as soon as V16 made her aware of the X-ray results she sent R1 to the hospital for an evaluation. V16 stated the night nurse should have reported R1 being in the floor to the oncoming nurse. V16 stated that even if the nurse thought it was a normal behavior, the day shift nurse would have known to do an assessment or keep a closer watch on R1. V16 stated there was no delay in care for R1 because as soon as he was having pain, it was addressed.On [DATE] at 8:20 A.M. V3 (Family Member) stated R1 passed away on [DATE]. V3 stated that R1 wouldn't get out of bed on the day of [DATE] and was complaining of terrible pain. V3 stated the facility notified her of his pain and that they were going to get an x-ray. V3 stated at this time no one told her that R1 had had a fall. V3 stated that she received a call around 6:30 P.M. - 6:45 P.M. on [DATE] stating that R1 had a fractured hip. V3 stated at that time V2 (Director of Nursing) stated that she spoke with the night shift staff and was made aware that R1 had been in the floor twice during the night. V3 stated that V2 explained that R1 was telling the staff he was working on his wheelchair. V3 stated with R1's dementia diagnosis and the extensive amount of help that he required she does not feel that R1 would get out of bed and sit in the floor. V3 stated during the initial phone call, the facility nurse could not tell her why R1 was having so much pain. V3 stated it wasn't until it was found that R1 had a fracture that anyone knew what happened. V3 stated there is no way R1 could get off the floor by himself and several staff members had to help him. V3 stated the staff that helped get him off the floor knew he had a fall and did not notify her of the fall. V3 stated after the x-ray showed a fracture, R1 was sent to the local hospital for evaluation. V3 stated that R1 was admitted to the hospital for pain control and surgery was not an option. V3 stated the decision was made to move R1 to Skilled Care Unit where R1 was placed on Hospice.A Facility Policy titled Assessing Falls and Their Causes with a revised date of [DATE] under Documentation states When a resident falls, the following information should be recorded in the resident's medical record: 1. The condition in which the resident was found (e.g., resident found lying on the floor between bed and chair). 2. Assessment data, including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment administered. 4. Notification of the physician and family, in an appropriate time frame as indicated. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls. 7. The signature and title of the person recording the data. Under Reporting documents 1. Notify the following individuals when a resident falls: a. The resident's family; in an appropriate time frame b. The Attending Physician (timing of notification may vary, depending on whether injury was involved); c. The Director of Nursing Services.Prior to the survey date, the facility took the following actions to correct the deficient practice:A 1.Quality Assurance and Performance Improvement (QAPI) meeting was held on [DATE]. In attendance - V1, V2, V7 (Regional Nurse), and V17 (MDS Nurse).2 2.Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents have the potential to be affected. It was noted that an accident / incident that occurred was not reported timely to R1's representative/family, and improper identification of what a fall is. 3 3.Measures put into place/systematic changes to ensure the deficient practice does not recur: All nursing staff were in serviced by V2 regarding timely notification of an accident / incident, what is considered a fall, and that resident's should be assessed immediately to ensure there is no delay in care completed on [DATE] and [DATE]. QA tool has been developed for all accidents / incidents to be reviewed to ensure timely notification of responsible party, proper identification of falls, and that nursing assessment was completed immediately.4 4.Plan to monitor performance to ensure solutions are sustained: QA Fall Audit Tool completed for each fall times 30 days by V2 and reviewed by V1. First QA Audit completed on [DATE].

Based on observation, interview, and record review the facility failed to ensure medications were properly stored at appropriate temperatures and lock medication cart. This failure has the potential to affect all 47 residents residing in the facility. Findings Include:On 7/23/25 at 11:40 AM, V8 (Licensed Practical Nurse/LPN) was observed administering insulin to R10. V8 gathered her supplies from the medication cart, left the cart unlocked, and entered R10's room. The cart was out of V8's visual control during the administration of the insulin. No observations were made of residents or staff near the unlocked cart.A list of ambulatory residents living at the facility dated 7/25/25 documented a total of 8 ambulatory residents.On 7/24/25 at 3:20 PM, V2 (DON) stated she re-educated V8 about the importance of keeping the medication cart locked when out of the nurses visual control.The facility's Storage of Medications Policy dated April 2007 documented, #7.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. The Long-Term Care Facility Application for Medicare and Medicaid form provided by the facility on 7/23/2025 documented there were 47 residents residing at the facility.

Based on observation, interview and record review the facility failed to ensure the dish machine was effectively sanitizing dishes to prevent cross contamination. This has the potential to affect all 47 residents residing in the facility. The Findings Include:On 7/22/25 at 9:00 AM, during the initial kitchen observation, the dish machine was being used to wash dishes. V6 (Dietary Aide) was asked to check the sanitizer level in the dish machine at this time. V6 was unable to get the test strip to register a sanitizer level, so V7 (Dietary Manager) got a new set of test strips to check the level. V7 was unable to get a level of sanitizer to register on the new strips and instructed V6 to begin washing dishes in the 3-compartment sink. On 7/22/25 at 11:00 AM, V7 stated that they are to check the sanitizer level 3 times a day prior to washing each meals dirty dishes. V7 stated it should be checked before breakfast, lunch and dinner dishes to ensure it is properly sanitizing the dishes.The dish machine sanitizer log was provided on 7/22/25 at 11:00 AM, and no level was recorded for 7/22/25. V7 confirmed that there is not documentation that the sanitizer level was checked this morning, prior to starting the breakfast dishes. The Sanitizing Solution policy documents that employees shall refer to the manufacturer guidelines for the proper use of the sanitizer solutions. 1. The employee will prepare sanitizer solution in accordance with manufacturer guidelines. 2. If a dispensing system is used it will be tested daily to insure solution is dispensed a the appropriate concentration level .The Long Term Care Facility Application for Medicare and Medicaid dated 7/23/25, documents 47 residents residing in the facility.

Based on observation and interview the facility failed to ensure the building had effective pest control for flies an gnats. This has the potential to affect all 47 residents residing in the facility. Findings Include: 1.On 7/22/25 on 9:00 AM, during the initial tour of the kitchen, the dish machine area had gnats and flies observed near the drain and the garbage disposal. At this same time, a wet towel was seen under the garbage disposal and crumbs and food debris were visible under the dish machine table as well. A this time, V4 (Dietary Aide) stated that the gnats and flies can get really bad down there if the floor is not kept clean and dry. V4 stated that they do pour bleach down the drain sometimes to help reduce the number of flies/gnats that accumulate down there. On 7/22/25 at 9:30 AM, the delivery door outside the kitchen entrance was observed to have a gap at the bottom as well as in the middle where the double doors meet, and the outside was visible through these gaps. These gaps leave a potential entrance for pests/flies to enter the building. 2. On 7/23/25 at 10:30 AM, R38 who was alert to person, place and time was observed in his room sitting in his wheelchair with flies and gnats flying around his wheelchair and floor. R38 stated that the flies and gnats are a nuisance, and he has them in his room all the time. 3. R1's admission Record documented an admission date of 5/29/24 and included diagnoses of dependence on wheelchair, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left dominant side, and chronic pain syndrome. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating R1 was cognitively intact. On 7/22/25 at 10:05 AM, R1's room was observed to have 2 flies crawling on the privacy curtain and 1 fly in the window. On 7/23/25 at 9:47 AM, R1 said there were a lot of flies in the facility. R1 said the flies make it hard to sleep because they fly around his nose and ears. During this interview, R1 had a fly crawling on his arm and a fly crawling on his leg. 4. R19's admission Record documented an admission date of 7/12/24 and included diagnoses of ataxia following cerebral infarction, dysphagia, major depressive disorder, and anxiety disorder. R19's MDS dated [DATE] documented a BIMS score of 15, indicating R19 was cognitively intact. On 7/22/25 at 10:00 AM, R19 was sitting in a motorized wheelchair in his room with a fly swatter swatting at flies. Two dead flies were lying on the floor of R19's room. R19 said in the past week the facility had a lot of flies, but this was not a new thing. R19 said the facility had a lot of spiders and there were a lot of gnats flying around the sink in his room. At this time, gnats were observed flying around the sink in R19's room and crawling on the lip of the sink. 5. R26's admission Record documented an admission date of 5/10/24 and included diagnoses of Raynaud's syndrome, primary open-angle glaucoma, and heart failure. R26's MDS dated [DATE] documented a BIMS score of 15, indicating R26 was cognitively intact. On 7/23/25 at 9:56 AM, R26 said gnats and flies were bad throughout the facility. R26 said she did not have any gnat or fly traps in her room, but did have a fly swatter she tried to kill flies with. The Long-Term Care Facility Application for Medicare and Medicaid dated 7/23/25, documents 47 residents reside in the facility.

Based on observation and interview the facility failed to ensure that resident wheelchairs are cleaned and free of dirt and debris for 2 (R28 and R38) of 2 residents reviewed for clean equipment in a sample of 31. The Findings Include:On 7/23/25 at 10:00 AM, R38 was observed in his room sitting in his wheelchair. R38 was noted to be alert and oriented. The cushion of R38's wheelchair and the seat of the chair had a dried white substance and several crumbs from food dried in the same place. R38's handles were also dirty from where he had self propelled and dust and dirt were observed on the outside of his seat as well. R38 stated he thought the white substance may have been from his drinks spilling. R38 stated that he was unaware of the last time his chair was cleaned.On 7/23/25 at 10:30 AM, R28 was observed sitting in the common area by the nurse's station watching television. R28 was noted to be alert and oriented. R28's wheelchair had dust and dried food debris/crumbs on the seat and on the outside of the seat near the self-propelled wheels. R28 stated that he was unaware of the last time his chair was cleaned.On 7/23/25 at 10:45 AM, V1 (Administrator) stated that all wheelchairs were immediately going to be cleaned and sanitized. A wheelchair cleaning policy was requested, but V2 (Director of Nursing) stated that she only found a maintenance policy regarding wheelchairs.

Based on observation, interview, and record review, the facility failed to provide a nutritional supplement in accordance with physician orders for one (R31) of three residents reviewed for dining in the sample of 31.Findings include:R31's admission Record documented an admission Date of 10/30/24 and included diagnoses of Vascular Dementia, Severe, with Agitation. R31's Minimum Data Set (MDS) assessment dated [DATE] documented that R31 has severe deficits in cognition. R31's Care Plan dated 5/8/25 documented a problem area of, I am at nutritional risk of weight loss related to poor intakes, secondary to Dementia, with a corresponding intervention, Supplements/alternates per order.R31's Current Orders documented a 5/22/25 diet order for regular texture, regular liquid consistency, add fortified pudding at lunch.On 07/22/2025 at 12:23 PM, lunch service was observed in the facility's dining room. R31, who was alert and oriented only to herself, received a regular texture lunch tray. The diet card specified the tray should contain fortified pudding at lunch, but there was none on the tray.On 7/22/25 at 12:44pm, V4 (Dietary Aide) stated all residents in the dining room had received their trays. When the surveyor asked if R31 should have received fortified pudding, V4 stated yes, and he would get her some. On 07/24/25 at 3:17 PM, V2 (Director of Nurses/DON) stated she was aware of R31 not receiving the fortified pudding and had already re-educated Certified Nursing Assistant staff to make sure the trays going out are consistent with the diet cards.The facility's Food and Nutrition Services Policy dated 3/22/20 documented, Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment.

Based on observation, interview and record review, the facility failed to ensure a resident's call light was in working order for 1 (R8) of 3 residents reviewed for resident call system in a sample of 12. Findings Include: R8's Face Sheet documented an admitted [DATE] with diagnoses that included weakness, unsteadiness on feet, unspecified abnormalities of gait and mobility, a unilateral primary osteoarthritis to right knee and personal history of transient ischemic attack. R8's Minimum Data Set (MDS) dated [DATE], documented under Cognitive Patterns a Brief Interview for Mental Status (BIMS) score of 13, indicating R8 is cognitively intact. Under Functional Abilities for Self Care, the MDS documented that R8 requires staff assistance for toileting hygiene, showering/bathing, and dressing. R8's current Care Plan documented a Focus Area of I have a self care deficit r/t (related to) osteoarthritis in right knee and weakness with a Goal of Assistance will be provided to meet needs. On 2/14/24 at 11:00 AM, R8 stated that her only concern is that the night shift does not answer her call light. At this time, surveyor pushed R8's call light and it did not light up. R8 stated she was unaware that her call light was broken. On 2/14/25 at 11:30 AM, V7 (Certified Nurse Assistant/CNA) entered R8's room. Surveyor showed V7 that R8's call light was not working. At this time, V7 clicked the call light quickly approximately 5 times and it turned on, but after that could not get it to work again. Surveyor then asked V7 if R8 would know to do that and V7 stated no. V7 confirmed the call light was not working as it should. On 2/14/25 at 1:00 PM, V7 stated that she had not yet informed anyone that R8's call light was broken. V8 (Regional Clinical Nurse) was present at this time and immediately went to get the maintenance man to fix the call light. On 2/14/25 at 2:00 PM, V17 (Regional Maintenance Director) stated there was a short in the cord that needed replaced and that has been done. On 2/4/2025 at 1:20 PM, V16 (Family) stated, there have been multiple times she had hit the call light with no staff member to answer it. V10 stated, one time it took 35 minutes for a staff member to answer the call light. The Facility Call Light Use/Response policy (undated) documented the following under Call Light Maintenance: Any issues regarding inappropriate operations of a call light, must be reported to the Director of Nursing or Administrator immediately. DON or Administrator will work with Maintenance to correct the issue and if necessary, provide alternate plan to provide call light availability to resident.

Based on interview and record review, the facility failed to provide a safe mechanical lift transfer for 1 of 1 resident (R1) reviewed for falls in a sample of 12. This failure resulted in R1 becoming scared she would fall and anxious during the transfer and becoming afraid of of future mechanical lift transfers. Findings include: R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Chronic Obstructive Pulmonary Disorder, Diabetes Type 2, and Anxiety disorder. R1's Care Plan dated 8/20/24 documented problem areas,I have an ADL (Activities of Daily Living) self-care/ mobility performance (functional abilities) deficit, and, I use anti anxiety medications. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 has minimal deficits in cognition and is totally dependent on staff for transfers. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that on the morning of 9/16/24, V4, Certified Nursing Assistant, was getting her out of bed and ready for a doctors appointment. R1 stated she had two family members present at the time. R1 stated V4 transferred R1 out of the bed into the wheelchair via mechanical lift. R1 stated V4 was the only staff member present during the transfer. R1 stated, Thank God those two (V10, V11, family members) were in the room to help because I about got dumped out of the (lift) sling. I don't think (V4) knows how to use a (mechanical lift). R1's was upset and distressed while discussing this. R1 stated she was extremely upset and scared that she was going to be dumped out of the sling. R1 stated now she is scared for staff to transfer her via mechanical lift and that is the only way for her to be transferred out of the bed. On 9/17/24 at 1:00pm V10 stated she was present during the above referenced transfer. V10 stated she and V11 assisted V4 with the transfer as V4 was the only staff member present. V10 stated she and V4 stood at the wheelchair while V11 worked the controls on the mechanical lift. V10 stated V4 was giving the directions about what to do. V10 stated the mechanical lift started heavily leaning to one side and R1 was hovering over the wheelchair in a nearly laying down position. V10 stated V10 and V11 got R1 under the arms and lowered R1 into the chair. V10 stated R1 was, Upset and scared to death. On 9/18/24 at 1:50pm, V4 corroborated R1 and V10's accounts of the transfer as stated above. V4 stated they were short staffed that day, and she could not find any staff to help with the transfer so V10 and V11 assisted, with V11 working the controls. V4 stated later V4 was called in by administrative staff because R1 told others about what happened and that she was scared. V4 stated,They told me next time if I cant find somebody come get administrative staff. On 9/19/24 at 12:50pm, V2, Director of Nurses, stated the incident with R1's transfer had come to her attention and she talked to V4 about it. V2 stated V4 said she couldn't find anybody to help, and was told to ask administrative staff to help next time. V2 confirmed it is against facility policy for there to be fewer than 2 staff members present and for family members to assist with a mechanical lift transfer. V2 stated she did not complete an incident report. A Mechanical Gait Belt and Mechanical Lift Policy dated 11/28/12 documented,The transferring needs of residents will be assessed on an ongoing basis and designated into one of the following categories: H: Mechanical lift (trade name) with 2 caregivers.

Based on interview and record review, the facility failed to provide showers and timely assistance with showers and incontinence care for five of twelve residents (R1, R2, R3, R6, R7) reviewed for ADL (Activities of Daily Living) care in the sample of twelve. Findings include: 1. R1's Face Sheet documented an admitted [DATE] and listed Diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Diabetes Type 2, and Morbid Obesity. R1's Current Care Plan a problem area, I have an ADL self-care/ mobility performance (functional abilities) deficit, with a corresponding intervention, Shower/Bathe self: I take a shower/bath (and) my usual performance is dependent on staff. The same Care Plan documented a problem area, I have a potential for impairment to skin integrity related to decreased mobility, (and)incontinence, with a corresponding intervention, Keep skin clean and dry. R1's Minimum Data Set, dated dated dated [DATE] documented that R1 is totally dependent on staff for bathing/showering and toileting and is always incontinent of bowel and bladder. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that she is incontinent and staff don't change her as often as she needs it. On 9/17/24 at 1pm, V10, family member of R1, stated she visits several times per week, always during day shift. V10 stated she will come in in the morning and R1 is soaked with urine and tells her she has been that way for hours. V10 stated she comes in daily because she is scared R1 won't get changed if she doesn't. 2. R2's Face Sheet documented an admitted [DATE] and listed Diagnoses including Chronic Kidney Disease Stage 3, Malignant Neoplasm of the Uterus, and Major Depressive Disorder. R2's Current Care Plan a problem area, I have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day, with a corresponding intervention, Shower/Bathe self: I take a shower/bed bath, and my usual performance is dependent (on staff). R2's Minimum Data Set, dated dated dated [DATE] documented that R2 is totally dependent on staff for toileting and showering/bathing and is always incontinent of bowel and bladder. R2's Shower Sheets for September 2024 document zero showers for that month. On 9/17/24 at 10:25am, R2 was alert and oriented to person, place, and time. R2 stated she is not always getting a shower or bath twice a week. 3. R3's Face Sheet documented an admitted [DATE] and listed Diagnoses including Cerebral Palsy, Heart Failure, and Hypertension. R3's Current Care Plan a problem area,I have alteration in urinary elimination, urinary incontinence, related to impaired mobility, and lack of sensation, with a corresponding interventions, Ensure call light is within reach and answer promptly, monitor for incontinence and change as needed. R3's Minimum Data Set, dated dated dated [DATE] documented that R3 is totally dependent on staff for toileting and showering/bathing and is always incontinent of bowel and bladder. On 9/17/24 at 9:55am, R3 was alert and oriented to person, place, and time. R3 stated he thinks night shift is especially short staffed, it can take over an hour for his call light call light and stated he is sometimes wet for hours at a time. 4. R6's Face Sheet documented an admitted [DATE] and listed Diagnoses including COPD, Morbid Obesity, and Diabetes Type 2. R6's Current Care Plan a problem area, I have an ADL self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day, with a corresponding intervention,Shower/Bathing self: I take a shower and my usual performance is set up/clean up assistance (from staff). R6's Minimum Data Set, dated dated dated [DATE] documented that R6 requires set up or clean up assistance from staff for showering/bathing and is always continent of bowel and bladder. R6's August 2024 Shower Sheets document R6 received one shower on the week of 8/18/24. On 9/18/24 at 10:45am, R6 was alert and oriented to person, place, and time. R6 stated call lights are not answered quickly enough, especially on the 6pm to 6am shift, and, There are always residents yelling for help for extended periods of time, and the emergency call lights in the bathroom are going off for up to 15 minutes because nobody is answering them. R6 stated she is independent for showering except she needs staff to dry her feet, and she is afraid she will fall if she has wet feet. R6 stated she, Turns on the shower room call light, which is an emergency light, and has to wait there til somebody comes, which might be 15 minutes later, or not at all. Last week nobody came so I sat on the chair part of my walker and scooted up to the nurses station for help. 5. R7's Face Sheet documented an admitted [DATE], and listed diagnoses including Dementia, Severe, with Agitation, Hypertension, and Anxiety Disorder. R7's Current Care Plan a problem area, I have potential for altered activity pattern related to Dementia. R7's Minimum Data Set, dated dated dated [DATE] documented that R7 is dependent on staff for toileting and showering/bathing and is always incontinent of bowel and bladder. On 9/18/24 at 11:45am, R7 was alert only to herself, and she was being fed a puree meal by her family member V7. V7 stated R7 has lived at the facility, For a couple of weeks. V7 stated R7 is incontinent and is not being changed often enough. V7 stated she visits several times a day at different times of the day, and has found R7 soaking wet with wet clothes multiple times. On 9/19/24 at 12:50pm, V2, Director of Nurses, stated residents are to get two shower per week and in between as desired or needed. On 9/20/24 at 2:00 pm, V2 stated it is her expectation that all call lights for assistance should be answered within three minutes. A Resident Council Meeting note dated 9/12/24 documented, New business: Nursing-hard to find (staff) when needing assistance. An Incontinence Care Policy dated 11/28/12 documented, Incontinent residents will be checked periodically in accordance with the assessed incontinent episodes or every two hours and provided perineal and genital care after each episode. A Shower and Tub Bath Policy dated 11/28/12 stated,A shower, tub bath,or bed/sponge bath will be offered according to the resident's preference two times per week or according to the resident's preferred frequency and as needed or requested.

Based on interview and record review, the facility failed to provide direct care staff in adequate numbers to ensure safe and timely resident care. This has the ability to affect all 34 residents living on the [NAME] and Daisy/Tulip halls. Findings include: A Resident Council Meeting note dated 9/12/24 documented, New business: Nursing-hard to find (staff) when needing assistance. A Room Roster dated 9/14/24 documented a total of 34 residents living on the [NAME] and Daisy/Tulip halls. A Daily Staff Schedule for Friday 8/31/24 documented one nurse and two CNAs (Certified Nursing Assistants) working the [NAME] and Daisy/Tulip halls on the 6am to 6pm shift. A Daily Staff Schedule for Sunday 9/15/24 documented one nurse and one CNA working the [NAME] and Daisy/Tulip halls on the 6pm to 6am shift. A Daily Staff Schedule for Monday 9/16/24 documented one nurse and 3 CNAs working the [NAME] and Daisy/Tulip halls on the 6am to 6pm shift. On 9/17/24 at 9:55am, R3 was alert and oriented to person, place and time. R3 stated night shift (6pm to 6am) is especially short staffed because call lights can take over an hour to be answered. R3 stated medications are frequently passed late, and it happens on all shifts, both through the week and one weekends. On 9/17/24 at 10:25am, R2 was alert and oriented to person, place, and time. R2 stated, They are definitely short staffed all the time, through the week and on the weekend, and on days and nights both. On 9/17/24 at 10:55am, R1 was alert and oriented to person, place, and time. R1 stated that on the morning of 9/16/24, V4, Certified Nursing Assistant, transferred R1 out of the bed into the wheelchair via mechanical lift without another staff member present. On 9/18/24 at 10:15pm, V12, Registered Nurse, stated there are always enough CNAs (Certified Nursing Assistants) scheduled, but there are daily call ins, both through the week and on weekends. On 9/18/24 at 10:45am, R6 was alert and oriented to person, place, and time. R6 stated, Staffing is hit or miss as to whether they have enough staff, weekends are worse, they seem to have a lot of call ins, both day and night shift. R6 stated medications on the 6pm to 6am shift are frequently passed late, both through the week and on the weekends. On 9/18/24 at 1:50pm, V4 stated she works both the 6am to 6pm and 6pm to 6am shifts both through the week and on weekends. V4 stated they are, Always short staffed because of last minute call ins. V4 confirmed she transferred R1 via mechanical lift on 9/16/24 without another staff member present. V4 stated on that date on the 6am to 6pm shift, she could not find any direct care staff to help with the transfer because they were working short staffed V4 stated residents complain about medications being passed late on the 6pm to 6am shift. On 9/18/24 at 2:20pm, V5, CNA, stated the facility frequently runs short of CNA's. V5 stated on 8/31/24 she worked 6am to 6pm with V8, CNA, and V13, Licensed Practical Nurse, on the Daisy/Tulip halls. V5 stated another CNA had also come in at 6am but had to leave due to a family emergency, so V6, Registered Nurse/Minimum Data Set Coordinator, came in to work as a CNA at around 9 am. V 5 stated V13 walked out without giving notice at around 2pm, leaving V6 to cover the nursing duties. V5 stated that left only V5 and V8 to provide direct care for the remainder of the shift. On 9/18/23 at 2:40pm, V8 confirmed V5's report of 8/31/24. V8 stated it is not the only occasion she and V5 have worked alone on [NAME] and Daisy/Tulip. V8 stated they are supposed to have at least 4 CNAs on [NAME] and Daisy/Tulip on both shifts. V8 stated she works the 6am to 6pm shift Monday through Friday and every other weekend. V8 stated she has heard complaints from residents about medication pass running late. On 9/19/24 at 11:10am, V4, Licensed Practical Nurse, stated she is the staff member responsible for scheduling the CNA staff, and V2, Director of Nurses, is the staff member responsible for scheduling nursing staff. V4 stated in addition to their own staff, the facility utilizes a staffing company that provides contractual licensed and CNA staff. V4 stated for both the 6am to 6pm and 6pm to 6am shifts, she schedules 4 or 5 CNAs and V2 schedules two nurses for the [NAME] and Daisy/Tulip halls, and one nurse and 2 CNAs for the [NAME] hall memory care unit. V4 stated administrative staff frequently have to work the floor both to cover licensed staff and CNA staff due to call ins. V4 stated the 2 CNAs on [NAME] hall very rarely float to [NAME] and Daisy/Tulip halls. V4 stated there have been occasions where there may have only been two CNAs to cover [NAME] Daisy/Tulip for an hour or so, until coverage could be obtained. On 9/19/24 at 12:50pm, V2, Director of Nursing, stated she believed the facility is meeting or exceeding minimum staffing requirements. V2 stated CNA call ins are an issue but coverage can usually be found. V2 stated she had to pass medications the morning of 9/17/24 due to staff member calling in. V2 stated morning medication pass usually starts about 6:30am with getting supplies ready, but she did not get started until about 7:30am. V2 stated as far as she is aware medications are being passed timely and she has not heard any complaints from residents about medications being late.

Based on observation, interview, and record review, the facility failed to identify and evaluate potential hazards/risks and implement interventions to ensure safe transfers via mechanical lifts for 1 (R1) of 3 residents reviewed for accident hazards and injuries of unknown origin in the sample of 6. This failure resulted in R1 sustaining injuries of bruising to the tops of both feet and a hematoma under the nail of the right great toe. Findings include: R1's Face Sheet documented an initial admitted [DATE] with diagnoses that included unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, and cerebrovascular disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 had moderate cognitive impairment. On 8/23/24 at 1:00 PM, R1's right great toenail was black with blood under the nail. R1's feet had greenish yellow bruising to the tops of both feet measuring approximately 3 inches x 3 inches. R1 stated he did not know how his feet had been injured. R1's Hospice Visit Note dated 7/26/24 documented R1 did not have any bruising to the feet. R1's Hospice Visit Note dated 7/29/24 documented in part .Rt. (right) foot and leg was swollen and had bruises present, SNF (Skilled Nursing Facility) reported no falls or injuries for (R1) . R1's Hospice Visit Note dated 8/2/24 documented in part . Lt (left) foot has a bruise on the top of foot size of a softball circle with purple/green in color. (Right) leg was swollen around ankle bone and had bruises present on top of the foot and side of ankle with purple/green bruise. SNF reported no falls or injuries . reported these findings to (V2 - Director of Nursing/DON). Pt (patient/R1) is unaware of how or when the bruise occurred . SN (Skilled Nurse) left a message with person answering (facility) work phone for Nurse on staff to give me a call, as SN needs a report of unknown bruise noted as staff nurses had not document on BLE (Bilateral Lower Extremities) having any bruise. (V7 - Registered Nurse/RN) on staff at SNF was not present during any SNV (Skilled Nurse Visit) and SN was unable to give (V7) report as no staff could find (V7) . R1's Hospice Visit Note dated 8/5/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V13 - Licensed Practical Nurse/LPN) and (V7) and stated SN needed a incident report since they have no report filled out stating that SNF staff has seen or document pt (R1) having bruises to BLE. Staff is supposed to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding . R1's Hospice Visit Note dated 8/9/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V5/LPN) and (V2/DON). SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding at last SNV and no report can be found or has been filled out per (V5) and (V2). (sic) Per (V2) a report will be filled out and SN can obtain a copy from them next week . R1's Hospice Visit Note dated 8/12/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V3 - Assistant Director of Nursing/ADON) SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, report is filled out but is not signed by any of the nurses yet . R1's Hospice Visit Report dated 8/16/24 documented in part .SN received report from (V17- Hospice Certified Nursing Assistant/CNA) that (R1) had bleeding to (right) great toe and bruising noted around toe nail bed. (R1's right) great toe has blood under toe nail bed . with bruising around nail bed noted. SN spoke with (V2) and (V3) and per them 'assessed toe d/t (due to) Hospice aide (V17/CNA) reported findings to (V2) and (V3)' . No reports noted of pt (patient) fall or injury noted per staff records. SN is still unable to get report from SNF of bruise noted on 8/2/24 as per (V2) and (V3) 'note is not signed yet' . R1's Hospice Visit Note dated 8/20/24 documented in part .brusied [sic] noted to Rt. great toe with dried blood under nail bed. SN reported SN findings to (V7/RN). SN still does not have report from 8/2/24 as it still not signed by RN .MD is aware of SN and CNA reporting SNF to (State Agency). R1's Electronic Medical Record (EMR) documented two progress notes on 8/11/24 that had been struck out citing incorrect documentation: R1's struck out progress note dated 8/11/24 at 1:58 AM documented in part Note Text: (R17) Follow up assessment completed. Bruising to top of left, right foot .reddish purple bruising noted . The note documents Strike Out Reason: Incorrect Documentation and Strike Out date: 8/14/24 09:05 (am). R1's struck out progress note dated 8/11/24 at 9:25 AM documented in part Note Text (R17) Follow up assessment completed. Bruising to top left of right foot .No skin issues noted. No Bruising noted. No s/s (signs/symptoms) of infection noted to site. No swelling noted. The note documents Strike Out Reason: Incorrect Documentation and Strike Out date: 8/14/24 09:05 (am). On 8/23/24 at 10:59 AM, V4 (Hospice RN) stated R1 had bruising found on 8/2/24 to the top of both feet about the size of a softball. V4 said she had reported the bruising to V2 (DON) when V4 found the bruising. V4 said that on 8/5/24, V4 had returned to the facility and V7 (RN) and V13 (LPN) said they were not aware of R1 having any injuries. V4 stated that on 8/9/24, she told V2 that V4 would need a report on the bruises because the staff could not tell V4 how R1 was injured and there was no documentation of the bruising in R1's medical record. V4 then stated that on 8/16/24, R1 was found to have bleeding and a hematoma under the right great toenail with surrounding bruising to the toe. V4 said the facility was not able to explain how R1's right great toe was injured. V4 said she had asked the facility several times for a report on R1's injuries of unknown origin but none had been provided. On 8/23/24 at 11:31 AM, V2 (DON) said staff would use the mechanical lift to transfer R1 when R1 was not feeling strong enough to stand for transfers. V2 said she thought the injuries to R1's feet had been caused by staff hitting R1's feet on the bar of the mechanical lift. On 8/27/24 at 11:00 AM, V16 (CNA) stated that the facility had several agency staff who don't care, and will hit resident's feet on the bar of the mechanical lift when transferring them. At the same time of this interview with V16, this surveyor observed a dark red substance that appeared to be dried blood on the center bar and central cross bar of the mechanical lift. On 8/27/24 at 11:11 AM, V1 (Administrator) verified the dark red substance found on the mechanical lift looked like blood. R1's Report to (State Agency) dated 8/28/24 documented in part .Interviews with staff revealed that resident is tall, a maximum assist, dependent with care. Resident is transferred by 2 staff or at times has had to use a (mechanical lift). Staff stated (R1) has bumped feet on (mechanical lift) before. Staff interviews revealed that resident has been observed to also attempt to self transfer, pulls rolling wheelchair toward him .Interview with (R1) revealed that (R1) was unable to tell me what happened but he could tell me he was alright and having no pain in feet . The facility's revised 10/24/22 Abuse Prevention and Reporting - (State) policy documented in part .Employees are required to report any incident, allegation or suspicion of potential abuse . they observed, hear about, or suspect to the administrator, or to an immediate supervisor who must immediately report it to the administrator .Upon learning of the report, the administrator .shall initiate an incident investigation .Injuries of Unknown Source .For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person orther source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury .or the number of the injuries observed at one particular point in time .If classified as an injury of unknow source, the person gathering the facts will document the injury, the location and time it was observed, any treatment given and notification of the resident's physician, responsible party .

