Every finding on record at Franklin Grove Living and Rehab

Based on observation, interview and record review the facility failed to ensure the menu was followed for the noon meal for the residents on pureed diets to 4 of 8 residents (R10, R59, R62 and R69) reviewed for dietary services in the sample of 18.The findings include: A facility document entitled Week at a Glance Menu documents, the menu for 4/13/26 showed rotisserie chicken, crispy fried potato with bacon, mixed vegetables, bread with margarine and cranberry short cake.On 4/13/26 during noon meal, R10, R59, R62 and R69 were served the noon meal but were not served the pureed bread with margarine.On 4/13/26 at 1:00 PM, V9 (Cook) said she did not know why the bread was not served to pureed residents which was part of the noon meal. On 4/13/26 at 1:15 PM, V9 (Dietary Manager) said the menu is carefully planned to ensure residents get the right balance of diet and must be served as scheduled on each meal.On 4/15/26/ at 11:30 AM, V14 (Dietician) said she reviews and approves the facility menu to ensure residents receive adequate nutritional value including the right amount of protein, carbohydrates and fats, the menu must be followed as planned.The policy entitled Menu planning dated 2017 documents, nutritional needs of individuals will be provided in accordance with the recommended dietary allowances of the food and nutrition board of the National Research Council, National Academy of Sciences through nourishing well balanced diets unless contraindicated by medical needs.

Based on observation, interview, and record review the facility failed to clean a pressure injury in a manner to prevent cross contamination and failed to have pressure injury preventions in place for three of four residents (R4, R30, R69) reviewed for pressure injury in the sample of 18.The findings include:1. R4's Order Summary Report dated April 14, 2026, shows he was admitted to the facility on [DATE], with diagnoses including history of pulmonary embolism, unsteadiness on feet, contact dermatitis, muscle weakness, pressure ulcer of sacral region, stage 4, major depressive disorder, and paraplegia. R4's Order Summary Report also show orders to: clean left gluteal wound x2 with wound cleanser, apply triad paste to wound beds and cover it with an island dressing, right gluteal wound: Cleanse with wound cleanser, pat dry, apply skin prep to peri-wound and apply hydrocolloid dressing, right inferior buttock wound: Cleanse with wound cleanser, apply 1/2 Strength Dakin's solution to gauze and pack lightly, cover with calcium alginate and secure with foam dressing, and to the sacrum wound: Cleanse with wound cleanser, apply 1/2 Strength Dakin's solution to gauze and pack lightly, cover with calcium alginate and secure with foam dressing.R4's Pressure Risk score dated December 11, 2025, shows he is a high risk of developing pressure injuries.R4's Wound Weekly Observation Tool dated April 8, 2026, shows R4 has a stage 4 pressure injury to his sacrum, stage 2 to his right buttock, shearing wound to his left gluteal, stage 2 to inferior left glute.On April 13, 2026, at 11:29 AM, V4 (Licensed Practical Nurse/LPN) and V5 (Wound Care Nurse/WCN) went into R4's room to change the dressings to his buttocks area. V4 removed the soiled dressings from R4 buttocks area. There were four open wounds noted on R4's buttocks area. V4 applied wound cleanser to 4 X 4 gauze and wiped all the wounds. There was yellow drainage noted to the gauze. V4 used the same gauze and wiped each wound, going from wound to wound. At 11:45 AM, V5 said that a new gauze should be used to clean each wound so that infection is not spread from one wound to the other.2. R30's Order Summary Report dated April 14, 2026, shows he was admitted to the facility on [DATE], with diagnoses including: muscle weakness, history of falling, need for assistance with personal care, abnormal posture, dementia, Alzheimer's disease, and cognitive communication deficit. Heel boots at all times dated January 8, 2025.R30's Scale for Predicting Pressure Sore Risk dated April 6, 2026 shows he is at high risk for developing pressure injuries.R30's Care-plan initiated November 21, 2022, shows R30 has potential impairment to skin integrity. R30 needs assistance to apply protective garments (heel boots to bilateral feet at all times).On April 13, 2026, at 11:08 AM, R30 was brought out to the tv room outside of the dining room. R30 was sitting in a wheelchair with socks on and no heel boots. R30's feet were on the footrests on the wheelchair. At 11:26 AM, R30 was observed with his left foot on the metal part of the wheelchair footrest, again with no heel boots in place.3. R69's Order Summary Report dated April 14, 2026 shows she was admitted to the facility on [DATE], with diagnoses including palliative care, history of falling, dementia, and heart failure. Heel protectors on at all times as tolerated dated August 13, 2025.R69's Scale for Predicting Pressure Injuries dated February 9, 2026, shows she is a high risk for pressure injuries.On April 13, 2026, at 9:27 AM, V6 and V7 (Certified Nursing Assistants/CNAs) placed R69 in bed. There was a heel boot on R69's nightstand next to her bed. V6 and V7 situated R69 in bed and covered her with a blanket. R69's heels were not elevated, nor did she have heel boots on. At 11:30 AM, R69 was observed in her chair with no heel boots on.On April 14, 2026, at 1:24 PM, V5 (Wound Care Nurse) said pressure injury prevention interventions include turning, pressure reduction mattresses, wheelchair cushions, heel boots, and geri sleeves. V5 said if residents have an order for heel boots at all times, then the heel boots should be in place.The facility's Skin Conditions-Wound Policy reviewed February 7, 2025 shows, To provide proper monitoring, treatment, and documentation of any resident with skin abnormalities, this facility understands that the resident's skin is their first line of defense against infections and strive to attain intact and healthy skin for our resident through a process of identification, monitoring, preventative, and treatment. Skin Ulcer Prevention: Use of elbow or heel protectors when appropriate.

Based on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter tubing was kept off the floor for 1 of 4 residents (R37) reviewed for indwelling urinary catheters in the sample of 18.The findings include:R37's Care Plan with an initiated date of 4/9/24 showed R37 had a supra pubic urinary catheter.On 04/13/2026 at 10:58 AM, R37 was in a wheelchair. R37's indwelling urinary catheter tubing was dragging on the floor as R37 self-propelled himself.On 04/13/2026 at 12:02 PM, R37 self-propelled himself into the dining room. The indwelling urinary catheter tubing was dragging on the floor. On 04/13/2026 at 1:42 PM, R37 was in a common area. R37's indwelling urinary catheter tubing was resting on the floor.On 04/14/2026 at 8:44 AM, R37 was in the dining room sitting in a wheelchair. R37's indwelling urinary catheter tubing was on the floor. R37 was stepping on the tubing with his left foot.On 04/14/2026 at 12:58 PM, V13 (Certified Nursing Assistant) said an indwelling urinary catheter drainage bag and tubing should be kept off the floor for infection control issues. The facility's Catheter Care, Urinary policy (undated) showed the purpose of the procedure is to prevent catheter-associated urinary tract infections. Listed under infection control was to be sure the catheter tubing was kept off the floor.

Based on interview and record review, the facility failed to ensure an as needed anxiety medication had a stop date for one of 18 residents (R69) reviewed for psychotropics in the sample of 18. The findings include:R69's Order Summary Report dated April 14, 2026, showed that R69 was admitted to the facility on [DATE], with diagnoses including palliative care, insomnia, restlessness and agitation, history of falling, dementia, major depressive disorder, and anxiety disorder. An order for Ativan oral tablet 0.5 milligrams (mg) give one tablet by mouth every three hours as needed (PRN) for agitation/anxiety/restlessness was started on February 10, 2026. There is no stop date on this order. On April 15, 2026, at 8:58 AM, V2 (Director of Nursing/DON) said as needed Ativan should have a stop date of 14 days. If the as needed medication is still needed, then the prescription needs to be done again. The nurse that enters the as needed order is responsible for putting in the stop date. The facility's Psychotropic Medication Policy reviewed March 21, 2025, shows, Licensed nurses will transcribe any new recommendations from the physician as received to the facility. The nurses shall enter all PRN orders with a 14 day stop date.

Based on observation, interview, and record review the facility failed to provide a resident with a plate guard for 1 of 2 residents (R8) reviewed for assistive devices in the sample of 18.The findings include:A facility assessment done on 3/20/26 showed R8 had limited range of motion to both upper extremities. R8's Order Summary Report printed on 04/14/26 showed an order that it was ok to use a plate guard. On 04/13/26 at 12:35 PM, R8 was served his meal. R8 was not provided with a plate guard. R8 held a spoon in his right hand and used his left hand to push mixed vegetables onto the spoon. Some of the mixed vegetables fell off onto the table. On 04/13/26 12:42 PM, R8 said the facility use to provide him with a plate guard but stopped providing the plate guard. R8 did not know why the facility stopped providing the plate guard. R8 stated the plate guard came in handy as food did not slide off the plate. R8 added that he could trap the food against the plate guard as he scooped up the food with the silverware. R8 said he could not move his fingers well. R8 attempted to move his fingers on his right hand. There was limited movement of his fingers.On 4/13/26 at 2:00 PM V8 (Dietary Manager) said plate guards are used for residents that have issues scooping up their food. The plate guard is used to help food from falling off the plate.On 4/14/26 at 8:35 AM, V8 said the kitchen knows to provide a resident with a plate guard because it is listed on a resident's meal ticket.R8's meal ticket (undated) listed under instructions to provide a plate guard.R8's Dietary Profile dated 12/22/25 showed R8 preferred to eat in his room because he was a messy eater.

Based on observation, interview, and record review the facility failed to ensure staff wore the required personal protective equipment (PPE) when providing care to a resident on enhanced barrier precautions. This applies to 2 of 18 residents (R37 and R50) reviewed for infection control in the sample of 18.The findings include: 1. R37's Care Plan with an initiated date of 4/9/24 showed R37 was on Enhanced Barrier Precautions for a supra pubic urinary catheter. On 4/13/26 at 11:31 AM, there was an Enhanced Barrier Precautions sign on the wall next to R37's room door. On 4/13/26 at 11:31 AM, V12 (Certified Nursing Assistant/CNA) emptied R37's urinary drainage bag. V12 had on gloves but no gown. On 4/13/26 at 11:34 AM, V12 said she emptied R37's urinary drainage bag. V12 confirmed the only PPE she wore was gloves. V12 said the only PPE needed when emptying a urinary drainage bag were gloves. On 4/14/26 at 12:58 PM, V13 (CNA) said a gown and gloves are to be worn when emptying a urinary drainage bag. The facility's Infection Control – Enhanced Barrier Precautions with a reviewed date of 3/6/25 showed enhance barrier precautions are generally indicated for residents with indwelling medical devices. Indwelling medical devices include urinary catheters. PPE of gowns and gloves should be worn prior to high contact resident care activities. High contact resident care activities included device care or use. 2. R50's Order Summary Report dated April 14, 2026 shows R50 was admitted to the facility on [DATE] with diagnoses including right femur fracture, repeated falls, and need for assistance with personal care. An order to clean small open area to the left side of his faced and place a small piece of silver alginate to the area and cover with a 2 X 2 island dressing daily was started on April 4, 2026. Place on Enhanced Barrier Precautions was entered on April 6, 2026. On April 13, 2026 at 9:40 AM, there was a sign on the door of R50's room that showed Enhanced Barrier Precautions and a dragonfly. V6 and V7 (Certified Nursing Assistants) transferred R50 into his bed via mechanical lift. There was a dressing half on to the left side of R50's face. V6 and V7 provided incontinence care to R50. V6 nor V7 wore gowns. On April 15, 2026 at 8:58 AM V2 (Director of Nursing) said any residents with a urinary catheter, percutaneous endoscopy gastrostomy tube, intravenous lines, and wounds should be on enhanced barrier precautions and staff should be wearing a gown if they are touching the resident doing cares. The purpose is to try and prevent passing on infections.

Based on interview and record review the facility failed to notify a resident's power of attorney (POA) of a change in condition for 1 of 4 residents (R3) reviewed for change of condition in a sample of 18.The findings include:R3's Facility assessment dated [DATE] showed R3 has severe cognitive impairment.R3's urine culture results dated 4/10/26 showed R3 was positive for an Escherichia Coli (E. coli) urinary tract infection (UTI).R3's Progress notes printed 4/14/26 showed R3 started having hematuria (blood in urine) on 4/5/26. These notes showed no contact was made with V15 (R3's POA) with R3's hematuria (4/5/26), urinalysis results (4/10/26), or the initiation of an antibiotic (4/10/26).R3's Physician Order Summary printed 4/14/26 showed R3 had an order placed for Macrobid (an antibiotic) 100 milligrams, give 1 capsule by mouth every morning and bedtime for UTI symptoms for 7 days.On 4/14/26 at 10:00 AM, V15 stated they did not know R3 was being treated for a urinary tract infection (UTI) or on an antibiotic. V15 stated they were contacted by the facility about a pneumonia shot, but nothing about a UTI.On 4/14/26 at 12:30 PM, V2 (Director of Nursing) stated the memory care unit residents' POAs need to be contacted about changes in condition and/or new medications.On 4/14/26 12:52 PM, V3 (Assistant Director of Nursing) stated a POA should be contacted when a resident is placed on a new medication or has a change in condition. A UTI is a change in condition.The facility's Acute Condition Changes Policy dated 4/11/26 showed the nurse with notify the resident's family or representative when there is a change in a resident's physical, mental, or psychosocial status.

Based on observation, interview, and record review the facility failed to monitor a non pressure wound for one of 18 residents (R4) reviewed for quality of care in the sample of 18.The findings include: R4's Order Summary Report dated April 14, 2026, shows he was admitted to the facility on [DATE] with diagnoses including history of pulmonary embolism, unsteadiness on feet, contact dermatitis, muscle weakness, pressure ulcer of sacral region, stage 4, major depressive disorder, and paraplegia. An order to monitor a callus to his right heel every day and evening shift was entered on September 16, 2025.R4's Treatment Administration Record dated April 1, 2026-April 30, 2026 shows staff signed off the treatment to R4's right heel twice a day from April 1-14, 2026.On April 13, 2026 at 11:29 AM, V4 (Licensed Practical Nurse/LPN) and V5 (Wound Care Nurse/WCN) went into R4's room to change his wound dressings. V5 removed the heel boot from R4's right foot. The was a bordered gauze dressing in place to his right heel that was dated April 8, 2026. V4 and V5 finished changing the dressings to R4 buttocks wounds then placed R4's heel boot back onto his right heel. The dressing to R4's right heel was not removed, nor was the wound observed.R4's Wound Weekly Observation Tool dated April 8, 2026 shows R4 has a callus to his right heel. The callus de-roofed revealing pink non-granulating tissue. The wound was draining serous drainage. The wound measured 0.5 cm (centimeters) X 0.5 cm with a 0.1 cm depth. The current treatment plan was triad paste with an island dressing daily and as needed.On April 14, 2026 at 1:24 PM, V5 (WCN) said R4's treatment to his right heel should be triad paste and bordered gauze. V5 said his right heel wound was not draining as much as it did from the past. V5 said she could not remember if the wound to R4's right heel was a daily treatment. V5 said that the floor nurses should be monitoring R4's heel wound. At 2:13 PM, V5 said she did not put the triad paste order in R4's physician orders so it hadn't been done since April 8, 2026. V5 said the staff should be monitoring the wound daily by removing the dressing in order to make sure the wound is not getting worse.The facility's Skin Conditions-Wound Policy reviewed February 7, 2025 shows, All caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations. The purpose: To provide treatment that promotes prevention of ulcerations and healing of existing ulceration.

Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were in place for four of four residents (R1-R4) reviewed for safety/supervision in the sample of four. The findings include:1. R1's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including encephalopathy, diabetes, nicotine dependence, cardiomegaly, and history of falling.V1 (Administrator) stated that R1 did not have a Care Plan as he discharged from the facility the same day he was admitted .R1's Fall Scale dated January 24, 2026 shows he was a moderate risk for falling.R1's Nurses Notes dated January 24, 2026 at 4:42 PM shows R1 was admitted to the facility. R1 was transferred to the bed and family was at the bedside. R1 had a scab on his right knee with numerous bruises to both of his lower extremities. R1's Nurses Notes dated January 24, 2026 at 8:16 PM, entered by V3 (Licensed Practical Nurse/LPN) shows R1 was found on the floor face down with his head near the head of the bed and his feet towards his dresser. R1 had a medium sized pool of blood on the floor in front of him. R1 was noted to be incontinent in bed prior to the fall. R1 did not have any clothes on other than socks. R1 initially told staff he fell reaching for food that had fallen on the floor and hit his head first. When the emergency medical personnel arrived, R1 told them he woke up when he hit the floor. Injuries were noted to his right eyebrow, nose, and right knee abrasion re-opened. R1 was transferred to the local emergency room for evaluation.On February 1, 2026 at 5:15 PM, V8 (R1's son) said the day his father fell, V8's sister and brother-in-law were with R1 for about 2.5 hours before they went home. V8 said facility staff left R1 sitting at the side of the bed. V8 said R1 received steri strips to his eyebrow. V8 said R1 went to a different rehab facility after he left the hospital.On February 2, 2026 at 1:20 PM, V6 (CNA) said she saw that R1's call light was on, so she went into his room. V6 said R1 was on the floor next to his bed face down. V6 said R1 did not have any clothes on. V6 said there was blood on R1's knee and his face. On February 2, 2026 at 1:35 PM, V3 (LPN) said R1 was sitting on the side of the bed eating supper. V3 said she did not love the idea of him sitting on the side of the bed since he was a new admission and the staff did not know if R1 would try and transfer himself. V3 said residents use a mechanical lift until therapy can evaluate them. V3 said staff could have used a mechanical lift to put R1 in a chair. V3 said R1 had a history of falling. V3 said when R1 fell, he had a laceration to his eyebrow and reopen the laceration to his knee. V3 said R1 stated his head hurt where he cut it opened. V3 said R1 was naked when he was on the floor. On February 2, 2026 at 2:05 PM, V4 (Certified Nursing Assistant/CNA) said her and V5 (CNA) went into R1's room because his call light was on. V4 said that R1 said he wanted to sit on the side of the bed. V4 said the R1's family was at his bedside. V4 and V5 asked R1's family to let them know when family left. V4 said she let V3 (LPN) know that R1 wanted to sit on the side of the bed. V4 said R1's family did not let staff know when they left. V4 said that R1 was on the floor face down. V4 said R1 told her he was trying to pick food up off of the floor. V4 said she did not get report on R1 when she came in for her shift. V4 said she was just told there was a new resident. On February 2, 2026 at 2:56 PM, V7 (Assistant Director of Nursing/ADON) said fall prevention interventions include opened doors, call light within reach, appropriate footwear, and side rails. V7 said residents are transferred using a mechanical lift until therapy can evaluate them. V7 said R1 was placed on a certain hall because there was higher traffic there so there was more supervision. V7 said there were two visitors with R1. V7 said V3 (LPN) called her and said R1 had been found on the floor and was sent to the hospital because he was on a blood thinner and there was blood on the floor. V7 said she let staff know when R1 was admitted , that R1 was a fall risk. V7 said she does not know how R1 fell out of bed. V7 said she assumed R1 was laying down in bed and may have rolled out. On February 2, 2026 at 3:21 PM, V5 (CNA) said R1 was at the facility when she arrived for her shift. V5 said she did not know how R1 transferred because therapy had not evaluated him yet. V5 said R1 was sitting on the side of the bed when she delivered R1's dinner tray. V5 said she tried to get R1 to lay in bed to eat, but R1 was insistent on sitting on the side of the bed. V5 said she educated R1 on the reason why she wanted him to lay down, so he did not fall. V5 said she let the nurse know that R1 was sitting on the side of the bed. V5 said family was at R1's bedside. V5 said she did not know that R1's family left, until she went into R1's room and he was on the floor. V5 said she prefers residents to lay in bed to eat, because it is safer. V5 said she was trying to prevent a fall. 2. R3's Face Sheet shows he was initially admitted to the facility on [DATE] with diagnoses including pneumonitis due to inhalation of food and vomit, sepsis, acute respiratory failure, anxiety disorder, restlessness and agitation, and bipolar disorder.R3's Fall Scale dated January 17, 2026 shows he has a high risk of falling.R3's Care Plan last revised on December 31, 2025 shows R3 is at risk for falls-ensure call light is within reach and encourage him to use it for assistance as needed.On February 2, 2026 at 9:37 AM, R3 was laying in his bed. R3's call light was on the floor at the foot of R3's bed. There were no floor mats in place to the side of R3's bed. There were floor mats folded up and against the windowpane next to R3's roommate's bed. On February 2, 2026 at 2:56 PM, V7 (ADON) said R3's fall prevention interventions include his call light in reach and floor mats on the floor. V7 said R3's call light is typically attached to his bed.The facility's Accident Incident logs shows that R3 had falls on December 27, 2025 and December 31, 2025. 3. R2's Face Sheet shows he was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, depression, anxiety disorder, history of falling, and restlessness and agitation. R2's Care Plan last revised on January 11, 2024 shows R2 is at risk for falls and ensure his call light is within reach and encourage him to use it for assistance. R2's Fall Scale dated December 1, 2025 shows R2 has a moderate risk of falling.On February 2, 2026 at 9:46 AM and 2:00 PM, R2 was laying in his bed on his left side. R2's call light was on his floor and out of reach at both times. 4. R4's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including dementia, depression, osteoporosis, anxiety disorder, difficulty in walking, and need for assistance with personal care. R4's Care Plan last revised on July 12, 2024 shows R4 is at risk for falls and ensure residents call light is within reach and encourage her to use it for assistance as needed. R4's Fall Scale dated December 17, 2025 shows she is a high risk for falling. On February 2, 2026 at 9:43 AM, R4 was laying in her bed. R4's call light was on the floor, not within R4's reach.The facility's Fall Prevention and Management Policy last reviewed on March 21, 2025 shows, Interventions will be implemented for residents, assessed by the admission nurse, determine to be at high risk at the time of admission for up to 72 hours. All staff must observed residents for safety.

Based on observation, interview, and record review the facility failed to ensure a physician ordered referral to a specialist was initiated and facilitated for one resident (R1) of three residents reviewed for community medical appointments. The findings include: On 5/30/25 at 9:45am R1 stated he was set up with an appointment for an Orthopedic appointment at a medical center for his arthritis. R1 stated he couldn't go, and the Administrator told him he had to find his own transportation as it was too far for the facility van to take him. R1 stated he did ask to be transferred to another facility that would be closer to the medical center, however I'm still here. Office Clinic Physician Note dated 3/1/24 indicates R1 was evaluated for bilateral hand issues. Note indicates R1 has a history of a right thumb amputation due to an infection about 2 years ago. R1 reported he is unable to take care of himself due to this impairment. Note indicates R1 questioned the possibility of a transfer to create a thumb and inquired about this procedure as an option. Physical Exam indicates Exam of right hand reveals significant contractures of the four remaining fingers of his right hand. (R1's) thumb was amputated at the level of the MP (metacarpophalangeal) joint. The contractures of the fingers are not passively correctable at this point. (R1) has some significant contractures on the left side as well. Assessment/Plan indicates Physician had an extensive discussion with (R1) explaining that I do not think there is much that can be done at this point regarding his finger contractures given their severity. (R1) would like to have a referral to an academic hand specialist for consideration of great toe transfer/pollicization. I explained to (R1) that I do not think he would be a good candidate for pollicization given his age and overall health but nevertheless (R1) is interested in a referral. Per his request we will go ahead and arrange that. Physician Order Sheet dated 3/1/24 at 11:34am indicates: Referral Management to Orthopedic Surgery (at a medical center), Multiple Finger Contractures; Possible great toe transfer/pollicization at a major medical center (approximately 2-3 hour drive from clinic). Care Plan Note Text dated 12/10/24 at 12pm indicates IDT (Interdisciplinary Team) met with R1 for care plan meeting. R1 is very upset as he needs a ride for a possible procedure to his hands, and the office where he would need to have it done is farther away than the facility will transport. Because of this, there would be a fee for transportation. R1 feels that this facility should pay for his transport to any facility he may need. Social Services Director has sent a referral to a facility of R1's choice, closer to where the procedure would take place. R1 was updated about the referral. Emotional support and encouragement provided. Will continue with current plan of care. Current Care Plan (5/2025) did not include referral to a medical center and/or transportation, insurance or payment issues related to this referral. No other facility progress notes were found or presented regarding efforts by the facility to obtain transportation for the referral made on 3/1/24. On 5/30/25 at 10:45am V6 (Transportation) stated the facility van only takes residents to local appointments. V6 stated the medical center would not be local and would be set up differently by V1 (Administrator). V6 stated she has no knowledge about what was being done for the referral for R1. On 5/30/25 at 11:30am V1 (Administrator) stated V2 (Director of Nursing/DON) is working with insurance the last couple weeks to see if they will help with transportation for R1. V1 stated we don't typically document about referrals and transportation needs. On 5/30/25 at 11:45am V4 (Social Service Director/SSD) stated she was not involved in the referral for R1 to go to the medical center. V4 stated that R1 wanted to be transferred to another long-term care facility closer to the medical center if he could not get assistance with transportation from the facility. V4 stated she had sent out several referrals to different facilities closer to the medical center however all were declined. V4 stated she did not keep the actual referrals sent to the facilities. Social Service Note dated 12/31/24 at 2:41pm indicates In the last month, I have sent referrals out to facilities for R1. The following have refused to take him (four local facilities were named). I talked with (R1) and told him to let me know if there is anywhere else, he would like me to check into. He has not given me any other facilities to check. The above Social Service Note dated 12/31/24 was the last documentation regarding referrals for R1 found or presented. On 5/30/25 at 1:10pm V2 (DON) stated I don't know where we are with (R1's) referral. V2 stated V4 (SSD) took the call from R1's insurance. V2 stated she only deals with clinical issues for residents. V2 stated the surgery R1 wants would be considered Elective and doesn't believe insurance would cover the procedure, but never spoke to anyone so really doesn't know. On 5/30/25 at 1:15pm V4 (SSD) stated I did not contact R1's insurance and never received a call from R1's insurance. On 5/30/25 at 3:30pm V1 (Administrator) acknowledged facilitating medical appointments and referrals to other facilities should be addressed by Social Service and documented as to progress of those referrals. Social Service Designee Job Description indicates: The primary purpose of your job position is to assist in planning, developing, organizing, implementing, evaluating, and directing our facility ' s social service programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to assure that the medically related emotional and social needs of the resident are met/maintained on an individual basis. Job Functions: Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. Responsibilities and Duties/Essential Functions: Refer resident/families to appropriate social service agencies when the facility does not provide the services or needs of the resident. Record and maintain regular Social Service progress notes indicating response to the treatment plan and/or adjustment to institutional life. Assist in providing solutions for social and practical environmental problems including seeking financial assistance, discharge planning (including collaboration with community agencies), and referrals to other community agencies when specialized assistance is required.

Based on observation, interview, and record review the facility failed to ensure staff wore the correct personal protective equipment (PPE) and failed to complete handwashing prior to leaving residents' rooms on contact isolation for norovirus while the facility is in outbreak status. This applies to 2 of 26 (R1, R2) residents reviewed for infection control. The findings include: On 2/26/2025 at 9:13AM, R1's room had a contact isolation sign posted clearly on the door frame. V5 (Certified Nursing Assistant/CNA) was observed moving R1 into her room in a chair. V5 moved R1 up next to the resident's bed and began rearranging the resident's pillow and pad on the bed. V5 did not have a gown or gloves on. When V5 exited R1's room she did not wash her hands. V5 stated R1 was on contact isolation for exposure to norovirus. V5 stated you need a gown and gloves when entering a contact isolation room. V5 said hand washing is required for residents suspected of having norovirus. V5 said she did not wash her hands because she did not touch a resident. On 2/26/2025 at 9:22AM, the isolation cart in the hallway with R1 and R2 was about two rooms away filled with gowns, gloves, masks, and bleach wipes. On 2/26/2025 at 9:51AM, V6 (Assistant Director of Nursing/ADON) said residents having norovirus symptoms are placed on isolation and it doesn't end until they are symptom free for 48 hours. V6 said hand sanitizer is ineffective for norovirus and staff must wash their hands. On 2/26/2025 at 10:04AM, V2 (Director of Nursing/Infection Control Preventionist) said R1 and R2 are currently roommates because they are having the same symptoms of nausea or vomiting, and diarrhea. V2 said contact isolation requires the staff to wear gown, gloves, and handwashing in required for norovirus. V2 said staff should apply gown and gloves before entering a resident's room and wash their hands prior to leaving the resident's room. On 2/26/2025 at 12:03PM, V8 (Health Department Infection Disease Coordinator) stated she would consider the facility in outbreak status as of 2/21/2025 based on the line list the facility provided to her on 2/24/2025. On 2/26/2025 at 12:30PM, V8 (Hospice Social Worker) was observed in R1 and R2's room talking to R1. V8 did not have a gown or gloves on in the resident's room. V8 exited R1's room without washing her hands. V8 said she did not know why the residents in that room were on isolation and she was only at the facility to see R1. V8 was seen using hand sanitizer in the hallway, but no hand washing was observed. The facility provided Acute Gastroenteritis Surveillance Line List from 2/26/2025 lists R1 as having a symptom onset date of 2/24/2025 and R2 as having a symptom onset date of 2/23/2025. R1 and R2's Order Detail document dated 2/26/2025 shows an order for contact isolation per facility guidelines order starting on 2/24/2025. The facility provided Norovirus Prevention and Control policy reviewed 8/29/2024, states . During outbreaks, use soap and water for hand hygiene after providing care or having contact with residents suspected or confirmed with norovirus gastroenteritis.

Based on observations, interviews, and record reviews, the facility failed to provide residents with a safe and comfortable home-like environment that enhanced each resident's overall quality of life by not maintaining an effective preventative maintenance plan due to observing wall in resident's room with areas of visibly scraped paint throughout room; chair railing not secured to the wall that exposed nails and caused drywall dust to accumulate on the floor; multiple bathroom doors with visible deep scrapes and holes to the middle and lower portions; and the heating baseboard cover plates were not firmly attached or were missing. This failure directly affected 14 residents (R1, R5, R6, R9, R14, R16, R25, R33, R49, R50, R59, R65, R69, and R75) within 13 total rooms in a sample size of 36. Findings include: 1. On 02/04/25 at 10:13 AM, R65 said the toilet seat in his bathroom was loose and that he has told staff about the issue several times. R65 added that he feels unsafe when sitting on the toilet and when getting up from the toilet because the seat is not sturdy and moves from side to side. Review of R65's face sheet documented resident admitted to the facility on [DATE]. On 02/04/25 at 12:25 PM, surveyor informed V10 (Housekeeping & Laundry Director) about the loose toilet seat in R65's bathroom who said that resident's toilets are to be cleaned daily by housekeeping. V10 added that when staff find an issue or when residents have a repair request, a staff member should complete a work requisition form and submit the request to maintenance. V10 then said that she would complete and submit a requisition form by end of day for R65's loose toilet seat. On 02/05/2024 at 11:16 AM, during interview with R49 and R50 who are roommates, surveyor observed large areas of scraped paint scattered throughout the wall that is directly behind the head of their beds, and observed a large, scraped area of paint to a portion of wall next to the room closet and across from the bathroom door. At 11:20 AM, R49 said look at the inside of the bathroom door. Surveyor observed to the inner bathroom door, deep scrapes and multiple holes to the middle and lower portions of the bathroom door. R49 said it looks like someone shot up the door and has resided at the facility for about a year with these issues that were present upon her admission. At 11:25 AM, R50 said she has resided at the facility for three years and the scraped paint and holes in the bathroom door have been present since her admission and said, it doesn't look good. Review of R49's face sheet documented resident admitted to the facility on [DATE]. Review of R50's face sheet documented resident admitted to the facility on [DATE]. On 02/05/2024 at 12:35 PM, surveyor observed the wooden chair railing on the wall directly behind R75's bed and recliner, not secured to the wall with exposed nails behind the railing and drywall dust falling to the floor upon slightly touching the railing. Review of R75's face sheet documented resident admitted to the facility on [DATE]. On 02/05/2024 at 12:40 PM, during interview with R59, surveyor observed several areas of scraped paint to the wall directly behind the head of R59's bed and observed to the inner bathroom door, deep scrapes, and multiple holes to the middle and lower portions of the door. R59 said that she has resided at the facility for several months and these issues have been present since her admission. Review of R59's face sheet documented resident admitted to the facility on [DATE]. On 02/05/2024 at 12:45 PM, during interview with R14, surveyor observed to the inner bathroom door of R14's room, deep scrapes, and multiple holes to the lower portions of the door. R14 said that she has resided at the facility for over a year and the holes have been present since her admission. Review of R14's face sheet documented resident admitted to the facility on [DATE]. On 02/05/2024 at 01:05 PM, R65 said the toilet seat in his bathroom is no longer loose and thanked surveyor for the assistance. On 02/05/2025 from 02:40 to 02:55 PM, surveyor performed building walk through with V4 (Maintenance Director) who said the railing to R75's wall was just fixed a few months ago and should be secured to the wall; the walls to R49 and R50's room were just painted a few months ago and should not be scraped then said he was not aware of the scrapes and holes to the bathroom doors in R14, R49, R50, and R59's rooms and that they should not be there. V4 then said he does monthly rounds throughout the facility and to all resident rooms to look for needed repairs or maintenance. Review of Preventative Maintenance policy last reviewed 10/17/2024 reads in part: maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. It is the job of all staff to identify areas of concern regarding the maintenance of the building. Preventative maintenance will occur throughout the year. Maintenance supervisor is responsible for developing and maintaining a schedule of maintenance to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Functions of maintenance personnel include but are not limited to: providing routinely scheduled maintenance service and repair to all areas. Review of Maintenance Work Request policy last reviewed 03/29/2024 reads in part: when a resident, staff member, or family member recognizes the need for maintenance services, a Maintenance Work Request form will be completed by a staff member, placed in designated place for maintenance personnel who will review work requests daily and prioritize work to be done. 36186 2. On 2/4/2025 during the initial tour of the facility, in resident rooms for (R1), (R9), (R25), (R5&6), (R69) and (R33&16), the base board heating units were observed to have face plates that were not firmly attached to the unit leaving exposed metal grids. The face plates were hanging down onto the floor in front of the units. On 2/5/2025 at 1:00 PM, R25 and R69's visitor said the face plates have been broken for a long time. On 2/5/2025 at 2:40 PM, V4 (Maintenance Director) said he was not aware of the plates being broken on the heating units in those rooms. V4 said he fixes things that are broken as the staff report them to him. V4 said he makes monthly rounds of the rooms and had not noticed this problem. The facility policy with a revision date of 10/17/2024 for preventive maintenance shows the maintenance department is responsible for maintaining the buildings in a safe and operable manner. Functions of the maintenance personnel are to complete monthly and weekly rounds.

