Every finding on record at Gillespie Health & Rehab CTR

Based on observation, record review, and interview, facility failed to ensure sufficient nursing staff to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being. This has the potential to affect all 75 residents residing in the facility.Findings include:1.R85's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, sepsis, chronic obstructive pulmonary disease and type two diabetes mellitus. R85's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact, required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers from staff. On 5/18/26 at 9:54 AM, R85 stated her only concern is the wait times for call lights. R85 stated sometimes her call light is never answered, and she will soil herself by the time they get to her. On 5/19/26 at 9:27 AM, R85's call light was on and blinking red. On 5/19/26 at 9:40 AM, V2 director of nursing (DON) assisted R85. 2.R54's Facesheet with a print date of 5/21/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, peritoneal abscess, protein calorie malnutrition, and artificial openings of gastrointestinal tract status. R54's MDS dated [DATE] documented he was cognitively intact and dependent on staff for toileting hygiene. On 5/19/26 at 9:18 AM, R54's call light was on. On 5/19/26 at 9:24 AM, V17 registred nurse (RN) walked past R54's room while call light was still on and did not check on him. On 5/19/26 at 9:29 AM, V16 certified nursing assistant (CNA) stated she couldn't help answer call lights because she had a resident with an alarm she could not leave. V16 went to check on R54's call light. 3.R83's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute kidney failure, asthma, and type two diabetes mellitus. R83's (MDS) dated [DATE] documented she was cognitively intact and required partial/moderate assistance from staff with toileting hygiene and toileting transfers. On 5/18/26 at 9:47 AM, R83 stated she was waiting for assistance to use the restroom. R83 was sitting in her wheelchair right outside her doorway and requested help from V12 certified nursing assistant (CNA) who told her she would be right there. R83 stated she doesn't know how long she has been waiting. On 5/18/26 at 9:59 AM, R83 was sitting in her wheelchair outside her door. R83 stated she was still waiting to be helped to the restroom. V12 (CNA) walked over and assisted R83 to her restroom at that time after she was done talking to another employee in the hallway. 4.R79's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, heart failure and type two diabetes mellitus. On 5/18/26 at 10:00 AM, R79 stated she doesn't get enough attention. R79 stated the call light response times can be 30 minutes. On 5/19/26 at 9:37 AM, R79's call light was on and she was yelling help me, I know you can hear me and just ignoring me. On 5/19/26 at 9:45 AM, R79 stated to V17 (RN) she pooped her pants as she was getting her medications and her call light was on. V2 director of nursing (DON) and V12 (CNA) assisted R79. 5.R56's Facesheet with a print date of 5/21/24 documented she was admitted to the facility on [DATE] with diagnosis of, in part, congestive heart failure, atrial fibrillation, and hypertension. R56's MDS dated [DATE] documented she was cognitively intact and dependent on staff for toileting hygiene and toileting transfers. On 5/18/26 at 9:36 AM, R56 stated her concerns is a management problem because there's not enough staff. R56 stated they schedule one aide at night down her hall and this morning she woke up around 3:05 AM needing to use the restroom. R56 stated she used her call light for assistance, but she didn't get helped until 5:25 AM. R56 stated she had to hold it until she was helped and that was too long. On 5/20/26 at 9:15 AM, R56 stated she has to wait long times for to use the restroom because of short staffing. R56 stated when they only have one aide assigned for the hall and she goes on break, no one comes in her place to take over and she has to wait. R56 stated she pays a lot of money to get more assistance. Resident Council Meeting Minutes dated 1/5/26 documented, On New Years night the call light was not answered at a timely manner when roommate needed help. Resident Council Meeting Minutes dated 2/2025 documented residents expressed concern about the length time oak hall residents wait to be toileted after lunch due to 5:00 AM to 1:00 PM shift aides leaving at this time. Resident Council Meeting Minutes dated 5/4/26 documented, CNA comes in to give care and watches T.V. (television) or looks out the window before they get to the resident. Resident Council Meeting Minutes dated 5/2025 documented, Oak residents ask for additional staff to combat behaviors on midnight shift. The policy continued to document, Residents question the possibility of acquiring help for the ward clerk to catch up on undone previous work. On 5/21/26 at 1:29 PM, V2 (DON) stated everyone wants to get help at the same time and one person can't answer 18 call lights at the same time. V2 stated her and V1 have been working the floor to help provide nursing coverage. On 5/21/26 at 1:34 PM, V1 (Administrator) stated they go off of the census and regulations for staffing. 6. R3's admission Record, dated 5/20/26, documents R3 was originally admitted to the facility on [DATE]. R3's Minimum Data Set (MDS), dated [DATE], documents R3 is cognitively intact. On 5/18/26 at 10:35 AM, R3 stated they have good staff, just not enough of them and sometimes she has to wait for assistance because they are assisting others and no one else available to help. 7. R23's admission Record, dated 5/20/26, documents R23 was originally admitted to the facility on [DATE]. R23's MDS, dated [DATE], documents R23 is cognitively intact. On 5/18/26 at 10:15 AM, R23 stated she falls a lot and that she uses her call lights and depending on staffing, sometimes it takes 20-40 minutes to get someone to answer it to help her, or they will come in and turn it off and say they will be back and forget to come back. R23 stated they need more help. 8. On 5/19/26 at 10:00 AM a Resident Council Meeting was held with R21, R39, R41, and R58 attending. R21, R39, R41, and R58 all stated that there are times when they use the call light. R21, R39, R41, and R58 stated that it takes a long time to get it answered and get the help they need. All agreed that it is not one particular time of the day. They all agreed that it could be anytime they use their call light, most of the time they answer timely, but there are times they must wait because staff is with other residents, and they have no one else to assist them. When asked if they feel the facility has enough staff to take care of them and all other residents' needs, they all stated No, they need more help. R21's Minimum Data Set (MDS) dated [DATE], documents that R21 is moderately cognitively impaired. R4's Transfer Evaluation, dated 5/4/2026, documents that R21 is alert and oriented. On 5/19/26 at 10:00 AM R21 stated that sometimes they don't come at all because there is no one to answer it. On 5/21/2026 at 10:57 AM V1, Administrator, stated that when she doesn't have enough aides, she uses LPNs (Licensed Practical Nurses) on the floor. V1 stated that she is actively hiring and currently has 2 interviews set up. 9. PBJ (Payroll Based Journal) Staffing Data Report FY (fiscal year) Quarter 1 2026 (October 1 - December 31) documents Excessively Low Weekend Staffing Triggered. Facility Submitted Weekend Staffing data is excessively low. The Long-Term Care Facility Application for Medicare and Medicaid, dated 5/18/2026, documents 75 total residents.

Based on observation, interview, and record review, the facility failed to properly store, label, and discard expired medication. This has the potential to affect all 75 residents residing in the facility.Findings include:On 5/18/2026 at 10:34 AM the 300/400 Medication Cart was inspected. The medication contained:1. R68's open and partially used multidose Novolog Pen. No open date on pen.2. R59's open and partially used multidose Novolog Pen. No open date on pen.3. R89's open and partially used multidose Artificial eye drops bottle. No open date in place.4. R6's open and partially used multidose Timolol eye drops bottle. No open date in place.5. 1 open and partially used bottle of Ofloxacin Ophthalmic solution. No name or open date on bottle.On 5/18/2026 at 10:35 AM V9, Licensed Practical Nurse (LPN) stated that R68's, R59's, R89's, and R6's medications were open and in use. V9 stated that the medications have a shortened expiration date once open. V9 stated that the handwritten date is how they tell what the new shortened date is. V9 stated that she does not know who the ofloxacin belonged to. V9 stated that the medication should be in its original container and labeled with a person's name.On 5/18/2026 at 11:05 AM the 300/400 hall Medication room was inspected. The medication room contained:6. 9 bottles of ear wax solution. Expiration date 6/25.7. 16 Acetaminophen Suppositories. Expiration dated 3/2026.On 5/18/2026 at 11:05 AM V1, Administrator, stated the medication is stock are for everyone with an order. V1 stated that the ear wax solution and suppositories should have removed from stock and destroyed.On 5/20/2026 at 9:49 AM V26, LPN stated that insulin and eye drops are to have a resident's name and open date. V26 stated that once these medications are open, they have a shortened use by and expiration date of 30 days. V26 stated that the handwritten date alerts them to the new expiration date. V26 the medication should be stored in its original packaging. If not, there should be identifiers such as the resident's name. V26 stated that stock medications can be given to any resident with an order. V26 stated that expired medications are removed from use and destroyed.The facility's Medication Storage policy, dated 7/1/23, documents that PURPOSE: To provide guidance to facility nursing staff on the proper storage of medication. Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and In accordance with state and federal regulations. Policy Interpretation and Implementation: 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date.The facility's Insulin Administration via vial Procedure, not dated, documents that Purpose: To provide guidelines for the safe administration of Insulin to residents with diabetes. Preparation: 5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use. General Guidelines: Steps in the Procedure: 4. Check expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendation for expiration after opening).The [NAME] Tree Pharmacy Medication Administration policy, dated 4/21/23, documents that Expiration Dating (Beyond-use dating) C. Certain medications or package types, such as IV solutions, multiple injectable vials, ophthalmic, nitroglycerin tablets, blood sugar testing strips, once opened, require an expiration shorter than the manufacturers' expiration date to insure medication purity and potency. D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated.The Long-Term Care Facility Application for Medicare and Medicaid, dated 5/18/2026, documents 75 total residents.