Based on observation, interview, and record review, the facility failed to ensure timely reporting of potential abuse and neglect allegations, including an injury of unknown origin for 2 (R1 and R4) of 4 residents reviewed for abuse in the sample of 6. Findings include: 1. R1's Face Sheet documented an initial admitted [DATE] with diagnoses that included malignant neoplasm of prostate, unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, and cerebrovascular disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 had moderate cognitive impairment. On 8/23/24 at 1:00 PM, R1's right great toenail was black with blood under the nail. R1's feet had greenish yellow bruising to the tops of both feet measuring approximately 3 inches x 3 inches. R1 said he did not know how his feet had been injured. R1's Hospice Visit Note dated 7/26/24 documented R1 did not have any bruising to the feet. R1's Hospice Visit Note dated 7/29/24 documented in part .Rt. (right) foot and leg was swollen and had bruises present, SNF (Skilled Nursing Facility) reported no falls or injuries for (R1) . R1's Hospice Visit Note dated 8/2/24 documented in part . Lt (left) foot has a bruise on the top of foot size of a softball circle with purple/green in color. (Right) leg was swollen around ankle bone and had bruises present on top of the foot and side of ankle with purple/green bruise. SNF reported no falls or injuries . reported these findings to (V2 - Director of Nursing/DON). Pt (patient/R1) is unaware of how or when the bruise occurred . SN (Skilled Nurse) left a message with person answering (facility) work phone for Nurse on staff to give me a call, as SN needs a report of unknown bruise noted as staff nurses had not document [sic] on BLE (Bilateral Lower Extremities) having any bruise. (V7 - Registered Nurse/RN) on staff at SNF was not present during any SNV (Skilled Nurse Visit) and SN was unable to give (V7) report as no staff could find (V7) . R1's Hospice Visit Note dated 8/5/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V13 - Licensed Practical Nurse/LPN) and (V7) and stated SN needed a incident report since they have no report filled out stating that SNF staff has seen or document pt (R1) having bruises to BLE. Staff is supposed to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding . R1's Hospice Visit Note dated 8/9/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V5/LPN) and (V2/DON). SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. (sic) Staff was suppose to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding at last SNV and no report can be found or has been filled out per (V5) and (V2). (sic) Per (V2) a report will be filled out and SN can obtain a copy from them next week . R1's Hospice Visit Note dated 8/12/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V3 - Assistant Director of Nursing/ADON) SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, report is filled out but is not signed by any of the nurses yet . R1's Hospice Visit Report dated 8/16/24 documented in part .SN received report from (V17- Hospice Certified Nursing Assistant/CNA) that (R1) had bleeding to (right) great toe and bruising noted around toe nail bed. (R1's right) great toe has blood under toe nail bed . with bruising around nail bed noted. SN spoke with (V2) and (V3) and per them 'assessed toe d/t (due to) Hospice aide (V17/CNA) reported findings to (V2) and (V3)' . No reports noted of pt (patient) fall or injury noted per staff records. SN is still unable to get report from SNF of bruised [sic] noted on 8/2/24 as per (V2) and (V3) 'note is not signed yet' . R1's Hospice Visit Note dated 8/20/24 documented in part .brusied [sic] noted to Rt. great toe with dried blood under nail bed. SN reported SN findings to (V7/RN). SN still does not have report from 8/2/24 as it still not signed by RN .MD is aware of SN and CNA reporting SNF to (State Agency). On 8/23/24 at 10:59 AM, V4 (Hospice Registered Nurse/RN) said R1 had bruising found on 8/2/24 to the top of both feet about the size of a softball. V4 said she had reported the bruising to V2 (DON) when V4 found the bruising. V4 said on 8/5/24, V4 returned to the facility and V7 (RN) and V13 (LPN) said they were not aware of R1 having any injuries. V4 said on 8/9/24 she told V2 that V4 would need a report on the bruises because the staff could not tell V4 how R1 was injured and there was no documentation of the bruising in R1's medical record. V4 said that on 8/16/24, R1 was found to have bleeding and a hematoma under the right great toenail with surrounding bruising to the toe. V4 said the facility was not able to explain how R1's right great toe was injured. V4 said she had asked the facility several times for a report on R1's injuries of unknown origin but none had been provided. On 8/23/24 at 11:31 AM, V2 (DON) said V4 had reported to V2 that R1 had injuries to his feet but was not sure of the dates V4 had reported R1's injuries. V2 said she thought R1's injuries had been caused by staff hitting R1's feet on the bar of the mechanical lift. V2 said R1's injuries were not witnessed by any staff to V2's knowledge. V2 verified R1's injuries were injuries of unknown origin. V2 said any injury of unknown origin should be reported to V1 (Administrator). V2 said any injury of unknown origin should be reported to (State Agency). V2 said she was not sure why she did not report R1's injuries of unknown origin to V1. On 8/23/24 at 11:40 AM, V1 said the facility's Electronic Medical Record (EMR) system would flag V1 when an incident was documented. V1 said R1 had an incident documented on 8/10/24 but was documented as injury of known origin. V1 said she had not been made aware of R1 having any injuries of unknown origin by staff. V1 said due to her not being aware of R1's injuries of unknown origin she had not reported them or started an investigation. On 8/23/24 at 2:00 PM, V13 (LPN) said he recalled the hospice nurse reporting something about R1's foot but was unsure what the hospice nurse had reported, or on what date. On 8/23/24 at 12:39 PM, V7 (RN) said the hospice nurse brought R1's bruising to her attention but was not sure of the date. V7 said R1 had bruising to the ankle and the tops of both feet. V7 said when she assessed R1, the bruising did not appear to be fresh due to the color. V7 said R1's bruising was not dark blue or purple, it was more of a greenish color. V7 said she did not report R1's injuries because V2 was aware of them. On 8/29/24 at 11:43 AM, V1 verified there was no skin assessment or progress note documenting R1's injuries on 8/10/24. V1 said V7 should have completed a skin assessment when V7 documented the incident in risk management. V1 said V13 should have completed a skin assessment when hospice notified him on 7/29/24. V1 said V2 should have completed a skin assessment when the hospice nurse notified her on 8/2/24. V1 said no skin assessments were completed for R1. R1's Report to (State Agency) dated 8/28/24 documented in part .Interviews with staff revealed that resident is tall, a maximum assist, dependent with care. Resident is transferred by 2 staff or at times has had to use a (mechanical lift). Staff stated (R1) has bumped feet on (mechanical lift) before. Staff interviews revealed that resident has been observed to also attempt to self transfer, pulls rolling wheelchair toward him . Interview with (R1) revealed that (R1) was unable to tell me what happened but he could tell me he was alright and having no pain in feet . 2. R4's Face Sheet documented an admitted [DATE] with diagnoses that included cognitive communication deficit, schizoaffective disorder, dementia, and lack of coordination. R4's MDS dated [DATE] documented a BIMS score of 2, indicating R4 was severely cognitively impaired. An undated and untitled abuse questionnaire signed by V18 (CNA) on 8/16/24 documented in part . Have you heard any resident say they have been abused? Yes . Do you know of any resident being abused? Yes . An undated and untitled abuse questionnaire signed by V20 (CNA) on 8/16/24 documented in part . Have you heard any resident say have been abused? Yes . Do you know of any resident being abused? Yes-ish . On 8/28/24 at 9:11 AM, V1 (Administrator) was asked why V18 (CNA) and V20 (CNA) had answered yes to the questions Have you heard any resident say they have been abused? and Do you know of any resident being abused? on R1's injury of unknown origin investigation packet, and V1 replied she was unsure because she found them the previous night. On 8/28/24 at 12:06 PM, V1 sent an email that documented in part .I just spoke with (V18) in person and (V20) by facetime. They answered yes because of an incident that occurred when they were working (specific hall). They reported to work at (6:00 AM) that day and noted that one of the residents was incontinent and appeared that (R4) may have been wet for some time. They felt like the midnight (CNA) did not change (R4) when needed . On 8/28/24 at 1:36 PM, V1 stated that on 8/16/24, V1 had sent V3 (ADON) to complete some staff abuse questionnaires. V18 and V20 reported the (R4) incident to V3 and V3 told V18 and V20 the incident with R4 was not what the abuse questionnaires were pertaining to. V1 stated that V3, V18, and V20 had not reported the incident regarding R4 to V1. V1 said she expected staff to immediately report any concerns with abuse or neglect to V1. V1 said she will be educating all staff on the definitions of abuse and reporting abuse. V1 said she would be starting an investigation immediately. On 8/28/24 at 1:08 PM, V18 (CNA) stated that on 8/16/24 when she arrived in the facility at 6:00 AM, R4 was found to be sitting in a recliner in the dining room. V18 said the recliner and R4's clothing was soaked in urine. V18 said R4's shirt was white and had brown lines of dried urine due to no one assisting R4 with incontinence care for a long time. V18 said she felt like this was possibly neglect and had reported it to the nurse working on 8/16/24. V18 said she could not recall who the nurse was she reported the incident to. V18 said she thought the nurse would report V18's concerns of neglect to management. V18 said she was aware R4 can be combative, but that was no reason to neglect someone. On 8/29/24 at 8:40 AM, V20 (CNA) stated that on 8/16/24 when she arrived at work at 6:00 AM, she found R4 to be sitting in the dining room in a recliner soaked in urine from mid-back to mid-thigh. V20 said R4 had a brown ring of dried urine on both her shirt and pants. V20 said she reported the incident to the nurse. V20 said later that day on 8/16/24 at approximately 4:30 PM, V3 (ADON) had given V20 an abuse questionnaire and V20 had reported the incident to V3. V20 said after reporting the incident to V3, V3 told V20 that was a hygiene problem, not abuse. V20 said she told V3 the incident was abuse because she felt R4 had been neglected. V20 said V3 did not say anything else and walked away. V20 said the night shift of 8/15/24 to 8/16/24 was staffed as usual with 1 licensed nurse and 2 CNA's. V20 said on multiple occasions she has arrived at work and had been told by V21 (CNA) that some residents were not up or had not been assisted with incontinence care because V21 says she is too old to do it. V20 said she has told V21 if V21 is too old to complete her job duties, V21 needs to find a different job that V21 can do. On 8/29/24 at 11:16 AM, V3 (ADON) stated that on 8/16/24, V1 had asked V3 to go around and ask staff members the questions on the abuse questionnaire. V3 said V18 and V20 had told her they had witnessed abuse but refused to elaborate any details. V3 said V18 and V20 told her V1 could come ask them for further details of their concerns. V3 said when she returned to V1's office, V1 was in a meeting and V3 had slid the abuse questionnaire papers under V1's door. On 8/29/24 at 11:43 AM, V1 said V3 did not slide the 8/16/24 abuse questionnaires under her office door. V1 said on 8/16/24 when V3 had completed the abuse questionnaires, V1 had already left the facility for the day. V1 stated that on 8/19/24, V1's office door was open and V1 was down the hall, and when V1 returned to her office, V3 had placed the abuse questionnaires on her desk. V1 said V3 never reported V18 and V20's abuse allegations. On 8/29/24 at 8:56 AM, V1 said she expected staff to report any concerns with abuse immediately to V1. The facility's revised 10/24/22 Abuse Prevention and Reporting - (State) policy documented in part .Employees are required to report any incident, allegation or suspicion of potential abuse . they observed, hear about, or suspect to the administrator, or to an immediate supervisor who must immediately report it to the administrator . All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse . to the administrator or an immediate supervisor who must then immediately report it to the administrator . Reports should be documented and a record kept of the documentation . Any incident that does not involve abuse and does not result in serious bodily injury shall be reported within 24 hours . The nursing staff is additionally responsible for reporting on a facility incident report the appearance of suspicious bruises . as they occur. Upon report of such occurrences, the nursing supervisor is responsible for assessing the resident, reviewing the documentation and reporting to the administrator . Injuries of Unknown Source . For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person other source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury . or the number of the injuries observed at one particular point in time . If classified as an injury of unknow source, . The (State Agency) will be notified. Time frames for reporting and investigation abuse will be followed .

Based on observation, interview, and record review, the facility failed to initiate and complete a timely and thorough investigation of an injury of unknown origin for 1 (R1) of 3 residents reviewed for abuse/neglect investigations in the sample of 6. Findings include: R1's Face Sheet documented an initial admitted [DATE] with diagnoses that included malignant neoplasm of prostate, unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, and cerebrovascular disease. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 had moderate cognitive impairment. On 8/23/24 at 1:00 PM, R1's right great toenail was black with blood under the nail. R1's feet had greenish yellow bruising to the tops of both feet measuring approximately 3 inches x 3 inches. R1 said he did not know how his feet had been injured. R1's Hospice Visit Note dated 7/26/24 documented R1 did not have any bruising to the feet. R1's Hospice Visit Note dated 7/29/24 documented in part .Rt. (right) foot and leg was swollen and had bruises present, SNF (Skilled Nursing Facility) reported no falls or injuries for (R1) . R1's Hospice Visit Note dated 8/2/24 documented in part . Lt (left) foot has a bruise on the top of foot size of a softball circle with purple/green in color. (Right) leg was swollen around ankle bone and had bruises present on top of the foot and side of ankle with purple/green bruise. SNF reported no falls or injuries . reported these findings to (V2 - Director of Nursing/DON). Pt (patient/R1) is unaware of how or when the bruise occurred . SN (Skilled Nurse) left a message with person answering (facility) work phone for Nurse on staff to give me a call, as SN needs a report of unknown bruise noted as staff nurses had not document on BLE (Bilateral Lower Extremities) having any bruise. (V7 - Registered Nurse/RN) on staff at SNF was not present during any SNV (Skilled Nurse Visit) and SN was unable to give (V7) report as no staff could find (V7) . R1's Hospice Visit Note dated 8/5/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V13 - Licensed Practical Nurse/LPN) and (V7) and stated SN needed a incident report since they have no report filled out stating that SNF staff has seen or document pt (R1) having bruises to BLE. Staff is supposed to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding . R1's Hospice Visit Note dated 8/9/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V5/LPN) and (V2/DON). SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. (sic) Staff was suppose to write up a report stating that bruise are from unknown causes, both (V7) and (V13) voiced understanding at last SNV and no report can be found or has been filled out per (V5) and (V2). (sic) Per (V2) a report will be filled out and SN can obtain a copy from them next week . R1's Hospice Visit Note dated 8/12/24 documented in part .Lt and Rt. feet bruises have improved no new bruises noted. SN spoke with (V3 - Assistant Director of Nursing/ADON) SN stated hospice needed a incident report since they have no report filled out stating that the SNF staff has seen or document (R1) having bruises to BLE. Staff was suppose to write up a report stating that bruise are from unknown causes, report is filled out but is not signed by any of the nurses yet . R1's Hospice Visit Report dated 8/16/24 documented in part .SN received report from (V17- Hospice Certified Nursing Assistant/CNA) that (R1) had bleeding to (right) great toe and bruising noted around toe nail bed. (R1's right) great toe has blood under toe nail bed . with bruising around nail bed noted. SN spoke with (V2) and (V3) and per them 'assessed toe d/t (due to) Hospice aide (V17/CNA) reported findings to (V2) and (V3)' . No reports noted of pt (patient) fall or injury noted per staff records. SN is still unable to get report from SNF of bruised noted on 8/2/24 as per (V2) and (V3) 'note is not signed yet' . R1's Hospice Visit Note dated 8/20/24 documented in part .brusied noted to Rt. great toe with dried blood under nail bed. SN reported SN findings to (V7/RN). SN still does not have report from 8/2/24 as it still not signed by RN .MD is aware of SN and CNA reporting SNF to (State Agency). R1's Report to (State Agency) dated 8/28/24 documented in part .Interviews with staff revealed that resident is tall, a maximum assist, dependent with care. Resident is transferred by 2 staff or at times has had to use a (mechanical lift). Staff stated (R1) has bumped feet on (mechanical lift) before. Staff interviews revealed that resident has been observed to also attempt to self transfer, pulls rolling wheelchair toward him . Interview with (R1) revealed that (R1) was unable to tell me what happened but he could tell me he was alright and having no pain in feet . On 8/23/24 at 10:59 AM, V4 (Hospice RN) said R1 had bruising found on 8/2/24 to the top of both feet about the size of a softball. V4 said she had reported the bruising to V2 (DON) when V4 found the bruising. V4 said that on 8/5/24, V4 returned to the facility and V7 (RN) and V13 (LPN) said they were not aware of R1 having any injuries. V4 said that on 8/9/24, she told V2 that V4 would need a report on the bruises because the staff could not tell V4 how R1 was injured and there was no documentation of the bruising in R1's medical record. V4 said that on 8/16/24, R1 was found to have bleeding and a hematoma under the right great toenail with surrounding bruising to the toe. V4 said the facility was not able to explain how R1's right great toe was injured. V4 said she had asked the facility several times for a report on R1's injuries of unknown origin but none had been provided. On 8/23/24 at 12:39 PM, V7 (RN) said the hospice nurse brought R1's bruising to her attention but was not sure of the date. V7 said R1 had bruising to the ankle and the tops of both feet. V7 said when she assessed R1, the bruising did not appear to be fresh due to the color. V7 said R1's bruising was not dark blue or purple, it was more of a greenish color. V7 said she did not report R1's injuries because V2 was aware of them. On 8/23/24 at 11:31 AM, V2 (DON) said V4 had reported R1's bruising to her but was unsure of the date. V2 said she thought V4 may have reported R1's bruising on 8/13/24. V2 said she thought R1 had probably hit his feet on the mechanical lift during a transfer. V2 said she was not sure when R1's injuries had appeared. V2 said there was an incident in risk management (a tracking system for any incidents in the facility) on 8/10/24 by V7 noting bruising to R1's feet and was documented as a known injury. V2 verified R1's injuries were of unknown origin. V2 said any injury of unknown origin should be reported to V1 (Administrator) so an investigation can be started. V2 said she was not sure why she did not report R1's injuries of unknown origin to V1. On 8/23/24 at 11:40 AM, V1 said V2 had told her something about R1 having a small cut or something on his toe possibly on 8/10/24. V1 said there was an incident documented in risk management on 8/10/24 by V7 documenting a known injury to R1's foot. V1 said she had not been made aware R1 had any injuries of unknown origin to open an investigation on. V1 said she had not started an investigation on R1's injuries but had asked residents and staff if they had witnessed abuse on 8/16/24. On 8/29/24 at 11:43 AM, V1 verified there was no skin assessment or progress note documenting R1's injuries on 8/10/24. V1 said V7 should have completed a skin assessment when V7 documented the incident in risk management. V1 said V13 should have completed a skin assessment when hospice notified him on 7/29/24. V1 said V2 should have completed a skin assessment when the hospice nurse notified her on 8/2/24. V1 said no skin assessments were completed for R1. On 8/29/24 at 11:16 AM, V3 (ADON) said if V1 was not in the facility to begin an investigation when any allegation of abuse was made, V2 would be next in the chain of command to start an investigation. V3 said V1 would be notified but it would be V2's responsibility to begin an investigation. On 8/29/24 at 11:43 AM, V1 said V2 is the second in the chain of command. V1 said V2 can start an investigation and has access to the portal to complete and send an initial report. On 8/29/24 at 8:56 AM, V1 said she expected any staff to immediately report any injury on unknown origin to V1. The facility's revised 10/24/22 Abuse Prevention and Reporting - (State) policy documented in part .Employees are required to report any incident, allegation or suspicion of potential abuse . they observed, hear about, or suspect to the administrator, or to an immediate supervisor who must immediately report it to the administrator . All residents, visitors, volunteers, family members or others are encouraged to report their concerns or suspected incidents of potential abuse . to the administrator or an immediate supervisor who must then immediately report it to the administrator . Reports should be documented and a record kept of the documentation . Upon learning of the report, the administrator . shall initiate an incident investigation . Injuries of Unknown Source . For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person other source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury . or the number of the injuries observed at one particular point in time . If classified as an injury of unknow source, the person gathering the facts will document the injury, the location and time it was observed, any treatment given and notification of the resident's physician, responsible party . Time frames for reporting and investigating will be followed. The appointed investigator will, at a minimum, attempt to interview the person who reported the incident, anyone likely to have direct knowledge of the incident and the resident, if interviewable. Any written statements that have been submitted will be reviewed, along with any pertinent medical records or other documents .

Based on interview and record review, the facility failed to provide timely incontinence care to 2 (R1 and R4) of 3 residents reviewed for Activities of Daily Living (ADL) care in the sample of 6. Findings include: R1's Face Sheet documented an initial admitted [DATE] with diagnoses that included malignant neoplasm of prostate, unsteadiness of feet, lack of coordination, abnormalities of gait and mobility, adult failure to thrive, cerebrovascular disease. R1's 8/6/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 12, indicating R1 had moderate cognitive impairment. R1's Order Summary Sheet printed 8/26/24 documented a 7/16/24 order admit to (Hospice Company) for end of life. On 8/23/24 at 10:59 AM, V4 (Hospice Registered Nurse/RN) stated that on one occasion, she had found R1's urinary catheter to be leaking. V4 said R1's bed was saturated with urine, with a brown ring around it. V4 said R1 had to be wet for a long time to form a brown ring. On 8/28/24 at 2:23 PM, V17 (Hospice Certified Nursing Assistant/CNA) said on one occasion, she had found R1 lying in bed soiled with dried feces and brown rings on the incontinence pads. V17 said she showed this to a (facility) nurse and told them this was unacceptable. V17 said she had spoken with V19 (Certified Nursing Assistant/ CNA) and was told V19 had not been in to care for R1 in a long time. V17 said on another occasion R1 was found lying in bed with R1's pants soiled with dried feces on them around his ankles. V17 said she had told V2 (Director of Nursing/DON) and V3 (Assistant Director of Nursing/ADON) this was unacceptable. V17 said she felt like the facility was not taking care of R1 and hospice was making extra visits to make sure R1 was getting cared for. On 8/23/24 at 12:30 PM, V8 (CNA) said the facility was short staffed regularly. V8 said when the facility is short staffed it was hard to get all the tasks completed. R1's Hospice Visit Note dated 8/12/24 documented in part .SN (Skilled Nurse) assessed pt (patient/R1) bed as it was soaked in urine SN found a CNA and had her obtained new set of sheets, upon further looking SN noted seen sediment into urine, slime mucous attached to in between pt legs with catheter leaking . R1's Hospice Visit Note dated 8/16/24 documented in part . Upon arrival, pt. (R1) was lying in bed, resting, he was up to getting a bath .noted that his pants were still on, with a soiled dry BM (Bowel Movement), noted that the area on scrotum was red as well as the area on his left upper buttocks .did talk to (V2) . and (V3), at facility about pt's (R1) condition . 2. R4's Face Sheet documented an admitted [DATE] with diagnoses that included cognitive communication deficit, schizoaffective disorder, dementia, lack of coordination. R4's MDS dated [DATE] documented a BIMS score of 2, indicating R4 was severely cognitively impaired. On 8/28/24 at 1:08 PM, V18 (CNA) said that on 8/16/24 when she arrived in the facility at 6:00 AM, R4 was found to be sitting in a recliner in the dining room. V18 said the recliner and R4's clothing was soaked in urine. V18 said R4's shirt was white and had brown lines of dried urine due to no one assisting R4 with incontinence care for a long time. V18 said she felt like this was possibly neglect and had reported it to the nurse working on 8/16/24. V18 said she could not recall who the nurse was she reported the incident to. V18 said she thought the nurse would report V18's concerns for neglect to management. V18 said she was aware that R4 can be combative but that was no reason to neglect someone. On 8/29/24 at 8:40 AM, V20 (CNA) said that on 8/16/24 when she arrived at work at 6:00 AM she found R4 to be sitting in the dining room in a recliner soaked in urine from mid-back to mid-thigh. V20 said R4 had a brown ring of dried urine on both her shirt and pants. V20 said she reported the incident to the nurse. V20 said later that day on 8/16/24 at approximately 4:30 PM, V3 (ADON) had given V20 an abuse questionnaire and V20 had reported the incident to V3. V20 said after reporting the incident to V3, V3 told V20 that was a hygiene problem, not abuse. V20 said she told V3 the incident was abuse because she felt R4 had been neglected. V20 said V3 did not say anything else and walked away. V20 said the night shift of 8/15/24 to 8/16/24 was staffed as usual with 1 licensed nurse and 2 CNA's. V20 said on multiple occasions she has arrived at work and been told by V21 (CNA) that some residents were not up or had not been assisted with incontinence care because V21 says she is too old to do it. V20 said she has told V21 if V21 is too old to complete her job duties, V21 needs to find a different job that V21 can do. On 8/29/24 at 11:16 AM, V3 (ADON) said she expected all residents to be assisted with incontinence care in a timely fashion.

Based on observation, interview, and record review the facility failed to supervise a known elopement risk resident and complete wander guard tests to ensure a wander guard was working for 1 of 5 residents (R1) reviewed for supervision in a sample of 5. This failure resulted in R1 eloping from the facility, falling down three steps onto asphalt in R1's wheelchair, and sustaining a laceration to the head requiring sutures. The Immediate Jeopardy began on 6/18/24 at approximately 2:00 AM when R1 was unable to be located by facility staff and was found to have eloped from the facility and had fallen down three steps in R1's wheelchair. V1 (Administrator), V7 (Regional Clinical Director), and V8 (Vice President of Operations) were notified of the Immediate Jeopardy on 7/31/24 at 2:40 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed, and the deficient practice corrected, on 6/20/24, prior to the start of the survey and was therefore past noncompliance. Findings include: 1. R1's face sheet documented an admitted [DATE] with diagnoses including: dementia, hypertension, atherosclerotic heart disease, type 2 diabetes mellitus, hyperlipidemia, presence of cardiac pacemaker. R1's 7/8/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. R1's care plan documented an initiated 8/30/23 focus area documenting in part . I am an elopement risk/ wanderer due to exit seeking, Resident wanders aimlessly . and an initiated 7/6/21 focus area documenting in part . I am at risk for fall/ injury (related to) wandering and poor safety awareness . R1's Order Summary Report documented an 8/6/23 order for Wanderguard (elopement alert device) check function on dayshift every Sunday. On 7/26/24 at 1:04 PM, V5 (Certified Nursing Assistant/ CNA) said she was caring for R1 during the night of 6/17/24 to 6/18/24. V5 said the facility was short staffed on the night of 6/17/24 to 6/18/24 and V5 and V4 (Licensed Practical Nurse/ LPN) were the only two staff working on R1's unit. V5 said R1 had been in R1's wheelchair ambulating around the facility. V5 said V6 (CNA) arrived at the facility at 2:00 AM. V5 said she was giving V6 report when V6 asked where R1 was in the facility. V5 said after looking around V4, V5, and V6 started a facility wide search. V5 said at approximately 2:36 AM, R1 was found lying in the parking lot in a pool of blood with R1's wheelchair on top of R1. V5 said R1 had fallen down three concrete steps in R1's wheelchair. V5 said the doors leading to the loading dock, where R1 fell , were usually locked but the locking mechanism was not working. V5 said there was no wanderguard alarm sounding and there was no other alarm on the loading dock doors. V5 said prior to the 6/18/24 incident R1 had exit seeking behaviors but R1 had never managed to get out of the facility. On 7/30/24 at 9:11 AM, V4 (LPN) said she was the nurse caring for R1 on the night shift from 6/17/24 to 6/18/24. V4 said she was sitting at the nurse's station charting at approximately 2:30 AM when V5 (CNA) and V6 (CNA) alerted her R1 was missing. V4 said she assisted V5 and V6 with a facility wide search for R1. V4 said at approximately 2:36 AM, V4 was called to the loading dock doors by V5 and found R1 to have fallen down three concrete steps in her wheelchair and was lying in a pool of blood with R1's wheelchair on top of R1. V5 said she could not recall if R1 was lying on R1's back or side but R1's head was busted and bleeding quite a bit. V5 said she immediately called Emergency Medical Services (EMS) to transfer R1 to the hospital for further evaluation. V5 said she was not sure if R1 had a wanderguard on 6/18/24 at the time of this incident but was sure the wanderguard alarm was not sounding. V5 said the door to the loading dock had malfunctioned at the time of the incident on 6/18/24. V5 said when exiting the building a button was pushed to unlock the door and a code had to be entered to unlock the door from the outside but during this incident she and other staff had went out of and back in the door without having to push any buttons or enter any codes. On 7/30/24 at 11:09 AM, V7 (Maintenance Director) said he hadn't received any work orders pertaining to the loading dock doors locking mechanism or the wanderguard system not functioning at the loading dock doors. V7 said prior to R1's 6/18/24 incident the facility did not have any logs of checking the wanderguard alarming system at points of exit in the facility. V7 said he did not have any logs of checking door locking mechanisms and was unsure how often the locking mechanisms were to be checked. V7 said he was not sure who was responsible for checking door locking mechanisms. On 7/30/24 at 11:25 AM, V7 measured the height from the top of the loading dock platform to the asphalt pavement, where R1 fell , to be 24.5 inches. On 7/31/24 at 2:29 PM, V9 (Physician) said he was familiar with R1. V9 said prior to R1 being moved to the locked unit in the facility it was possible R1 was an elopement risk. V9 said he expected the facility to follow their policy for checking wanderguards. V9 said he expected the facility would have a system in place to keep residents from eloping and the facility should follow their protocol. R1's 6/18/24 hospital record documented in part . EMS states: (R1) eloped out the back door of (skilled nursing facility) and fell down 3 stairs causing trauma to the right side of (R1's) head Significant swelling noted to (right) eye. Multiple abrasions to right side of face with one deep laceration/ avulsion to the right forehead that is still bleeding a light amount. Moderate amount of clotted blood present in hair/ on wounds. Unknown if (R1) lost consciousness or not. According to EMS (R1's) cognition is at baseline . wound repair of 6 (centimeter) . subcutaneous laceration to face. Irregularly shaped Skin closed with 16 4-0 Ethilon using simple sutures . R1's 6/18/24 reportable incident investigation folder contained 3 written statements by V4 (LPN), V5 (CNA), and V6 (CNA). V5's (CNA) 6/18/24 statement documented in part .Around midnight (R1) was sitting on the side of the bed. I know she is a fall risk, so I asked her if she wanted to get up and she did. I placed her in her (wheelchair). She was moving about and I redirected her from other hallway and brought her back to sit by the birdcage. I last seen her sitting at the birdcage. I gave report and went and answered a call light. (V6) asked where (R1) was. We did not immediately see her so we began to search the building. I heard a voice out the dock doors as I was down that way looking. (V6) and I opened the door and (R1) was on the parking lot face down with her (wheelchair) on top of her. We called for help. Nurse came. EMS came. That was about 2:36 AM when we seen the resident . V6's (CNA) 6/18/24 statement documented in part . I arrived to work at 2 AM. I received report from (V5). I then heard a call light going off. So (V5) and I went to assist that resident. As I was walking back up the hall I looked toward (R1's) room and noticed she was not in there. (V5) and I immediately began to search the building for her. After 2 passes we informed the nurse (V4) that there was a missing resident. (V5) was down the back hall near the dining room and she thought she faintly could hear something outside. We pushed the door open and seen (R1) down the 3 stairs onto the parking lot in a pool of blood. I opened the door back up and got the nurse to come. (R1) was face down with her (wheelchair) on top of her . Did the door open when you pushed the buttons to get in and out? No all I had to do was open door several times. No code needed . V4's (LPN) 6/18/24 statement documented in part .at about 2:30 AM I was at the computer charting. The 2 CNA's informed me that they could not find (R1) after looking for her in the building. I immediately got up to help with the search. I went down the halls toward therapy (department) and started to walk back up toward the nurse station when I noticed the CNA down the other hall by the dining room waving her arms for me to come. I seen resident lying on stomach and noticed a head injury. I immediately assessed resident. Splinted head (and) neck with a blanket to limit movement and called 911. EMS transported resident next door to hospital . The facility's revised 9/13/19 Elopement Device policy documented in part . Purpose: To establish procedures for ensuring personal elopement devices are used in accordance with identified risk, physician orders and to ensure the security system is inspected to identify malfunctions should they occur . Procedure: 1. Elopement alert devices will be used as an interventional tool to prevent resident elopements . 3. The elopement alert exit door device will be inspected for proper working and documented by nursing . 5. The ankle or bracelet device will be inspected by nursing personnel at least once each day by: a. Inspecting the location of the device on the arm or leg. b. Placing the transmitter tester near the anklet or bracelet to test the battery for proper working order. 6. In the event the test reveals a malfunctioning personal elopement device, the device will be removed and replaced . The facility's undated Preventive Maintenance and Inspection policy documented in part . In order to provide a safe environment for residents, employees, and visitors, a preventative maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition . The following are recommended guidelines and may be revised or adjusted as indicated by the individual needs of the facility or according to facility policy . Inspections checklists are developed for at least . the building . exterior inspection will be conducted and documented weekly . interior inspections will be conducted and documented weekly . building inspection includes at a minimum . electronic doors . alarms are calendared on the routine inspection checklists on a weekly basis. Alarms are inspected to verify that they are in working order and are calendared for inspection in accordance with manufacturer's specifications . The Immediate Jeopardy that began on 6/18/24 was removed prior to the survey date on 6/20/24 when the facility took the following actions to remove the immediacy and correct the deficient practice as confirmed through observation, interview, and record review: 1) Immediate actions taken for those residents identified: 1. R1 was moved to the locked Dementia unit (Completed by Interdisciplinary Team (IDT) 06/18/2024). 2. R1 was immediately placed on 15-minute checks until New Wander guard device implementation (Completed by Nursing Staff and IDT Completed 06/18/2024). 3. R1 Elopement assessment and care plan were reviewed and updated accordingly. (Minimum Data Set/ Care Plan (MDS/CP) Coordinator 06/20/2024). 4. R1 's Fall Assessment and Care Plan has been reviewed and updated accordingly. (Director of Nursing (DON), Assistant Director of Nursing (ADON) Completed 06/20/2024). 2) Measures put into place/ System changes: 1. The Facility's Code Pink Policy has been reviewed by the IDT with no changes needed at this time, (Completed IDT 06/19/2024). 2. The Facility's Elopement Policy has been reviewed by the IDT with no changes needed at this time. (Completed IDT 06/19/2024). 3. All Staff have been educated on the Facility's Elopement Policy (Completed by Administrator (ADM) 6/19//2024). 4. All Staff have been educated on the Facility's Code Pink Guidelines (Completed by ADON 6/19/2024). 5. All Residents at Risk for Elopement have been placed on 15 minute checks until New Wander guard devices implemented. (Completed by Nursing Staff and IDT 06/18/2024) 6. Affected Door was secured with 1:1 until new alarm was placed. (Completed by Nursing & Activities 06/19/2024). 7. New Wander guard devices implemented as per assessment (Completed by IDT 06/19/2024). 8. All Resident's Elopement Assessments have been reviewed and updated accordingly. (Completed by Social Services Director (SSD), MDS/CP Coordinator, DON, ADON 06/19/2024). 9. All Residents at Risk Plan of Care's has been reviewed and updated accordingly based off the individual Elopement Assessment. (Completed MDS Care Plan Coordinator, SSD, DON, ADON 6/20/2024). 10. An Elopement Drill has been completed on all shifts (ADM 06/19/2024). 11. Functionality of all Door Alarms have been checked. (Completed by ADM, Maintenance Director 06/18/2024). 12. New Door Alarms placed as needed on Exit Doors (Completed by Maintenance 06/19/2024). 13. Maintenance has been educated on the Preventative Maintenance and Inspections Policy. (Completed by ADM 06/20/2024). 14. A QAPI Meeting was held with the Medical Director to discuss R1's incident including interventions and Plan of Care. (Completed 06/19/2024 ADM). 3) How the corrective actions will be monitored: 1. ADM/Maintenance will complete random 5 observations a week of the door alarms to ensure they are functioning properly for 12 weeks. 2. Maintenance will continue to complete weekly checks of the door alarms to ensure they are functioning properly. 3. ADM/Designee will complete 5 interviews a week with Residents at risk for Elopement to ensure their well-being for 12 weeks. 4. ADM/Designee will complete Elopement Drills bi-weekly on alternating shifts for 12 weeks. 5. DON/Designee will complete 5 Residents Medical Records a week for 12 weeks to ensure appropriate Fall Interventions have been implemented. The results of these interviews will be reviewed in Quality Assurance Meeting monthly x6 months or until an average of 100% compliance or greater is achieved x3 consecutive months. The QA Committee will identify any trends or patterns and make recommendations to revise the plan of correction as indicated.