Based on observation, interview, and record review the facility failed to have interventions in place to prevent a pressure ulcer, failed to identify an area of pressure before becoming a stage 3 and failed to have a new pressure ulcer assessed by the wound care provider while in the facility. These failures resulted in R39's pressure ulcer worsening. This applies to two of four residents (R39, R27) reviewed for pressure in the sample of 36. The findings include: 1. The facility face shows R39 was admitted to the facility 11/8/2024 with diagnoses to include dementia, chronic pain syndrome and edema. The Braden scale for predicting pressure sores dated 11/29/2024 shows R39 to be at risk. The facility admission assessment dated [DATE] for R39 shows her to have severe cognitive impairment, was able to walk without any mobility aides, was occasionally incontinent of bowel and bladder and required moderate staff assistance with toileting. The same assessment for R39 shows on the date of assessment she did not have any pressure sores but was at risk for them. The observations of R39 on 2/4/2025 to 2/6/2025 shows R39 to not have an air mattress to her bed. On 2/6/2025 in the afternoon an air mattress was added to R39's bed. On 2/06/2025 at 8:45AM, V3 (Licensed Practical Nurse/LPN/Wound Nurse) was observed doing wound care on R39. R39 was lying in bed on her side and V3 cleansed the wound and applied a new dressing. As V3 was doing this R39 could be heard moaning and guarding the area. The wound was irregular in shape and located between the buttock cheeks. The cheeks had to be separated to observe the wound clearly. Slough was observed at the base of the wound and the skin surrounding the wound appeared red and irritated. V3 said she was surprised when she heard R39 had a pressure sore. R39 was ambulatory but is incontinent of her bowel and bladder and needed assistance from staff with getting cleaned up. V3 said the pressure wound should have been found sooner, before becoming a stage 3 wound, but R39 can be combative with care and sometimes refuses care. The location of the wound also makes it harder to see if she is being combative. V3 said R39 will be seen by the NP next week and said she wasn't sure why she wasn't seen on the 4th. V3 said R39 should be on an air mattress for better healing and will get that done today. The weekly skin observation dated 1/13/2024 shows R39 had no skin issues but was extremely uncooperative during the assessment. The note shows the nurse documenting this nurse did the best assessment possible due to resident becoming agitated and combative]. No other nursing documentation was done to show the skin check was attempted again. The wound-weekly observation tool for R39 dated 1/30/2025 shows a stage three pressure ulcer to the sacrum. The date acquired shows 1/27/2025. The note shows there was slough (presence of dead yellow or white tissue) and small amounts of drainage present. The wound measured 3 CM (Centimeters) by 1.5 CM by 0.2 CM and the tissue surrounding the wound was described as maceration (skin softening or breaking down). A treatment for the wound was put in place and a note shows the resident to see the wound NP (Nurse Practitioner) on 2/4/2025. No note from that date by the NP was found. The wound-weekly observation tool dated 2/4/2025 for R39 shows the stage 3 sacral wound continues with slough and macerated tissue surrounding the wound. The wound measurements were unchanged from 1/30/2025. The note on the tool shows the resident will see the wound MD (Medical Doctor) next Tuesday. On 2/06/25 at 10:28 AM, V12 (Wound NP) said, The residents at risk should be repositioned every 2 hours, this is very important. If a new wound is found it should be seen as soon as possible by us, I'm not sure why they didn't have me see her on Tuesday when I was there. She should have been put on an air mattress right away as well. A pressure ulcer can develop quickly but I wouldn't say in one day. Usually, redness is visible for some time before it gets to a stage 3 pressure sore. On 2/06/25 at 9:40 AM, V2 (Director of Nursing/DON) said she did not want to make any excuses for why the pressure ulcer was not found until it was a stage 3, but R39 can be combative at times and does refuse care. R39 came to the facility from another nursing home and did have some issues adjusting to the new routine. V2 said R39 liked to do for herself but the staff learned that she was not doing a good job keeping herself clean. She was incontinent of bladder and bowel and would put the dirty undergarments in her drawer. V2 said the staff are now able to help her more, but she does still get combative. V2 said I would expect the staff to keep trying to observe her skin during skin checks and if one nurse can't get it done maybe the next one can. V2 said R39 has been like that with the staff. V2 said an air mattress will be put on her bed today. On 2/06/25 at 10:00AM, V6 (Certified Nursing Assistant/CNA) said she works with R39 and provides peri care to her. V6 said R39 can get aggressive with them and tries to hit them and pushes them away. V6 said she will just go back later and try again. V6 said she never noticed and redness to R39's sacral area. On 2/05/25 at 1:59 PM, V11 (LPN) said she did not feel like R39 was having a change in her condition. She recently had a flu shot and maybe that's why she was sleepier on that day V11 said R39 decides when she is up and when she stays in bed. V11 said she has not seen any change in her behaviors or condition other than the pressure sore. A nursing progress note dated 2/6/2025 at 09:01 AM shows [Resident noted on dressing to Sacrum increased redness and tenderness to peri wound. Noted slough to wound bed with foul odor, moderate drainage noted. MD notified via phone d/t possible infection. New orders to obtain a wound culture and start resident on Augmentin 500mg BID x10days and Acidophilus probiotic x20 days. Consult with wound NP next Tuesday. Next of Kin called and left voicemail to call facility with any questions or concerns.] A nursing progress notes dated 2/4/2025 at 12:44PM, shows a standard pressure relief mattress was in place for the resident. The note also shows the resident R39 will see the wound NP the following week. (The wound care NP was in the building on 2/4/2025 making wound rounds.) The weekly skin checks for December shows no skin issues. The weekly skin check dated 2/3/2025 (7 days after the stage 3 pressure ulcer was found) shows no skin issues. The POS (Physician Order Sheet) dated February 2025 shows an order dated to start 2/6/2025 for an air mattress due to sacral wound. (10 days after the pressure ulcer was found.) An order for a wound culture was also ordered on 2/6/2025 for suspected wound infection. The same POS also shows an order an antibiotic for wound infection to start 2/6/2025. The care plan for R39 dated 11/21/2024 for potential for impairment to skin integrity shows the interventions for skin checks with care and weekly on her shower day. A care plan for resistance to care dated 1/12/2025 shows if resistant to care reassure her, leave, and return 5-10 minutes later and try again. The facility policy with a review date of 8/29/2024 for skin conditions-Wound policy shows a licensed staff will complete a head-to-toe skin assessment weekly and as needed. The skin assessment will be documented in the clinical record on the weekly skin assessment. The facility policy reviewed on 8/29/2024 for pressure ulcer shows to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer, once identified. 1. Prevention measures are assessed upon admission, any significant changes and at least quarterly based on the resident risk assessment. Implementation of preventive measures are based on the factors specific to each resident. 38488 2. R27's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include metabolic encephalopathy, essential hypertension, chronic pain syndrome, hyperlipidemia, morbid obesity, osteoarthritis, difficulty walking, weakness, and anxiety disorder. R27's Wound Practitioner Note dated 2/4/25 showed, . Referred on 12/17/24 . pressure ulcer of the left buttocks and coccyx . Preventative measures in place . has LAM (air mattress) . weight 268.8 lbs . R27's medical record showed her weight on 2/5/25 as 266.2 lbs. On 2/04/25 at 9:25 AM, R27 was lying in bed. R27's air mattress pump attached to the end of her bed was set on 350 lbs. On 2/05/25 at 12:46 PM, V11 (LPN) said, . [R27's] wounds aren't improving like we want them to . On 2/06/25 at 8:18 AM, V3 (LPN/Wound Care Nurse) said the purpose of R27's air mattress is to alleviate pressure and it gets set by the resident's weight. V3 confirmed the air mattress was set at 350 lbs. V3 said 350 lbs is too high because R27 only weighs about 260 pounds. V3 adjusted the setting on the mattress. On 2/06/25 at 9:55 AM, V5 (Assistant Director of Nursing/ADON) said, It is my understanding is that mattress is supposed to be based on her weight and having it set too high affects the pressure. The heavier the resident is the higher it is set and the more it would be filled. Having it set too high would increase the firmness. It would be important to be set to the resident's weight because it affects how firm the mattress is, and we would like it to be providing the right amount of pressure. On 2/06/25 at 10:11 AM, V2 (DON) said, 350 lbs is too high for her, it won't do its job if it's too firm. The mattress is supposed to reduce pressure and promote wound healing. The air mattress Operations Manual showed, . Indications: [air mattress product name] pump and overlay system . is indicated for the prevention and treatment of any and all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program . Pressure-adjust knob (2) Determine the patient's weight and set the control knob to that weight setting on the control unit .

Based on observation, interview, and record review the facility failed to ensure a dependent resident received timely incontinence care and failed to ensure a resident with an indwelling catheter maintained the drainage bag below the level of the bladder for 2 of 4 residents (R21, R12) reviewed for bowel and bladder in the sample of 36. The findings include: 1. R21's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, hypertension, dysphagia, need for assistance with personal care, anxiety disorder, and major depressive disorder. R21's facility assessment dated [DATE] showed she has severe cognitive impairment and is frequently incontinent of bowel and bladder. R21's care plan initiated 3/31/2017 showed, . offer more frequent toileting . Toilet [R21] frequently, especially after meals and before placing in recliner or bed . R21's care plan initiated 1/24/2019 showed, [R21] is at risk of skin breakdown related to needing assistance with ADL's, decreased mobility, frequent incontinence . [R21] is frequently incontinent. Assist with toileting needs/incontinent care needs, every 2 hours and/or per resident request . Keep skin clean and dry as possible . On 2/05/25 at 12:57 PM, R21 was provided incontinence care by V6 and V7 (Certified Nursing Assistants/CNAs). R21 was assisted to a standing position from her wheelchair and there was urine puddled on her wheelchair cushion. R21's pants were saturated with urine from the buttocks area, down the back of the legs to just above the knees. R21's incontinence brief was removed and was completely saturated with urine. R21 had a strong urine smell. On 2/06/25 at 10:07 AM, V2 (Director of Nursing/DON) said, I expect them to do incontinence care every two hours . or sooner if they need it. They should be rounding back there on the memory unit because those are the more confused residents . It is important to keep residents clean and dry to prevent skin breakdown and UTIs (Urinary Tract Infections). The facility's policy and procedure with review date of 8/29/24 showed, Perineal Care; Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . 45395 2. R12's face sheet indicated that the resident last admitted to the facility on [DATE] with a past medical history not limited to: need for assistance for personal care, hypertension, obstructive and reflux uropathy, hydronephrosis, and artificial openings of urinary tract status. On 02/04/25 at 10:18 AM, R12 was observed in a reclining chair in his room with an indwelling urinary catheter in place with the tubing laid across R12's abdomen and over the arm rest of the recliner to his right side. The urine collection bag was placed next to R12's right lower thigh on the seat of the recliner that was not within a privacy bag, contained small amounts of sediment withing the tubing, and was not below the level of his bladder. R12 said that he has had a catheter for years due to his history of severe urinary tract infections (UTI). On 02/04/25 from 10:30 AM to 12:00 PM, R12 was observed multiple times by survey team self-propelling himself in a powered wheelchair throughout the hallways near the 500 unit with his urinary catheter tubing laid across his upper thighs, and the urine collection bag was hung on the armrest to R12's left side that was level to the arm rest that not hanging below the level of his bladder. The collection bag was partially placed within a privacy bag with the upper and middle portions of the bag clearly visible. During this timeframe, no staff members were observed by surveyor redirecting R12 or attempting to adjust the level of his urinary collection bag so that it was below the level of his bladder. On 02/04/25 at 12:07 PM, observed R12 enter the smaller dining room that is off the 400/500 units with his urinary catheter tubing laid across his upper thighs, and the urine collection bag was hung on the armrest to R12's left side that was hanging level to the arm rest and not below the level of his bladder. Several staff members were present in the dining room at this time. R12 then self-propelled himself out of the dining room approximately 30 minutes after he entered. No staff members were observed by surveyor either redirecting R12 or attempting to adjust the level of his urinary collection bag so that it was placed below the level of his bladder while R12 was in the dining room. Review of R12's active physician orders showed change suprapubic catheter as needed if increase in sediment, blockage, or unable to irrigate. R12's care plan last reviewed on 12/26/2024 reads in part: requires enhanced barrier precautions (EBP) related to suprapubic catheter with date Initiated of 04/09/2024. No further documentation regarding catheter care or monitoring found. On 02/04/25 from 02:00 PM to 03:00 PM, R12 was again observed multiple times by surveyor self-propelling himself with his powered wheelchair throughout the facility and on the 500 unit with his urinary catheter tubing laid across his upper thighs, and the urine collection bag was hung on the armrest to R12's left side that was level to the arm rest and not hanging below the level of his bladder with no staff redirection or education regarding collection bag being hung below the level of his bladder. On 02/05/25 at 12:15 PM, V8 (Licensed Practical Nurse) said that R12 gets verbally aggressive with staff and can be non-compliant but staff redirect and educate him daily regarding the placement level for his urine collection bag below the bladder and of it being in a privacy bag. V8 was unsure if R12's non-compliance and aggression were care planned but indicated that they should be. On 02/05/25 at 09:18 AM, 12:10 PM, and 2:16 PM, R12 was observed in the reclining chair in his room with the urinary catheter tubing laid across his abdomen and over the arm rest of the recliner to his right side. The urine collection bag was observed hanging on a garbage can next to R12 that was not within a privacy bag, and the tubing was observed on the floor between the garbage can and the recliner. On 02/06/25 at 07:56 AM, R12 was observed self-propelling himself with his powered wheelchair to the front lobby area where several staff members were present. R12's urinary catheter tubing was laid across his upper thighs, and the urine collection bag was hung within a privacy bag on the armrest to R12's left side that was level to the arm rest and not hanging below the level of his bladder. No staff members were observed by surveyor redirecting R12 or attempting to adjust the level of his urinary collection bag so that it was hanging below the level of his bladder. On 02/06/25 at 10:13 AM, V2 (Director of Nursing) said R12 likes things where he wants them and has been educated in the past regarding the placement of his collection bag. V2 added that R12 is alert, oriented and can be easily angered so most of the time, staff leave him alone and do not attempt to redirect or re-educate R12 regarding his urine collection bag being in a privacy bag and hung below the level of the bladder to avoid angering resident. V2 (Director of Nursing) also said that the indwelling catheter tubing and collection bag should be below the level of the bladder to avoid backflow of urine and prevent urinary tract infections. V2 then said that she thought these behaviors were care planned for R12 but discovered they weren't, so she revised R12's care plan yesterday (02/05/2025). At 10:25 AM, after interview with V2 (Director of Nursing), surveyor requested documentation regarding the education provided to R12, and of any non-compliance or behaviors related to his catheter care. On 02/06/25 at 10:30 AM, R12's revised care plan (02/05/2025) was reviewed and documented that the resident has suprapubic catheter obstructive and reflux uropathy with interventions not limited to: position catheter bag and tubing below the level of the bladder and away from entrance room door, may move it per his own preference; and provide privacy bag, often refuses to use privacy bag on wheelchair that was created by V2 (Director of Nursing) on 02/05/2025. No documentation was found during review of R12's medical record or provided by facility during course of this survey regarding provided education to R12, or of any non-compliance and behaviors related to his catheter care. Catheters, Emptying a Urinary Bag policy last reviewed 08/29/2024 reads in part: The purposes of this procedure are to prevent the drainage bag from becoming full and allowing urine to flow back into the bladder, to measure output, and to obtain a sterile specimen. General Guidelines not limited to: Always check tubing when emptying a urinary drainage bag to be sure there are no kinks, and that the urine is draining freely. Attach the drainage bag to the bedframe while resident in bed if allows for bag to not touch the floor. Keep the drainage bag below the level of the resident's bladder. Keep the drainage bag and tubing off the floor at all times to prevent contamination and damage.

