Every finding on record at Fairhaven Christian Ret Center

Based on interview and record review, the facility failed to identify a significant weight loss for a resident (R4), failed to notify a resident's physician, dietician, and power of attorney for a significant weight loss and failed to obtain consistent meal intakes. These failures resulted in R4 experiencing a significant weight loss with no nutritional interventions for 22 days. This applies to 1 of 6 residents reviewed for nutrition in the sample of 28.The findings include:R4's electronic face sheet printed on 2/26/26 showed R1 has diagnoses including but not limited to chronic kidney disease stage 3, urinary tract infection, chronic obstructive pulmonary disease, and Alzheimer's disease.R4's facility assessment dated [DATE] showed R1 has no cognitive impairment and has not experienced weight loss.R4's care plan dated 10/24/25 showed, My health problems may impact my nutritional status .monitor and record food intakes, monitor/record weight. Notify physician and family of significant weight change.On 2/25/26 at 8:57AM, R4 stated, I have had a weight loss since I moved in here a few months ago. I don't think I take any nutritional supplements but I'm not sure.R4's weight record showed on 11/12/2025 R4 weighed 124.4 lbs. On 02/11/26, R4 weighed 114.2lbs which is a -8.2% loss within 3 months.R4's dietician note dated 1/12/26 showed, Notable downward trend in weight since admission with significant weight loss of 5.5% from October to November. Weight has since stabilized, however remains down overall.weight stability desired.Current plan of care remains appropriate as tolerated. Goal for weight and appetite stability.R4's physician's orders dated 1/20/26 showed, Weekly weights x4 weeks to monitor downward weight trend. No weights were documented in R4's medical record for 1/21 or 1/28. The first weight for R4 after the 1/20/26 physician's order was on 2/4/26 (14 days after the order was placed and showed R4's significant weight loss).R4's meal intake logs for January and February 2026 showed R4's meal intakes were not documented/recorded on 29 out of the 57 days.On 2/26/26 at 10:48AM, V12 (Licensed Practical Nurse) stated the CNA's (Certified Nursing Assistants) obtain the weights and will give them to the nurse. We will give them to nursing administration to enter. If there is a significant weight change, we will obtain a reweigh to ensure it is accurate. We will do it the next day or day after so we make sure we get the weight. If it's a true significant weight loss, then we notify the physician and we put a dietary slip in the dietician's box to have her evaluate for interventions. I'm not sure how often the dietician is here. I think maybe once a month. V12 stated, (R4) had a significant weight change but didn't get weighed in January. From December to February she had a significant weight loss. They reweighed and it is still a significant weight loss. February 4th she was 113lbs and reweighed on February 11th and she was 114.2lbs. If a resident is unavailable when their weight is due, then we would try and get it when they return to facility or I leave it open on the orders and tell the next shift to get the weight so we can ensure it is done.On 2/26/26 at10:56AM, V3 (Director of Nursing) stated, CNA's obtain the weights and give them to the nurse's and the nurse is entering them unless there is a discrepancy then they call nursing administration for further direction. If a resident is unavailable for their scheduled weight, then the nurse should enter a one-time order for the weight to be completed the next shift or the next day, whichever is more convenient for the resident. I think the dietician is here monthly, but she also does remote work too. If a significant weight change is noted, the nurses notify the resident's physician and power of attorney and we document that in a progress notes. We wait for direction from the physician which is usually a referral to dietician and maybe a supplement in the meantime. The dietician will send me reports for weights and any interventions when she does remote work. The last report I got from her was on 2/20/26 and she made no recommendations for (R4). V3 then obtained the weight book for R4's unit and confirmed no weights were written down for R4 on 1/20 or 1/28.On 2/26/26 at 11:39AM, V11 (Registered Dietician) stated, I am in the facility every other week, but I do assessments remotely on a weekly basis. I document a progress note for every resident I perform a review or assessment on. I run a weight change report once or twice a month to check for weight changes. If the staff note a weight change, they will send me a referral by e-mail or put it in my folder at the nurse's station. (R4) is on my list to review today. She lost a significant amount of weight from November to present. She did not have a weight obtained last month which is a problem because she is supposed to be a monthly weight at the very least. She had a weight loss shortly after she was admitted and stabilized and has now had another weight change. I ran my report last week and then again today. I will be recommending a health shake once or twice a day to see how she accepts that. I did not get notified on 2/4 of (R4's) significant weight change. I just pulled the report last week and haven't done my assessments yet. I would say this is a problem that I haven't been notified. I would have requested a reweigh to ensure it was accurate and since it was, I would have implemented a nutritional shake right away to hopefully stabilize or increase her weight.The facility's policy titled, Policy and Procedure for Resident Weights dated 9/22/25 showed, Policy: To monitor weights and weight changes that may indicate a significant weight change in the resident's nutritional status. Significant changes in weight.7.5% gain or loss in 3 months.4. All weights must be documented in the weight book and in (electronic medical record).6. The clinical nurse manager or designee will complete the paperwork (fax) found in the weight book to notify the resident's Doctor/Nurse Practitioner of weight changes.8. Weekly weights will be done as follows.b. any resident with a 5% or greater weight loss or gain over the past month. C. any resident with a physician's order for weekly weights.

Based on observation, interview and record review the facility failed to check the temperatures of food before serving and failed to use utensils to stir and remove food. These failures apply to all residents in the facility.The findings include:The CMS Center for Medicare and Medicaid Services form 671 dated 2/24/2026 shows there are 69 residents in the facility.1.On 2/24/2026 at 9:30 AM, V4 (Dietary Manager) said the food for the facility is prepared in the main kitchen and then placed in hot boxes and taken to the kitchenettes on the two nursing units on the second and third floor. V4 said the food temperatures will be taken on the units from the steam table prior to serving the food. At 11:10 AM, V5 (Cook) took the hot boxes containing the noon meal to the second-floor kitchenette. V5 placed all the food for lunch onto the steam table and then checked the temperatures of the regular meat and the pureed meat. V5 documented the temperatures on the log and then proceeded to get serving utensils. When V5 was asked about checking the temperatures of the rest of the food on the steam table, V5 replied, I only need to check the meats, the rest is checked in the kitchen prior to being taken to the kitchenettes. That's how I always do it. At 11:25 AM, V5 delivered the hot box containing the lunch to the third-floor kitchenette. V5 placed the food on the steam table and said she did not have a thermometer to check the temperatures. V4 left the kitchenette to obtain a thermometer for V5. V5 only checked the temperatures of the pureed meat and the regular meat. V4 told V5 she needed to check the temperatures of all the food being served. At 11:42 AM, V4 asked the surveyor to accompany her back to the second-floor kitchenette to make sure the temperatures were taken correctly. In the kitchenette on the second floor, V6 (Prep Cook) and V7 (Cook's Helper) were getting ready to serve the noon meal. V4 told V6 and V7 that the temperatures of the food needed to be checked and documented. V4 said the meat had already been checked. V6 grabbed a thermometer and attempted to take the temperatures; however, the thermometer was not reading the temperature adequately. V4 again had to leave to obtain a new thermometer. V6 then checked the temperatures of the food and would look at V4 for confirmation it was okay. V6 needed to be told repeatedly that all the food needed to be checked for the proper temperature. The temperature for the pureed vegetable was 101 degrees Fahrenheit (F) and V4 told V6 she needed to reheat the food and check the temperature again. V6 placed the pan of pureed vegetables in the steamer to reheat. As V6 was observed checking the temperature of the pureed vegetables several times, V4 could be heard telling V6 it needed more time in the steamer. On 2/24/2026 at 12:15 PM, V6 said the temperatures of the food on the steam table needed to be at 165 degrees F.On 2/24/2026 at 12:15 PM, V7 said the temperature of the food on the steam table needed to be at least 150 degrees F.On 2/24/2026 at 12:45 PM, V4 said all food needs to have the temperature checked before serving to ensure the food is at 140 degrees F for the safety of the residents to prevent a food borne illness.The Food Temperature Monitor Sheets dated 2/24/2026 shows the temperature of the hot cereal and regular egg for breakfast and the regular meat and the pureed meat were the only food temperatures being taken. On the menu for 2/24/2026 for breakfast the food served was cream of wheat or cold cereal, fried egg, ham and hashbrowns. The noon meal for 2/24/2026 was French dip with au jus, French fries and succotash.The Food Temperature Monitor Sheets for February 1 to February 23, 2026, shows multiple meals where the temperature was not documented as taken prior to serving the meals.The undated Cooking Foods-Internal Temperatures policy shows the appropriate food service staff will be trained on how to use a thermometer. The undated policy for Food Temperatures-Cooked Foods shows the major cause of food borne illness are improper cooking, cooling, reheating and holding temperatures. Hold all hot foods at 135 degrees F and check temperatures frequently.2. On 2/25/2026 at 9:57 AM, V8 (Cook) was preparing the mechanical soft foods and the pureed foods. V8 placed the meat in the blender and pulsed to a ground consistency, then scooped out the meat with a gloved hand. V8 then placed the next piece of meat into the blender and broke apart the meat with the same gloved hand. V8 then sprayed the pan and grabbed the lid to the blender with the same gloved hand and then V8 pulsed the meat and then using the same gloved hand, scooped out the meat. V15 (Dietary Supervisor) then grabbed a spatula and handed it to V8 to use. V8 made all the portions of meat and then did the vegetables, added it all into a bowl and mixed and scooped out the portions and wiped off the spoon with gloved hands he had just used to arrange the pans. V15 said utensils must be used to move food from one place to another to prevent cross contamination.

Based on observation, interview, and record review the facility failed to ensure an indwelling catheter was secured and failed to ensure catheter tubing was kept off the floor for 1 of 2 residents (R11) reviewed for indwelling catheters in the sample of 28. The findings include:On 2/24/26 at 11:49 AM, R11 was seated in his wheelchair in the dining room. R11's indwelling catheter drainage bag was under his wheelchair in a privacy bag. R11's catheter tubing was looped under the chair and touching the floor. R11 finished eating lunch at 12:39 PM and self-propelled his wheelchair from the dining room table to the nurses' station. R11's catheter tubing continued to drag on the floor. R11 self-propelled to V9 (Registered Nurse) at the nurses' station and obtained a chocolate wafer bar. R11 sat in the common area talking with another Certified Nursing Assistant (CNA) regarding his shower. R11 said he needed to use the bathroom first. V9 placed the foot pedals on R11's wheelchair and pushed him toward his room. R11's catheter tubing continued to drag on the floor. V10 (CNA) said the shower was ready for him. R11 said he needed to go to the bathroom. V10 donned a gown and gloves and pushed R11's wheelchair into his bathroom. R11's catheter tubing continued to drag on the floor. V10 assisted R11 to stand from the wheelchair and pivot transfer to the toilet. V10 pulled R11 pants down and he sat on the toilet. R11 did not have a catheter secure device in place. V10's catheter tubing was hanging freely. After R11 finished using the bathroom, V10 assisted him back to the wheelchair. R11's catheter tubing was touching the floor when he propelled to the sink to wash his hands. As R11 self-propelled his wheelchair out of the bathroom, he stepped on his catheter tubing with his right foot, then his left foot. R11 exited the bathroom and waited for V10. R11's catheter tubing was under his right foot. V10 exited the bathroom and R11 began self-propelling forward. R11's catheter tubing went under his left foot, then drug on the floor as V10 pushed R11 to the shower room. R11's Physician Order Report dated 1/26/26-2/26/26 showed R11 had diagnoses to include, but no limited to Alzheimer's Disease, history of urinary tract infections (UTIs), weakness, polyosteoarthritis, retention of urine, and benign prostatic hypertrophy (enlarged prostate). This document showed R11 had an indwelling catheter. R11's Care Plan initiated 4/28/25 showed he had an indwelling catheter related to urinary retention. This care plan showed an intervention to use a catheter strap (catheter secure device). R11's facility assessment dated [DATE] showed he had severe cognitive impairment and had an indwelling urinary catheter. On 2/26/26 at 8:54 AM, V3 (Director of Nursing - DON) said R11's catheter tubing should not be dragging on the floor for infection control purposes. V3 said the catheter tubing and/or drainage bag should not touch the floor due to the risk of cross-contamination. V3 said the facility staff should ensure any resident with an indwelling catheter had a secure device in place. V3 said the purpose of the catheter secure device was to keep the catheter positioned properly and prevent irritation. V3 said if a resident steps on the tubing it could cause an obstruction, or the catheter could come out. The facility's Urinary and Suprapubic Catheter Management Policy revised 9/6/24 showed, Purpose: Establish the routine care administered when an indwelling catheter is in place. This routine care protects the resident from infection, injury, and promotes comfort.

Based on observation, interview, and record review, the facility failed to wear personal protective equipment (PPE) in a manner to prevent the spread of COVID-19. This applies to 1 of 2 (R19) residents reviewed for isolation precautions in the sample of 28.The findings include:R19's electronic face sheet printed on 2/25/26 showed R19 has diagnoses including but not limited to Alzheimer's disease, diarrhea, rash, and vascular dementia.R19's nursing progress notes dated 2/16/26 showed R19 tested positive for COVID-19 and was placed on contact, droplet, and airborne precautions.On 2/24/26 at 9:47AM, R19's door had a sign posted showing, Contact, droplet, airborne precautions.On 2/24/26 at 12:24PM, V13 (Certified Nursing Assistant-CNA) applied a gown, gloves, shoe covers, and an N95 mask over her surgical mask and entered R19's COVID positive room.On 2/25/26 at 8:53AM, V14 (CNA) came out of R19's room with a surgical mask underneath her N95 mask. V14 stated, I just wear a surgical mask under my N95 mask because I already had a surgical mask on so it doesn't make sense to take it off to put an N95 mask on. (R19) is on isolation because he has COVID.On 2/26/26 at 11:09AM, V3 (Director of Nursing) stated, PPE for COVID isolation should be a gown, N95 mask, goggles/face shield, and gloves. A Surgical mask shouldn't be worn underneath the N95 because it does not create a seal for the N95 to be worn correctly and puts staff at risk for contracting COVID.The facility's policy titled, (Facility) mask policy) dated 1/23/23 showed, Masks and face covering are intended to limit the risk of the wearer exposing a coworker or resident to undetected illnesses or infection, including COVID-19.The Centers for Disease Control document titled, How to Use your N95 Respirator dated 3/2/25 showed, Your N95 respirator must form a seal to your face to work properly. Your breath must pass through the N95 respirator and not around its edges. Jewelry, glasses, and facial hair can cause gaps between your face and the edge of the respirator. The N95 respirator works better if you are clean shaven. Gaps can also occur if your N95 respirator is too big, too small, or it was not put on correctly.