Based on observation, interview and record review the facility failed to perform complete incontinent care for 4 of 5 (R2, R45, R65, R70) residents reviewed for toileting in a sample of 39. Findings include: 1 R45's Care Plan, dated 2/5/2024, documents that R45 has Self-Care Deficit As Evidenced by: Needs assistance with ADLs (Activities of Daily Living) Related to right side deficits due to CVA (stroke). It also documents Toilet Use: Two person physical assistance required. R45's Minimum Data Set (MDS), dated [DATE], documents that R45 is cognitively impaired frequently incontinent of bowel, always incontinent of urine and dependent on staff for toileting. On 5/18/2026 at 9:55 AM V7, Certified Nurse Assistant (CNA), assisted R45 onto the toilet using a mechanical lift. V7 pulled R45's pants and incontinent brief down revealing that R45 was incontinent of urine. V7 then removed the urine soiled brief and lowered R45 onto the toilet. R45 then indicated she needed to have a bowel movement. With R45 on the toilet V7 then left the room. At 10:15 V8, CNA, assisted R45 with toileting and off the toilet. R45 had a bowel movement. V7 using toilet paper wiped R45's anal area. V7 then applied R45's incontinent brief and pulled up R45's pants. V7 then assisted R45 from the bathroom to the bed. V7 did not cleanse R45's peri area, vaginal area, inner and outer labia, inner and outer thigh or both buttocks. On 5/20/2026 at 9:55 AM V8 stated that when cleaning a resident that is incontinent you clean all areas. V8 stated that this includes the groin, peri area, vagina, buttocks, inner and outer thighs and both buttocks. V8 stated that when a resident is placed on the toilet and is incontinent care that resident receives peri care. V8 stated that she was notified by V7 that R45 was on the toilet. V8 stated that she was not informed that R45 was incontinent. V8 stated that once in the bathroom she became aware that R45 had a bowel movement. V8 stated that she was not aware of R45 being incontinent or she would have provided peri care. On 5/20/2026 at 10:00 AM V16, CNA, stated that when cleaning a resident incontinent of urine the peri area, groin, vagina, penis, inner thighs and buttocks are cleaned. V16 stated that if a resident is incontinent and placed on the toilet that resident would be given peri care the same as if they were incontinent and in the bed. V16 stated that if she did not place the incontinent resident on the toilet she would not know they were incontinent. V16 stated that it would need to be communicated to her that the resident was incontinent so that the right care could be given. 2. On 05/19/2026 at 9:48AM During incontinent care R70 in bed on back. V6 CNA and V19 CNA removed wet pants, adult diaper and Hoyer sling and placed in bag. After removing both CNA's sanitized hands and donned gloves. V19 CNA with cleansing wipe wiped R groin, disposed of wipe, obtained another wipe and cleansed L groin, disposed of wipe, with clean wipe, wiped down front of peri area, disposed of wipe, with clean wipe took one hand separated labia and wiped front to back. V19 then removed gloves, sanitized hands and donned clean gloves. R70 then turned to right side facing V6. V19 CNA did not cleanse R70's inner thighs prior to turning to right side. V19 then with clean wipe wiped R70 from front to back, visible stool on wipe, removed gloves, cleansed hands and donned new gloves then obtained wipe, repeated this process 3 times until no visible stool seen on wipe. then placed clean pad under old pad and rolled adult diaper part way under R70. V19 did not cleans R70's buttocks prior to turning. V6 CNA then removed old pad unfolded new pad and unfolded adult diaper. With R70 on her back both secured adult diaper. R 70's care plan dated 4/22/2026 documents R70 as a potential for impaired skin integrity related to: Dementia, edema to bilateral extremities, occasional incontinence. R70's care plan documents intervention to provide peri care as needed. R70's Minimum Data Set (MDS), dated [DATE] documents R70 is always incontinent of bowel and bladder. R 70's undated face sheet documents a diagnosis in part of CHRONIC KIDNEY DISEASE, STAGE 5. On 5/21/2026 at 9:36AM V5, CNA stated when providing incontinent care all areas are to be cleansed including legs. 3. R2's admission Record, dated 5/20/26, documents R2 was originally admitted to the facility on [DATE]. R2's Care Plan, dated 1/11/23, documents R2 at risk for impaired skin/DTI (deep tissue injury) related to immobility and incontinence. R2 needs one assist for bed mobility, dressing, personal hygiene. Interventions: Provide incontinence care after each episode according to facility protocol. R2's MDS, dated [DATE], documents R2 has a severe cognitive impairment and is dependent on staff for ADLs with substantial/maximal assistance for transfers. R2 is frequently incontinent of both bowel and bladder. On 5/19/26 at 9:10 AM, R2 sitting in wheelchair with V6, CNA, entering to transfer R2 to the restroom. V6 brought in the sit-to-stand device and transferred R2 to the restroom. V6 pulled R2's pants and incontinence brief down and R2 was lowered to the toilet. R2 had a bowel movement (BM) and was ready to be cleaned up. V6 had R2 stand up using the assist device, while V6 used a handful of toilet paper and wiped R2's anal area. V6 then lowered R2 back to the toilet, changed gloves and did hand hygiene, then lifted R2 back off the toilet, pulled R2's brief and pants up without wiping the front side, vaginal area, or buttocks of R2. 4. R65's admission Record, dated 5/20/26, documents R65 was originally admitted to the facility on [DATE]. R65's Care Plan, dated 2/20/26, documents R65 needs assistance with ADLs related to weakness, falls, impaired balance/gait/mobility. Interventions: Toilet Use: One-person physical assist required. R65 has the potential for impaired skin integrity related to weakness, falls, and impaired balance/gait/mobility. Interventions: Assist/provide peri-care after each incontinence episode. R65's MDS, dated [DATE], documents R65 is cognitively intact and requires partial/moderate assistance from staff for ADLs and transfers. R65 is frequently incontinent of both bowel and bladder. On 5/19/26 at 9:32 AM, R65 stated she is not sure if she still has a wound on her butt but believes they are still doing dressing changes. V5, CNA, entered to assist R65 to the restroom. V5 did not don gloves and applied a gait belt around R65 and assisted her to stand with her walker, then R65 ambulated to restroom. V5 still without gloves on, pulled R65's pants and incontinence brief down and used her bare hands to spread R65's buttocks to show R65's coccyx (wound appeared healed). V5 then assisted R65 to sit on the toilet. V5 then donned gloves to clean R65 who had a bowel movement (BM) while on the toilet. V5 assisted R65 to stand and hold onto her walker while she got toilet paper and wiped R65's anal area several times. V5 then kept the same soiled gloves on and pulled R65's incontinence brief and pants back up. V5 then doffed her gloves and assisted R65 to ambulate back to her bed to lie down. V5 did not wipe R65's front side, vaginal area or buttocks during peri-care. On 5/21/26 at 10:18 AM, V24, CNA, stated when doing peri-care, if she is helping a resident on the toilet and they were voiding or having a BM, she will clean front and back sides because most likely, they voided urine as well as having a BM. V24 stated she changes gloves when they are visibly soiled and does hand hygiene upon entering a resident's room, between glove changes, and upon exiting the room. On 5/21/26 at 9:35 AM, V2, Director of Nursing (DON), stated I would expect the staff to provide complete incontinent care, even when the resident is using the toilet. I would expect all staff to perform hand hygiene and glove changes when appropriate. The facility's Resident Council Meeting minutes, dated 2/4/25, documents in part Resident's expressed concern about the length of time oak hall residents wait to be toileted after lunch due to the 5AM to 1PM shift aides leaving at this time. Activity director informed residents that a 1PM to 9PM aide is only scheduled on certain days. The facility's Incontinence Care Policy, dated 7/1/23, documents in part All incontinent residents will receive incontinence care in order to keep skin clean, dry arid free of irritationand/or odor. Incontinence care will be provided as required. Procedure: 1. Assemble equipment. 5. Perform hand hygiene, apply gloves. 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. 12. Perform hand hygiene. The facility's Handwashing/Hang Hygiene Policy, undated, documents in part This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel; residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly wiled. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively; soap (antimicrobial or nonantimicrobial) and water for the following situations: b. Before and after direct contact with residents; g, Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or body fluids; j. After handling used dressings, contaminated equipment, etc.; k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; l. After removing gloves; o. Before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview and record review the facility failed to perform hand hygiene, change gloves, follow enhanced barrier precautions, ensure adaptive devices were in clean condition that promoted infection control standards of practice for 4 of 4 (R2, R8, R12, R42, R65, R68) reviewed for infection control in a sample of 39.Findings include:1 On 5/19/2026 at 9:53 AM observed V13, Certified Nurse Assistance (CNA), and V16, CNA, perform incontinent care. R68 was incontinent of urine. V13 and V16 assisted R68 into a standing position revealing urine-soaked pants and wheelchair cushion. V13 and V16 assisted R68 into the bathroom and provided peri care, changed R68's urine-soaked incontinent brief and pants. V13 and V16 then placed R68 back in the wheelchair on top of the urine-soaked wheelchair cushion. V13 and V16 did not cover, cleanse or replace R68's wheelchair cushion prior to placing him on it. On 5/20/2026 at 9:55 AM V8, CNA, stated that if a resident is soiled through to the wheelchair cushion, after cleansing the resident she would place them in the bed or in the recliner or chair in the room. V8 stated that the cushion would have to be cleansed prior to sitting the resident in it. On 5/20/2026 at 10:00 AM V16, CNA, stated that when toileting R68 they cleaned him, changed his clothes and placed him back in the wheelchair. V16 stated that when the chair is soiled with urine it is to be cleaned before placing the resident back in it. 2. On 05/20/2026 at10:00 AM Wound treatment on R8 observed with V26 Licensed Practical Nurse (LPN). Sign posted on door documents enhanced barrier. V26 LPN donned gown and entered room with wound treatment supplies V26 did not sanitize hands and don gloves prior to entering the room. V26 placed napkins on top of R8's bedside table. V26, LPN into bathroom and washed hands with soap and water donned gloves. V26 then had R8 turn to left side, dressing had already been removed. V26 LPN cleansed wound with wound cleanser, after treatment to R8's sacral wound V26 removed gloves and gown tied trash bag and exited room with trash and wound cleanser. V26 did not sanitize hands after exiting room. V26 then walked down hall with trash bag and entered soiled utility room. R8's undated face sheet documents a diagnosis in part, acute transverse Myelitis in demyelinating disease of central nervous system. R8's care plan dated 5/9/2026 documents R8 has a pressure sore to coccyx. On 5/21/2026 at 9:36AM V5, CNA stated if providing care to resident with wound would sanitize hands, don gown and gloves when entering room. The Enhanced Barrier Precaution sign documents Stop Enhanced Barrier Precautions Everyone Must: Clean their hands, including beore entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities; dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, wound care: any skin opening requiring a dressing. 3. R65's admission Record, dated 5/20/26, documents R65 was originally admitted to the facility on [DATE]. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact. On 5/19/26 at 9:32 AM, R65 stated she is not sure if she still has a wound on her butt or not, but believes they are still doing dressing changes. V5, Certified Nursing Assistant (CNA), entered to assist R65 to the restroom. V5 did not don gloves and applied a gait belt around R65 and assisted her to stand with her walker, then R65 ambulated to the restroom. V5 still without gloves on, pulled R65's pants and incontinence brief down and used her bare hands to spread R65's buttocks to show R65's coccyx. V5 then assisted R65 to sit on the toilet. V5 then donned gloves to clean R65 who had a bowel movement (BM) while on the toilet. V5 assisted R65 to stand and hold onto her walker while she got toilet paper and wiped R65's anal area several times. V5 then kept the same soiled gloves on and pulled R65's incontinence brief and pants back up. V5 then doffed her gloves and assisted R65 to ambulate back to her bed to lie down with no gloves. 