Every finding on record at Fairview Rehab & Healthcare

Based on interview and record review, the facility failed to notify the physician of abnormal vital signs and a change in resident's condition for 1 of 4 residents (R1) reviewed for physician notification in a sample of 9. Findings include: R1's admission record documents an admitted [DATE] and the following diagnoses in part, unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing, unspecified displaced fracture of first cervical vertebra, subsequent encounter for fracture with routine healing need for assistance with personal care. R1's Minimum data set (MDS) dated [DATE] documents a Brief Interview for Mental Status of 15, indicating that R1 was cognitively intact. R1's progress notes documents on 12/10/2024 at 12:01am, This nurse went into pt's (patient's) room and son visiting had pulse oximeter on his mother's finger and it was reading 90%. He states when it first was put on it was 80. This PT very anxious. Color natural skin w/d (warm/dry). Resp (respirations) even and slightly labored. This nurse put her pulse oximeter on her, and it read 93. Spoke with son and ask his concerns. He states she gets confused, and he think her oxygen might be going down. He also states with her swelling may be making it worse, but she is on metolazone now and should help. States he does not want her sent to hospital and to just wait and see. Placed on 2 L (liters) O2 per NC (nasal cannula) and SPO2 increased to 95. This occurred at 730pm. R1's progress notes documents on 12/10/24 at 12:22am, resting quietly in bed with eyes closed, HOB (head of bed) elevating 30 degrees to facilitate breathing. resp (respirations) even and NL (not labored) .to begin metolazone in the AM for edema to BLE's (bilateral lower extremities). Noted 2+ edema to BLE's. The following vital signs were documented, Respirations of 20, oxygen level of 95 on 2 liters of oxygen via nasal cannula, blood pressure of 134/78. R1's progress notes documents on 12/11/2024 at 12:42pm, this nurse approached resident to administrate noon meds and res is lethargic, sleepy, difficult to arouse. this nurse assessed res (resident). The following vital signs were documented temperature of 98.1, pulse 73, respirations 14, and a blood pressure of 89/53. R1's progress notes document on 12/11/2024 at 2:23pm, Res (resident) has been differing from her last known normal since yesterday morning. Res is lethargic and slow to respond to verbal commands. Res son requests that she go to the er. Dr agrees. EMS contacted and en route. On 02/18/25 at 11:14am, V5 (Physician) stated if R1's blood pressure was 89/53, and if her baseline is much higher than that, he would expected to be notified. V5 stated especially if they are more lethargic than usual. V5 stated it is his expectation that the nursing staff rely on nursing judgment and if there is any question they should contact him. V5 stated he did not believe the facility contacted him on 12/10/25 or 12/11/25 until they were requesting for R1 to be sent out to the hospital. On 02/18/25 at 1:44pm, V2 (Director of Nurses/DON) stated they do not have a facility or corporate policy on vital signs, she stated their expectation is for vitals to be obtained for any change in condition and per doctor's orders. V2 stated anything abnormal, staff should contact the physician. On 02/20/2025 at 7:43 am, V16 (Licensed Practical Nurse/LPN) stated, she would have notified V5 if a resident had a change in behavior, vital signs of baseline, including a blood pressure of 80/50 or if she applied oxygen to a resident. On 02/20/2025 at 9:26am, V2 (DON) stated the only standing order we utilize is the bowel protocol. She stated anything else, including oxygen the physician must be contacted. V2 stated there may be standing orders in Point Click Care, but staff knows it is her expectation they contact the physician. V2 stated her expectation is that nurses use nursing judgment and if they have concerns or unsure they should contact V5. V2 stated if a resident needs oxygen, they will contact the physician for an as needed order for oxygen, usually will start residents out on 2 liters. V2 stated that the day R1's blood pressure was 89/53, the nurse decided to try to push fluids before notifying the physician. V2 stated her expectation would have been for staff to have contacted the physician right away and recheck the vital signs. On 02/20/2025 at 9:43 AM, V4 (Registered Nurse/RN) stated, R1 started to have behavior changes on 12/10/2024. V4 stated, she had assessed R1 on 12/10/2025 and R1 had been lethargic, more confused than usual and not able to communicate well with her. V4 stated, R1 had been more resistant to care and refused water. V4 stated, she encouraged fluids for R1 and did not notify V5. V4 stated on 12/11/2024 R1 continued to have a change in behavior when she arrived for her morning shift. V4 stated, she did take R1's blood pressure at 12:42pm on 12/11/2024 and documented the 89/53. V4 stated, she did not call V5 at this time, but did encourage fluids. V4 stated, at 2:43 PM on 12/11/2024, R1 had not been getting any better so she notified V5 and then V3 (family) that R1 would be going to the local hospital for evaluation. V4 stated she did not recheck R1's blood pressure after documenting the 89/53 at 12:42 PM. V4 stated she would immediately notify V5 for any resident who had a change in behavior, vital signs from baseline, declining to eat or drink, etc. V4 stated she did not contact V5 immediately with R1's change in behavior or blood pressure reading. On 02/20/2025 at 11:16am, V19 (LPN) stated she had a vague recollection of R1, she did not care for her often. V19 stated she recalled the incident on 12/10/25 that involved R1 having decreased oxygen saturation and applying oxygen via nasal cannula. V19 stated the facility has an as needed order for oxygen. V19 could not recall if she contacted the physician but stated she would have noted it if she did. V19 stated she may have sent him a text message, but she couldn't recall. V19 stated a physician should be contacted anytime they notice a change in condition or anything concerning. V19 stated if a vital sign is obtained that is abnormal from someone's baseline, the physician should be contacted right away. Facility Change in a Resident's Condition or Status (revised May 2017) under Policy Statement, our facility shall promptly notify the resident, his or her attending physician and representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). In this same document under Policy Interpretation and Implementation, 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): d. significant change in the resident's physical/emotional/mental condition.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed for elopement risk in the sample of 9. This failure resulted in a cognitively impaired resident (R1) exiting the facility without staff knowledge and being found approximately two miles away from the facility. The failure required the sheriff to call an ambulance that transported R1 to a local hospital emergency room . This failure resulted in an Immediate Jeopardy, which was identified to have begun on 2/2/25 at 1:46 am when R1 exited the facility through the bird room double doors without supervision and was found by the sheriff's office approximately two miles from the facility. This past non-compliance occurred from 2/2/25 to 2/2/25. V14 (Administrator) was notified of the Immediate Jeopardy on 2/5/24 at 11:04 AM. The Surveyor confirmed by observation, record review and interview that the immediacy was removed on 2/2/25. Findings Included: R1's Facility's Admission Record documented admission to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, bipolar disorder, unspecified and Parkinson's disease without dyskinesia. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 4, indicating R1 has severe cognitive impairment. Section GG0170. Mobility in this same MDS documented R1's mobility as independent for rolling left to right, sitting to lying, sit to stand, chair to bed transfer, toilet transfer, tub/shower transfer, walking 10 feet and walking 50 feet with two turns. Section E of this MDS for Wandering-Presence and Frequency documented behaviors of this type occurred and O (Behavior not exhibited) was answered to the question has the resident wandered? R1's Facility Elopement Risk assessment dated [DATE] documented a score of 32.0 which indicated R1 is at risk of elopement. R1's current care plan documents R1 has a focus area of risk of elopement with diagnosis of Parkinson and ambulates: 6/24/2024 got out the door unnoticed and was picked up. Date initiated 6/24/24. Interventions in place all dated 6/24/2024 documented 15-minute checks, picture placed in wonderer book at nurses' station, and redirect R1 away from doors. R1's Facility Progress Note dated 2/2/2025 at 3:35 AM by V5 (Licensed Practical Nurse/LPN) documented, she received a call from the local sheriff's office, asking if the facility was missing R1. V5 stated, not that she was aware of, but would go check his room. V5 went to R1's room and R1 was not in there. V5 documented there had been no recent door alarm noted, except for earlier in the night in the bird room about 1 hour to 1.5 hours earlier. V5 documented the last time she recalled seeing R1 had been around 1:30 AM. R1's Facility Progress Note dated 2/2/2025 at 3:55 AM by V5 (LPN) documented she notified V10 (family) that R1 had wandered out, he didn't have any shoes and socks on because he was put to bed. V5 documented, when V10 had been notified of the incident, V10 stated What, did he escape again? V5 notified V10 that R1 had been taken to local hospital for further evaluation. R1's Local Hospital History and Physical report dated 2/2/2025 at 5:42 AM completed by V15 (Nurse Practitioner) documented under Present Illness that R1 with a history of Parkinson's disease, dementia who eloped from the skilled nursing facility where he resides was found approximately 2 miles from the facility walking in socks and a gown. The temperature outdoors was 43 degrees Fahrenheit. R1 was brought to the emergency room to be evaluated. At the time of presentation R1 was found to have an oral temperature of 97 degrees Fahrenheit. R1 also had purplish discoloration to the bottoms of both feet. R1 was chilled and shivering at the time. R1 was admitted for observation with the diagnoses of hypothermia, bilateral frostbite of feet, and Influenza. R1's Local Hospital emergency room Report by V19 (emergency room Physician) dated 2/2/2025 at 4:07 AM documents under initial comments, R1 had been found by a driver on (name of local road heading out of town) and was walking in socks and a gown. V19 documented R1 had evidence of exposure with discoloration on bottoms of both feet, abrasions noted to both hands, R1 is chilled and difficulty speaking. This same document under Course, V19 documented R1 had significant exposure to the cold, unsure how long R1 had been outside in the weather, away from the facility. V19 documented, R1 had been located approximately 2 miles away from the facility and it would take R1 quite a while to walk this distance with his medical conditions. Under Progress, V19 documented, R1's temperature was 97, but R1 felt colder than that and R1 was shivering uncontrollable. V19 documented, R1 had been initiated rewarming R1 with warmer, intravenous fluids and discoloration to feet is the most concern for frostbite. According to https://www.timeanddate.com/weather/@4237312/historic, on 2/2/25 the temperature in the city facility is located in was 45 degrees Fahrenheit at 1:52 am with a wind speed of 9 miles per hour, was 43 degrees Fahrenheit at 2:52 am with a wind speed of 8 miles per hour and was 42 degrees Fahrenheit at 3:52 am with a wind speed of 6 miles per hour. According to https://google.com/maps, R1 traveled 1.9 miles from the facility to the location he was found by police. Also, according to the website, the journey would take a minimum of 40 minutes by foot. On 2/3/2025 at 1: 30 PM, V5 (Licensed Practical Nurse/LPN) stated she had been the nurse working the night of 2/2/2025 when R1 had gotten outside of the facility. V5 stated, R1 has the tendency to wander the facility. V5 stated, on 2/2/2025 R1 had not been feeling well and been up at the nurses' station around 1:00 AM. V5 stated, V6 (Certified Nurse Aide/CNA) took R1 to his room to lay down around 1:30 AM. V5 stated, the door alarm in the bird room went off between 1:30 AM- 1:40AM. V5 stated, she looked at the camera's and did not see anyone at the front door. V5 stated, she left the door alarm on while her and V6 (CNA) walked down to the bird room door. V5 stated, when she and V6 got to the bird room, R2 had been standing by door. V5 stated, she assumed that R2 had been the resident to set the alarm off. V5 stated, she did receive a call around 3:30 AM from the local sheriff's office that R1 had been found outside of the nursing home walking down the road. V5 stated, she had not been aware that R1 had been outside the facility. V5 stated, she went down to R1's room to verify if he had been in there and R1 was not in his room or the facility. V5 stated, R1 had been transported to the local hospital via ambulance from where he was located outside the facility. V5 stated, the facility policy is when a door alarm sounds, staff is to immediately check the cameras and go to the door to investigate what caused the door alarm to sound. V5 stated, if a resident is trying to go outside or made it outside the facility, staff is to attempt to bring them back into the facility and walk outside to double check no other resident had gone outside. V5 stated, if the door alarm sounds, the staff are to do a head count of all residents to verify all residents are accounted for. V5 stated, she did not go outside when the door alarm sounded the night of 2/2/2025 to make sure no other resident had been outside and staff did not do a resident head count to verify all residents were accounted for prior to the call at 3:30 AM. V5 stated, she assumed R2 had set the door alarm off. On 2/3/2025 at 12: 40 PM, V6 (CNA) stated she did work the night that R1 did get outside the facility. V6 stated, R1 does have tendencies to wander, and exit seek. V6 stated, the bird door alarm went off around 1:30 AM -1:40 AM on 2/2/2025. V6 stated, her and V5 (LPN) went to investigate the alarm. V6 stated, the door alarm in the bird room and the front door has the same alarm with every other door having a different alarm. V6 stated, when her and V5 got to the bird room, R2 was the resident they found by the bird door while open and she and V5 assumed R2 had set the alarm off. V6 stated, there are no cameras in the bird room to verify anyone exiting the facility. V6 stated, she had laid R1 down in his room sometime around 1:30 AM on 2/2/2025. V6 stated, resident bed checks are completed every 2 hours on even hours but not documented anywhere. V6 stated, she did not have R1's side of the hall during the bed check at 2:00AM so she cannot say if he had been in his bed. V6 stated, V9 (CNA) would have completed the bed check for R1 at 2:00 AM. V6 stated, the policy stated if a door alarm goes off, staff is immediately to go to the door alarm to investigate, do a resident head count to verify that no resident had exited the building and visually look outside. V6 stated, she and V5 did not visually look outside or do a head count on residents after the door alarm in the bird room went off. V6 stated, she had been on lunch when a call came in around 3:30 AM from the local sheriff department that R1 had been found walking down the road. V6 stated, she had not been aware that R1 had gotten outside the facility. V6 stated, she is not aware of any interventions in place for R1 prior to him getting out of the facility on 2/2/2025. On 2/4/2025 at 10:16 AM, V9 (CNA) stated she was working the night R1 got out of the facility on 2/2/2025. V9 stated, she was not for sure how R1 got out of the facility, but R1 is a resident who does seek exits and wanders the facility. V9 stated, R1 had been known to get outside the facility on multiple occasions. V9 stated the door alarm went off while she had been helping another resident and V5 (LPN) and V6 (CNA) responded to the door alarm in the bird room. V9 stated, V6 reported to her that R2 had been the resident who set the door alarm off in the bird room. V9 stated V6 did put R1 to bed sometime after 1:00 AM. V9 stated, the alarm went off sometime after that. V9 stated, V6 reported that R2 had been the resident found at the bird room door so V5 and V6 thought it was him who had set the alarm off. V9 stated, when a door alarm goes off the facility policy stated to notify the nurse of the alarm, staff are to go to the door to see why the alarm is sounding. V9 stated, staff members are supposed to look outside to make sure no residents had gotten outside when the door alarms go off and do a resident head count to account for all residents. V9 stated, she did not do a resident head check after the door alarm went off. V9 stated resident bed checks are completed every 2 hours on even hours. V9 stated, she did the resident bed check at 2:00 AM down R1's hallway, but R1 was not in his room. V9 stated, I thought R1 had been up at the nurses' station, and I should have gone up to the nurse's station to make sure R1 was there, but I did not. V9 stated V5 received a call sometime around 3:30 AM from the local sheriff's office stating R1 had been picked up all the way down (name of local road leading out of town) and would be taken to the local hospital for further evaluation. V9 stated R1 did not have any intervention of 15 minutes checks before the incident on 2/2/2025. V9 stated there was no resident head count after the door alarm went off. On 2/5/2025 at 3:35 PM, V15 (Nurse Practitioner/NP) stated he was the provider in charge