Based on observation, interview, and record review the facility failed to ensure hot food was served at palatable temperatures for 3 of 3 residents (R3, R54, & R60) reviewed for dining in the sample of 28.The findings include:On 2/24/2026 at 9:49 AM, R3 was sitting in her recliner in her room. R3 stated she had some concerns about the hot food being served cold. R3 stated she eats in the dining room and by the time her food gets to her it is cold. R3 stated residents have brought it up at the Resident Council meetings.On 2/24/2026 at 12:14 PM, R3 was served her lunch meal of roast beef on a bun, au jus, fries, and cooked carrots. R3 stated her food was cold. R3 stated she is tired of food coming out cold. R54 was served her lunch and stated her fries and carrots were cold. At 12:57 PM, R60 stated her food was served cold.The Resident Council Meeting Minutes dated November 20, 2025, showed dietary concerns that included residents wanted more efficient ordering, so food is not cold. A resident suggested that staff wait and serve 4-6 tables at a time, so everyone's food is hot, and they all get it at the same time.The Resident Council Meeting Minutes dated January 22, 2026, showed residents mentioned that vegetables are always cold. Residents stated that the dinner meal on 1/22/26 was also cold. Residents wondered where the temperatures were being taken for the food: on the surface or deep in the pan. On 2/26/26 at 8:58 AM, V15 Dietary Supervisor stated the food is prepared in the main kitchen and the temperature is checked before it leaves the kitchen and is taken to the health center. The food is put on the steam table in the health center, and the temperatures are checked again. V15 stated it was important for food temperatures to be what they should be such as hot foods served hot for good food quality. V15 stated it was also important, so the food is enjoyable and palatable. The Minimum Data Set (MDS) dated [DATE] for R3 showed no memory problems or cognitive impairment. The MDS dated [DATE] for R54 showed no memory problems or cognitive impairment. The MDS dated [DATE] for R60 showed no memory problems or cognitive impairment.The facility's Resident Meal Service policy (2009) showed Residents will be provided with nourishing, palatable, attractive meals that meet daily nutritional and special dietary needs. The dining experience will enhance the resident's quality of life by supporting their individual dining needs. Food items and plating will be consistent with the residents' needs. The food service manager will perform meal rounds routinely to determine if meals are attractive and nutritious and meet the needs of the individual. The food service manager will observe meals for preferences, portion sizes, temperature, flavor, variety and meal passes for accuracy.

Based on interview and record review, the facility failed toensure R1 was supervised while eating and food items were present within R1's reach. This failure resulted in R1 choking on R1's food and expiring. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] at 6:00 PM, when facility staff failed to ensure R1 was supervised at the dining room table when food was present. R1 impulsively grabbed food, put it in her mouth, choked, and died . The facility was notified of the Immediate Jeopardy on [DATE] at 9:28 AM. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE] at 9:28 AM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE]; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The Face Sheet dated [DATE] for R1 showed diagnoses including Alzheimer's disease, fracture of neck, type 2 diabetes mellitus, vascular dementia moderate, with psychotic disturbance, deep vein thrombosis, delusional disorder, anxiety, tremors, muscle weakness, and cerebellar stroke syndrome. The Progress notes for R1 showed on [DATE] at 12:27 PM, during lunch resident was having a difficult time swallowing her food (stringy meat) as evidenced by coughing/choking during the meal. Residents' food was cut up into very small pieces and message was left for hospice to return a call to the facility to further discuss the resident's diet. At 2:15 pm, verbal orders received from hospice to downgrade resident's diet to mechanical soft texture. POA (Power of Attorney) contacted and in agreement with diet change orders. Diet slip completed and submitted to dietary. The Physician Orders for R1 showed on [DATE] an order was entered for a general, mechanical soft diet. The Progress Notes for R1 showed on [DATE] at 10:37 PM, at 6:00 PM R1 was in the dining room eating supper. A CNA (Certified Nursing Assistant) was sitting beside her. R1 was so fast eating her supper that made her choke. She was already turning blue. She was unresponsive. Did Heimlich maneuver. We brought her to her room and did some suctioning. We were able to get some pieces of food. Resident was grimacing when I was pinching her fingers. At 6:11 PM called the POA and informed him that resident was unresponsive and informed him about what happened. At 6:23 PM, resident was no longer breathing. Vital signs have ceased and eyes fixed. Pronounced death of resident at 6:23 PM. Hospice was notified and said she would call all the parties concerned. The facility's Incident Report Telephoned to Regional Office form (no date) showed, Date of Incident: [DATE]; Time of Incident: 6:00 PM. Name of patient/Resident: (R1). Describe what happened, causes(s), injury: Upon investigating it was determined that the resident (R1) was sitting at her regular seat where she was served a general/regular meal for supper on [DATE]. On [DATE] the resident's diet order was changed to mechanical soft. At 6:00 PM the resident began to choke. Staff immediately responded with back blows and Heimlich maneuver. The resident was assisted to her room and the Heimlich was continued. The resident went unconscious and was assisted to bed. Suction was attempted. At 6:11 PM, the POAHC (Power of Attorney for Healthcare) was called and requested hospice be notified instead of sending the resident out. Hospice was notified at 6:18 PM .oxygen saturation 89% on room air, 3 liters of oxygen applied. At 6:23 PM the resident was pronounced deceased . All parties notified. On [DATE] a full investigation took place. On [DATE] at 10:35 AM, V8 (Food Service Supervisor) stated, one of our (dietary) staff was passing plates for supper on Thursday night. We were serving pulled pork sandwiches. She got confused; R1 was supposed to have ground meat and got pulled pork instead. V13 Dietary Aide gave the wrong diet to R1. V13 gave pulled pork instead of the ground meat which is mechanical soft. On [DATE] at 1:28 PM, V14 Server stated, I remember someone came in (to kitchen) and said a resident was choking and turning blue. When I came back from break the nurse said R1 ate too fast, choked, and died . On [DATE] at 1:39 PM, V15 Dietary Aide stated she was told that R1 was choking, and someone was helping her. Later the nurse came in with a card and said R1 was dead. V13 didn't know R1 was on a mechanical soft diet and gave her a regular diet. She got bigger pieces than she should have, and it caused her to choke on the food. On [DATE] at 3:34 PM, V3 CNA stated she gave R1 a bite of food and heard another CNA tell one of her other residents to sit down so she went over to check on that resident. V3 stated when she was checking the other resident, R1 started choking. The nurse came over and tapped R1 on the back. Two other CNAs came over and rushed R1 to her room. V3 stated sometimes R1 would have to be fed and sometimes not; she was able to do finger foods herself. V3 stated R1 ate fast so if they fed her, she would slow down when eating. On [DATE] at 3:46 PM, V5 CNA stated she was with the nurses when they tried to help R1. They tried to do the Heimlich and tried to suction R1. V5 stated R1 has choked before; she would eat too fast and cough it up. V5 stated most of the time R1 would eat too fast so someone needed to be with her monitoring that. On [DATE] at 4:15 PM, V1 (Administrator) and V2 DON (Director of Nursing) stated the facility has cameras and they saw what happened. They stated V3 CNA had been assisting/supervising R1 for her meal. V3 got up from the table and R1 grabbed food from her plate and put it in her mouth. They stated R1 was very impulsive, and the dietary aides are the ones responsible for removing plates. V2 stated the CNA could have taken R1's plate away. R1 started choking and the nurse was right there and responded right away. V2 stated she asked what R1 choked on, and they told her they were pulling bread out of her mouth. On [DATE] at 12:18 PM, V7 RN stated she was R1's nurse the day that she choked. V7 stated she was at the nurse's station when she heard a commotion in the dining room; someone was choking. V7 stated she went to R1, and she could not talk; her face was turning blue. V7 stated she bent R1 forward and did back blows. V7 stated she did a finger sweep but the blockage was not relieved. V7 stated she did the Heimlich; R1 couldn't talk. V7 stated the 2 CNA's put R1 in bed while she got the suction and oxygen. V7 stated they were still trying and doing abdominal thrusts and suctioning. V7 stated small pieces/chunks of meat came out. V7 stated R1 died at 6:23 pm. On [DATE] at 9:45 AM, V8 (Food Service Director) stated she did not have a recipe for the pulled pork. V8 stated the meat for mechanical soft is supposed to be ground to make it safe so there are no chunks of meat. V8 stated her thought with the pulled pork is what if they don't pull it/shred it enough and there are still big pieces. That wouldn't be safe. V8 stated her rule is that meat needs to be ground to the ground beef consistency for mechanical soft. V8 stated the policy for mechanical softs says chop, shred, or grind but she does ground meat and that is what she has always done. On [DATE] at 11:00 AM, V19 (R1's POA - Power of Attorney) stated, he was contacted when this was happening. R1 has been a Do Not Resuscitate (DNR) for a long time and did not want any heroics done. R1 would not have wanted the CCC (continuous cardiac compressions) done, and I would have told the facility to stop. V19 stated he did not want compressions done and neither did R1. On [DATE] at 11:00 AM, V18 (Medical Director) stated on [DATE] R1 choked on meat, he was notified, and R1's diet was downgraded to a mechanical soft diet. V18 stated R1 was on hospice and comfort care. V18 stated in R1's case her diet was downgraded to reduce the risk of aspiration and choking. V18 stated R1 choking on the food is most likely why she died . V18 stated it is expected that staff follow diet orders. R1's Care Plan dated [DATE] showed, Nutritional status: my health problems could affect me nutritionally Dietary will provide me a general/mechanical soft, thin liquids with super cereal daily. I eat independently with supervision. R1's care plan did not show that she is impulsive, grabs at food or will eat too fast if not monitored. On [DATE] at 12:37 PM, V2 DON stated, R1's last care plan was done on [DATE]; she was in her ARD (Assessment Reference Date) period. V2 stated R1's diet was changed on [DATE] to a mechanical soft diet. When there is a diet change the registered Dietician will review and update the nutrition care plan. V2 stated R1 had a problem of eating fast; impulsive is the word she would use for her eating. V2 stated R1 needed supervision for meals for that purpose. V2 stated supervision means a staff member would be near her for her meals; not to help her eat but to provide verbal cues to not be impulsive. V2 stated R1's care plan did not show that she is impulsive; it said she fed herself and needed supervision. V2 stated it would have been a good idea to have that on the care plan, so staff were aware of exactly what they were supervising her for. V2 stated what could have been done better in that situation would have been to take R1's plate away, and the care plan could have said the reason R1 needed supervision for meals. On [DATE] at 1:02 PM, V22 LPN (Licensed Practical Nurse/ MDS/Care Plan Coordinator) stated, nursing does nurse related care plans and dietary does the resident's nutrition care plans. V22 stated she coordinates the care plans and conducts the care plan conferences. V22 stated R1 was known for hoarding, eating too fast, and being impulsive with eating. V22 stated this should have been on R1's care plan so staff could have been alerted to why R1 needed supervision at meals. R1's MDS (Minimum Data Set) dated [DATE], showed partial/moderate assistance needed for eating. The facility's Aspiration Precautions and Choking Prevention Policy ([DATE]) showed, Purpose: To establish guidelines for creating a safe consumption experience and prevent aspiration and/or choking by providing basic nursing interventions to decrease the risk of aspiration. Behavioral risk factors for choking include eating too quickly, putting too much food in their mouth. Ensure food prepared is in accordance with resident dietary orders. The Immediate Jeopardy that began on [DATE], was removed on [DATE] when the facility took the following actions to remove the immediacy: Facility actions to remove immediacy include: 1. All nursing staff via our electronic platform were instructed that plates need to be cleared from the table when a resident that requires supervision/assistance is done eating and no longer has direct staff supervision. Completed [DATE]. 2. All care plans for those residents needing supervision or assistance with meals will indicate the reason they need assistance. Completed [DATE]. 3. The white board will be updated as diets are changed by the dietary supervisor/designee. Dietary staff were re-trained and trained to the new system. Dietary staff will initial on their schedule indicating that they reviewed the diet cards and the white board at the beginning of their shift. Initiated [DATE]. 4. Diet card color system was implemented on all tables showing each resident's diet (see POC). Dietary staff trained to new system or will be trained before working. Initiated on [DATE]. 5. Residents will be verified by staff to ensure the correct resident is in their preferred seating arrangement. If the resident is unable to verbally verify name/location, wheelchair or other staff will verify their name. Dietary staff trained to the new system or will be trained before working. Initiated [DATE]. 6. Resident Feeding Assistance Policy developed (see Attached). Completion [DATE]. 7. Medical Director notified of Immediate Jeopardy for F689. Completion [DATE]. 8. Compliance will be monitored through the QA process: A. DON or designee will be auditing a minimum of ten (10) current residents to ensure that they are receiving the appropriate level of assistance with meals, and we will be auditing a minimum of ten (10) of current residents to ensure care plan is updated to reflect dietary assistance needs. Initiated [DATE]. B. Staff are being in-serviced on safety and supervision in the dining room and the removal of plates when the resident that needs assistance has finished eating. Initiated [DATE].

Based on interview and record review, the facility failed to ensure a resident was transferred and ambulated in a safe manner for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 4 residents. This failure resulted in R1 falling and sustaining a right clavicle fracture. Findings include: R1's current Face Sheet provided by the facility on 2/26/25 shows R1's diagnoses include but are not limited to dementia, fracture of right clavicle, right shoulder pain, syncope and collapse, fatigue, pain in right knee, depression, and kyphosis. R1's current care plan last reviewed 2/8/25 shows R1 is at risk for falling due to her age, muscle weakness and overall physical decline. R1 requires contact guard assistance with bed/chair/toilet transfers and is ambulatory with a walker and staff assistance. Staff are to monitor R1 for unsteady gait and unsteady balance. R1's Minimum Data Set (MDS) dated [DATE] shows R1 requires supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) to sit, to stand, chair/bed to chair transfer, walking 10 feet, and walking 50 feet with two turns. On 2/26/25 at 1:22 PM, V6, Certified Nursing Assistant (CNA), said she was caring for R1 when she fell at around 8:00 PM on 2/20/25. V6 said she was trying to transfer R1 from the recliner to the wheelchair to take her to the bathroom. V6 said she was using R1's walker to help her stand. V6 said she got R1 to a standing position from the recliner, R1 was holding onto her walker, took a couple steps, then she just dropped and fell to the floor. V6 said she tried to grab R1 underneath her elbows, but R1 caught her off guard and she did not expect it. V6 said R1 usually walks well and is a one staff assist with the walker or wheelchair and a gait belt. V6 said R1 was in her room on isolation for cold symptoms (cough and fever), that evening and no one told her R1 was not walking well. V6 said she should have had a second person help her; she should have asked for help. V6 said the only reason she grabbed R1's arms was to prevent her from hitting the ground really hard. V6 said she got scared and grabbed R1's arms and it probably wasn't the best method, but she was caught off guard, she wasn't expecting R1 to fall. V6 said once the nurse, V7, Licensed Practical Nurse (LPN), came to assess R1, they realized that R1 was very weak and could not stand and V7 put a gait belt on R1. On 2/26/25 at 10:46 AM, V7 said she was called to R1's room after R1 fell around 8:00 PM on 2/20/25. V7 said she went to R1 room, R1 was on the floor with her feet stretched out and her walker in front of her. V7 said R1 did not have a gait belt on when she found her on the floor with the V6. V7 said V6 told her she was trying to transfer R1 from standing with the walker to the wheelchair. V6 reported that R1 was weak and started to fall and V6 assisted R1 to the floor. V7 said she checked R1's vital signs and her temperature was 102.7 degrees Fahrenheit, she had cold symptoms, and was weak. On 2/26/25 at 11:30 AM, V9, CNA, said if a resident needs supervision, she uses a gait belt with their transfers/ambulation. V9 said even if a resident is usually independent, they may need to modify their needs if they are not feeling well. For example, an independent resident may need to use a walker or a wheelchair if they are weak or not feeling well. On 2/26/25 at 11:40 AM, V3, Director of Rehab said Contact Guard Assistance means that the resident requires a gait belt for ambulation and transfers, and the staff is guarding the resident with their hand nearby. If needed, assistance is offered. V3 said if a resident is ill and feels weaker than usual, staff can use more assistance than the resident usually requires. On 2/26/25 at 11:56 AM, V4, MDS Coordinator, said she is helping with the restorative program for the last couple of months since the previous restorative nurse resigned. V4 said Contact Guard Assistance means that the resident uses/wears a gait belt and staff guide then with the gait belt for ambulation and transfers. V4 said if a resident is ill or having an acute situation and cannot safely transfer/ambulate at their current level, staff can go to the next level to ensure the safest mode of transfer/ambulation. V4 said R1 needs a gait belt and uses a walker for ambulation and transfers. On 2/26/25 at 2:09 PM, V2, Director of Nursing, said R1 fell and later started to complain of pain in her shoulder. V2 said they got and X-ray and found that R1's clavicle was fractured. V2 said with an acute illness, people are more weak, and may require more assistance. V2 said a gait belt should be used for transfers and ambulation; it's not safe to grab a resident by their arms. On 2/26/25 at 2:16 PM, V5, Physician, said R1's fall likely caused her clavicle fracture. R1's Resident Accident/Incident Report dated 2/20/25 shows under the heading Cause/Probable cause of Event: Resident has unsteady gait due to weakness from illness. R1's Radiology Report of her right shoulder dated 2/23/25 shows a fracture of the clavicle with modest displacement. A written statement of an interview with V6 dated 2/24/25 regarding R1's fall on 2/20/25 shows V6 stated, The resident is contact guard assistance with the use of a walker at baseline. She (V6) was aware that the resident had not been feeling well earlier in the day. The facility's Safe Ambulation/Gait Belt Policy dated April 2024 shows during a transfer, when assisting with resident ambulation, or during other applicable care procedure, a gait belt must be used for the safety of each resident. During a transfer of ambulation, the gait belt is used to assist the resident without using their clothing or arms to give assistance in balance or movement.