4. R2's admission Record, dated 5/20/26, documents R2 was originally admitted to the facility on [DATE]. On 5/20/26 at 9:47 AM, V26, LPN, brought in dressing supplies to change R2's chest wound. V26 stopped as she entered the room and saw the Enhanced Barrier Precautions (EBP) sign on the door, donned PPE, then entered the room. No hand hygiene was done prior to donning gloves. V26 removed R2's dressing which was dated 5/20/26. V26 washed her hands and donned clean gloves, then used wound cleaner and 4x4's to clean R2's wound under her right breast. V26 then kept the same soiled gloves on and dried the site, then put xeroform dressing onto the wound, and applied occlusive dressing to site. 5. On 5/18/26 at 12:15 PM during the Lunch Observation:V6, CNA, was seen grabbing R16's dinner roll with her hands and buttered the roll with no hand hygiene seen done. V6 was also seen grabbing R12's dinner roll and buttering it with bare hands, then continued to provide feeding assistance while sitting between R2 and R12 and no hand hygiene seen done between residents. V7, CNA, seen assisting R42 and used her bare hands to grab R42's dinner roll and butter it. V8, CNA, was seen using her bare hands to pick up R2's dinner roll to butter it, then used one of her bare hands and a knife to grab R2's toasted cheese sandwich and cut it in half. No hand hygiene seen done. On 5/21/26 at 10:18 AM, V24, CNA, stated she changes gloves when they are visibly soiled, and does hand hygiene upon entering a resident's room, between glove changes, and upon exiting the room. On 5/21/26 at 9:35 AM, V2, DON, stated I would expect all staff to perform hand hygiene and glove changes when appropriate. I would expect all staff who are assisting a resident with feeding to perform hand hygiene between residents and to use gloves when appropriate to avoid using their bare hands to handle the food. The facility's Handwashing/Hang Hygiene Policy, undated, documents in part This facility considers hand hygiene the primary means to prevent the spread of infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel; residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: a. When hands are visibly wiled. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively; soap (antimicrobial or nonantimicrobial) and water for the following situations: b. Before and after direct contact with residents; g, Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or body fluids; j. After handling used dressings, contaminated equipment, etc., k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; l. After removing gloves; o. Before and after assisting a resident with meals. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview and record review the facility failed to implement an individualized transfer plan, initiate and implement appropriate interventions for 4 of 8 residents (R20, R9, R17 and R39) reviewed for accidents in the sample of 39.The findings include: 1 On 5/20/2026 at 9:02AM V24 Certified Nursing Assistant (CNA) and V23 CNA transferred R20 from wheelchair to bed with mechanical lift. Prior to transfer R20 sitting in wheelchair with sling in place. After attaching sling straps to the lift. V23 CNA operated the lift. V24 held on to sling and V24 placed her right foot on bar underneath wheelchair that attaches to wheel of wheelchair. R20's Minimum Data Sheet (MDS) dated [DATE] documents R20 is cognitively intact with a Brief Interview of Mental status (BIMS) of 15. R20's MDS documents R20 is dependent on staff for chair to bed transfer. R20's care plan dated 10/20/2025 document R20 needs assistance with Activities of Daily Living (ADL's) related to limited Range of Motion (ROM) to bilateral shoulders as well a muscle weakness and wasting. R20's care plan documents intervention 10/20/2025 transfer- mechanical lift. R20's care plan fails to document any instructions of how to transfer R20 with the mechanical lift. R20's undated face sheet documents in part a diagnosis of spinal stenosis, thoracic region, other intervertebral disc degeneration, thoracic region. On 5/18/2026 at 9:28AM R20 in her room in bed with hospital gown on with hob (head of bed) elevated. R20 stated back in September she was being transferred from the chair to bed by 2 CNA's. R20 stated one of the CNA's was not very attentive. R20 stated one CNA was messing with the blinds and the other CNA was mad at other CNA and yelling at her. R20 stated the chair was flipped backwards during mechanical lift transfer. R20 stated she did not fall out of the wheelchair or hit the floor. R4 stated she was 4 inches from the floor. R4 stated this caused pressure on her tailbone. R20 stated she required the use of numbing cream to her tailbone. R20 stated she does not remember the name of the staff. R20 stated the staff need to be trained. 05/19/2026 3:08 PM V20 CNA stated when transferring R20 from the chair to the bed you have to hold foot on the chair or the chair will also be lifted with the lift. V20 stated R20 needs a bigger chair. On 5/20/2026 at 9:04AM V24, CNA stated she placed her foot on the bar on wheelchair to keep the wheelchair in place. The facility compliance incident documentation, undated documents R20 made a complaint to internal compliance consulting on the evening of 9/20//2026.In the report R20 stated 2 CNAs were assisting in moving R20. R20 stated the individual in charge of steadying the wheelchair was unable to assist in getting R20 up and into it from the mechanical lift. The report documents R20 stated the lift operator became flustered and began yelling. R20 further stated that the staff responsible for the wheelchair was looking out the window and not paying attention. The facility corrective action plan completed by V1, Administrator on 9/25/2026 documents issue/problem; while staff were attempting to transfer R20 from her w/c (wheelchair) to bed with total lift the wheelchair was tipping. Staff lowered R20 back down in wheelchair twice and then went to get the nurse to help with the transfer. The plan documents root cause evaluation: resident too large for her wheelchair and refuses to let the facility get her a larger one. The corrective action plan documents action steps: discuss with resident about getting a bigger chair and she declines. Talked with staff and re-educated new employee on transfers and personally trained employee on how to transfer resident out of wheelchair with total lift to bed on 9/24/2025. The corrective action plan documents improvement benchmarks and timeframe; for staff to properly transfer R20 from wheelchair to bed when they work on 9/25/2025. On 5/19/2026 at 1:41PM V1, administrator presented staff training dated 10/26/25 CNA October 2025 meeting including safe handling policy. V1, administrator was asked by surveyor how this training benefited staff when R20 required different plan for the transfer due to her chair. V1 administrator stated, I personally retrained the 2 staff she had a problem with and had them do a return demonstration. On 5/20/2026 at 4:01 PM V30 CNA stated I was a new employee I think it was my first day. I did not know you were supposed to hold R20's wheelchair so it would not come up with the lift. V30 stated she had not been trained on transfers on R20 prior to transferring R20. The facility policy safe handling dated 7/1/23 documents to provide staff guidance on promoting resident safety through safe resident handling/transfers. The policy documents In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. The policy documents it is the responsibility of all nursing staff to know the safe handling policy and procedures. The policy documents resident safety, dignity, comfort and medical condition will be Incorporated Into goals and decisions regarding the safe lifting and moving of residents. The policy documents Nursing staff, in conjunction with the rehabilitation staff, shall assess Individual residents' needs for transfer assistance on an ongoing basis. The policy documents staff will document resident transferring and lifting needs in the care plan. 2. R9's Care Plan, dated 2/5/24, documents that R9 is at risk for falls and injuries r/t (related to) Medications: Cardiovascular Meds/Pain Meds. Medical Factors: metabolic encephalopathy, HTN, arthritis, sciatica, spinal stenosis, muscle weakness, requires wheelchair for mobility. It also documents 10/2/2024 Assess toileting needs. 11/05/2025- educate staff on keeping foot pedals and foot board on while in wheelchair. 01/30/2025- Dysum placed to seat of wheelchair. R9's Minimum Data Set, dated [DATE], documents that R9 is cognitively impaired and dependent on staff to transfer. R9's Fall Assessment, dated 4/6/2026, documents that R9 is at high risk for falls. R9's F/U (follow up) Occurrence Note, dated 5/18/2026 at 10:25 AM, documents Note Text: Incident Note: Resident was observed on the floor by state surveyor, this writer was told, then gathered assistance, assessed resident for pain, collected vitals, don (Director of Nursing) was present and admin (Administrator) was notified. Poa (Power of Attorney) was called, and MD (doctor) was made aware. resident was sent to ER (emergency room) for eval. R9's Incident report, dated 11/5/2025, documents that R9 slid to floor attempting to stand. It also documents that cause of fall was due to staff not having interventions in place with staff being educated about keeping foot pedals and foot board on while in wheelchair. R9's Incident report, dated 5/18/2026, document that R9 was found on floor. It also documents that the root cause was determined to be resident attempting to transfer self. R9's Health Status Note, dated 5/18/2026 at 5:00 PM, documents that Note Text: Resident returned to this community from the hospital with no new orders. R9's Health Status Note, dated 5/19/2026 at 5:32 AM, documents that Note Text: IDT (interdisciplinary) team met, and root cause of fall determined to be resident attempting to transfer self. Immediate intervention put into place for res (resident) to have pressure pad alarm for bed/chair (may use pull tab alarm is pressure pad alarm is not available). POA (power of attorney) notified. On 5/18/2026 at 10:22 AM observed R9 on floor knees bent. R9 head and upper body under over bed table and feet wheelchair wrapped in catheter tubing. R9 complained of neck pain and left arm pain. No dycem observed in wheelchair seat or foot board in place to foot pedals. On 5/21/2026 at 8:50 AM V2, Director of Nursing (DON), stated that she is familiar with R9's falls and interventions put in place. V2 stated that the interventions are put in place to prevent falls. V2 stated that if the interventions are not in place, it will cause the resident to fall. V2 stated that she was in the room performing assessment and observed the fall interventions not in place. V2 stated that the interventions in place would've prevented the fall. V2 stated that staff have been educated. On 5/21/2026 at 9:50 AM V16, Certified Nurse Assistant (CNA), stated that they are in serviced on fall interventions after each fall. V16 stated the interventions are to always be in place. 3. R39's admission Record, dated 5/20/26, documents R39 was admitted to the facility on [DATE] with diagnosis of lateral sclerosis, spinal stenosis, repeated falls, cerebral ischemia, Type 2 diabetes mellitus (DM), hypertension (HTN). R39's Care Plan, dated 2/21/26, documents R39 is at risk for falls and injuries related to Medications: Psychotropic meds/Diuretic meds/Cardiovascular Meds/Pain Meds. Medical Factors: weakness, falls, impaired balance/gait/mobility. Interventions: 2/21/26: Orient to room, provide adequate lighting, 3/15/26- slipper nonskid socks. 3/29/26- Encourage resident to lay down after meals. R39 needs assistance with ADLs related to weakness, falls, impaired balance/gait/mobility. Interventions: Toilet Use: One-person physical assist required, Ambulation: One-person physical assist required, uses adaptive devices wheelchair, transfer: One-person physical assistance required. R39's MDS, dated [DATE], documents R39 has a moderate cognitive impairment and requires partial to substantial assistance for ADLs. R39 requires supervision/touching assistance for mobility and transfers. Facility's fall log for past 6 months, documents R39 has had falls on 10/23/25, 3/15/26, and 3/29/26. R39's Health Status Note, dated 10/24/25 at 12:59 PM, documents IDT (interdisciplinary team) team met, and root cause of fall determined to be resident up with regular socks on. Immediate intervention is put into place for resident to wear grippy socks when not wearing shoes as res (resident) will allow. POA (power of attorney) aware. R39's admission Fall Risk Assessment, dated 8/22/25, documents R39 was a Low fall risk. R39's Fall Risk Assessment, dated 10/25/25, documents R39 was a High fall risk. R39's Fall Risk Assessment, dated 2/21/26, documents R39 was a Low fall risk. R39's Fall Risk Assessment, dated 3/16/26, documents R39 was a High fall risk. R39's Fall Risk Assessment, dated 3/30/26, documents R39 was a High fall risk. On 5/18/26 at 9:30 AM, R39 was seen sitting in her wheelchair in her room, call light seen in the bed. R39 stated she uses her walker with staff assistance, uses walker to get to her restroom. R39 stated one staff member assists her using a gait belt. R39 stated she slipped and fell a month or two ago. There is a star taped on R39's door frame indicating she is a fall risk. There was no new intervention placed after R39's fall on 10/23/25. 