of R1 when R1 was brought into the emergency room . V15 stated R1 had been in the local emergency room for quite some time before he got to the medical floor. V15 stated, R1 arrived at the local emergency room , very cold and shivering. V15 stated, the emergency room did give R1 some warm IV (intravenous) fluids to help warm him up. V15 stated, it was his understanding that R1 had been found 2 miles away from the facility, with no shoes on. V15 stated, R1 did have a diagnosis of hypothermia based on his symptoms when he arrived but did resolve prior to R1 being discharged . V15 stated, in his opinion, you do not have to have a low body temperature to be diagnosed with hypothermia, R1 had symptoms that included shivering, being cold, discoloration to feet and had been outside for an extended time. V15 stated, R1 had been observed for frost bite as well because R1 did have some purplish discoloration to the bottoms of his feet when arriving to the local emergency room . V15 stated, this later resolved as well. V15 stated, R1 did have an injury to his left under foot that he was aware of and observed to be bruising and a blister to the area. V15 stated, R1 had been diagnosed with influenza prior to his admission for observation. V15 stated, R1 was given some Tamiflu to help with symptoms, but was not diagnosed with influenza at the hospital. On 2/4/2025 at 9;10 AM, V10 (Family) stated, she received a call around 4:00 AM on 2/2/2025 from the nursing facility. V10 stated, when she answered the phone, she said Please don't tell me he escaped again. V10 stated, V5 (LPN) stated R1 had been found by a passersby driver that seen him walking down (name of local road leading out of town) and called the local sheriff's office. V10 stated, R1 had been found 2 miles from the facility and about 2 driveways down from her home. V10 stated, R1 did not have any shoes or coat on at the time he was found. V10 stated, V5 did state that the facility had not been aware that R1 had gotten outside the facility. V10 stated, the local hospital did take pictures of his feet that had a blister and bruises on his left heel and a skinned-up knee. V10 stated, she had not been aware of any interventions in place for R1 prior to 2/3/2025 and R1 had gotten outside the facility, twice last summer. V10 stated, one-time last summer, R1 got outside of the building, and she had been notified that R1 was standing by the facility sign. V10 stated, another time last summer in June 2024, R1 had gotten out, a passerby in a car called her and notified her that R1 had been walking down by the local middle school road. V10 stated, at that time, she had asked the passerby to have R1 get in her car and drive him back to the facility. On 2/3/2025 at 10:52 AM, V3 (Licensed Practical Nurse/LPN) stated, if the facility had a resident who is exit seeking or attempting to leave the facility, the facility policy is to redirect the resident. V3 stated, if a resident does make it outside of the facility, a staff member should walk with the resident. V3 stated, if they cannot walk with the resident, you are to leave the door alarm on for another staff member to come and help. V3 stated, once the resident is returned to the facility, there should be a head count of residents to make sure every resident is accounted for. V3 stated, it was reported to her by V5 (Licensed Practical Nurse/LPN) when she arrived for her shift on Sunday morning (2/2/2025) at 6:00 AM that R1 did get outside of the facility on the night shift and had been found between 3:00 am and 4:00 am. V3 stated, it had been reported to her by V5 (LPN) that there had apparently been 2 residents (R1 and R2) at the bird cage double doors when the door alarm went off earlier that night. V3 stated, V5 had only been aware of R2 being witnessed in the bird room with his hands on the door when the alarm went off and V5 was unaware that R1 had gotten outside the facility. On 2/3/2025 at 12:50 PM, V7 (CNA) stated, she did work the night that R1 had gotten outside of the facility. V7 stated, she had not been working R1's hallway that night, however, she had seen R1 at the nurses' station around 1:00 AM. V7 stated, V6 (CNA) did take R1 to his room to lay down around 1:30 AM. V7 stated, resident bed checks are completed every 2 hours on even hours. V7 stated, there had been a door alarm in the bird room that went off earlier that night, but she is not sure of the time. V7 stated, if a door alarm goes off, staff are to check the door immediately, look outside, if a resident is attempting to go outside or is outside the facility then you are to attempt to talk the resident back inside. V7 stated, a resident head count is to be done when a door alarm goes off. V7 stated, around 3:30 AM, V5 (LPN) did receive a phone call from the local sheriff's office that R1 had been found walking down the road. V7 stated, V5 (LPN) did go to R1's room to verify that he had not been in there. V7 stated, R1 was not in his room. On 2/3/2025 at 7:58 AM, V8 (CNA) stated, she was notified during report on 2/2/2025 at 6:00 AM by V6 (CNA) that R1 had gotten outside the facility on the night shift. V8 stated, it was reported to her by V6 in report that she had laid R1 down in his bed around 1:30 AM. V8 stated, V6 reported to her that the door alarm in the bird room had sounded sometime around 1:30 AM-1:40 AM. V8 stated, V5 and V6 responded to the door alarm and they found R2 at the door in the bird room. V8 stated, V6 reported around 3:30 AM, V5 received a call from the local sheriff's office that R1 had been found walking down (name of local road leading out of town) and had been taken to the local hospital for further evaluation. V8 stated, resident bed checks are to be completed every 2 hours by staff on even hours. V8 stated, if a resident is not located during every 2-hour bed check, all staff is supposed to look for that resident and notify the nurse. V8 stated, the facility policy is if a door alarm sounds, staff are to immediately check the cameras, go to the door to investigate what caused the alarm to go off, check outside to make sure no resident made it outside. V8 stated, the front door and the bird room door have the same alarm sound and there are no cameras in the bird room. V8 stated, if a door alarm sounds, after investigating the area, staff is to complete a resident head count to make sure all residents are accounted for. V8 stated, R1 does have tendency to wander the facility and exit seek. V8 stated, R1 did have 15 minutes visual checks for interventions prior to 2/2/2025 but they were never documented. On 2/4/2025 at 11:03 AM, V12 (CNA) stated, she worked the morning that R1 had gotten out of the facility. V12 stated, V9 (CNA) reported to her that R1 did get out of the facility overnight. V12 stated, V9 reported to her that R1 had been laid down in bed around 1:30 AM. V9 stated, the door alarm in the bird room sounded sometime between 1:30 AM - 1:40 AM. V12 stated, V9 reported that V5 (LPN) and V6 (CNA) did go to the bird room to investigate the door alarm and found R2 at the door. V12 stated, resident bed checks are scheduled for every 2 hours on even hours. V12 stated, if a resident is not in their bed during bed checks, the staff are to immediately start looking for the resident and notify the nurse. V12 stated, the facility policy states that when a door alarm sounds, staff are to respond immediately to the alarm, investigate what caused it and go outside to make sure no resident is outside the facility. V12 stated, a head count is supposed to be completed on all residents after a door alarm is set off. V12 stated, R1 does have tendency's to randomly exit seek and wander. V12 stated, R1 did not have any interventions in place prior to R1 getting outside the facility on 2/2/2025. V12 stated, R1 did not have 15-minute visual checks prior to 2/3/2025. On 2/4/2025 at 12:56 PM, V1 (Director of Nursing/DON) stated, V14 (Director of Operations) is the acting administrator at this time. V1 stated, she did receive a phone call from V5 (LPN) around 3:34 AM on 2/2/2025. V1 stated, V5 notified her that R1 had been found outside the facility by the local sheriff's office. V1 stated, V5 was not sure at what time R1 had gotten outside of the facility. V1 stated, she had been notified that R1 had been restless all night and had been sitting up at the nurse's station. V1 stated, V5 notified her that V6 (CNA) had laid R1 down in his room sometime before 2:00 AM but was not sure of the exact time right then. V1 stated, that was the last time R1 had been seen by staff. V1 stated, V5 notified her that the bird alarm door did alarm after 1:30 AM. V1 stated, V5 (LPN) and V6 (CNA) went to investigate the bird door alarm when they found R2 with the bird door open. V1 stated, V5 and V6 did close the door and walked R2 back to his room. V1 stated, V5 received a phone call around 3:30 AM from the local sheriff's office stating that R1 had been found down by (name of local road leading out of town). V1 stated, R1 had been taken to the local emergency room for further evaluation. V1 stated, that the facility policy stated that when a door alarm sounds, staff is supposed to go to the door to verify why the alarm is going off. V1 stated, staff are to look outside to make sure no resident had gotten outside and do a resident head count to verify all residents are accounted for. V1 stated, V5 and V6 did not go outside to make sure any resident had gotten outside, and they did not do a resident head count. V1 stated, R1 does randomly wander the facility, exit seeks and had gotten out of the facility at least two times in the Summer of 2024. V1 stated, R1 had been found by a V10's (Family) friend walking down the road on (name of local street) on 6/24/24. V1 stated, R1 had been brought back by V10's friend to the facility. V1 stated, R1 did get out of the facility a second time in the summer of 2024 but only made it to the parking lot before staff had been able to get R1 to come back in the facility. V1 stated, R1 did have interventions in place prior to 2/2/2025 that included activities, sitting up at the nurses' station, and talking to staff. V1 stated, R1 did have every 15-minute checks placed as an intervention for the 6/24/2024 elopement. V1 stated resident bed checks are completed every 2 hours on the even by staff. V1 stated, her understanding was that V9 (CNA) did not do a bed check on R1 at 2:00 AM because V6 had laid him down at 1:30 AM. V1 stated, there should have been a head count completed by staff after the door alarm went off. V1 stated, she did review the video surveillance tape from the night that R1 got outside of the facility. V1 stated, when she observed the camera, R1 was taken to his bed to lay down by V6 (CNA) around 1:35 AM on 2/2/2025. V1 stated, at 1:43 AM on 2/2/2025, R1 was seen stepping outside of his room, looking into his roommates' room across the hallway, then started walking down the hallway towards the dining room and into the bird room. V1 stated, at 1:46 AM V5 (LPN) and V6 (CNA) were observed going to the bird room to investigate the door alarm and was seen returning with R2 from the bird room. V1 stated, R1 did return from the hospital with a bruise to his right lateral heel area and abrasion to the right dorsum 1st metatarsal joint that happened during the time he had been out of the facility on 2/2/2025. On 2/4/2025 at 1:30 PM, V14 (Director of Operations) stated, she had been notified by V1 sometime Sunday 2/3/2025 morning that R1 had gotten outside the facility. V14 stated, she is not for sure what time that morning she received the call. V14 stated, V1 did notify her that R1 had been laid down by V6 (CNA) sometime in the night. V14 stated, she had been notified that the bird alarm door did go off and staff did go investigate the area. V14 stated, she is not aware of what time the door alarm had gone off. V14 stated, V1 did notify her that when V5 and V6 went to investigate the alarm they found R2 standing at the bird room door. V14 stated, that V5 received a phone call around 3:30 AM from the local sheriff's office that R1 had been found outside the facility. V14 stated, the facility policy documented that staff is to complete a resident head count when the door alarms are sounded. V14 stated, staff should also be checking outside to make sure no resident made it outside the facility. V14 stated, there was no resident head count completed by staff on 2/2/2025 prior to the local sheriff's office notifying them that R1 was found outside the facility. On 2/5/2025 at 2:07 PM, V11 (Medical Director/Primary Care Physician) stated, he did visit R1 on Monday (2/3/2025) morning at the local hospital and Monday afternoon at the facility but did not document his progress note until 2/4/2025. V11 stated, his understanding after talking with V15 (Nurse Practitioner/NP), had been R1 was admitted for observation for hypothermia but did not need any treatment. V11 stated, V15 probably needed to justify keeping R1 for the observation. V11 stated, he had been notified that R1 had been found down the road from the facility but did not know how far R1 had been. V11 stated, V15 discussed the bruise noted to R1's left heel with him, but V11 did not evaluate the bottom of R1's feet. V11 said V11 had seen R1's wound pictures at the facility on 2/3/2025 when staff showed him. V11 stated, he cannot say if the blister to the right big toe came from R1's elopement from the facility. V11 stated, he had not been aware of the R1's frost bite diagnosis at the time he saw R1 in the hospital. On 2/4/2025 at 11:29 AM, R1 was noted in a regular sitting chair next to the nurse's station, alert but not oriented. V13 (LPN) removed both shoes and socks to evaluate R1's feet. Observation made of a bruise to R1's left heal approximately 2 centimeters (cm) by 1.5 centimeters, the right big toe noted to have redness the length of toe with a blister approximately 1 cm x 1 cm, and R1's right knee with a blister noted approximately 1.5 cm by 1/2 cm. V13 stated, it is her understanding that R1 returned from the hospital with these areas. R1's Facility's Wound Evaluation dated 2/3/2025 at 2:26 PM, documented #4 Abrasion to the right dorsum 1st metatarsal phalangeal joint new. area 0.19 centimeters (cm), length 0.46cm and width 0.53 cm. Picture attached with evaluation. R1's Facility's Wound Evaluation dated 2/3/2025 at 2:28 PM, documented #6 Bruise to right heel-lateral-new. area 1.85 cm, length 1.45 cm, width 1.69 cm. Picture attached with evaluation. Facility's 24 Hour Door Alarm Policy (revised 1-1-2024) under Procedure for when alarms sound: step 1. Upon hearing the alarm, the staff will visually check to see which door has alerted. Staff will then visually check that door. 2. The first available staff member will deactivate the alarm and visually check the area around the door. (immediately outside the building, surrounding rooms, etc.). 3. If there is no obvious reason for the activation of the door alarm, an immediate head check will be initiated with wander risks being counted first, then all remaining residents, until all are accounted for. The surveyor confirmed through interview and record review that the facility took the following actions, which were initiated on 2/2/25 and completed on 2/2/25 to remove the Immediate Jeopardy: All staff, including department heads, have been educated to ensure that they are aware of policy related to resident elopement, including steps to take if alarm is sounding (doing thorough check of both inside and outside the facility along with facility head count), residents' supervision and not leaving residents unattended in potentially unsafe locations. Education was provided by the V1 (Director of Nursing) and was completed on 2/2/25, with education on-going. All staff will be educated prior to their next shift. The facility completed an elopement assessment on 12/13/24, 2/1/25 and completed another assessment on 2/3/25 for R1. R1's care plan has been updated and does identify R1 is at risk for elopements with interventions put into place. The staff have always answered the door alarms and will continue to do so. On 2/2/25, interventions were reviewed, and new interventions put into place for R1 by V20 (Chief Operations Officer) and V1 (Director of Nursing Services). Resident interventions are as follows: 1. Resident placed on 15-minute checks. 2. Resident has activity basket in his room that has DVDs and magazines about sports 3. Resident 1:1 activity increased. He likes playing bags, watching movies or TV that talk about playing ball. 4. Increase visual checks and monitoring of resident. 5. Offer activity blanket. 6. Offer resident snacks that he likes such as soft cookies and milk. 7. Resident information placed in facility wander book. 8. Resident will be redirected by offering to sit and reminisce of past times. 9. Resident will be redirected to courtyard for outdoor walks weather permitting. 10. Resident will be redirected away from doors. On 2/2/25, residents at risk for elopement were reviewed by V1 (Director of Nursing Services) to ensure person centered interventions are in place and are in careplan, to address elopement behaviors and to decrease risk. Elopement assessments are completed upon admission, quarterly, annually, and as needed for all residents by V1 (Director of Nursing Services) and/or V21 (Minimum Data Set/MDS coordinator). On 2/2/25, all alarmed exit doors were inspected and found to be in good working order by V22 (Regional Environmental Director). On 2/2/25, a QAPI meeting was held with team members to discuss R1 incident and plan of correction. Plan of correction initiated immediately. On 2/5/25, at 11:04am, the QA team has been notified of the Immediate Jeopardy and the abatement plan has been put into place. QA team will review the results of the audits once a week for 2 weeks then monthly for 2 months to ensure Plan of Correction is effective.