Based on interview and record review the facility failed to provide enough staff to supervise residents ensuring residents do not elope for 1 (R1) of 5 residents reviewed for supervision out of a sample of 5. Findings include: 1. R1's face sheet documented an admitted [DATE] with diagnoses including: dementia, hypertension, atherosclerotic heart disease, type 2 diabetes mellitus, hyperlipidemia, presence of cardiac pacemaker. R1's 7/8/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. R1's care plan documented an initiated 8/30/23 focus area documenting in part . I am an elopement risk/ wanderer due to exit seeking, Resident wanders aimlessly . and an initiated 7/6/21 focus area documenting in part . I am at risk for fall/ injury (related to) wandering and poor safety awareness . R1's Order Summary Report documented an 8/6/23 order for Wanderguard (elopement alert device) check function on dayshift every Sunday. On 7/29/24 at 1:04 PM, V5 (Certified Nursing Assistant/ CNA) said she was caring for R1 on the night shift from 6/17/24 to 6/18/24 when R1 eloped from the facility and was injured. V5 said she usually does not work night shift but had agreed due to the facility being short staffed. V5 said on 6/18/24 from 12:00 AM to 2:00 AM V5 was the only CNA working on the nonlocked unit with V4 (Licensed Practical Nurse/ LPN). V5 said when there is only one nurse and one CNA working the nonlocked unit they could not supervise all the residents. V5 said due to V5 not usually working night shift she was unsure how often the night shift was short staffed. On 7/30/24 at 12:48 PM, V3 (Assistant Director of Nursing/ ADON) said she was working in the facility on 6/18/24 until almost 2:00 AM. V3 said while she was working on 6/18/24, she was in her office completing paperwork. V3 said the night shift should be staffed with 4 CNAs and 2 Nurses, 1 nurse and 2 CNAs for the locked unit and 1 nurse and 2 CNA for the nonlocked unit. On 7/30/24 at 12:21 PM, V2 (Director of Nursing/ DON) said night shift should be staffed with 4 to 5 CNA and 2 Nurses. V2 said to meet all the resident needs during the night shift would require 4 to 5 CNA and 2 Nurses. V2 said she was not sure how often the night shift is short staffed. On 8/1/24 at 2:35 PM, V1 (Administrator) verified V4 (LPN) and V5 (CNA) were the only two staff working on the nonlocked unit on 6/18/24 from 12:00 AM to 2:00 AM. V1 said V12 (CNA), V13 (CNA), and V11 (LPN) were working on the locked unit on the night shift of 6/17/24 to 6/18/24. The facility's 6/18/24 Daily Census documented V4 (LPN) and V5 (CNA) were responsible for supervising and providing care to 41 residents. The facility's Semi-Monthly Time Schedule from 6/9/24 through 6/22/24 documented V4 (LPN) and V11 (Registered Nurse/ RN) were working on 6/17/24 to 6/18/24 from 6:00 PM to 6:00 AM and that the facility only had 5 full time night CNA's. V5's (CNA) Copy of Time Card Report documented V5 clocked in on 6/17/24 at 5:51 PM and clocked out on 6/18/24 at 5:55 AM. V14's (CNA) Copy of Time Card Report documented V14 clocked in on 6/17/24 at 5:54 PM and clocked out on 6/18/24 at 12:02 AM. V6's (CNA) Copy of Time Card Report documented V6 clocked in on 6/18/24 at 2:03 AM, clocked out on 6/18/24 at 10:15 AM, clocked in on 6/18/24 at 10:44 AM, and clocked out on 6/18/24 at 2:03 PM. V12's (CNA) Copy of Time Card Report documented V12 clocked in on 6/17/24 at 6:02 PM and clocked out on 6/18/24 at 6:14 AM. V13's (CNA) Copy of Time Card Report documented V13 clocked in on 6/17/24 at 6:02 PM and clocked out on 6/18/24 at 6:20 AM. On 8/2/24 at 9:40 AM, V8 (Vice President of Operations) said the facility did not have a staffing policy. V8 said the facility is to follow the regulations.

Based on interview and record review, the facility failed to provide enough staff to meet residents' needs and provide timely assistance with care. This failure has the potential to affect all 59 residents currently residing at the facility. Findings Include: The facility Midnight Census Report dated 6/16/24 documents 59 residents currently reside at the facility. 1. R1's Transfer/Discharge Report dated 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diarrhea, hypertension, clostridium difficile, flaccid neuropathic bladder, and morbid obesity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toilet transfers, is occasionally incontinent of urine, and frequently incontinent of bowel. R1's current Care Plan does not document a focus area for incontinence care/toileting. On 6/17/24 at 2:52 PM, V4 (Care Plan/MDS Coordinator) stated he just missed it when he did R1's care plan. On 6/17/24 at 10:50 AM, R1 stated his call light hadn't been working so they gave him a different kind of call light that beeps at the nurse's station. R1 stated if the button gets turned off on his call light, he just calls the nurse's station. R1 stated sometimes at night the call light doesn't get answered and they don't answer the phone. R1 stated the time it takes them to answer, varies. R1 stated when they are short staffed it can take forever. R1 stated he has told the CNA's and the nurse's but hadn't talked to administration about it. R1 stated he was stuck on the bed pan for over two hours waiting for them to assist him recently. R1 stated he called, and it rang for over 100 minutes per his phone screen. R1 stated then he called the local police station to see if they could get in touch with anyone at the facility. R1 stated after the third call to the police they were able to get in touch with someone from administration. R1 stated he has had bowel surgery and can't say it would make a difference if they got to him quicker after the incontinence episodes, but he has laid for up to two hours. On 6/17/24 at 2:57 PM, V16 (Certified Nurse Assistant/CNA) exited R1's room with dirty linens, V16 (CNA) and V18 (CNA) returned to R1's room to provide incontinence care. R1 was assisted to roll to his side. R1's buttocks were red and excoriated. V18 stated when they removed his bed pan, they took the bed pad that was under him, and it had a brown ring of urine on it. This indicates R1 had not been checked or changed for a long period of time. R1 stated no one had been in his room to provide care since this surveyor had been in there at 10:50 AM. This indicates no incontinence care was provided from 10:50 AM until 2:57 PM. 2. R2's Transfer/Discharge Report with a print date of 6/17/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, morbid obesity, acute kidney failure, cerebral palsy, chronic kidney disease, hypertension, and scoliosis. R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toileting and is always incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Disease Process (CP/cerebral palsy), Limited Mobility. This Focus area includes the intervention, Toilet hygiene- My usual performance is dependent. On 6/17/24 at 11:04 AM, R2 stated it takes a little while for staff to answer his call light. R2 stated they need more help here; they don't have enough CNA's. R2 stated sometimes it takes longer than 20 minutes. When asked if he had ever had to lay in urine/feces due to it taking loner, R2 stated not because he had to wait but just because he urinates a lot. 3. R5's Transfer/Discharge Report with a print date of 6/17/24 documents R5 was admitted to the facility on [DATE] with diagnoses that include heart disease, chronic fatigue, hypertension, heart failure, unsteadiness on feet, and diabetes. R5's MDS dated [DATE] documents a BIMS score of 15, which indicates R5 is cognitively intact. This same MDS documents R5 is always incontinent of bowel and bladder. R5's current Care Plan does not include a Focus area for incontinence care. On 6/17/24 at 9:59 AM, R5 stated it can take more than 30 minutes for the staff to answer the call lights. R5 stated it happens at all times of the day because they don't have enough staff. R5 stated they try but they just don't have enough staff. 4. R6's Transfer/Discharge Report with a print date of 6/17/24 documents R6 was admitted to the facility on [DATE] with diagnoses that include abnormal posture, chronic kidney disease, mild intellectual disability, diabetes, and schizoaffective disorder. R6's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assistance with toileting and is occasionally incontinent of bladder and frequently incontinent of bowel. R6's current Care Plan documents a Focus area of, I have an ADL self-care performance deficit r/t Mild intellectual disabilities and lack of coordination. This Focus area includes the intervention, Toilet Use: (R6) requires extensive assistance by 2 staff with toileting at all times. On 6/16/24 at 11:08 PM, V5 (Registered Nurse/RN) stated he works night shift 6 PM to 6 AM. V5 stated the normal staffing each night shift, is two nurses and four certified nursing assistants (CNA's). V5 stated two CNAs on each side is the minimum staffing to be able to meet the resident needs. V5 stated he had worked with just three CNA's but not for 3-4 weeks. V5 stated all the care was provided but it was slow. On 6/17/24 at 12:11 PM, V6 (CNA) stated she works from 6 PM to 6 AM. V6 stated they have two CNA's on each side on night shift, a total of four CNA's per 12-hour shift. V6 stated there were times they only had three CNA's working and when that happened, she was able to provide the care needed but call lights weren't answered timely. On 6/17/24 at 12:14 AM, V7 (CNA) stated she normally works from 6 AM to 6 PM. V7 stated they have two CNA's on each side on that shift as well. V7 stated it isn't enough to meet the needs of the residents. V7 stated showers don't get done and call lights aren't answered timely. On 6/17/24 at 12:16 AM, V8 (Licensed Practical Nurse/LPN) stated she works 6 PM to 6 AM and the normal staffing is two nurses and two CNA's per side (total of four CNA's). V8 stated she has worked with less than that but not recently. V8 stated the 6 PM to 10 PM time frame is difficult with two CNA's. V8 stated they probably don't provide every two-hour incontinence care during that time frame. On 6/17/24 at 12:22 AM, V9 (CNA) stated two CNA's on the Alzheimer's unit is enough with the residents they currently have. V9 stated she has worked by herself on that unit, and she wasn't able to meet the needs of the residents. On 6/17/24 at 1:32 PM, V15 (CNA) stated she had worked with three CNA's on night shift (6 PM to 6 AM). When asked if she was able to do bed checks every two hours, V15 stated she thought they did them every three hours. On 6/17/24 at 1:45 PM, V16 (CNA) stated they were currently working with five trained CNA's and one trainee. V16 stated that isn't enough to meet the needs of the residents. V16 stated showers don't always get done. When asked if call lights were answered timely, V16 stated, Probably not. When asked if there was a negative impact related to working with less staff, V16 stated being short-staffed effects everything. When asked if incontinence care was provided timely, V16 stated when she is there, she gets it done. When asked if she had any residents complain they weren't provided timely incontinence care, V16 stated R1 and R6. When asked if she had ever seen anyone who appeared like they had been laying in urine/feces for a long period of time, V16 stated at shift change and identified R6 as one of the residents. On 6/17/24 at 1:54 PM, V17 (CNA) stated they have five CNA's and a trainee working. V17 stated two on the Alzheimer's unit is pretty good but two on the other units is a little rough. V17 stated they try to do the best they can. V17 stated it is sometimes hard to get showers and the little extra things done. The facility Daily Staffing Sheet dated 6/12/24 documents two CNA's worked from 6 PM to 8 PM and three CNA's from 8 PM to 6 AM. The untitled, handwritten, undated sheet provided to this surveyor documents V2 (Director of Nurses/DON) stayed at the facility until 9:45 PM and V3 (Assistant Director of Nurses/ADON) stayed at the facility until 9:30 PM. This leaves three CNA's with no administrative assistance from 9:45 AM until 6:00 AM. his facility Daily Staffing Sheet dated 6/13/24 documents three CNA's in the facility from 6 PM to 6 AM and four CNA's from 10:50 PM to 2:50 AM. The untitled, undated handwritten sheet with V2 and V3's extra hours documents V2 stayed at the facility until 6:00 PM, and V3 stayed until 8:00 PM. This leaves three CNA's with no administrative assistance from 8:00 PM until 10:50 PM, and from 2:50 AM until 6:00 AM. On 6/17/24 at 3:22 PM, V2 (DON) stated she has not had any complaints/concerns brought to her related to call lights being answered timely and/or incontinence care being provided timely. V2 stated they try to have five CNA's on day shift- two in the back (Alzheimer's unit) and three in the front. V2 stated that is enough staff to meet the needs of the residents. This surveyor reviewed the schedule with V2 and asked about the days there were only two or three CNA's on the schedule for night shift, V2 stated V3 (ADON) is the one who does the schedules so she would have to check with her. On 6/17/24 at 3:30 PM, after reviewing the CNA schedule with V3 (ADON), she stated she stays late on Friday nights and does rounds with the wound specialist, so she is at the facility on those nights to assist the CNA's. When asked if she stayed after midnight since there were only two or three CNA's working during that time frame, V3 stated she would have to get the times she and V2 worked for this surveyor. V3 stated she always writes her times down since she doesn't clock in/out. The untitled undated handwritten document that was provided documents V2 (DON) and V3 (ADON) stayed until 3:00 AM on 6/16/24. This same document notes V2 and V3 left the facility between 6:00 and 9:45 PM on 6/10, 6/11, 6/12, 6/13, and 6/14 and didn't stay late on 6/15/24. On 6/17/24 at 3:59 PM, V1 (Administrator) stated he hadn't had any concerns related to incontinence care being provided timely, call lights answered timely, and/or residents left in feces/urine for long periods of time. V1 stated he would say three CNA's wouldn't be able to do it, but they also have administration staff stay or come in and assist.

Based on observation, interview, and record review the facility failed to ensure incontinence care was provided timely for three residents (R1, R2, and R6) of 9 residents reviewed for incontinence care in the sample of 9. Findings Include: 1.R1's Transfer/Discharge Report with a print date of 6/17/24 documents R1 was admitted to the facility on [DATE] with diagnoses that include diarrhea, hypertension, clostridium difficile, flaccid neuropathic bladder, and morbid obesity. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a BIMS (Brief Interview for Mental Status) score of 14, which indicates R1 is cognitively intact. This same MDS documents R1 is dependent on staff for toilet transfers, is occasionally incontinent of urine, and frequently incontinent of bowel. R1's current Care Plan does not document a focus area for incontinence care/toileting. On 6/17/24 at 2:52 PM, V4 (Care Plan/MDS Coordinator) stated he just missed it when he did R1's care plan. On 6/17/24 at 10:50 AM, R1 stated that recently, he was stuck on the bed pan for over two hours waiting for them to assist him. R1 stated he called, and it rang for over 100 minutes per his phone screen. R1 stated then he called the local police station to see if they could get in touch with anyone at the facility. R1 stated after the third call to the police they were able to get in touch with someone from administration. R1 stated he has had bowel surgery and can't say that it would make a difference if they got to him quicker after the incontinence episodes, but he has laid for up to two hours. On 6/17/24 at 2:57 PM, V16 (Certified Nurse Assistant/CNA) exited R1's room with dirty linens, V16 (CNA) and V18 (CNA) returned to R1's room to provide incontinence care. R1 was assisted to roll to his side. R1's buttocks were red and excoriated. V18 stated when they removed his bed pan, they took the bed pad that was under him, and it had a brown ring of urine on it. This indicates R1 had not been checked or changed for a long period of time. R1 stated no one had been in his room to provide care since this surveyor had been in there at 10:50 AM. This indicates no incontinence care was provided from 10:50 AM until 2:57 PM. 2. R2's Transfer/Discharge Report with a print date of 6/17/24 documents R2 was admitted to the facility on [DATE] with diagnoses that include heart failure, morbid obesity, acute kidney failure, cerebral palsy, chronic kidney disease, hypertension, and scoliosis. R2's MDS dated [DATE] documents a BIMS score of 14, which indicates R2 is cognitively intact. This same MDS documents R2 is dependent on staff for toileting and is always incontinent of bowel and bladder. R2's current Care Plan documents a Focus area of I have an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Disease Process (CP/cerebral palsy), Limited Mobility. This Focus area includes the intervention, Toilet hygiene- My usual performance is dependent. On 6/17/24 at 11:04 AM, R2 stated it takes a little while for staff to answer his call light. R2 stated they need more help here; they don't have enough CNA's. R2 stated sometimes it takes longer than 20 minutes. When asked if he had ever had to lay in urine/feces due to it taking loner, R2 stated not because he had to wait but just because he urinates a lot. 3. R6's Transfer/Discharge Report with a print date of 6/17/24 documents R6 was admitted to the facility on [DATE] with diagnoses that include abnormal posture, chronic kidney disease, mild intellectual disability, diabetes, and schizoaffective disorder. R6's MDS dated [DATE] documents a BIMS score of 12, which indicates a moderate cognitive deficit. This same MDS documents R6 requires substantial/maximal assistance with toileting and is occasionally incontinent of bladder and frequently incontinent of bowel. R6's current Care Plan documents a Focus area of, I have an ADL self-care performance deficit r/t Mild intellectual disabilities and lack of coordination. This Focus area includes the intervention, Toilet Use: (R6) requires extensive assistance by 2 staff with toileting at all times. On 6/17/24 at 1:32 PM, V15 (CNA) stated she had worked with three CNA's on night shift (6 PM to 6 AM). When asked if she was able to do bed checks every two hours, V15 stated she thought they did them every three hours. On 6/17/24 at 12:16 AM, V8 (Licensed Practical Nurse/LPN) stated she works 6 PM to 6 AM and the normal staffing is two nurses and two CNA's per side (total of four CNA's). V8 stated she has worked with less than that but not recently. V8 stated the 6 PM to 10 PM time frame is difficult with two CNA's on one side. V8 stated they probably don't provide every two-hour incontinence care during that time frame. On 6/16/24 at 11:08 PM, V5 (Registered Nurse/RN) stated he works night shift 6 PM to 6 AM. V5 stated the normal staffing each night shift, is two nurses and four certified nursing assistants (CNA's). V5 stated two CNAs on each side is the minimum staffing to be able to meet the resident needs. V5 stated he had worked with just three CNA's but not for 3-4 weeks. V5 stated all the care was provided but it was slow. On 6/17/24 at 1:45 PM, V16 (CNA) stated they were currently working with five trained CNA's and one trainee. V16 stated that isn't enough to meet the needs of the residents. V16 stated showers don't always get done. When asked if call lights were answered timely, V16 stated, Probably not. When asked if there was a negative impact related to working with less staff, V16 stated being short-staffed effects everything. When asked if incontinence care was provided timely, V16 stated when she is there, she gets it done. When asked if she had any residents complain they weren't provided timely incontinence care, V16 stated R1 and R6. When asked if she had ever seen anyone who appeared like they had been laying in urine/feces for a long period of time, V16 stated at shift change and identified R6 as one of the residents. On 6/20/24 at 12:31 PM, V2 (Director of Nurses/DON) stated she would expect bed checks to be done every two hours and incontinence care provided as needed. On 6/17/24 at 3:59 PM, V1 (Administrator) stated he hadn't had any concerns related to incontinence care being provided timely, call lights answered timely, and/or residents left in feces/urine for long periods of time. V1 stated he would say three CNA's wouldn't be able to do it, but they also have administration staff stay or come in and assist. The facility Incontinence Care policy dated 4/20/21 documents, Purpose: to prevent excoriation and skin breakdown, discomfort and maintain dignity. Guidelines: Incontinent resident will be checked periodically in accordance with the assessed incontinence episodes or approximately every two hours and provided perineal and genital care after each episode .

Based on observation, interview and record review, the facility failed to provide additional nourishment as ordered in the form of nutritional supplements and fortified foods for five (R50, R31, R36, R44, and R45) of 12 residents reviewed for nutrition in a sample of 38. This failure resulted in R50 experiencing a significant weight loss of 17.5% in 3 months, and R31 experiencing a significant weight loss of 6.68% in 1 month or 8.58% in 3 months. Findings Include: 1. R50's Transfer/Discharge report documents an admitted [DATE] with diagnoses including: Alcohol abuse with alcohol induced mood disorder, Alcohol Dependence with alcohol induced persisting dementia, Cognitive Communication Deficit, Unspecified Dementia, Wernicke's Encephalopathy, Chronic Obstructive Pulmonary Disease (COPD), and Mood Affective Disorder. R50's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 04, indicating severe cognitive impairment. R50's MDS section GG documents eating ability as: supervision or touching assistance - helper provides verbal cues and or touching/steading and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. R50's Order Summary Report documents orders including: general diet: Regular texture, regular consistency, fortified foods with meals, ice cream with lunch and supper with a start date of 01/26/24, no end date documented; and house nutrition supplement - three times a day in between meals with a start date of 05/16/24 and no end date listed. R50's Care Plan documents a Focus Area dated 03/05/24 documenting: R50 has a nutritional problem or potential nutritional problem regarding the diagnosis of Dementia, Wernicke's Encephalopathy, COPD, and Mood Affective Disorder. R50's care plan documents interventions of: Administer medications as ordered. Monitor/Document for side effects and effectiveness, Encourage PO (by mouth) intake of meals and snacks, Invite the resident to activities that promote additional intake, Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated, provide, serve diet as ordered. Monitor intake and record with meal, and RD (Registered Dietician) to evaluate and make diet change recommendations PRN (as needed), all interventions are dated 03/05/24. R50's Electronic Medical Record (EMR) documents weights as: 162.8 pounds (lbs.) on 01/26/2024, 161.4 lbs. on 02/07/2024, 161.0 lbs. on 3/18/2024, 139.5 lbs. on 4/9/2024, and 133.0 lbs. (pounds) on 5/15/2024. The weights documented indicate a 17.6 % weight loss in 3 months. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk non fat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. On 05/20/24 at 12:40 PM, R50 did not receive a nutritional house supplement, fortified potatoes or ice cream with his lunch tray. On 05/20/24 at 1:30 PM V16 (Dietary Manager) stated the nutritional supplements came in on the truck that morning and they are frozen, they will have to give them out at snack time. On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. On 05/20/24 at 2:40 PM, V28 (Activity Aide/Certified Nurse Aide/CNA) passed afternoon snacks and there were no nutritional house supplements on the snack cart. On this same date between 2:30 - 3:15 PM, R50 did not receive a nutritional house supplement or ice cream during snack time. On 05/21/24 at 12:40 PM, R50 did not receive a nutritional house supplement or ice cream with his lunch tray. On 05/21/24 at 2:30 PM, V28 (Activity Aide/Certified Nurse Aide) passed afternoon snacks and there were no nutritional house supplements observed on the snack cart. At 2:35 PM, R50 did not receive a nutritional house supplement or ice cream during snack time. On 05/22/24 at 1:00 PM, R50 did not receive a nutritional house supplement or ice cream with his lunch tray. On 05/22/24 at 1:25 PM, R50 had eaten all of the food on his plate and R50 started reaching out for other residents' food. V28 (Activity Aide/CNA) was assisting R28 with her lunch. V28 attempted redirecting R50 and telling him it was not his food. After several attempts at redirecting and R50 starting to get aggressive, V28 asked R50 if he was still hungry and R50 answered yes. V28 went to the snack room and placed some cheese puffs onto a small plate and brought them back for R50. On 05/22/24 at 2:35 PM, V28 (Activity Aide/CNA) passed afternoon snacks and there were no nutritional house supplements on the snack cart. R50 did not receive a nutritional house supplement or ice cream during snack time. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated she was aware of R50's weight loss between March and April and on 04/26/24 she noted she had requested a re-weigh for R50. V29 stated, in her note from 05/16/24, May's weight was consistent with April's weight and she ordered the supplements for R50. 2. R31's Face Sheet documents an admitted [DATE] with diagnoses in part of Heart Failure, Type 2 Diabetes Mellitus, Malignant Neoplasm of Prostate, Hypertension, and Hyperlipidemia. R31's MDS dated [DATE] documents in Section C a BIMS score of 12, which indicates moderate cognitive impairment. Section GG documents that R31 requires set-up and clean-up assistance with eating. R31's Care Plan dated 05/02/24 documents R31 has an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) a diagnosis of CHF (Congestive Heart Failure), DM (Diabetes Mellitus), AFIB (Atrial Fibrillation), MDD (Major Depression Disorder) and HTN (Hypertension) with interventions in part of Eating- My usual performance is set-up. Risk for Depression/Decreased appetite. R31 able to consume regular consistency food with interventions of Monitor and record intake q (Every) shift, monitor for sign/symptoms of aspiration, monitor weight as indicated monthly and PRN (as needed), position for eating and drinking safely, provide diet as ordered, regular diet with super cereal, nutritional shakes with meals as desired, and refer to ST (Speech Therapy) R31's Weight summary in part documents the following weights: 12/21/23 - 200 lbs., 01/17/24 -197.5 lbs., 02/17/24 - 197 lbs., 3/18/24 - 196 lbs., 4/18/24 - 193 lbs., and 05/20/24 180.1 lbs. R31 has had a 6.68% weight loss in 1 month from April to May and 8.58% weight loss in 3 months from February to May. R31's Physician Order documents general diet, regular texture, thin consistency, house nutritional supplement with meals ordered 01/04/24. R31's Nutritional Progress note dated 04/28/24 documents RD (Registered Dietitian) consult for -5.0% change (Comparison Weight 03/30/2024, 195.4 Lbs., -5.1%, -9.9 Lbs. April. Wt. (weight) 186# BMI (Body Mass Index) 34.2 overweight per standards. On 05/20/24 at 11:30 AM, R31 was sitting in the Dining Room in his wheelchair falling asleep at the lunch table. At 12:30 PM, R31 was still sleeping at the lunch table, still waiting on a lunch tray. At 12:33 PM, R31 was taken out of the dining room and placed in the hallway with no tray served to him. At 1:52 PM, R31 was placed in his recliner in his room. At 1:58 PM, V7 (Certified Nurse Assistant/CNA) was asked if R31 had received a lunch tray yet. V7 stated that she was unsure if R31 had eaten yet. At 1:59 PM, V7 looked on the hall tray cart and was unable to find a tray with R31's kitchen card on it. At 2:00 PM, V7 went to the kitchen and asked kitchen staff about R31's lunch tray. V7 stated that the kitchen staff told her they had lost R31's lunch ticket and that they did finally find it. At 2:05 PM, V7 went to R31's room to ask R31 what he would like to eat and R31 stated he would like some soup and crackers with a drink. At 2:15 PM, R31 was served a lunch tray by V7. R31's Order Summary dated 05/21/24 documents send to local hospital emergency room r/t (related to) decline in condition no appetite and lethargy. R31's Progress note dated 05/21/24 at 5:02 PM documents in part, Patient (R31) is going to be admitted to local hospital with dx (diagnosis) of hyponatremia, hypercalcemia and AKI (Acute Kidney Infection). On 05/28/24 at 11:00 AM, V16 (Dietary Manager) stated that she found out last week that the program she uses to print meal tickets wasn't printing off all the meal tickets. V16 said some of the residents' meal tickets were missing. V16 stated that this is the main way they serve residents their meals, by the meal tickets, so if one was missing, they didn't know to serve that resident. V16 said that when she found out the program wasn't printing all of the resident meal tickets, she started to double check to make sure they were all there. V16 said that she must go in and manually print just one or two resident tickets sometimes on her own if they didn't print up with all the other residents' meal tickets. V16 stated sometimes residents can also get missed during mealtimes if a meal ticket gets stuck together. V16 said that she is working on trying to get a better system going so they don't miss any meal tickets or residents' trays. V16 said she wasn't aware of residents missing nutritional supplements last week. V16 said they were very short last week and that could be the reason many of the supplements were forgotten. V16 said that usually the supplements, such as the nutritional shakes and nutritional supplement ice cream comes out of the kitchen served on the tray and the person serving should double check the ticket to make sure that it is correct. V16 said they didn't have a lot of staff last week, she even had to work in the kitchen on 05/23/24 because she was short staffed. V16 stated that she knows that R31 is on a nutritional supplement and doesn't know why he didn't get the supplement or why they forgot his tray. On 05/28/24 at 11:54 AM, V29 (Registered Dietitian) stated she was not aware that R31 was not served a tray on 05/20/24 until staff had to ask for one. V29 stated that she was not aware of V16 having trouble with not being able to print all the residents' meal tickets out and that some of the residents' tickets would be missing and they may not be served a tray. V29 stated R31 was to receive a nutritional supplement with meals related to him having a weight loss. V29 said R31 would take the supplement sometimes, but other times he would refuse them. V29 said R31 was on comfort care and that they offer R31 supplements as he desires. V29 said she knew R31 has recently had a 5% weight loss in a month. V29 stated she was going to work with the kitchen to help straighten out some of the problems that they had going on with residents not receiving all the supplements that are ordered for them and making sure all residents get their meals. 3. R36's Transfer/Discharge Report documents an admitted [DATE] with diagnoses including: Schizoaffective Disorder, Dementia, and Major Depressive Disorder. R36's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) was performed due to resident is rarely/never understood. Section GG documented for R36's eating ability, substantial/maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) is needed. R36's Order summary report documents and order dated 03/30/2022 with no end date listed for: General diet - mechanical soft texture. Thin consistency, plate guard with pureed vegetable, extra gravy, fortified foods and ice cream with afternoon and evening meals. Another order dated 01/17/23 with no end date listed documents an order for health shakes two times a day in between meals at 7:00 AM and 3:00 PM. R36's Care Plan documents a Focus Area that R36 is unable to consume regular consistency foods and requires a mechanically altered diet with fruit and vegetables pureed. R36 has cognitive impairment and difficulty swallowing/chewing with a date of 04/25/21. The interventions documented are: monitor and record intake every shift, monitor for signs/symptoms of aspiration with a date of 09/07/2020, monitor weight as indicated monthly and PRN (as needed) with a date of 09/07/2020, position for eating and drinking safely with a date of 09/07/2020, provide diet as ordered, mechanical soft with pureed fruits and vegetables, fortified foods, extra desserts, heath shakes, 1 time daily with meals or as desired, whole milk at all meals. Plate guard provided to encourage self feeding with a date of 05/14/2021. Provide medications for hyperlipidemia and monitor for side effects and adverse reactions and report to MD if noted, with a date of 04/25/2021. Refer to ST (Speech Therapy) for evaluation and treat as indicated with a date of 09/07/2020. On 05/20/24 at 11:00 AM, V22 (Cook) made mashed potatoes with creamy classic mashed potatoes and hot water. No fortified potatoes were observed to be prepared. The recipe titled power potatoes documents ingredients: milk 2%, milk nonfat dry, potato, mashed instant, sour cream, margarine, and salt. On 05/20/24 at approximately 12:00 PM during lunch service, there was only one pan of mashed potatoes on the steamtable. Regardless if dietary cards listed fortified potatoes, the creamy classic mashed potatoes were observed to be served to all residents. On 05/20/24 at approximately 12:45 PM, R36 received a #10 dip of regular mashed potatoes, no fortified mashed potatoes, no extra gravy and no ice cream on his lunch tray. On 05/20/24 at 2:00 PM, V22 (Cook) stated that the mashed potatoes that were made for lunch were made with the potato flakes and hot water, and they were the only potatoes made and served that day. On 05/20/24 at 2:40 PM V28 (Activity Aide/CNA) passed afternoon snacks and there were no nutritional house supplements/shakes or ice cream on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/20/24 between 2:20 PM and 3:30 PM, R36 did not receive a health shake and no ice cream was given during snack time either. On 05/21/24 at approximately 12:40 PM, R36 received ground philly chicken sandwich, soft tater tots, and soft chopped fruit salad, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/21/24 at 2:30 PM, V28 passed afternoon snacks and there were no nutritional house supplements on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/21/24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream during snack time. On 05/22/24 at 1:00 PM, R36 did not receive a nutritional house supplement, a fortified food item or ice cream with his lunch tray. On 05/22/24 at 2:35 PM, V28 passed afternoon snacks and there were no nutritional house supplements/shakes on the snack cart. At approximately 3:00 PM, V28 was done passing snacks and moved the snack cart from the dining room. On 05/22//24 between 2:35 PM - 3:15 PM, R36 did not receive a nutritional house supplement or ice cream. 4. R44's Transfer/Discharge Report documents an admitted [DATE] with diagnoses including: Alzheimers's Disease with early onset, Disorientation, Essential Hypertension, Hypothyroidism, Unspecified Psychosis not due to a substance or known physiological condition, Dehydration, Fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, Seizures, and Rhabdomyolysis. R44's MDS dated [DATE] documents no BIMS was conducted due to R44 is rarely/never understood. Section GG indicates R44 is dependent for eating. R44's Physician Order Sheet documents an order for house nutrition supplement two times a day for nutritional supplement iso source 1.5 give 90cc (cubic centimeters) BID (twice a day) with an order date of 04/18/2024. R44's dietary card documents: lunch- nutritional ice cream in a bowl, power pudding, health shake for all meals. R44's Care Plan documents a Focus Area of R44 is unable to consume regular consistency foods with toast or breads all meals. R44 needs total assistance with all her meals with a revision date of 06/13/23 with interventions documented as: monitor and record intake every shift with a date of 11/06/20, monitor for sign/symptoms of aspiration dated 11/06/20, monitor weight as indicated weekly and prn dated 12/16/20, provide diet as ordered, mechanical soft with breads or toast with all meals, adding nutritional ice cream one time daily with meal of choice, health shake three times a day with meals, diet supplemented with 120 mls (milliliters) med pass TID (three times a day) dated 06/13/23, and refer to ST for evaluation and treat as indicated dated 11/06/20. On 05/20/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/21/24 at 12:40 PM, R44 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. On 05/22/24 at 1:00 PM, R50 did not receive nutritional ice cream in a bowl, power pudding, or a health shake. 48356 5. R45's Transfer/Discharge Report dated 5/22/24 documents an admitted [DATE] with diagnoses in part of Cognitive Communication Deficit, Dysphagia, Alzheimer's Disease, Lack of Coordination and Contracture of left hand. R45's MDS dated [DATE] documents in Section C a BIMS score of 0, indicating R45 was unable to complete the BIMS. Staff assessment for mental status was completed and documents short term memory problems and long-term memory problems with moderately impaired decision making, which indicates that R45 makes poor decisions. Section GG documents R45 requires supervision or touching assistance with eating. R45's Care Plan undated, documents an ADL (Activities of Daily Living) self-care/mobility performance (functional abilities) deficit that may fluctuate with activity throughout the day r/t (related to) Alzheimer's disease process. Interventions for eating include in part, R45's usual performance is substantial or maximal assistance. R45 is able to consume regular consistency foods .provide diet as ordered R45's Physician Orders document an order dated 11/29/23 of nutritional ice cream supplement with lunch and dinner and resident (R45) to have house stock nutritional supplement TID (Three times a day) with meals. An order dated 1/28 24 documents general diet mechanical soft texture, regular consistency, nutritional supplement TID (3 times daily), and nutritional ice cream at lunch and supper. On 05/20/24 at 1:15PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/21/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/22/24 at 12:20PM, R45 was served a mechanical soft tray with no nutritional supplement shake or ice cream. On 05/29/24 at 11:10 AM, V29 (Registered Dietician) stated, she would expect all supplements and fortified foods that were ordered to be served as ordered. The dietary policy dated 2020 titled, Fortified Food, Supplements, and Snacks documents: Residents who cannot consume adequate amounts of regular foods at meals to meet their nutritional needs may be considered for Fortified Foods, snacks or supplements in order to increase nutritional intake. Commercially prepared supplements and nutritional interventions may be ordered by the food service manager, dietician, or nursing staff. Fortified foods, house supplements, or snacks will be provided within the specifications of the diet order and may be substituted with nutritionally equivalent interventions if a specific brand or type of supplement in unavailable. The facility policy titled, weights dated 10/17/19 documents: 3. Re-weight should be obtained if there is a difference of 5# (pounds) or greater (loss or gain) since previously recorded weight. 4. Re-weight should be taken as soon as possible after an unanticipated weight change is noted and prior to calling the physician. (Usually within 72 hours). 5. Efforts should be made to obtain all weights and re-weights by the 10th of each month. 6. Undesired or unanticipated weight gains/loss of 5% in 30 day, 7.5% in three months, or 10% in six months shall be reported to the physician, dietician and/or dietary manager as appropriate.