4. R17's admission Record, dated 5/20/26, documents R17 was admitted to the facility on [DATE] with diagnosis of Alzheimer's disease, polymyalgia rheumatica, cervical disc degeneration, cerebrovascular disease, arthropathy, chronic kidney disease-stage 3, generalized anxiety disorder. R17's Care Plan, dated 8/22/25, documents R17 is at risk for falls and injuries related to Medications: Psychotropic meds/Diuretic meds/Cardiovascular Meds/Pain Meds. Medical Factors: Dementia, lack of safety awareness, impaired memory. Interventions: 8/22/25: Ensure proper footwear when ambulating, instruct resident to avoid sudden position changes, orient to room, provide adequate lighting. R17's Care Plan, dated 5/15/26, documents R17 has an alarm pressure pad, may use pull tab alarm if pressure pad alarm not available in a place for my safety related to high fall risk and lack of safety awareness. interventions: Apply recommended alarm - pressure pad alarm, may use pull tab alarm if pressure pad alarm is not available, attempt to discontinue the use of my alarm when my condition allows, check placement and function of my alarm every shift and PRN (as needed), evaluate use of alternative interventions that may be put in place instead of alarms as my condition allows, perform alarm assessment quarterly and as needed, replace batteries to alarms as required. R17's MDS, dated [DATE], documents R17 has a severe cognitive impairment and requires partial/moderate assistance for ADLs, and requires supervision/touching assistance for transfers. Facility Fall Log for past 6 months, documents R17 as having falls on 1/11/26, 2/1/26, and 3/18/26. R17's Physician Order, dated 5/15/26, documents Device: Alarm: Bed and Chair Alarm - pressure pad alarm, may use pull tab alarm if pressure pad alarm not available. Check for placement and functioning every shift. Every shift for high fall risk/lack of safety awareness. R17's admission Fall Risk Assessment, dated 8/22/25, documents R17 was a Low fall risk. R17's Fall Risk Assessment, dated 1/12/26, documents R17 was a Low fall risk (after the fall on 1/11/26). R17's Fall Risk Assessment, dated 1/18/26, documents R17 was a High fall risk. There was no Fall Risk Assessment completed after the fall on 2/1/26. R17's Fall Risk Assessment, dated 3/19/26, documents R17 is a High fall risk. R17's Health Status Note, dated 2/3/26 at 10:33 AM, documents IDT team met, and root cause of fall determined to be resident slipped by his bed, immediate intervention put into place for res to have nonskid strips on floor by his bed. On 5/18/26 at 10:13 AM, R17 seen getting pushed out of his room by hospice and placed at the nurses desk, fall alarm seen on R17's wheelchair but it was not flashing, indicating that it was on, there were no nonskid strips on his floor. On 5/19/26 at 4:00 PM, R17 lying in bed, fall mat on side of bed, alarm was seen under R17 but it was not flashing, indicating that it was on. There are no slip strips on the floor by the bed or in the restroom. On 5/20/26 at 2:45 PM, V30, CNA, stated We have two types of alarms, one is a pressure alarm, and it goes off when a resident lifts their body off, the other is a tab alarm and is clipped to resident's clothing and when they stand up, it pulls the tab off and alarms. Both of them should be flashing if they are turned on. If they are not flashing, then they are either turned off or the battery went dead. On 5/21/26 at 9:35 AM, V2, DON, stated I would expect all staff to follow fall precautions for residents who are high fall risk to keep them safe. I would also expect the staff to do fall risk assessments after every fall or change in condition, and to enter a new fall intervention after each fall. On 5/21/26 at 10:18 AM, V24, CNA, stated they have a fall book at each nurse's station that has everyone who is a fall risk. V24 stated they are supposed to review the book at the start of their shift and sign it off that they reviewed it. V24 stated this book will have any new interventions or information about a resident in it. The facility's Resident Council Meeting minutes, dated 7/1/25, documents in part Resident inquired as to if hourly bed checks could be done to ensure safety. Administrator informed Activity Director that laundry, dietary, nurses, aides, housekeepers, and more are making frequent checks on the hall. No hall is ever left without supervision and oversight. The facility's Resident Council Meeting minutes, dated 3/2/26, documents in part Residents are concerned that staff keep raising the bed, making it hard to get up. The facility's Fall Prevention Program/Protocol Policy, dated 7/1/23, documents in part Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. 1. The interdisciplinary will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk (based on the falls assessment results) or with a history of falls. s. If falling recurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions, or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, the team will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The resident, and/or responsibility, the physician and therapy department may be involved in the process for a holistic evaluation. 7. The team shall identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole Intervention to prevent falls but rather will be used to assist the staff In identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. Early Prevention and Fall Risk detection: 1. New admissions shall be reviewed for fall history and interventions shall be put in place prior to admission to the facility. 2. Fall Risk Assessments shall be completed upon admission, quarterly, and with any significant change or fall. S. Resident's individualized fall interventions shall be accessible to all staff for quick review in a Fall Binder at each nurse's station. 6. Resident found to be at High Risk, scoring 10 or higher on Fall Risk Assessment, shall have a visual identifier on room door and on assistive/mobility device to alert staff of the fall risk.

Based on observation, interview and record review, the facility failed to answer call lights in a timely manner for 5 out of 18 residents (R85, R54, R83, R79, R56) in a sample of 39; reviewed for Residents Rights.Findings include:1.R85's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, sepsis, chronic obstructive pulmonary disease and type two diabetes mellitus. R85's Minimum Data Set (MDS) dated [DATE] documented she was cognitively intact, required substantial/maximal assistance with toileting hygiene and partial/moderate assistance with toilet transfers from staff.R85's Care Plan dated 4/2/26 documented she needs assistance with ADLs (activities of daily living).On 5/18/26 at 9:54 AM, R85 stated her only concern is the wait times for call lights. R85 stated sometimes her call light is never answered, and she will soil herself by the time they get to her. On 5/19/26 at 9:20 AM, R85's call light was on, V12 answered it at 9:22 AM and assisted to bathroom.On 5/19/26 at 9:27 AM, R85's call light was on and blinking red.On 5/19/26 at 9:39 AM, R85's red blinking call light was on. V17 registered nurse (RN) walked out of R85's room leaving the light on after assisting her roommate. V17 when to her medication cart. V17 stated the red light in R85's room was on indicating someone was in the restroom then continued looking at her computer with the medication cart and did not check on R85 in the restroom while her red call light was blinking. On 5/19/26 at 9:40 AM, V2 (DON) assisted R85.2.R54's Facesheet with a print date of 5/21/26 documented he was admitted to the facility on [DATE] with diagnosis of, in part, peritoneal abscess, protein calorie malnutrition, and artificial openings of gastrointestinal tract status.R54's MDS dated [DATE] documented he was cognitively intact and dependent on staff for toileting hygiene.R54's Care Plan dated 2/21/26 documented he needs assistance with ADLs.On 5/19/26 at 9:18 AM, R54's call light was on.On 5/19/26 at 9:24 AM, V17 (RN) walked past R54's room while call light was still on and did not check on him. On 5/19/26 at 9:27 AM, R54's call light was now blinking white. On 5/19/26 at 9:29 AM, V16 (CNA) stated she couldn't help answer call lights because she had a resident with an alarm she could not leave. V16 went to check on R54's call light.On 5/19/26 at 9:39 AM, V16 (CNA) stated R54 was needing help with the bathroom when she checked on him.3.R83's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, acute kidney failure, asthma, and type two diabetes mellitus.R83's (MDS) dated [DATE] documented she was cognitively intact and required partial/moderate assistance from staff with toileting hygiene and toileting transfers.R83's Care Plan dated 5/13/26 documented she needs assistance with ADLs.On 5/18/26 at 9:47 AM, R83 stated she was waiting for assistance to use the restroom. R83 was sitting in her wheelchair right outside her doorway and requested help from V12 certified nursing assistant (CNA) who told her she would be right there. R83 stated she doesn't know how long she has been waiting.On 5/18/26 at 9:59 AM, R83 was sitting in her wheelchair outside her door. R83 stated she was still waiting to be helped to the restroom. V12 (CNA) walked over and assisted R83 to her restroom at that time after she was done talking to another employee in the hallway.4.R79's Facesheet with a print date of 5/21/26 documented she was admitted to the facility on [DATE] with diagnosis of, in part, chronic obstructive pulmonary disease, heart failure and type two diabetes mellitus.R79's Care Plan dated 5/15/26 documented she needs assistance with ADLs.On 5/18/26 at 10:00 AM, R79 stated she doesn't get enough attention. R79 stated the call light response times can be 30 minutes.On 5/19/26 at 9:37 AM, R79's call light was on and she was yelling help me, I know you can hear me and just ignoring me. On 5/19/26 at 9:45 AM, R79 stated to V17 (RN) she pooped her pants as she was getting her medications and her call light was on. V2 director of nursing (DON) and V12 (CNA) assisted R79.5.R56's Facesheet with a print date of 5/21/24 documented she was admitted to the facility on [DATE] with diagnosis of, in part, congestive heart failure, atrial fibrillation, and hypertension.R56's MDS dated [DATE] documented she was cognitively intact and dependent on staff for toileting hygiene and toileting transfers.R56's Care Plan dated 8/6/24 documented she needs assistance with ADLs.On 5/18/26 at 9:36 AM, R56 stated her concerns is a management problem because there's not enough staff. R56 stated they schedule one aide at night down her hall and this morning she woke up around 3:05 AM needing to use the restroom. R56 stated she used her call light for assistance, but she didn't get helped until 5:25 AM. R56 stated she had to hold it until she was helped and that was too long.On 5/20/26 at 9:15 AM, R56 stated she has to wait long times for to use the restroom because of short staffing. R56 stated when they only have one aide assigned for the hall and she goes on break, no one comes in her place to take over and she has to wait. R56 stated she pays a lot of money to get more assistance.On 5/21/26 at 8:47 AM, V2 (DON) stated her expectation is for staff to respond to call lights and get to them as soon as possible. V2 stated she would expect staff to check on a call light before leaving a room or moving onto something else. V2 stated the white blinking light means it has been longer than 5 minutes and the red blinking light is for the bathroom.On 5/21/26 at 11:13 AM, V1 (Administrator) stated her call light response expectations are for staff to respond to them as soon as they can, we shoot for 5 minutes. V1 stated the staff should not walk out of a room with a bathroom call light on without checking on them. V1 stated staff should check on a call light before moving on to anything else, to make sure it is not an emergency and if they cannot assist, they can let someone else know.Resident Council Meeting Minutes dated 1/5/26 documented, On New Years night the call light was not answered at a timely manner when roommate needed help.Resident Council Meeting Minutes dated 2/2025 documented residents expressed concern about the length time oak hall residents wait to be toileted after lunch due to 5:00 AM to 1:00 PM shift aides leaving at this time.Resident Council Meeting Minutes dated 5/4/26 documented, CNA comes in to give care and watches T.V. (television) or looks out the window before they get to the resident.Resident Council Meeting Minutes dated 5/2025 documented, Oak residents ask for additional staff to combat behaviors on midnight shift. The policy continued to document, Residents question the possibility of acquiring help for the ward clerk to catch up on undone previous work.The facility's Call Light Guidance Policy dated 7/1/23 documented resident's call lights shall be responded to within a reasonable amount of time, and it is the responsibility of all staff to respond to call lights. The policy continued to document if responding staff is unable to meet the request/need of resident, staff shall leave the light on and elicit the assistance of appropriate staff.The facility's Resident's Rights Policy dated 7/2/23 documented residents have the right to a dignified existence and to be treated with respect, kindness and dignity.