Based on observation, interview and record review the facility failed to provide 80 square feet of living space per resident bed for 4 of 4 residents (R10, R20, R27, and R44) reviewed for adequate room space in a sample of 30. Findings include: On 05/15/24 at 10:30 AM, V10 (Maintenance Director) measured R10 and R27's room with a measuring tape. The room measured 143 inches (11.92 feet) by 152.5 inches (12.7 feet), equaling 75.7 square feet per resident living space. The room contained: two beds, two bedside tables and an inset dresser. V10 did not include the closet or the inset dresser space in the measurements. At that time, R10 and R27 were sitting in their room watching TV. R10 and R27 who are alert to person, place and time, stated, they have no concerns with their room size. On 05/15/24 at 10:40 AM, V10 measured R44 and R20's room with a measuring tape. The room measured 143 inches (11.92 feet) by 152.5 inches (12.7 feet), equaling 75.7 square feet per resident living space. The room contained: two beds, two bedside tables and an inset dresser. V10 did not include the closet or the inset dresser space in the measurements. At that time R44 and R20 were sitting in their room watching TV. R44 and R20 who are alert to person, place and time, stated, they have no concerns with their room size. On 05/16/24 at 10:20 AM, V1 (Regional Administrator) stated A hall rooms 1 - 11, 14, 15 are certified for 2 beds and room [ROOM NUMBER] is certified for 3 beds. On B hall, rooms 1 - 11, and 13 are certified for 2 beds and room [ROOM NUMBER] is certified for 3 beds. V1 stated, all rooms on the A hall and B hall are under 80 square feet per resident living space and are Medicaid certified. A facility room roster provided by the facility on 5/13/24 and dated 5/13/24, documents that R10, R20, R27, and R44 reside in the rooms observed and measured by V10. Review of 6 months of Resident Council meeting minutes indicated no concerns related to the size of the rooms.