Based on observation, interview and record review the facility failed to ensure a multidose vial was labeled and dated when opened. This failure has the potential to affect all residents at the facility. The findings include: On 1/7/25 at 8:38 AM, this surveyor and V2 (Director of Nursing-DON) checked the 2nd floor medication room in the Healthcare Services Unit. A multidose vial of Tubersol (tuberculin (TB) testing solution) was noted in the refrigerator opened but not labeled with the date of opening. The preprinted date labeled on the vial was 9/16/24. V2 (DON) said this (vial) is months old, it should have been disposed of after 28-30 days. V2 said the Tubersol vial was used to all residents including new admits and any residents needing yearly TB testing including staff. V2 said any multidose vial should be dated and labeled once opened. The facility Policy titled Multi dose vial medication management dated 11/10/24 shows, 3. When a multi dose vial is opened, the nurse is required to complete sticker with the following- date of opening the vial, expiration date 28 days from opening or the manufacturer's expiration date whatever is sooner. Nurse initials when placing the sticker. The CMS report dated 1/6/25 show there were 63 residents residing at the facility.

Based on observation, interview, and record review the facility failed to ensure staff used the required personal protective equipment (PPE) when entering COVID-19 isolation rooms and failed to ensure N95 masks were not worn over a surgical mask. The facility also failed to ensure gloves were changed to prevent cross contamination. This applies to 5 of 16 residents (R12, R10, R45, R54, and R27) reviewed for infection control in the sample of 16. The findings include: 1. R12's progress note dated 01/06/25 indicated R12 was on isolation for COVID-19. On 01/06/25 at 8:35 AM, there were signs on R12's room door indicating R12 was on airborne isolation, droplet isolation, and contact isolation. On 01/06/25 at 12:29 PM, V8 (Housekeeper) put PPE on to enter R12's room. V8 entered R12's room with gloves, gown, and a surgical mask on. V8 did not have on a N95 mask or eye protection. On 01/06/25 at 12:42 PM, V8 exited R12's room and stated she cleaned the room. V8 said she knows what PPE to wear when entering an isolation room based on the signs on the door. The signs on R12's door indicated a N95 mask and eye protection were required. On 01/07/25 at 10:04 AM, V16 (Infection Control Nurse) said the required PPE for entering a resident's room on isolation for COVID-19 was gown, glove, N95 mask, and goggles. 2. On 01/06/25 at 8:35 AM, V7 (Certified Nursing Assistant) had R12's meal tray and placed on PPE to enter R12's room. V7 had a surgical mask on under a N95 mask when entering R12's room. On 01/07/25 at 10:04 AM, V16 said a surgical mask should not be worn under a N95 mask. 33760 3. On 1/6/25 at 8:30 AM, R10 and R45's room was closed with a sign on the door of droplet and contact precautions. V12 (License Practical Nurse) said both R10 and R45 were on isolation due to positive for Covid 19. R10's result detail show R10 is positive for Covid 19. R45's result detail show R45 is positive for Covid 19. At 9:15 AM, V14 (Certified Nursing Assistant-CNA) was in the room with gown, gloves and surgical mask on and brought R10 and R45 their breakfast. V14 stayed in the room to monitor both residents while eating their breakfast. At 1:15 PM, V14 (CNA) said while she was in R10 and R45's room, she applied an N95 mask over her surgical mask when she realized she was only wearing a surgical mask. V14 said she removed the N95 mask before she exited the room. On 1/7/25 at 8:35 AM, V13 (CNA) said she was the Covid CNA today. V13 was in R10 and R45's room with no PPE (no gown, no N95 mask and no eye protector). V13 said she removed her surgical mask and N95 mask, gown and faceshield while she was still in the Covid positive room since she was planning to leave the room shortly. On 1/8/25 at 11:15 AM, V2 (DON-Director of Nursing) said the facility is on Covid 19 outbreak. All staff providing care to Covid 19 positive residents should wear gown, gloves and N95 mask. Staff cannot put a surgical mask under the N95 mask. The facility policy on Preventing the spread of Covid 19 show, the facility will implement al three types of transmission based precaution-contact, droplet and airborne. PPE use will include:gloves, gown and N95 respirators and eye protection. 34506 4. R54's Face sheet shows she was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, delusional disorder, restlessness and agitation. R54's Care Plan dated June 12, 2023 shows R54 was frequently incontinent of bladder and bowel. R54 needs staff assistance with incontinence cares and her hygiene needs. Observe R54 for verbal and non verbal cues that I need to use the toilet. On January 6, 2025 at 11:50 AM, V10 and V11 (CNAs-Certified Nursing Assistants) provided peri care for R54. R54's incontinence brief was saturated from front to back with dark urine. V11 removed R54's soiled incontinence brief, place a new brief onto R54, and then proceeded to pull R54's pants up above R54's knees. V11 did not change her gloves or perform hand hygiene when going from touching dirty items to clean. V11 placed a new set of gloves on, wiped a stool smear from R54's buttocks and then pulled R54's pants all the way up. V11 did not change her gloves or perform hand hygiene prior to touching R54's pants. 5. R27's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, urinary tract infection, dysuria, delusional disorders, restless legs syndrome, muscle weakness, overactive bladder, and major depressive disorder. R27's Care Plan dated November 22, 2017 shows, Provide toileting assistance as needed. R27's MDS (Minimum Data Set) dated December 16, 2024 shows R27 is not cognitively intact, requires substantial/maximal assistance with toileting, and is dependent on staff for toilet transfers. R27 is occasionally incontinent of bowel and bladder. On January 6, 2025 at 1:17 PM, V10 and V9 (CNAs) transferred R27 onto the toilet. V10 removed R27's soiled with urine incontinence brief and then placed a new clean brief onto R27. V10 wiped R27's peri area and put skin protectant cream onto R27's buttocks. V10 did not removed her gloves nor perform hand hygiene when going from dirty to clean items. On January 7, 2025 at 11:08 AM, V16 (Infection Control Nurse) said gloves should be changed each time they are soiled. Gloves should be changed when going from dirty to clean items. The facility's Proper Use of Gloves policy revised November 12, 2024 shows, Take gloves off an perform hand hygiene in the following scenarios: When your contact with blood or bodily fluid is complete.

Based on interview and record review, the facility failed to ensure a significant medication error did not occur for one of one resident (R28) reviewed for significant medication error in the sample of 16. The findings include: R28's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses of congestive heart failure, urinary tract infection, diabetes mellitus, generalized anxiety disorder, edema, atrial fibrillation, supraventricular tachycardia, cardiac pacemaker and hypotension. R28's Progress Note dated November 28, 2024 at 12:00 PM shows, Resident was given wrong medication by agency nurse this am. Writer informed DON (Director of Nursing) and on call nurse practitioner (NP) about this situation. NP ordered vitals every 30 minutes for two hours, then every hour for four hours. Give midodrine if blood pressure (BP) drops below 90. Resident started to exhibit symptoms of low BP. Writer checked BP and then administered midodrine as directed. Residents BP has since gone up to normal ranges. 3:17 PM, Writer couldn't keep resident BP up, NP said to send resident to emergency room . R28's Vital Results dated November 28, 2024 at 8:38 AM, shows her blood pressure was 123/67. At 10:17 AM, R28's blood pressure was 75/42. At 10:42 AM, R28's blood pressure was 87/52. At 11:10 AM, R28's blood pressure was 109/60. At 1:12 PM, R28's blood pressure was 75/43 and at 1:40 PM, R28's blood pressure was 77/51. R28's After Visit Summary from the local emergency room dated November 28, 2024 shows R28 was seen in the emergency room for a medication overdose. The facility's Medication Error Report dated November 28, 2024 shows, Description of error (include name of medication, dose, route, and time administered. Amlodipine (high blood pressure medication) 2.5 mg + 5 mg to equal a total of 7.5 mg, aspirin 81 mg, calcium D3 500 mg, hydralazine (high blood pressure medication) 50 mg, losartan (high blood pressure medication) 100 mg, magnesium 400 mg, omeprazole 20 mg, potassium 10 meq, vitamin E, and Vitamin B complex. Outcome of resident: BP 75/42 heart rate 75. Received orders for midodrine 10 mg is BP drops <90. Corrective action taken: Sent to emergency room to be evaluated and update power of attorney. On January 8, 2025 at 9:47 AM, V2 (DON-Director of Nursing) said an agency nurse was looking for R44 in order to administer R44's medications. The agency nurse asked V15 (LPN-Licensed Practical Nurse) who R44 was and V15 pointed to who R44 was. V2 said that the agency nurse gave R44's medications to R28. V2 said that R28 and R44 sit at the same table for meals. V2 said that the nurses have pictures of the residents on their computers which should be checked prior to administering medications. V2 said staff should be verifying resident names, picture, medication, right person, right dose, right time, and right route prior to administering medications. On January 8, 2025 at 10:10 AM, V15 (LPN) said she was working with an agency nurse when that nurse asked V15 who R44 was. V15 said she pointed to R44. V15 said the nurse acknowledged who R44 was. V15 said a dietary aide came to V15 and asked why R28 had thickened liquids in front of R28. V15 said that R44 is the one that should have thickened liquids in front of her so V15 said Oh my gosh, she gave the wrong medications. V15 said the nurses are the ones that provide the thickened liquids. V15 said she went up to R28 and asked R28 if the agency nurse gave her medicine and R28 said yes. V15 said that R28 is cognitively intact. V15 said she ran to the medication cart and told the agency nurse that she gave the medications to the wrong resident. V15 said she notified the doctor and the Director of Nursing. V15 said the nurse practitioner said it was ok to not give R28 her regular scheduled medications. V15 said that R28's blood pressure was dropping. (R28 received high blood pressure medications that were not ordered for her). V15 said she was monitoring R28 frequently. V15 said the nurse practitioner gave orders to give R28 a medication to increase her blood pressure if her blood pressure decreases, so V15 did that and R28's blood pressure increased. V15 said there was staff sitting with R28 offering her fluids. V15 said that R28 reported to V15 that she was feeling funny so V15 ran in and took R28's blood pressure again and R28's blood pressure had dropped again so V15 notified the nurse practitioner again. The nurse practitioner told V15 to lay R28 in bed and to elevate R28's feet. V15 said that R28 told her that R28's vision was blurry. V15 said R28 was more lethargic and more dizzy than normal. V15 said that at this time, R28's blood pressure only went up a little bit so V15 was told to send R28 to the local emergency room . R28's Progress Notes dated November 29, 2024 at 1:39 AM shows, R28 returned from the local hospital at approximately 7:30 PM (November 28, 2024). R28's blood pressure was within normal limits. R28 stated she was feeling better. The facility's Medication Incident/Event Policy and Procedures dated 2023 shows, Purpose: To safeguard the resident and provide emergency care as necessary. The facility must ensure that its residents are free of any significant medication errors.

Based on observation, interview, and record review the facility failed to ensure a splint was placed for a resident with limited range of motion for 1 of 2 residents (R51) reviewed for range of motion in the sample of 16. The findings include: A facility assessment done on 11/18/24 showed R12 had limited range of motion to his upper extremity. On 01/06/25 at 08:51 AM, there was a sign above R51's bed. The sign indicated that a splint was to be placed on R51's right hand in the mornings. The initial wear time was 1-2 hours and progressing to wearing the split all day. The sign was dated 11/29/24. There was a blue splint sitting in the chair next to R51's bed. On 01/06/25 at 10:49 AM, R51 was in bed. There was no splint on R51's right hand. The splint remained sitting on the chair. R51's right hand was in a closed fist. R51 was asked if he could open his right hand. R51 could not open his right hand. On 01/06/25 at 1:12 PM and 2:27 PM, the splint remained off. On 01/07/25 at 9:10 AM, R51 was sitting in the common area in a chair. R51 did not have a splint on. On 01/07/25 at 9:10 AM, V3 (Certified Nursing Assistant- CNA) said she was familiar with R51. V3 said she was not sure if R51 used a splint and referred the surveyor to V4 (CNA assigned to V51). On 01/07/25 at 9:15 AM, V4 said restorative was responsible for placing the splint on R51's right hand. On 01/07/25 at 9:41 AM, V5 (Restorative CNA) said R51 was not on any restorative programs and restorative was not putting R51's splint on. On 01/07/25 at 9:44 AM, V6 (Rehabilitation Director) said occupational therapy was seeing R51 two times a week for a contracted right hand. According to V6, the last time occupational therapy worked with R51 was 12/31/24 (7 days ago). V6 said R51 was on a splinting program. V6 added that the floor CNAs or restorative staff were responsible for placing the splint on the days occupational therapy did not see R51. R51's Progress Note dated 11/21/24 showed occupational therapy plan of care was for splinting of R51's right wrist to maintain joint mobility. R51's Progress Note dated 12/02/24 showed occupational therapy updates was for R51's splint to be placed on the right hand in the morning with an initial wear time 1-2 hours and to progress to all day wear. R51's Care Plan with a start date of 12/2/24 showed R51 required a right hand splint daily.