Based on interview, observation, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in Activities of Daily Living (ADLs), including a resident's mobility or walking, does not diminish for 1 of 1 resident (R65) reviewed for maintaining resident's ADLs in the sample of 39.The findings include:R65's admission Record, dated 5/20/26, documents R65 was originally admitted to the facility on [DATE] with diagnosis of Ataxia, Takotsubo syndrome, macular degeneration, cerebrovascular disease, chronic kidney disease, and chronic obstructive pulmonary disease.R65's Care Plan, dated 2/20/26, documents R65 Needs assistance with ADLs related to weakness, falls, impaired balance/gait/mobility. Interventions: Ambulation: One-person physical assist required. 4/22/26: R65 has a decline with walking skill due to joint mobility, weakness related to diagnosis of ataxia. Interventions: Resident to walk with assist of 1 using wheeled walker and 1 assist, report any decline to therapy and nursing, provide cues to keep close when standing, needs cues to turn when getting up form wheelchair/ bed, monitor for signs of pain or stiffness and alert nurse to change, allow rest periods when needed. R65's Minimum Data Set (MDS), dated [DATE], documents R65 is cognitively intact and requires partial/moderate assistance from staff for ADLs and transfers.R65's Physical Therapy Discharge summary, dated [DATE], documents in part Gait: 150 feet X 2 with CGA (care giver assistance) with wheelchair backup.On 5/18/26 at 9:43 AM, R65 stated I need one person assist to get up and I have been working with Physical Therapy (PT) for rehab and strengthening. When asked if she had any falls, R65 stated I had not fallen in here, but I did fall prior to coming here. I was told by therapy that a staff member should be walking with me to all of my meals using my walker with another person pushing my wheelchair following behind me in case I get weak or tired, but they only transport me with my wheelchair because they don't have enough people to do that, and I am not very happy about that.On 5/18/26 at 1:00 PM, When asked if she walked to lunch, R65 stated They brought me back from lunch in my wheelchair and did not let me walk like I'm supposed to.On 5/20/26 at 9:55 AM, V15, Therapy Director, stated (R65) was discharged from therapy due to meeting her highest practical level/maximal potential achieved. (R65) was able to walk about 150 feet and our recommendation was to have her walk to and back from each meal using her wheeled walker. Sometimes she would get tired, so you would have to follow her in a wheelchair for her safety. If she is telling the staff she is tired, they should be walking behind her with a wheelchair.On 5/20/26 at 10:30 AM, When asked if she has been walking to her meals lately, R65 No, the staff has been taking me to eat in my wheelchair, and I am supposed to be walking with someone following behind me with my wheelchair, and that is not happening.On 5/20/26 at 11:27 AM, V2, Director of Nursing (DON), stated (V28, Infection Preventionist/Restorative Nurse) is our restorative nurse, but she is new. (V29, Wound Nurse/Transportation Nurse) has been covering for restorative until (V28) gets herself going. (V28) will be revieing therapy's recommendations for resident care, then she will be writing orders that will go to the Certified Nursing Assistants (CNAs) tasks list for them to do. I believe that (V29) is doing that now.On 5/20/26 at 12:56 PM, V29, Wound Nurse/Restorative Nurse, stated (R65) is supposed to be walking and I put in for a walking restorative on her. I don't see the therapy's recommendations. I only put in the restoratives into the computer, and it goes to the CNAs POC (point of care) documentation. I don't enter orders for restorative therapy. When asked if R65 is supposed to have someone walk behind her with a wheelchair, per R65 and V15, Director of Therapy, V29 stated (R65) does really good with walking. I think we have been walking her to meals. I'm not sure about the wheelchair behind her.On 5/20/26 at 1:10 PM, V26, Licensed Practical Nurse (LPN), stated The CNAs are supposed to be walking with (R65) to each meal and follow her with a wheelchair.On 5/20/26 at 1:23 PM, While attempting to find R65, she was not in her room, not in the dining room, or the activity room. R65's walker was seen in her room. R65 was then seen in a small hallway outside the dining room sitting in her wheelchair by herself. When questioned, R65 appeared upset and stated This is what I was talking about. They are supposed to leave my walker in the dining room so I can walk back to my room. They took it and left me in there without it, so I have to use my wheelchair to get back to my room. This frustrates me because therapy told me I am supposed to be walking. The facility's Restorative Program/Range of Motion/ROM) Policy, dated 7/1/23, documents in part All residents will be assessed on admission and quarterly; or more often as a change of condition warrants; for risk factors for development of contractures. A program will be developed based on the resident's unique risk factors and involving formalized therapy and/or restorative nursing, as applicable. This program will be reflected in the interdisciplinary care plan and will be systematically and consistently followed. The facility protocol for ROM is ten repetitions daily, seven days a week for prevention of contractures.

Based on record review and interview the facility failed to initiate a physician ordered antibiotic timely for 1 of 1 resident (R2) reviewed for Urinary Tract Infection (UTI) in the sample of 4.Findings include:1. On 9/17/2025 at 8:59AM R2 stated she had symptoms of Urinary Tract Infection (UTI) and a specimen to the lab and results had been sent to the physician, but (the physician) was in the hospital. R2 stated she was not receiving an antibiotic for a UTI. R2 stated she has had UTI's in the past and septic. R2's culture report dated 9/15/2025 documents greater than 100,000 Eschericia Coli in urine. R2's report (faxed back to the facility from the physician) documents Macrobid (antibiotic) 100 milligrams (mg) twice a day (BID) x10 days dated 9/16/2025. R2's Medication Administration Records dated 9/16/25 did not document the initiation/administration of physician ordered Macrobid. R2's current face sheet dated 9/17/2025 documents R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. On 9/17/2025 at 12:44PM V1, Administrator stated the facility had notified the physician and the report with the order had been faxed to the facility and R2 would be provided initial dose from convenience box. V1 stated she would expect the facility to follow up on lab results to ensure orders are received.The facility policy Test results dated 7/1/23 documents the resident's physician will be notified of the results of diagnostic tests. The policy documents results of laboratory, radiological, and diagnostic tests shall be reported in writing to the resident's attending physician or to the facility. The policy documents should the test results be provide to the facility, the attending physician shall be promptly notified of the results. The policy documents the Director of Nursing (DON), or charge nurse receiving the test results, shall be responsible for notifying the physician of such results.The facility policy Culture Testing dated 7/2/23 documents should the attending physician order cultures, they shall be obtained and completed as soon as practical. The policy documents all test results shall be reported to the physician as soon as the results are obtained.