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 residents (R1) reviewed for elopement risk in the sample of 9. This failure resulted in a cognitively impaired resident (R1) exiting the facility without staff knowledge and being found approximately one- and one-half blocks away requiring police calling an ambulance and transporting R1 to a local hospital emergency room . This failure resulted in an Immediate Jeopardy, which was identified to have begun on 9/13/23 at 9:17am when R1 exited the facility through the entrance door without supervision and was found by police approximately one- and one-half blocks from the facility. This past non-compliance occurred from 9/13/23 to 9/13/23. V1 (Administrator) was notified of the Immediate Jeopardy on 2/27/24 at 8:30am. The Surveyor confirmed by observation, record review and interview that the immediacy was removed on 9/13/23. Findings include: R1's face sheet documented admission to the facility on [DATE] with diagnoses including Unspecified Dementia, Unspecified Severity with Agitation, Hypertension, Anxiety Disorder. On 2/21/24 at 8:21am, V16 (Family Member) stated she had to put (R1) in the nursing home due to not being able to handle him at home. V16 stated (R1) was trying to leave the house and the facility was aware of this issue. R1's Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, indicating R1 has severe cognitive impairment. Section GG of this same MDS documented R1 required set up/clean assistance for eating, toileting hygiene, upper and lower body dressing, putting on footwear, rolling left to right, lying to sitting, sitting to standing, chair to bed transfers, and documented R1's ability to ambulate up to 150 feet. Section E of this MDS for Wandering-Presence and Frequency documents behaviors of this type occurred daily and yes was answered to the question does wandering place the resident at significant risk of getting to a potentially dangerous place (e.g. (for example) stairs, outside of facility). R1's Admission Elopement Risk Assessment completed 9/10/23 documented a score of 4, indicating a high risk of elopement. R1's Elopement Risk Tool completed on 9/10/23 documented Elopement Risk Summary: Resident has been found to be at risk for elopement. This document asks the question has the family communicated that the resident had eloped or attempted to elope from home, or shared concerns that the resident may have wandering/elopement tendencies and the question is answered yes. R1's Elopement Risk assessment dated [DATE] documents a score of 7 which also identified R1 as a high risk for elopement. R1's baseline care plan dated 9/10/23 documented R1 was at risk for elopement. Interventions listed were: Ask family about elopement history, observe for wandering behaviors and intervene as needed, photo taken and added to elopement book, Social Services notified for behavior management and inform staff of elopement risk. The same care plan documented an update dated 9/13/23 noting (R1) to be at risk for Elopement, Resident walked a block and a half and was found on the ground. No injuries noted. Was taken to a local hospital to get evaluated and returned. On 9/13/23 the following interventions were listed: Resident will be redirected to Courtyard for outdoor walks, stop signs placed on all exit doors, Redirect and play country music (Likes [NAME]). R1's Nurses note dated 9/13/23 at 9:47 AM documented, 9:20am call received from (name of city) police department. Resident on [NAME] Street in ditch. Police sent resident (name of local hospital) ER (emergency room ) for eval (evaluation) and treatment. Resident last seen at 9:10 am in dining room drinking coffee. No door alarms went off in between these times. (V16/Family Member) POA (Power of Attorney) and V5/Physician) called and made aware. On 2/21/24 at 8:21am, V16 (Family Member) stated the only way the police knew who (R1) was when they found him, was that she had put his name on his socks. R1's Resident Incident report dated 9/13/23 documented in part, Narrative of incident phone call received from (Name of City) police department resident on [NAME] Street in ditch. 9:20am Resident seen at 9:10am in dining room drinking coffee . Narrative of investigation: IDT Interdisciplinary Team) met and root cause of elopement is that resident has dementia and appears he followed a visitor out per camera review . Resident was last seen in dining room drinking coffee at 0910 (9:10am) when facility administrator was alerted by (Name of City) police that resident had been located on [NAME] Street (which is 1 block and 1/2 away) in a ditch with a noted abrasion to resident right knee, Management staff and nurse (V14/ Licensed Practical Nurse/LPN) ran to scene of incident and spoke with (R1), EMT (Emergency Medical Technician) and police officer. (R1) reported, I was just walking back to (Hometown), I love you, and I told them I just live down the block. Temperature was around 80 degrees and was wearing a short sleeved t-shirt and jeans . R1's Local hospital emergency room notes dated 9/13/23 at 10:47am, document [AGE] year old gentleman with a history of dementia. He has a history of agitation. He walked away from the nursing facility this morning. He was found down in the grass. States he stumbled and fell . No loss of consciousness. He is brought in by EMS (Emergency Medical Services), the patient was stable at the time. No witnessed abnormal behavior. Denies chest pain or shortness of breath. No seizure-like activity. His blood pressure was normal on their arrival. The last blood pressure they obtained was lower when he got here to the emergency department. He was found to have an abrasion on his left knee. He does not have any pain in his knee. He thought he fell on his bottom. The same document also noted found to be hypotensive. Medication is reviewed. EKG (electrocardiogram) shows prolonged QT interval. He is on 2 antipsychotropics. IV (intravenous) fluids were initiated, Monitoring continued. Pressure has improved. Lactated Ringer's given as a bolus. No need at this time for pressor agents. He is showing no signs of decompensation or sepsis. Lab studies reviewed. Blood pressure has responded to fluid bolus and he is at 110 systolic. Will be discharged at this time. On 2/21/24 at 1:00 PM, V1 (Administrator) said that a picture of R1 was added to the elopement book and put at the nurses station along with the business office, with a physical description, mental emotional status, BIMS score, language spoken and home address when he was admitted on [DATE]. V1 also said that staff was informed of R1's elopement risk. V1 said that she was not aware that R1 was gone and received the call from the police department that R1 had been found on [NAME] street, (which is a block and a half from the facility) and that they were transporting him to a local emergency room . V1 said herself and another staff got in their cars and drove to where he was found. V1 said that when she got back to the facility, she immediately began an investigation. V1 said they reviewed the tapes and saw where R1 went out with visitors. V1 said they also did another risk assessment on R1 when he returned in which R1 scored a 7 which is high risk. On 2/22/24 at 2:00 PM, V3 (Licensed Practical Nurse/LPN) said she was the nurse on duty when R1 eloped. V3 said she had last seen R1 around 9:10 AM drinking coffee in the dining room. V3 said that the alarm never went off or they would have went running. V3 said that V1 and V4 (MDS Coordinator) went to where the police found R1. V3 said that when R1 returned, R1 only had a scrape on his left knee. V3 said that upon R1's return, he was put on every 15 minute checks for 3 days. On 2/22/24 at 2:30 PM, V4 (MDS Coordinator) said that she got in her car and went to where R1 was found, which was just around the block from the facility. V4 said when she arrived, the ambulance drivers already had R1 on the gurney and was going to take him to the local emergency room . V4 said she was here when R1 returned and he was still confused but was at his baseline. V4 said R1 had a scrape to his knee but was otherwise was fine. The surveyor confirmed through interview and record review that the facility took the following actions, which were initiated on 9/13/23 and completed on 9/13/23 to remove the Immediate Jeopardy: The facility completed an elopement assessment upon admission on 9/10/23 and completed a subsequent elopement assessment on 9/13/23. The care plan was updated and does identify the resident (R1) was at risk for elopement with new interventions put in place. On 9/13/23, interventions were reviewed and new interventions put into place: 1. Resident will be redirected to courtyard for outdoor walks. 2. Signs placed on all exit doors to ensure the safety of our residents, please ensure the door closes behind you, please do not allow residents or people you don't know, to exit the facility. For questions, please speak with Administration or nurse. 3. Play country music for resident. The facility completed Elopement inservicing with all staff on 9/13/23. This was completed by V1 (Administrator) and former Director of Nurses/DON. All staff absent during the time of the inservice, were inserviced prior to their next scheduled shift. Residents at risk for elopement have been reviewed to ensure person-centered interventions were in place and in the care plan, to address elopement behaviors and to decrease risk. This was completed on 9/13/23. Vulnerable residents requiring supervision were identified and training was completed on Supervision and not leaving residents unattended in potentially unsafe locations. This was completed on 9/13/23 by former DON and V1.