Based on observation, interview, and record review, the facility failed to implement planned fall interventions to prevent falls for 1 (R1) of 5 residents reviewed for falls in a sample of 5. This failure resulted in R1 falling, fracturing his right hip and undergoing surgical repair of the fractured hip on 4/2/2024. This past non-compliance occurred from 3/31/2024 to 4/1/2024. Findings included: Per R1's EHR (electronic health record) R1 was admitted to this facility on 11/7/2024 with diagnoses of Alzheimer's, Chronic Atrial Fibrillation, Weakness and Insomnia. Per R1's MDS (Minimum Data Set) dated 1/23/24 under section C, R1 was assessed with a BIMS (Brief Interview for Mental Status) in which R1 scored 3 out of 15 total, indicating R1 has severe cognitive impairment. This same MDS under section GG, documents R1 as needing substantial/maximum assistance from staff for all transferring activities and uses a wheelchair for locomotion about the facility. A Fall Risk Assessment for R1, dated 4/1/2024, documents R1 is a high risk for falls. R1's care plan (initiation date of 11/30/23) documents a focus area of: (R1) is at risk for falls related to decreased safety awareness, unsteady gait and medications that may cause dizziness. This same care plan documents the goal of the focus area as: (R1) will not sustain serious injury through the review date (7/15/24) and planned interventions of: Ensure (bedside) recliner is in down position with foot rest down (initiation date 1/4/24), Anticipate and meet (R1's) needs (initiation date 3/10/24), Bed height to be placed where my feet are flat on the floor (initiation date 11/30/23), Educate (R1)/family/caregivers about safety reminders and what to do if (R1) falls (initiation date 11/30/23), Encourage (R1) to participate in activities that promote exercise, physical activity for strengthening and improved mobility (initiation date 11/30/23), Ensure call light is within reach (initiation date 11/30/23), Follow fall protocol (initiation date 3/10/24), Staff to assist (R1) with toileting upon awakening, before and after meals and at bedtime as (R1) allows (initiation date 4/2/24), and (R1) uses chair/bed electric alarm. Ensure the device is in place as needed (initiation date 11/30/23). On 4/4/2024 at 9:23am, V5 (family) said due to R1's dementia, R1 has increased confusion during the night and attempts to get up without assistance. V5 said the facility implemented a chair/bed pad alarming device to alert staff when R1 attempts to get up without assistance. V5 said she had not seen R1's chair/bed alarm recently when she visited R1 about a week before R1's fall. On 4/4/2024 at 12:30pm, V13 (Registered Nurse/ RN) said R1 uses a chair/bed pad alarm as a safety precaution to help prevent him from getting up and falling. V13 said she has performed safety rounds on R1's hallway and has seen R1's chair/bed pad alarm in his bedside recliner in the past. V13 was asked to point out where R1's chair/bed pad alarm was at, since the alarm pad could not be located in R1's room at the time of this interview. After searching, V13 responded she could not find the alarm. On 4/9/2024 at 8:45am, V20 (RN) was asked if she could locate R1's chair/bed pad alarm since a search of R1's room could not locate the alarm at the time of this interview. After searching, V20 said she could not find the alarm. On 4/4/2024 at 12:40pm, V6, V14, V15 (all Certified Nursing Assistants/CNA) said they are the usual day time staff who provide care for R1 and R1 is supposed to have a chair/bed pad alarm on. On 4/4/2024 at 2:40pm, V7 (CNA) said she, V8 (CNA) and V4 (RN) were the staff providing care for R1 on 3/31/2024 at the time R1 fell . V7 said R1 likes to sleep in his bedside recliner and does not really sleep in his bed. V7 said R1 does not use a chair/bed pad alarm and only uses a call light when R1 needs assistance. V7 said R1 did not have a chair/bed alarm on when he got up and fell the morning of 3/31/2024. On 4/4/2024 at 2:45pm, V8 (CNA) said she was working with V7 and V4 on 3/31/2024 when R1 fell . V8 said R1 did not have a chair/bed alarm on when he fell . On 4/9/2024 at 8:30am, V4 (RN) said on 3/31/2024, she was working with V7 and V8. V4 said at about 5:00am, she was passing medications when she heard R1 call out for help. V4 said she saw R1 on the floor in the hallway near R1's doorway. V4 said R1 told her he was looking for the bathroom when he fell . V4 said she assessed R1, determined he had a right hip injury due to complaints of pain and sent him to the local hospital ER (emergency room ) for evaluation. V4 said R1 did not have on a chair/bed pad alarm on 3/31/2024 when he fell . A facility document titled Post Fall Investigation, dated 4/1/2024 documents R1 had an unwitnessed fall due to loss of balance when ambulating without staff, had on non-skid socks, and stated to staff at the time of his fall I was just trying to go to the bathroom. This same document has a place to mark if R1's chair/bed pad alarm was present and if the alarm was sounding at the time of the fall, however this section is left blank and nothing is marked. On 4/4/2024 at 9:23am, V5 (family) said she received a phone call from V4 (Registered Nurse/RN) on 3/31/2024 at around 6:00am informing her R1 had fell , was complaining of right hip pain and was being sent to the local hospital ER for evaluation. V5 said the ER told her R1 had a fractured right hip and needed surgery to repair the fracture. Th local hospital ER records dated 3/31/2024 documented R1 was seen for complaints of right hip pain after falling at his nursing home. A CT (Computed Tomography) scan and X-ray of R1's right hip documented R1 had a displaced intertrochanteric fracture of right femur and R1 was admitted for surgical management. These same hospital records included a document titled (local hospital) Report of Operation which documented on 4/2/2024, R1 underwent a surgical procedure of Right hip closed reduction with cephalomedullary nail to treat R1's right hip fracture. The facility Fall Prevention Policy dated 11/28/2012, documents the following in part: Purpose: To assure the safety of all residents in the facility. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions, to provide necessary supervision and assistive devices are utilized as necessary. Safety interventions will be implemented for each resident identified at risk. All assigned nursing personnel are responsible for ensuring on-going precautions are put in place and consistently maintained. Fall risk interventions will be identified on the care plan. On 4/9/2024 at 4:00pm, V1 (Administrator) pointed out R1's chair/bed alarm pad located in R1's room. A facility form titled In-service Sign in Sheet (dated 4/1/2024) documented all staff were in-serviced on the topic of: Fall Prevention and included a specific section related to R1's planned fall interventions. On 4/9/2024, V1 provided a document titled Past Non-Compliance Removal Time for outlining the actions taken by the facility prior to the survey date to correct the non-compliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: A Quality Assurance Performance Improvement Meeting was held on 4/1/2024 in which V1, V2 (Director of Nursing), V23 (Medical Director), V13 (RN), V24 (Activity Director), V25 (Assistant Director of Nursing), V26 (Care Plan Coordinator) and V27 (Social Service Director) were in attendance and identified the facility was not in compliance with specific regulatory requirements at the time the situation occurred. Actions Taken: 1.) Affected resident (R1) has been assessed, sent to the ER for treatment and assessed. (completed on 4/1/2024) 2.) All nursing staff have been educated on fall interventions. (completed on 4/1/2024) 3.) Affected resident's (R1) care plan updated. (completed 4/1/2024) 4.) Affected resident's (R1) family has been notified of fall (completed on 4/1/2024) 5.) All staff have been educated on fall intervention binders at nurses station (completed on 4/1/2024) 6.) A QAPI (Quality Assurance Performance Improvement) meeting was held with the medical director to discuss alleged allegation and facility comprehensive follow up (completed on 4/1/2024) 7.) The policy for fall prevention has been reviewed by the ID (interdisciplinary) Team with no changes needed at this time. (completed 4/1/2024)

Based on interview and record review, the facility failed to administer regularly scheduled ordered pain medication for 1 (R1) of 5 residents reviewed for pain management. This failure resulted in R1 experiencing loss of sleep and significant pain to R1's shoulders, back, and knees due to missing R1's 2/5/24 pm dose of her regularly scheduled pain medication. This past noncompliance occurred between 2/05/2024 - 2/09/2024. Findings: R1's face sheet documents an admission to the facility on [DATE] with diagnoses of Chronic Kidney disease, Stage 3 Unspecified, Malignant neoplasm of uterus, part unspecified, other intervertebral disc degeneration, lumbar region, unspecified osteoarthritis, unspecified site, other sleep apnea. R1's Minimum Data Set (MDS) dated [DATE], documents R1 has a Brief Interview for Mental Status (BIMS) score of 13, indicating she is cognitively intact. R1's MDS Section J, Pain Management, documents she has a scheduled pain medication regimen. R1's Care Plan documents a Focus of: R1 has chronic pain; Goal: R1 will not have an interruption in normal activities due to pain through the review date; Interventions: Administer analgesia per orders; Evaluate the effectiveness of pain interventions; Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; Monitor/document for side effects of pain medication; Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. R1's Physician's Orders dated 4/20/2023 documents Pain Assessment every day and night shift; 4/19/2023 documents Acetaminophen 500mg (milligrams) (2 tabs) every 4 hours as needed for pain; 4/21/2023 documents Percocet 5/325mg three times a day for pain (Unspecified Osteoarthritis, Unspecified site; Other Intervertebral disc degeneration, lumbar region); 2/6/2024 documents Hydrocodone 5/325mg every 8 hours as needed for pain (may substitute if Percocet is unavailable). R1's Medication Administration Record (MAR) dated February 1 - 29, 2024 does not document Percocet 5/325mg was given on 2/5/2024 (9:00 PM); 2/6/2024 (5:00 AM, 1:00 PM, 9:00 PM) and 2/07/2024 (1:00 AM). R1's MAR dated February 1-29, 2024 documents pain assessment every day and night shift completed with pain rating on 2/5/2024 to be 6 and on 2/6/2024 to be 7. No alternative medication was ordered until 2/6/2024 and first dose was given at 5:37 PM. R1's Narcotic Administration Sheet for Percocet 5/325mg documents last dose given on 2/5/2024 at 1:00 PM and documentation of Percocet 5/325mg received on 2/7/2024 (30 tabs) with the next dose given on 2/7/2024 at 12:30 PM. R1's Progress Notes dated 2/06/2024, 6:00 PM (Late Entry) by V4 (Quality Assurance/Licensed Practical Nurse/LPN) documents in part .R1 came to this nurse and spoke about being out of her pain pills .asked R1 if she was having pain and R1 stated she was and had been to a doctor's appointment .told R1 a nurse sent a script to V20 (Primary Nurse Practitioner/NP), Monday (2/5/2024) to get signed .it came back Tuesday morning (2/6/2024) that it didn't have quantity amount or DEA (Drug Enforcement Administration) number on it .so V20 was going to escribe it to pharmacy .told R1 that hopefully it would come in on the delivery we would get Tuesday night .When pharmacy delivered Tuesday evening around 10:30 PM, did not have R1's pain medication. R1's Progress Notes dated 2/07/2024, 11:58 AM, documents in part .med delivery guy had been there and delivered R1's pain medications. On 2/14/2024, at 12:30 PM, R1 stated Last week either Sunday or Monday evening, the nurse came in and told me that I was out of my regular pain medication. R1 stated they told her a new nurse forgot to reorder it. R1 stated that the nurse told her that it probably wouldn't be here until tomorrow night and R1 stated that she was not offered any other type of pain medication until the following day. R1 stated that she has arthritis in her shoulders, back, and has had multiple knee replacements. R1 stated that she didn't get any sleep for three nights after missing her regularly scheduled pain medication and her pain was unbearable in her shoulders, back, and knees. R1 stated that she has been on scheduled Percocet for over twenty years and that is the only medication that helps to relieve her pain. On 2/14/2024, at 1:10 PM, V2 (Director of Nursing/DON) stated that R1's Percocet medication is not in the facility's emergency medication kit (E-Kit). V2 stated that it is the expectation of her nurses to have any medication that needs to be refilled, to be refilled in a timely manner before the medication runs out. V2 stated that it is the expectation of the nurses to call the primary physician when a medication runs out and get it refilled as soon as possible or get another order for an alternative medication to be given. V2 stated that R1 did get offered an alternative medication on 2/6/2024 and on 2/7/2024. On 2/14/2024, at 1:25 PM, V6 (Ombudsman) stated that V19 (Family) contacted her and told her that R1 ran out of her pain medication. V6 stated that she called R1 and R1 stated to her that she had not received her pain medication for 24 hours. V6 stated that R1 told her that she had been on regularly scheduled Percocet for over [AGE] years and that is the only pain medication that works for her. V6 stated that she offered R1 a grievance form to fill out. V6 stated that she spoke with V1 (Administrator) and was told R1 was offered an alternative medication but that she refused. V6 stated that V1 verified to her that R1's Percocet was not in the facility's emergency medication kit. V6 stated that V1 verified to her that R1 had missed 5-6 doses of her Percocet medication. V6 stated that V1 told her that R1's Percocet did arrive on 2/7/2024 and that the facility is monitoring to make sure this doesn't happen again. On 2/14/2024, at 1:40 PM, V1 (Administrator) stated that he spoke with V6 (Ombudsman) and told her that R1 ran out of her pain medication and that a back-up alternative was offered and given. V1 stated that R1's Percocet was ordered on 2/5/24 & 2/6/24 and received on 2/7/2024. On 2/14/2024 at 2:00 PM, the emergency medication kit was observed to have no Percocet available. There was hydrocodone 5/325mg available in the emergency medication kit. On 2/14/2024 at 3:05 PM, V9 (Registered Nurse/RN) stated that she works 6:00 AM - 6:00 PM regularly and she worked on 2/5/2024, day shift. V9 stated that she was told in report by V5 (RN) that R1 had one Percocet pill left and that it would need to be reordered. V9 stated that she called V20 (Primary Nurse Practitioner) and told her that we needed a new script for R1's Percocet medication. V9 stated that she gave R1 her last dose of Percocet at 1:00 PM on 2/5/2024. V9 stated that she told V5 (RN) in report that R1's Percocet medication was supposed to come in that evening. On 2/14/2024 at 3:10 PM, V5 (RN) stated that she worked Sunday night, 2/4/2024, and noticed that R1 only had one dose of Percocet left after she gave R1 her regularly scheduled 5:00 AM dose. V5 stated that she did not notify the primary physician at that time, just told V9 (RN) that R1 only had one dose of Percocet left and it needed to be reordered. On 2/20/2024 at 8:10 AM, V10 (RN) stated that she worked on 2/6/2024 and R1 was out of her Percocet medication. V10 stated that she called V20 (Primary Nurse Practitioner) and got an alternative medication (Hydrocodone 5/325mg) ordered for her until the Percocet would come in from the pharmacy. V10 stated that she offered Tylenol to R1 but R1 refused stating, That will not work for me and V10 stated she offered the hydrocodone to her and R1 refused the first time, stating, Those will not work for me, I threw 120 tablets away because that medication would not work for me. V10 stated that she talked to R1 and explained to her that hydrocodone was equivalent to Percocet and R1 finally agreed to take a dose of it. V10 stated that R1 was experiencing more pain than usual that day. V10 stated that R1's Percocet was supposed to arrive from pharmacy later that evening. On 2/20/2024 at 8:20 AM, V11 (Licensed Practical Nurse/LPN) stated that she worked on 2/6/2024, the night shift and was told in report that R1 was out of her Percocet medication and that hydrocodone could be given as needed until her Percocet medication could be delivered from pharmacy. V11 stated that R1's Percocet medication was supposed to arrive to the facility on [DATE] but did not show up that evening. V11 stated that she called the pharmacy and they told her that it would arrive on the next pharmacy delivery, which would be in the morning. V11 stated that she administered the hydrocodone as ordered for R1 when she was able to have it. On 2/20/2024, at 8:40 AM, V20 (Primary Nurse Practitioner) stated that she was notified on 2/5/2024 that R1 needed her Percocet re-ordered. V20 stated that she reordered R1's Percocet that day but it was sent to the wrong pharmacy. V20 stated that she received another phone call on 2/6/2024 regarding R1 needing her Percocet reordered. V20 stated that when she went into the computer to order it again on 2/6/2024, she noticed she had sent the initial Percocet order to the wrong pharmacy. V20 stated that she reordered the Percocet again as well as ordered an alternative pain medication, hydrocodone 5/325mg that could be given as needed until the Percocet became available. V20 stated that it is her expectation for the nurses to notify her in a timely manner to refill medications and not wait until residents run out of medications. The facility's Pain Management policy dated 7/6/2018 documents in part .Purpose: To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. The facility's concern/compliment form dated 2/7/2024 documents being filled out by R1 stating: I have to have my pain med regularly; I got my evening med and the nurse told me we were out of percocet and she would check to see if they were ordered; I didn't get my pain med until 2/7/2024 at noon; A very painful 2 days and nights. On 2/15/2024, at 10:30 AM, V1 (Administrator) stated that the facility had a Quality Assurance (QA) meeting on 2/9/2024 to discuss narcotic medications and medication refills. V1 stated the following people attended the QA meeting: V1 (Administrator), V2 (Director of Nursing), V4 (Quality Assurance/LPN), V16 (LPN/MDS/Care Plan Coordinator). V1 stated the measure put in place to ensure that deficient practice does not recur are: V2 (DON) and V4 (QA/LPN) will be checking narcotic books weekly (Tuesday) to see if the facility needs to get any scripts for narcotic medication refills to ensure that they don't run out of any narcotic medications. On 2/14/2024, V1 (Administrator) provided their QAPI (Quality Assurance Performance Improvement) Ad Hoc Form outlining the actions taken by the facility prior to the survey date to correct the noncompliance. Prior to the survey date, the facility took the following actions to correct the non-compliance: 1. A Quality Assurance and Performance Improvement meeting was held on 2/09/2024. In attendance - V1, V2, V4, and V16. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All residents who receive narcotic medication have the potential to be impacted. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: V2 and V4 provided in-service training on 2/9/2024 to nursing staff, (narcotic medications and medications refill). 4. Plan to monitor performance to ensure solutions are sustained: Narcotic medication audits to be conducted weekly x 4 weeks by V2 & V4. The first complete facility audit was completed on 2/13/2024.

Based on observation, interview and record review, the facility failed to complete weekly skin assessments, implement interventions to reduce pressure, and complete readmission assessments to identify any skin changes for 1 of 3 residents (R1) reviewed for being at risk for pressure injury in the sample of 3. This failure resulted in R1 developing pressure wounds. Findings include: 1. R1's face sheet documented an admitted [DATE] and diagnoses including: chronic kidney disease, hypertension, dementia, hyperkalemia. R1's 9/15/23 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment. R1's 9/15/23 MDS documented R1 required extensive two person assist with bed mobility, transfer, locomotion, dressing, and personal hygiene. R1's 7/3/23 Braden Observation documented a score of 18, indicating R1 was at risk for pressure wounds. R1's 9/15/23 Skin & Wound Evaluation documented a deep tissue injury related to pressure that was in-house acquired on the right lateral forefoot measuring 5.2 centimeters (cm) x 3.5 cm, a deep tissue injury related to pressure that was present on admission to the rear right malleolus (heel of the foot) measuring 5.6 cm x 4.7 cm, and a deep tissue injury related to pressure that was present on admission on the rear left malleolus measuring 5.64 cm x 4.21 cm. R1's Electronic Medical Record (EMR) documented R1 was transferred to the hospital on 9/10/23 and returned from the hospital on 9/14/23 at 7:40 PM. A progress note dated 9/14/23 at 7:40 PM documents that R1 returned to the facility with a new order for a daily dressing to the left heel. There was no readmission assessment documenting any skin conditions or wounds to R1's left heel. On 9/19/23 at 10:21 AM, R1 was lying in bed watching television. R1's bilateral heels were wrapped in kerlix dated 9/19/23. R1 was not interviewable and refused to have bandages removed. On 9/19/23 at 12:52 PM, V2 (Director of Nursing/ DON) said on 9/15/23 she went into R1's room to administer Intravenous antibiotics and while repositioning R1 noticed the wounds on R1's bilateral heels and side of the right foot. V2 said R1 had returned from the hospital on 9/14/23 and may have had the pressure wounds on admission but no readmission assessment was completed to document any skin conditions. V2 said all residents should have a skin assessment on admission or readmission. On 9/19/23 at 12:30 PM, V4 (Certified Nursing Assistant/ CNA) said R1 had large blisters on R1's bilateral heels 3-4 days or maybe a week prior to 9/10/23 when R1 was transferred to the hospital. V4 said she did report the blisters to the nurse but was unsure of who the nurse was or on what day she reported it. On 9/20/23 at 11:32 AM, V9 (CNA) said she noticed R1's bilateral heels to be black prior to 9/10/23 and reported it to 2 or 3 nurses but was unsure who. V9 said she was working on 9/14/23 when R1 returned to the facility from the hospital. V9 said R1's bilateral heels were black and looked really bad. V9 said she reported R1's skin changes to V8 (RN) on 9/14/23. On 9/20/23 at 11:27 AM, V8 (RN) said she did not recall R1. V8 said she did not work on R1's unit often and did not know the resident's names. V8 said she no longer was employed at the facility. On 9/20/23 at 11:38 AM, V10 (CNA) said she noticed one of R1's heels to black and nasty looking prior to 9/10/23. V10 said she had reported it to the nurse and thought the nurse was V6 (LPN). On 9/19/23 at 10:31 AM, V6 (LPN) said he was not aware of R1 having any pressure wounds prior to R1's 9/10/23 hospitalization . On 9/19/23 at 11:52 PM, V5 (Wound Nurse/ Registered Nurse/ RN) said she worked in the facility one day a week and would complete the wound documentation and take pictures of resident wounds. V5 said she had assessed R1's pressure wounds earlier in the day on 9/19/23. V5 said R1's right lateral foot pressure wound was closed and was a dark purple color measuring 5.59 cm x 3.83 cm, R1's right heel malleolus pressure wound measured 7.04 cm x 4.9 cm with 75% eschar and 25% of the wound bed being pink open tissue, and R1's left heel malleolus pressure wound measured 5.52 cm x 3.31 cm with 75% eschar and 25% of the wound bed being pink open tissue. V5 provided the pictures of R1's wounds on the wound treatment cell phone. R1's EMR documented a 9/15/23 care plan I have a pressure ulcer r/t (related to) disease process no previous care plan for pressure was documented. On 9/19/23 at 1:43 PM, V3 (Care Plan and MDS Coordinator/ LPN) said R1 had a Braden score of 18 indicating R1 was at risk for a pressure wound and should have had a care plan in place for being at risk for impaired skin integrity. V3 said he was unsure why R1 did not have a care plan in place prior to developing pressure wounds. V3 said he must have overlooked R1's need for a care plan for pressure to be implemented. On 9/19/23 at 12:52 PM, V2 (Director of Nursing) said any resident with a Braden score documenting a resident is at risk for a pressure wound should have a care plan with interventions to off load pressure. On 9/19/23 at 11:52 AM, V5 (Wound Nurse/ RN) said interventions for off-loading pressure would be found in a resident's care plan. V5 said she would expect any resident who was at risk for pressure wounds to have a care plan with interventions such as repositioning every 2 hours, floating a resident's heels while in bed, and wedges or pillows for positioning. On 9/19/23 at 10:31 AM, V6 (Licensed Practical Nurse/ LPN) said he was unsure what interventions R1 had in place to off-load pressure. V6 said for off-loading pressure all residents should be assisted to reposition every 2 hours. R1's EMR documented R1 requiring weekly skin assessments. R1's EMR documented a Weekly Skin Observation on 6/22/23, 6/29/23, 7/6/23, 7/13/23, 8/4/23 (23 days later), 8/11/23, 8/18/23, 9/1/23 (14 days later). The last documented skin assessment completed before R1's hospital admission on 9/10/23 was dated 9/1/23. The 9/1/23 weekly skin assessment documents that R1 had a blister to the left sole, ball of the foot that is blistered and scabbed over. R1's 9/1/23 assessment further documents no for the question Are any of these foot concerns new? There is no other documentation in the progress notes or physician's orders regarding a wound, or treatment to the wound, on the left heel prior to R1's 9/1/23 assessment. On 9/19/23 at 12:52 PM, V2 (DON) said the Weekly Skin Observations were automatically generated in the EMR and was unsure why they were not completed on R1. V2 said the Weekly Skin Observations were completed to assure new skin changes would be identified, documented, and treated. On 9/20/23 at 4:37 PM V11 (Physician) said if the facility had interventions in place to off-load pressure R1's pressure wounds could have been avoidable. The facility's 6/8/18 Skin Condition Assessment & Monitoring - Pressure and Non- Pressure policy documented . A skin condition assessment and pressure ulcer risk assessment (Braden) will be completed at the time of admission/ readmission. The pressure ulcer risk assessment will be updated quarterly and as necessary. Residents identified will have a weekly skin assessment by a licensed nurse. A wound assessment will be initiated and documented in the resident chart when pressure and/ or other non- pressure skin conditions are identified by a licensed nurse . The resident's care plan will be revised as appropriate, to reflect alteration of skin integrity, approaches and goals for care .