Based on observation, interview, and record review the facility failed to ensure ADL (Activities of Daily Living) assistance was provided for two of 16 residents (R54, R27) reviewed for ADL care in the sample of 16. The findings include: 1. R54's Face sheet shows she was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, delusional disorder, restlessness and agitation. R54's Care Plan dated June 12, 2023 shows R54 was frequently incontinent of bladder and bowel. I need staff assistance with incontinence cares and my hygiene needs. Observe me for verbal and non verbal cues that I need to use the toilet. R54's MDS (Minimum Data Set) dated December 2, 2024 shows R54 is not cognitively intact, R54 required partial/moderate assistance with toilet hygiene, and was dependent on staff for toilet transfers. R54 is occasionally incontinent of bowel and bladder. On January 6, 2025 at 8:47 AM, R54 was observed sitting in the television room in her wheel chair. R54 was observed in the same spot until 9:19 AM. At 9:19 AM, V17 and V7 CNAs (Certified Nursing Assistants) used a stand lift to transfer R54 into a gray recliner. R54 was observed continuously from 9:41 AM-11:44 AM. During this time, R54 was observed being restless: leaning forward in the recliner, trying to get up from the recliner, and removing her blankets multiple times. At 10:41 AM, V7 gave R54 a snack. At 10:43 AM, another staff member asked R54 where she was going and told R54 she had to stay in the recliner. At 10:47 AM, another staff member went to R54 and asked R54 where she was going and covered R54 back with the blanket. R54 was mumbling non sensical words. At 10:55 AM, V7 sat with R54. At 11:18 AM, V7 went to lunch. Another staff member check in with R54 at 11:27 AM. At 11:44 AM, R54 was attempting to stand up again. R54 was transferred into her wheel chair at 11:44 AM. At 11:50 AM, V10 and V11 (CNAs) transferred R54 onto the toilet in her room. V11 removed R54's incontinence brief. R54's incontinence brief was saturated with dark urine from front to back of the brief. R54's buttocks was reddened and had creases in it. 2. R27's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, dementia, urinary tract infection, dysuria, delusional disorders, restless legs syndrome, muscle weakness, overactive bladder, and major depressive disorder. R27's Care Plan dated November 22, 2017 shows, Provide toileting assistance as needed. R27's MDS (Minimum Data Set) dated December 16, 2024 shows R27 is not cognitively intact, requires substantial/maximal assistance with toileting, and is dependent on staff for toilet transfers. R27 is occasionally incontinent of bowel and bladder. On January 6, 2025 at 8:48 AM, R27 was observed in a high back wheeled recliner feeding herself breakfast. At 9:07 AM, R27 was moved into the television room. At 9:15 AM, R27 was transferred into a recliner. At 9:40 AM, R27 was observed sleeping in the same recliner until 11:45 AM when R27 was transferred into her wheelchair. At 11:47 AM, R27 was brought into the dining room for lunch. At 12:04 PM, R27 was being fed lunch. At 12:53 PM, R27 was placed back into the television room. At 1:01 PM, V10 (CNA) said she was not sure when she was going to perform peri care for R27. At 1:17 PM, V9 and V10 (CNAs) transferred R27 onto the toilet. R27's incontinence brief had urine in it. V10 said that R27 is usually continent. On January 8, 2025 at 9:04 AM, V2 (DON-Director of Nursing) said that incontinence care/toileting should be performed at least every two hours, unless the resident is cognitive enough to tell staff when they have to use the bathroom. The facility's Perineal Management-Peri Care policy dated January 24, 2007 show perineal care is done to promote cleanliness and comfort and to reduce infection potential by removing irritating secretions or excretions, microorganisms, and offensive odors.

Based on interview and record review, the facility failed to allow a resident (R1) choices regarding their care for 1 of 3 residents reviewed for resident rights in the sample of 10. Findings include: R1's electronic face sheet printed on 8/13/24 showed R1 has diagnoses including but not limited to Alzheimer's disease, low back pain, pain in left knee, and osteoarthritis. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment and requires staff assistance for activities of daily living. R1's care plan dated 1/6/23 showed, I have a diagnosis of Alzheimer's Disease. I am generally able to identify my needs but can be forgetful. I do not want to show my forgetfulness, so I may disguise this with humor or something [NAME] .Provide me with options for my care and routine. I am very independent minded and appreciate choice and options. Talk with me in a quiet area, so that I can focus on you and re-approach if I am too tired. The facility's undated written statement from V5 (Certified Nursing Assistant-CNA) showed, On the 5th of August at about 6:45AM, I went into (R1's) room, turned on her light and got her dressed for the day as usual. She never likes to leave her bed. She always complains of back pain and never wants to get up .she kept saying I don't want to leave me bed, leave me alone and get out of my room. Me and (V6-CNA) continued to get her ready and took her out of her room . On 8/13/24 at 9:33AM, V5 stated, I take care of (R1) a lot and it's awful. As soon as I go to get her up she moans and doesn't want to get up. On 8/5/24 I went into her room, called her name, and began singing. She told me to get out of her room. This is nothing new for her so me and (V6) continued to get her up. I guess I was wrong and should have stopped doing cares for her when she told me she didn't want to get up and to get out of her room. I was written up by my supervisor for not honoring (R1's) rights. I didn't say anything to anyone because she's always like this. It's nothing new and we always make her get up even if she doesn't want to. On 8/13/24 at 10:35AM, V8 (Licensed Practical Nurse) stated, (R1) will refuse cares at times but 99% of the time if you re-approach her or talk with her she will agree to it. You just have to do it on her terms and she is fine with it. You can't force any resident to be on an agenda or the staff's timelines. You have to go at their pace and honor their rights to be in charge of their care. (R1) sometimes doesn't want to get out of the recliner for meals so we just bring the tray over to her and she is happy. There is never a time where it is ok to continue with cares or treatments when the resident is telling you no unless they are in danger. On 8/13/24 at 12:48PM, V3 (Director of Nursing) stated, If a resident refuses any type of care the staff should leave them and try to re-approach them. If they continue to refuse, then they should report it to the nurse right away so they can try and approach the resident. (V5) did not honor (R1's) resident rights in this situation. The Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities revised 11/18 showed, Your rights to dignity and respect: you have a right to make your own choices, your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life .Your rights to participate in your own care: you have the right to request, refuse, and/or discontinue any treatment .

Based on interview and record review, the facility failed to assess, report and treat a resident's pain for 1 of 3 residents (R1) reviewed for pain management in the sample of 10. Findings include: R1's electronic face sheet printed on 8/13/24 showed R1 has diagnoses including but not limited to Alzheimer's disease, low back pain, pain in left knee, and osteoarthritis. R1's facility assessment dated [DATE] showed R1 has moderate cognitive impairment. R1's care plan dated 1/6/23 showed, My comfort is compromised. I have a diagnosis of osteoarthritis, left knee and low back pain .Administer medications as ordered. Scheduled Tylenol and Tylenol as needed . The facility's undated written statement from V5 (Certified Nursing Assistant-CNA) showed, On the 5th of August at about 6:45AM, I went into (R1's) room, turned on her light and got her dressed for the day as usual. She never likes to leave her bed. She always complains of back pain and never wants to get up .she kept saying I don't want to leave me bed, leave me alone and get out of my room. Me and (V6-CNA) continued to get her ready and took her out of her room . On 8/13/24 9:33AM, V6 stated, During morning cares on 8/5/24, (R1) was saying, Ow, my back, my back. I didn't report anything to the nurse that day because (R1) always says this and then once she is up she is fine. She's not really in pain, she just says she is. I have always been taught to report pain to the nurse but (R1) isn't actually in pain. On 8/13/24 at 10:18AM, V7 (CNA) stated, Whenever a resident reports pain we are to report it to the nurse. It doesn't matter if it is an ongoing issue or not, we still have to report it. We have special papers that we fill out and give them so they can follow up on the resident concerns. We also give a copy to (V3-Director of Nursing) so that she can make sure it's followed up on. On 8/13/24 at 11:31AM, V6 (CNA) stated, I was helping (V5) give (R1) cares on 8/5/24. When I walked in the room, (R1) kept saying her back was hurting and she was in pain. I didn't report it to the nurse because the last time I reported it, the nurse told me that was normal and (R1) wasn't in pain so I figured there was no point in reporting it. R1's medication administration record showed R1 did not receive Tylenol for pain or a pain assessment until 8/5/24 at 6:00PM (11 hours and 15 minutes) after she was reporting pain to V5 and V6). R1's nursing progress notes for 8/5/24 did not show any documentation related to R1's pain being reported or assessed on or around 6:45AM. On 8/13/24 at 8:53AM, V3 (Director of Nursing) stated, We were made aware of (R1's) reports of pain during an abuse investigation and now that she is on scheduled Tylenol she has not had any complaints of pain. It has really helped her and I wish the aides would have reported it when it was occurring so we could have given her Tylenol and alleviated her pain. The staff all know that we have a program that the aides fill out a paper of any resident concerns for the nurse and myself to follow up on. This was not completed for (R1) so no follow-up would have been done because it was never reported to the nurse. The facility's policy titled, Pain assessment dated [DATE] showed, Purpose: To assess for the presence and level of pain, to distinguish between acute and chronic pain; assess for chronic, undetected or under-treated pain, and provide pain management to enhance the residents quality of life .

Based on observation, interview, and record review, the facility failed to ensure a safe transfer was provided for 1 of 3 residents (R1) reviewed for risk for falls on the sample list of 3. This failure resulted in R1 sustaining a clavicle fracture during a stand lift transfer on 3/20/24. The findings include: The Nurse's Note dated 3/20/24 for R1 showed, called to room by CNAs (Certified Nursing Assistant) at 3:10 PM. CNAs stated R1 was transferring from toilet to wheelchair when she became weak and had to be lowered to floor by CNAs. R1 sitting on floor between toilet and wheelchair with her legs under her. R1 was holding onto the wheelchair and resting her head against door frame. Staff were able to lift R1 off floor, onto toilet, then transfer her into wheelchair, and lifted into bed. Had a bowel movement while in toilet. Vital signs: (temperature) 98.0, (heart rate) 100, (respiratory rate) 20, and (blood pressure) 158/90. Oxygen saturation 90% on room air. Range of motion x 4 extremities without pain. Denies any pain or complaint. Beginning of a bruise becoming visible to right inner leg below knee. No other injuries seen. R1 changed by CNAs and assisted to wheelchair. R1 ambulating in wheelchair per her normal behavior. Called to (R1's) room by CNAs a second time at 7:50 PM. R1 passed out on toilet during HS (bedtime) care. Vital signs: (temperature) 98.1, (pulse) 110, (respiratory rate) 26, (blood pressure) 112/82. Started responding after several minutes but remained lethargic. R1 was hooked to the stand lift while on the toilet as precaution after falling earlier while in bathroom. R1 was not able to assist staff with transfer off toilet. Stand lift used to pull R1 far enough forward to get a wheelchair behind her but this nurse had to pull on her arms to keep her from falling through the stand lift. Transferred R1 into the wheelchair and then lifted her into bed. R1 complained of left arm pain after transfer. Contacted daughter/POA (power of attorney) 8:05 PM and informed her of her mother becoming unresponsive while on toilet during HS (bedtime) care. Also informed of difficulty transferring mother into wheelchair and then to bed and mother complained of left arm pain after transfer. Inquired if she wanted R1 sent to hospital. Stated to send mother to hospital for evaluation. R1 remains lethargic but responds to questions. Denies any pain at rest but complains of left shoulder pain with movement. No pain when shoulder gently palpated. New bruise noted next to old bruise on left arm above left wrist. Ambulance arrived at 8:55 PM. R1 out to the emergency room at 9:00 PM. The facility Resident Accident/Incident Report dated 3/22/24 for R1 showed, resident became unresponsive while on the toilet. After a few minutes the resident started to become responsive but lethargic. Staff attempted a stand lift transfer but was unable to complete safely. Staff assisted the resident to the wheelchair then to bed. R1 complained of arm pain. The hospital Inpatient Progress Note dated 3/22/24 for R1 showed she had sepsis due to acute cystitis, left clavicular midshaft fracture, acute metabolic encephalopathy with underlying history of dementia, acute kidney injury, and hypertension. The Nurse's Note dated 3/25/24 for R1 showed, R1 returned from the hospital with a diagnosis of sepsis and left clavicle fracture. R1 was tired with confusion noted. R1 had a sling to her left arm; she complained of left shoulder and leg pain with any movement. The staff nurse spoke with V2 DON (Director of Nursing) who stated to make R1 a full mechanical lift transfer until she was evaluated by the rehabilitation nurse. The Restorative Nurse assessment dated [DATE] for R1 showed R1 is to be transferred with a full mechanical lift and two staff due to her fractured left clavicle and being non-weight bearing to her left arm. On 3/27/24 at 9:15 AM, V2 DON (Director of Nursing) stated, R1 had two incidents on 3/20/24. The first incident the CNA was getting R1 off the toilet. R1 was a standby assist at that time. The CNA lowered R1 to the floor. The CNA said R1 was going down so she lowered R1 to the floor. The second incident was after supper; R1 needed to use the bathroom. R1 became lethargic and they got the stand lift. It sounded like R1 was able to stand at the beginning of the transfer but during the transfer she couldn't complete it. V7 LPN (Licensed Practical Nurse) was trying to hold R1 up on the stand lift and get her to her wheelchair. The safest way to transfer R1 would have been using the full mechanical lift. When V7 was trying to hold R1 up in the stand lift, I think that is when her clavicle was fractured. I think I would have put a gait belt on R1 and lowered her to the floor and then transferred R1 with a full mechanical lift. It would have been hard to get the full mechanical lift in there, but they could have moved her out a little and then lifted R1 with the full mechanical lift. On 3/27/24 at 11:52 PM, V3 CNA stated, if a resident is not responding appropriately, she would let the nurse know first. V3 stated the stand lift machines are for residents that can bear some type of weight and it would be unsafe to use one if the resident wasn't able to bear weight. On 3/27/24 at 11:59 AM, V5 CNA was in R1's room. R1 was asleep on her right side in bed. R1's bed was low to the floor with a mat on one side of the bed. R1 had a clip alarm in place. V5 stated the care plan above the resident's bed tells staff how a resident transfers. V5 stated R1 has not gotten out of bed since she came back from the hospital. The care plan on the wall above R1's bed dated 1/18/24 showed she transfers with 1 assist, has no special aides, and uses a wheelchair for mobility. On 3/27/24 at 1:20 PM, V6 APN (Advanced Nurse Practitioner) stated that she would have to agree with V2 and using the stand lift if R1 wasn't able to bear weight or was unresponsive or her vitals were off would not be the way to transfer R1. V6 stated she agreed with V2 stating that R1 should have been lowered to the floor and then the full mechanical lift used for the resident's safety. V6 stated the resident needed to be able to bear weight and know what to do in order to use the stand lift. On 3/27/24 at 1:39 PM, V7 LPN (Licensed Practical Nurse) stated, R1 was unresponsive on the toilet and sitting awkward on the toilet. V7 stated he did R1's vital signs. R1 started to respond but was not herself. R1 was already in the stand lift. V7 stated they decided to use the stand lift to transfer R1 even though she could not stand. V7 stated he held R1's arms up and out while he was facing the resident. V7 stated he was trying to hold R1 up or she would have fallen through the sling and crumbled. V7 stated the stand lift was pulled out of the bathroom to the doorway and R1 was transferred to her wheelchair. V7 stated R1 complained of pain after that. V7 stated 4 staff lifted R1 from her wheelchair to her bed. On 3/27/24 at 2:04 PM, V8 CNA stated, when she got R1 up the first time to use the bathroom R1 was struggling a little bit and is usually a standby assist for transfers. V8 stated she got R1 to the toilet, cleaned her up, and stood her up. V8 stated when she went to transfer R1 to the wheelchair, R1's knees buckled so she lowered the resident to the floor. V8 stated she yelled for help. V9 CNA, V7 LPN and I picked R1 up with a gait belt, sat her on the toilet, brought the stand lift in and used it to transfer R1 to her wheelchair. V8 stated after supper she took R1 to the bathroom using the stand lift and R1 did not want to hold onto the stand lift when V8 was putting her on the toilet. V8 stated when she tried to get R1 off the toilet, R1 wouldn't hold on and almost went to the ground. V8 stated she had to put R1 on the toilet and call the nurse. V8 stated V7 LPN came in, they lifted R1 up using the stand lift with V7 holding R1 under her arms; R1 was not bearing weight. V8 stated they got R1 out of the bathroom, lifted her a little bit and put her in the wheelchair. V8 stated to use the stand lift the resident needs to be able to bear weight and hold on so they don't fall. V8 stated R1 couldn't hold on. V8 stated I guess we should have used the full mechanical lift. The Fall Risk form dated 1/17/24 for R1 showed a score of 17; a score of 10 or greater is high risk for falls. The facility's Safe Handling and Limited Lift/Movement Policy (6/12/23) showed, Purpose: To determine safe handling and transferring of residents in a manner that recognizes safety for all residents and staff. Policy: Mechanical lifting equipment and/or other approved resident handling aids will be used to prevent manual lifting of residents except when absolutely necessary, such as in a medical emergency or building emergency (such as fire). If a resident can stand for 4 seconds or less, while bearing weight, with assistance and is cooperative, and able to sit with no support - use a stand lift. If a resident is non-weight bearing or unable to assist with a transfer - use a full mechanical lift. If a resident has fallen on the ground and is unable to get up on their own, use a full mechanical lift to recover them from the ground. Two staff persons must be present for all mechanical aided transfers, including stand lift and full mechanical lift.