Based on observation, interview, and record review, the facility failed to provide the required 80 square feet per resident bed for 42 residents of 42 residents (R1-R6, R8-R15, R17-R22, R24-R27, R29, R31-R34, R36- R39, R41-R46, R49, R50, and R111) reviewed for room size in the sample of 52. Findings Include: On 6/14/23 beginning at 2:45 PM, V5 (Assistant Maintenance Director) accompanied by this surveyor measured resident rooms that didn't meet the required 80 square foot per resident. The measurements were as follows: A hall room [ROOM NUMBER], 2, and 3 measured at 141 1/2 (inches) x 150 1/8 which equals 147.52 square (sq) feet, which indicates 73.76 sq feet per person. room [ROOM NUMBER] measured at 150 x 150 1/8 which equals 156.38 sq feet, which indicates 78.19 sq feet per person. room [ROOM NUMBER] measured at 141 1/4 x 149 1/2 which equals 146.65 sq feet, which indicates 73.32 sq foot per person. room [ROOM NUMBER] measured at 146 x 150 which equals 152.08 sq feet, which indicates 76.04 sq feet per person. room [ROOM NUMBER] measured at 140 1/8 x 151 1/4 which equals 147.17 sq feet, which indicates 73.59 sq feet per person. room [ROOM NUMBER] measured at 138 1/4 x 150 1/2 which equals 144.49 sq feet, which indicates 72.24 sq feet per person. room [ROOM NUMBER] measured at 141 1/2 x 150 3/4 which equals 148.13 sq feet, which indicates 74.07 sq feet per person. room [ROOM NUMBER] and 11 measure at 140 1/2 x 150 1/2 which equals 146.84 sq feet, which indicates 73.42 sq feet per person. room [ROOM NUMBER] measured at 221 1/2 x 149 1/4 which equals 229.57 sq feet, which indicates 76.53 sq feet per person. room [ROOM NUMBER] measured at 221 3/8 x 150 1/2 which equals 231.11 sq feet, which indicates 77.12 sq feet per person. room [ROOM NUMBER] measured at 148 1/2 x 150 1/2 which equals 155.20 sq feet, which indicates 77.60 sq feet per person. B hall room [ROOM NUMBER] and 5 measured at 142 1/2 x 150 1/2 which equals 148.93 sq feet, which indicates 74.47 sq feet per person. room [ROOM NUMBER] measured at 142 x 150 1/2 which equals 148.41 sq feet which indicates 74.20 sq feet per person. room [ROOM NUMBER] and 9 measured at 141 1/4 x 151 which equals 148.11 sq feet, which indicates 74.06 sq feet per person. room [ROOM NUMBER] measured at 142 1/2 x 151 which equals 149.43 sq feet, which indicates 74.71 sq feet per person. room [ROOM NUMBER] measured at 141 1/2 x 150 1/2 which equals 147.89 sq feet, which indicates 73.94 sq feet per person. room [ROOM NUMBER] measured at 140 1/4 x 150 1/2 which equals 146.58 sq feet, which indicates 73.29 sq feet per person. room [ROOM NUMBER] measured at 142 1/4 x 150 3/8 which equals 148.30 sq feet, which indicates 74.27 sq feet per person. room [ROOM NUMBER] measured at 140 1/2 x 150 1/2 which equals 146.84 sq feet, which indicates 73.42 sq feet per person. room [ROOM NUMBER] measured at 223 x 150 which equals 232.29 sq feet, which indicates 77.43 sq feet per person. room [ROOM NUMBER] measured at 148 1/2 x 149 3/4 which equals 154.43 sq feet, which indicates 77.21 sq feet per person. This surveyor observed all of the rooms that were measured, and they each had one or two beds, one or two nightstands, dressers, and over the bed tables. Some of the rooms observed/measured contained adaptive equipment such as wheelchairs and walkers, and some contained recliners. The Resident Census List dated 6/12/23 documents R1-R6, R8-R15, R17-R22, R24-R27, R29, R31-R34, R36- R39, R41-R46, R49, R50, and R111 live in rooms 1-12, 14, 15 on A Hall and rooms 1-10, 12 and 13 on B Hall. On 6/14/23 at 2:50 PM, R18 stated she had enough space in her room for her belongings On 6/14/23 at 3:04 PM, R14 stated he had enough space in his room. On 6/14/23 at 3:13 PM, R29 stated he didn't really have enough space in his room because his roommate had a wheelchair that took up the space. On 6/14/23 at 3:17 PM, R9 denied concerns with the space in her room. On 6/14/23 at 3:25 PM, R6 stated he had enough space, but it does get a little crowded when they put another bed in it. R6 stated his current roommate sleeps in a recliner so right now there is only one bed. On 6/14/23 at 3:25 PM, V5 stated, the following rooms were licensed for three residents, B12, A12, and A14. On 6/15/23 at 8:57 AM, V1 (Administrator) stated the following rooms have less than the required 80 square foot per resident and are Medicaid certified beds, A hall- rooms 1-12 and rooms [ROOM NUMBERS], B hall rooms 1-10 and rooms [ROOM NUMBERS]. V1 stated rooms [ROOM NUMBERS] on A hall and room [ROOM NUMBER] on B hall are licensed for 3 residents but they only have two residents in each of those rooms. V1 stated she hasn't had any concerns brought to her that residents don't have enough space in their rooms for the necessary items and is not aware of any falls/injury related to the space of the resident rooms.

Based on interview, observation and record review the facility failed to provide at least 80 square feet of space per resident bed for 44 of 44 residents (R1-R9, R11-R26, R29-R31, R33-R34, R36-R37, R39-40, R42-R50, R52, and R153) reviewed for room size in the sample of 54. Findings include: On 7/13/22, V1 (Administrator) and V8 (Maintenance Supervisor) both said all resident bedrooms rooms on A and B Hall did not provide the minimal 80 square feet of space per resident bed as required. V1 and V3 both verified the rooms that provided less than 80 square feet per resident bed were A1-A12, A14-A15 and B1-B13. V1 confirmed all rooms were Medicare/Medicaid certified for two residents. During this survey observations were made of rooms A1-A12, A14-A15 and B1-B13. These rooms were adequate to meet the needs of the residents. No complaints were voiced regarding room size from residents or family. The facility provided a census sheet on 7/11/22 documenting that R1-R9, R11-R26, R29-R31, R33-R34, R36-R37, R39-40, R42-R50, R52, and R153 reside in rooms A1-A12, A14-A15 and B1-B13.

Based on record review and interview, the facility failed to ensure resident assessments were accurately completed for 4 of 12 residents (R5, R9, R24, R32) reviewed for accuracy of assessments in the sample of 27. Findings include: 1. A review of R9's February thru April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation in the nursing progress notes for February thru April 2021 and the February thru April 2021 Treatment Administration Records (TAR) indicate the presence of a urinary catheter during this time. R9's 2-26-2021 admission Minimum Data Set (MDS) resident assessment, Section H-Bladder and Bowel, does not reflect the presence of a urinary catheter for this time frame. V3, RN, MDS and Care Plan Coordinator verified on 4-28-2021 at 2 PM that this was a coding error and the assessment should have indicated R9 had a urinary catheter at the time of the assessment. 2. R24's 2-25-2021 MDS assessment section N- Medications documents R24 as receiving an anticoagulant medication for 7 of 7 days of the look back period. R24's February thru April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is an antiplatelet medication and should not be coded as an anticoagulant on the MDS. V3, RN, MDS and Care Plan Coordinator verified on 4-28-2021 at 2 PM that this was a coding error and the assessment should not have indicated R24 as receiving an anticoagulant. 3. R32's 2-26-2021 MDS assessment section N- Medications documents R32 as receiving an anticoagulant medication for 7 of 7 days of the look back period. R24's February thru April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] is an antiplatelet medication and should not be coded as an anticoagulant on the MDS. V3, RN, MDS and Care Plan Coordinator verified on 4-28-2021 at 2 PM that this was a coding error and the assessment should not have indicated R32 as receiving an anticoagulant. 4. Review of R5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional review of this order documents a discontinuation date for the Foley of 4/27/21. Review of R5's Minimum Data Set (MDS) dated [DATE] does not document the use of a urinary catheter. Review of R5's Plan of Care with a start date of 12/29/20 documents a Care Plan description of Urinary Catheter: Indwelling. On 4/29/21 at 1:40 PM, V3 (Minimum Data Set Coordinator) acknowledges that R5's Minimum Data Set, dated dated dated [DATE] was coded incorrectly, as R5 did have an indwelling urinary catheter at that time this MDS assessment was complete.

Based on observation, interview, and record review, the facility failed to maintain a toenail length that promotes good hygiene, skin integrity, and comfort for 1 (R5) of 3 residents reviewed for Activities of Daily Living in the sample of 27. Findings include: On 04/27/21 at 02:25 PM, R5 was attending activities in the dining room. R5 was sitting in her wheel chair with no sock or shoe noted to her left foot. R5's left great toenail appears thick, with the 2nd toenail being so long it is curling around the end of her toe. On 4/29/21 at 9:35 AM, V1 (Administrator) states that nursing staff are responsible for providing nail care including fingernails and toenails for diabetic residents as needed, but is usually performed on shower days. V1 states for residents who are not diabetic, Certified Nursing Assistant's provide fingernail and toenail care during showers which are scheduled two times weekly. R5's Minimum Data Set (MDS) dated [DATE] document's a Brief Interview for Mental Status (BIMS) Score of 8, indicating moderate cognitive impairment. The same MDS documents R5 requires total dependence of two plus persons physical assist for bathing, and extensive assistance of two plus persons physical assist for personal hygiene. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Plan of Care with a start date of 7/1/19 documents a plan description of Self Care Deficit. The plan includes a Goal that states, Assistance will be provided to meet needs. Review of the facility policy titled Fingernails/Toenails, Care of with a revision date of February 2018 documents the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines listed documents: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed. The same policy documents in the section Reporting to 1. Notify the supervisor if the resident refuses the care. Review of R5's Clinical Record reveals no documentation of refusal of nail care services noted. On 4/29/21 at 3:00 PM V2 (Director of Nursing) acknowledges that R5's toenails are long to the point of curling around the end of her toes on her left foot. V2 states she will trim them for her. R5's Clinical Record document's an admitted to the facility of 5/31/18.