Based on observation, interview and record review the facility failed to provide complete incontinent and peri care to 3 of 3 residents (R1, R2, and R3) reviewed for incontinent care in the sample of 4. Findings include: 1.On 9/17/2025 R2 placed on bedpan per V6 and V7, Certified Nursing Assistants (CNA'S). R2 voided on the bedpan. Both V6 and V7 removed bedpan from under R2. V6, CNA cleansed R2's bilateral groin, inner thighs, wiped peri area front to back. V6 did not separate R2's labia. V6 rinsed and dried all areas, prior to V6 and V7 turning R2 on side to cleanse buttocks and rectal area. R2's current face sheet dated 9/17/2025 documents R2 has a diagnosis in part of chronic kidney disease, stage 4 (severe), and personal history of urinary tract infection. R2's urine Culture results dated 9/15/2025 documents equal or greater 100,000 Escherichia Coli. R2's Care plan dated 5/11/2023 documents R2 is at risk for impaired skin/ deep tissue injury related to immobility, obesity, incontinence of bowel and bladder. R2's Care plan documents intervention dated 3/26/2019; provide incontinence care after each episode according to facility policy.R2's Minimum Data Set (MDS) dated [DATE] documents R2 is cognitively intact. 2. On 9/17/2025 at 10:59AM during incontinent care V7, CNA cleansed left groin, then right groin. V7, CNA took soaped cloth and wiped down front of R1's peri area. V7 did not separate the labia. V7 then rinsed area and dried. R1's MDS dated [DATE] document R1 is cognitively intact. R1's MDS documents R1 is always incontinentR1's Care plan dated 8/7/2025 documents R1 is at risk for impaired skin to impaired mobility and incontinence. R1's care plan documents intervention to provide incontinent care after each episode according to facility protocol. 3. On 9/17/2025 at 1:27PM during incontinent care to R3. V3, CNA after cleansing R3's front. V5, CNA turned R3 to left side. V3 with soaped cloth cleansed buttocks, then with clean soaped cloth took cloth and cleansed rectal area going from rectum to peri area, V3 then got a clean wet cloth and rinsed R3 going from rectal area to peri area.R3's MDS dated [DATE] documents R3 is always incontinent R3's Care plan dated 12/28/2021 documents R3 is at risk for ADL self-care Performance Deficit with intervention dated 12/28/2021 R3 is frequently incontinent of urine and requires extensive assistance with toileting.On 9/17/2025 at 1:55 PM V3, CNA stated when providing peri care cleansing is to be done going from the front to the back. On 9/18/2025 at 10:33 AM V2, Director of Nursing (DON) stated she would expect staff to provide complete peri care and incontinent care. The facility policy Perineal Care Procedure, undated, documents the purpose 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. The procedure documents to fill the basin one half full of warm water. The procedure documents for a female resident: wash perineal area, wiping from front to back; separate labia and wash downward front to back. The procedure documents wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks.

Based on observation, interview and record review, the facility failed to ensure a multi dose vial with a shelf life of 30 days was dated to indicate when it was opened and failed to ensure a bottle of controlled substance medication was labeled the residents name and physician's order. This failure has the potential to affect all 63 residents residing in the Facility. Findings include: 1. On 4/14/2025 at 2:52 PM the medication storage room and mediation cart were inspected with V10, Licensed Practical Nurse (LPN). 1. There was a bottle of Morphine Sulfate (Opioid pain medication/controlled substance) in a locked box. Neither the bottle or the box was labeled with a name or physician's orders. At this, time V10 stated the medication had been opened and there had been medication used from the bottle. V10 stated, I don't know whose (medication bottle) that is. That one doesn't even have a name on the box. During this observation, V2, Director of Nursing (DON) entered the medication storage room. V2 stated, That one (morphine bottle) is (R17's). It needs wasted. She doesn't have an order for it anymore. The (a medication disposal system designed to safely and effectively neutralize and contain unused or expired medications, preventing potential misuse, abuse, and environmental contamination) was on back order. We got one in last Tuesday or Wednesday. On 4/15/2025 at 9: 59 AM, V2, stated the bottle of morphine should have been labeled with the resident's name. R17's Order Audit Report dated 4/16/2025 documents R17's Morphine was discontinued on 2/14/2025. 2. Located in the refrigerator, there was a multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) Tubersol (aids in the detection of infection with mycobacterium tuberculosis) with no cap intact. At this time, V10 verified the vial had been accessed. The label on the vial documented it was opened on 3/1/2025. V2 stated she would call the pharmacy to inquire what they recommend regarding the timeframe and storage of the vial. On 4/15/25 at 9:49 AM, V2 stated she called pharmacy and was informed the vial should be disposed after 30 days of being opened. The Package Insert document titled Tuberculin Purified Protein Derivative (Mantoux) Tubersol dated 4/15/2025 documents, A vial of Tubersol, which has been entered and in use for 30 days should be discarded. The Facility's Policy titled, Medication Storage dated 7/1/2023 documents, Purpose: To provide guidance to facility nursing staff on the proper storage of medication. It continues, Drug containers that have missing, incomplete, improper or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. The Resident's Census and Conditions of Resident, CMS 671, dated 4/14/2025, documents that the facility has 63 residents living in the facility.

Based on interview, observation, and record review, the facility failed to provide substitute food choices for 5 of 24 residents (R16, R28, R30, R49, R63) reviewed for meals. Findings include: 1. On 04/14/25 at 12:25 PM, R63 was served her lunch by V6, Dietary Manager, R63 was served a grilled cheese sandwich. R63 stated she wanted turkey. V6 stated she would get her turkey. V6 returned with the turkey. The turkey was on bread and had gravy on top. R63 stated I just want turkey that I could cut up with my knife and eat with a fork. V6 stated, How about a sandwich. V6 folded the turkey into a sandwich and walked away. On 4/15/25 at 2:35 PM, V1, Administrator, stated R63 should have been given plain turkey. V1 stated, She doesn't eat that much already. R63's Face Sheet, print date of 4/15/25, documents R63 was admitted on [DATE] and has diagnoses of Dementia and severe Protein Calorie Malnutrition. R63's Minimum Data Set, (MDS), dated [DATE], documents R63 is severely cognitively impaired and requires set up clean up assistance. 44967 2. R30's Admission Record, dated 4/16/25, documents R30 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Infarction (CVA), Hemiplegia and Hemiparesis, and Nutritional Anemia, Type 2 Diabetes Mellitus (DM), and Chronic Kidney Disease-stage 3. R30's Care Plan, dated 1/29/25, documents R30 is receiving a Consistent Carbohydrate Diet (CCHO) regular diet related to (r/t) diagnosis of Diabetes. He may be at risk for malnutrition related to diagnosis of CVA with hemiplegia. Interventions: Encourage R30 to eat at least 75-100% at all meals daily, monitor weight and intakes and refer to Registered Dietitian (RD) as needed (PRN), monitor, document and report to Medical Doctor (MD) PRN for signs/symptoms of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, provide and serve CCHO regular diet as ordered, offer substitutes for dislikes or food uneaten, provide, serve diet as ordered, monitor intake and record all meals, RD to evaluate and make nutritional recommendations PRN, weigh per schedule at same time of day and record. It continues R30 has a potential for safety concerns and injury from hot liquids. Interventions: Set up for meals, staff supervision or assistance with hot liquids. It continues R30 needs assistance with Activities of Daily Living (ADLs). Interventions: Eating - Setup help only / Cueing required. It continues R30 has a potential for impaired skin integrity. Interventions: Encourage oral (PO) intake, provide diet as ordered. R30's Minimum Data Set (MDS), dated [DATE], documents R30 is cognitively intact and requires supervision or touching assistance for eating. On 4/14/25 at 12:30 PM, R30 seen in small dining room for lunch with no staff seen in the room to assist R30. R30 only ate a few bites of mashed potatoes, a piece of cake, and milk. R30 left the dining room and went to his room. Upon interviewing R30 about not eating, R30 stated I don't like processed Turkey and couldn't cut it up anyway. When asked about staff offering alternatives, R30 stated They don't ask if we want anything different, we get what they serve. 3. R49's Admission Record, dated 4/16/25, documents R49 was admitted to the facility on , with diagnoses of Type 2 DM, Anxiety Disorder, Depression, Hypothyroidism, Anemia, and Dysthymic Disorder. R49's Care Plan, dated 3/20/25, documents R49 may be at risk for malnutrition r/t having multiple dislikes of food and diagnosis of peptic ulcer. R49 is receiving a mechanically altered regular diet r/t having no natural teeth or dentures. Interventions: Encourage R49 to try a variety of foods at all meals, explain and reinforce to R49 the importance of maintaining a balanced diet, encourage R49 to comply, may have hi-pro ice cream with all meals for supplement, monitor weight and for nutritional needs and refer to RD PRN, monitor, document, and report to MD PRN for s/sx of dysphagia: Pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals, offer substitutes for dislikes or for food uneaten, provide and serve diet as ordered, monitor intake and record all meals, RD to evaluate and make nutritional recommendations PRN, weigh per schedule at same time of day and record. It continues R49 is at risk for an ADL Self Care Performance Deficit r/t Musculoskeletal impairment. Interventions: Restorative Eating: R49 will improve her current level of function and consume at least 50% of each meal to provide her with adequate calories needed to prevent a weight loss through next review date, staff to ensure that R49 is at an assisted eating table, provide diet as ordered by MD, provide set up of my tray, provide V/C (verbal cues) to begin eating/drinking, If she does not like what she is offered, staff to provide her with something else to eat. report any c/o (complaints) to nurse. R49's MDS, dated [DATE], documents R49 is cognitively intact and requires setup or clean up assistance for eating. On 4/14/25 at 12:32 PM, R49 seen in small dining room for lunch with no staff seen around. R49's lunch ticket documented R49 is on a Regular Mechanical Soft diet. R49 had a grilled cheese sandwich, a magic cup, and drinks. R49 only ate the magic cup and her milk. When interviewed, R49 stated I don't like grilled cheese sandwiches and that is what they give me almost every day for lunch. I don't even ask for it, that is what they just give me. When asked about alternatives, R49 stated They never ask us if we want something else, they just bring us a tray and we have to eat what is on the tray. On 4/15/25 at 12:20 PM, R49 seen in small dining room for lunch, no staff in the room. R49 only has a grilled cheese sandwich and a cup of chocolate ice cream on her tray, along with a few cups of drinks. R49 is not touching her grilled cheese and stated, I got it again, and did not ask for it. R49 was seen rolling herself out of the dining room without eating anything on her plate. On 4/15/25 at 12:25 PM, when asked about R49 receiving a cheese sandwich every day, V6, Dietary Manager, stated (R49) does not have any teeth and was