Based on interview and record review the facility failed to transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure has the potential for R5 to develop ketoacidosis which could result in coma and possible death. The Immediate Jeopardy was identified to have begun on 10/07/22 when R5 was admitted to the facility and the facility failed to transcribe physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 11/04/2022, but non-compliance remains at Level Two because addition time is needed to evaluate the implementation and effectiveness of the in-service training. Findings Include: R5's facility Admission Record with a print date of 10/20/22 documents R5 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS (Minimum Data Set) dated 10/8/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R5 is cognitively intact. R5's regional hospital after visit summary with hospital stay dates of 10/04/22 to 10/7/22 includes the following medications on the medication list, [MEDICATION(S)] inject 52 units into the skin daily and [MEDICATION(S)] 100 unit/ml inject into skin 3 times daily. R5's regional hospital records document under Scheduled meds sorted by name an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . If BS remains consecutively greater than 300 at next scheduled recheck call MD (physician) R5's regional hospital record documents under Basic Metabolic Panel that R5's blood glucose level was 176 on 10/07/22. There is a noted discrepancy in R5's hospital discharge orders that lists both [MEDICATION(S)] and [MEDICATION(S)] as the fast acting insulin to be administered via sliding scale. Since these orders were never implemented at the facility, it was never clarified which fast acting insulin was correct. R5's Progress Notes document on 10/08/22, R5 was transferred from the local [CONDITION(S)] center to the local emergency room for evaluation of chest pain. R5's progress notes document R5 was admitted to a regional hospital. R5's progress notes document R5 was discharged from the regional hospital back to the facility on [DATE]. R5's regional hospital records, under Patient Care Orders, include physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If BS remains consecutively greater than 300 at next scheduled recheck, call MD. R5's Order Summary Report dated Active orders as of 10/13/2022 do not document physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's facility progress notes document on 10/12/22 7:30 AM, Resident (R5) had an un-witnessed fall 10/12/22 6:30 AM. Location of Fall: Resident Room, Resident attempted to arise from recliner to take self to bed. Resident slid from recliner to the floor. Resident stated no injuries were obtained. On 10/12/2022 6:30 AM Assessment: Witnessed Fall- Did not strike head; Neurological checks not indicated. Alert and oriented to time, person, place, and situation. No changes in range of motion from normal baseline. No injuries observed. Actions Taken: Multiple staff assisted resident from floor to recliner. Full body assessment completed with no findings of any new areas. Daughter insisted that resident be seen in the ER. Resident was seen in ER with a full work up completed, IVF (Intravenous fluids) administered, labs drawn, and CT (computerized tomography) of head completed. Resident returned to the facility with daughter escorting him. Report given by ER nursing staff and no areas of concern noted. No findings all test negative. No new orders given at time to discharge from emergency room . Vitals: [CONDITION(S)]: medications reviewed, and areas of concern noted R/T (related to) consistent with low blood pressure. V4 (Physician) notified and full admission assessment completed. V4 (Physician) will continue to monitor. R5's local hospital records dated 10/12/22 documents under Assessment, Patient (R5) brought to ER (emergency room ) from (name of facility) by family member who reports patient fell at nursing home this morning. Patient was in floor for approx (approximately) 4 hrs (hours) and is unsure if he slid off the bed or had stood up and fell . Patient is slightly confused and family states that patient has been declining cognitively since Sunday. Family reports she requested nursing home have a CT (computerized tomography) of the head done but the order had never been obtained. Under additional history R5's hospital record documents, AMS (altered mental status) x (times) 2 days. Recent Subarachnoid bleed from MVC (motor vehicle crash) 10/3/2022, possible fall early this AM. R5's local hospital Lab Results Summary dated 10/12/2022 documents a blood glucose level of 273 with the normal range listed as 65-110. On 10/19/22 at 9:32 AM, R5 stated the facility staff didn't stick his finger (blood glucose monitoring) or give him his insulin. R5 stated his blood sugar was a little high while he was at the facility. When asked what symptoms he would have when his blood sugars were elevated R5 stated, dizziness and weakness. On 10/18/22 at 4:00 PM, V5 (Family Member) stated R5 was admitted to the facility for physical therapy after a hospital stay for a motor vehicle accident with a subsequent brain bleed. V5 stated on 10/08/22 R5 was readmitted to the hospital from [CONDITION(S)] for evaluation for complaints of chest pain. V5 stated on 10/10/22 she transported R5 back to the facility and delivered his hospital discharge orders to the facility staff. V5 sated on 10/11/22 she stopped to visit R5 on her lunch break and an unknown CNA mentioned he seemed a little confused. V5 stated that was not normal for R5 but he sometimes gets really tired after [CONDITION(S)]. V5 stated after sitting with R5 she determined R5 did not seem himself intermittently throughout her visit. V5 stated she asked R5 if he had been getting his blood sugars checked and he said he had not. V5 stated she asked R5 if he had been getting his insulin and he wasn't sure. V5 stated she spoke with the nurse (believed to be V11) and told V11 about R5's Dexcom reader in his room and V11 stated he would share it with the other nurse's. V5 stated on 10/12/22 she was notified by a family member R5 had fallen. V5 stated she spoke with V2 (DON) on the phone on 10/12/22 and asked her if R5 had been receiving his insulin and V2 stated they had been checking his blood sugar with R5's reader and had been administering R5's insulin. V5 stated after she got off work she asked the facility if they had gotten the CT scan she had requested to ensure R5's intermittent confusion and falling were results of the brain bleed worsening and they had not so V5 signed R5 out of the facility and took him to the local emergency room for evaluation. V5 stated upon returning to the facility she reported to the nurse working that R5 needed his insulin and the nurse (V14) stated R5 did not have orders for insulin. V5 stated she went home and got R5's insulin to administer to him. V5 stated R5 administered his insulin himself as his blood sugars were over 300. V5 stated V14 found R5's hospital discharge orders from the regional hospital. V5 stated around midnight V14 came to R5's room and reported she had found R5's insulin orders and R5 had not been administered insulin since his admission to the facility on [DATE]. V5 stated she asked V2 on 10/13/22 why she had told her R5 had been getting his insulin when in fact he had not and V2 stated the nursing staff had told her he was. V5 stated then V2 told her R5 did have blood glucose monitoring ordered and V5 told V2 that ordered was put in at midnight on 10/12/22 after it was determined they weren't being done. V5 stated at this point R5 had returned to his normal baseline since his blood sugars were back within normal range. R5's FreeStyle Libre 2 AGP Report documents R5's blood glucose readings and was obtained from V5 (Family Member) on 10/20/22 at 7:06 AM. This report dated 10/7/22 to 10/13/22 documents R5's blood sugar reading on 10/07/22 at approximately 8 PM as being 226. There are no blood sugar readings documented for 10/08, 10/09, 10/10, and 10/11/22. The report documents on 10/12/22 beginning at 6:00 PM and ending at midnight, R5's blood sugars were 238, 241, 266, 298, 307, 322, 312, 275, 252, 248, 240, and 215. R5's blood sugars on 10/13/22 beginning at 2:00 AM and ending at 12:00 PM are 192, 182, 180, and 154. This indicates R5's blood sugars were as high as 322 before being administered insulin on 10/12/22 and down to 154 after getting insulin. On 10/19/22 at 1:15 PM, V11 (LPN/Licensed Practical Nurse) stated he provided care for R5 one day (unable to recall which day). R5's MAR (Medication Administration Record) dated 10/1/22 to 10/31/22 documents V11 signed off as administering medications on 10/11/22. V11 stated he knew R5 had the Dexcom (blood glucose monitor/reader) because V5 (daughter) had told him it was there, and some nurses were having issues using it. When asked if he administered insulin to R5, V11 stated he didn't recall giving R5 any injections. On 10/20/22 at 6:45 AM, V14 (LPN) stated she worked at the facility on 10/12/22 and provided care to R5 when he returned to the facility from the emergency roiagnom on this same day. V14 stated when they (R5 and V5) returned from the emergency room they told her they had stopped at the cafeteria and eaten so R5 would need his insulin. V14 stated she informed them she didn't have physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V14 stated she reviewed R5's admission paperwork/orders and located the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/19/22 at 1:35 PM, V12 (LPN) stated she only provided care one day while R5 was at the facility. V12 stated it was the last day R5 was at the facility (10/14/22), before being transferred to another Long-Term Care Facility. V12 stated she didn't administer R5's insulin because R5's daughter administered it. When asked if R5 had insulin in the medication cart, V12 stated, he didn't. On 10/20/2022 at 1:33 PM, V16 (Pharmacist) stated R5 did not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Order Summary Report Active Orders as of: 10/13/2022 documents the following orders with start date of 10/13/22; blood glucose check before meals and bedtime as needed, blood glucose check before meals and bedtime, [MEDICATION(S)] Kwik pen 100 unit/ml (milliliter) (this order has pending confirmation documented next to) inject as per sliding scale if 0-70 = 0 unit, if 71-100 = 4 units, if 101-150 = 8 units, if 151-200 = 12 units, if 201-400 = 16 units, subcutaneously before meals, [MEDICATION(S)] flex pen 100 unit/ml inject as per sliding scale before meals and bedtimes with the same sliding scale dosing as listed above, [MEDICATION(S)] 100 unit/ml inject 52 units subcutaneously in the morning. R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This indicates R5 did not receive [MEDICATION(S)] insulin as ordered on 10/08, 10/11, and 10/12/22. However, V5 reported self-administering R5's insulin on the night of 10/12/22. R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] =0 units, 71-100 = 4 units, 101-150=8 units, 151-200 = 12 units, 201-400 = 16 units inject subcutaneously before meals with a start date of 10/13/22 at 5:00 AM. R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . This indicates R5 should have received sliding scale insulin on 10/13/22 at 11:00 AM, 4:00 PM, and 8:00 PM and on 10/14/22 at 5:00 AM and 11:00 AM. R5's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/21/22 at 9:45 AM, V2 (DON) stated there were insulin orders for R5 on his hospital discharge orders, but it was confusing because some of it was handwritten in. V2 stated if it isn't handwritten by the physician, then it throws her off. When asked what her expectation would be, in that situation, V2 stated she would expect the nursing staff to call the physician and clarify the orders. When asked if she did a med error report V2 stated, No, I will. At 1:55 PM on this same date V2 stated the nurse responsible for reviewing and transcribing R5's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated she was made aware R5 had not received his insulin the day he came back from the hospital (10/12/22). V2 stated when she became aware of it, she reviewed the orders, and did an audit of each resident on insulin on 10/20/22. On 10/25/22 at 3:00 PM, V2 stated R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 confirmed the blood glucose checks were done as ordered and R5 should have received sliding scale insulin. V2 stated she would consider it a medication error and she would expect insulin to be administered as ordered. On 10/21/22 at 11:30 AM, reviewed R5's orders and administration records with V4 (Physician) which documented R5 should have received long-acting insulin as well as sliding scale insulin. V4 stated, That is inexcusable. V4 stated he takes that very seriously. Reviewed with V4 what R5's blood glucose levels (273) were when he was evaluated at the hospital and V4 stated he didn't think R5 not getting his insulin was a contributing factor for the fall. When asked what the potential negative outcomes are for a diabetic to not get insulin as ordered V4 stated, Ketoacidosis, coma, and possible death. R5's undated care plan documents a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility Medication Variance Report dated 10/13/22 documents R5 had an order of [MEDICATION(S)] inject 52 units subcutaneously every morning related to Type 2 diabetes mellitus with the order date documented as 10/10/22. The variance report documents R5 didn't receive the medication. The report documents it was a missed order under transcribing error. The report documents V4 (Physician) was notified with no date or time of notification. The report documents (V5) asked V14 (LPN) about insulin, which V14 found on orders but not in (electronic health record). Nurse (V14) then put all insulin orders in (electronic health record). The report documents no harm with circumstances or events have capacity to cause event, marked. The report documents the involved staff person was educated. The facility Medication Errors and Adverse Drug Reactions policy dated 11/7/2012 documents, Purpose: 1. To safeguard the resident. 2. To identify causes and prevent future errors. 3. To provide guidelines for reporting and recording. General Guidelines: 1. All medication, treatment errors, and drug reactions must be reported promptly. Notify the attending physician or Medical Director if the attending physician is not available. The Medication Error report is to be given to the Director of Nursing during or before the end of the shift for follow up. A detailed account of the incident must be recorded in the resident's medical record. Documentation should be factual and should not contain words such as error or incident Just state the facts. Documentation should include a. The time and date of the incident b. The name, strength, and dosage of medication administered c. The resident's reaction to the medication d. The condition of the resident e. Any treatment administered, and f. The date and time the physician and family was notified and his/her instructions. 4. Residents receiving incorrect medication or having a drug reaction should be observed as needed. Any change in the resident's condition will be reported to the physician and Director of Nursing . The facility Medication Administration Policy dated 1/1/2015 documents under, II. Administration of Medications. Medications must be administered in accordance with a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] ., the right resident, right medication, right dosage, right route, and right time. The Immediate Jeopardy that began on 10/07/22 was removed on 11/04/22 when the facility took the following actions to remove the immediacy. Removal Plan: Description of Occurrence: Medication Error: 1. Insulin audit was conducted and found to be in compliance. Insulin audit began on 10/19/22 by V2 (Director of Nurses) and V3 (Assistant Director of Nurses). The second audit was completed on 11/2/2022. 12 residents were identified as being potentially affected. 2. Third shift nurse to follow up with a medication reconciliation to ensure medications are all followed through for all medications and will be ongoing. 3. Educate all licensed staff on admission, re-admission process including obtaining orders from MD (physician) and reconciliation with hospital transfer form. Educate nurses on med pass administration and monitoring for side effects of drugs. Additional training was completed on medications rights of administration and identifying and addressing change in condition and causative factors Training and Education will be performed by V2 (DON) and V3 (ADON). Any on leave or unavailable will be educated via phone and again before next scheduled shift. This was completed on 11/01/2022 by V2 (DON) and V3 (ADON). 4. All admissions will have a medication reconciliation completed using admission audit (QA tool admission readmission checklist/audit) by facility leadership within 72 hours of admission. This began on 11/1/2022 and will be on going. This IDT (Interdisciplinary) team is included in leadership. 5. Pharmacy consultant group consulted to complete admission audit within 72 hours of admission starting on 11/1/2022. 6. Licensed nurse who did initial admission is no longer employed since 10/18/2022 at the facility- other nurse doing subsequent admission has been disciplined and educated by V1 (Administrator) and V3 (ADON). 7. Medical director notified of incident on 11/01/2022 and reviewed the facility's immediate action plan. He was in agreement with immediate action plan. 8. QAPI review with Medical Director to review medication orders, medication review and reconciliation. 9. R5 discharged to other facility on 10/14/2022. 10. All audits will be going with no stop date by V2 (DON) and V3 (ADON).

Based on observation, interview, and record review the facility failed to ensure call lights were answered timely for 6 of 6 (R5, R6, R7, R8, and R9, R20) residents reviewed for resident rights in the sample of 20. This failure resulted in the following 1. R5, who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. R9 who has a history of pressure ulcers and is being up in his chair for more than two hours, sitting in urine that [CONDITION(S)] his skin, and being in pain. 3. R6 who had recently had a catheter removed does not get timely bladder training and has to do bladder training herself in her adult incontinent brief since it took facility staff too long to respond to the call light. This has the potential to affect all 67 residents residing in the facility. Findings Include: 1. R5's facility Admission Record with a print date of 10/20/2022 documents R5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's MDS (Minimum Data Set) dated 10/08/22 documents a BIMS (Brief Interview for Mental Status) score of 15, which indicates R5 is cognitively intact. Section G of R5's MDS documents R5 requires two-person physical assist for transfers and one-person physical assist for bed mobility. R5's undated care plan documents a Focus area date initiated 10/08/22 of I am at (Specify High, Moderate, Low) risk for falls r/t (related to). Goal: I will not sustain serious injury through the review date. Date initiated: 10/08/2022, Target Date: 01/06/2023, Interventions/Tasks: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt responses to all requests for assistance. Date initiated 10/08/2022. R5's progress notes document on 10/12/2022 7:30 AM that R5 had an un-witnessed fall at 6:30 AM in his room when he attempted to arise from his recliner to take himself to bed. The note documents that R5 slid from his recliner to the floor, stated no injuries were obtained. The progress note also documents R5 was alert and oriented to time, person, place, and situation. No injuries observed. The note further documents the following intervention: re-educate resident frequently to use call light, assure call light and cell phone is within reach at all times. The facility Concern/Compliment Form dated 10/13/2022 documents under Nature of Concern/Compliment, R5 stated that he slid out of his recliner into the floor. Resident (R5) stated he doesn't know what happened or how long he had been there. Stated he has moments where he forgets. Under Summary of Pertinent Findings, the report documents, After investigating incident, resident was found to be in floor for only a short amount of time. No injuries noted. Under Corrective Actions Taken: Staff educated on timely call light monitoring. On 10/18/22 at 4:00 PM, V5 (Family Member) stated she was informed by a family member that R5 had reported to them he ended up in the floor around 2:00 AM and that R5 had pushed the call light multiple times and hollered for help, but no one came until around 6:30 AM to assist him. R5's local hospital emergency room record dated 10/12/22 documents R5 was evaluated at the local hospital at 2:33 PM for a fall. Under Assessment R5's hospital Nurse's Notes documents, Patient brought to ER (emergency room ) from (name of facility) by family member who reports patient fell at nursing home this morning. Patient was in floor for approx. (approximately) 4 hrs (hours) and is unsure if he slid off the bed or had stood up and fell . Patient is slightly confused and family states that patient has been declining cognitively since Sunday. On 10/19/22 at 9:32 AM, R5 was alert and oriented and asked about his fall on 10/12/22. R5 stated he was sitting in his chair in his room and must have dozed off. R5 stated when he woke up, he had slid down the front of his chair and couldn't get back up. R5 stated he tried to find the call light but couldn't find it at first. R5 stated he hollered out several times. R5 stated he then found the call light and pushed it around 2:00 AM. R5 stated the facility staff finally came in after 6:00 AM and got him up and took him to the bathroom. R5 stated he pulled the chain in the bathroom, and no one came back. R5 stated he would tell staff he needed something, and they wouldn't come back. When asked how he knew how long he was laying in the floor the morning of his fall, R5 stated because he could see the clock on the wall. R5 stated at some point he ended up with his head on the floor under the table next to his bed in his room. On 10/27/22 at 10:39 AM, surveyor observed the room where R5 resided while at the facility. The beds in the room were facing a wall with a clock in the center of that wall. A recliner was beside one of the beds also facing the wall with the clock. The clock was noted to have accurate time displayed. On 10/18/22 at 12:58 PM, V6 (CNA/Certified Nursing Assistant) stated R5's call light was on when she came to work on 10/12/22 at 6:00 AM. V6 stated V8 (CNA) went into R5's room and found R5 on the floor. V6 stated she didn't provide care to R5 that day. On 10/18/22 at 3:00 PM, V8 (CNA) stated R5's call light was on when she got to work on 10/12/22. V8 stated she answered a different residents call light first and provided care to that person then went to R5's room. V8 stated when she entered R5's room she saw him on the floor in front of his recliner with his head in front of his recliner. V8 stated R5 appeared to have missed his chair when sitting down. V8 stated she immediately went to get the nurse to assess R5. V8 stated R5 reported to them he had been laying there for hours and had been calling for help. On 10/21/22 at 12:02 PM, V20 (LPN/Licensed Practical Nurse) stated she was working on 10/12/22 when R5 fell . V20 stated the CNA told her he had fallen. V20 stated it was after she had given report to the oncoming day shift. V20 stated it appeared as if R5 had fallen out of his recliner. V20 stated she couldn't remember if R5's call light was on at that time, but she knew it wasn't on when she was on that hall around 4:30 or 5:00 AM. V20 stated she was pretty sure R5 had received medications on the morning of 10/12/22. V20 stated she wasn't sure, but she knew she was in the room next to R5's that morning and had a conversation with the CNA's in the hallway right outside R5's room. R5's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/26/22 at 10:30 PM, V21 (CNA) stated she took care of R5 on the night of 10/11/22 into the morning of 10/12/22. V21 stated she couldn't remember if R5 used his call light on the night of 10/11/22 or the morning of 10/12/22. V21 stated she couldn't remember when exactly they were in R5's room that night but she checks on every resident every couple of hours. On 10/26/22 at 10:24 PM and 10:40 PM, V22 (CNA) stated she provided care to R5 on 10/11/22 into the morning of 10/12/22. V22 stated she was in R5's room around 8:30 PM or 9:00 PM and then again at 2:00 AM and 4:00 AM. V22 stated she didn't remember if R5's call light was on at any time through the night. V22 stated it takes approximately 3 minutes to answer the lights and she hasn't had any residents complain call lights aren't being answered timely. When asked if she was involved with R5's care when he fell on the morning of 10/12/22, V22 stated she was probably giving report. When asked how they give report, V22 stated they do rounds. When asked to explain what that means, V22 stated they go to each room and tell the oncoming shift what happened with the resident through the night. When asked if she remembered doing rounds on the morning of 10/12/22, V22 stated they try to do them every morning. When asked if she saw R5 when she was doing rounds on the morning of 10/12/22, V22 stated, No, he was probably already up. On 10/27/22 at 10:52 AM, V6 (CNA) stated she got report at the nurse's station on the morning of 10/12/22. When asked if they did rounds and saw each resident, V6 stated they did not. When asked if anyone reported R5 falling V6 stated, No. On 10/26/22 at 9:41 AM, V1 (Administrator) stated R5 couldn't have been in the floor from 2AM to 6AM like R5 said. V1 stated he knew R5 didn't have his call light on because R5 said it was in his hand and then he said it slid out of his hand and the video shows people walking up and down the hallway. When this surveyor asked to view the video, V1 asked if it would help his case. This surveyor stated she was unsure due to not having seen the video yet. On 10/27/22 at 2:15 PM, this surveyor observed the video of R5's hall on 10/12/22 with V1 and V2 (DON/Director of Nurses) present. The door to R5's room was not clearly visible as the camera was facing the opposite wall and there was something obstructing the direct view of R5's doorway. At 5:48 AM, there was a CNA (possibly V21) who entered the hallway and got linens off the cart in the hallway. V21 then entered either R5's room or the room next to it. V21 then exited the room with dirty linens and placed them in a receptacle. On this same date and time, V2 stated R5 had been incontinent. R5's nurses notes reviewed from 10/07/22 to 10/13/22 document R5 is continent of bowel and bladder. V1 (Administrator) walked down the hall on live video to show this surveyor V21 entered R5's room. It was not clear on the live camera feed, which room V1 was entering. Based on the view available from the video, it was not possible to determine if V21 entered R5's room or the room next to it. 2. R9's facility Admission Record with a print date of 10/26/22 documents R9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R9's MDS dated [DATE] documents a BIMS score of 13, which indicates R9 is cognitively intact. Under Section G of this same MDS, R9 is documented as requiring assist of two staff for transfers and toileting. R9's undated and incomplete care plan documents a Focus area of I have an ADL (activities of daily living) self-care performance deficit r/t (related to) Interventions included are, Bed Mobility: The resident requires (Specify what assistance) by (X) staff to turn and reposition in bed (specify frequency) and as necessary toilet use: The resident requires (Specify assistance) by (X) staff for toileting, transfer: The resident requires Mechanical Lift (specify) with (x) staff assistance for transfers. R9's care plan documents a Focus area of I have diabetic ulcer of the (specify location) r/t with interventions that include, Position resident off affected area. Change position every 2 hours and PRN (as needed). On 10/18/22 at 3:00 PM, V8 stated she has told R9 he could talk with V2 (DON) about call light complaints. V8 stated she left a note in V2's office addressed to the Director of Nurses and Administrator for R9. On 11/03/22 at 1:04 PM V2 (DON/Director of Nurses) stated she knew she had gotten notes and/or verbal updates related to R9, but she couldn't remember a specific note related to call lights. On 10/27/22 at 3:00 PM, R9 was observed sitting in his motorized wheelchair in the hallway. R9 entered his room and stated he had been waiting to go to bed for two hours. R9 stated staff come and turn his call light off and then he turns it back on. R9 stated his bottom hurts bad as well as his hips and his legs. R9 stated he has had to wait for them to change his depends and when the urine sits on his skin it [CONDITION(S)], like it is right now. R9 stated he has been in his chair since 11:00 AM and he starts hurting about an hour after he gets up. R9 stated the pain just gets worse and worse. R9 stated it makes him angry when they do this and he has never been angry in his life, but they are making him that way when they don't answer the call lights and/or provide care. R9 stated, watch this. R9 pushed his call light at 3:03 PM. This surveyor did continuous observation from inside R9's room. At 3:25 PM this surveyor could hear staff talking in the hallway outside R9's room. Staff entered R9's room at 3:32 PM and R9 told them he wanted to go to bed. They left and returned with a mechanical lift at 3:38 PM. This indicates R9's call light was unanswered from 3:03 PM until 3:32 PM. On 11/10/2022 at 12:15 PM, R9 stated, he would like to report another late call light experience that just happened. R9 stated, today (11/10/22) at about 11:00 AM, he was in bed, turned on his call light wanting to get up, and an unidentified staff member came in the room and shut off his light. R9 stated, he waited and called the nurses station to have them get him up and was told they would send someone to his room. R9 stated, he did not know names of any of the staff because he did not ask and they do not wear name tags. R9 showed his phone to surveyor with a call to the facility at 11:39 AM. R9 stated, at about 12:00 PM he turned on his call light again and a CNA came in and got him up within about 5 minutes. R9 stated, he has reported call light issues to administration before and nothing has been done about it. R9 stated, his roommate (R7) also has issues with staff not answering his call light timely. 3. R6's facility Admission Record with a print date of 10/20/22 documents R6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's MDS dated [DATE] documents a BIMS score of 12, which indicates R6 has a moderate cognitive impairment. Section G of R6's MDS documents that R6 requires assist of two staff for bed mobility, transfers, and toilet use. R6's undated care plan documents under the Focus area, I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) obesity, DM II (type 2 diabetes), mild cognitive impairment with interventions that include R6 requires extensive assist by 2 staff for toileting and transfer. On 10/18/22 at 5:44 AM, R6's call light was observed on. R6 stated her call light had been on for about 20 minutes. R6 stated that is about the average time it takes for a call light to be answered. R6 stated she has waited for up to four hours before to get assistance to be lifted with the mechanical lift. R6 stated she recently had a catheter removed and has some urge incontinence. R6 stated the light situation is so frustrating. R6 stated staff will come to her room, turn the call light off, say they need to find someone to help them, then leave, and you never know when they will come back. R6's call light remained on throughout the interview with at least one unidentified staff member passing by her room during the interview. R6's call light was observed on and not answered until 6:16 AM. This indicates R6's call light was unanswered by staff for 32 minutes. On 10/18/22 at 3:00 PM, when asked if she had residents complain call lights weren't being answered timely V8 (CNA) stated, Absolutely. V8 stated R6 was very appreciative of the care V8 provided and had reported to V8 that R6 will have a need for something that requires two people such as a mechanical lift transfer and R6 reported it may be up to four hours before she gets assistance. V8 stated she told R6 she could talk with V2 (DON) about it and R6 declined on that day. On 10/25/22 at 10:12 AM, R6 was observed sitting in her recliner in her room with her family at her side. R6 stated she had to wait an hour yesterday (10/24/22) when she needed a mechanical lift to get up. On 10/27/22 at 3:55 PM, R6 was observed sitting in the recliner in her room. When asked if there was any negative impact when it took a while for staff to answer her call light R6 stated, It makes me feel like I don't matter. R6 stated she had a urinary catheter until recently and she is supposed to be doing bladder training since it has been removed. R6 stated it is really hard to train your bladder when it takes two and a 1/2 hours for them to answer the call light. R6 stated she has been bladder training herself in her incontinence brief. 4. R7's facility Admission Record with a print date of 10/26/22 documents R7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's MDS dated [DATE] documents a BIMS score of 11, which indicates R7 has a moderate cognitive impairment. Under Section G, the same MDS documents R7 requires assist of two staff for transfers and toileting. R7's undated Care Plan documents a Focus area of I have an ADL self-care performance deficit r/t Mild Intellectual disabilities and lack of coordination. Interventions documented on the care plan include, Toilet Use: R7 is dependent on mechanical and 2 staff with toileting at this time. Transfer: R7 is dependent on mechanical lift and 2 staff for transfers between areas as necessary. On 10/25/22 at 2:12 PM, R7 was observed sitting in his room. R7 stated the facility staff don't answer call lights timely. R7 pushed his call light at 2:13 PM. A CNA came into R7's room almost immediately and he told her he was wanting to get up. She stated she would have to get the mechanical lift after other staff were finished using it and would be right back. On 10/25/22 at 2:38 PM, this surveyor observed R7's call light back on. Upon entering the room R7 was observed still laying in bed. R7 stated staff haven't been back in to get him up. On 10/25/22 at 2:42 PM, R7 was observed still in bed, and he stated staff keep coming in and turning his call light off and saying they have to get help and will be right back. At 2:48 PM staff are observed entering R7's room with a mechanical lift. This indicates R7 waited 36 minutes for staff to assist him out of bed. 5. R8's facility Admission Record with a print date of 10/20/2022 documents R8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R8's MDS dated [DATE] documents a BIMS score of 14, which indicates R8 is cognitively intact. Section G of R8's MDS documents that R8 requires two-person physical assist for transfers and toileting. R8's undated care plan documents a Focus area I have an ADL self-care performance deficit r/t decreased mobility, lack of coordination with interventions that include R8 requires extensive assist by 2 staff for toileting and R8 requires a mechanical lift with two staff to move between surfaces. R8's care plan documents a Focus area of I am a non-reliable responder with interventions that include, Allow resident to voice perceptions thru active listening, ask open ended questions, investigate resident statements and/or concerns, praise factual statements, redirect with kindness, do not argue with resident. On 10/18/22 at 6:00 AM, 6:15 AM, and 6:21 AM R8's call light is observed on. On 10/18/22 at 6:21 AM, R8 was observed lying in bed. R8 stated the facility staff were supposed to have gotten her up at 5:00 AM. When asked why they were to get her up that early R8 stated Because I wanted to get up. R8 stated she put her light on at 5:00 AM and told the staff last night she wanted to get up at 5. When asked if it normally takes a while for them to answer call lights R8 stated, Oh my God, yes, sometimes 2-3 hours. When asked if anything negative had happened when it took staff awhile to answer her call light R8 stated, wet the bed, pooped the bed. On 10/18/22 at 6:45 AM, staff entered R8's room to assist her up. Aside from R8's verbal report of activating her call light at 5AM, R8's call light was visually seen by this surveyor as unanswered from 6:00 AM until 6:45 AM, indicating her call light was on for 45 minutes. On 10/18/22 at 12:58 PM, V6 (CNA) stated they usually have three CNA's, a shower aide, and a restorative aide on [NAME] and two CNA's on Rose. When asked if this is enough staff to provide care for the residents, V6 stated she believed so. When asked why it took so long answer the call lights on the morning of 10/18/22, V6 stated she wasn't sure. V6 stated she wasn't at the facility the whole time. V6 stated she usually gets to the facility around 6:00 AM. V6 stated night shift didn't say anything about the light being on or how long it had been on. On 10/18/22 at 3:00 PM, when asked if 45 minutes was too long for a call light to not be answered, V8 (CNA) stated she thought a call light that was not answered for that long could be dangerous. 6. R20's facility Admission Record with a print date of 11/3/22 documents R20 was admitted to the facility on [DATE] and discharged from the facility on 8/3/22. R20's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R20's MDS dated [DATE] documents a BIMS score of 12, which indicates R20 has a moderate cognitive impairment. The same MDS Section G documents R20 requires assist of two staff for transfers and toileting. R20's facility care plan with a Focus area of I have an ADL self-care performance deficit r/t with interventions of Transfer: R20 requires limited assist by 1 staff at times to move between surfaces as necessary. PT/OT (physical therapy/occupational therapy) evaluation and treatment as per MD (physician) orders. The facility Concern/Compliment Form dated 7/6/22 documents under Nature of Concern/Compliment waited over an hour to be changed, yelling out for help. Resident (R20) say (sic) he wearing (sic) Put in bed and did not change, left me there, change clothes finally this morning. His bottom is red and hurts. On 10/19/22 at 12:55 PM, V10 (Social Services Director) stated R20 was discharged home. V10 stated she was the one who assisted him with his concern. V10 stated R12 had his call light on, and staff came down and put him to bed without changing him. V10 stated they didn't put his pajamas on and left R20 in his clothes. V10 stated R20 had [CONDITION(S)] (C-diff) and would sometimes have accidents and he was supposed to get assistance to go to the bathroom. V10 stated R20 reported to her that he knew the staff hear residents hollering all day and night. V10 stated he was a little upset, but he just wanted the facility to know what happened. V10 stated she thought R20's bottom was red and hurting because of the C-diff not because he had been left all night without changing him. V10 stated R20 reported they would pass the call light up and he would yell out and the staff weren't responding to him. V10 stated R20 went an hour until someone came and answered his call light and took him to the bathroom, but he went all night in his clothes. The facility Resident Council meeting minutes documents the following, 5/11/22 Old business .Hard to get help in rooms during mealtimes. 6/8/22 Old Business .Hard to get help in rooms at meal times- Getting better. 7/13/22 .Nursing Call lights- Not answered on timely manner . 8/10/22 .Nursing: Call lights not getting answered timely. 9/14/22 .Nursing: .Call lights looked (sic) 10/12/22 .Nursing: Good- Still need work on call lights. Residents waiting long periods to be laid down. The facility Complaint Resolution Form dated 7/13/22 documents, Problem: Call lights- Not answered on a timely manner. Department: Nursing. Resolution: Call light education for staff on 7/25/22. The facility Complaint Resolution Form dated 8/10/22 documents, Problem: .Call light not answered timely manner .Resolution: call light response time will be monitored . There were no other Complaint Resolution Forms provided to this surveyor. On 10/19/22 at 12:55 PM, V10 (Social Services Director) stated she was responsible for reviewing and following up with some of the facility grievances/resident council meeting concerns. V10 stated they have had concerns with call lights not being answered timely brought up in resident council meetings. Reviewed with V10 the resident council meeting minutes that document concerns for the past four months. When asked what the facility has done to address the call light concerns V10 stated they had educated staff, including non-nursing staff that anyone can answer the call light. V10 stated if the person that answers the call light is not able to fulfill the need, they should pass it on to the nursing staff and then follow up with the resident in 15 minutes to ensure the need was met. V10 stated she also knows the facility did a questionnaire and an in-service, but she wasn't involved in implementing those. On 10/20/22 at 6:45 AM, when asked if she knew why call lights weren't being answered timely, V14 (LPN), stated if they put the call light on when supper trays go out or in the morning when people are getting up it may extend the time it takes to answer them. On 10/21/22 at 1:55 PM, when asked how quickly call lights should be answered V2 (DON) stated, In a timely fashion. V2 stated they have educated staff on answering call lights timely and are implementing nursing staff and CNA staff to come in at different times so they can monitor call lights better. V2 stated they did a call light audit, but she felt it would be more accurate if they had a different system. V2 stated she has also come to the facility at different times at night to audit call lights. On 10/26/22 at 9:41 AM, when asked when he became aware call lights weren't being answered timely and what the facility did about it, V1 stated, the majority of call lights happen all at the same time. V1 stated that is when everyone wants to lay down or get up. V1 stated he has tried to teach staff to prioritize call lights and they have done call light audits. V1 stated it usually takes them about 10 minutes on average to answer the lights. This surveyor informed V1 that call light observations revealed they weren't answered for 30-45 minutes on the morning of 10/18/22, and he stated that is when everyone wants to get up and the nursing staff are doing their rounds during that time frame. When asked if that was an appropriate time frame for call lights to be answered V1 stated he would like to see them answered sooner than that. This surveyor informed V1 that R8 stated she wanted to get up at 5:00 AM and V1 stated that was funny because R8 never wanted to get up early. When asked if he thought R8 really didn't want to get up early V1 stated, No. She (R8) is one who could lay in bed all day and never want to get up. When asked what his expectation would be in the situation where staff turn the call light off, leave, and don't come back, V1 stated he would expect them to go back and finish the task or leave the call light on until the need is met. Reviewed with V1 the observation on 10/25/22 of staff telling R7 they would have to wait for the mechanical lift and V1 stated, maybe the battery wasn't charged on the mechanical lift, or some staff don't like to use the manual lift, or one resident takes a lot longer to transfer. When asked if that was an acceptable time frame to wait to get up, V1 stated he would like it to be sooner, but it just depends on the circumstances. On 11/04/22 at 3:21 PM, V2 stated there is no specific time frame that call lights are to be answered in the facility call light policy. When asked how staff know what the expectations are regarding how quickly a call light should be answered, V2 stated, they should just be prioritized by what resident needs, need to be met first. The facility Call Light policy dated 11/28/12 documents, Purpose: To respond to residents' requests and needs in a timely and courteous manner. Guidelines: Resident call lights will be answered in timely manner. 1. All residents that have the ability to use a call light shall have the nurse call light system at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location. 2. All staff should assist in answering call lights. Nursing staff members shall go to resident respond to call system and promptly cancel the call light when the room is entered. 3. Bathroom lights should be viewed as emergencies and immediate attention will be given. 4. Requests shall be responded to in a courteous and professional manner. 5. Hand bells will be provided for alert dependent residents when position out of reach of permanent call light when needed. 6. Call bell system defects will be reported promptly to the Maintenance Department. Check room frequently until system is repaired . The facility Daily Census dated 10/16/22 given to this surveyor on 10/18/22 documents 67 residents reside at the facility.