Based on interview and record review the facility failed to follow their policies and procedures on reporting an allegation of abuse for 1 of 7 residents (R1) reviewed for abuse in the sample of 7. The findings include: R1's face sheet shows she was admitted to the facility on [DATE] and has diagnoses that include dysphagia, adult failure to thrive and a history of a cerebral infarction without residual deficits. R1's care plan shows she is incontinent of bowel and bladder and requires staff assistance with all her activities of daily living including toileting, bathing, and bed mobility. On 11/4/24 at 9:00 AM, V5 (R1's Power of Attorney/POA and daughter) said she was at the facility on 10/11/24 and the facility staff were doing a trauma assessment on R1 while she was present in the room. When the question was asked if (R1) had any history of sexual abuse she replied yes here. V5 said (R1) then made the allegation that someone had come into her room and put something in her bottom. V5 said at that point the staff person went and got (V1) the Administrator, who then took her mom to ask more questions about the allegation. V5 said (R1) has never made an allegation like this before so she was concerned that she may have been assaulted by someone. V5 said she is not sure if the facility called (R1's) physician or not but they did not send her out for any examination. On 11/4/24 at 10:48 AM, V8 (Social Services) said she was the person who did some of the admission assessments on 10/11/24 with (R1) including a trauma informed screening. V8 said when she got to the question if (R1) had ever been sexually abused (R1) replied here. V8 said (R1) went on to say staff, a nurse or doctor, put something in her bottom. V8 said she went and called her supervisor (V7) and the Director of Nursing (V2) immediately and they informed V1 who came to speak to (R1). On 11/4/24 at 12:13 PM, V1 (Administrator) said she did receive an allegation on 10/11/24 that (R1) had indicated she had been sexually abused at the facility by staff who put something in her bottom. V1 said when she interviewed (R1) she would not give her any detail about the incident, so she interviewed a few nursing staff asking questions if she had a suppository or something like that. V1 was not sure if the physician had been called or not but she did not report the allegation to the state surveying agency. On 11/6/24 at 9:15 AM, V4 (R1's Physician) said she was not notified of the allegation that (R1) had made on 10/11/24 until 10/24/24 when (R1) made another allegation of continued sexual abuse in her room at the facility. V4 said she should have been contacted about the allegation at the time and if she was not able to come and examine the resident at the facility, she would have had her sent out to the emergency room for evaluation. V4 said she is familiar with (R1) because she had just been transferred from another facility to the current facility, and she has never made a sexual abuse allegation that she is aware of. V4 said she would expect the facility to do a thorough investigation and follow the abuse policy and call the physician and police if a resident makes any potential sexual abuse allegation. On 11/6/24 at 11:13 AM, V1 verified that R1's physician (V4) was not contacted about the allegation, the police were not contacted, and the state surveying agency was not notified of an initial or final report. V1 said typically when an allegation is made that is founded, they then contact the state surveying agency. V1 said she probably should have notified (R1's physician) about the allegation. V1 said when a sexual abuse investigation is done the physician is contacted, the police are called, and the resident is sent to the emergency room if indicated. V1 said she did not do the facility abuse prevention program worksheet that is part of the abuse policies and procedures because they thought (R1) may have made the allegation because she is very tiny and had a hard bowel movement which may have been what (R1) was referring to. The facility provided Abuse Prevention Program policy and procedure which includes an investigative pathway worksheet last reviewed on 4/8/24 defines abuse as any physical, mental, or sexual assault that may inflict trauma or mental anguish to a resident. The policy shows any allegation of abuse that results in serious bodily injury the initial report should be reported to (state surveying agency) in 2 hours and if it does not result in serious bodily injury should be reported to (state surveying agency) in 24 hours, followed by a final report in 5 days. The policy also shows when an allegation of sexual abuse is made the physician and local law enforcement should be contacted.

Based on interview and record review the facility failed to ensure a resident's personal funds were refunded upon discharge. This applies to 1 of 4 residents (R1) reviewed for personal funds in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Medicaid is listed as the payor source. Her diagnoses include Wernicke's Encephalopathy, depression, alcohol dependence, and COPD. On 1/30/24 at 10:33 AM, V7 (R1's family) said R1 was discharged from the facility on 12/12/23. She called the facility to follow up on R1's social security check, it was being directly deposited to the facility when she was there. V3 (Business Office) told her they received R1's Social Security check for January 2024, R1 has not received a refund for her January personal funds. V7 said the facility did not report to Social Security she was discharged and that's why her personal funds were deposited with the facility's management account. On 1/30/24 at 11:00 AM, V3 (Business Office) said she got a call from V7 regarding R1's Social Security check. V7 said, This was my first time experiencing a resident being discharged to the community with her personal funds being deposited with the facility. I did not notify Social Security of (R1's) discharge from the facility. (R1's) January check was deposited to the facility, we switched management systems and the previous company would report to Social Security when a resident was discharged . Someone must report to Social Security when a resident is discharged so the resident can receive their funds. (V7) was a little upset and I told her we were working on it. V3 said she requested a refund from the management company yesterday. R1's Resident Fund Management Service Authorization and Agreement to Handle Resident Funds form dated 8/9/23 shows a signed signature by R1 and elected direct deposit of her social security funds with the facility's management service. R1's Resident Statement Fund provided on 1/29/24 shows a deposit on 1/10/24 (29 days after discharge) from Social Security for $1215.00. On 1/10/24 an auto withdrawal for care cost of $1185.00 (R1 was discharged on [DATE]). A Check Request form dated 1/29/24 (48 days after R1's discharge) shows a refund was requested due to her discharge. The form shows an area For Office Use Only including account number, check amount approved by and date approved are all blank.

Based on interview and record review the facility failed to provide a resident's medications upon discharge. This applies to 1 of 3 residents (R1) reviewed for discharge in the sample of 4. The findings include: R1's face sheet shows she is a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Medicaid is listed as the payor source. Her diagnoses include Wernicke's Encephalopathy, depression, alcohol dependence, and COPD. R1's Physician Order Sheets dated December 2023 shows orders to discharge to home with current medications (order date 12/8/23) including buspirone (anti-anxiety) 10 mg (milligram) twice a day for Wernicke's encephalopathy and Zoloft 100 mg one tablet for depression. On 1/30/24 at 10:33 AM, V7 (R1's family) said when R1 was discharged , she was not sent home with her psych medications. V7 said, I called and spoke with the head nurse, and she told me (R1's) medications got sent back to pharmacy. (R1's) payor source is Medicaid and her medications for the month were already paid for when she was in the facility. (R1) was having increased behaviors without her medications and she paid for her medications out of pocket. On 1/30/24 at 1:05 PM, V6 (Licensed Practical Nurse/LPN) said she discharged R1. Medications should be sent home with the resident based on the payor source. She remembers sending R1's inhaler home but does recall if she sent home her psych medications. R1 was alert and had some behaviors and paranoia issues. On 1/30/24 at 10:04 AM, V5 (LPN) said she is not sure if medications are sent home with residents. On 1/30/24 at 1:27 PM, V2 (Director of Nursing) said residents should receive their medications on discharge if they have Medicaid, because they have been charged for those medications for the month. V7 contacted her and reported R1 did not receive her medications on discharge. She was asking about R1's psych medications. V2 said R1's medications were sent back to the pharmacy. R1's Discharge Summary form dated 12/12/23 does not show her medications were sent home upon discharge. The facility did not provide a policy regarding medications upon discharge.

Based on observation, interview and record review the facility failed to have interventions in place to prevent a pressure injury for 1 of 4 residents (R57) reviewed for pressure injuries in the sample of 17. The findings include: R57's January 2024 order summary sheet documents he was admitted to the facility on [DATE] with multiple diagnoses including hypertension, gout, muscle weakness, and need for assistance with personal care. R57's nursing progress notes of 12/22/23 document he was on droplet isolation precautions and all meals, cares and therapies were provided in his room. R57 refused to get out of bed even after several attempts were made. The notes show on 12/26/23 a 6.35 cm oval area on his left heel that is hard, purple/black in color from pressure on his mattress. The 12/26/23 weekly wound observation tool documents a facility acquired SDTI (Suspected Deep Tissue Injury) to the left heel. The tissue was necrotic (brown, black, leather, scab-like). The wound measured 4 cm in length by 6 cm wide and a depth of 0.1 cm. The 7/19/22 care plan was revised on 12/26/23 and shows R57 is at risk for impaired skin integrity and pressure ulcer development related to very limited mobility requiring extensive assist with all ADL's (Activities of Daily Living) and total dependence for transfers. The 12/15/23 quarterly facility assessment shows he required substantial/maximal assistance to roll left and right and return to lying on his back on the bed. On 1/4/24 at 9:01 AM, V5 (Certified Nursing Assistant/CNA) said R57 is a mechanical lift transfer, he used to stand and transfer but after he was sick, he had a decline. V5 said the staff have to reposition him every 2 hours. He is unable to move himself in bed, he will stay in the same position if not moved. We have to put pillows under his heels, and boots for protection. On 1/4/24 at 9:09 AM, V3 (Wound nurse/Licensed Practical Nurse) said R57 has a deep tissue injury to his heel. She said he was really sick with influenza and had a lot of edema in his feet. While sick, he was in bed more, and assumes that is how he acquired the wound. V3 said R57 was not able to move himself around in the bed and had an overall decline. He should have had his heels floated when in bed, and he did not have the boots, or other interventions in place until after the wound was identified. On 1/4/24 at 10:33 AM, R57's left heel appears to be swollen, dry and purple/black in color. He has knee high compression socks on with tennis shoes. He was sitting in a recliner with his feet elevated. A mechanical lift sling was observed under him. The facility's 7/28/23 pressure ulcer/pressure injury policy documents 1. Prevention measures are assessed upon admission, any significant changes and at least quarterly based on the resident risk assessment. Implementation of preventative measure are based on the factors specific to each resident.

Based on observation, interview and record review, the facility failed to ensure quarterly smoking assessments were completed for 1 of 2 residents (R32) reviewed for smoking safety in the sample of 17. The findings include: R32's Admission Record, provided by the facility on 1/4/24, showed he was admitted to the facility on [DATE] with diagnoses including paraplegia (an impairment in motor or sensory function of the lower extremities), chronic obstructive pulmonary disease with acute exacerbation, muscle weakness, gastro-esophageal reflux disease, major depressive disorder, and idiopathic peripheral autonomic neuropathy (damage to the nerves that control automatic body functions. The nerve damage affects the messages sent between the brain and other organs, and areas of the autonomic nervous system, including the heart, blood vessels and sweat glands). R32's Order Summary Report, provided by the facility on 1/4/24, showed the following order: May smoke at specified smoking times. The report showed the order was still active. R32's facility assessment dated [DATE] showed he has a traumatic spinal cord injury and uses a manual wheelchair. R32's smoking care plan, with a revision date of 4/20/23, showed the following interventions Allow (R32) to smoke in designated areas only. Repeated reminders of safety hazards. While smoking, will have supervision by staff. R32's ADL (activities of daily living) care plan, with a revision date of 4/20/23, showed he requires assistance from one staff member for bed mobility, dressing, personal hygiene, toileting, and transfers. The Smoker's List provided by the facility showed R32 was listed as one of the residents in the facility that smoke. On 1/3/24 at 1:05 PM, R32 was outside smoking in the designated smoking area with another resident and a staff member present. A review of R32's electronic medical record on 1/3/24, showed the last smoking assessment for R32 was on 4/10/23. The assessment showed R32 was safe to smoke with supervision. On 1/4/24, all of R32's smoking assessments were requested. The facility provided smoking assessments dated 3/27/19; 4/3/23; 4/10/23; and 1/4/24 (the day the assessments were requested). On 1/4/24 at 1:58 PM, V6 (Regional Nurse Consultant) said the smoking assessments for R32 were not completed quarterly as scheduled. The facility's Smoking Policy, with a review date of 7/25/23, showed b. Residents will be evaluated upon admission, quarterly or more frequently as dictated by any significant changes in condition to ensure that they continue to be capable of smoking and using smoking materials without presenting a danger to themselves or others.

Based on interview and record review the facility failed to perform testing for two weeks after a resident tested positive for Covid 19. This applies to all 73 residents residing at the facility. The findings include: The Facility Data Sheet dated 10/30/23 show the facility has 73 residents residing at the facility. On 10/30/23 at 9:02 AM, V3 (Health Department Nurse) said the facility was on outbreak status. The facility still had a positive resident all the way up to 9/25/23 and did not do any further testing for staff and residents after this resident had become positive. V3 said she had instructed the Administrator (V1) that testing should continue until there were no more positive staff and residents for 14 days to remove them from outbreak status. An electronic mail (email) correspondence between V1 (Administrator) and V3 (Health Department Nurse) dated 9/25/23 showing V3 instructed V1 that since there was a resident who was positive on 9/25/23 that the facility had to continue to test until 10/9/23. On 10/30/23 at 2:20 PM V2 (Director of Nursing) said the facility was testing the whole facility (wide based) twice a week during the outbreak (9/1/23-9/25/23). On 9/22/23, R4 was admitted to the facility from the hospital. The hospital did not send any Covid testing results to the facility. V2 said the facility did not do any Covid testing on admit (9/22/23). On 9/25/23 the facility was scheduled for wide based testing and R4 tested positive for Covid 19. On 10/31/23 at 1:20 PM V1 (Administrator) and V2 (DON) said the facility switched from wide based to unit-based testing on 10/2/23 but no other testing done after 10/2/23. The facility policy entitled Covid 19 Outbreak Control dated 10/21/21 show-Guidelines: 1. In the event of a facility outbreak institute outbreak management protocols and emergency response: Outbreak Investigation and testing. 1. Determine which approach to use for outbreak investigation. 2. Contact tracing approach is more focused approach and starts with identifying staff and residents who have had exposure to positive case. Testing will continue every 3-7 days until there are no more positive cases for 14 days.