Based on observation, interview, and record review, the facility failed to provide services to improve or maintain Range of Motion status and functioning for 3 (R1, R11, R29) of 4 residents reviewed for Range of Motion in the sample of 27. Findings include: 1. On 04/27/21 at 01:14 PM, R1 has a splint attached to the left arm of wheel chair with quick release strap holding R1's left arm in place. On 04/28/21 at 11:50 PM, R1 is alert and oriented to person, place, and time. R1 states she receives no therapy or range of motion services to her left hand or arm from aides or other staff and notes that her fingers are drawn up into a fist. R1 states she has no voluntary movement to her left hand or arm. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) Score of 15 indicating she is cognitively intact. The same MDS documents Range of Motion (ROM) impairment to one side of R1's body for her upper and lower extremities. R1 is documented as requiring Extensive Assistance of Two plus persons physical assist for Transfers, Locomotion on unit, and Bed Mobility. This MDS documents R1's primary active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R1's Plan of Care with start date of 7/1/19 documents a plan description area of ADL's: Requires assistance with Mobility. Interventions listed with this area includes, Exercises: Active range of motion exercises. This intervention is listed as being in active status and being completed by nursing assistants. Restorative Nursing Flow Record for R1 dated for April 2021 documents R1 receives AAROM (Active Assistive Range of Motion) due to being at risk for a decline in ROM (Range of Motion). Despite R1 being unable to move her left arm or hand, this record documents staff, Give verbal cues and physical examples as needed to accomplish task. On 4/30/21 at 9:32 AM, V6 (Certified Nurse Assistant) states that to her understanding a ROM program can include getting dressed, toileting, and changing positions in the bed, which is why she has documented on R1's Restorative Nursing Flow Record as R1 receiving AAROM services. V6 states as far as a formal program which would include stretches to all extremities and repetitive repetitions, that is not in place. An Assessment of Contracture Risk for R1 most recently dated 4/16/21 documents a score of 7. The form states, Residents with scores above seven (7) should be considered at risk and should be on a regular positioning schedule for both bed and chair. Facility Contracture Protocol should be implemented. A facility policy titled Resident Mobility and Range of Motion with a revision date of July 2017 documents, Resident with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. This same policy documents, Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. R1's Clinical Record documents an admitted to the facility as 8/21/18. 2. R29 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G, Functional Status indicates R29 has limitations in both upper and lower extremities. Section O, Special Treatments, Procedures, and Programs documents no range of motion services or restorative services are provided for R29. A 2/5/2021 Assessment of Contracture Risk documents R29 is at risk for contractures and states that the facility Contracture Protocol should be implemented. R29's current Care Plan with a start date of 7/1/2019 does not include an intervention to provide range of motion services for R29. At 11:00 AM on 4/28/2021, V7, Certified Nurse Aide was performing Passive Range of Motion (PROM) with R29. When asked if PROM is done routinely with R29, V7 stated that R29 is pretty resistive and is hard to perform with her so it is not really completed routinely and indicated there is no routine documentation of when PROM is actually provided. 3. R11 is a [AGE] year old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Section G-Functional Status indicates R11 has limitations in both upper and lower extremities and does not document R11 as receiving range of motion or restorative nursing services. R11's Contracture Risk assessment dated [DATE] indicates he is at risk for contractures. R11's current 4/21/2021 reviewed and Care Plan does not include interventions to address limited range of motion. On 4/28/2021 at 2:45 PM, R11 stated that staff do not routinely perform range of motion exercises with him. R11 has a cognitive score of 12 on his MDS assessment of 2/27/2021 indicating moderately cognitive intact. V3, MDS/Care Plan Coordinator stated on 4/28/2021 at 2:00 PM that the facility does not have a Restorative Nurse currently.

Based on record review and interview, the facility failed to ensure there is ongoing communication and interdisciplinary collaboration between the nursing facility and the [CONDITION(S)] center and failed to plan for nutritional dietary needs on [CONDITION(S)] days for 1 of 2 residents (R9) reviewed for [CONDITION(S)] services in the sample of 27. Findings include: R9 was newly admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4-22-2021 Registered Dietician progress note by V9 addresses R9's weight discrepancies and documents the need for the facility to monitor for amount of weight loss after [CONDITION(S)]. There is no record of weights being done before and after scheduled [CONDITION(S)] visits either by the facility or while at [CONDITION(S)] center. V5, LPN stated to her knowledge, there is no information sent with R9 when she goes to [CONDITION(S)] or that comes back with her from [CONDITION(S)] but they may get a random call from [CONDITION(S)] if a lab is really out of normal range. A 4-21-2021 nursing note documented someone from the [CONDITION(S)] center had called to report R9 had complained of being hungry while at [CONDITION(S)] and suggested R9 get a snack before she arrives at [CONDITION(S)]. No further documentation was noted of what happened with this information. V8, Dietary Manager stated on 04/29/21 at 1:16 PM that R9 is given a snack or whatever the resident wants before leaving for [CONDITION(S)] which is usually a peanut butter sandwich or deli style lunch meat sandwich. V4 Social Services, stated she transports R9 to [CONDITION(S)] on Mondays and R9 is usually eating a bag of chips or some sort of snack on the ride to [CONDITION(S)] and if R9 is hungry when she returns, she will see that she gets something. R9's diet orders, as noted on the current April 2021 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interview and record review the facility failed to provide written notification to residents/resident representatives that were transferred/discharged to the hospital for 2 of 4 residents (R12, R19) reviewed for hospitalization s in the sample of 49. Findings include: 1. R12's Nurses Notes dated 3/14/19 at 8:30 PM, documents R12 was unresponsive, 911 was called and R12 was taken by ambulance to the hospital. R12's Nurses Notes dated 3/14/19 at 11:00 PM document R12 was admitted to a local hospital with a UTI (Urinary Tract Infection) and AKF (Acute Kidney Failure). R12's Nurses Notes dated 4/5/19 at 6:52 PM, documents R12 was sent to the local hospital by ambulance due to decrease in over all well being. R12's Nurses Notes dated 4/5/19 at 11:00 PM document R12 was admitted to the local hospital. R12's clinical record does not contain documentation that written notification was given to either R12 or R12's representative after either transfer to the hospital. 2. R19's Nurses Notes dated 6/15/19 at 5:50 PM, documents R19 was transferred to the hospital by ambulance for being unresponsive cold and clammy. R19's Nurses Notes dated 6/15/19 at 8:45 PM, documents R19 was admitted to the local hospital with a [DIAGNOSES REDACTED]. R19's Clinical Record does not contain documentation that written notification was given to either R19 or R19's representative after her transfer to the hospital on [DATE]. On 07/17/19 at 01:24 PM, V2 Director of Nursing (DON) stated the facility calls the POA (Power of Attorney) when a resident is sent to the hospital and written notification is not sent. V2 stated the only written forms that are sent after transfer/discharge to the hospital are the bed hold forms.

Based on interview, and record review the facility failed to provide at least 80 square feet of space per resident bed for 41 of 41 residents (R1-R11, R13-R23, R25-R30, R32-R34, R37-R40, R42-R46) reviewed for room size in the sample of 49. Findings Include: On 7/15/19, V1 (Administrator) and V3 (Maintenance Supervisor) both said all resident bedrooms rooms on A and B Hall did not provide the minimal 80 square feet of space per resident bed as required. V1 and V3 both verified the rooms that provided less than 80 square feet per resident bed were A1-A12, A14-A15 and B1-B13. V1 confirmed all rooms were Medicare/Medicaid certified for two residents. There were no negative resident or family observations or interviews regarding room size. At the time of the survey the space provided in these rooms were adequate to meet the needs of the residents. The facility provided a census sheet on 7/15/19 documenting that R1-R11, R13-R23, R25-R30, R32-R34 reside in rooms A1-A12, A14-A15 and B1-B13.

Based on interview and record review, the facility failed to prevent staff to resident verbal abuse for 1 of 3 residents reviewed for abuse (R3) in the a sample of 3. The Findings Include: A final report dated 9/5/18, was submitted to Illinois Department of Public Health (IDPH) regarding a staff to resident verbal abuse allegation and investigation. The summary of the incident reported that on 8/31/18 at 7:07 PM, V1 (Administrator) was notified of an allegation of verbal abuse. The report details documented that V4 (Certified Nurse Assistant/CNA) was verbally abusive to R3 in the dining room. V4 was placed on immediate administrative leave and an investigation was initiated. The report shows that R3's Healthcare Power of Attorney (POA) and physician were notified of the alleged incident. At the conclusion of the investigation, the verbal abuse was substantiated and V4 was terminated as an employee. At this time all staff were mandated to complete an abuse in-service on 9/6/18. R3's quarterly Minimum Data Set ((MDS) dated [DATE], documents that R3 is cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 6. R3's admission record face sheet documents a [DIAGNOSES REDACTED]. R3's current care plan has a problem area with an onset date of 11/14/17 that she becomes easily agitated with staff when attempting to assist with activities of daily living (ADL's). A goal for this problem area is that staff may need to attempt several times before a resident allows staff to assist. Under the comment section there is an update on 9/6/18 that states additional staff are to assist with R3 if she becomes agitated to assure resident is safe, and allow R3 time alone, and staff to re-approach after R3 calms. Behavior tracking in the care plan has a target behavior listed to monitor R3 for signs and symptoms such as cursing or using inappropriate words at staff or peers. R3's progress note lists that on 8/31/18 at 6:15 PM in the main dining room, that nurses were called for assistance between V4 and R3. At 9:35 PM, R3 was given a full body assessment and no marks, bruises, or signs of abuse were noted. At this time the physician and POA were notified of the alleged abuse. V1 was in the building conducting an investigation into the allegation. In a signed interview found in the abuse investigation, dated 9/5/18, V4 verified that she let the situation get the worst of her. R3 doesn't have the ability to control her emotions. I should have been able to control mine. It is upsetting to everyone. I should have handled it better. I could kick myself for that. All my training went out the window. On 10/9/18, at 9:30 AM, V1 stated that the staff is aware of how serious abuse allegations are taken in this facility and all are investigated. V1 stated that after this incident happened on 8/31/18, all staff were re-educated on the abuse definition and the policy the facility follows. V1 said she has not had any previous issues with V4's behavior and was surprised that this had happened. On 10/9/18, at 10:30 AM, V5 (Laundry) stated that she was one of the witnesses to the the verbal abuse, and was the one whom reported to her immediate supervisor after the incident occurred. V5 stated that V4 called her the B word after R3 slapped V4 in the face two times. V5 stated that R3 was confused in the main dining room and was looking for her clothes at the serving window. While R3 was standing there in her gown she had an incontinent episode, and V4 was trying to get R3 to sit down so she wouldn't slip in the wet puddle. This is when R3 slapped V4 in the face two times and V4 then called her the name. On 10/9/18 at 2:00 PM, V6 (Dietary Aide) was contacted via telephone. V6 was the other witness to the verbal abuse. V6 stated that R3 was at the serving window in her gown asking for clothes to brought from upstairs (the building has no upstairs). V6 stated that she then had an incontinence episode, and V4 was afraid she would slip in the puddle and tried to get her to sit down. R3 then struck V4 in the face two times and R3 called her a b**ch. More help was called to the dining room to assist V4 with R3, and R3 calmed down and went to her room. The facility's abuse policy states that Fairview Healthcare and Rehabilitation affirms the right of our residents to be free from abuse, neglect, misappropriation of property, corporal punishment and involuntary seclusion. The facility therefore prohibits mistreatment, neglect, verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion and misappropriation of property against any resident.