Based on observation, record review, and interview the facility failed to ensure residents were not restrained for staff convenience for 1 of 3 (R3) residents reviewed for restraints in the sample of 20. R3 who has a severe cognitive impairment, had a fall on night shift, was unsteady on his feet, and refusing to stay in bed. Facility staff placed R3's mattress on the floor and placed R3 on his mattress. R3 was unable to stand up from the floor and crawled on his hands and knees to the door and asked for help. A reasonable person would have felt humiliation, fear, had loss of dignity, anxiety, and agitation, as well feelings of being dehumanized by being placed in a position they were only able to crawl away from. Findings Include: R3's Admission Record with a print date of 10/20/22 documents R3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's MDS (Minimum Data Set) dated 9/8/22 documents a BIMS (Brief Interview for Mental Status) score of 01, which indicates R3 has a severe cognitive impairment. R3's same MDS documents R3 requires assist of two staff for bed mobility and transfers. Under balance during transitions and walking, R3's MDS documents R3 is not steady, only able to stabilize with staff assistance. Under Functional Abilities R3's MDS documents, to go from lying to sitting on side of bed R3 requires partial/moderate assistance. R3's Restorative Observations dated 9/14/22 documents R3 is able to voluntarily move or reposition in bed and no restraints are in use. Under Care Plan it documents (R3) is able to turn side to side, go from lying to sitting and sitting to lying with supervision and verbal cues of staff at times. R3 is supervision for transfers and supervision for locomotion and mobility at times. R3's progress notes document, 9/9/22 6:25 PM Resident had a witnessed fall 09/09/2022 6:25 PM Location of fall: Residents room, Res (resident) found on floor in room and noted to have a small laceration to back of head, approx. (approximately) 3 cm. Resident assisted up and onto bed. Refuses to stay in bed, gait is unsteady and leaning backwards. Alert and disoriented per usual baseline. Assisted into bed but refuses to stay. Interventions: Mattress put on floor. R3's Fall IDT (Interdisciplinary Team) Note dated 9/12/22 10:10 AM documents, Resident observed laying on floor in room, noted to have hematoma and laceration approx. 3 cm to back of head. Moves all ext (extremities) without difficulty or c/o (complaints of). Hollering get me up. Denies any c/o (complaints of) of discomfort. Neuro (neurological) checks initiated and WNL (within normal limits). Assisted up x (times) 2 staff and amb (ambulated) to bed. Refuses to stay in bed. Ambulating per self, gait is unsteady, and resident is leaning backwards when walking. Root Cause of fall: Resident lost balance, ambulating without assistance. Intervention and care plan updated: Resident moved to room right across from nurse's station for increased monitoring. On 10/20/22 at 9:52 AM, V15 (LPN/Licensed Practical Nurse) stated, one-night (date unknown), R3 fell and bumped his head and she put his mattress on the floor that night. V15 stated R3 had a 2-3 cm laceration on the back of his head. V15 stated she did neuro (neurological) checks, fall monitoring, and behavior monitoring, called the physician, and gave R3 snacks. When asked how putting the mattress on the floor helped, V15 stated, Well he wasn't able to get up. V15 stated she was the only one on that unit and she wasn't able to properly supervise R3. V15 stated the CNA (Certified Nursing Assistant) working with her on that night got sick and left the facility around 2:00 AM. V15 stated she tried to call people in, but no one was able to. V15 stated it is not typical to only have one staff member working on the unit. On 10/20/22 at 12:46 PM, this surveyor informed V2 (DON/Director of Nurses), of V15's interview of putting R3's mattress on the floor and V15 stated R3 couldn't get up. V2 stated she would consider putting R3's mattress on the floor a restraint and R3 isn't assessed for needing restraints. A statement by V15 dated 10/20/22 that was provided to this surveyor by V1 (Administrator) and V2 (DON) documents, I spoke with the state surveyor concerning R3 the night he fell , I was alone on unit as the CNA scheduled was sick and left. R3 was restless, refusing to stay in bed. I told her he was restless, refusing to stay in bed. I also had told her I walked with him, gave him snacks and attempted to sit with him to calm him down. Ineffective. He was leaning backwards while walking and balance was very poor and put his mattress on floor for his safety r/t (related to) balance and restlessness and attempting other redirection without success. On 10/21/22 at 12:02 PM, V20 (RN/Registered Nurse) stated she had never seen R3's mattress on the floor. V20 stated R3 would be able to get up from the floor without assistance. V20 stated she had never seen R3 get up from the floor, but he got out of his bed that was in a low position without assistance. On 10/26/22 at 1:08 PM, V23 (MDS Coordinator/Certified Restorative Nurse) stated he does restorative assessments on the residents and last assessed R3 on 9/14/22. V23 stated he saw R3 walking in the hallways after that assessment and wasn't aware of a decline in his functional capabilities. V23 stated he believed R3 could get up off the floor. V23 stated he believed R3 would have to crawl to some type of support to get up but that he could get up, once he had the support of a bed, wall, or chair. On 10/21/22 at 1:55 PM, when asked why R3's mattress wasn't still on the floor V2 (DON) stated they probably moved it after that because they came up with a different intervention. V2 stated they probably changed it because it didn't work, and they didn't want R3 to trip over it. On 10/26/22 at 9:41 AM, V1 (Administrator) was asked about R3's mattress being put on the floor as an intervention. V1 stated (V15) ensured the safety of the resident, and he was good with the mattress being on the floor, if it was being used as a safety measure. V1 stated he thought increased monitoring would have ensured R3's safety, so his mattress wouldn't have to be put on the floor. On 11/01/22 at 4:20 PM, V15 (LPN) stated on 9/9/22 after she had moved R3's mattress to the floor R3 was able to get off the mattress and, did in fact get off it, while she was working that night. V15 stated R3 crawled on his hands and knees to the door of his room and asked for help. V15 stated she had to go to the other side to get another nurse to assist her in getting R3 off the floor. V15 stated she did not believe it would have been safe for her to assist R3 off the floor by herself. V15 stated she put R3 back in his bed and she believed he stayed there the remainder of the night. R3's undated Care Plan documents a Focus area of I am at High risk for falls r/t (related to) dementia, reduce safety awareness and wandering behaviors. Goal: All falls will be reviewed by the IDT (Interdisciplinary Team) through next review. Interventions documented on the care plan are as follows, 4/29/19- Be Sure R3's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs. Encourage R3 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: walking to meals and activities. Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes. 5/2/2019- Staff educated to make sure all personal items including water glass on the bed side table are in reach when in bed. 12/17/19-Sign (tractor) to be put on R3's door to assist him while finding is (sic) room. 12/27/19- R3 needs activities that minimize the potential for falls while providing diversion and distraction. 3/4/20-Remove all tripping hazards from room at this time. 4/13/20- Staff to ensure that R3 has all items in reach when eating. 7/13/20-Encourage R3 is (sic) wearing appropriate footwear non-skid socks or shoes when ambulating as he allows. 12/15/21- Ensure rolling desk chair is securely pushed up under desk. Place stationary chair behind nurse's station. 9/12/22-R3 room relocated closer to nurse's station to increase monitoring. 10/19/22- Night light added to R3's room to decrease falls. 10/10/22-Staff to offer assistance when R3 is ambulating as he will allow. There is no restraint focus area documented on R3's undated care plan. The facility Abuse Prevention and Reporting - Illinois policy dated 11/28/16 documents, Guidelines: The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.

Based on observation, interview, and record review the facility failed to ensure falls were investigated, new and/or appropriate interventions to prevent falls were implemented, and appropriate levels of supervision were in place to prevent injury for 4 of 4 residents (R2, R3, R4, and R5) in the sample of 20 investigated for falls. This failure resulted in R3 having four falls from 9/9/22 to 10/19/22 that resulted in hematomas and lacerations to his head with neurological checks not completed per facility policy, multiple bruises and cuts, and a subsequent stay at a mental health facility for a medication evaluation and adjustment. Findings Include: 1.R3's Admission Record with a print date of 10/20/22 documents R3 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's Disease, dementia, [CONDITION(S)], dysphagia, brief [CONDITION(S)], chronic kidney disease, mood disorder, and [CONDITION(S)] disorder. R3's MDS dated [DATE] documents a BIMS score of 01, which indicates R3 has a severe cognitive impairment. R3's same MDS documents R3 requires assist of two staff for bed mobility and transfers. Under balance during transitions and walking R3's MDS documents R3 is not steady, only able to stabilize with staff assistance. Under Functional Abilities R3's MDS documents to go from lying to sitting on side of bed R3 requires partial/moderate assistance. R3's Restorative Observations dated 9/14/22 documents R3 is able to voluntarily move or reposition in bed and no restraints are in use. Under Care Plan it documents (R3) is able to turn side to side, go from lying to sitting and sitting to lying with supervision and verbal cues of staff at times. R3 is supervision for transfers and supervision for locomotion and mobility at times. R3's Fall Risk assessment dated [DATE] documents a score of 12, which indicates R3 is at risk for falls. The facility fall risk assessment does not document if someone is at low, moderate, or high risk for falls. It documents if someone is at risk or not at risk for falls. R3's undated Care Plan documents a Focus area of I am at High risk for falls r/t (related to) dementia, reduce safety awareness and wandering behaviors. Goal: All falls will be reviewed by the IDT (Interdisciplinary Team) through next review, Interventions: Be Sure R3's call light is within reach and encourage the resident to use it for assistance as needed (date initiated 4/29/19). The resident needs prompt response to all requests for assistance (date initiated 4/29/19). Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs (date initiated 4/29/19). Encourage R3 is (sic) wearing appropriate footwear non-skid socks or shoes when ambulating as he allows (date initiated 7/13/2020). Encourage R3 to participate in activities that promote exercise, physical activity for strengthening and improved mobility such as: walking to meals and activities (date initiated 4/29/19). Ensure rolling desk chair is securely pushed up under desk. Place stationary chair behind nurse's station (date initiated 12/15/21). Night light added to R3's room to decrease falls (date initiated 10/19/22). Remove all tripping hazards from room at this time (date initiated 3/4/20). Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregivers/IDT as to causes (date initiated 4/29/19). R3 needs activities that minimize the potential for falls while providing diversion and distraction (date initiated 12/27/19). R3 room relocated closer to nurse's station to increase monitoring (date initiated 9/12/22). Sign (tractor) to be put on R3's door to assist him while finding is (sic) room (date initiated 12/17/19). Staff educated to make sure all personal items including water glass on the bed side table are in reach when in bed (date initiated 5/2/19). Staff to ensure that R3 has all items in reach when eating (date initiated 4/13/20). Staff to offer assistance when R3 is ambulating as he will allow (date initiated 10/10/22). A) R3's progress notes documents, 9/9/22 6:25 PM Resident had a witnessed fall 09/09/2022 6:25 PM Location of fall: Residents room, Res (resident) found on floor in room and noted to have a small laceration to back of head, approx. (approximately) 3 cm. Area slightly raised, dry drsg (dressing) applied. Resident assisted up and onto bed. Refuses to stay in bed, gait is unsteady and leaning backwards. No other signs of injuries present on 09/09/2022 6:25 PM. Assessment Unwitnessed fall, neurological checks initiated. Alert and disoriented per usual baseline. No changes in range of motion from normal baseline. New injury observed. Laceration to back of head approx. (approximately) 3 cm. Actions Taken: Dry drsg to back of head. Assisted into bed but refuses to stay. Interventions: Mattress put on floor. This progress note documents the fall as both witnessed and unwitnessed. The note then documents R3 was found on the floor in his room indicating it was an un-witnessed fall. R3's neurological (neuro) checks were reviewed, and documents neuro assessments were completed on 9/9/22 at 6:40 PM, 6:55 PM, 7:25 PM, 7:55 PM, 8:05 PM, 8:35 PM, and 12:00 AM. Neuro checks were documented as completed on 9/10/22 at 12:35 AM and 8:35 PM. All neurological checks documented have vital signs dated 9/9/22 at 6:25 PM and a pain assessment dated [DATE] at 2:48 AM. This indicates R3 did not have neurological checks done 10 times during the 72-hour post fall period. The neurological checks also document R3's vital signs and pain assessment were completed once in the same 72-hour post fall period. R3's Fall IDT (Interdisciplinary Team) Note dated 9/12/22 10:10 AM documents, Resident observed laying on floor in room, noted to have hematoma and laceration approx. 3 cm to back of head. Moves all ext (extremities) without difficulty or c/o (complaints of). Hollering get me up. Denies any c/o (complaints of) of discomfort. Neuro checks initiated and WNL (within normal limits). Assisted up x (times) 2 staff and amb (ambulated) to bed. Refuses to stay in bed. Ambulating per self, gait is unsteady, and resident is leaning backwards when walking. Root Cause of fall: Resident lost balance, ambulating without assistance. Intervention and care plan updated: Resident moved to room right across from nurse's station for increased monitoring. On 10/20/22 at 9:52 AM, V15 (Licensed Practical Nurse/LPN) stated one-night (date unknown) R3 fell and bumped his head and she put his mattress on the floor that night. V15 stated R3 had a 2-3 cm laceration on the back of his head. V15 stated she did neuro checks, fall monitoring, and behavior monitoring, called the physician, and gave R3 snacks. When asked how putting the mattress on the floor helped, V15 stated, Well he wasn't able to get up. V15 stated she was the only one on that unit and she wasn't able to properly supervise R3. V15 stated the CNA (Certified Nursing Assistant) working with her on that night got sick and left the facility around 2:00 AM. V15 stated she tried to call people in, but no one was able to. V15 stated it is not typical to only have one staff member working on the unit. On 10/20/22 at 12:46 PM this surveyor informed V2 (DON/Director of Nurses), of V15's interview of putting R3's mattress on the floor and V15 saying R3 couldn't get up. V2 stated she wasn't aware of them only having one nurse on the unit and no CNA's. V2 stated she would expect facility staff to call her if that happened. V2 stated she would consider putting R3's mattress on the floor a restraint and R3 isn't assessed for needing restraints. A statement by V15 dated 10/20/22 that was provided to this surveyor by V1 (Administrator) and V2 (DON) documents, I spoke with the state surveyor concerning R3 the night he fell , I was alone on unit as the CNA scheduled was sick and left. R3 was restless, refusing to stay in bed. I told her he was restless, refusing to stay in bed. I also had told her I walked with him, gave him snacks and attempted to sit with him to calm him down. Ineffective. He was leaning backwards while walking and balance was very poor and put his mattress on floor for his safety r/t (related to) balance and restlessness and attempting other redirection without success. On 10/21/22 at 12:02 PM, V20 (RN/Registered Nurse) stated she had never seen R3's mattress on the floor. V20 stated R3 would be able to get up from the floor without assistance. V20 stated she had never seen R3 get up from the floor, but he got out of his bed that was in a low position without assistance. On 10/26/22 at 1:08 PM, V23 (MDS Coordinator/Certified Restorative Nurse) stated he does restorative assessments on the residents and last assessed R3 on 9/14/22. V23 stated he saw R3 walking in the hallways after that assessment and wasn't aware of a decline in his functional capabilities. V23 stated he believed R3 could get up off the floor. V23 stated he believed R3 would have to crawl to some type of support to get up but that he could get up, once he had the support of a bed, wall, or chair. On 10/21/22 at 1:55 PM when asked why R3's mattress wasn't still on the floor V2 (DON) stated they probably moved it after that because they came up with a different intervention. V2 stated they probably changed it because it didn't work, and they didn't want R3 to trip over it. On 10/26/22 at 9:41 AM when asked about R3's mattress being put on the floor, V1 (Administrator) stated, she (V15) ensured the safety of the resident. V1 stated he was good with the mattress being on the floor, if it was being used as a safety measure, but he thought increased monitoring would ensure that, so you didn't have to put the mattress on the floor. When asked if he was aware the CNA had to go home and there was only one staff member on the unit V1 stated he was not. V1 stated there were three CNA's working on the other halls and they would have floated over to that unit to help. On 11/01/22 at 4:20 PM, V15 (LPN) stated on 9/9/22 after she had moved R3's mattress to the floor R3 was able to get off the mattress and did in fact get off it while she was working that night. V15 stated R3 crawled on his hands and knees to the door of his room and asked for help. V15 stated she had to go to the other side to get another nurse to assist her in getting R3 off the floor. V15 stated she did not believe it would have been safe for her to assist R3 off the floor by herself. V15 stated she put R3 back on his mattress that was still located on the floor, and she believed he stayed there the remainder of the night. When asked if that was the only time another staff member came to the unit to assist her, V15 stated the other nurse came over to the unit around 5:30 AM so she could go to the other side to pass medications. When asked if she notified V1 or V2 she was the only staff working on the unit V15 stated the other nurse made the calls since she had been working at the facility longer and she knew she had attempted to call staff in but wasn't sure if she had attempted to call V1 or V2. B) R3's unwitnessed fall report dated 9/23/22 documents, R3 was asleep in room with door to room closed. CNA (Certified Nursing Assistant) was sitting at the nurse's station desk and she seen the resident open up his door. The resident had blood all over himself, the floor, and his bed, appearing to come from an open area on the back of his head, that also includes a knot area. Resident unable to give description. Description: The CNA called this nurse. and this nurse preformed an assessment, as able, due to resident's dementia and combative behavior. He appeared to be alert with confusion, able to stand and walk around and get in and out of his bed. The blood appeared to come from an open area to the back of his head. His vital signs were taken and he was assisted to the shower by 2 CNA's. Resident was very angry with getting a shower, he was yelling and hitting staff while shower was in progress Resident taken to hospital: Laceration back of head R3's Fall IDT Note dated 9/23/22 documents Intervention and care plan updated: Staff education for making sure door is open when not doing resident care. R3's neurological checks were reviewed, and documents neuro assessments were done on 9/23/22 at 3:45 AM, 6:30 AM, 10:30 AM, 2:30 PM, 6:30 PM, and 10:30 PM; and on 9/24/22 at 2:30 AM, 6:30 AM, and 2:30 PM, 9:25/22 at 6:30 AM and 2:30 PM. This indicates R3 did not have neurological assessments completed 7 times in the 72-hour post fall period. C) R3's 10/08/22 witnessed fall report documents, R3 was walking down hall and lost balance and fell to right side onto floor, resident did not hit head. Immediate Action Taken: Resident trying to get self-up, staff helped resident up after assessed. No injuries at time of incident. R3's Fall IDT Note dated 10/10/22 documents, Intervention and care plan updated: Staff to assist resident with ambulation as he allows. D) On 10/18/22 at 6:42 AM, R3 was observed walking the length of the dining room and out into the hallway. R3 was wearing pajamas and no shoes. R3 was unsteady and stumbling some during this observation. R3 had dried blood on his shirt on the top of his left shoulder, on his left ear, and on his neck behind his left ear. There were no staff observed in the dining room or in the hallway. This surveyor noted V7 (CNA) behind the nurse's station in a small room eating breakfast. This surveyor notified V7 of the blood and she stated she thought the blood on his shirt was dried blood. This surveyor agreed with her that it was dried blood and pointed out the blood on R3's ear and neck. V7 stated she didn't know if it was something new and walked with R3 to a room located down the hall, not near the nurse's station. She then went back to the small room behind the nurse's station and began eating. R3 was observed two more times throughout the day on 10/18/22, both times he was in bed. Immediately following this observation and throughout the day on 10/18/22, R3's medical record was reviewed and did not document incident reports, assessments, or follow up related to the dried blood on R3's left ear/neck. On 10/18/22 at 1:30 PM, V7 (CNA) stated R3 had been really combative on 10/18/22. V7 stated they told the nurse about his ear, and she thinks maybe he scratched it. V7 stated they tried cleaning his ear, but he wouldn't let them. When asked if she was aware of any recent fall, V7 stated, there was nothing in report and nothing happened on day shift on 10/18/22. (The most recent fall documented in R3's record was on 10/08/22.) On 10/20/22 at 6:30 AM, V13 (LPN/Licensed Practical Nurse) stated she didn't know what happened to R3's left ear. On 10/21/22 at 10:05 AM, V18 (CNA) stated she had provided care to R3 but not when he had any falls. When asked if she knew what happened to R3's ear V18 stated she had no clue. On 10/20/22 at 11:51 AM, V17 (LPN) stated she worked on Tuesday 10/18/22. When asked if she knew what happened to R3's ear V17 stated, just what she was told, that he had hit it on his bed or something the night before. (There is no documentation in R3's medical record of him hitting his head on the bed on 10/17/22). On 10/20/22 at 12:46 PM when asked about the injury to R3's ear V2 (DON) stated there was always an ongoing investigation for R3. When asked if I could see the investigation V2 stated she didn't have anything written on it that she could give me. After this interview V2 provided this surveyor with the following documentation on 10/20/22. R3's Skin Tear report dated 10/18/22 4:45 PM documents, Resident ambulating falling back to hit the closet door with his left arm causing multiple skin tears to upper-elbow-forearm of left arm, wounds cleansed with wound cleanser non adhere drsg (dressing) applied arm wrapped with cling wrap and secured with tape. R3's Progress note dated 10/18/22 at 5:22 PM Resident has been very restless, hitting the doors and walls with his hands, difficulty with sitting still, resident was in his old room and fell back against the closet doors and caused skin tears to back side of upper middle and lower left arm, combative with staff when trying to provide care, hitting, kicking, pinching, and biting at staff. Notified V4 (Physician) with new order received to give PM dose of [MEDICATION(S)] now and hold tonight dose. Notified ADON (Assistant Director of Nurses) and POA (power of attorney) of health care with a return call from (family member) with update on condition. Staff assist to DR (dining room) for supper meal resident unable to sit long enough to eat, carried around bowl of peas to eat. The skin tear report dated 10/18/22 at 4:45 PM and the progress note dated 10/18/22 at 5:22 PM indicate R3 did not have documentation in his medical record related to a fall prior to the observation on 10/18/22 at 6:42 AM that would account for the dried blood on his ear/neck. Upon requesting the investigation for the areas on R3's neck/ear this surveyor was provided with the following progress note. R3's 10/20/22 8:48 AM progress note documents, Resident had fall, struck side of bed on LT (left) side of head, scratches to LT side of ear which is consistent with striking head on bed on LT side, Injury with dried blood was noticed within one day, healing was already taking place which is consistent with time of fall. This report has handwritten on it, From 10/18/22 fall This information is consistent with the information provided by V17 (LPN) in her interview on 10/19/22 at 11:51 AM. There is no other documentation in R3's medical record related to follow up, neurological checks, or new interventions related to a fall where R3 hit his head on his bed. R3's Injury of Known report with the date cut off and not readable documents Resident had a fall where he struck the left side of his head, scratch is on left side of head. This report was given to this surveyor with R3's progress notes dated 10/20/22 8:48 AM, attached to it. When asked for a copy of this report with the date viewable received the following risk management report from V2. R3's Risk Management report dated 10/20/22 8:48 AM documents, Resident had a scratch to left ear. Under Description of Action Taken the report documents, Resident had a fall where he struck the left side of his head, scratch is on left side of head. On 11/02/22 at 4:32 PM, V1 and V2 were asked to clarify the discrepancies in the progress notes, skin tear report, and risk management report. They stated they would see what they could find. As of 11/03/22 they had not provided this surveyor with any other information. On 11/04/22 at 9:49 AM spoke with V1 and V2 and explained that I needed clarification related to the different reports on R3's fall related to the area on his ear. V2 stated she had sent me the report with handwritten information at the bottom of the report. V2 stated she would see what else they had and send it to me. On 11/04/22 at 11:46 AM received an email with an Investigation of Skin Tear, Bruises, and Abrasions attached dated 10/18/22. The report documents the location as left ear with no description of injury documented. The report documents R3 had several recent falls et (and) behaviors. Handwritten at the bottom of the report it documents, We do weekly skin assessments, done 10/11/22, then 10/18/22. After wound was cleaned, it was a small scratch. R3 has many behaviors, including beating on walls and doors, tearing fixtures off of wall. R3's frequently taking clothes off, refuses to have nails trimmed, so resident does scratch self often. Scratch is consistent with resident behavior. Blood spot was found on resident pillowcase, consistent with scratch. On 11/4/22 at 12:50 PM spoke with V1 and V2 related to the information provided in the email dated 11/4/22 at 11:46 AM. V2 stated R3 did not have any behaviors or falls on 10/17/22. V2 stated the skin tear report dated 10/18/22 at 4:45 PM and the progress note dated 10/18/22 at 5:52 PM are referencing the same incident that occurred at 4:45 PM. V2 stated she thinks the progress note dated 10/20/22 at 8:48 AM was when she was talking with nurses and trying to determine where the dried blood on R3's ear and neck had come from. V2 stated she assumed it came from the other fall. When asked what other fall she was referencing she stated the nurses had told her R3 had fallen by his bed. V2 then stated R3 didn't actually fall and hit his head on his bed, but she believes he scratched his ear while in bed. E) R3's progress notes document the following on 10/19/22 at 7:27 AM Resident up and down this shift, after fall resident made one on one so he would have supervision to prevent further falls, no s/s (signs of symptoms) of distress noted will cont (continue) to monitor. This is signed by V13 midnight shift nurse and is not documented as a late entry. R3's progress note dated 10/19/22 at 8:05 AM Nurse contacted MD (physician) about resident behavior. New order rec'd (received) to give [MEDICATION(S)] early et (and) hold bedtime dose. This is signed by V2 (DON). On 10/19/22 at 10:30 AM this surveyor with V8 (CNA) present observed R3 lying in bed. R3 had a large red and purple hematoma on the left side of his head that went from the top of his forehead down his nose and across his face covering his left eye. When asked what happened V8 stated R3 had fallen last night but she didn't have any of the details. R3's Un-witnessed fall report dated 10/18/22 at 6:30 PM documents This nurse was at nurse's station getting report, other nurse helped resident to bed, staff heard resident yelling help sitting in floor on bottom, trying to get up, resident noted to have hematoma to left forehead. Under description the report documents resident helped to feet and bed; ice applied to forehead. R3's 10/19/22 3:47 PM Fall IDT Note documents, This nurse was at nurse's station getting report other nurse helped resident to bed, staff heard resident yelling help sitting in floor on bottom, trying to get up, resident noted to have hematoma to left forehead. Root Cause of Fall: Resident in dark room. Intervention and care plan updated: Night light placed in resident's room to better see when room is dark. On 10/20/22 at 6:30 AM, V13 (LPN) stated she was working recently (unsure of date) when R3 had a fall. V13 stated they were in the middle of report, and she got up because R3 had been walking to the door and she put R3 in bed. V13 stated she continued to give report and then heard R3 say help me. V13 stated R3 was sitting on his bottom with a hematoma on his forehead. V13 stated she had one of the girls sit with him one to one after that and made sure the chairs were out of his room. On 10/19/22 at 11:51 AM when asked if she felt they had enough staff to provide care for R3, V17 stated, No I think he would need to be 1:1 to prevent falls and/or behaviors. On 10/19/22 at 1:35 PM, V12 (LPN) stated R3 did not have one to one ongoing but they are doing frequent checks on R3. V12 stated the one to one stopped about 7:00 AM on 10/19/22. On 10/21/22 at 1:55 PM when asked how R3 fell and got a hematoma to his head on 10/19/22 if he was 1:1, V2 stated, That is a good question. When asked if he was supposed to be 1:1 at the time of the fall on 10/19/22, V2 stated they had sitters for R3 since the night of 10/18/22. When asked if she knew where R3's one to one sitter was when he fell on [DATE], V2 stated she hadn't looked into it yet. Reviewed R3's progress notes with V2 and she stated he should have been one to one at the time of the second fall. V2 then stated she doesn't know where the nurse got the order from and R3 probably fell during report. On 10/25/22 at 12:19 PM when asked if she had any more information on R3 having a 1:1 sitter when he fell on [DATE], V2 stated she did not. V2 stated she knew the staff kept an eye on R3 but there was no documentation of 1:1 monitoring. When asked if he was supposed to be 1:1 monitoring at the time of the fall V2 stated, Yes the nurse had implemented it. When asked if there was someone with R3 when he fell V2 stated he would have been right there, someone would have been close to him. When asked if there was a staff member right with R3 when he fell V2 stated it didn't seem like it. V2 stated she couldn't say for sure since she wasn't there, but it wasn't documented. On 10/26/22 at 12:46 PM, V1 (Administrator) stated R3 was made 1:1 short term on night shift on 10/18/22 after he fell and that when the IDT team met, they changed the intervention to a place a night light in his room since it was dark. V1 stated any resident who is to be placed 1:1 would be approved through him so he could get more staff to assist with monitoring and R3 had not been one to one other than the short time after a fall. This indicates R3's progress notes document on 10/19/22 at 7:27 AM R3 had a fall and the intervention implemented was 1:1 staff. R3's un-witnessed fall report documents the fall on 10/18/22 at 6:32 PM. R3's 10/19/22 7:27 AM progress note does not document if it is a late entry and referencing the fall on 10/18/22 at 6:32 PM. V2's interview documents R3 was 1:1 with sitters beginning on 10/18/22. V2 did not investigate if R3 was supposed to have had a 1:1 sitter and if so where the 1:1 sitter was at the time of the fall on 10/19/22. F) On 10/19/22 at 3:45 PM, R3 was observed sitting on the side of a bed with no sheets on it, wearing torn pajama pants, a dressing was observed to R3's left hand, a hematoma to R3's left forehead, left cheek and left eye area is black/red/blue. R3 doesn't speak to this surveyor. There is a recliner next to the bed with the footrest raised and blankets in the recliner. V31 (LPN) was present with this surveyor and stated to R3 that he had gotten out of the recliner. V31 attempted to redirect R3 when he stood up from the bed. R3 was very unsteady on his feet. R3's soles of his feet were either bruised or dirty and there were scratches observed on the side of R3's left foot. R3's progress notes document on 10/11/22 at 10:00 PM, Weekly skin observation completed for R3. Skin is warm, dry, within normal limits. Skin turgor is good. Skin Concerns: Skin concerns observed: Back of head-scabbed area from recent fall. No s/s of infection. No swelling, Skin concerns observed are not new. This skin assessment does not document any other areas observed to R3's skin. R3's progress notes document on 10/19/22 at 4:01 PM Skin assessment completed today and V4 (Physician) notified for treatments for skin tears. Skin tear noted left wrist, old skin tear noted to left second digit and slight bruising starting around it. 3 skin tears noted near left elbow area, left upper forearm has a skin tear, old skin tear noted on right wrist, bruise noted on left shoulder area pinkish purple in color, right lower back has a small scab noted, abrasion noted behind left ear/neck, left lower ear lobe has a small open area like skin tear, bruising pinkish purple noted to center of upper chest, right buttocks and right post thigh has bruising and it is spreading to other side of buttocks and starting to go down scrotum and lower back, back of scalp has a small scabbed area left eye and cheek and forehead has dark purple pinkish red bruising and eye lids are swollen and left eye is reddened, right lower ext (extremity) has a small scab approx. (approximately) 1.5 cm ( centimeter), left lower ext has a small scab approx. 0.5 cm long, few small scattered bruises noted to bil (bilateral) hands, pinkish purple bruising noted to right temple area and right side forehead. On 10/20/22 at 6:30 AM when asked if they had enough staff to provide care for R3, V13 (LPN) stated, Sometimes. V13 stated lately R3 had not been easily redirected and she thinks it started when he started the [MEDICATION(S)]. V13 stated R3's feet aren't bruised they are just dirty because he refuses to cover his feet On 10/26/22 at 9:41 AM when asked if he investigated the injuries of unknown origins including the bruises noted on R3's skin assessment from 10/19/22, V1 (Administrator) stated they were just going by the several falls that he had and his picking. V1 stated R3's behaviors have been escalating for the past month. When asked how he knew the injuries came from the falls/behaviors and didn't come from abuse, V1 stated, I interview, I look at the bruising, the type of bruising, and determine if it is consistent with the fall. When asked for that investigation documenting those findings, V1 stated he didn't have one in writing, but he could write it up for me. On 11/0/1/22 at 5:36 PM, V1 provided this surveyor with the following investigations: R3's Investigation of skin tear, bruises, abrasions dated 10/18/22 documents left ear under location with no type or description of injury documented. The areas of First noted by whom, Date, Time, Date/Shift of last shower, and transfer status, Equipment, any new assistive devices or equipment, any signs/symptoms of infection, Resident interview, Most likely cause, Staff interviews conducted, New intervention, Care plan updated, Investigation Completed by, Date, and Reviewed by Administrator are all blank. Under Recent Fall or injury-date and specifics it documents, several recent falls et (and) behaviors. Handwritten at the bottom of the report it documents, We do weekly skin assessments, done 10/11/22, then 10/18/22. After wound was cleaned it was a small scratch. R3 has many behaviors including beating on walls et doors, tearing fixtures off of wall. Resident frequently taking clothes off, refuses to have nails trimmed, so resident does scratch self often. Scratch is consistent with resident behaviors. Blood spot was found on resident pillowcase consistent with scratch. V1 (Administrator) verified via email on 11/07/22 at 11:49 AM the skin assessment referred to in this investigation is the same as the assessment dated [DATE]. V1 stated the assessment was started on 10/18/22 and completed on 10/19/22. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/08/22 documents a bruise to right posterior thigh. Under description of area, it documents right side. Under Resident Fall or injury- date and specifics the report documents, Resident had recent fall 10/8/22 in hallway landing on right side. The following areas are blank on the report, Recent IV therapy, Recent LOA (leave of absence) with family, Equipment, any new assistive devices or equipment, any signs/symptoms of infection, Resident interview, most likely cause, staff interview conducted, new interventions implemented, and care plan updated. With no person documented under Investigation completed by and no date of completion documented. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/19/22 documents a bruise to left buttocks noted on 10/19/22. Under Recent Fall or injury- date and specifics the report documents, had recent fall in room landing on buttocks. The remainder of the report is blank except the resident interview is marked as NA and reviewed by DON (Director of Nurses) and Reviewed by Administrator has signatures. The areas of staff interviews, equipment observed, most likely cause, and investigation completed by, and date are all blank. At the end of the report the following is handwritten in, Due to recent falls IDT (Interdisciplinary Team) team and family (POA) send to (name of mental health hospital) for med review. R3's Investigation of Skin Tear, Bruises, and Abrasions dated 10/19/22 documents a bruise to left 2nd digit noted on 10/19/22. Under Recent Fall or injury -date and specifics the report documents, had recent fall hitting closet door and hits second doors. The areas of staff interview, observing equipment, investigation completed by, and date are all blank. This indicates the investigations into the bruises of unknown origin identified on 10/19/22 were not complete or thorough. The bruise to R3's chest and the area behind R3's left ear is not addressed in these investigations. The investigations were also dated prior to V1's interview that do[TRUNCATED]