Based on observation, interview, and record review the facility failed to assess a resident with a change of condition, failed to notify the physician of a change of condition, and failed to implement interventions for a resident with a fractured ankle for 1 of 3 residents (R1) reviewed for care and services in the sample of 7. This failure resulted in R1 experiencing a delay in treatment for her fractured ankle for 3 days and pain. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include dementia, other disorders of brain in diseases classified elsewhere, reduced mobility, weakness anemia, amnesia, and osteoarthritis. R1's facility assessment dated [DATE] showed she is severely cognitively impaired and requires extensive assistance of two staff members for bed mobility, transfers, toileting, and dressing. The same assessment showed R1 has an inattention behavior (easily distractible/having difficulty keeping track of what was being said) and disorganized thinking continuously present without fluctuations. R1's care plan initiated 1/25/21 showed, [R1] has impaired cognitive function related to dementia . Interventions: Ask [R1] simple yes or no questions in order to determine her needs. She can be anxious at times so reassure her that we want to help her Present just one thought, idea, question, or command to [R1] at a time. Use task segmentation to support short term memory deficits . R1's Patient Report from the mobile x-ray company with date of service 4/6/23 showed, Right ankle, 2 views Findings there is a nondisplaced acute fracture of the distal fibula . Impression: Acute distal fibular fracture . On 4/13/23 at 9:57 AM, R1 was in her room sitting in her wheelchair. R1 said, My foot hurts, take off my sock. I'd like to go to bed. R1 had a very short attention span while answering questions and repeatedly asked the surveyor to feel how soft her shirt sleeves were. R1 could not maintain focus long enough to give any more than short answers before losing her train of thought and refocusing on the environment around her. On 4/13/23 at 10:03 AM, V3 (Certified Nursing Assistant/CNA Supervisor) and V4 (CNA) were assisting R1 to bed with the mechanical lift and providing incontinence care. R1 expressed pain with movement of her right ankle and requested blankets be removed from her right foot because she was experiencing pain. V3 said, [R1] does have a bruised foot. It is broken. We don't know how it happened. On 4/13/23 at 12:55 PM, V12 (CNA) said, It was after lunch when I went to take [R1's] shoe off. She usually is always saying help me, help me but this time she screamed out in pain. I looked at her ankle and saw bruising and swelling . I reported it to the nurse. I have no idea what happened but I'm sure it did not happen on that day because the bruising was already so set it that day. It was purple. On 4/13/23 at 2:21 PM, V14 (CNA) said, The first time I noticed her ankle was swollen and bruised was on Wednesday (4/5/23). I reported it to V11 (Licensed Practical Nurse/LPN) and she told me it had already been reported the day before (4/4/23) and was being handled. On 4/13/23 at 2:37 PM, V11 LPN said, I think it was last Wednesday (4/5/23) when I found out about [R1's] swelling. I don't remember who reported it to me. Typically, we fax the doctor explaining what we found, measurements, symptoms, and find out what testing they want done. I faxed the doctor. I didn't get a response. I know the DON (V2) had to contact the doctor. I don't know when [V2] called her but I know an x-ray was ordered. V11 said she does not have the fax she sent to the physician, did not complete an incident report, and did not document an assessment on R1. On 4/13/23 at 3:00 PM, V2 said, The ankle injury was discovered on Tuesday (4/4/23). [V11] said she got report of the ankle injury and faxed the doctor. The faxes generally go on the clipboard at the nurse's station. I never did find the copy of the fax. We would typically scan it into the resident's record, but we don't know what happened to that. I looked everywhere. There was an x-ray done Thursday (4/6/23) and when I came in on Friday morning the results had not been received yet, so I contacted the x-ray company for the results. We didn't get the results until Friday afternoon that the ankle was fractured. Generally, if a fax was sent to the doctor, we would follow up with a phone call if we don't hear back. I feel like a fax was an acceptable way to contact the physician in this case because all we knew was, she had a bruise. It was not until Friday when we knew the ankle was fractured. If she had a fall with an injury, we would have called the physician or if there was something emergent. She should have documented a progress note and an assessment. I can't tell you with any certainty when the physician or the family was notified because I have to go with what is documented. I would have probably faxed the physician and if I had not heard back in a couple hours I would have called because of the pain [R1] was having. The nurse was educated on what more she could have done. On 4/5/23 it was reported to V11 again by another CNA but V11 told her it was already handled. On 4/6/23 when we still did not have an answer, we called it in. It is important to follow up with the physician because we need an answer to treat the resident. The incident report was not completed until 4/6/23. We did find problems with nursing care, there was education done. Once we found out it was fractured, we set her up with orthopedics. From 4/4/23 through 4/6/23 there were no changes made to R1's plan of care. No acute treatment done such as ice, elevating, or splinting. There was nothing new until we knew it was fractured. I looked at the documentation though and she was not having pain unless the ankle was manipulated. Taking a sock on and off if you have a fractured leg would hurt. During mechanical lift transfers her foot could get manipulated but not bent or anything. It (ankle) would move with the lift up, at times they have to guide the feet and legs, and then it would move with the lay down. R1's 4/6/23 (2 days after the injury was initially identified) nursing note entered at 11:00 AM showed, Upon assessment by this nurse resident noted to have faded purple/yellow/green bruising to right ankle with moderate swelling to extremity, and treatment in place to monitor area until bruising resolved. Very tender to touch. Measuring 14 cm x 12 cm. When resident asked what happened she said she thinks she banged it on something, but she wasn't sure when or what. MD (physician) and POA (Power of Attorney) updated. New order to obtain 2 view x-ray of right foot and ankle. Resident extremity elevated in bed . Tylenol given with some relief unless touched . R1's 4/6/23 nursing note entered at 8:20 PM showed, . Right ankle area remains swollen and bruised. No complaints of pain unless touched or moved . R1's 4/9/23 nursing note entered at 5:42 AM showed, Updated MD of residents increase of pain in regard to fracture to right fibula. Pain signs include tensing, loud crying out, and facial grimacing. Request was made for PRN (as needed) pain medication . The facility's policy and procedure with review date of 7/20/22 showed, Acute Condition Changes . 3. Direct care staff, including Nursing Assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the Nurse. Nursing Assistants are encouraged to communicate subtle changes in the resident to the nurse promptly . 7. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response. 8. The attending physician (or practitioner providing back up coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The staff will notify the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response . Cause Identification; 1. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. If necessary, the physician will order diagnostic tests or evaluate the resident directly . Treatment/Management; 1. The physician will help identify and authorize appropriate treatments . Notification; 1. The nurse will notify the resident's attending physician or on-call physician when there has been: . b. A discovery of injuries of an unknown source . 2. the nurse will notify the resident's family or representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; . 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status . The facility's policy and procedure with review date of 7/20/22 showed, Bruise Monitoring; . To provide proper monitoring, treatment, and documentation of any resident with skin abnormalities . 1. Identification - Bruising will be identified by the nurse through review of weekly skin assessments and the weekly shower sheets. Additionally, any reports generated verbally by direct care staff will be forwarded to the skin nurse in writing. All information will be reviewed by the DON or designee as the means to identify residents experiencing bruising .

Based on observation, interview, and record review, the facility failed to transfer a resident in a safe manner for two of four residents (R1, R4) reviewed for transfers in the sample of 7. This failure resulted in R1 suffering a fracture of the right femur. The findings include: 1. R1's face sheet lists R1's diagnosis of senile degeneration of the brain, fracture of lower end of the right femur (dated 11/18/22), hypertension, major depressive disorder, colostomy status, seizures, osteoarthritis, and glaucoma. On 12/14/22 at 11:05 AM V3 (Certified Nursing Assistant/CNA) said on 11/17/22 she had R1 in her room in a shower chair. V3 had just showered R1. V3 said V5 (CNA) was in the room and was asked to assist to transfer R1 to bed using a total mechanical lift. V3 said V5 operated the lift control and V3 supported R1 during the transfer. V3 said R1's back was facing her so she could not see R1's extremities and their position. I'm not sure if she hit the bed or if it (leg) got caught. I think her (R1's) foot got caught and pulled. As soon as we turned, she said my leg. V3 said something occurred during the transfer that caused her (right leg) injury. Now, I make sure the (resident's) legs are in the correct position prior to the transfer. V3 said V9 (CNA supervisor) did [mechanical] lift training with all of us a couple of days later. So now, even if I'm behind the resident, I make sure their legs are in a correct position. Both me and V5 should have made sure (R1's) legs were the correct position prior to moving her. V3 said she did not document the incident anywhere in R1's record or for investigative purposes. On 12/14/22 at 11:24 AM V4 (Licensed Practical Nurse/LPN), said she didn't witness what happened on 11/17/22 but initially documented in R1' record what was reported to her by V3. V4 said V2 (Director of Nursing/DON) asked her to reenter a note showing V4's assessment of R1 as opposed to what was reported to her. V4 said so the first note was struck out and she entered a second progress note later in the day on 11/17/22 with her assessment. V4 said R1 was in obvious pain and was able to say where the pain was but not what had occurred. R1 was confused. I believe something happened to cause her pain; I could tell. R1's voice was strained, and her breathing was heavier. On 12/14/22 at 11:33 AM V5 (CNA) said on 11/17/22 she helped V3 transfer R1 with the total mechanical lift. V5 said she was running the lift. R1 did not complain of pain prior to the transfer. R1 caught her right leg on something and said she was in pain. She (R1) complained of right knee pain. I believe they (legs) were caught in the way when we were maneuvering her from the shower chair to the bed. Maybe the legs were on the wrong side of the lift. Now, I pay more attention to where the resident's extremities are. V5 said she didn't really see what happened. On 12/14/22 at 11:40 AM V10 (R1's physician) said a resident's legs should be together (when being transferred with a lift). You shouldn't be able to catch your leg (on something). On 11/17/22, R1 suffered a right femur fracture. I didn't order an X-ray right away. It was thought to be a soft tissue injury initially. The mechanism of injury was the leg got caught and spread. R1's lower legs were contracted. I would expect staff to safely transfer a resident. Getting a resident's leg caught on something is not a safe transfer. R1's face sheet showed admission to the facility on [DATE]. R1's 11/17/22 6:31 AM original nursing note (authored by V4 LPN) was struck out and showed: during transfer from shower chair to bed, residents legs got caught on either side of (mechanical) lift causing them to extend further than comfortable when staff began to turn her to place her in position for transfer. Resident exclaimed pain when staff began transfer. Staff then realized the position legs were in. Legs placed into proper position and resident assisted to bed. Bilateral legs examined once in bed. It is noted that the right knee and leg appears to be larger than the left especially at the knee. Assessed for pain which she rates a 10 to right hip and back. Resident difficult to assess ROM (range of motion) as she is normally contracted. On 12/14/22 at 10:59 AM V2 (DON) said she wasn't sure why R1's initial nurse note was struck out and a new one entered later in the day. Sometimes they put stuff that doesn't belong there. Nobody told her to remove it. R1's 11/17/22 nursing note (authored by V4) and created after 4:00 PM, showed resident in bed c/o (complains of) right hip and back pain. Bilateral legs examined. It is noted that the right knee and leg appears to be larger than the left. Assessed for pain which she rates a 10 to right hip and back. Resident difficult to assess ROM as she is normally contracted. R1's 12/4/22 physician order sheet showed an order dated 4/29/19, may use mechanical lift for transfers. R1's fall care plan showed R1 requires full mechanical lift with two assistants for all transfers. R1 is totally dependent on staff for her locomotion. R1's self-care performance deficit care plan showed R1 was totally dependent on two staff for transfers, bathing/showering, bed mobility, and toilet use. R1's 7/20/20 care plan showed R1 at risk of impaired cognition related to dementia. R1's 9/28/22 facility assessment showed moderately impaired cognition and total dependence on two plus persons physical assistance for bathing, toilet use, and transfers. The facility's 11/17/22 incident reported to the State agency showed R1 complained of right hip and leg pain after a transfer to bed. This reported incident showed R1's X-ray report stated acute fracture of the right distal femur. The facility's 6/24/22 Using a Mechanical Lift Policy showed to assist the resident in guiding his or her legs. Be sure the resident is turned in such a manner that the resident is facing you. Do not pull the resident backwards. The facility's investigation and root cause analysis documents were requested for review and not received. The facility's November incident/accident log did not include R1's 11/17/22 incident. The facility's 11/17-11/18/22 Record of Inservice Education showed staff were educated on (mechanical) lift transfer, reviewed safe lifting and movement of residents. The facility's 11/18/22 mechanical lift competency assessment record showed V3 was educated on the proper placement and height of the (total mechanical lift) on 11/17/22. The facility's 11/17/22 mechanical lift competency assessment record showed V5 was educated on the proper placement/awareness of resident limbs and height of mechanical lift during transfers. 2. R4's face sheet listed R4's diagnosis of heart failure, Type 2 diabetes, obesity, dysphagia, history of COVID-19, anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease. On 12/14/22 at 10:00 AM V7 (CNA) was in R4's bathroom with R4. R4 stood upright and V7 was cleaning R4's bottom. R4 was barefoot and had a dressing to the left great toe area. R4 said I'm slipping. V7 had a gait belt around her own waist. V7 assisted R4 to turn and sit in a wheelchair without using the gait belt. On 12/14/22 V2 (DON) said residents should have something on their feet during a transfer if they stand, for safety. Gait belts should be used for transfers to ensure resident safety. R4's 10/13/22 Mobility Assessment showed R4's walking (with assistive device if used), moving on and off the toilet, and turning around and facing the opposite direction was not steady, only able to stabilize with staff assistance. R4's 10/13/22 fall risk assessment showed a high risk for falling. R4's 10/13/22 facility assessment showed severe cognitive impairment and required extensive assistance of one-person physical assistance to transfer, walk in room, and toilet. R4's fall care plan showed to ensure R4 is wearing appropriate footwear when ambulating or mobilizing in wheelchair. R4 is to ambulate with one assist, gait belt, and use of rolling walker. R4 to transfer with one staff assist, use of gait belt and rolling walker. R4's potential for alteration in skin integrity care plan showed R4 had poor safety awareness. The facility's 4/26/22 Safe Lifting and Movement of Residents Policy showed gait belts should be used on residents unless residents are independent with ambulation or contraindicated in the resident's care plan.