Based on observation, record review and interview, the facility failed to provide 80 square feet of space per resident bed for 37 residents (R1-R9, R10-R14, R16-R19, R20-R26, R28, R29, R31, R34-R36, R38-R41, R243, R244) reviewed for room size in the sample of 48. Findings include: On 06/5/18 at 1:00 PM, V1 (Administrator) stated all rooms on A Hall and all rooms on B Hall are the rooms included in the facility room size waiver. Wing A resident rooms affected are 1-12, 14-15, and Wing B resident rooms affected are 1-13 and were noted to be multiple resident rooms. All of the rooms have been measured and do not provide the required 80 square feet per resident bed. V1 also said all rooms are Medicaid certified. Inquiries regarding these rooms throughout the survey from 06/5/2018 to 06/7/2018 found no negative interviews from residents or families of residents who reside in these rooms. Observations of the rooms found there was adequate space to meet the medical and personal needs of the residents living in the waiver rooms. Incident and Accident Records were reviewed (MONTH) (YEAR) to (MONTH) (YEAR) and did not identify any problems regarding room size. On 6/6/18 at 2:00 PM, V1 (Administrator) verified that the waivered rooms are occupied by R1-R9, R10-R14, R16-R19, R20-R26, R28, R29, R31, R34-R36, R38-R41, R243, R244

Based on observation, record review, and interview the facility failed to implement a monitoring system to ensure refrigerated medications were stored at the appropriate temperature. The failure has the potential to affect all 47 residents who reside in the facility. Findings include: A Resident Census sheet provided by the facility on 8/15/17 documents 47 residents reside in the facility. On 8/17/17 at 1:45 PM, during a tour of the Medication Storage Room with E2 (Director of Nursing), the refrigerator which is used to store medication was noted to have no temperature monitor system. No method was noted to ensure medications in which refrigeration is required and/or recommended is in place. A thermometer was noted in the refrigerator which read 34 degrees Fahrenheit. Along with storing medications specifically assigned to residents, the refrigerator also included stock Bisacodyl and Tylenol Suppositories along with a pharmacy provided and sealed emergency medication kit. On 8/17/17 at 1:45 PM, E2 acknowledged no regular monitoring of the refrigerator temperature was done, she just did occasional spot checks. E2 verifies the refrigerator contains medications that potentially may be used for any resident in the facility.

Based on interview and record review, the facility failed to ensure a comprehensible plan of care for residents with dementia was in place for 1 (R10) of 8 residents reviewed for [MEDICAL CONDITION] medication in the sample of 12. Findings Include: Review of R10's Minimum Data Set ((MDS) dated [DATE] documents [MEDICAL CONDITION], Anxiety, and Depression as Active Diagnoses. Physician order [REDACTED]. On 8/17/17 at 2:00 PM in an interview with E2 (Director of Nursing), E2 states the as needed [MEDICATION NAME] dose is given at the nurses discretion after non pharmacological behavior interventions have been attempted. E2 acknowledges the vagueness of the current physician's orders [REDACTED]. Review of R10's Behavior Tracking Sheet in regards to the [MEDICAL CONDITION] Medication: [MEDICATION NAME] / [MEDICATION NAME] and Diagnosis: [REDACTED]. Although the behavior tracking record documents the non pharmacological interventions listed as not effective, documenting Behavior Continued, no new interventions have been implemented.

Based on interview and record review the facility failed to ensure [MEDICAL CONDITION] medication reductions were complete for 1 (R3) of 8 residents reviewed for [MEDICAL CONDITION] medication in the sample of 12. Findings Include: Review of R3's clinical record shows R3 has a [DIAGNOSES REDACTED]. Review of R3's Care Plan dated 5/21/14 documents the last [MEDICATION NAME] reduction attempt was on 4/14/16 in which the dose was reduced to 20 mg by mouth daily with it being held on Sundays. Behavior Tracking for Depression was reviewed for June, July and August 2017 with no behaviors being documented. Minimum Data Set's dated 6/6/17 documents Section D0300, Mood Total Severity Score, as 3 which documented R3 was only noted to have poor appetite or overeating that occurred 12-14 days. On 8/17/17 at 1:30 PM, in an interview with E2 (Director of Nursing), E2 states after Z1 (Physician) verbally declined [MEDICATION NAME] reduction in 2016 due to other medication changes taking place at that time, it was just missed to look back at considering a [MEDICATION NAME] reduction at a later time. E2 states she contacted Z1 today and he gave the order to decrease [MEDICATION NAME] to 10 mg by mouth daily and continue to hold on Sundays to begin 8/18/17.

Based on record review and interview, the facility failed to: a) ensure that three (R2, R3, R7) of five residents reviewed for pneumococcal immunizations received the education addressing the benefits and risks or had the opportunity to receive the 13-valent pneumococcal conjugate vaccine (PCV13, or Prevnar13 (brand name)) and b) failed to develop policies and procedures to include current standards of practice to ensure residents who were eligible were offered the 13-valent pneumococcal conjugate vaccine which would minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal pneumonia. This had the potential to affect all 47 residents residing in the facility. Findings include: Review of resident medical records confirmed: R2-Under Last [MEDICATION NAME] indicated date of 5/24/16. There was no record that the PCV13 was administered. R3-Under Last [MEDICATION NAME] indicated the resident received the [MEDICATION NAME] prior to admission. There was no record that the PCV13 was administered. R7- Under Last [MEDICATION NAME] indicated the resident refused. There was no record that the PCV13 was administered. Review of R2's medical record did not indicate that R2 had received the education addressing the benefits and risks and had the opportunity to receive or decline a dose of the PCV13. Review of R3's medical record did not indicate that R3 had received the education addressing the benefits and risks and had the opportunity to receive or decline a dose of the PCV13. Review of R7's medical record did not indicate that R7 had received the education addressing the benefits and risks and had the opportunity to receive or decline a dose of the PCV13. Review of the Fairview Nursing Center policy, does not include the 13-valent pneumococcal conjugate vaccine (PCV13) offering or education to residents. The policy only refers to the pneumococcal [MEDICATION NAME] vaccine. During an interview on 8/17/17 at 1:30pm, E2 (Director of Nursing) confirmed that the PCV13 was not included in the facility's current pneumococcal vaccine policies and procedures and stated that it is not offered, nor are residents educated on the benefits of receiving the vaccine. Review of the ACIP(American Committee on Immunization Practices)Recommendations for PCV13 and PPSV23 (pneumococcal [MEDICATION NAME] vaccine) Use, available at <https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6140a4.htm>, indicated Adults with specified immunocompromising conditions who are eligible for pneumococcal vaccine should be vaccinated with PCV13 during their next pneumococcal vaccination opportunity. The recommendation also included the following: Pneumococcal vaccine-naive person age 65 or greater: PCV13 then 6-12 months later, PPSV23. Persons who previously received PPSV23 at age 65 or greater: PCV13 at or after 1 year of PPSV23. Persons who previously received PPSV23 before age 65: PCV13 at age 65 or greater or after 1 year of PPSV23, then PPSV23 6-12 months after PCV13.

Based on observation, interview and record review the facility failed to provide 80 square feet of space per resident in multiple resident rooms for 9 of 11 residents (R1, R3-R6, R8-R11) reviewed for adequate room size in the sample of 12, 29 residents (R15, R17-44) in the supplemental sample. The Findings Include: On August 15, 2017 at 9:30 AM during the initial tour of the facility, Wing A resident rooms 1-12, 14-15, and Wing B resident rooms 1-13 were noted to be multiple resident rooms and provide only 75 square feet of space per resident. E1 (Administrator) stated on August 18, 2017 at 9:30 AM that all rooms are Medicare and Medicaid certified, and the room waiver needs to be requested again this year. There were no interviews from residents or families indicating problems with the waivered rooms. At the time of the survey, there were no observations to indicate there was no sufficient space to meet the needs of residents residing in these rooms. Review of the midnight census dated 8/15/17, waivered rooms were occupied by the residents R1, R3-R6, R8-R11, R15, R17-R44.