Based on interview, observation, and record review, the facility failed to implement care plan fall interventions of placing the bed in the lowest position with locked wheels and against the wall for 1 of 3 residents (R7) reviewed for falls in the sample of 10. This failure resulted in R7 falling out of bed, and fracturing her (R7) left hip. Findings include: R7's Face Sheet documented an admitted [DATE]. R7's Diagnosis List included Unspecified Dementia without Behavior Disturbance, [CONDITION(S)], and [CONDITION(S)]. R7's 03/03/22 Fall Risk Assessment documented a score of 16, indicating R7 was at risk for falls. R7's Care Plan dated 02/06/22 documented a problem area, I am at risk for falls, Date initiated 6/30/21 with corresponding interventions, Ensure the bed is in the locked and lowest position, Date initiated and Revision date 03/04/22, re arranged room, Date initiated 07/14/21. R7's Minimum Data Set (MDS) dated [DATE] documented a Brief Mental Status Score of zero, indicating that R7 was so cognitively impaired that she was rarely or never understood. The same MDS documented that R7 required extensive assistance from at least two staff members for transfers and bed mobility. An Initial Report to IDPH (Illinois Department of Public Health) dated 03/03/22 documented, Description of Occurrence: Resident was found in floor between wall and bed on left side. No obvious sign of injury . Emergency Management System (EMS) called for transport to (local emergency room ). A Final Report to IDPH dated 03/10/22 documented, (R7) returned to facility with hospice consult. admitted to hospice services on 03/04/22. Will continue current (fall) interventions and ensure that the resident's bed is in the lowest and locked position. R7's Nursing Progress Note dated 03/03/22 at 9:25pm documented, Description: Resident had an un-witnessed fall 03/03/2022 9:25 PM Location of Fall: Resident room. Resident was found on floor between bed and wall on left side on 03/03/2022 at 9:25 PM. Resident statement (if applicable): Resident has a diagnosis of dementia, unable to interview Resident just yelled out normal cognitive status of resident . EMS called for transport. No obvious sign of injury noted. Unable to determine pain resident has a diagnosis dementia unable to interview. R7's Fall Report dated 03/03/22 documented,(R7) was found on floor between the wall and bed on the left side. Immediate action taken: New order received (from R7's Physician) to transport to (emergency room ). Intervention: Ensure bed is in the lowest and locked position. R7's Hospital emergency room (ER) Physician Documentation authored by V8, Physician, dated 03/03/22, documented, This [AGE] year old female presents .with complaints of being found on the floor (following) an unwitnessed fall or crawl, details unknown. A Computerized Tomography (CT) Scan dated 03/03/22 documented, Acute intertrochantic left hip fracture. Right hip (shows) dynamic screw and intramedulary rod (placement). Old healed right pubic rami fractures. A 03/04/22 Interdisciplinary Team (IDT) Note documented, Summary of IDT meeting: Recent fall with ER visit and fracture. Fall investigated. Intervention - bed in lowest and locked position against wall. An 03/04/22 Nursing Progress Noted documented, Patient returned from ER with diagnosis of left hip/femur fracture. Residential hospice to consult. On 03/15/22 at 11:05am, V12, Licensed Practical Nurse (LPN) stated that around 9pm on 03/03/22, V7, Certified Nursing Assistant (CNA), came to her and stated R7 fell . V12 stated when she came into room R7 was on the floor curled up between the wall and the bed, lying on her left side. V12 stated she thinks that the bed was in the lowest position and the wheels were locked. V12 stated R7 had no obvious signs of injury. V12 stated she called EMS and notified R7's Physician and family. On 03/16/22 at 8:45am, V7 stated she worked the 6pm to 6am shift on Rose Hall, the memory care unit, on 03/03/22. V7 stated she checked on R7 at about 8:00pm, and R7 was already in bed although still awake. V7 stated R7 was wet so she changed R7 clothing and linens, positioned R7 facing the door with a wedge rolled under her front, and a large pillow to her back (facing the window). V7 stated all beds on the Rose Hall are to be in lowest position at night, so she assumes the bed was in the lowest position but does not specifically remember. V7 stated she was in hall at about 9pm, heard a noise, and went into R7's room to find R7 in floor between the bed and the wall, laying on left side. V7 stated R7 had dislodged the pillow behind her. V7 stated R7 was always very fidgety in bed. V7 stated she ran to get V12, who assessed R7 for injuries and called EMS. V7 stated, Before (R7) got a roommate (R10) a few months back, it was very handy because we would push (R7s) bed up against the wall and put a wedge to her front, this worked great, but when she got a roommate there wasn't enough room, her roommate is also a fall risk and we have to put her bed up against the wall on the long wall where the overhead lights are. V7 stated they don't have that many empty beds on the Rose Hall so she guesses they could not move R7 or R10. On 3/16/22 at 9:35am, V3, LPN/MDS Coordinator/Care Plan Coordinator, was interviewed in R7's room. V3 stated R7's Care Plan interventions were for the bed to be in the lowest position with the wheels locked. V3 stated the Care Plan intervention, Rearranged room, which was implemented on 07/14/21, meant that staff had decided to push R7's bed against the wall as a fall intervention. V3 stated this intervention continued until R7 got a roommate, R10, in January 2022, who also had an intervention of the bed being against the wall, so R7's bed could no longer be against the wall due to space constraints. On 03/16/22 at 9:45am R7's bed was observed to be parallel to the window, with neither side against the wall. R10's bed was observed against the room's long wall, with the right side of the bed pushed flush against the wall. V3 stated the room had not been rearranged since R7's fall. V3 stated R10's bed was now positioned where, prior to January, R7's had been. On 03/16/22 at 9:50am V3 stated the Interdisciplinary Team (IDT) met on 3/4/22 as a function of the facility's quality assurance program. V3 stated he is a member of this team. V3 stated the team checked the room and bed which were in same position as the night before when the fall occurred. V3 stated the team determined the root cause analysis of the fall was that R7's body movements dislodged the pillow to her back. V3 stated the team also found that the care plan interventions of a low bed with locked wheels, and the bed being up against the wall, were not in place. V3 stated the bed control had about a one second push until it was all the way down, and the wheels had not been locked. On 03/16/22 at 10:35am, V1, Administrator, stated the IDT team determined that R7 rolled out of bed, and the interventions as outlined above had not been in place. V1 stated when staff made the decision to put R10 in with R7, R7's behaviors had been the main topic of discussion, not fall precautions. V1 stated R7's family wanted R7 to remain in her room. V1 stated staff did not discuss with them the fall intervention of her bed being against the wall as a potential problem. On 03/17/22 at 12:00pm, V8 (Physician) stated R7 came to emergency roiagnom on [DATE] at around 10pm. V8 stated R7 was extremely frail and confused, and yelling out in pain, which required the use of [MEDICATION(S)] for pain control. V8 stated R7's CT scan showed left hip fracture. V8 stated the report that came from the facility was that R7 fell out of bed. V8 stated he had several conversations with the family about end of life care decisions to be made. V8 stated ultimately the family decided on transferring R7 back to the facility on hospice services. V8 stated he was not at all surprised to hear that R7 had passed away. V8 stated it is possible that R7 developed a pulmonary embolism after the fracture, but without an autopsy, the cause of death is impossible to determine. An 03/11/22 Nursing Progress Note documented, Called to residents room by family to check pulse. No pulse noted, listened to heartbeat, heard a total of 4 beats then none. Status checked with second nurse (to confirm). Time of death: 0845 am. R7's Death Certificate dated 03/11/22 documented, Cause of Death: Alzheimer's (Disease). The facility's Fall Prevention Program Policy dated 11/21/17 documented, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Care Plan incorporates interventions (that) are changed with each fall, as appropriate, (and) preventative measures. Safety interventions will be implemented for each resident identified (as) at risk .The bed locks will be checked to assure they are in the locked position at all times.

Based on interview, observation, and record review, the facility failed to use side rails and supervise resident during meal time for 1 of 3 residents (R2) reviewed for falls in the sample of 3. This failure resulted in R2 falling out of bed and sustaining 2 fractures of the cervical spine. Findings include: R2's Medical Records, Diagnoses, documents the following Diagnoses: [REDACTED]. R2's Care Plan, dated 10/9/20, states Focus: (R2) is at risk for falls r/t (related to) Gait/balance problems, has history of frequent falls at home. Intervention: (R2) needs a safe environment with: .Side rails as ordered. Another Focus documented on the 10/9/20 Care Plan is I have been assessed to need bedrails. Intervention: I will benefit from side rails to enable bed mobility. R2's Side Rail Assessment, dated 5/21/18, documents the following: Used for positioning, and mobility aid. Use 1/2 right, and left rails. Use to increase bed mobility, increase transfer ability, and increase independence for self care. Physician Order, dated 7/20/20 documents, Side rails as Enabler. R2's Fall Risk Assessment 1, dated 10/6/20 and 12/26/20, is scored 12 and R2 is documented as At Risk for Fall. R2's MDS (Minimum Data Set) Section C, dated 11/3/20, documents a Brief Interview Mental Status that is scored a 7 indicating R2's Cognition is Severely Impaired. Section G- Functional Status for Eating (how resident eats, and drinks regardless of skill) indicates that a One Person Physical Assist is required while eating. In R2's Medical Record, the Fall-Initial Occurrence Note documents the following: Resident had an un-witnessed fall 12/20/2020 at 2:47 PM Location of Fall: Residents Room. Staff was alerted to resident room, when residents roommate yelled out for help. Resident was found on floor on her back. Staff had just assisted resident in room and placed her tray on her bedside table over her lap. Residents side rail on right of bed was not put back into place. Residents tray was found on the floor. Resident assessed, vitals WNL (within normal limits), small skin tear to right heal, and resident has raised area to front of forehead. Neuros WNL on 12/20/2020 at 2:47 PM. R2's Nurse's Notes, dated 12/20/2020 at 3:06 PM, Narrative: Spoke with ER; resident (R2) has a burst C1 fracture and is being sent to (Regional Hospital). R2's emergency room Physician Documentation, dated 12/20/20, states 'Complaint of Patient sitting up eating lunch, and rolled out of bed landing on the front of her head. Diagnoses: [REDACTED]. Resident transferred to (Regional Hospital) for further care. R2's CT (Computed Tomography) Spine Report, dated 12/20/20, Impression: Nondisplaced Type II Odontoid Fracture and Burst Fracture of C1. On 12/24/20 at 2:00 PM, R2 was sitting by the Nurse's Station in a high back wheelchair sleeping and would not respond when aroused. R2 had a bluish green bruise to her forehead with dried abrasions. A cervical collar was in place. On 12/24/20 at 3:15 PM, V4 (Certified Nurse Aide/CNA) stated that she set R2 up in her bed for lunch and she fell out of bed, knocking over the bed table over. Side rails were not up due to the over the bed table was in place. R2 was left without a person to help her eat so other trays could be passed to other residents. V4 stated that now the staff has to get R2 up in a chair when she eats. On 12/24/20 at 3:00PM, V3 (Registered Nurse) stated that R2 fell out of bed on Sunday and was sent to the ER. She was placed up in bed to eat as she was able to feed herself. The CNA left R2's room to pass trays to other residents. She was eating on a over the bed table when she fell out of bed. She is always confused but eats 100% of her meal. Her side rails were not in place due to the over the bed table. Due to the fall R2 received a bruise on her forehead, and a C1 Burst Fracture. R2 requires physical assistance during mealtimes. On 12/24/20 at 1:30 PM, V2 (Director of Nursing) stated that R2 recently had a fall during lunch and was sent to the ER (emergency room ). R2 was diagnosed with [REDACTED]. R2 is very confused and now wears a cervical collar. On 1/5/20 at 8:30 AM, V2 stated that V4 (Certified Nurse Aide) took the tray into R2's room. R2 was in bed so V4 rolled the head of her bed up and put the side rail down because R2 could not reach the table with the side rail up. R2 needs the side rails due to poor positioning control. R2 needs the side rails to be up at all time while she is in bed. R2 also has a wheelchair with special positioning to accommodate R2's needs. V4 left R2 to pass lunch trays to other residents. On 1/5/21 at 8:51 AM, V7 (Physician) stated that R2 is almost [AGE] years old and had been declining with her other medical issues. The nursing home is at fault for R2's fall and fracture of C1. V7 stated the side rail should have been up. V7 stated he has talked to the Director of Nurses regarding this issue. R2 is now on Hospice per the family's request. On 12/24/20, V1 (Administrator) stated that side rail assessments are reviewed quarterly during care plan meeting and are not altered in the system unless changes are made. R2's Fall IDT (Interdisciplinary Team), dated 12/21/20, Root Cause of Fall: Resident eating in Bed. Intervention and Care Plan Updated: Resident should be up in chair for all meals. Fall Prevention Program policy, revised 11/21/17, states the following: Safety interventions will be implemented for each resident identified at risk. Residents will be observed approximately every 2 hours to ensure the resident's is safely positioned in the bed or a chair and provide care as assigned in accordance with the plan of care.

Based on interview, and record review, the facility failed to implement their post fall protocol which includes immediate assessment, physician notification, communication with direct care staff members, and documentation requirements for 1 of 3 residents (R6) reviewed for falls in the sample of 13. This failure resulted in R3 not receiving care for 14 days after falling from her wheelchair and sustaining a right femoral fracture, requiring hospitalization with surgical repair. Findings Include: Review of R6's Plan of Care lists a focus area of R6 requires the use of a physical restraint. Interventions listed include an initiation date of 8/2/19 documenting the use of a self- releasing lap belt. The same plan of care also documents a focus area for R6 of, I am at risk for fall R/T (related to): depression, poor balance, poor safety awareness, non-ambulatory with a date initiated as 2/8/19. Interventions listed for this focus area include: Assist resident as needed with ADLS (activities of daily living) and Notify physician as needed of any changes. R6's Restraint / Evaluation Review last completed 2/11/20 regarding the use of the self-releasing seatbelt documents the Reason for use of physical restraint as, frequent falls and Sliding out of chair / wheelchair. The same document lists the benefits of use of the self -releasing seatbelt as, Prevents injury to self. R6's Fall Risk Assessment 1 completed 12/1/19 documents a score of 12, indicating R6 is At risk for falls. R6's MDS (Minimum Data Set) dated 12/2/19 documents R6 is not cognitively intact. R6's functional status for transfer is documented as 3, 3 indicating R6 requires extensive assistance of two plus physical assist when R6 is transferred between surfaces (bed, chair, wheelchair). A Facility Policy titled Fall Prevention Program with a revision date of 11-21-17 documents, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The same policy goes on to state the fall prevention program includes the following components: .Use and implementation of professional standards of practice Notification of physician, family / legal representative communication with direct care staff members documentation requirements. An undated Facility Policy titled Incident / Accident Reports defines an incident as, Any happening, not consistent with the routine operation of the facility, that does not result in bodily or property damage. An accident is defined as, Any happening, not consistent with the routine operation of the facility that results in bodily injury other than abuse. An incident / accident report will be completed for: 1. All serious accidents or incidents of residents 3. Any unusual occurrences 6. All unexpected events that occur that cause actual or potential harm to a resident or employee 9. Any condition resulting from an accident requiring first aid, physician visit, or transfer to another health care facility. The same policy documents, An incident / accident report is to be completed by a RN (Registered Nurse) or LPN (Licensed Practical Nurse) and is to include a. Date and time of an incident / accident. b. Full written statement and possible cause of incident, physical assessment, injuries noted, vital signs, treatment rendered, and notification of appropriate parties. A Fall with Fracture Final Investigation Report dated 2/19/20 documents R6 sustained a witnessed fall in the dining room on 1/29/20 at 7:25 AM. The report documents R6 was seen by Nurse Practitioners from Tapestry Telehealth on 2/4/20, 2/5/20 and 2/11/20. This report does not document they were notified of R6's fall that had occurred on 1/29/20. The report documents V29 (Physician) was notified of the 1/29/20 fall on 2/12/20 at 4:54 PM, with new orders for x-rays. X-rays were obtained at the local hospital with the [DIAGNOSES REDACTED]. V29 was notified of the x-ray results with orders to send to the local ER for evaluation. The same report goes on to document after being seen in the ER, R6 was transferred to an area hospital for orthopedic care. R6 returned to the facility on [DATE] after surgical right femur repair. The facility documents their investigation concluded R6's right femur fracture is Possibly related to the fall and/or occurred during routine ADL (Activities of Daily Living) care / transfers and comorbidities of [MEDICAL CONDITION] and contractures to both lower extremities. The facility documents staff were In-serviced on the Incident / Accident Reporting Policy to include that all change of planes is considered falls and all falls are to be documented per facility protocol with DON (Director of Nursing) notification. The report also goes on to state that (name) V28 (Licensed Practical Nurse/LPN) was in-serviced regarding the occurrence and requirement of timely documentation and physician notification. On 2/20/20 at 2:10 PM, video surveillance was observed which captured R6's fall in the living area of the Garden unit. Observation of video surveillance was timestamped as starting on 1/29/20 @ 7:42 AM. Video shows R6 sitting in her wheelchair with seatbelt unfastened and hanging to the side of wheelchair. R6 was observed leaning forward in her wheelchair, pulling at a tablecloth located in front of her. R6 was observed falling forward landing on right hip / right side of body. The tablecloth is pulled off the table with TV that was sitting on the table falling on top of R6's left hip / upper leg area. V16 (Certified Nurse Aide/CNA) is observed immediately responding and lifting the tv off R6, along with making a come here motion. V31 (CNA) was shown entering the video footage where she and V16 lifted R6 back into her wheelchair and V16 fastened R6's seatbelt. V31 and V16 then fixed the tablecloth, sat the tv back on the table, and exited the video surveillance area. At no time was V28 (LPN) observed evaluating R6. R6 exited the video surveillance area per staff transfer at the video time stamp of 8:05 AM. On 2/20/20 at 8:45 AM, V28 stated the normal facility practice for when a resident sustains a fall or incident which may cause injury would be for the nurse to immediately assess, notify the physician & resident representative regardless of if there is an injury, and fill out the incident / risk management report. V28 stated he does remember a fall involving R6 occurring on 1/29/20, which he recalls being around a mealtime. V28 stated V16 reported to him R6 fell in the dining room and said he was given the impression it was a simple fall. V28 stated he just visually glanced at R6 to be sure she wasn't bleeding and was her normal self. V28 stated R6 was already back up in her wheelchair when he went to look at her. V28 said he resumed passing medications. V28 stated once R6 was laid down in bed within approximately an hour of the fall, he looked at her and saw no concerns. V28 stated R6 was vocal and babbling / resistive to care which he describes as being her normal status at times. V28 stated when V16 reported the fall to him, there was no mention of a TV involvement. V28 stated he did not contact the physician, resident representative, or complete any documentation regarding the fall occurrence. V28 said some days are just busier than others. V28 stated the fall occurrence was not passed on to the next shift and acknowledged because of that, no follow up evaluation or care was completed. V28 stated he did work with R6 some days post fall when he described R6 as being inconsolable. V28 described R6's inconsolable status to include being very loud / vocal, babbling, resisting care, behaviors escalating when staff would try to comfort, redirect, or reposition her. V28 described R6 as not being cognitively intact and unable to make her needs known. When asked if he ever considered her increased behaviors and inconsolable status as an effect from the fall, V28 stated no. V28 acknowledged those factors should have been considered and acknowledged his failure to not complete the appropriate post fall forms, physician, and resident representative notification. On 2/19/20 at 11:15 AM, V16 (Certified Nurse Assistant, CNA) stated he was aware of a fall R6 had around the end of January in which R6 fell forward out of her chair. V16 stated he did in fact witness the fall which occurred in the Garden hall living/dining room. V16 confirmed R6's seatbelt was not on at the time of the fall. V16 stated V31 (CNA) was also working during that time. V16 stated R6 was placed back in her chair and he reported the fall to V28 who was the nurse. V16 stated he wasn't sure what V28 did with that information. V16 confirmed a tv had also fallen off a table as she pulled the tablecloth during the fall. On 2/19/20 at 2:20 PM, V31 stated she was working with V16 and V28 on or around 1/29/20 when R6 experienced a fall. V31 described being in the hallway getting ready to pass breakfast trays when she heard a thud, followed by V16 hollering for her from the living/dining room. V31 confirms R6 was on the floor and she helped V16 lift R6 back into her wheelchair and went back to passing hall trays. V31 states she did not observe V28 evaluate R6 post fall. On 2/19/20 at 12:57 PM, V29 (Physician) stated the facility did not notify him of a fall sustained by R6. V29 stated he could not recall the name, but facility staff had notified him of an incident on the day R6 went to the ER when it was reported to him that a TV had reportedly fallen on her on an earlier date. V29 states he was not notified of any incident involving a tv falling on R6 at the time it occurred. V29 stated he finds the care and timeliness of care provided to R6 as unacceptable. V29 stated had he been notified of a fall or incident involving R6 which may have resulted in injury immediately, it would have changed the plan of care for R6. V29 stated R6 had a history of [REDACTED]. V29 stated with the inconsolable and increased crying, resident character changes, etc. (etcetera) he would have ordered further medical evaluation and attributed the crying more to the possibility of discomfort. V29 stated a femoral fracture would cause significant pain, and even further pain with R6 being moved and manipulated without the fracture being stabilized. V29 once again confirms the lack of prompt physician notification regarding a fall and/or incident which may cause injury, along with the questionable accuracy of the events resulted in R6 receiving inaccurate, insufficient, and untimely care. On 2/20/20 at 11:10 AM, V36 (Nurse Practitioner) stated she recalls being contacted regarding R6. V36 stated residents are seen by video teleconference. V36 stated she was never told R6 had sustained a fall. V36 stated she suspected R6 was experiencing possible gastric discomfort due to the report of an emesis and R6's abnormal posturing. V36 stated had she been notified of a fall, it would have changed her treatment plan and included ruling out injury. V36 acknowledged that the facility's failure to provide accurate occurrences created a hindrance in R6's plan of care. On 2/20/20 at 11:26 AM, V37 (Nurse Practitioner) stated she recalls seeing R6 via video teleconference. V37 stated this was her 1st time seeing R6, so she asked many questions to try and establish her baseline. V37 stated it was never communicated to her that R6 had sustained a fall. V37 stated she was contacted due to R6 having abnormal positioning in her wheelchair which included constant leaning forward. V37 stated V15 (who was the nurse present during the conference) did state it was questionable if R6 was experiencing pain in her left lower extremity when in her wheelchair. V37 stated V15 demonstrated range of motion (ROM) to R6's left lower extremity during this time but noted R6 was in bed rather than her wheelchair. R6 displayed no sign of discomfort with the ROM being performed to that extremity. V37 states R6 was also contracted and thought based on this assessment, wheelchair comfort may be a factor in the postural changes related to her demented status or possible [MEDICAL CONDITION]. V37 stated a tilt wheelchair was recommended to try. V37 stated had she been notified R6 had sustained a fall, it would have changed her course of treatment to include ruling out injury with diagnostic testing. V37 verifies a femoral fracture would cause significant pain. On 2/20/20 at 8:45 AM, V1 (Administrator) stated during the AM (morning) meeting on 2/12/20, the team was discussing R6 due to her new onset abnormal postural changes in her wheelchair. V1 stated V34 (Medical Records / Restorative Aide) mentioned she thought she heard V16 saying R6 had a recent fall. V1 stated he was not aware of a fall that had recently occurred with R6. V1 stated he asked V16, who was working at that time about a fall, in which he confirmed what had happened. V1 stated V11 (Registered Nurse/RN) notified V29 (Physician) who gave orders for an x-ray, which revealed a fracture. V1 stated the occurrence of the fall R6 sustained had not been communicated to Tapestry due to V28's lack of documenting and reporting the fall. V1 stated the facility does have surveillance cameras which were reviewed, showing the fall. V1 described the video as showing R6 in the dining room next to a smaller coffee table like table which had a tablecloth and TV sitting on top of it. V1 described the video as showing R6 leaning forward in her wheelchair, pulling the tablecloth, and falling forward out of her chair onto her right side, and causing the tablecloth and TV to fall off the table and onto R6's left side. V1 stated he does not recall seeing R6 undo her seatbelt prior to falling out of her chair and isn't sure why her seatbelt wasn't on. V1 stated V16 and V31 (CNA's) were seen getting R6 back into her chair on the video and stated V28 was not visualized. V1 described R6's normal status as being alert to person only, anxious, and unable to communicate. V1 acknowledged if accurate information such as the occurrence of the fall followed by a change in condition had been communicated to Tapestry (which is a teleconference system where nurse practitioners/MD's can evaluate the residents' via video) he expects it would have changed their course of treatment. V1 acknowledged V28's failure in not reporting the fall to the physician, resident representative, or completing any necessary documentation post fall. On 2/20/20 at 12:57 PM, V2 (DON) acknowledged V28 failed to notify the physician and complete the required paperwork documenting R6's fall on 1/29/20. V2 stated V28's failure to report R6's fall to the MD (Medical Doctor) resulted in R6 receiving delayed treatment and lack of care. V2 would expect staff to notify the MD of a fall regardless of injury status and acknowledged that a femoral fracture would be painful. V2 stated she would expect if someone was displaying signs or symptoms of pain to be evaluated and administered pain medication as needed, along with reporting to the MD if no pain resolution. V2 stated staff should notify the MD of any falls regardless of injury status. Progress Notes for R6 dated 2/12/20 at 7:30 PM by V10 (Licensed Practical Nurse) documents ER called and stated R6 was being sent to area hospital for orthopedic services. Review of R6's Clinical Record from 1/29/20 - 2/16/20 includes no documentation indicating a fall occurred or that any physician had been notified of a fall. The first entry documenting a fall is noted on 2/17/20 at 10:28 AM, which was made by V3 (Regional Nurse Consultant) with the type of note listed as Fall IDT (Interdisciplinary Team) Note This note documents: Summary of the fall: resident was in her chair and bent over to grab something and fell . Root cause of the fall: Confusion, leaning over. Intervention and care plan updated: leave resident in bed until therapy can eval for safety needs while up in w/c. The local hospital Radiology Report dated 2/12/20 documents the Reason for Study as Increased pain and contracted today Nursing home patient. Findings are documented as a Displaced sub capital [MEDICAL CONDITION] femur. The report goes on the state that the Bone is displaced anteriorly at least 1.8 cm (centimeters). There is also lateral and superior displacement of around 2.2 cm. The area hospital R6 was transferred to for orthopedic care documents on the Orthopedic Operative Note with admission date of [DATE] a Preoperative and Postoperative [DIAGNOSES REDACTED]. The same report documents the Procedure performed as a Right Hip Girdlestone Procedure. The report documents R6 had been transferred to the emergency room with concern for a fracture of undetermined timeframe.

Based on observation, interview, and record review, the facility failed to identify and treat pain for 1 of 3 residents (R6) reviewed for pain in the sample of 13. This failure resulted in R6 having unidentified and delayed pain care for 14 days after sustaining a fall with an undiagnosed femoral fracture, requiring hospitalization with surgical repair. Findings Include: A Fall with Fracture Final Investigation Report dated 2/19/20 documents R6 sustained a witnessed fall in the dining room on 1/29/20 at 7:25 AM. The report documents R6 was seen by Nurse Practitioners from Tapestry Telehealth (which is a teleconference system where nurse practitioners/MDs can evaluate the residents' via video) on 2/4/20, 2/5/20 and 2/11/20. This report does not document they were notified of R6's fall that had occurred on 1/29/20. The report documents V29 (Physician) was notified of the 1/29/20 fall on 2/12/20 at 4:54 PM with new orders for x-rays. X-rays were obtained at the local hospital with the [DIAGNOSES REDACTED]. V29 was notified of the x-ray results with orders to send R6 to the local ER for evaluation. The same report goes on to document after being seen in the ER, R6 was transferred to an area hospital for orthopedic care. R6 returned to the facility on [DATE] after surgical right femur repair. The facility documents their investigation concluded R6's right femur fracture is Possibly related to the fall and/or occurred during routine ADL (Activities of Daily Living) care / transfers and comorbidities of [MEDICAL CONDITION] and contractures to both lower extremities. The facility documents staff were In-serviced on the Incident / Accident Reporting Policy to include that all change of planes is considered falls and all falls are to be documented per facility protocol with DON (Director of Nursing) notification. The report also goes on to state that (name) V28 (Licensed Practical Nurse/LPN) was in-serviced regarding the occurrence and requirement of timely documentation and physician notification. Progress Notes for R6 document on 2/4/20 at 4:04 PM, V36 (Nurse Practitioner) was notified via Tapestry telehealth services for a chief complaint of nausea and vomiting. V36 documents, This is a 75 y/o (year old) female with dementia with behaviors. Noted to have increased agitation 2 days ago, curled up into the fetal position today. Emesis times 1 at 10 AM. Usually cries out with care, now is crying out constantly. Review of Systems includes the Psychiatric review of Displays Mood Changes, and Constitutional review of Displays fatigue. Displays poor appetite. Physical Exam documented as, The patient is awake, well developed but appears ill. Laying in fetal position. Extremities documented as having 1 plus [MEDICAL CONDITION]. The same document goes on to state R6 is oriented to person only. Care Plan / Assessment is documented for R6 as Nausea with vomiting, unspecified. (brand name) [MEDICATION NAME] 4 milligrams (mg)[MEDICATION NAME](orally disintegrating tablets) Q (every) 6 hours prn (as needed). Unspecified abdominal pain. Cath (catheter) UA (urinalysis), CBC (complete blood count), CMP (complete metabolic profile), vitals Q shift. Unspecified dementia with behavioral disturbance, other mixed anxiety disorders. [MEDICATION NAME], (brand name) [MEDICATION NAME] Acid, (brand name) [MEDICATION NAME]. Return Appointment: Tomorrow. Progress Notes for R6 documented on 2/11/20 at 2:00 PM by V15 (Registered Nurse) state Resident more combative and yelling out with care. While in wheelchair resident leaning forward with head towards floor and yells if you try to sit her up. (Telehealth company) V37 seen at this time and N.O. (new order) high back tilt and space w/c (wheelchair) and some labs. Progress Notes for R6 documented on 2/12/20 at 2:00 PM by V11 (Registered Nurse) state, Called (name) V29's office regarding increased s/sx (signs/symptoms) of pain crying out, bending over at waist and more resistive with care. N.O. (new orders) rec.'d (received) x-ray of pelvis and bilateral hips. V11 goes on to document at 2:15 PM, R6 was transported to local hospital for outpatient x-ray. On 2/12/20 although x-ray results not documented in Progress Notes, the entries included which are all made by V11 state: 4:00 PM- Administration notified of x-ray results. 4:54 PM- Received x-ray results MD (medical doctor) notified. (Name) V24 (family member) notified. 4:58 PM- N.O. received to send to (name) local ER. 5:00 PM- Transported to (name) local ER per cart and 2 staff assist. V24 notified of N.O. The local hospital Radiology Report dated 2/12/20 documents the Reason for Study as Increased pain and contracted today Nursing home patient. Findings are documented as a Displaced sub capital [MEDICAL CONDITION] femur. The report goes on the state that the Bone is displaced anteriorly at least 1.8 cm (centimeters). There is also lateral and superior displacement of around 2.2 cm. The area hospital R6 was transferred to for orthopedic care documents on the Orthopedic Operative Note with admission date of [DATE] a Preoperative and Postoperative [DIAGNOSES REDACTED]. The same report documents the Procedure performed as a Right Hip Girdlestone Procedure. The same report documents R6 had been transferred to the emergency room with concern for a fracture of undetermined timeframe. On 2/19/20 at 12:57 PM, V29 stated the facility did not notify him of a fall sustained by R6. V29 stated he finds the care and timeliness of care provided to R6 as unacceptable. V29 stated if he had been notified immediately of a fall or incident involving R6 which may have resulted in injury, it would have changed the plan of care for R6. V29 stated R6 had a history of [REDACTED]. V29 stated with the inconsolable and increased crying, resident character changes, etc. (etcetera) he would have ordered further medical evaluation and attributed the crying more to the possibility of discomfort. V29 stated a femoral fracture would cause significant pain, and even further pain with R6 being moved and manipulated without the fracture being stabilized. V29 once again confirmed the lack of prompt physician notification regarding a fall and/or incident which may cause injury, along with the questionable accuracy of the events resulted in R6 receiving inaccurate, insufficient, and untimely care. On 2/20/20 at 11:10 AM, V36 (Nurse Practitioner) stated she recalls being contacted regarding R6. V36 stated residents are seen by video teleconference. V36 stated she was never told R6 had sustained a fall. V36 stated she suspected R6 was experiencing possible gastric discomfort due to the report of an emesis and R6's abnormal posturing. V36 stated had she been notified of a fall, it would have changed her treatment plan and included ruling out injury. V36 acknowledged that the facility's failure to provide accurate occurrences created a hindrance in R6's plan of care. On 2/20/20 at 11:26 AM, V37 (Nurse Practitioner) stated she recalls seeing R6 via video teleconference. V37 stated it was never communicated to her that R6 had sustained a fall. V37 stated she was contacted due to R6 having abnormal positioning in her wheelchair which included constant leaning forward. V37 stated V15 (RN who was present during the conference) did state it was questionable if R6 was experiencing pain in her left lower extremity when in her wheelchair. V37 stated V15 demonstrated range of motion (ROM) to R6's left lower extremity during this time but noted R6 was in bed rather than her wheelchair. R6 displayed no sign of discomfort with the ROM being performed to that extremity. V37 stated R6 was also contracted, and thought based on this assessment, wheelchair comfort may be a factor in the postural changes related to her demented status or possible [MEDICAL CONDITION]. V37 stated a tilt wheelchair was recommended to try. V37 stated had she been notified R6 had sustained a fall, it would have changed her course of treatment to include ruling out injury with diagnostic testing. V37 verified a femoral fracture would cause significant pain. On 2/20/20 at 8:45 AM, V28 (LPN) stated the normal facility practice for when a resident sustains a fall or incident which may cause injury would be for the nurse to immediately assess, notify the physician & resident representative regardless of if there is an injury, and fill out the incident / risk management report. V28 stated he does remember a fall involving R6 occurring on 1/29/20 which he recalls being around a mealtime. V28 stated he just visually glanced at R6 to be sure she wasn't bleeding and was her normal self. V28 stated R6 was already back up in her wheelchair when he went to look at her. V28 stated he resumed passing medications. V28 said once R6 was laid down in bed within approximately an hour of the fall, he looked at her and saw no concerns. V28 stated R6 was vocal and babbling / resistive to care which he described as being her normal status at times. V28 stated when V16 reported the fall to him, there was no mention of a TV involvement. V28 stated he did not contact the physician, resident representative, or complete any documentation regarding the fall occurrence. V28 said some days are just busier than others. V28 stated the fall occurrence was not passed on to the next shift and acknowledged because of that, no follow up evaluation or care was complete. V28 stated he did work with R6 some days post fall when he described R6 as being inconsolable, and describes R6's inconsolable status to include being very loud / vocal, babbling, resisting care, behaviors escalating when staff would try to comfort, redirect, or reposition her. V28 described R6 as not being cognitively intact and unable to make her needs known. When asked if he ever considered her increased behaviors and inconsolable status as an effect from the fall, V28 stated no. V28 acknowledged those factors should have been considered and also acknowledged his failure to not complete the appropriate post fall forms, physician, and resident representative notification. On 2/21/20 at 8:57 AM, V41 (Certified Nurse Assistant, CNA) stated she learned of R6 having a previous fall on approximately 2/10 or 2/11 when staff were discussing R6's change in status, which she described as being, tearful, red face, vocal, resistive to care, and anxious. V41 stated she had been reporting to nursing staff for greater than a week that R6 was not acting right and it was evident to see she was in pain. V41 stated I know she was hurting. That wasn't my (name) R6. On 2/18/20 at 1:15 PM, V15 (RN) stated R6 is not cognitively intact and cannot make her needs known. V15 stated R6 does have behaviors of grabbing, hollering, and crying at times, which she described as being easily re-directed. V15 stated although she cannot recall the specific date, she was working one of the days prior to R6 being diagnosed with [REDACTED]. V15 stated she contacted Tapestry. V15 stated Tapestry was not notified of a previous fall because she was not aware R6 had a fall that she needed to report. V15 states the normal procedure after a resident experience a fall would be to notify the nurse, the nurse evaluates, notify the physician and resident representative of the fall and take any new orders received and complete the risk management evaluation report of fall. On 2/20/20 at 11:54 AM, V11 (RN) stated she was the nurse who was on duty that contacted V29 and received orders for x-ray that ended up diagnosing the fracture. V11 stated V41 (CNA) reported to V11 that R6 just wasn't acting right. V11 stated, it was very evident she (R6) was in pain. V11 described R6 as being loud and seems to be in pain. V11 stated that no matter what they did to try and redirect / reposition R6 they could not calm her. V11 stated V41 mentioned hearing R6 had possibly had a recent fall. V11 stated she checked R6's record and did not see any fall documentation, nor had it been passed on in shift report of any falls. On 2/20/20 at 8:45 AM, V1 (Administrator) stated during the AM (morning) meeting on 2/12/20, the team was discussing R6 due to her new onset abnormal postural changes in her wheelchair. V1 stated V34 (Medical Records / Restorative Aide) mentioned she thought she heard V16 (CNA) saying R6 had a recent fall. V1 stated he was not aware of a fall that had recently occurred with R6. V1 stated he asked V16 who was working at that time about a fall, in which he confirmed what had happened. V1 stated V11 (RN) notified V29 (Physician) who gave orders for an x-ray, which revealed a fracture. V1 stated the occurrence of the fall R6 sustained had not been communicated to Tapestry due to V28's lack of documenting and reporting the fall. V1 stated the facility does have surveillance cameras which were reviewed, showing the fall. V1 described the video as showing R6 in the dining room next to a smaller coffee table like table which had a tablecloth and TV sitting on top of it. V1 described the video as showing R6 leaning forward in her wheelchair, pulling the tablecloth, and falling forward out of her chair onto her right side, and causing the tablecloth and TV to fall off the table and onto R6's left side. V1 described R6's normal status as being alert to person only, anxious, and unable to communicate. V1 acknowledged if accurate information such as the occurrence of the fall followed by a change in condition had been communicated to the telehealth service, he expects it would have changed their course of treatment. V1 acknowledges V28's failure in not reporting the fall to the physician, resident representative, or completing any necessary documentation post fall. On 2/20/20 at 12:57 PM, V2 (DON) acknowledged V28 failed to notify the physician and complete the required paperwork documenting R6's fall on 1/29/20. V2 states V28's failure to report R6's fall to the MD (medical doctor) resulted in R6 receiving delayed treatment and lack of care. V2 would expect staff to notify MD of a fall regardless of injury status and acknowledged a femoral fracture would be painful. V2 states she would expect if someone was displaying signs or symptoms of pain to be evaluated and administered pain medication as needed, along with reporting to the MD if no pain resolution. V2 stated staff should notify the MD of any falls regardless of injury status. A policy titled Pain Management Program with a revision date of 7/6/18 documents the purpose of this program is To establish a program which can effectively manage pain in order to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness. This same policy goes on to state When a resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the presence of pain. R6's Plan of Care with an initiation date of 2/8/19 and revision date of 2/18/20 documents a Focus area of, I have a potential for pain r/t depression, [MEDICAL CONDITION], immobility Fx. femur. Interventions included for this focus area include: Administer [MEDICATION NAME] per orders with an initiated date of 3/21/19. Monitor/record/report to Nurse any s/sx (sign / symptoms) of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/Behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide, open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing), Body (tense, rigid, rocking, curled up, thrashing). Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents experience of pain. R6's MDS (Minimum Data Set) dated 12/2/19 documents R6 is not cognitively intact. R6's functional status for transfer is documented as 3, 3 indicating R6 requires extensive assistance of two plus physical assist when R6 moves between surfaces (bed, chair, wheelchair). Review of R6's Medication Administration Record [REDACTED]. Review of R6's Medication Administration Record [REDACTED]. Despite R6's current medication regimen including scheduled pain medication, progress notes and interviews in which it was conveyed R6 was experiencing many nonverbal signs and symptoms of pain, no pain acknowledgement or as needed pain medication is documented as being administered until 2/12/20 at the time the femur fracture was diagnosed . The MAR indicated [REDACTED]. R6's physician orders [REDACTED]. Apply 1 patch [MEDICATION NAME] every 72 hours for pain and remove per schedule with a start date of 2/13/19. On 2/18/20 at 12:36 PM, R6 was observed lying in her bed. R6 is observed as being not alert to person, place, or time during this encounter. R6 was observed as having a surgical dressing present to her right hip area.