Based on interview and record review, the facility failed to prevent a resident from being physically, mentally, and verbally abused by a staff member for one of one resident (R1) reviewed for abuse in the sample of 16. This failure resulted in R1 feeling tearful, feeling unsafe, and R1 stating R1felt like garbage. The findings include: R1's face sheet showed R1 was admitted to the facility on [DATE]. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/20/22 at 9:50 AM, R4 (R1's roommate) said on 9/9/22,V5 (Certified Nursing Assistant/CNA) pushed the walker into R1, and she almost fell . I saw it happen and there was another CNA (V6) in the room also. V5 called R1 a fat a**. I didn't report it to anyone, but I know R1 and V6 did. It bothered me. R1 was screaming for V5 to get out of our room. V5 wasn't assigned to this hallway. V5 was being nice to me to irritate R1. V5 made it seem like we were great buddies. I don't really know her. I was upset. R1 was upset. V5 came into our room a whole bunch of times that night even after being told to get out. On 9/20/22 at 9:57 AM, R1 said it was horrible. My roommate saw it and V6 saw it happen. The CNA reported it. From the first day I got here V5 had been bothering me. V5 came up to me the first day and said I hear you don't like CNAs. V5 said she comes into my room to see R4 my roommate. But R4 said she doesn't really know her. On 9/9/22, V5 entered my room to talk to R4. Before she got to R4 I told her we did not want her in our room. V5 entered our room again later and I began screaming at her to get out. V5 said she could be in here if she wanted and she could do whatever she wanted. I tried to block her with my body from entering the room. She entered the room four or five times despite me yelling and telling her to get out. V5 then called me a fat a** and b**ch and pushed my walker into me almost knocking me over. This incident made me feel like sh**, garbage. I cried I was so upset. I felt like less than what I am. I told V1 (Administrator) about the incident the next day. They wouldn't fire her. They offered to move me to another room or facility. That was disgusting to tell you the truth. I don't feel safe when V5 is around. She intentionally seeks me out and makes sure I see her. V5 comes in my room and down our hall when she isn't even assigned there. V5 even went outside my window and made sure I saw her there. On 9/20/22 at 10:35 AM, V7 (Licensed Practical Nurse/LPN) said on 9/15/22, V5 was working on another unit and went into R1's room. V5 said she went in to talk to and hug R4. R1 told V5 to get out of the room. R1 was calling for me. When I entered her room, she told me V5 wouldn't leave the room as she asked and called her a child or something. I apologized to R1 and told her I'd tell V5 to stay out of the room. I contacted V2 (Director of Nursing/DON). The DON told me nothing was established after the 9/9/22 incident prohibiting V5 to enter R1's room. I told the DON R1 still doesn't want V5 in her room. V5 going into R1's room was like throwing gasoline onto a fire. That same night, V8 (CNA) couldn't find V5 to assist in transferring R2. I helped with the transfer. When I saw V5, I asked her why she left her work area without telling anyone. Then, V5 went into R2's room and confronted V8 about (arguing in front of R2) about telling V7 she couldn't be found. This upset R2. R2 told me she didn't want V5 in her room the rest of the night. I told V5 to stay out of R2's room. V5 went back into R2's room anyway. V7 said, I told V5 just because you think it is okay, it's not okay if I told you to not go in someone's room. V5 always comes up with excuses to her behavior. I called V2 (DON) and V1 (Administrator) to report the incidents. The Administrator said she'd talk to V5. I can't believe she's still employed here. The Administrator is the Abuse Coordinator. On 9/20/22 at 11:15 AM, V8 (CNA) said R1 came up to her crying and told her V5 was rude and would not stop going into her room. R1 would not make something up. V8 said V5 is just unkind to some of the residents. V5 intentionally agitates R3 also. On 9/20/22 at 12:05 PM, V6 (CNA) said on 9/9/22, R1 and V5 had an argument in the dining room at supper. V6 said she witnessed part of it. V5 asked R1 in front of her tablemates why she's telling people she is mean to her. R1 screamed at V5 and told her to go away and leave her alone. After supper, R1 and R4's call light was on. V6 said she went into their room and was talking to R1. V5 came in behind me. R1 began screaming and told V5 to get out. V5 told R1 to shut the f**k up. R1 asked V5 what she had just said and V5 said shut up. V5 then pushed R1's walker into her so hard R1 could have fallen. V5 told R1 to back the f**k up and stay away. It could have been bad. Luckily, R1 was able to catch herself. V5 then called R1 a b***h and fat a**. My jaw dropped. I was assigned to R1's hall and V5 was assigned to an adjacent set of rooms. V5 goes over there (R1 & R4's room) just to start trouble. R1 had told V5 a number of times to stay away from her. R4 said she didn't want her in there either. V9 called V1 (Administrator) and we told her everything. The second incident on the 16th (later corrected to the 15th), V5 was told plenty of times not to go into R1's room. I wasn't in the room that time. R1's call light came on and V5 asked me to answer it because she said I think the light is on because of me. V5 asked me to go into R1's room and turn the call light off. I told V5 no and V7 (LPN) went into R1's room. V6 said yes, I observed V5 physically and verbally abuse R1. V5 continued to intentionally annoy R1, and she used R4 as an excuse to enter the room. On 9/20/22 at 2:37 PM, V9 (LPN) said she spoke to R1 after she heard the screaming in the room around 7:30 PM. V9 said R1 told her she had a disagreement with V5.V9 said V6 didn't report the incident details to her until 11:00 PM. On 9/20/22 at 1:53 PM, R13 said she sits at R1's table for meals and saw R1 and V5 shouting at each other (on 9/9/22). R13 said I don't know who started it or what caused it. It made me uneasy because of course it's not acceptable for staff to be yelling at the residents. V5 was mad and yelling at R1. It looked like V5 was going to be violent and V5 was intimidating R1. On 9/20/22 at 2:03 PM, R15 said she sits at the table with R1 for meals. R15 said I don't know what R1 and V5 were arguing about (9/9/22) but V5 has a problem with her attitude. I've had problems with her. I told her to cool it once and she told me to cool it, right back. On 9/20/22 at 2:45 PM, V1 (Administrator) said if a resident doesn't want a CNA in their room, the CNA can be reassigned or the CNA can bring a witness with them in the room. V1 said she was notified about the incident on 9/9/22 around 11:30 PM-12:00 AM. On 9/20/22 at 2:37 PM, V9 (LPN) said on 9/9/22 I was sitting at the nurses' station and heard R1 screaming. I didn't go see what was going on. On 9/9/22 at around 11:00 PM, V6 (CNA) told me V5 called R1 a stupid b**ch and pushed R1's walker almost knocking R1 down. I spoke to R1 around 7:30 PM that night. R1 said she didn't want V5 in her room. V5 did go back into R1's room later. Then I told her (V5) to stay out. Around 8:30-8:45 PM, V5 told me she didn't understand why R1 was being such a b**ch. V5 can be [NAME] to the residents. I called V1 (Administrator) to report the incident and V6 spoke to her also. V1 said she'd deal with it in the morning. On 9/20/22 at 3:15 PM, R4 said I was dumbfounded as to why V5 was being exceptionally nice to me. We didn't have a special relationship. I didn't know why all of a sudden, she was being so gushy with me. I could see this thing escalating and it scares me. V5 doesn't like anyone questioning what she does. On 9/20/22 at 3:20 PM, R1 said it started in the dining room that evening. V5 is rude and ignorant to me all the time. V5 came up to me in front of my tablemates and said I hear you were telling people I was rude to you. And I said Well, you were. She (V5) finally left after I raised my voice. It all just escalated from there. I fear for my life if she loses her job. Like a postal worker, she'd come back and shoot me. I don't want to get anyone hurt. I'd try to fight her. I'd lose but I won't be silent. She (V5) scares me, and I can't do anything about it. The facility's abuse investigation of the incident on 9/9/22 showed V1 (Administrator) told V5 to avoid going into R1's room. The facility's 9/9/22 and 9/15/22 evening shift staff assignment showed V5 was not assigned to R1's area. The facility's 1/22 Abuse Prevention Program showed this assumes that all instances of abuse of residents cause physical harm or pain or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. Verbal abuse is the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of an individual's age, ability to comprehend or disability. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. R1's care plan and 8/15/22 facility assessment does not show any behaviors. The facility assessment showed R1 was cognitively intact.

Based on interview and record review the facility failed to adequately supervise a new admission with a history of falls, and have individualized interventions in place to safely care for a resident at risk for falls. The facility failure resulted in R4 sustaining a fracture to her recently repaired left hip, and R4 required a second surgery. This applies to 1 of 3 residents (R4) reviewed for falls in the sample of 5. The findings include: R4 was admitted to the facility on [DATE] after a fall in her apartment. R4's face sheet shows [DIAGNOSES REDACTED]. The nursing discharge/transfer hospital communication form dated July 31, 2017 shows R4 to be alert but confused with more confusion noted at night. R4 was a fall risk at the hospital and was using a bed alarm. The facility's fall log for August 2017 shows R4 slid out of her recliner on August 1, 2017 at 6:30 AM (the next morning after admission) and fell a second time at 11:30 PM ( 17 hours later) that same day. On August 18, 2017 at 10:00AM, E2 DON (Director of Nurses) said R4's daughter brought to the facility a pink incontinent pad for her mother to use. E2 said the facility does not use these in a recliner as they have been identified as a risk for falls from the recliner. E2 said she was not aware how long this pink incontinent pad was in R4's recliner but she would have preferred it would have been removed. E2 said R4 was placed on the yellow dot or alternate call system after her first fall just so staff could have more frequent observations of her. E2 said there is no documentation to show how often R4 was observed. (The policy for the alternate call system shows it is used for residents that need an alternate source of monitoring for needed assistance. Part of the procedure from this policy shows all staff will be instructed to look into the open room to check the resident as staff passes by the door. Residents will be checked approximately every 30 minutes). On August 16, 2017 at 11:05 AM, E5 CNA (Certified Nursing Assistant) said R4 was very confused. R4 would keep trying to get up and down from her recliner. R4 didn't know where she was and would fidget and pick at her incontinent brief. On August 16, 2017 at 4:50 PM, E6 LPN (Licensed Practical Nurse) said R4 was alert but had periods of confusion. E6 said R4 at times thought she was at work as a nurse at a hospital and had forgotten she had a broken hip. E6 said R4 fell [DATE] at 11:30 PM; from her recliner a second time after trying to get up on her own. E6 said R4 never slept in her bed because it was more comfortable for her to sleep in the recliner. E6 said R4 did not have a chair alarm until after the second fall. On August 18, 2017 at 9:30 AM, Z4 (R4's Orthopedic Surgeon) said the second fracture of the left hip is definitely a result of the falls R4 had while at the nursing facility. On August 16, 2017 at 10:30 AM, Z1 (R4's family) stated, R4 was confused at the hospital so I was with her when she was admitted to the facility, I did not feel she was aware of what all was going on. I was worried about her overnight so I asked E2 DON (Director of nurses) and E3 (Resident Services) if I could pay for a sitter or spend the night and was told no. She fell for the first time at 6:25 AM on August 1, 2017, I went to see her that day and she was even more confused. I told the nurse about the confusion. She fell again that night at 11:30 PM, slid out of her chair again. I was called and told about it and that there were no injuries. The next morning when I was visiting her she moved her leg and I heard a pop and some crackling noise. I got the nurse and demanded an x-ray. Her left leg was broken around her prosthesis. She went back to the hospital but had to be transferred to another hospital that could handle the repair of this type of fracture. On August 16, 2017 at 9:50 AM, E1 (Administrator) stated, R4's daughter mentioned something about staying the night with her mother, I encouraged her to go home. The residents rest better when family are not here. The Nurses' Admission Record for R4 shows nothing documented in the condition on admission regarding alertness and orientation. R4's undated care plan shows that R4 required extensive assistance with weight bearing support, had a history of [REDACTED]. The care plan also shows R4 had full weight bearing of her lower extremities and no weight bearing to left arm. The care plan does not show any interventions related to the recliner for R4 after the two falls from her recliner. The facilities fall risk assessment tool dated July 31, 2017 shows R4 to be at high risk for falls. The cognition section of the assessment tool shows R4 to have a lack of understanding of one's physical and cognitive limitations. The nursing progress note dated August 1, 2017, at 6:25 AM, shows, Resident attempted to get up from recliner and slid out onto floor. Call light was within reach but not on. Resident educated on use of call light for assistance. The incident report completed by the facility after this fall shows her condition prior to the fall to be confused. The nursing progress note dated August 2, 2017 at 3:30 AM shows, at 5:00PM on August 1, 2017 R4 was alert with periods of confusion. At 11:30 PM that same note shows R4 had slid out of her recliner while trying to get up on her own. The note goes on to show resident was disoriented to where she was, thought she was at home. R4 was reoriented to time of day, date and recent hip fracture and surgery. E6 LPN (author of this note) stated and documented confusion for R4 and this is why she placed R4 on a chair alarm after the second fall. The nursing progress note dated August 2, 2017 at 7:30 AM, shows R4's daughter told the nurse she heard a pop from R4's hip. The nurse documented the left leg was shorter than the right leg. The x-ray report dated August 2, 2017 shows acute periprosthetic fracture (fractured bone around a surgical hip implant) involving the lateral femoral cortex of the left leg. (Same leg originally fractured and just repaired) The facilities Fall Reduction and Prevention Policy dated May 2017 shows the purpose is to reduce the risk of injury acquired as a result of resident falls. Interventions will be put into place based on the total fall risk score of the fall risk assessment tool and individualized for that resident to reduce the risk of injury from a fall. The policy also shows in the event of a fall nursing personal will initiate an immediate intervention based on nursing judgment. Immediate interventions are to be documented on the incident report and in the resident's clinical record. Interventions may include but are not limited to the following: A. alternate call system, B. monitors/alarms, C. alternate transportation, D. room placement, E. environmental changes, F. evaluation/treatment from therapy, G. hip protectors, and H. night lights.

Based on observation, interview, and record review the facility failed to ensure resident incidents were investigated to prevent recurrence. The facility repeatedly failed to investigate and record events where lift slings failed during transfers. The facility failed to ensure policies and procedures for falls, accident reporting, and manufacturer's guidelines were followed. The facility failed to ensure the structural integrity of the lift slings before using a sling during transfers with mechanical lifts. These failures resulted in a sling breaking while R1 was being transferred on [DATE]. R1 fell and sustained fractures to both her lower extremities and was hospitalized on [DATE]. R1's fall contributed to her death on [DATE]. The neglect existed between [DATE] and [DATE]. An Immediate Jeopardy began on [DATE] at 3:00 PM. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:15 AM. While the immediacy was removed on [DATE] at 10:00 AM the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementations This applies to 4 of 5 residents (R1, R2, R3, R4) reviewed for policies and procedures in the sample of 5. The findings include: 1. On [DATE] at 1:15 PM, E12 Certified Nursing Assistant (CNA) stated during R1's mechanical lift transfer, the black loop (on the lift sling) snapped and (R1) went down. R1's [DATE] Incident Report shows R1 was transferred to the hospital after the fall. On [DATE] at 3:30 PM, Z2 (hospital RN) stated R1 broke her left leg near her hip, and broke her right leg near her knee. On [DATE] at 10:15 AM, Z2 (family member) stated R1 died on [DATE]. On [DATE] at 8:30 AM, Z5 (hospital physician) stated R1's fall led to her fractures, which is why R1's condition deteriorated, and the injuries contributed to her demise. On [DATE], at 12:30 PM, E1 (Administrator) showed R1's torn lift sling to surveyors. The lift sling had four loops on each of its four corners that are used for attachment to the mechanical lift (one corner each to support a patient's arms, and one corner each to support a patient's legs.) One of the black support loops on the sling was ripped in half where the loop attached to the lift bar. On [DATE] at 12:30 PM, E2 (Administrative Assistant/RN) explained the torn loop corresponded to R1's left leg during the transfer. On [DATE] at 12:30 PM, E1 examined the green support loops on the sling used during R1's [DATE] transfer. Green fabric was missing from the surface of the green loops and the black threads underneath the green surface were exposed and flexible. E1 stated lift slings should be pulled from the floor if they look like they are frayed, or tearing, or do not look sturdy. On [DATE] at 8:45 AM, E1 stated she would have pulled R1's mechanical lift sling on [DATE] (prior to R1's fall) if she had seen the condition of the green loops then. On [DATE] at 1:05 PM, E5 (CNA Supervisor) stated the last time she checked the lift slings before R1's fall on [DATE], was probably three weeks ago. On [DATE] at 2:40 PM, E2 (Administrative Assistant) stated there is no specific policy for the lift slings. On [DATE] at 1:35 PM, E20, (CNA) stated a lift sling broke on R1 during a mechanical lift transfer shortly after she was admitted to the facility. On [DATE], at 2:15 PM, E21 (CNA) verified R1's lift sling previously broke during a transfer not long after she was admitted . R1's Face Sheet shows she was admitted on [DATE]. 2. On [DATE] at 1:45 PM, E15 (CNA) stated she and E17 (CNA) were transferring R2 with the mechanical lift when the center of a lift sling loop ripped. R2 fell on to the bed. On [DATE] at 9:45 AM, E17 verified R2 fell on to the bed when the sling loop ripped. The date of the occurrence cannot be verified because no incident report was generated and there is no documentation in the nursing notes describing the incident. On [DATE] at 11:00 AM, E10 (CNA) stated she was present for a different instance where R2's sling broke during a transfer, this time on [DATE]. E10 stated she was transferring R2 from the wheelchair into the bed with E20 (CNA). On [DATE] at 1:35 PM, E20 verified R2's sling ripped while being transferred to her bed. 3. On [DATE] at 10:30 AM, E16 (CNA) stated one of the lift sling loops snapped while R4 was being transferred. E16 stated she thought the incident occurred on [DATE]. On [DATE] at 12:45 PM, E9 (CNA) stated he entered R4's room and E16 and E5 (CNA Supervisor) were transferring R4, and he saw R4's sling loop snap during the transfer. On [DATE] at 11:45 AM, E11 (Restorative Nurse) stated she tracks the facility incident reports for falls or other incidents that occur that are out of the norm. E11 stated she has no incident reports showing any residents fell from a lift sling. E11 stated an incident report should be generated even if someone is in a mechanical lift sling and falls only inches. On [DATE] at 11:00 AM, E11 stated if an occurrence is out of the ordinary and not consistent with a resident's care plan, an incident report should be completed. E11 added if an occurrence is a near-miss and the resident has no injuries, there should be an incident report for that, too. 4. On [DATE] at 10:15 AM, R3 was in his wheelchair with a mechanical lift sling placed under him. The sling is left under the resident after the resident is transferred. The blue support loop on the sling near his right shoulder was torn. There were no documented incident/fall reports for R1's first fall, R2's falls & R4's fall. There was no documentation in the nurse's notes regarding these incidents. R1's fall report (dated [DATE]) does not show R1's fall was the result of a torn sling. The facility's [DATE] Resident Accident/Incident Reporting policy shows 1.) An accident/incident report must be completed by the nurse on duty at the time of the accident/incident. A descriptive summary of the incident must be noted in the Nurse's Notes in the resident's chart. The policy shows 3.) Reports must be forwarded to the Restorative nurse or designee upon initial completion for investigation and follow-up . The facility's [DATE] Fall Policy Purpose section shows Supervisors are required to investigate all incidents promptly for the purpose of preventing repeated incidents. The Nurse's Notes should contain complete information regarding the incident. The facility's [DATE] Fall Policy Procedure section shows 2. B. Nursing personnel will timely complete an incident report . Section C. shows Each fall will be reviewed by the Interdisciplinary Team (IDT) during daily IDT meeting or sooner. Root cause/extrinsic factors of the fall will be identified by IDT at this time. Care plan interventions to further prevent falls will be discussed and implemented, and the IDT Post Fall Evaluation form will be completed. In the lift sling Owner's Operator and Maintenance Manual, Patient Slings, (dated 2008), Section I, General Guidelines, (page 5) shows In case of damage, do not use the equipment. Section I, General Guidelines, (on page 6) includes a WARNING that shows After each laundering (in accordance with instructions on the sling), inspect sling (s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Under Care (page 6), the manual shows Air dry or dry at low temperature. Inspect with each use. On [DATE] at 12:30 PM, E1 stated (E5) checks the slings in the mornings either weekly or monthly, and laundry looks at them, too. On [DATE] at 3:00 PM, E14 (Laundry Aid) stated he usually has to dry the slings in the dryer at least once each week and he doesn't inspect the lift slings. On [DATE] at 9:55 AM, E14 stated he sets the dryer on C setting to dry the slings. E14 added it depends on the load, but one dryer cycle doesn't dry the slings. On [DATE] at 9:50 AM, E22 (Laundry and Environmental Supervisor) stated C setting on the clothes dryer is 160 degrees Fahrenheit. The Special Notes Section on page 4 categorizes the word WARNING as a signal word, which is defined as Warning indicates a potentially hazardous situation, which, if not avoided, could result in death or serious injury. Based on interview and record review the surveyor confirmed that the facility took the following actions to remove the Immediate Jeopardy: 1. A team of administrative nurses have inspected and replaced all full-body lift slings for the facility. 2. Policies for Sling Care have been developed to focus on laundering, CNA inspection prior to every use, removal from service and unusual occurrences. 3. Administrative Nurses reviewed and revised the Accident and Incident policy and procedure with focus on unusual occurrences, definition of fall, documentation and reporting regardless of injury or not. 4. Direct care staff will be in-serviced on the sling care policy and procedure by Manufacturer Representative and Regional Administrator/Nurse on [DATE]. 5. Direct care staff and Nursing staff will be in-serviced on policy and procedures for reporting and documenting unusual occurrences and definition of fall. 6. All staff will be in-serviced prior to providing care in the facility including new employees upon hire and annually. 7. Quality Assurance Root cause analysis was initiated post incident and completed on [DATE]. QA review of unusual occurrences will be completed post incident and reported to the Safety committee and QAPI committee. 8. QA Checks will be completed daily and reviewed by safety committee monthly. The trends and concerns reported to the QAPI committee quarterly.