Based on observation, interview, and record review, the facility failed to monitor temperatures in two medication refrigerators, failed to ensure a refrigerator with a controlled drug was double locked, failed to administer a medication when prepared, failed to label an insulin vial when opened, and failed to discard an open insulin pen after 28 days. These failures have the potential to affect all 70 facility residents. The findings include: The facility's 2/13/24 application for Medicare and Medicaid showed 70 residents in the facility. On 02/13/24 at 11:51 AM, the second-floor long hall medication cart had a plastic medication cup with a round white tablet inside. V5 Licensed Practical Nurse (LPN) said it belonged to R30 and identified it as his blood pressure medication. V5 said she was waiting to see if he was going to come to the dining room. R30's medication administration record (MAR) showed V5 administered this medication at 9:00 AM. At 12:00 PM, the second-floor medication room was checked. There was no log of the refrigerator temperature being checked. V5 said it's usually right here (pointing to the refrigerator door). The temperature gets checked every shift. This refrigerator contained numerous medications for individual resident and stock use. At 12:37 PM, V5 said she found the temperature log. I guess night shift checks it. This temperature log showed no temperatures were checked 2/3-2/7/24. On 02/13/24 at 12:15 PM, the third-floor long hall medication cart was checked. There was an insulin pen with an opened date on the label showing 1/11/24. There was an opened insulin vial with no open date on it. Both insulins were in a bag designated for R22. V6 LPN said she gave both insulins to R22 with the insulin in the vial administered twice her shift. V6 was unable to determine when the vial was opened. V6 said insulin can be used for 30 days after opening. R22's MAR showed he received both insulins this date with the insulin in the vial administered twice. The third-floor medication room was checked, and the medication refrigerator was unlocked. Inside the door of the refrigerator was a bottle of Ativan (Schedule IV controlled drug) with R42's name on it. This refrigerator contained numerous medications for individual resident and stock use. V6 said yes the refrigerator should be locked and the insulin pen and vial should be dated when opened. There was no temperature log on the refrigerator. The log was in a drawer at the nurse's station. V6 said the night shift checks the temperatures. The last temperature check recorded was dated 2/8/24. On 02/15/24 at 09:00 AM, V3 Director of Nursing (DON) said its important medications are stored at certain temperatures. If we don't ensure the meds are stored correctly, the meds might not serve their purpose and lose its efficacy. Medications should be administered when prepared and not stored outside their labeled package in the medication cart. Controlled substances should be double locked to prevent diversion. An insulin pen dated 1/11/24 should have been discarded. The insulin vial should have been dated when opened. They're only good for 28 days after opening so you must know when you opened it, so you know when to discard it. The facility's 5/16/2022 Medication Storage Policy showed medications administered to individuals will be stored under proper conditions of sanitation, temperature, light, humidity, and security. Schedule II through Schedule IV narcotics shall be stored in a separate compartment under double lock and key. The Director of Nursing and Site Supervisors shall periodically inspect medication storage areas to ensure that medications are stored under proper conditions. The facility's 4/21/23 Management of the Unit Medication Refrigerator Policy showed all unit refrigerators will be managed and maintained according to the procedure outlines below to ensure security, segregation, and environmental control at all storage locations. Medications shall be stored under proper conditions of security, segregation, and environmental control at all storage locations. The inside temperature of the refrigerator in which drugs are stored shall be maintained within a 36-to-46-degree Fahrenheit range and be monitored and logged each day on night shift. The facility's 2017 Medication Administration Policy showed medications will be administered to residents in a manner consistent with standards of practice. Medications are administered at the time they are prepared. Medications are not pre-poured. The facility's Insulin Storage Recommendations posting showed NovoLog insulin pens are good for 28 days after opening. The facility's second floor med room refrigerator temperature log showed no temperatures were checked on 2/3-2/7/24. The facility's third floor med room refrigerator temperature log showed temperatures were not checked daily and there were no records of a temperature check since 2/8/24.

Based on Interview and Record Review the facility failed to ensure a resident's side rail was working properly for 1 of 4 residents (R64) reviewed for safety and supervision in the sample of 19. The findings include: The Progress Notes dated 2/9/24 at 11:35 PM for R64 showed, at 8:00 PM the CNA (Certified Nursing Assistant) called my attention that the resident fell in her room. When I entered the room, the resident was kneeling on the floor near her bed. The CNA narrated that when she was transferring the resident from wheelchair to bed, she stood up holding the bed rails. The rail went down. The CNA was holding R64, she was wobbling and ended up kneeling on the floor. Assessment was done. On 2/11/24 at 3:17 PM - The Resident continues on post fall vitals Resident complained of mild back pain today, so as needed Tylenol was given. On 2/11/24 at 11:30 PM - Post fall follow-up. Resident alert and verbally responsive. Complaints of back pain. As needed pain medication was administered. On 2/12/24 at 8:37 AM, R64 had a fall this weekend. Found on her knees next to her bed, assisted up, no injury. The left bed rail is not working, will not lock in place when brought to stay up. Spoke to V4 ADON (Assistant Director of Nursing), she is aware and a work order is in place. Message left for the Housekeeping Supervisor to follow up. On 2/12/24 at 11:06 AM, Residents bed was evaluated by the resident technicians and checked by this writer; it is working correctly at this time. On 2/14/24 at 10:58 AM, R64 was not in her room and there were 1/4 side rails near the head of the bed that were in place. V9 RA (Resident Aide) stated R64's bedrail (side rail) was broke but has been fixed. V9 stated it did not lock in place. She stated if she found something like that then she would report it to the housekeeping supervisor right away so it can be fixed. On 2/14/24 at 12:32 PM, V5 LPN (Licensed Practical Nurse) stated, All I know is what I was told in report. They told me that she (R64) was lowered to the ground. R64's side rail was up, they went to get her out of bed, R64 was using the side rail to lift herself up and the side rail ended up going down. R64 lost her balance and the CNA lowered her to the ground. It was a broken side rail. We usually call maintenance and they will look at it. If maintenance cant fix it they will replace it with a different bed that is working. One of the aides will tell us if the bed is not working or broke. On 2/14/24 at 12:41 PM, V10 (Unit Clerk) stated, someone told me Thursday (2/8/24) or Friday (2/9/24) that R64's side rail was broken. I called down to maintenance to tell them it was broken. They were aware it was broken before this fall happened. On Monday (2/12/24) when I came in someone told me R64's side rail was broken. V10 stated she told the person that she new that. V10 stated she called maintenance and told them the rail was broke, R64 fell , and the side rail needed to be fixed. It is important to fix it right away because R64 fell . V10 stated she didn't know if the first message she sent did not get to them or what. On 2/14/24 at 1:30 PM, V11 (Maintenance Director) stated, when there is problem with the bed/side rail they call 1400 and enter a work order that goes to the maintenance shop. Someone will take the work order to check it out. We usually try to fix it the same day. If they call maintenance after hours we do have an on call person. I am not sure if the on call person comes in for side rails. They would get the work order the next morning. If there is a message on the answering machine after hours then the work order will be entered the next morning. At 1:46 PM V11 stated, I have two maintenance reports for the bed rail being broken. The first report was 2/6/24 and the rail on the left side of the bed was fixed. The second report was on 2/12/23 for the side rail. They took it apart, cleaned it, put some grease on it and put it together. There was nothing really wrong with it. The side rail could fall if it is not completely engaged. On 2/15/24 at 10:35 AM, V3 DON (Director of Nursing) stated, It sounds like her (R64) side rail went down when she was holding onto it during a transfer. If you don't push back on the side rail it won't lock in place. I don't know if it was broke or not. I know someone looked at it. I don't think the side rail was locked and it should have been for safety. The Care Plan dated 2/8/24 for R64 showed, Problem: I am at risk for falls due to poor safety awareness and I have a history of falls. I am a stand by assist with gait belt (SBA/GB) for my transfers. I have balance deficits that I need staff to help me correct at times. I use a wheelchair with one staff assistance for my locomotion on the unit. I continue to receive restorative nursing services and physical therapy. I have a PSA (personal safety alarm) on myself at all times for staff awareness to my self-transfer status and for safety/fall prevention. I have a yellow safety/fall star on my wheelchair and above the door of my room for staff awareness of my fall/safety risk. Last Fall : 2/9/24 witnessed fall while transferring resident. Bed rail broke during transfer. No injuries. I will follow safety interventions/approaches that are in place to reduce risk of fall with injury. Monitor me for unsteady gait, unsteady balance, poor posture, leaning, tilting, dizziness, fatigue, poor/double vision and proper footwear. Please walk with my wheelchair behind me when I am ambulating with my walker. The Face Sheet dated 2/14/24 for R64 showed diagnoses including osteoarthritis, hypertension, rheumatoid arthritis, anxiety disorder, urinary tract infection, right knee effusion, generalized edema, dizziness and giddiness, bilateral knee pain, vitamin deficiency, type 2 diabetes mellitus, diarrhea, hypokalemia, hyperlipidemia, and disorders of electrolyte and fluid balance. The Minimum Data Set, dated dated dated [DATE] for R64 showed partial/moderate assistance needs for transfers and moderate cognitive impairment. The Side Rail assessment dated [DATE] for R64 showed she is not ambulatory, has poor safety awareness, has a history of falls, and does use the side rails for positioning or support. The facility's Bed Rail Policy (2017) showed it is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular maintenance program will include regular inspection of all bed systems (e.g. rails, frames, and mattresses, and operational components) to ensure they are clean, comfortable and safe. The facility's priority is to ensure safe and appropriate bed rail use.

Based on observation, interview and record review the facility failed to follow infection control practices while administering medication to 1 of 5 residents (R18) in the sample of 19. The findings include: On 2/13/24 at 12:17 PM, V12 (RN - Registered Nurse) sat an empty medication cup on top of the medication cart. Then opened the medication cart and narcotic box to retrieve R18's medication sheet containing Norco 5-325 mg tablets. V12 used her thumb to push the Norco out of the medication sheet into her bare hand. V12 dropped the Norco into the medication cup from her bare hand. R18's Face Sheet 2/15/24 showed diagnoses to include, but not limited to: sacral back pain, polyarthritis, chronic pain, major depressive disorder, chronic fatigue, and psoriasis. R18's Physician Order Sheet dated 2/15/24 showed an order for Norco (hydrocodone-acetaminophen) 5-325 mg tablet three times a day (1200, 1700, 2000). R18's February 2024 Medication Administration Record showed V12 (RN) administered R18's noon dose of Norco. On 2/15/24 at 9:55 AM, V2 (DON - Director of Nursing) said the nurses should not touch the resident medications with their bare hands for infection control purposes. V2 said the Norco should have been pushed directly into the medication cup. The facility's Medication Administration Policy dated 2017 showed, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner that consistent with good infection control and standards of practice.

Based on observation, interview, and record review the facility failed to follow orders written by the Nurse Practitoner regarding a resident's skin condition. This applies to 1 of 3 residents (R22) reviewed for skin conditions in a sample of 19. The findings include: R22's undated Facesheet shows his diagnoses to include Type 2 Diabetes Mellitus, open wound to buttocks, irritant contact dermatitis due to contact with body fluids, dementia, psychotic disturbances and muscle weakness. R22's 2/13/24 wound care notes shows he had MASD (Moisture Associated Skin Damage) with an onset date of 2/10/24. On 02/15/24 at 10:13 AM, V15 CNA (Certified Nursing Assistant) and 2 other CNA's changed R22's adult brief. When removing the soiled brief an extra liner was noticed under R22's adult brief. R22 has an order from V13 Wound Nurse practitioner written on 2/13/24 to avoid the use of a liner in R22's brief. When the CNA was ready to put a new brief on R22 she asked him if he wanted a liner placed inside the brief, and R22 said what are my options? The CNA said, you can have the liner with the brief, or just the brief by itself. R22 said, might as well put the liner in there, and she did. V15 said R22 would be checked again before lunch (in two hours). On 02/15/24 at 10:06 AM, V6 LPN (Licensed Practical Nurse) said, R22 is a heavy wetter and insist upon having the extra padding. V6 said, R22's CNA's are aware of the order for no extra liner. V6 said, V13 writes that same order for all residents with wounds because she thinks it will hold moisture against the skin. On 02/15/24 at 11:00 AM, V14 (Wound Nurse) said, we don't want an extra liner in the diaper because it will hold moisture and possibly cause MASD. V14 said R22 already has MASD so we don't want to make it worse. V14 said, she will talk to the CNA's and to R22 to re-educate them why we don't want an extra liner in his brief. On 02/15/24 at 11:13 AM, V13 (Wound Nurse Practitioner) said, she wrote that order for R22 because he had MASD on his right upper buttocks and the extra liner will hold moisture to the affected area. V13 said she would expect the CNA's to follow her order and educate R22 on why it's important. R22's 2/13/24 Wound Care weekly assessment (done by V13) shows he has MASD to his right upper buttocks measuring 5.7 cm (centimeters) x 4.8 cm x 0.1 cm MASD. V13 made a note that R22 was double diapered during her assessment which is noted to hold moisture against the skin. V13 noted R22 to be obese and non-ambulatory.