Based on observation, record review, and interview the facility failed to follow the current assessment and care plan interventions for fall prevention for 3 (R1 - R3) of 4 residents reviewed for falls and assistance in the sample of 4. This failure resulted in R2 sustaining fractures of the 6th - 9th ribs, increased pain, and treatment with additional prescribed pain medication. Findings Include: 1. A Report to IDPH (Illinois Department of Public Health) Regional Office, submitted by the facility as notification on 8/23/17, notes R2 to be [AGE] years old, lists an 8/14/17 Date of Occurrence, and under Description of Occurrence, states the following: Staff assist of 1 ambulating to bed from BR, staff let go of resident to move chair out of way. Resident lost her balance and fell on to bed. R2's Minimum Data Set ((MDS) dated [DATE] documents an entry in the functional status section of R2 requiring an extensive assist with two person (plus) physical assist for: bed mobility, transfer, and walk in room. R2's CNA (Certified Nurse Assistant) Flow Sheet dated August 2017 documents R2 is coded as a 2 person assist for transfers, and the resident Fall Risk Assessment shows R2 as a high risk for falls. On 8/31/17 at 11:35 AM, E3, CNA (Certified Nurse Assistant) stated that if a staff member needed to check the number of staff assistance needed for transfers, that information is found in the resident's medical record. On 8/31/17 at 12:45 PM, R2 was assisted to bed by E4 (CNA) only. E4 confirmed, at this time, that R2 was just transferred by a one person assist, and stated we can do R2 with a one person transfer, we just use a gait belt, and R2 does fine. On 8/31/17 at 2:10 PM, E8 (Director of Therapy) stated that R2 is a two person assist for safety. On 8/31/17 at 2:00 PM, E2 (Director of Nursing) stated that per the MDS and CNA flow sheet, the resident should be transferred by a minimum of two staff. On 9/1/17 at 10:00 AM, E2 verified that the MDS, therapy orders, and CNA flow sheet should all show the same mobility status. On 8/21/17 at 1:15 PM, R2 stated that she is in pain on her right side and would just rather stay in bed. R2's July and August 2017 Medication Administration Records (MAR) show that R2 is prescribed Oxycodone/Acetaminophen 5-325 milligrams every four hours PRN (as needed). R2's August 2017 MAR showed an increase of PRN oxycodone administrations, as compared to the July 2017 MAR. The July 2017 MAR documents a total of 19 PRN oxycodone administered to R2 for that entire month. The August 2017 MAR shows only 1 PRN oxycodone administration from 8/1/17 through 8/13/17, however a total of 32 PRN oxycodone administrations are documented after R2's fall occurrence on 8/14/17 through 8/31/17. R2's Fall Occurrence Report dated 8/14/17 documents a fall occurring with a witness statement of I was helping R2 from the bathroom to the bed. I was moving the wheelchair out of the way and she lost her balance and fell backwards and hit the bed. The witness statement on the fall occurrence report was written by E6 (CNA). On 8/31/17 at 2:00 PM E6 (CNA) stated, that she was assisting the resident alone on the day of the fall occurrence (8/14/17) from the bathroom to the bed and she let go of the gait belt to move the wheelchair out of the way. When she let go of the gait belt, the resident lost her balance and fell on to the bed. On 8/31/17 at 11:00 AM, E5 (CNA) stated, that it is the expectation that if a person is in need of an assisted transfer, then the staff that is assisting the resident should never let go of the gait belt to ensure balance is never lost and a fall does not occur. On 8/31/17 at 9:30 AM, E2 stated that R2 and R2's Power of Attorney initially declined obtaining X-rays or any further treatment. On 9/1/17 at 9:15 AM, E2 stated that R2 was taken to the hospital on [DATE] for X-rays due to persistent pain in right abdomen. The Report to IDPH Regional Office submitted on 8/23/17 as notification of the 8/14/17 fall occurrence and injury also documents Family and resident declined Xrays at time of incident. Continued pain complaints nursing staff convinced resident and family to get Xrays on 8/22/17. Hospital records dated 8/22/17 document X-Ray results showing 4 ribs (6th - 9th) were broken on the right side. 2. R1's current MDS (Minimum Data Set) dated June 12, 2017, documents R1's transfer status and walking in room and corridor status is coded as limited assistance, with a one person physical assist. R1's CNA (Certified Nurse Assistant) Flow Sheets for June, July, and August of 2017 document that R1 has an independent mobility status with a walker, and nothing marked for Transfer. On 8/31/17 at 11:35 AM, E3 (CNA) clarifies that the CNA Flow Sheets are the reference material the CNA's go by to ensure the proper transfer and/or mobility status is being followed. Review of these documents show the CNA's sign off on them daily on each shift, and that they are replaced monthly with a new CNA Flow Sheet. On 9/1/17 at 10:14 AM, E2 (DON- Director of Nursing) states he would expect the MDS and CNA flow sheet to reflect the same mobility and transfer status. In response to being shown R1's MDS dated [DATE] and R1's CNA flow sheet for June 2017, which reflect different transfer and mobility status' between each of them, E2 acknowledged there was an error made and stated both documents should have the same assistance level listed. R1's Face Sheet in the clinical record documents [DIAGNOSES REDACTED]. R1's Nurses Notes from July and August 2017 document R1 had 6 falls since July: two falls are documented on 7/10/17, and then one fall each on 7/27/17, 8/4/17, 8/11/17, and 8/27/17. R1's Resident Care Plan with problem area of Resident high risk for falls RT (related to) actual falls, with an initial date of 3/27/17 lists a fall prevention approach of Keep call light within reach. R1's resident care plan also notes a fall occurrence with injury (bruise to head) on 7/10/17, and an additional approach dated 7/10/17 of PT (Physical Therapy) to evaluate. On 8/31/17 at 2:00 PM, E8 was asked to provide R1's last therapy evaluation. E8 provided a copy of a Physical Therapy evaluation dated 9/24/15. The facility is unable to provide documentation to show that a physical therapy evaluation has been completed since the 7/10/17 fall incident with corresponding intervention of PT to evaluate. Other fall prevention approaches listed after the 7/10/17 entry state: Monitor bruise to forehead for adverse effects. Monitor for swelling. Post fall monitoring for 72 hours. Assist while ambulatory around others. Encourage to accept frequent rest periods. This same care plan documents a different problem area for R1 of Resident has self care deficit RT (related to) dementia, with initial date of 3/27/17, and approaches stating Resident transfer self with assist of walker, and Ambulates per self with assist of w/w (wheeled walker) through facility. This problem area documented a review and continue date of 6/19/17 with no new or updated approaches since that date. On 8/31/17 at 11:54 AM, R1 was observed sleeping in bed with no call light noted within her reach, or visible at all. At this time, E3 walked into R1's room and was asked to show surveyor where R1's call light was. E3 found it clipped by the call light base on the wall, which was out of R1's reach or view. E3 stated someone probably made her bed and moved it and just forgot to put it back. On 8/31/17 at 12:59 PM, R1 was observed ambulating with her walker in the hallway and common area in which several other residents were present with no staff assisting her. On 8/31/17 at 3:00 PM, E2 states he would expect staff to ambulate with R1 while she is around others or at least have staff close enough so if she started to fall, they could assist her. 3. R3's Resident Care Plan for falls, initially dated 9/26/16, lists an approach of having her call light within her reach. On 8/31/17 at 1:28 PM, R3 was observed sitting in a chair in her room, with no call light noted to be visible or within R3's reach. Further observation noted the call light to be lying on the floor behind R3's chair, which was out of her reach. When asked where her call light was, R3 responded, I don't know.

Based on record review and interview, the facility failed to provide nursing services to aid in prevention of aspiration pneumonia: these failures include failing to follow the facility policy for reporting a change in a tube fed residents, not reporting a change in condition to the physician, including vomiting and failing to stop infusion of the enteral feeding formula when directed by the care plan and maintaining the head of bed elevated at least 30 degrees for 2 of 2 residents (R5, R14) reviewed for gastric tube feeding in the sample of 16 and one resident (R30) in the supplemental sample. These failures led to the hospitalization and [DIAGNOSES REDACTED]. R14 returned from the hospital on comfort care only, all IV (Intravenous) fluids, PEG (Percutaneous Endoscopic Gastrostomy) tube feedings and IV antibiotics discontinued. R14 expired on [DATE]. The failures were repeated on [DATE] and [DATE] with R5's emesis not being reported to the physician and failing to suspend the tube feeding infusion as required. The continued lack of assessment, notification and failure to follow procedures places residents (R5 and R30) currently fed by enteral feedings, as per [DATE] physician's orders [REDACTED]. Although the facility had identified the failure of E11 on [DATE], investigated, and implemented corrective measures the facility failed to re-evaluate to ensure that all nurses and nursing staff were educated on gastric tube care and standards of practice and these failures were repeated on [DATE] by E11 (Licensed Practical Nurse) and on [DATE] by E16 (Registered Nurse). These failures resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2 as the facility continues to educate and monitor staff on abuse policies and procedures. The findings include: 1. The Physician order [REDACTED]. R14's care plan dated [DATE] states Resident is dependent on Percutaneous Endoscopic Gastrostomy (PEG) tube feeding for all nutrition and hydration. R14 does not receive any medication or nutrition by mouth. The approaches related to this need included: Hold feeding if diarrhea or emesis, notify MD (Medical Doctor) and Keep head of bed elevated at 30 degrees, Observe for signs and symptoms of aspiration. The facility presented policy's dated [DATE] regarding Tube Feedings for: Gastrostomy Tube Replacement, Verifying Placement of Feeding Tubes, Checking Gastric Residual, Gastrostomy/Jejunostomy Skin Care, Continuous Tube Feeding, Administering Medications and Flushing Feeding Tubes; none of these policies included using a Foley catheter instead of gastrostomy tube, or any emergency procedures to follow. The Policy and Procedure Change in Condition dated [DATE] states in part: Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden onset, a change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed: 2. Specific information that requires prompt notification include . b. Prolonged/unresolved emesis o. A need to transfer the resident to a hospital/treatment center; r. Instructions to notify the physician of changes in the resident's condition. Nursing notes dated [DATE] at midnight state: This nurse went to flush res (resident) [DEVICE] and [DEVICE] had come out. MD notified and gave order to replace with F/C (indwelling catheter) and to consult Z1 (Surgeon). F/C inserted without difficulty. No s/s (signs or symptoms) of distress. A further nursing note dated [DATE] at 6:30am states: Given in report that resident had 2 emesis since putting Foley - no x-ray had been gotten to check placement nor had 2 emesis been reported to on call. This nurse answered call light to residents room - roommate had put light on to let someone know about roommate - resident had a dried towel full of brown emesis on lap, on face and chest - res starts profuse vomiting out mouth and trachea site - Gurgles noted ??? - on call called - number out of service - attempted to call E14 (Physician/ Medical Director) twice - call Z2 (Doctor)- gave order to send to ER - O2 (oxygen) applied O2 sat 78 - 80 % - Blood Pressure ,[DATE] - Pusle 97 - Temp.100, Resp. ,[DATE]. Resident to ER via gurney, and nurse report called to ER nurse. The hospital discharge summary dated [DATE] for R14 documents admission Diagnoses: [REDACTED]. 2. Urinary tract infection with urosepsis with elevated lactic acid and markedly elevated pyuria. 3. [MEDICAL CONDITION] with [MEDICAL CONDITION] secondary to prior accident. 4. [MEDICAL CONDITION]. The discharge plan : At this point, the patient will be transferred back to facility on comfort care only. We will discontinue IV fluids, PEG tube feedings and IV antibiotics. We will continue IV [MEDICATION NAME] and [MEDICATION NAME] PRN (as needed). We will add [MEDICATION NAME] . Continue oxygen, and we will do our best to keep him comfortable. The hospital Patient Discharge Summary Report dated [DATE] states as Diagnosis: [REDACTED]. The death certificate for R14 dated [DATE] documents R14 died on [DATE] and the cause of death is noted as: Aspiration Pneumonia. An undated Investigation summary regarding R14 documents nurses will receive education on documentation for change of condition, when to notify physician. Also, they will receive disciplinary action for failure to perform job safely, satisfactorily and efficiently. Continuing Education was documented for nursing staff dated [DATE] related to Enteral Tube: Checking placement residual and Care of. A Performance Correction Notice for E11( LPN) dated [DATE] was written for failing to chart vital signs for a resident with signs and symptoms of distress. A second Performance Correction Notice for E11 dated [DATE] was written for Neglecting to provide care. The notation states tube placement wasn't charted with insertion of catheter with g tube removal. Did not clarify order, resume/hold tube feeding . Did not call MD with change of condition/ vomiting. There was no documentation available for review that the facility reevaluated the nursing staff on following the policy and procedures reviewed [DATE] continuing education course. The [DATE] inservice documentation has 10 nurse's signatures. The facility provided a list of the 14 nurses employed. The inservice documentation did not include: E11 or E16. (Registered Nurse) There was no documentation to confirm that these nurses were initially reeducated. E16 stated on [DATE] at 9:45am that she has had no inservice education regarding enteral feeding or physician's notification. No evidence that Certified Nurse Aides received inservice education regarding care of residents with enteral feedings. E14 (Physician/Medical Director) stated via telephone on [DATE] at 3:50pm that he had been informed in the early morning of [DATE] that R14's PEG tube had become dislodged. E14 told E11 to replace the tube with an indwelling catheter tube. E14 stated this was done to keep it open until the surgeon could replace it. E14 indicated he believed he had a standing order not to continue the feeding while using the indwelling catheter tube. E14 stated I don't know if that contributed to R14's change in condition. E14 indicated he was not aware of R14's vomiting until later in the morning of [DATE] while performing hospital rounds. E14 said if I had been informed of the vomiting earlier we might have known to stop the tube feeding. R14 is high risk for aspiration and has had his head elevated when I have seen him in the nursing home. It only takes one time to vomit to aspirate. We would have watched him more closely if they had told me E14 was vomiting. Usually aspiration doesn't show up until the next day. If I remember right we admitted E14 because his sodium level was high. Review of physician standing orders for the facility on [DATE] found no reference to enteral feeding. E17 (Certified Nurse Aide) stated via phone on [DATE] at 2:30pm that she had reported to work at 10:00pm and was the float aide for the night. E17 stated that early in the night R14 had looked at them when R14's name was called but later appeared sick and would not look at them. E17 stated that E11(License Practical Nurse) had put a catheter tube in for R14's PEG tube and restarted the feeding. E17 indicated that R14 began projectile vomiting at sometime after their lunch time and she had cleaned R14 up. E17 stated the nurse did not know what to do and gave R14 a breathing treatment. E17 stated that E11 did not contact the physician. At the end of the shift E17 stated R14 had increased vomiting that was coming from the nose, trachea opening (stoma from a discontinued [MEDICAL CONDITION]) and mouth. E17 indicated the vomit was brownish - reddish and no bright red blood was seen. E11 stated on [DATE] at 9:00am, that around midnight on [DATE], R14's Gastric tube was out. E11 stated that she called E14 (Medical Director) and reported the Gastric tube was out and he gave orders to put in a 14 French catheter. E11 stated that she started the tube feeding after she checked for placement of R14's Gastric tube by checking residual and E11 stated she also checked for placement by auscultation. E11 stated that R14 vomited one time and she checked R14's lung sounds for gurgling and crackles and did not hear any unusual lung sounds. E11 stated that R14 vomited one more time before she gave E9 (Registered Nurse) report. E11 also stated that she did not contact E14 about the emesis or get an X-ray to verify placement of the 14 French catheter, nor did E11 review the facility policies regarding Gastric tubes. E11 stated that the head of R14's bed was elevated and she elevated R14's bed higher when he started vomiting. E11 stated that she can't remember Certified Nurse Aides (CNA) names that were working that morning, but they had cleaned vomit from R14's face and clothing. E11 also stated that she was inserviced about not calling R14's doctor concerning the Gastric tube. On [DATE] at 6:15 PM, E9 (Registered Nurse) stated that E11 told her in shift change report that R14's Gastric tube came out and E11 notified E14 and she received an order to insert a 14 French catheter which she did. E11 reported to E9 that R14 vomited one time and she waited a little while then started the [DEVICE] feeding. E9 stated that she asked E11 if she had notified R14's doctor about the emesis and if E11 got an X-ray to verify placement of the [DEVICE], and E11 stated, no. E9 stated that she went down the South and East halls to answer call lights and noticed that R14's call light was on and E9 stated that she knew R14 hadn't turned it on, so E9 hurriedly went to his room. E9 stated that R14 was lying almost completely flat and was gurgling and she immediately elevated R14 to a complete sitting position and when E9 elevated R14's bed, he began to projectile vomit, had feeding formula coming out of his nose, mouth, and an old [MEDICAL CONDITION] stoma that was not being used. E9 also stated that when she entered into R14's room there was a towel lying over him that had dried, coffee ground colored emesis. E9 stated she immediately notified the emergency room doctor, (couldn't remember his name) because she couldn't reach E14 by phone. On [DATE] at 9:50 AM, E9 stated that she couldn't remember an inservice being given about Gastric or Nasogastric tubes. 2. The June, 2016 physician's orders [REDACTED]. The orders state R5 has a gastric feeding tube with orders for [MEDICATION NAME] 1.5 Calories of Liquid to run at 60 centimeters (cc's)/hour per the GT for 20 hours everyday. On [DATE] at 0345 Nurse's Note signed by E11 stated, Res (Resident) had emesis x 1. Res cleaned up and had no further emesis. Tolerated feeding and meds well. No signs/symptoms of distress. (E1 stated on [DATE] at 11:00AM, the note should be dated [DATE].) A [DATE] 10PM-6AM Nurse's Note signed by E16 stated, Resident had one episode of emesis at 0130-no further episodes. The Nurse's Notes do not state if the tube feeding was stopped during the episodes of emesis, if tube placement was checked or if the physician was notified. R5's [DATE] Gastric Tube Resident Care Plan (Reviewed [DATE]) states, Hold feeding if diarrhea or emesis, notify MD (Medical Doctor). 3. E1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 10:20 AM. The Immediate Jeopardy was determined to have begun on [DATE] at midnight when R14's PEG tube had been dislodged and replaced with an indwelling catheter tube and the feeding was resumed. R14 developed profuse vomiting after this event and the physician was not notified until 6:30am. The facility failed to provide care and treatment of [REDACTED]. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy. A. The Facility maintains that residents who are fed by naso- gastric or gastrostomy tube receive appropriate treatments and services to prevent aspiration pneumonia , diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers and to restore, if possible, normal eating. Education to all nurses on Gastrostomy Policies began on [DATE] concluding on [DATE]; included the following: Administering Medications Checking Gastric Residual GTube/J Tube Skin Care GTube Replacement Continuous Tube Feeding Flushing Tube Feeding Verifying Placement of Feeding Tubes Change in Condition Care Path GI Symptoms Signs and Symptoms of Aspiration Keeping the Head of the Bed elevated 30 degrees or greater at all times. E11 (Licensed Practical Nurse) identified for not receiving education on prior incident was educated prior to starting her shift the evening of [DATE] and again on [DATE]. Education provided to nurses by E2(Director of Nursing), E8 (Assistant Director of Nursng), E22 (Minimum Data Set/Care Plan Coordinator) and E1 (Administrator). Effective [DATE] no nurse returned to work without receiving the above education. Additional education on Gastrostomy tubes was provided again on [DATE], [DATE] and [DATE]. Education to all Certified Nurse Aides began on [DATE] concluding on [DATE] included the following: Signs /Symptoms of Aspiration Keep head of bed elevated 30 degrees or greater at all times. Education provided to Certified Nurse Aides by E2, E8, and E22. Effective [DATE], no Certified Nurse Aide returned to work without receiving the above education. Documentation on residents with gastric tubes each shift began effective [DATE] and will continue. Review of residents with gastric tubes charts, Medication Administration Record [REDACTED]. Effective [DATE] any non-compliance with policy will be addressed upon identification with employee through continued education, return demonstrations and /or disciplines up to termination where appropriate. B. R5 and R30 were observed during the survey on [DATE] at 3:00PM, [DATE] at 10:00 AM, [DATE] at 1:45 PM, with the head of their beds elevated, between 30 and 45 degrees. They were alert, calm and quiet. They were not vomiting. Their breathing was not labored. Their skin color was pink. On [DATE] at 2:00 PM, E 20 (RN) cleaned R5's gastric tube. R5 was alert and comfortable. The gastric tube was intact. The enteral feeding was infusing. R5's skin was clear. C. R5 and R30's Nurses Notes had entries each shift, each day starting on [DATE]. D. During interviews on [DATE] from 1:20 PM to 2:30 PM , the following Certified Nurse Aides stated they received training last week regarding elevating the head of the bed and signs of aspiration for residents who are tube fed. E4, E20 and E37 who work day shift. E4 and E31 who work evening shift and E33 who works night shift. Between 1:20 PM and 2:30 PM, on [DATE] the following nurses could identify signs and symptoms of aspiration, how to care for a resident with a gastric feeding and when to notify the doctor of changes in residents condition. The nurses knew to elevate the head of residents beds at least 30 degrees if they are receiving enteral feedings. E30 night shift nurse and E10 day/evening shift nurse stated that they received training on [DEVICE]s and could identify signs of aspiration, a change in condition and when to notify the doctor, and knew to elevate the head of the bed at least 30 degrees if a resident is receiving enteral feedings. On [DATE] at 9:00 AM, E1 stated that all Registered nurses and Licensed Practical nurses received additional training on [DEVICE]s from [DATE] through [DATE] and that included a Pre-test and Post-test to ensure they know the signs of aspiration, what constitutes a change in resident condition, and when to notify the residents physician.

Based on interview and record review the facility failed to answer a call light timely for 1 of 1 (R4) resident reviewed for the answering of call lights timely in the sample of 4. This failure resulted in R4 requiring surgical intervention after falling and fracturing her right hip and pelvis. On 09-26-2013 at 10:30 AM, R4 was alert and oriented, R4 stated during interview that she fell on [DATE] because the staff did not answer her call light within an hour, to help her get to the bathroom and she tried to get to the bathroom on her own, fell and broke her right hip and pelvis. R4 further stated that she had to have surgery to repair the hip. R4 stated that she timed the staff on several occasions and it takes over an hour for the staff to answer her call light. Z1 (family member) was visiting R4 and stated that she has witnessed on several occasions the staff walking past a call light that had been on for a long time. Z1 also stated that R4 is alert and knows what is going on and she was sure that her R4 fell on [DATE] because she was trying to get to the bathroom before she urinated on herself. E4 (MDS/ Care Plan Coordinator) stated that R4 is alert and oriented. E4 also stated that R4 needed assistance with ambulation because she was unsteady and would not wait for assistance. R4's MDS dated [DATE], Section B; States that R4 understands and is able to make self understood, and has good recall. R4's Fall Risk assessment dated [DATE] states that R4 is high risk for falls. R4's Care Plan dated 04-11-13 states that R4 is potential risk for injury secondary to use of a walker for mobility, blind in left eye, generalized weakness and she doesn't always wait for assistance. R4's Care Plan states in "Approaches" that R4 is to be assisted with transfers and ambulation. The Incident Report-IDPH Notification with date of incident of 7-17-13, dated 07-18-2013 in the description of what happened states, CNA (Certified Nurses Aide) walked past R4's room and saw the door shut and the call light on. The CNA went into the room and found R4 sitting on the floor leaning on her right elbow up against the bedside nightstand. R4 told the staff that she closed the door because she needed to go to the bathroom. The Incident Report also indicates that R4 is alert and oriented and was complaining of right hip pain and right elbow pain. This report indicates that R4 was hospitalized on [DATE]. The Radiology Report dated 7-17-13 indicates that R4 sustained an Acute Intertrochanteric Right Femur Fracture and a Left Parasymphyseal Pubic Ramus Fracture. R4's Care Plan with a date of 7-25-13 states "Re-entry S/P (status [REDACTED].

Based upon observation, interview, and record review, the facility failed to adequately identify, implement and evaluate safety hazards to prevent falls for 2 of 3 residents (R1 & R2) in the sample of 3. These failures resulted in 1 resident, R2, being hospitalized after sustaining a compression fracture. 1. The shower room where R2 fell was observed to have 1 inch by 1 inch tile flooring and a tiled wall partition that has been removed. According to E1 (Administrator) the shower room is being repaired after R2's fall to remove the hump that was in front of the shower stall and the half wall partition to allow more room in the shower area for movement of the residents in the shower chairs. An interview with E1, on [DATE] at 1:15 pm and E2, (Certified Nurses Aide/Shower Aide) on [DATE] at 2:40 pm verified R2 fell in the shower room and that 4 - one inch by one inch tiles were missing in the floor of the shower at that time. R2 was in the shower chair when the shower chair fell backward causing R2's head to hit the floor. During an interview with E2 on [DATE] at 1:40 P.M., E2 said she was pushing R2 in a shower chair backwards in the shower to get the chair over the raised hump in front of the shower and into the shower area when the shower chair wheel went down in the missing tile area and a black rubber mat on the shower area floor wrapped around the wheel causing the chair to stop moving. The chair went backwards with R2 in the chair causing R2's head to hit the floor of the shower. An interview with E3, (Shower Aide) on [DATE] at 10:42 A.M., verified R3 has been a shower aide at Way Fair for 1.5 to 2 years. R3 stated she had received no training by the facility on giving showers or for maneuvering the shower chair over the tile hump. E3 stated that when placing residents in the shower she picks up the matts and hangs them on the handrail, pushes the shower chair with the resident in it backward into the shower area over the tile hump by standing in front of the shower chair and resident and pushing the shower chair backward into the shower area. Once the resident is in the area, the matts are placed on the floor in front of and on the side of the shower chair for the resident to stand on, due to the floor being slick, for dressing and self bathing if needed. The nursing notes in R2's medical record dated [DATE] at 10:45 A.M. indicates R2 was sent to the emergency room (ER) for evaluation and treatment of [REDACTED].M. The radiology report on R2 for a x-ray computed tomography (CT scan) of the Head with Intervenous contrast, date examined [DATE], has findings of "no significant change since February 12, 2013." Nursing note on [DATE] at 10:45 A.M., indicates R2's family requested R2 be transferred to an out of town hospital for another work up due to back pain, and non medical transportation was called, upon arrival due to R2's low oxygen saturation the Emergency Medical Technician's (EMT) made the decision to take R2 back to the local hospital. Radiology reports for a CT chest with a date examined as [DATE] documents "several bilateral rib fractures of varying ages", CT of the head without intervenous (IV)contrast indicates "left posterior scalp swelling, and no fracture" and CT of the lumbar spine without contrast states "Mild to moderate compression deformity of L2, new since [DATE] of uncertain acuity." An interview with Z1 attending physician, on [DATE] at 2:45 P.M., reports R2 was hurting all over from the fall, the x-ray report reviewed indicated R2 had a mass in the lung, R2's family wanted R2 to be transferred to an out of town hospital on [DATE] as they did not like the radiology department at the local hospital, and the fall did not lead to R2's death. Upon review of the Discharge Summary from the out of town hospital, R2 was discharged from the out of town hospital on [DATE] to her daughters home and referred to a hospice provider to receive services. According to the Medical Examiner/Coroner's Certificate of Death Worksheet, R2 expired on [DATE] at home with the cause of death stated as Pneumonia. 2. R1's facility Accident Incident report dated [DATE] at 9:00 am documents that E4, (Registered Nurse), heard R1's body alarm sounding and went in the room. R1 was standing up with the wheeled walker, walking toward the bath room. E4 assisted R1 to the bath room, placed R1 on the toilet, and instructed R1 to pull call light. E4 went to the hallway to pull resident medications and a few seconds later heard R1 yelling for help. E4 ran to the bath room and saw R1 laying face down on the floor. R1 stood up, lost his balance and fell on the floor. R1 sustained a skin tear to the left elbow measuring 2 cm by 0.1 cm, bloody in color per the [DATE] Accident Incident report. The interventions given to prevent the reoccurrence were to counsel R1 on factors that affect his safety and need to use the call light for assistance and "re-educated E4 to never leave an assist resident alone in the bathroom. Res (resident) should have had supervision." According to the [DATE] quarterly Minimum (MDS) data set [DATE], R1 needs supervision for transfers, ambulation, dressing and eating. R1's Resident Flow Records for [DATE] through [DATE] documents that R1 had general weakness present on those days.