Based on observation, interview, and record review the facility failed to ensure staff performed safe transfers while using a resident sling with a mechanical lift. The facility failed to have a system in place to ensure staff did not transfer resident with a worn out or damaged sling. The facility failed to ensure the integrity of the sling before staff used the sling during a resident transfer with a mechanical lift. These failures resulted in a sling breaking while R1 was being transferred with the mechanical lift. R1 sustained fractures to both her lower extremities and was hospitalized on [DATE]. R1's fall contributed to her death on [DATE]. The Administrator was notified of an Immediate Jeopardy on [DATE] at 9:15 AM. The Immediate Jeopardy began on [DATE] at 3:00 PM. While the immediacy was removed on [DATE] at 10:00 AM the facility remains out of compliance at Severity Level 2. Additional time is needed to monitor and evaluate the effectiveness of the revised policies and procedures to ensure their implementations. This applies to 4 of 5 (R1, R2, R3, R4,) residents reviewed for safe transfers in the sample of 5. The findings include: 1. On [DATE] at 1:15 PM, E12 Certified Nursing Assistant (CNA) stated during R1's mechanical lift transfer, the black loop (on the lift sling) snapped and (R1) went down. E12 added as far as I remember she went straight to the floor and it would be impossible to catch her when there's that much force. On [DATE] at 2:00 PM, E13 (CNA) verified the sling loop ripped during R1's transfer on [DATE]. R1's [DATE] Incident Report shows R1 was transferred to the hospital after the fall. On [DATE] at 3:30 PM, Z2 (hospital RN) stated R1 broke her left leg near her hip, and broke her right leg near her knee. On [DATE] at 10:15 AM, Z2 (family member) stated R1 died on [DATE]. On [DATE] at 8:30 AM, Z5 (physician) stated R1's fall led to her fractures, which is why R1's condition deteriorated, and the injuries contributed to her demise. On [DATE], at 12:30 PM, E1 (Administrator) showed R1's torn lift sling to surveyors. The lift sling had four loops on each of its four corners that are used for attachment to the mechanical lift (one corner each to support a patient's arms, and one corner each to support a patient's legs.) One of the black support loops on the sling was ripped in half where the loop attached to the lift bar. On [DATE] at 12:30 PM, E2 (Administrative Assistant/RN) explained the torn loop corresponded to R1's left leg during the transfer. On [DATE] at 12:30 PM, E1 examined the green support loops on the sling used during R1's [DATE] transfer. Green fabric was missing from the surface of the green loops and the black threads underneath the green surface were exposed and flexible. E1 stated lift slings should be pulled from the floor if they look like they are frayed, or tearing, or do not look sturdy. On [DATE] at 8:45 AM, E1 stated she would have pulled R1's mechanical lift sling on [DATE] (prior to R1's fall) if she had seen the condition of the green loops then. E1 also stated, it is eveyone's job to ensure a sling is in good repair before using. On [DATE] at 1:35 PM, E20 (CNA) stated R1's [DATE] fall was actually the second time a lift sling broke while transferring R1. E20 stated the first time R1's sling just snapped was during a transfer with E21 (CNA). On [DATE], at 2:15 PM, E21 verified R1's lift sling broke during a transfer shortly after she was admitted , but he could not remember the date. (R1's Face Sheet shows she was admitted to the facility on [DATE].) 2. On [DATE] at 1:45 PM, E15 (CNA) stated she and E17 (CNA) were transferring R2 with the mechanical lift when the center of a lift sling loop ripped. R2 fell on to the bed. On [DATE] at 9:45 AM, E17 verified R2 fell on to the bed when the sling loop ripped. On [DATE] at 1:55 PM, E2 (Director of Nursing) stated it was reported to her that R2's full-body mechanical lift sling had broken the same way R1's lift sling did on [DATE]. E2 stated no incident report was written for R2 because R2's sling broke before R2 had really gotten off the bed and she had no injuries. When asked what staff can learn from near-miss occurrences, E2 replied they teach us how to prevent them. On [DATE] at 11:00 AM, E10 (CNA) stated she was present on [DATE] for a second instance where R2's sling broke during a transfer. E10 stated she was transferring R2 from the wheelchair into the bed with E20 (CNA). E10 stated R2 was not fully off her wheelchair and she and E20 used a stand-up lift to transfer R2 into bed. E10 stated the lift sling ripped on the fabric where the support loops are sewn to the main part of the sling. On [DATE] at 1:35 PM, E20 verified R2's sling ripped while being transferred to her bed. On [DATE] at 9:00 AM, Z6 (family member) stated it happened once, and then it happened around two weeks later. On [DATE] at 10:30 AM, R2 stated the sling broke twice during a transfer and she gets nervous and anxious during transfers because of the occurrences. 3. On [DATE] at 10:30 AM, E16 (CNA) stated one of the lift sling loops snapped while R4 was being transferred. E16 stated she thought the incident occurred on [DATE]. On [DATE] at 12:15 PM, E16 stated R4 was being transferred out of the bed into the wheelchair. E16 stated the transfer was almost complete and R4 was a few inches above his wheelchair in the air when the loop closest to the sling snapped. E16 stated R4 landed a little sideways in his wheelchair. On [DATE] at 12:45 PM, E9 (CNA) stated he entered R4's room while E16 and E5 were transferring R4, and he saw R4's lift sling loop snap during the transfer. On [DATE] at 10:35 AM, E18, Licensed Practical Nurse (LPN) verified CNAs reported that R4's sling loop snapped and he fell into his wheelchair during a transfer with the mechanical lift. 4. On [DATE] at 10:15 AM, R3 was in his wheelchair with a mechanical lift sling placed under him. The blue support loop on the sling near his right shoulder was torn. On [DATE] at 1:05 PM, E5 (CNA Supervisor) stated the last time she checked the lift slings before R1's fall on [DATE], was probably three weeks ago. On [DATE] at 3:00 PM E5 and surveyors checked slings that were out on the floor for resident use. E5 removed 4 other mechanical lift slings that showed signs of damage or wear that were in use to transfer residents. In the Owner's Operator and Maintenance Manual, Patient Slings, (dated 2008), the Special Notes Section (page 4) categorizes the word WARNING as a signal word, which is defined as Warning indicates a potentially hazardous situation, which, if not avoided, could result in death or serious injury. The manual shows in Section I, General Guidelines, (page 5), In case of damage, do not use the equipment. Section I, General Guidelines, (page 6) includes a WARNING that shows After each laundering (in accordance with instructions on the sling), inspect sling (s) for wear, tears, and loose stitching. Bleached, torn, cut, frayed, or broken slings are unsafe and could result in injury. Discard immediately. Based on interview and record review, the surveyor confirmed the facility took the following actions to remove the Immediate Jeopardy: 1. A team of administrative nurses have inspected and replaced all full-lift slings for the facility. 2. Policies for Sling Care have been developed to focus on laundering, CNA inspection prior to every use, removal from service, and unusual occurrences. Slings will be removed from service immediately by any staff member who identifies any issue with the sling and turned in to administrative nurse. 3. All laundry staff have been ins-serviced on Sling Care Policy and Procedure. All slings are being laundered per manufacturer guidelines. Slings will be removed from service by any staff member who identifies any issue with the sling and turned in to administrative nurse. 4. Direct care staff will be in-serviced on the sling care policy and procedure by Manufacturer Representative and Regional Administrator/Nurse, including that slings will be removed from service immediately by any staff member who identifies any issue with the sling and turned in to the administrative nurse, and CNA inspection prior to every use. 5. All staff will be in-serviced prior to providing care in the facility including new employees upon hire and annually. Slings will be removed from service immediately by any staff member who identifies any issue with the sling and turned in to administrative nurse. 6. Quality Assurance Root cause analysis was initiated post incident and completed. 7. Quality Assurance tools have been developed to ensure proper sling inspection and laundering of slings. Checks will be completed daily by charge aids and reviewed by safety committee monthly. The trends and concerns reported to the QAPI committee quarterly.

Based on interview and record review the facility failed to identify pressure ulcers before deep tissue injury and stage II wounds developed and failed to ensure pressure reduction interventions were in place. The facility failed to perform a wound care treatment as ordered and failed to notifiy a physician of a wound decline. The facility failed to perform complete wound assessments, failed to monitor an area of skin concern identified on admission, and failed to ensure reddend skin areas were reported to the nurse. This applies to 2 of 8 residents ( R1, R6) reviewed for pressure in the sample of 17. The findings include: 1. R1's MDS of February 12, 2016 shows R1 requires extensive assistance from staff with transfers, bed mobility, eating, bathing, and toileting. The MDS shows R1 has 1 unstageable pressure ulcer with slough. R1's admission assessment for predicting pressure sore risk dated January 25, 2016 shows R1 was at a mild risk for pressure ulcers, and showed that R1 had no sensory impairment, was able to respond to verbal commands, and had no sensory deficit which would limit her ability to feel or voice pain or discomfort. R1's admission assessment dated [DATE], shows she was chair ridden, required help with feeding, and was forgetful and confused. This assessment showed R1 was admitted with a 1 cm reddened area to her right buttock. The next wound assessment completed on R1 was February 5, 2016 and showed a 4cm x 3 cm stage 2 pressure ulcer to R1's coccyx. There was no description of R1's wound bed, surrounding tissue, drainage, or odor. R1's Emergency Department visit records dated February 2, 2016 shows R1 had a stage II pressure ulcer to the sacrum present during the visit, and R1 would require a wound care nurse consult, and frequent adjustments of position to help with her history of a pressure ulcer while she was at the hospital. R1's February 8, 2016 assessment shows the wound increased to 6.8cm x 4.9cm x Unable to Determine the Depth, the wound bed declined, and was 100% covered with yellow/white slough and the wound was unstageable. R1's wound care clinic assessment dated [DATE] shows the original cause of R1's wound to her coccyx was from a pressure injury. This assessment shows R1 had a deep pressure ulcer wound that measured 4.5cm length x 2 cm width x 0.5 cm depth with exposed muscle, a medium amount of necrotic tissue within the wound including slough, and a large amount of necrotic foul smelling material in the wound (dead tissue). R1's skin condition report dated March 8, 2016 (return to facility from surgical debridement) shows R1's wound measured 7cm x 5.5cm x 6cm (length, width, depth), with 30% slough. R1's wound care clinic documentation dated March 2, 2016 shows R1's wound was malodorous with dark necrotic tissue visible around the entire region ,with purulent drainage. This assessment shows R1 was admitted to the hospital (from wound clinic) for a bacterial infection, and stage 4 pressure ulcer of the sacral region. R1's wound care clinic orders dated February 23, 2016 shows an order to clean the wound twice daily (and more if needed) with Dakin's (bleach based wound cleanser) or soap and water, then rinse with Dakin's, and cover with dry gauze, and moisten gauze with Dakin's sol then apply to open area and cover with gauze. R1's Pressure Ulcer care plan dated February 23, 2016 shows an intervention for treatments as ordered. R1's Treatment Administration Record (TAR) shows R1 did not receive any dressing changes with Dakin's on February 23, February 24, and the first treatment was not completed until the evening of February 25. R1's wound culture dated February 25, 2016 shows the wound had gram negative rods, E. Coli, and Extended spectrum Beta Lactamase (ESBL - bacteria) present in the wound. On March 10, 2016 at 1:30 PM, E19 (CNA-Certified Nurse Assistant) and E26 (Wound Care Nurse) positioned R1 on her left side in bed. E26 removed the dressing to R1's sacrum, and R1 had a large, grapefruit sized , deep open pressure ulcer to her sacrum. E26 cleaned the wound with saline, and a strong foul odor was present. R1's wound bed had gray, tan strands of slough present throughout, and bone was present to the center of the wound. E26 pointed to open areas around the outside of the wound on the left side and said R1 had new breakdown that wasn't there when she returned from surgery. E26 said she knows the wound is deep and described the wound odor as rotting, and said there was an increase in slough to the wound bed compared to when R1 returned from the hospital after the surgical debridement. E26 pointed to a dark circular spot inside the wound and said it was R1's exposed bone. E26 placed a 4x4 gauge pad, covered with Santyl inside the wound, and then placed 4 (4x4) Dakin's soaked gauze pads, over the gauze with Santyl, inside R1's wound, and taped a gauze pad over the top of the wound. On March 9, 2016 at 1:30 PM, Z1 (Family Member) said R1's pressure ulcer was found when she was in the ER (emergency room ) at the hospital. Z1 said when R1 got to the ER, and they rolled her over, the staff found the pressure ulcer. Z1 said R1 had it prior to going to the ER but the facility did not know it. On March 10, 2016 at 4:40 PM, E27 (LPN - Licensed Practical Nurse) said the nurses do not conduct skin assessments on residents unless an area of concern is identified by a CNA, or on admission. E27 said R1 was high risk for skin breakdown on admission to the facility. On March 11, 2016 at 8:30 AM, E23 (LPN) said the nurses rely on the CNAs to report any reddened areas they see during care to the nurses, and all reddened areas or areas of concern should be reported to the nurse by the CNAs . On March 11 at 9:00 AM, E26 (Wound Care Nurse) said if a resident has an identified area of concern like R1 did with the reddened area on admission, the site should be assessed by both nursing or the Wound Care Nurse at least twice a week until the area resolves. E26 said a complete assessment should be documented on the treatment assessment sheet. E26 said preventative measures should be put in place, including a soft foam dressing to prevent the area from breaking down. E26 said she determined how to apply R1's treatments, and did not check with the wound care clinic on how they wanted the Dakin's and Sanytl applied. E26 said she should have notified the wound care doctor on 3/10/16 after she noticed the decline in R1's wound with additional slough and breakdown present outside the wound, plus a stronger smelling foul odor. E26 said she did not notify the wound doctor of the decline. E26 said a complete assessment should be done on wounds to include size, depth, wound bed, drainage, color odor, and stage. E26 said the CNAs do skin assessments with cares and should report any areas of concern to the nurse. The nurse would then perform and document a complete assessment of that area. At 9:40 AM, E30 (LPN) said she became aware of R1's pressure ulcer when R1 returned from the hospital on February 5, 2016. E28 said the hospital said R1 arrived to the emergency room with the pressure ulcer, but she (E28) did not know R1 had one. At 10:10AM, E3 (ADON-Assistant Director of Nursing) said she felt R1 was high risk for skin breakdown on admission to the facility and R1's assessment for predicting pressure sore risk dated January 25, 2016, shows did not accurately assess R1's sensory impairment. At 10:20 AM, Z2 (Primary Care Physician) said R 1 was at a high risk for skin breakdown on admission to the facility, and the wound to her sacrum was from pressure. At 10:30 AM, E1 (Administrator) said wound care treatments should be completed as ordered. E1 and E2 said a physician should be notified immediately with a decline in a wound, and all reddened areas observed by a CNA should be reported to the nurse and an assessment completed if the area is pressure related. At 10:40 AM, E2 (DON-Director of Nursing) said R1 did not get a wound treatment with Dakin's solution on 2/23/16, 2/24/16, or in the morning on 2/26/16. E2 said the solution was not available because it was not delivered until later in the day on February 26, 2016. E2 said if a treatment square is blank, or initialed and circled, the treatment was not done. 2. R6's MDS of January 2, 2016 shows R6 requires extensive staff assistance with transfers, dressing, hygiene, bathing, and toileting. On March 8, 2016 at 11:05 AM, E9 (LPN) said R6 had an event this morning in which she had a possible [MEDICAL CONDITION] or stroke, and would not be getting out of bed, until she was more alert. On March 9, 2016 at 1:00 PM, E21 and E24 (CNAs) provided care to R6 while she was in bed. E24 said R6 had not been out of bed that day. E21 and E24 had R1 on her left side. R1 had dark red circular area to her right buttock. E24 said the area wasn't so red this morning. On March 10, 2016 at 10:00 AM, E24 said R6 had the same red areas yesterday to her right buttock. On March 11, 2016 at 8:00AM, R6 was assisted off the toilet by E8 (CNA), and R6 had a dark reddened area to her right buttock. There was no assessment of R6's reddened buttock from March 9, 2016 until March 11, 2016 (3 days after the CNA was aware it was present). The facility Skin Conditions Policy dated June, 2014 shows: We strive to attain to maintain intact and healthy skin for our residents through a process of identification, monitoring, preventative and treatment protocols. All direct care staff .will be trained to observe for and report skin conditions including redness, bruising, and skin tears.