put on a mechanical soft diet. (R49) asked for bologna and cheese sandwich which she was getting for a while, then didn't want that anymore, so we have been giving her a grilled cheese sandwich for the past couple of weeks, but I guess she's tired of that now. (R49) is a very picky eater and refuses to eat anything ground up. We can have ST (Speech Therapy) re-evaluate her to see if they can advance her diet. ST left for the day, but I will check with them tomorrow. On 4/15/25 at 12:30 PM, when questioned by V6 about meals, R49 stated I'm not sure what I want. I don't like ground-up meats. Maybe if I get back to a normal meal, I will like that. On 4/16/25 at 1:15 PM, R49 stated Today for lunch, I got meatballs that were chopped up, small potatoes that were cut up, green beans, and a fudge round which I don't like. I only ate a couple of bites of each because I didn't like them. When asked if there was any staff assisting her or asking her if she wanted something else, R49 stated No, I didn't see anyone, and no one asked me if I wanted anything else. 4. R16's Admission Record, dated 4/16/25, documents R16 was admitted to the facility on [DATE], with diagnosis of CVA, Dysarthria, Dysphagia, Morbid Obesity, Dementia, and Major Depressive Disorder. R16's Care Plan, dated 3/11/25, documents R16 has a self-care deficit as evidenced by needs assistance with ADLs. Interventions: Eating: Setup help only / cuing required. It continues R16 has a potential for impaired skin integrity. Interventions: Provide diet as ordered, refer to RD PRN to evaluate diet/needs. R16's MDS, dated [DATE], documents R16 has a severe cognitive impairment and requires Setup or clean-up assistance for eating. On 4/14/25 at 12:34 PM, R16 seen in small dining room for lunch with no staff seen around. R16's lunch ticket documented R16 is on a Mechanical Soft Diet. R16 had turkey, mashed potatoes, cake, and drinks on her plate. R16 stated I don't like the turkey. No one asked me if I want something different, they never do, so we just have to eat what they give us. R16 only ate her piece of cake and a few bites of her mashed potatoes. 5. R28's Admission Record, dated 4/16/25, documents R28 was admitted to the facility on [DATE], with diagnosis of Parkinson's Disease, Vascular Dementia, and Generalized Anxiety disorder. R28's Care Plan, dated 3/3/25, documents R28 is at risk for nutritional deficits r/t having a low BMI (Body Mass Index) of 18.8. Interventions: Alert dietician if consumption is poor for more than 48 hours, encourage fluids at and between meals daily, encourage R28 to eat at least 75%-10% at all three meals daily, Help R28 to fill out her menu and to choose a balanced diet, as she sometimes only orders one item on the menu, monitor and record food intake at each meal, monitor weight & nutritional status and refer to RD PRN, offer substitutes as requested or indicated or for food not eaten, RD to evaluate and make nutritional recommendations PRN, weigh at same time of day and record, report significant weight loss to MD immediately. It continues R28 has a Self-Care Deficit As Evidenced by: Needs assistance with ADLs. Interventions: Eating - Setup help only / Cueing required. R28's MDS, dated [DATE], documents R28 has a moderate cognitive impairment and requires setup or clean-up assistance for eating. On 4/14/25 at 12:35 PM, R28 seen in small dining room for lunch with no staff seen around. R28's lunch ticket documented R28 is on a Regular Diet. R28 was not eating much of her meal and when interviewed, R28 stated They don't ask us what we want to eat, we just have to eat what they bring us, and I don't like that. On 4/17/25 at 9:00 AM, V2, Director of Nursing (DON), stated I would expect all staff to be checking with the residents to see if they are eating, and if not, offer them something else to eat. On 4/17/25 at 10:00 AM, V1, Administrator, stated I can't find a policy on offering substitutions for dietary. It is posted all over and I understand the residents may not remember they do have substitutions; the staff definitely know and should be offering the residents something if they don't like what is served. V6, Dietary Manager, provide the Facility's Quick Resource Tool: Food Preference and Portions Policy, dated 9/1/21, documents in part Guidelines: 3. The food Preference Interview will be entered into the medical record. 5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. 6. The Dining Service Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care. 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies, and alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage selection will be provided in a timely manner. The Meal Assistance Policy, dated 7/3/23, documents, Policy: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. It continues, Facility Staff will serve resident trays and will help residents who require assistance with eating.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, change gloves when soiled, cleanse soiled surfaces, wear Personal Protective Equipment, and track infections for trends for 5 of 16 residents ( R31, R41, R50, R55, R216) reviewed for infection control in the sample of 49. Findings include: 1. On 4/16/25 at 10:57 AM, V3, Infection Preventionist was questioned on how she tracks the infections in the facility. V3 stated she looks at the 24-hour report for new antibiotic orders, checks the order, and puts that information on the tracking sheet that she uses. V3 was questioned why on the monthly infection tracking log R41 is documented as needing contact precautions what type of infection did she have, V3 reviewed the culture and stated, Oh she doesn't does she? I guess it would be standard precautions. V3 was questioned how she tracks for trends in the infections, V3 stated, I keep track of it in my mind. We are a small home. R41's Face Sheet, print date of 4/17/25, documents, R41 was admitted on [DATE]. R41's Health Status Note, dated 4/11/2025, documents, Resident seen by MD (Medical Doctor) Received orders for Levaquin 250 mg (milligram) PO (oral) daily x 7 days for a UTI (urinary tract infection). R41's Urine Culture, dated 4/11/25, documents Organism: serratia marcescens > 100,000 CFU (colony forming unit)/ ml (milliliter). The Infection Prevention and Control Log, dated April 2025, documents, R41 has an in house acquired urinary tract infection with the organism of serratia marcescens which requires contact isolation. This log entry fails to document the onset date, or the colony count of the organism. The Policy Antibiotic Stewardship policy/ Procedure, dated 7/1/23, documents, Data will be compiled by the infection preventionist, who will interpret monthly data, define necessary action steps, and compile information for the Monthly ASP (Antibiotic Stewardship Program) Tracking Report. 2. On 4/15/25 at 12:30 PM, V14, Licensed Practical Nurse, put gloves on without hand hygiene and opened a 25-milligram hydroxyzine capsule and mixed it with 3 milliliters (ml) of water. V14 entered R50's room. R50 has a J-tube for medications and feedings. V14 stopped R50's tube feeding, disconnected the tube feeding, administered 15 ml of water, the hydroxyzine cocktail, and flushed with another 15 ml of water. On 4/16/25 at 11:25 AM, V14 was questioned why she did not perform hand hygiene before putting on gloves, V14 stated, I thought I did. 3. On 4/14/25 at 11:25 AM, V11, Certified Nurse Aide (CNA) and V12 CNA entered R31's room to provide incontinent care. Neither V11 nor V12 wore a Personal Protective gown while providing incontinent care. V11 changed gloves 3 times without hand hygiene in between. V12 changed gloves 2 times without hand hygiene in between. R31's door has signage that R31 is on Enhanced Barrier precautions. On 4/15/25 at 2:35 PM, V2, Director of Nurses, stated R31 is on Enhanced Barrier Precautions and staff should be using gowns and gloves with patient care. On 4/15/25 at 1:00 PM, V12 stated I did not know that he was on Enhanced Barrier Precautions. R31's Face Sheet, print date of 4/15/25, documents R31 was admitted on [DATE] and has diagnoses of atherosclerosis of native arteries of other extremities with ulceration and overactive bladder. The policy perineal Care Procedure, undated, documents, 10. Remove gloves and discard into designated container. 11. Perform hand hygiene. The policy Enhanced Barrier Precautions, undated, documents, The use of gown and gloves for high - contact resident care activities are indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and /or indwelling medical devices regardless of MDRO (multi drug resistant organisms) colonization as well as for residents with MDRO infection or colonization. It continues, Examples of high- contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: Dressing. Bathing / Showering. Transferring. Providing hygiene. Changing linens. Changing briefs or assisting with toileting. Device care or use: central line, urinary catheter, feeding, tracheostomy / ventilator. Wound Care 44967 4. R55's Admission Record, dated 4/16/25, documents R55 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction with Hemiplegia and Hemiparesis, Dysphagia, Emphysema, Asthma, Congestive Heart Failure, Major Depressive Disorder, Generalized Anxiety Disorder, Malignant of Neoplasm of Sigmoid Colon, Gastrointestinal Hemorrhage, and Diverticulitis. On 4/15/25 at 1:05 PM, R55 used call light to let staff know he had to use restroom. V4, CNA, assisted R55 to the toilet to have bowel movement (BM). When finished, V4 wiped R55's buttocks and anal area with a wet washcloth sprayed with peri-wash, then dried R55. Using the same soiled gloves, V4 then pulled R55's incontinence brief and pants up, adjusted R55's shirt, and assisted R55 back to his wheelchair, then removed her soiled gloves. 5. R216's Admission Record, dated 4/16/25, documents R216 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident (CVA), Aphasia, Dysphagia, Chronic Kidney Disease-stage 2, Hypertension, Congestive Heart Failure, and Progressive Supranuclear Ophthalmoplegia. On 4/14/25 at 9:55 AM, V4, CNA, entered to assist R216 to the toilet, used the rails by toilet, and upon R216 lowering to toilet, he began urinating all over, into his brief, pants, and down his legs. R216 grabbed a small piece of toilet paper and tried to wipe himself and upon pulling his hand out from under him, R216 had a handful of feces that he dropped into the toilet and on the seat. R216 then grabbed the handrail with his soiled hand. After V4 cleaned R216, there was no wiping of the handrail after R216 grabbed it with his soiled hand. On 4/20/25 at 8:20 AM, V19, CNA, stated I change my gloves any time they are soiled, and when going from a soiled area to clean area. If I am doing incontinent care and wiping the resident from a BM, I change my gloves after wiping the back and before wiping anywhere else or putting their clothes on. I think it's better to change gloves more often than not. On 4/17/25 at 8:55 AM, V2, Director of Nursing, stated I would expect the staff to change their gloves when soiled and when going from dirty to clean areas. Anytime there is a piece of equipment or something like the handrail in a resident's restroom that is soiled, I would expect the staff to clean that before leaving the room. The Facility's Hand Washing Policy, dated 7/1/23, documents To provide guidelines for adequate hand washing in order to reduce the transmission of organisms for resident to resident, staff to resident, and from resident to nursing staff. It is the responsibility of all staff to ensure that they properly wash their hands after direct contact with resident, contaminated substances, and as needed. Procedure: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. If hands are not visibly soiled, use hand sanitizer: f. Before moving from contaminated body site to a clean body site during resident care.