Based on interview and record review the facility failed to have an ongoing assessment of a resident post fall, failed to ensure medical care and services were provided to a resident post fall in a timely manner for 1 of 3 residents (R2) reviewed for nursing care. This failure resulted a delay in care and pain control for a resident (R2) with multiple pelvic fractures tha required hospitalization and surgery. The findings include: R2's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include pain in right hip, generalized anxiety disorder, restlessness and agitation, chronic atrial fibrillation, weakness, essential hypertension, chronic congestive heart failure, and mild cognitive impairment of uncertain or unknown etiology. R2's facility assessment dated [DATE] showed she had moderate cognitive impairment and required assistance of one staff for most cares. R2's facility fall risk assessment completed 5/17/23 showed she is a high risk for falls. R2's care plan initiated 2/10/23 showed, Falls: I am at risk for falling related to weakness and a history of falls. I use a wheeled walker and one staff supervision for ambulation. This same care plan showed a personal alarm was in place. R2's Resident Accident/Incident report dated 7/23/23 showed, Unwitnessed Event: 7/23/23 at 6:25 AM. Sitting in recliner in lounge area, stood up and fell on right side of body. Chair alarm sounded, Resident was already on floor- Right elbow skin tear, complains of right hip pain. The same Resident Accident/Incident report showed on the back of the form in different handwriting the nurse practitioner was called at 9:30 AM and contact with the nurse practitioner occurred at 10:45 AM (4 hours and 15 minutes after the incident occurred). This document also showed new orders to obtain an x-ray and maintain non-weight bearing status until xray results were received. R2's nursing progress note dated 7/23/23 at 6:25 AM showed, Agency nurse reports that resident fell this AM (morning) at 6:25 AM. As noted on the Incident Report sheet resident is complaining of right hip pain. No information charted by agency nurse. This nurse to make all phone calls and assess residents right leg. R2's nursing progress note dated 7/23/23 at 9:30 AM showed, Call placed to residents POA (Power of Attorney) to inform her that resident has had a fall this morning and is complaining of right hip pain. Will inform POA of any changes in her condition or plan of care. R2's nursing progress note dated 7/23/23 at 9:50 AM showed, Call placed to DON (Director of Nursing) to inform her of residents fall this morning. Message left on house voicemail but if there are any changes to residents condition, will call DON on phone. Waiting for reply from [nurse practitioner]. No answer so message left for return call due to fall and need for xray. R2's nursing progress note dated 7/23/23 at 11:05 AM showed, Return call from [Nurse Practitioner], order received for xray right hip two view STAT (as soon as possible) and for resident to be non weight bearing until results obtained. Call to [mobile xray], will be here in approximately 4 hours. Staff informed of non weight bearing status. R2's nursing progress note dated 7/23/23 at 11:54 AM showed, Resident states she is not hungry and wants to lay down. Transferred with two assist and hoyer lift. Frequent complaints of pain upon movement. R2's nursing progress note dated 7/23/23 at 2:45 PM showed, [Mobile xray company] here to take xray and results sent showing right hip fracture with dislocation. [Nurse Practitioner] called and order received to send resident to the hospital. R2's nursing progress note dated 7/23/23 at 3:45 PM showed, Resident transported to [acute care hospital] at 3:34 PM. R2's July 2023 eMAR (electronic Medication Administration Record) showed R2 receives Tylenol 325 mg three times a day at 9:00 AM, 1:00 PM, and 8:00 PM. R2's eMAR showed R2's 9:00 AM dose of Tylenol was not administered until 11:02 AM (2 hours past the scheduled time and 4 hours and thirty minutes past R2's fall with complaints of pain). R2's acute care hospital History and Physical dated 7/23/23 at 10:47 PM showed, Her daughter is at bedside says that she is at baseline. She apparently attempted to get out of bed alone and fell at her nursing facility. This is not uncommon for her. Evaluation in the emergency department showed a right femoral subcapital neck fracture, right superior and inferior pubic rami fractures, suspicion for nondisplaced fracture of the right sacral ala, intermediate material in the ventral lower pelvis and prepubic region concerning for possible hemorrhage. Hemodynamically stable. Musculoskeletal: General: Deformity (Right Lower Extremity externally rotated) present. No swelling. Normal range of motion. CT Pelvis: Right femoral subcapital neck fracture. 2. Right superior and inferior pubic rami fractures. 3. Suspicious for nondisplaced fracture right sacral ala. 4. Intermediate material in the ventral lower pelvis and prepubic region obscuring margins of anterior urinary bladder and in part appearing to be within the space of Retzius. Although this may be hemorrhage related to the pubic ramus fracture, the volume is somewhat unexpected, the possibility of bladder injury cannot be excluded. 5. Recommend CTA of the pelvis and 5 minute delayed imaging of the entire pelvis to evaluate urinary bladder integrity. R2's nursing progress note dated 7/24/23 at 9:56 AM showed, The resident is scheduled for surgery for her right hip repair. On 8/23/23 at 3:00 PM, V24 RN (Registered Nurse) said on 7/23/23 at about 6:30 AM, R2 had a fall in the common area near the nursing station. V24 said she believes the CNAs (Certified Nursing Assistants) had R2 up, dressed, and in the common area because she is a fall risk. V24 said she heard R2 fall and when she got to R2 she was laying on the floor. V24 said she told the CNAs she needed to do an assessment. V24 said she looked over R2 and saw a skin tear but did not notice anything wrong with R2's legs. V24 said it did not seem to her that anything was injured and she felt R2's hip area and it felt normal to her. V24 said they used 3 CNAs to get R2 up off the floor and into the chair. V24 said, Honestly, I don't recall if she said she had pain. I filled out an incident report. I reported to the nurse that came on. I asked that nurse what else I was supposed to do and she said she would take care of it. I know she was a charge nurse. I don't remember her name. I didn't make any calls because the other nurse said she was going to take care of it. I gave report and I left. The resident seemed fine, she was sitting in the chair and that was it. On 8/23/23 at 3:50 PM, V16 LPN (Licensed Practical Nurse) said R2's fall had happened right before she got there. V16 said the agency nurse said she had fallen and did not think she was hurt. V16 said the agency nurse (V24) started the incident report but did not make any of the notification calls. V16 said that morning R2 was in the wheelchair at breakfast and told V16 her leg was hurting. V16 said she talked to R2's POA (Power of Attorney) and she asked that R2 not be sent out for the xray but to the do the xray in house. V16 said when the xray technician was done doing the xray he looked at the xray screen and said 'I'm not a professional but I can see that's not aligned.' V16 said she knew something was not right. V16 said R2 was laid down in her bed for the xray and she stayed in bed the rest of V16's shift. V16 said she thinks she gave her some Tylenol because that is all she had orders for to treat pain. The surveyor asked V16 if R2 was given something in addition to her already scheduled dose of Tylenol for pain and V16 responded that she did not necessarily give R2 any of the medications herself but that she was the charge nurse that day so she asked the floor nurse to give R2 something for pain. V16 said she did not do pain assessments after breakfast and she did not assess R2 after breakfast because she was afraid to move her any more than necessary. V16 said R2 was verbalizing pain, saying oh oh ow ow with any movement. V16 said she made the first notification call to the Nurse Practitioner at about 9:30 AM. V16 said typically when the nurse does the incident report she would fill out both sides of the sheet and ensure the notifications were made but V24 only completed the first side. V16 said when she arrived for her shift R2 was in her wheelchair so she thought V24 had checked everything out. V16 said V24 told her that R2 had said her leg hurt but it was not until she went in and checked R2 out better when she realized she had not done her incident report, charting, or notifications. V16 said R2 reported pain to her and after breakfast is when she did an assessment. On 8/24/23 at 9:28 AM, V20 CNA said she was the one who had transferred R2 into the recliner in the common area that morning. V20 said we heard [R2] fall. V20 said the nurse was at the desk and jumped up. V20 said the nurse said to get R2 up off the floor and into her wheelchair. V20 said she and two other CNAs got her up off the floor and set her into her wheelchair. V20 said R2 was not really complaining of a lot of pain at that time but that around breakfast time she was making noises and saying oh ouch and said she had pain in her thigh and hip. V20 said she told the nurse R2's thigh was hurting and she thinks she gave R2 her medicine around that time. V20 said they got R2 into bed for her xray using 2 assist with a gait belt. V20 said R2 did not say anything during that transfer. V20 said R2 was laid down and she was fine. On 8/24/23 at 10:00 AM, V21 CNA said she had been working night shift the day of R2's fall. V21 said R2 was in the common area sitting in the recliner with the feet up from about 5:00 AM so staff could keep a closer eye on her. V21 said about 6:15 AM or 6:30 AM she was at the whole other end of the hallway finishing her rounds when she saw R2 standing at the recliner holding the alarm box in her hands. V21 said R2 was taking stumbling steps forward and backward and was very unsteady. V21 said she yelled to R2 and ran toward her but could not get there in time. V21 said when she got to R2 she was moaning and groaning in pain. V21 said R2 landed right on the floor, she was in pain. V21 said R2 said one of the legs was hurting, her side, and her hip was hurting. V21 said there was an agency nurse working that day whom she does not remember her name. V21 said the nurse took R2's vitals and then had 3 CNAs lift R2 off the floor and back into the chair. V21 said she was present when the nurse was looking at R2 and R2 was in pain. V21 said she knew R2 was in pain because she was still groaning but it did not appear to be excruciating pain. On 8/24/23 at 9:48 AM, V22 CNA said R2 is a fall risk, has alarms, a low bed, and she sits in the common area because she likes to stand up and try and transfer herself. V22 said it did not seem right away when she came in (6:30 AM) like R2 was in a lot of pain. V22 said then R2 started saying she was hurting. V22 said they laid R2 down before the xray company arrived and R2 said she was hurting and in pain. On 8/22/23 at 2:51 PM, V5 (Restorative Nurse) said she is part of the team that investigates falls. V5 said the nurse should be informed immediately of a resident fall and complete a head to toe assessment. The nurse will notify the physician of the assessment and obtain orders for care of the resident. V5 said she was unsure of the specifics of R2's fall. V5 said R2 had a short, tiny stature and required standby assistance and the use of a walker for ambulation. V5 reviewed R2's Resident Accident/Incident Report and said the form was completed by the nurse. V5 said the form showed the fall occurred in a common area at 6:25 AM. V5 said R2's small stature combined with the fall and complaints of hip pain would be concerning. V5 stated, I would do a head-to-toe assessment immediately if she was complaining of hip pain after a fall. I would suspect a broken hip and would want the resident to receive the proper care by an orthopedic surgeon. The phone calls to R2's family and physician should have been done right away. V5 said R2's complaints of pain with movement would be concerning and were a sign of a possible hip fracture. V5 said she was not sure why the nurse delayed sending R2 to the emergency room for evaluation and treatment. V5 said Tylenol would not have provided sufficient pain control for a hip fracture. On 8/24/23 at 3:00 PM, V27 NP (Nurse Practitioner) said she would expect to be notified as soon as possible after a fall. V27 said the nursing assessment would be used to determine what the orders would be. V27 said she would expect the resident to receive their scheduled medications on time for pain and if they were still reporting pain the nurses should be contacting them to get something else for pain. On 8/24/23 at 1:40 PM, V26 RN (Registered Nurse) said she worked 2:30 PM to 11:00 PM on 7/23/23. V26 said she is the one that sent R2 to the hospital. V26 said she sent R2 to the hospital after she notified the nurse practitioner of the xray results from the xray done earlier that day. V26 said she received in report from the previous nurse that R2 had fallen and was reporting pain. V26 said when a resident falls and reports pain they should contact the physician and family right away. On 8/24/23 at 4:02 PM, V3 DON (Director of Nursing) said she had received a call around 9:00 AM or 9:30 AM on 7/23/23 telling her R2 had experienced a fall and was having pain. V3 said she told V16 LPN to contact the daughter and the doctor. V3 said she expects nursing to do a complete assessment after a fall which should include a body assessment looking for skin tears, bleeding, lacerations, and bone deformity. V3 said the nurse should be looking for shortening or turning of the leg and hip. V3 said this should be a head to toe assessment checking for fractures or even dislocations. They should assess for pain or guarding. V3 said she does not know what the case was with R2 because of her confusion. V3 said she just knows when they were providing care they noticed R2 was in pain but she wasn't sure if she was in pain right after the fall. V3 said there should be documentation regarding the fall entered in the resident record in the progress notes. V3 said she believes there was confusion between the night nurse and the day shift nurse regarding who was completing the notification phone calls. V3 said if a resident reports pain they should be offered pain medications and if they continue to report pain the nurse should reach out to the provider regarding additional pain control. V3 said the nurse should sign off when pain medication is received in the resident's MAR. V3 said the nurses should contact the provider if the resident's pain is not controlled. V3 said she remembers a conversation she had with V16 LPN so maybe she gave pain medication but did not sign it out. V3 said she expects the physician or nurse practitioner to be notified of falls right away or as soon as possible. The facility's Pain Assessment Policy with revision date of 3/11/11 showed, Purpose: To assess for the presence and level of pain, to distinguish between acute and chronic pain, assess for chronic, undetected or under-treated pain, and provide pain management to enhance the residents quality of life. Should the pain be of an acute nature, the physician shall be contacted concerning signs and symptoms displayed by the resident. Ongoing monitoring of pain management will occur so that lack of pain control can be communicated to the physician. Pain management will be assessed on admission, quarterly, with a significant change in the residents physical or mental condition or any time pain control is not controlling the resident's pain. The facility's Fall Protocol with revision date of 3/13/14 showed, Purpose: To coordinate appropriate facility response to a resident fall. Protocol: 1. No staff member shall assist a resident to rise from the discovered position until first assessed by a nurse. 2. Nursing assessment shall include: vital signs, visual observations looking for possible displacement or fractures, evaluation of resident's pain and any other physical or environmental concerns that may be present. The facility's Policy/Procedure Emergency Care for Falls with Resulting Fractures with revision date of 10/21/03 showed, A. Leave resident in the discovered position until a nurse assesses the resident. B. Assess resident for injuries: 1. Gently feel along extremity for possible displacement, edema, pain and tenderness. 2. Check for external/internal rotation or radiating pain is suspected hip fracture. The facility's Notification of Changes Policy with revision date of 11/9/16 showed, Policy: It is the policy of this facility that changes in a resident's condition or treatment are immediately shared with the resident and/or the resident representative, according to their authority, and reported to the attending physician or delegate (hereafter designated as the physician) All pertinent information will be made available to the provider by the facility staff. Nurses and other care staff are educated to identify changes in a resident's status and define changes that require notification of the resident and/or their representative, and the resident's physician, to ensure best outcomes of care for the resident . The objective of the notification policy is to ensure that the facility staff makes appropriate notification to the physician and Non-Physician Practitioner and immediate notification to the resident and/or the resident representative when there is a change in the resident's condition, or an accident that may require physician intervention. The intend of the policy is to provide appropriate and timely information about changes relevant to the resident's condition . to the parties who will make decisions about care, treatment. 1. Requirements for notification of resident, the resident representative and their physician: 1) An accident involving the resident, which results in injury and has the potential for requiring physician intervention . Procedure: 1. The nurse will immediately notify the resident, resident's physician and the resident representative(s) for the following: a. An accident involving the resident, which results in injury and has the potential for requiring physician intervention: 3. Document the notification and record any new orders in the resident's medical record.