Based on observation, record review, and interview, the facility failed to ensure proper urinary catheter anchoring for 2 of 3 residents (R3,R7) reviewed for catheter care in a sample of 12. This failure resulted in R3 being hospitalized and treated for [REDACTED]. 1. On 7/20/2016 at 1:30 PM, urinary catheter care was observed on R3. No urinary catheter anchor was noted upon the start of catheter care. E2, Director of Nurses, was present during the observation and instructed E4, Certified Nursing Assistant to apply an anchor, which she did after care was completed. According to the Admission record, R3 is [AGE] years old with a [DIAGNOSES REDACTED]. According to a nursing note written by E5, Licensed Practical Nurse, on July 18, 2016, it was noted R3's catheter had blood in the catheter tubing. During interview with E5 on July 21, 2016 at 10:10 AM regarding the blood in the tubing noted on July 18, 2016, E5 stated He (R3) did not have a leg strap (catheter anchor) on at the time and he said 'yes' when I asked him if the tubing had been pulled. The following day at lunch I watched him roll over the bag with his wheel chair. I notified Z1, R3's physician, on the afternoon of July 18, 2016 per fax and heard nothing that day. The following morning (July 19, 2016) I called Z1's office to inquire if they had received the fax and was told yes and was sent a fax that said 'no' in response to any other orders regarding the blood in the catheter tubing. I changed R3's catheter on July 19, 2016 and met a lot of resistance and there was still bleeding in the tubing so I called Z1 again to let him (Z1) know and was told to send him (R3) to the hospital. A nursing note dated July 19, 2016 at 6:35 PM showed R3 was sent to a local hospital on this date. On July 21, 2016 at 11:24 AM, Z1 states For Catheters it is common for there to be bleeding as a result of it being pulled on or caught on a chair. They notified me and we decided to watch it for a day or two and encourage fluids, the majority of time it will clear up. If there was enough bleeding in the bladder he may not be able to pass the clots from the bladder and it does not surprise me they would have to evacuate the clots from his (R3's) bladder. A catheter sits inside the bladder and when there is trauma by being pulled on it, it bleeds internally and causes clots. He (R3) has the catheter due to [MEDICAL CONDITION] from a stroke, I am not sure about prostate enlargement. I do know the local hospital had to send him to a larger hospital due to not being able to get the catheter inserted. According to a History and Physical Preliminary report dated July 20, 2016 from a local hospital, History of Present Illness: When his (R3's) initial (indwelling catheter) was removed, the nursing staff was unable to introduce a new (indwelling catheter) due to patient passing numerous clots and inability to place a new (indwelling catheter) and was transferred to (this facility) for urological evaluation with (a local physician). On this same document under Review of Systems The patient's foreskin was retracted and had some soft tissue swelling around the urethra, passing some bright red blood clots and some drainage as well. A consultation report dated July 20, 2016 lists the following: Reason for Consultation Patient with history of gross hematuria. The patient is a nursing home patient with a [MEDICAL CONDITION], also with an indwelling urethral catheter with traumatic removal of urethral catheter. Multiple attempts to replace the catheter proved unsuccessful. Under Genitalia on the same document Gross hematuria at urethral meatus. 2. On 7/19/2016 at 12:20 PM, urinary catheter care was observed on R7. No urinary catheter anchor was noted upon the start of catheter care nor was an anchor applied upon completion of care. In R7's record, Minimum Data Sets dated 02/02/16 and 06/03/16 indicated R7 has an indwelling catheter present. On 7/20/2016 at 1:30 PM, an interview was obtained with E2, Director of Nurses, regarding the use of urinary catheter anchors. E2 stated that catheters should have an anchor in place at all times. E2 also stated staff training is in process.

Based on observation, interview, and record review, the facility failed to ensure that residents received adequate supervision to prevent falls, and failed to assess the environment for hazards for 6 of 6 residents (R5, R4, R11, R2, R6, and R7) reviewed for falls and injuries of unknown origin in the sample of 12. This failure resulted in R5 falling and sustaining a subdural hematoma and having to be hospitalized for [REDACTED]. Findings include: 1. According to the August 2011 physician's orders [REDACTED]. According to the quarterly minimum data set ((MDS) dated [DATE], R5 requires a wheelchair and extensive assist of one for ambulation. During an interview on 8/9/11 at 1:00 p.m., Z5, R5's wife, stated that she received a phone call a few weeks prior from the facility at 5:00 AM to inform her that R5 had tried to get up from his wheelchair and had fallen. Z5 went on to say that R5 sustained a concussion and some internal bleeding. According to an accident/incident report investigation form dated 6/25/11, R5 attempted to transfer himself from his wheelchair to his bed on 6/25/11, and fell to the floor. The accident/incident report investigation form indicates factors possibly contributing to the incident were intermittent confusion and an unsteady gait, and that R5 had been assessed as being at risk for falls with the potential for injury. The accident/incident form indicates that in order to prevent a recurrence, R5 "need call light w/in reach. 1:1 w/wife (Z5) and res; re: wife can alert staff to res needs. No transfer. Res to use call light when in need of assist." According to an accident/incident report dated 7/26/11, at 4:40 a.m. R5 was found on the floor in the living room of the facility. This room is located at the front of the facility at the opposite end from the nurse's station, beyond the dining room and administrative offices. The report stated that R5 stood up from his wheelchair and attempted to walk, then fell and hit his head on the floor. According to a history and physical form, dated 7/26/11, R5 sustained a "5 mm hyperdense hemorrhage along the right side of the midline falx consistent with subdural hematoma." The form indicates that R5 was transferred from the local hospital to a hospital in Missouri. According to the 7/29/11 nursing notes, R5 returned from the hospital to the nursing home on 7/29/11. E2 stated on 8-16-11 at 12:40 PM that after R5's accident, the facility started using a personal body alarm on R5 and stopped bringing him to the living room when he awoke early in the morning. E2 stated that R5 was unable to ambulate independently, and that staff took him to the living room. E2 stated that she did not know how long R5 was on the floor before he was found. E2 indicated that R5 had been found on the floor by E17, Licensed Practical Nurse. 2. On 8-9-11 at 10:05 AM, Certified Nurses Aide (CNA) E13 was pushing R7 past R4 who was sitting in the hall. E13 pushed R7's left wheel to her wheel chair over R4's left foot. R4's rubber to her left shoe was noted to be under the wheel and the other wheel that is used to push the wheel chair came across the top of R4's foot. R4 said, "Ow". E13 stated "Oh watch out", as she looked down at R4's feet. E13 then continued pushing R7 and did not check R4's foot. On 8-9-11 at 2:06 PM, E3 was asked if any staff reported any injury to R4's foot. Nurses E4 and E3 stated no, and then confirmed that she was not aware that a staff member had rolled over R4's foot. E3 went with surveyor to check R4's feet. Upon removal of both of R4's soft red tennis shoes bruising was noted to R4's left foot that was not present to the right foot. The bruising was noted from the 2nd digit to the 4 th digit, and started on the proximal digit and ended approximately 1.5 centimeters up R4's foot. R4's right foot had some pink discoloration. At 3:00 PM, E2 stated that R4 has peripheral vascular disease, and presented an evaluation of R4's feet. The bath and skin report dated 8-6-11 identified that R4's bilateral toes were red and hurt. No areas on R4's feet were identified as discolored. 3. R11 has [DIAGNOSES REDACTED]. Review of the incident report for the incidents dated 7-4-11 and 7-10-11 indicate that R11 had been left in an area where there was not visual control at all times by staff. The 7-4-11 incident report indicates that R11's personal safety alarm was not with her and attached as it should have been and that R11 had been left in the television area without staff supervision. The incident report of 7-10-11 documents that R11 was left unattended in the bathroom. Review of the care plan conference summary dated 6-7-11 indicates that R11 is to have a personal safety alarm on at all times. Review of the accident/incident report investigation dated 7/11/11 indicates that staff were inserviced that R11 is not to be left unattended on the toilet. The initial resident assessment instrument (RAI) dated 4-11 indicates that R11 was severely cognitively impaired and required extensive assist with transfers. The 7/18/11 RAI reflects the same. 4. Incident reports provided by the facility on 8-10-11 showed that on 8-5-11 at 1:15 PM, R2 was found in her room where staff noted blood on R2's skin sleeve to her left arm. The incident report dated 8-5-11 identified an unwitnessed hematoma with skin tear to R2's left forearm. The report stated that the hematoma was 9.2 cm's by 6.5 cm's and that the staff applied steri strips. Observation of R2 on 8-9-11 at 2:10 PM, showed that R2 still had the steri strips with bruising to her left forearm and that R2 was wearing protective sleeves to her arms. An incident report dated 3-30-11 at 0530 AM, showed that R2 was found to have a bruise to her right upper posterior arm. On this report the contributing factor identified by the nurse was that R2 was up in the reclining chair during the day and leans to the side. The report failed to identify the describe the appearance and color of the bruised area. Neither incident had identified preventative steps that needed to take place to prevent reoccurrence. R2's care plan dated 7-21-11, and observation of R2 on 8/9/11 at 11:45 a.m. demonstrated that R2 was totally dependent on staff for all care and required a mechanical lift for transfers. On 8-11-11 E1 and E2 were interviewed regarding R2's incidents. E1 stated that the facility considered the incidents to be injuries of unknown origin. At approximately 10:00 AM on 8-12-11, E2 presented R2's incident report of 8-5-11, and interviews for the incident of 3-30-11. In regards to the 8-5-11 incident E2 stated that she only got 3 interviews because R2 was found with fresh blood. None of the interviews identified when R2 was last transferred and by whom. On 8-12-11 at 3:15 PM, E1 and E2 were interviewed. They could not provide any further information regarding the facility's failure to identify preventive steps to prevent recurrences, or possible causes to the hematoma and skin tear of 8-5-11. 5. Review of the facility incident/accident log for June 2011 indicated that R6 had a bruise of unknown origin which was found on 6-21-11. The bruise was documented on the 6/21/11 incident report as being purple green in color on the right breast and was 7.5 centimeter (cm) by 6.8 cm. The facility "Injury of Unknown Origin Report"dated 6-21-2011 is not complete. There is no assessment of possible causes of this bruising other than to note that R6 was on a blood thinner medication. This was verified by interview with E1, Administrator, on 8-12-11 at 3:15 PM. 6. According to R7's side rail safety assessment, dated 5/18/11, full side rails were indicated on both sides of her bed. Safety risks noted with use were skin tears and bruises; the option "going over/out end of bed rails" was not checked. Interventions to minimize risk included "Pad rails." According to nursing notes dated 5/12/11 at 12:00 a.m., R7 was in bed with both side rails in the up position. According to nursing notes dated 5/12/11 at 2:15 a.m., R7 "has scooted down to end of bed with legs hanging off bed." R7 was observed in her room on 8/9/11 at 2:00 p.m. Two 3/4 length side rails were in the raised position. They were not padded.