Based on Interview and Record Review the facility failed to provide safety for residents during transfers. This failure resulted in R26 sustaining a large, deep laceration to her right leg that occured during a transfer. The facility failed to provide supervision for a resident when a general diet tray was given to a resident who cannot have anything by mouth due to Dysphagia. This is for 3 of 3 residents (R4, R6 & R26) reviewed for incidents in the sample of 29 and 8 residents (R32,33,30,34,31,35,36,38) in the supplemental sample. The findings include: 1. The Incident Report dated 12/9/12 for R26 showed, "CNA's were assisting R26 into the wheelchair using the mechanical lift. When they went up to adjust the foot pedals they noticed a large laceration to R26's right lower extremity. Upon examining the right leg, unable to steri-strip due to the depth. Only complains of pain with touch. Called the physician and nursing order received to send R26 to the emergency room ." The Nurses Note dated 12/9/12 showed, "Called to R26's room for right lower extremity bleeding and noted a laceration to the right lower extremity; R26 returned at 9:15am with 24 staples to the right lower extremity and an antibiotic order." The Resident Transfer Form dated 12/9/12 for R26 showed she was transferred to the emergency room for a laceration to her right lower leg. The hospital Discharge Intructions dated 12/9/12 for R26 showed, "Diagnosis: [REDACTED]." The Care Plan dated 9/21/12 for R26 showed, "Mechanical Lift x 2 assist for all transfers; Uses wheelchair for mobility. The Care Plan Review Notes dated 2/6/13 for R26 showed, "R26 is non-ambulatory and is assisted with wheelchair for locomotion." On 3/13/13 at 9:15am, E2 (Director of Nursing - DON) stated, "When they went to put R26 in her wheelchair her leg got caught in the foot pedal. R26 is transferred with a mechanical lift. I write who is involved in the incident on a nurses note and the nurses note goes in a folder in E1 (Admnistrator) office." The folder with the nurses notes for incident investigations was requested. On 3/13/13 at 9:55am, E2 brought a stack of incident reports to the survey team and stated that it was all of the incidents and notes for the incidents. There were no additional notes for the incident on 12/9/12 for R26. On 3/12/13 at 10:40am, E4 (Restorative Nurse/ Licensed Practical Nurse) stated, "Education was done on transfers, mechanical lifts and body mechanics because the CNA's were hurting their backs. It is done with all of the CNA staff. The inservices are usually mandatory. There are only 50 to 60 percent of the CNA's that show up to the inservices." 2. The Incident Report dated 9/3/12 for R36 showed, "R36 was brought back to his room after his shower on a shower chair. Shower aide waiting for assistance to transfer, R36 began fidgeting, fell forward landing on the right side fetal position on the floor. Right arm under him; head on the floor - 2cm round red area to right forehead. R36 moving extremities but guarding right hip. R36 assisted up with 3 assist and a gait belt. R36 yelled out when he attempted to put right foot down; Sent to the emergency room - Fractured Hip." The Incident Report dated 9/3/12 for R36 did not show who the shower aide was that was involved in the incident. The "Quality Assurance Review" (on the back of the Incident Report dated 9/3/12 for R36) showed, "Will assess proper transfer when returns." On 3/11/13 at 3:30pm, R4 stated, "The CNA's were not paying attention because they were talking to each other when they were transferring me using the mechanical lift. My toe hit the mechanical lift and that hurt. I didn't get stitches. They put steristrips on it." The Nurses Note dated 2/8/13 for R4 showed, " R4 noted to have a small skin tear to the left great toe. Cleansed with normal saline and applied steri-strips. " The Pain assessment dated [DATE] for R4 showed she was complaining of pain to her left great toe. On 3/12/13 at 12:15pm, E2 (Director of Nursing - DON) stated, " I didn ' t know anything about R4 ' s toe. " On 3/12/13 at 10:40am, E4 (Restorative Nurse/ Licensed Practical Nurse) stated, " I didn't know anything about R4's toe. I should have been told if it happened during a transfer. " The Incident Report dated 4/17/12 for R32 showed, "Hospice Certified Nursing Assistant (CNA) reported she was transferring R32 to the chair when the chair moved. CNA lowered R32 to the floor." The Incident Report dated 5/28/12 for R33 showed, "R33 just reported that her right 5th toe was run over. Toe has a 1 cm round light pink bruise, non-raised and no open skin." The Incident Report dated 7/8/12 for R30 showed, "R30 stated that when being put into bed she was hit on the left eye with a bar on the mechanical lift. R30 noted to have a 2.5cm by 1.0cm swollen area to the left eye with bruising noted." The Incident Report did not show the names of the staff involved in the incident but stated that staff were educated on the back of the form. The Incident Report dated 7/21/12 for R34 showed, "CNA was assisting resident from the recliner to the wheelchair and had to lower R34 to the floor; Called to the room and noted gait belt on but no socks or shoes." The Incident Report dated 8/3/12 for R31 showed, "CNA reports the mechanical lift bar hit R31 while transferring him to bed; 1 cm scratch noted below the left eye." The Incident Report dated 8/3/12 for R31 did not show the names of the CNA's involved in the incident and The "Quality Assurance Review" on the back of the Incident Report showed, "Staff Education on mechanical lift transfers." The Incident Report dated 8/13/12 for R35 showed, " CNA's were doing AM care and when rolling R35 they bumped the right side of her head causing a red mark." The Incident Report dated 1/4/13 for R31 showed, "CNA's report R31's sock is saturated with blood. Upon inspection of the left little toe, a laceration was noted. Staff reports R31 was being sat upright in the reclining wheelchair and his foot hit on the chair." The "Staff " that reported the incident was not identified in the incident report and the Quality Assurance Review on the back of the Incident Report was blank and did not show responses to "Incident reviewed by the Interdisciplinary Team (IDT); Immediate Interventions; Care Plan Review or Comments/Ideas." On 3/13/13 at 3:40pm, E1 (Administrator) stated, "They (Incident Reports) don't show any follow through." 3. The Physician order [REDACTED]. R38 was admitted to the facility on [DATE]. R38's admission care plan states she is not to receive anything to eat or drink by mouth. R38 has a PEG (percutaneous endoscopic gastrostomy) tube related to dysphagia and NPO fluid restriction. The Minimum Data Set of 5/31/12 states R38 receives 51% or more of her fluid and 51% or more of her nutrition needs via a gastrostomy tube. The incident report dated 5/29/12 documents "R38 was given a general diet meal tray at suppertime in her room that was prepared by the kitchen staff and passed out as a room tray. There was no name card noted on the tray. There was no sign above the bed stating she was NPO. Resident consumed approximately 50% of the tray." On the back of the incident report it is documented the resident was monitored for signs and symptoms of aspiration. However, there was no resident assessment or follow up specific to the incident documented for R38 on 5/29/12 in the nurses' notes. On 3/13/13 at 10:20 AM, E2 (Director of Nurses) stated she could not recall the incident and was not sure how it happened (that R38 was served a general diet tray). E2 stated " "CNA staff are informed of dietary restrictions verbally, on the delegate sheets and a sign should be posted in the room." E2 stated she did not have any investigation notes or follow up actions relative to the incident. On 3/12/13 at 3:20 PM, E12 (Registered Nurse) confirmed she was on duty during the shift when R38 consumed the general diet tray on 5/29/12. E12 stated R38 was a fairly new admission and was ordered NPO because she had dysphagia and received her feedings through a stomach tube (PEG). E12 stated R38 received a general diet and ate half of a sandwich before the error was discovered. E12 stated the CNA staff are informed of diet orders through their verbal report and on the delegate sheets. 4. The Physician order [REDACTED]. The Minimum (MDS) data set [DATE] shows R6 requires a mechanical lift for transfers and has range of motion limitation of both lower extremities. The incident report dated 10/6/12 at 9:00 PM states, "The CNA reports that the loop of the (mechanical) lift sling hit R6's left eye. The left eye noted to have periorbital redness with no edema, and the sclera was reddened, with a small amount of yellow drainage present." On the back of the unsigned incident report for R6 on 10/6/12, it is documented the plan was to investigate how it happened and in-service the staff. On 3/12/13 at 10:40 AM, E4 (Restorative Nurse - LPN) stated, "I believe we discussed the incident the next day during the morning meeting. E2 stated she was going to find out who was involved and follow up. It is out of my hands." E4 continued, "I wrote in the communication book that attention needs to be on what they are doing, this should not have happened." E4 added, "I have no idea who was involved in this incident". E4 stated she has in-serviced the staff on mechanical lift transfers but it was related to staff having back injuries and using poor body mechanics. On 3/12/13 at 10:45 AM, E1 (Administrator) stated, "This error is on the part of the people transferring R6. I have no idea who was involved." The surveyor requested the incident investigation and/or notes of the follow up actions taken. No report was submitted during the survey.

Based on observation, interview, and record review the facility failed to provide medically related social services for R1 by not developing interventions to protect or reassure R1 after an incident between R1 and R2. These failures resulted in R1 being afraid to leave her room, having a fear of going to the dining room for meals, and being worried for her safety. These fears caused R1 to experience increased anxiety resulting in respiratory distress, and feeling afraid all the time. This applies to 1 of 3 residents (R1) reviewed for medically related social services in the sample of 3. The findings include: R1's Minimum Data Set (MDS) of 11/17/12, shows that R1 is cognitively intact and has had an increase in depressive symptoms since the previous MDS (11/1/2012). A depression/mood care plan, dated 9/3/12, does not document R1 has a history of anxiety or fear. R1's Abuse/Neglect assessment dated [DATE] identifies R1 as being at high risk for abuse/neglect related to her "physical impairment", and "dependence on others for care and eating". A facility investigation report, signed by E1 (Administrator) states, "Received report of possible resident to resident abuse 2/20/13. Resident's were seated together in dining room when (R2) reached over and grabbed R1's hotdog and crumbled it up. (R1) moved (R2's) hand away at which time (R2) grabbed (R1's) left arm causing skin tear in 2 places with some bruising noted..." An undated and untimed nurse's note documents R1 alerted a nursing assistant that she could not get her breath. The nurse documents the resident was in respiratory distress with an oxygen saturation of 78% on room air. The note states the resident was given a nebulizer treatment and pain medication. The physician was notified of the situation. A facility "A/I Log" of 2/20/2013 states, "(R1) was attacked by (R2), R1 very upset, and oxygen saturation was 78%." A bruise report, dated 2/22/2013, documents R1 has 2 bruises on her left arm measuring 3.2 cm (centimeters)X 3.5 cm and the other measuring 2.7 cm X 3.9 cm. R1 had a skin tear measuring 3.0 cm X 3.0 cm. The report also documents R1 had a bruise to the left anterior hand measuring 4.1 cm X 1.1 cm. On 2/26/2013 at 11:18 AM, E1 and E2 (Director of Nursing) were interviewed. E2 verified the respiratory distress documented occurred on 2/20/2012, in the evening in the dining room after the incident between R1 and R2. E1 said R1 told her she was having a hard time breathing because she was anxious and scared over the incident in the dining room. On 2/26/13 at 11:30 AM, R1 stated, "I don't feel like they watch her. This is my home and I should be able to live here and feel safe. I should not have to be afraid all the time in my own home. She walks up and down the halls at night, goes in and out of everyone's rooms, and she walks in my room and touches everything". R1 said on 2/20/2013, she was sitting in the dining room, waiting for dinner, when she was approached by R2. R1 said R2 is "not all there", she wanders from table to table, taking clothing protectors and silverware from other residents. She wipes tables with the clothing protectors. R1 said R2 took her clothing protector and when R1 asked for it back, R2 became angry, told her no, and called her a name. R2 told R1 she was "going to spit on her". R1 said she raised her arm to protect her face and R2 grabbed it with her hand. R1 said, "(R2) grabbed and squeezed my arm and the force of her strength was so strong that it took four women to get her off of me". R1 said when R2 shook her arm it caused her arm to bleed and left bruises. R1 said after the incident, she told a Nursing Assistant in the dining room that she did not want to sit by R2 anymore. Staff moved R2 but she kept going back to R1's table. R1 stated, "I don't want to go to the dining room to be by her, I'm worried she will do it again to me or someone else". R1 stated, "I feel like I constantly have to look over my shoulder to see where she is because I am afraid she will come up to me and if you felt the force of her strength you wouldn't want to be there either". R1 said, "Every time I go to the dining room I feel anxious". R1 said later that night she was thinking about what had happened in the dining room and became very anxious. R1 stated, "My heart rate went up, I couldn't breathe, my oxygen level dropped down low, and the nurse had to give me a breathing treatment and call my doctor". R1 showed her left arm injury to the surveyor. A scabbed skin tear approximately 4 inches long, and bruising was noted to her left forearm. R1 said on the day after the incident she was in the blue room making a phone call. She said R2 came up to her "a couple times" and would not leave. R1 said she had to ask a CNA to make her leave the room. R1 said, "I was afraid when she kept coming up to me because I have no legs and only one good arm and cannot protect myself or get away from her if she tries to hurt me and every time I turn around, I'm worried about where she is." On 2/26/13 at 9:30 AM, a confidential interview took place. The interviewee verified R1 was on the phone the day after the dining room incident (2/20/2013). R2 kept coming up to R1. The interviewee said, " R1 was scared. R2 had to be removed from the area." On 2/26/13 at 12:35 PM, E3 (social service designee) said she spoke with R1 after the incident occurred between R1 and R2. She said they talked about her dining experience and food preferences. E3 said she did not discuss the altercation between R1 and R2. E3 said she was not aware that any other facility staff discussed the incident with her either. Quarterly social service Progress Notes, dated 2/20/13, show that the incident involving R1 and R2 were not discussed with R1. R1's concerns, fears, and anxiety regarding the 2/20/2013 altercation were not discussed. On 2/26/13, at 1:00 PM, E2 (DON) and E4 (Registered Nurse) were interviewed. E2 said no interventions to protect or reassure R1 had been initiated since the incident occurred. E4 said no interventions were put into place for R1 because she was not the one who exhibited the behaviors during the incident. The facility's Abuse Prevention Program (undated) states, "This facility desires to prevent abuse, neglect or misappropriation of property by establishing a resident sensitive and resident secure environment..."