Based on interview and record review the facility failed to safely ambulate a resident with a history of falls. This failure resulted in R1 falling and sustaining a hip fracture and hematoma to the head. R1's hip fracture required surgical intervention and hospitalization . This applies to 1 of 3 residents (R1) reviewed for falls in the sample of 3. The findings include: The facility's Incident Report dated 7/31/23 showed R1 fell in the lounge area and sustained a right hip fracture and hematoma to the right side of her head. This document showed she was a standby assist with a wheeled walker. The staff assisted R1 to the bathroom. R1 lost her balance and she fell on her right side. R1 said she felt dizzy before falling. R1 complained of right leg pain after the fall and her blood pressure was high (166/104). The resident was sent to the emergency room for further evaluation. R1 was admitted to the hospital for a right femur fracture. R1's Face Sheet dated 8/22/23 showed diagnoses to include, but not limited to: Alzheimer's; left femur fracture (following a fall); pain; low blood pressure; generalized weakness; Parkinson's Disease; ; nutritional deficiency; rheumatoid arthritis; and anxiety. R1's facility assessment dated [DATE] showed R1 had severe cognitive impairment; did not reject care; and required limited assistance of staff for toilet use. R1's Fall Risk completed 4/27/23 showed R1 was High Risk, related to intermittent confusion, poor recall, judgement, and safety awareness. This document showed R1 suffered from neuromuscular/functional conditions that can increase her risk for falls. R1's Fall Care Plan reviewed 7/723 showed, I am at risk for falls due to poor safety awareness, Parkinson's Disease and I have a history of falls. I am a stand pivot transfer with one staff assist. I use a walker for my mobility on the unit and a (wheelchair) for any distance. I have a yellow safety/fall star on my walker and above the door of my room for staff awareness of my fall/safety risk. I am working with therapy and Restorative Nursing for ambulation with my walker and one SBA (Standby Assist). I take medications that could affect my fall risk. R1's ADL Function Status Care Plan reviewed 7/13/23 showed R1 was admitted to the facility following a fall in supportive care that resulted in a left hip fracture. R1 had balance deficits and needed staff to help stabilizer her and required standby assistance for locomotion on the unit. R1's Progress Note dated 7/27/23 at 9:37 PM, showed R1 transferred with SBA-GB (Standby Assistance with a Gait Belt). R1's Progress Note dated 7/31/23 at 1:25 AM, showed R1 was ambulating to the toilet with a walker and SBA x 2 (standby assistance of 2 staff). R1 lost her balance and fell over landing on her right side. R1 reported feeling dizzy prior to falling. R1 reported hitting her head and right hip. She had complaints of pain in these areas. R1 was transferred to the emergency room for evaluation. R1's Progress Note dated 7/31/23 at 5:42 AM, showed R1 was admitted to the hospital with a closed, displaced right hip fracture. R1's Resident Accident/Incident Report dated 7/31/23 showed R1 fell in the dining room at 12:40 AM. V7 (CNA) was ambulating R1 to the bathroom. R1 fell , landing on her right side. R1 sustained a hematoma to the right side of her head and was complaining of head and hip/leg pain. This document showed R1's BP was 166/104 (high). This document showed the Cause/Probable cause of this event: Not using a gait belt. R1's Hospital Records faxed 8/4/23 showed R1 had X-rays of her right hip/pelvis due to trauma, pain, injury, and a fall. The results showed R1 had an acute minimally displaced right femur (hip) fracture. R1's Admitting Note dated 7/31/23, showed R1 was reportedly walking with 2 staff members in the bathroom when she tripped over her feet, falling and hitting her head. She was complaining of pain mostly in right hip. R1's initial assessments were consistent with right hip fracture. The plan was to admit the resident for an orthopedic surgery evaluation. R1's Hospitalist Note dated 7/31/21 showed R1 had an acute closed hip fracture following a ground level, mechanical fall. This note showed R1 was lying in bed and appeared uncomfortable with complaints of increasing pain in her hip. R1's Internal Medicine Note dated 8/3/23 showed R1 was admitted with an acute closed right hip fracture and underwent hip replacement surgery on 7/31/23. This note showed R1's postoperative course was complicated by delirium, inability to participate in therapy, decreased oral intake and R1 was not showing significant improvement. This was discussed with R1's daughter and the decision was made to start hospice care. R1 was to be discharged with hospice care. On 8/22/23 at 2:30 PM, V7 (Certified Nursing Assistant - CNA) said she was working the night R1 fell (7/31/23). R1 had been sleeping in a recliner in the lounge (common area). R1 kept trying to get up out of the recliner, which usually means she needs to go to the bathroom. V8 (CNA) assisted me with putting on R1's shoes. We started walking with R1 toward the bathroom, but V8 walked away to help another resident. R1 was walking with her walker and then she fell . V7 said R1 fell forward and to the right side. V7 stated, It happened so fast. She did not have a gait belt on, so I couldn't catch her. R1 was complaining of hip pain. R1 said the CNAs are supposed to use gait belt when they walk with residents. The gait belt helps keep the resident steady and if they lose their balance, we can try to stabilize them. On 8/22/23 at 2:51 PM, V5 (Restorative Nurse) said R1 had Parkinson's. R1 had a slow, shuffling, unsteady gait. V5 said R1 was supposed to have Standby Assistance with a Gait Belt (SBA w/ GB) for any ambulation. V5 stated, I didn't see the cameras for her fall, but I think there was separation from R1 and the young male CNA (V8). The CNAs are provided a gait belt during orientation. They are told that it is part of their uniform and they should always have it. If they are ambulating a resident, then they should have the gait belt and hands on the resident at all times. The gait belt allows the CNA to keep the resident steady and prevents the resident from going horizontal (or falling). On 8/23/23 at 3:35 PM, V11 (Agency RN) said she was the nurse the night R1 fell . V11 said she saw V7 (CNA) walking R1 to the toilet, but she did not see R1 fall. V11 said she can not recall if R1 had a gait belt on. V11 stated, The CNAs are supposed to use gait belts with all transfers and ambulation. A gait belt would have allowed the CNAs to steady her and possibly prevent the fall. V11 said R1 was lying on the floor on her right side. V11 said R1 hit her head and right side. R1 was complaining of head and hip pain. V11 stated, I only work there once a month, so I had one of the CNAs get [V12 - LPN] to help me. She has been the facility like [AGE] years, so I ask her when I need help. She came down and helped me complete the paperwork, make the phone calls, and she stayed with us until R1 went with the ambulance. She did some education with the CNAs (V7, V8) before she went back to her floor. On 8/23/23 at 3:53 PM, V8 (CNA) stated, I worked the night [R1] fell , but I wasn't ambulating her. She said she needed to go to the bathroom and I helped put on her shoes. That's all. [V7 (CNA)] is the one who walked R1. I didn't see R1 fall. I heard a noise and looked over and R1 was on the floor. She was lying flat on her face. She said she was in pain. After the nurse checked R1, I helped sit her up, but that's it. I don't remember R1 having a gait belt on her. On 8/24/23 at 9:07 AM, V17 (Nurse Practitioner) said she does not see R1 regularly, but she was on call for the facility on 7/31/23. V17 said she reviewed her call logs. V17 said she received a call that R1 had fallen, had a head injury and was complaining of hip pain. V17 said an order was given to send R1 to the hospital for evaluation. V17 said a resident with Parkinson's will likely have a shuffling, unsteady gait. R1 should have been evaluated to see if she needed a gait belt for safety. V17 stated, I would expect the facility to follow the recommendations to use a gait belt during ambulation. V17 said gait belts allow the staff to help stabilize residents and keep their hands on the resident. When a gait belt is used properly, it is possible it could prevent a fall or decrease the severity of the injuries. V17 said R1's fall was the likely cause of her injuries, including a right head hematoma and right hip fracture. The facility's Self Ambulation/Gait Belt Policy dated 1/2008 showed, During a transfer, assisting ambulation, or other care procedures, unless contraindicated for a medical condition, a gait belt is to be used for the safety of each resident. Procedure: 1. Gait belt is part of the standard uniform of the staff giving direct care . Each staff member should always have his or her gait belt on their person for easy access at all times. 3. During transfer or ambulation, etc. The gait belt is used to assist the resident without using their clothing, or arms to give assistance in balance or movement. It is the responsibility of all direct care giving staff to abide by this policy at all times.

Based on observation, interview and record review the facility failed to transfer a resident in a safe manner using a mechanical lift for 1 of 3 residents (R1) reviewed for safety during mechanical lift transfers in the sample of 5. This failure resulted in R1 sustaining a fractured hip. The findings include: The resident face sheet for R1 shows she was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including disorientation, nontraumatic subdural hemorrhage, and fractured hip. The 12/9/22 facility annual assessment documents R1 to have severe cognitive impairment. The same assessment shows she was dependent on two staff for transfers between surfaces including to or from bed and wheelchair. R1's 12/28/18 care plan for falls shows she is at risk for falls due to poor safety awareness and a history of falls. She uses a wheelchair for mobility and mechanical lift for transfers with two staff assist. The care plan was updated with a fall on 2/12/23 and notes she fell during a mechanical lift transfer and fractured her left hip. The 2/12/23 nursing progress notes for R1 document the nurse was called to R1's room and observed her lying on her right side with her legs lying across the leg of the mechanical lift, and her head resting on the other leg of the lift. Blood was noted on the right side of her head and the left hip was observed to be hyper-flexed. R1 stated the left hip hurt when touched. The note documents R1 was sent out to the emergency room and diagnosed with a left hip fracture. The notes show she returned to the facility on [DATE]. The 2/12/23 facility incident report shows R1 was being transferred via mechanical lift from the wheelchair to the bed when she began to lean to the right side and fell from the lift sling unto the floor. On 3/7/23 at 10:10 AM, V6 CNA (Certified Nursing Assistant) said she was walking in the hallway when she heard a big boom. She opened the door to R1's room and found V3 CNA in the room, and R1 was on the floor. She said V3 was the only person in the room, and was saying she fell , I always ask for help. V6 said V3 appeared to be shock and really scared. V6 said V3 never called for assistance to transfer R1, the staff have radios and can easily call for help with transfers. V6 said she remembers R1 way lying across the legs of the mechanical lift and had blood near her head. The sling for the mechanical lift was still hanging from the bar above R1, and the leg part of the sling was criss-crossed. V6 said she believes R1 fell out the side of the sling. V6 said it is the policy of the facility to use 2 people for mechanical lift transfers, for safety. V6 said V2 DON (Director of Nursing) had an in-service on resident safety and transfers on 1/31/23. V6 said there was no reason for V3 to transfer R1 by herself, she should have asked for help. On 3/7/23, calls to V3 were not returned. Her written statement for the 2/12/23 facility incident report documents she hooked the sling to the mechanical lift and started transferring R1 from the wheelchair to the bed. R1 began to lean to the right side and fell from the lift sling. She tried to catch her but could not. On 3/7/23 at 10:00 AM, V5 CNA said R1 was a mechanical lift transfer, and there are always 2 staff members required for the transfer. She said one staff drives the lift and controls the up and down transfer. She said the second staff keeps their hands on the resident and keeps them safe. She said if a second staff is present, they would be able to catch the resident leaning and prevent them from falling. It is dangerous to do it (transfer) alone. On 3/7/23 at 12:15 PM, V2 said she had an in-service on 1/31/23 regarding safe transfers, and the facility policy to always use 2 staff when using the mechanical lift. She said V3 did not follow the policy, and as a result R1 fell about 4 feet from the sling and sustained a fractured hip when she landed on the floor. V2 said the fracture was complicated and non-repairable with surgery. V2 said when she interviewed V3, she admitted to transferring R1 alone with the mechanical lift. When R1 returned to the facility, she was on bed rest and pain management. She was placed on comfort measures and did not return to the quality of life she had prior to the fall. The facility's 1/8/08 policy and procedure for limited lift program documents the purpose of the policy is to determine safe handling and transferring of residents. The procedure: 6. Two (2) staff persons must be present for all mechanical aided transfers.

Based on observation, interview, and record review the facility failed to identify pressure wounds prior to becoming advanced stages, failed to implement pressure relieving interventions, and failed to start new treatment orders timely for 2 of 3 residents (R1, R3) reviewed for pressure in the sample of 11. These failures resulted in R1 obtaining a new stage 4 pressure wound. The findings include: 1. R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires extensive assistance of 2 staff for bed mobility and is totally dependent for transfers. R1's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's care plan with problem start date of 1/21/2022 showed, I am at risk for pressure ulcers due to my nutrition and hydration may vary. It can be hard for me to move around by myself . CNA's (Certified Nursing Assistants) to provide a skin assessment daily with ADL (activities of daily living) assist. Pay particular attention to the bony prominences Report any signs of skin breakdown (sore, tender, red, or broken areas) . The care plan did not include R1 having an actual pressure ulcer with treatment orders. R1's facility Wound Management Detail Report printed 8/26/2022 showed R1 had an area to R1's right buttock identified on 4/1/2022 which was documented as healed on 4/27/2022. This same document showed this area was identified as open again as a stage 4 pressure ulcer with moderate serous yellow drainage on 7/12/2022 measuring 2.7 cm x 0.6 cm x 0.2 cm. R1's Wound Nurse Practitioner wound assessment note dated 7/5/2022 showed a new stage 4 pressure wound was identified on 7/3/2022 to R1's sacrum/coccyx with 100% yellow slough tissue. This same assessment showed new wound care orders to Cleanse with wound cleanser or saline. Calazone to peri wound. medicated Ointment (chemical debridement) on 2x2 gauze moistened with saline . change 3 times weekly . This new treatment order was not entered until 7/14/2022 (7 days after the order was received). R1's Treatment Administration Record (TAR) for July 2022 showed an order dated 4/11/2022 to cleanse wound with saline or wound cleanser, put silicone bordered dressing, change twice weekly . This treatment had a discontinue date of 7/14/2022 and the July 2022 TAR showed this order was documented as completed 7/5/2022, 7/8/2022, and 7/12/22 instead of R1's new wound care orders from 7/5/2022 being put into place including debridement of the pressure ulcer to occur 3 times per week. The same TAR showed documentation of the 7/15/2022 not being completed but did not include the reason it was not completed. The July 2022 TAR showed the first time the 7/5/2022 wound care order was completed was on 7/19/2022 (14 days after the order was written). R1's Wound Nurse Practitioner wound assessment note dated 7/26/2022 showed, . Discussion: Importance of reduction of pressure to help with wound healing: Pressure relief recommend increasing to low air loss . Wound Care Orders: . Low air loss mattress to bed . R1's Wound Nurse Practitioner wound assessment note dated 8/2/2022 showed, . Air waffle on bed . Recommend the following . Low air loss mattress since patient declines to get out of bed . On 8/25/22 at 12:18 PM, V4 (Treatment Floor Nurse) said they do not have an official wound care nurse here to do the weekly assessments but someone rounds with the wound nurse practitioner who is in the facility once a week. If there is a new wound identified we would do the initial assessment in the progress notes, update the family, notify the wound nurse practitioner to get orders, and when she comes in the next time she would assess the wound. On 8/26/22 at 10:17 AM, V12 (Unit Clerk) said all the mattresses in the facility are considered pressure relieving. V12 said R1 has one of the bubble-like mattresses. V12 said she calls it a waffle mattress but it is an overlay not actually a mattress. On 8/26/2022 at 1:00 PM, V17 (Infection Control Nurse) said R1 has an alternating pressure mattress overlay. V17 said she is not aware if a low air loss mattress and an alternating pressure mattress overlay are the same thing. V17 said R1 had a previous pressure area that was healed and then it reopened a few months later. V17 said R1 is documented on more frequently because she is bed bound and at increased risk for pressure ulcers. V17 said the staff document on R1 hourly due to her increased risk for pressure ulcers and falls. V17 said she is unsure if the wound should have been identified before progressing to a stage 4 because they can progress quickly for someone with a history of pressure ulcers. V17 said one of the floor nurses rounds with the wound nurse practitioner and follow up on the nurse practitioners recommendations and orders. On 8/26/2022 at 1:48 PM, V18 (Wound Nurse Practitioner) said she rounds at the facility every week and a staff member from the facility rounds with her. V18 said she writes new orders when she is rounding. V18 said when she assessed the wound it was a stage 4. The facility's policy and procedure updated 8/3/2016 titled Pressure Injury Care showed, Goal: To provide care and services to promote the prevention of pressure injuries and promote healing of those that may be present despite preventative measures . Prevention: Implementation of interventions individualized to remove or modify a resident's risk as identified on the comprehensive assessment . Individual interventions shall be documented on the resident's care plan . The facility's policy and procedure updated 7/26/2016 titled Pressure Injury Policy showed, To promote healthy skin New pressure injuries will be care planned by the nurse using a temporary care plan upon discovery of the injury . All pressure injuries will be reported to the residents physician for treatment and order obtained for the Wound Care Nurse to provide follow up care if applicable. The resident care plan and treatment sheet will reflect treatment and interventions 2. R3's face sheet showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's facility assessment dated [DATE] showed she has moderate cognitive impairment and requires assistance of 1 staff member for most cares. R3's nursing progress note dated 7/22/2022 showed, Hospice CNA reported resident having sores on her heels that she noticed during her shower this morning. Left heel open area measures about 2.0 cm x 2.5 cm, with some brownish scab covering part of the open area. Right heel open area measures about 1.0 cm x 1.0 cm. No drainage noted . R3's wound nurse practitioner wound assessment dated [DATE] showed R3 had two new wounds. The same assessment showed, . Pressure Ulcer of Left Heel, Unstageable, Pressure Ulcer of Right Heel, Stage 2 . Heel Protectors to feet at all times . R3's wound nurse practitioner wound assessment dated [DATE] showed, . Discussion: Importance of reduction of pressure to help with wound healing: heel pressure ulcers. Heel protectors applied during visit since patient did not have protectors on . R3's complete care plan was reviewed with no care plan addressing R3's risk for developing pressure or R3 having actual pressure ulcers present. On 8/25/22 at 11:50 AM, V5 RN (Registered Nurse) said R3 has open areas to both of her heels and wears bilateral heel protectors. On 8/25/2022 at 1:35 PM, R3 was sitting up in her wheelchair in her room. V4 LPN (Licensed Professional Nurse) was providing wound care for R3's bilateral heel wounds. V4 said R3's right heel is pretty well healed at this time but her left heel remains with an open sore. On 8/26/2022 at 9:47 AM, R3 was sitting up in her wheelchair with her feet resting on the foot board of her wheelchair without her heel protectors on. R3's heel protector boots were on the chair in the corner. On 8/26/2021 at 10:21 AM, V14 CNA said she was not sure if R3 was supposed to have heel protectors on or not because she is an agency CNA. V14 went to the nursing station and consulted with V13 LPN. V14 returned and said R3 is supposed to have heel protectors on.

Based on interview and record review the facility failed to ensure a resident (R3) was free from sexual abuse and the facility failed to ensure a resident (R1) was free from verbal abuse for 2 of 6 residents reviewed for abuse in the sample of 6. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on March 22, 2022 when the facility failed to notify V11 (R2's Physician) or V12 (R2's Psychiatric Nurse Practitioner/NP) of R2's worsening sexual behaviors exhibited by R2 pulling out his penis in front of another resident. R2 was later found with his hand in R3's pants (female resident). V1 (Administrator) was informed of the Immediate Jeopardy on June 2, 2022. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on June 2, 2022, however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: 1. R2's current care plan showed R2 was severely cognitively impaired related to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan showed R2 did not have the cognitive ability to understand the behaviors he exhibited were inappropriate. R2's progress note dated March 17, 2022 showed R2 was admitted to the health care unit of the facility. It showed R2 was confused and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] R2's progress note dated March 19, 2022 showed R2 was found standing in the doorway of his room without any pants on by staff. R2's progress note dated March 20, 2022 at 1:02 PM showed, Resident was found standing in door way without pants on .Resident has been found standing in doorway disrobed multiple times throughout the day. Nursing staff has also found resident roaming in the hallway disrobed, attempting to wander into other resident's rooms . The note showed R2 became agitated when redirected by staff. R2's progress note dated March 20, 2022 at 9:19 PM, showed. Resident has been making sexual advances towards male staff members, both physically and verbally throughout the night. Nursing staff has had to redirect resident back into his room multiple times, due to resident attempting to wander hallways disrobed . On May 31, 2022 at 11:53 AM, V9 CNA was interviewed about R2's behaviors on March 20, 2022. V9 stated, I walked into his room that day and (R2) was standing there with no pants or underwear on. I bent over to help put underwear on (R2) and he tried to hug me naked and then grabbed my butt. I backed away and tried to redirect him. I told the nurse about it. R2's progress note dated March 22, 2022 at 3:08 PM showed R2 was found by staff standing naked in a doorway, holding wet underwear. R2's progress note dated March 22, 2022 at 4:43 PM showed R2 walked to stand in front of a male resident, unzipped his pants, and pulled out his penis. The note showed no documentation that this incident was reported to V11 (R2's Physician) or V12 (R2's Psychiatric Nurse Practitioner/NP) at the time this incident occurred. R2's progress note dated March 22, 2022 at 5:04 PM showed, Resident seen coming out of male resident room across the hall from his room in just his underwear. Started toward his room and then turned and re-entered other room . The note showed no documentation that this incident was reported to V11 (R2's Physician) or V12 (R2's Psychiatric Nurse Practitioner/NP) at the time this incident occurred. R2's progress note dated March 22, 2022 at 7:01 PM showed R2 was found outside of his room with no clothes per facility staff. R2's progress note dated March 23, 2022 at 9:16 PM showed R2 tried to grab CNA's privates and said I want it. Come to bed with me. Let me have it. The note showed no documentation that this incident was reported to V11 (R2's Physician) or V12 (R2's Psychiatric Nurse Practitioner/NP) at the time this incident occurred. R2's progress note dated March 25, 2022 showed R2 was observed by facility staff asking a male staff member if he would like to get together later . R2's progress note dated April 12, 2022 showed R2 Director of Nursing (DON) was notified of an allegation of sexual behavior that R2 had exhibited towards another resident. The note showed V11 (R2's Physician) or V12 (R2's Psychiatric Nurse Practitioner/NP) were notified of the incident. R2 was sent to a local hospital for an evaluation. The facility's sexual abuse allegation report dated April 12, 2022 showed V7 Certified Nursing Assistant (CNA) witnessed R2 place his left hand down the front of (inside of) R3's pants. V7 CNA intervened and was able to remove R2's hand away from R3. On May 31, 2022 at 9:30 AM, V7 CNA stated on April 12, 2022, (R3) was seated in her wheelchair in the main sitting area by the nurse's station. (R2) was seated next to (R3) in a recliner. I watched (R2) take his left hand and put it down the front of (R3's) pants. I am not sure if he got inside her incontinence brief. I just know his hand was inside her pants. I immediately got up and walked towards them. I kept saying, No, no! (R2) finally removed his hand from (R3's) pants once I got up in front of them. They were immediately separated. (R2) said nothing about what had happened. (R3) was wiggling around in her wheelchair. She is not really verbal. On May 31, 2022 at 11:15 AM, V8 Licensed Practical Nurse (LPN)/Third Floor Nurse Manager stated, (R2) had many sexual behaviors prior to the incident with (R3) on April 12, 2022. He would walk around naked, he tried to pull his penis out, and he made sexual comments towards male staff. I am not sure if (V11 R2's Physician) was notified of all of his behaviors. We just tried to watch him closely. On May 31, 2022 at 12:00 PM, V10 Registered Nurse stated, I took care of him on March 22, 2022. (R2) walked up to another male resident, unzipped his pants, and pulled out his penis. His penis was actually out of his pants. I told him to put it away and he did .I did not inform his physician of the incident but I did notify (V2 DON). I was just told to watch him closely. He was not a 1:1 (1 staff member assigned to R2) care at that time. On May 31, 2022 at 12:50 PM, V2 DON stated, I don't recall informing (V11 R2's Physician) or (V12 R2's Psychiatric Nurse Practitioner/NP) of (R2) pulling out his penis in front of another resident on March 22, 2022. I know I told them about the incident (from 3/22/22) after the incident occurred on April 12, 2022. (V11 and V12) were aware of (R2's) sexual behaviors but he had never actually touched anyone on March 22, 2022. We were just working on trying to adjust (R2's) medications to help control his behaviors . On June 1, 2022 at 10:19 AM, V2 stated she felt the behaviors R2 exhibited in March 2022 which included R2 disrobing and exposing his penis were related to R2's incontinence issues and his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On May 31, 2022 at 12:20 PM, V11 (R2's Physician) stated, (R2) has dementia and disinhibition syndrome where he can't recognize his wrong doing and can't control his behaviors. I don't recall being notified of him pulling out his penis on March 22 or him grabbing the groin of facility staff on March 23, 2022. If I had been notified, it would be documented in a note. If I had been notified by staff, I would have tried to handle the behaviors internally by making him 1:1 care and keeping him in his room. If that didn't work, I would have ordered him to be sent to the hospital for an evaluation. On June 1, 2022 at 10:22 AM, V11 (R2's Physician) again stated that he doesn't recall being notified of R2 pulling out his penis on March 22 or him grabbing the groin of facility staff on March 23, 2022. On May 31, 2022 at 1:12 PM, V12 (R2's Psychiatric Nurse Practitioner/NP) stated she didn't recall facility staff ever calling her about him pulling out his penis on March 22 or him grabbing the groin of facility staff on March 23, 2022. R3's current care plan showed R3 was not ambulatory and was placed in a high back wheelchair when not in bed. The care plan showed R3 was severely cognitively impaired due to her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On May 31, 2022 at 1:55 PM, V13 (Daughter of R3) stated, (R3) is really nonverbal due to her dementia. She has really gone downhill mentally over the last five months. The facility did inform me of the incident that occurred in April (2022). In her right mind, my mom would have never allowed that to happen. She would be so mad. She'd be mortified. She would have slapped him. The Immediate Jeopardy that began on March 22, 2022 was removed on June 2, 2022, when the facility took the following actions to remove the immediacy: IMMEDIACY REMOVAL PLAN - R2 was sent to the local hospital for evaluation and treatment on 4/12/22. -Upon return (on 4/12/22) from the hospital, a caregiver was put in place for R2, 24 hours per day/7days per week, and will remain in place as long as R2's sexual behaviors continue. -R2's behaviors are monitoring continually by the 1:1 caregiver. Any behaviors exhibited by R2 are documented in the residents chart and reported immediately to the assigned nurse. DON or designee will ensure 1:1 is being provided. -The facility is continuing to seek alternate placement for R2 in a facility that can better meet his needs. -Computer training/In-servicing held 4/21/22-4/25/22 for all nursing staff on Understanding Abuse and Neglect. This mandatory training was completed by all nurses and CNA's by 4/25/22. -The facility will initiate today and complete mandatory re-education and training (see below) for nurses, C.N.A.'s, dietary staff, housekeeping/laundry staff, agency staff and life enrichment by 6/06/22. If a staff member has not completed this in-service by that date, they will need to complete the training before allowed to return to work. The re-education/training will include the following: Identifying the signs and symptoms of sexual behaviors in dementia residents Identifying escalating sexual behaviors Reporting sexual behaviors in dementia residents Identifying the signs/symptoms of sexual abuse Staff educations on interventions/ways to protect other residents from a resident that is exhibiting behaviors. * The current in-service training includes housekeeping/laundry and dietary staff and is focused on the incident with R2 and sexual abuse prevention, response, and reporting with the scenario of the incident. The 4/25/22 training included the same overall training with all types of abuse including prevention, response, and reporting. The only difference would include the scenario given at the current in-servicing and was provided to nursing and CNA staff only. -The education will be done by the DON and/or designee. This in-service will be available on-site June 2, June 3, and June 6. Any staff not in-serviced by June 6 will be individually in-serviced before working a scheduled shift. -The adherence to the above plan will be monitored by randomly questioning the staff - that they know how to identify the signs/symptoms of sexual behaviors in dementia residents, how to identify escalating behaviors and reporting sexual behaviors in dementia residents and identifying the signs/symptoms of sexual abuse. Ten random staff members will be questioned weekly in regards to the above abuse education, starting June 7, 2022 through September 7, 2022. The random monitoring will occur monthly for 3 months, quarterly for 2 cycles and then as directed by the QAA Committee. The DON or designee will conduct the random monitoring/questioning. 2. The facility's verbal abuse investigation report dated April 21, 2022 showed V2 Director of Nursing (DON) was notified that V5 CNA had verbally abused R1 on April 12, 2022. It was reported to V2 DON that on April 12, 2022, V5 CNA told R1 to Shut your f .g mouth. The report showed V5 CNA admitted to making that statement to R1 on April 12, 2022. V5 CNA's employment was immediately terminated. R1's current care plan showed R1 was severely cognitively impaired related to her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . It showed R1 exhibited physical and verbal behaviors towards staff. On May 31, 2022 at 8:40 AM, R1 was seated in a high back wheelchair by the second floor nurse's station. When this surveyor asked R1 about the incident on April 12, 2022, R1 looked confused and said, I'm fine. What are you talking about? Leave me alone! On May 31, 2022 at 9:57 AM, V5 CNA stated, On that day (4/12/22), I was trying to get (R1) up out of bed and she kept hitting me in the face. She looked at me and said You shut your f .g mouth. I then responded, No, you shut your f .g mouth. It just slipped out I know it was wrong because it was verbal abuse . On May 31, 2022 at 10:10 AM, V2 DON stated, (V5 CNA) confessed to telling (R1) to shut her f .g mouth. (V5) was terminated immediately. That is verbal abuse . The facility's abuse policy (undated) showed, It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation, and misappropriation of resident property . The policy defines sexual abuse as non-consensual sexual contact of any type with a resident. Generally sexual contact is nonconsensual if the resident either: Appears to want the contact to occur, but lacks the cognitive ability to consent; or does not want the contact to occur . The policy showed, Verbal abuse may be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability .

Based on interview and record review the facility failed to ensure a safe transfer with a mechanical lift for a resident dependent upon staff and a mechanical lift for trasnfers for 1 of 2 residents (R62) reviewed for safety. This failure resulted in R62 being transferred to the acute care hospital for evaluation of lacerations and hematomas sustained from the incident. The findings include: R62's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to Alzheimer's disease, [CONDITION(S)] [CONDITION(S)], urinary tract infection, spinal stenosis, anxiety disorder, spondylosis, and right artificial hip joint. R62's facility assessment dated [DATE] showed he is dependent upon staff for all cares. R62's nursing progress note dated 8/31/20 showed, Resident was being hoyered from bed to chair with 2 CNAs (Certified Nursing Assistant) when the strap on the sling broke causing him to fall on the floor. He received a laceration to left side of head with hematoma, a busted lip on left side, and a skin tear to left arm with a hematoma. POA (Power of Attorney) and hospice was notified and DR (doctor) was sent a fax. Sent out to hospital and came back with dressings on head and arm, CT and xray came back OK. Hospice says to change dressings weekly and PRN. R62's Emergency Department provider note dated 8/31/20 showed, . Patient was being lifted out of his bed with a hoyer lift. The lift broke and the patient was dropped onto his face and left elbow. Injury location: mouth and shoulder/arm, Mouth injury location: Upper inner lip, Shoulder/arm injury location: left elbow . Impact surface: hard floor . R25's 8/31/20 Resident Accident/Incident Report showed, .resident was being hoyered from bed to wheelchair when strap on sling broke causing him to fall face down to the left side . Resident was laying face down toward the left side with a laceration to the left side of head above ear, skin tear to left forearm above elbow with hematoma on arm and head, also busted lip on left side . On 6/17/21 at 9:50 AM, V3 DON (Director of Nursing) said, R62 had a fall on 8/31/20 from the hoyer lift when one of the hoyer straps snapped. V3 said he nurse on the floor starts the fall investigation and then the restorative nurse gets involved. V3 said when the incident with R62 occurred the Restorative Nurse was V5 LPN (Licensed Practical Nurse). V3 said she was not involved in this incident but would check with V5 for the incident report. V3 said the staff did bring her the hoyer sling that had broken and it was disposed of. V3 said the night shift goes through and checks all of the straps on the slings for any fraying and brings them to her to dispose of. V3 said laundry does the same thing. V3 said this has been the process in place since before R62's incident with the hoyer sling. V3 said for the most part each resident has their own sling which goes by height and weight of the resident per the recommendation of the company. V3 said the facility has a certain number of medium and large size slings, have toilet slings and shower slings. V3 said the slings are just labeled with the facility name and a date that it was put into use. On 6/17/21 at 10:21 AM, V5 LPN said she took the incident report to V2 DON. V5 said the incident report was pretty much the whole investigation because it was pretty clear cut as to what happened. V5 said she thinks there was an inspection of all the other slings but she was not really involved in this incident because they were really busy back in that time. V5 said V2 was the one that handled the fall so she can't say if they went through all the slings. V5 said if they did an inspection of all the slings she does not know who was assigned to do all that or if it was documented. V5 said it is the night shift's responsibility to check and make sure the slings are workable. V5 said the slings are labeled with 2nd and 3rd floor. V5 said she she thinks this was a process that was an intervention in response to the incident with R62. On 6/17/21 at 10:35 AM, V6 Laundry Supervisor said the hoyer slings are only labeled with 2nd and 3rd floor. They are not labeled for each resident and are not labeled 1-5 or anything like that. V6 said she is unsure if hoyer slings come in different sizes but does think they probably do. On 6/17/21 at 2:30 PM, V3 DON brought the quality assurance tool dated August 2020 and titled Check Stand-Lift/Hoyer/Shower Slings Monthly on the 15th for freys which did not show what floor the slings checked were for and only showed 4 hoyer slings were looked at. The hoyer sling check tool showed, Hoyer Sling #1 through #4. The hoyer slings were not numbered. V3 said there are more than hoyer slings than 4 on each unit. The facility's policy titled Safe Handling and Limited Lift/Movement dated 9/5/07 showed, Purpose: To ensure resident handling and limited lifting is in a manner that recognizes safety for resident sand staff . The facility's policy titled Fall Protocol showed, Purpose: To coordinate appropriate facility response to a resident fall (B)