Based on interview and record review, the facility failed to justify the use of an antibiotic and utilize infection surveillance when considering initiation of an antibiotic for 2 of 4 (R32, R41) residents reviewed for antibiotic stewardship in the sample of 49. Findings include: 1 On [DATE] at 10:57 AM, V3, Infection Preventionist was questioned on how she tracks the infections in the facility. V3 stated she looks at the 24-hour report for new antibiotic orders, checks the order, and puts that information on the tracking sheet that she uses. V3 stated that the computer program infection tracker has the information on McGreer and the cultures if any were obtained. V3 was asked to pull up R41's McGreer assessment for a urinary tract infection that is on the monthly infection tracking log. V3 pulled up the McGreer and stated, I am not sure how the system works because it never tells you if they qualify for a true infection. V3 was questioned what symptoms R41 presented with to get a urine culture, V3 stated, Her daughter requested it, and it turned out she had an infection. R41's Face Sheet, print date of [DATE], documents, R41 was admitted on [DATE]. R41's Health Status Note, dated [DATE], documents, Resident seen by MD (Medical Doctor) Received orders for Levaquin 250 mg (milligram) PO (oral) daily x 7 days for a UTI (urinary tract infection). R41's Infection Screening Evaluation, dated [DATE], documents a blank Infection Analysis. 40701 2. On [DATE] at 1:50 PM, V5, Licensed Practical Nurse (LPN) stated, (R32) would try to clean herself up (after using the restroom) and didn't do a very good job. She kept getting UTIs (Urinary Tract Infections). We finally talked the doctor into putting her on something prophylactic. On [DATE] at 12:39 PM, V3 (Infection Preventionist) stated, (R32) had a lot of UTIs. We did not get a culture prior to her starting it. She's been on it a while-since March of 24 (2024). We don't always check cultures before starting an antibiotic. Some doctors just start them on something (antibiotic). A lot of times the hospital will start them on something, and I'll have to call. One time (a resident)'s culture wasn't susceptible (to the antibiotic), so I have to get it stopped, but he had already been on it for five days. I am not finding a culture for (R32) (urine). The last one I can find was from March of '23 (2023) and it had no growth. R32's Progress Note dated [DATE] documents a new physician's order was received to discontinue Macrobid for UTI prevention. On [DATE] at 2:00 PM, V15, Nurse Practitioner stated, As primary physicians we don't prescribe prophylactic antibiotics. If the family is requesting it, we would send them to a urologist. We use the McGeer's criteria and most of the time, the resident wouldn't meet it. On [DATE] at 2:06 PM, V3 stated the doctor who prescribed R32's antibiotic is a nurse practitioner, not a urologist. V3 stated she will call and get the antibiotic discontinued. R31's Medication Administration Record (MAR) documents R32 began Nitrofurantoin 100 mg daily on [DATE] and it was discontinued on [DATE]. On [DATE] at 10:19 AM, V3 stated, I'll be honest. I am the one who requested the prophylactic antibiotic for (R32). She would double over in pain when she went to the bathroom. That was pretty much her only symptom. She has not been seen by a urologist. We are supposed to do an infection screening form with an analysis. V3 verified she did not have an infection screening evaluation for R32 and that R32's last urine urinalysis was done in 2023. The Facility's Antibiotic Stewardship Policy/Procedure dated [DATE] documents, Antibiotics are powerful tools for fighting and preventing infections. However, widespread use of antibiotics has resulted in an alarming increase in antibiotic-resistant infections and a subsequent need to rely on broad-spectrum antibiotics that might be more toxic and expensive. In addition to the development of antibiotic resistance, antibiotic use is associated with an increased risk of Clostridium difficile (a bacteria that can cause a serious infection in the intestines, leading to severe diarrhea and inflammation of the colon, a condition called colitis) infection and adverse drug reactions. Since antibiotics are frequently over or inappropriately prescribed, a concerted effort to decease or eliminate inappropriate use can make a big impact on resident safety and the reduction of adverse events. Antibiotic stewardship consists of coordinated interventions aimed at treating infections while promoting appropriate antibiotic use. The practice of antibiotic stewardship requires commitment, leadership, communication and actions informed by best practice guidelines and defined protocols. It continues to document, Assessment of resident suspected of having an infection. Providers will utilize the McGeer Criteria when considering initiation of antibiotics. Consistent with these criteria, the criteria for urinary tract infection form should be provided to, or information communicated with, the provider. It is encouraged that McGeer criteria be used for other suspected infections. It further documents urinalysis and cultures should be considered.

Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for three of seven residents (R31, R38, R216) reviewed for incontinence care in the sample of 49. The Findings Include: 1. R38's Admission Record, dated 4/16/25, documents R38 was admitted to the facility on [DATE] with diagnoses of Chronic Kidney Disease-stage 3, Hypertension, Descending Thoracic Aorta Aneurysm, Cerebral Infarction without residual deficits. R38's Care Plan, dated 3/20/25, documents R38 has a Self-Care Deficit as Evidenced by: Needs assistance with ADLs (activities of daily living). Interventions: Toilet Use - One-person physical assist required. It continues R38 has a Potential for impaired skin integrity related to: falls, impaired mobility, occasional incontinence. Interventions: Provide peri-care as needed. R38's Minimum Data Set (MDS), dated [DATE], documents R38 has a severe cognitive impairment and requires setup or clean-up assistance for toileting, partial/moderate assistance for bathing. On 4/14/25 at 12:58 PM, R38 was seen ambulating down the hall and was being assisted back to her room by V2, Director of Nursing (DON). R38's back of her pants and between her legs were saturated with urine. R38 was seen going into her room and sitting in her recliner. A few minutes later, V4, Certified Nursing Assistant (CNA), entered and assisted R38 to the toilet. V4 donned gloves, removed R38's pants and incontinence brief, ran the water in sink, wet a washcloth, sprayed with peri-wash, wiped the inside of both thighs and down the legs of R38, then put a clean pair of pants on R38's lower legs. R38 then stood up while V4 used a wet washcloth to wipe R38's buttock and anal area, then put R38's brief and pants back on and assisted her to her wheelchair. There was no wiping of R38's groins, front side pubic area, or complete cleaning of R38's genital area. 2. R216's Admission Record, dated 4/16/25, documents R216 was admitted to the facility on [DATE] with diagnoses of Cerebral Vascular Accident (CVA), Aphasia, Dysphagia, Chronic Kidney Disease-stage 2, Hypertension, Congestive Heart Failure, and Progressive Supranuclear Ophthalmoplegia. R216's Care Plan, dated 2/7/25, documents R216 needs assistance with ADLs related to CVA, weakness. Interventions: Bathing and Personal Hygiene - One-person physical assist required, Transfer: Two-person physical assistance required. It continues R216 has a potential for impaired skin integrity. Interventions: Provide peri-care as needed. R216's MDS, dated [DATE], documents R216 has a severe cognitive impairment and is dependent on staff for toileting. R216's MDS documents is always incontinent of both bowel and bladder. On 4/14/25 at 9:55 AM, V4, CNA, entered to assist R216 to the toilet, used the rails by toilet, and upon R216 lowering to toilet, R216 began urinating all over, into his brief, pants, and down his legs. V4 removed R216's brief and pants. R216 grabbed a small piece of toilet paper and tried to wipe himself and upon pulling his hand out from under him, R216 had a handful of feces that he dropped into the toilet and on the seat. R216 then grabbed the handrail with his soiled hand. V4 left the room to get more washcloths, returned and wet cloths, sprayed with peri-wash, then wiped R216's buttocks and anal area. There was no washing of the front side of R216, including his legs. There was no wiping of the handrail after R216 grabbed it with his soiled hand. On 4/17/25 at 8:55 AM, V2, Director of Nursing, DON, stated I would expect the staff to change their gloves when soiled and when going from dirty to clean areas. I would expect the staff to provide timely and complete incontinent care, including cleaning the front and the back side of a resident when soiled. 33112 3. On 4/14/25 at 11:25 AM, V11 CNA and V12 CNA entered R31's room to provide incontinent care. R31 was rolled over to the left side. V11 cleansed the buttocks and rectal area of stool and dried the buttocks and rectal area. R31 was rolled over onto the right side and V12 cleansed and dried the buttock. R31 was placed on his back and his inner thighs and scrotum was cleansed and dried. R31 has an inverted penis which sits on top of his swollen scrotum. R31 urinated a visible amount urine which pooled on top of his scrotum. Neither V11 or V12, cleansed the scrotum again or provided care to the penile head. An incontinent brief was placed on R31, and care was completed. On 4/15/25 at 1:00 PM, V12 stated I was not the one cleaning him but if I would notice that he had urinated on himself, I would have cleaned it. R31's Face Sheet, print date of 4/15/25, documents R31 was admitted on [DATE] and has diagnoses of atherosclerosis of native arteries of other extremities with ulceration and overactive bladder. R31's MDS, dated [DATE], documents R31 is cognitively intact, dependent on staff for toileting, and is always incontinent of bowel and bladder. The policy perineal Care Procedure, undated, documents, For a female resident: a wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) separate labia and wash area outward from front to back. (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, with fresh water and a clean cloth. It continues, (4) Gently dry the perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Rinse wash cloth and apply soap or skin cleansing agent. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. For a male resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with the urethra and working outward. c. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse the urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and inner thighs. g. thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. l. Rinse washcloth and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Perform hand hygiene.

Based on interview, observation, and record review, the facility failed to check placement of a J-tube (Jejunostomy) and label enteral feeding for 1 of 1 resident (R50) reviewed for tube feeding in the sample of 49. Findings include: On 4/15/25 at 12:30 PM, V14, Licensed Practical Nurse, entered R50's room. R50 has a J-tube for medications and feedings. V14 stopped R50's tube feeding, disconnected the tube feeding, administered 30 milliliters (ml) of water, the hydroxyzine cocktail, and flushed with another 30 ml of water. V14 stated, I have to go and get another ruler. I dropped the one I had. V14 left the room and returned with another ruler and measured the length of the J-tube. On 4/15/25 at 12:40 PM, R50's hanging disposable tube feeding bag is dated 4/15/25. The bag fails to document what type of feeding or rate of the feeding. On 4/15/25 at 12:40 PM, V14 stated, I should have measured the J-tube before I administered the medications. I recently hung a new disposable tube feeding bag and filled it with Jevity 1.5. On 4/15/25 at 12:41 PM, V2, Director of Nurses, stated that the bag is not labeled with the type of tube feeding. V2 stated, Is it supposed to be labeled with the rate? On 4/17/25 at 8:56 AM, V2 stated R50's J-tube should be measured for placement before it is used. V2 stated R50 is our only tube feeder, and everyone knows that she gets Jevity 1.5. R50's Face Sheet, print date of 4/15/25, documents R50 was admitted on [DATE] and has a diagnosis of Multiple Sclerosis and quadriplegia. R50's Physician Orders, dated 3/24/25, documents, Check placement of J-tube by measuring the tube. 12cm (centimeters) From top of Abdominal disk to end of tube prior to adapters. If more than 12cm do not run feeding send res (resident) to ER (emergency room ) to verify placement via Xray. R50's Physician Orders, dated 3/10/24, documents, Enteral Feed every shift Administer Jevity 1.5 VIA an Enteral Pump and Infuse at 80 ml/hr (hour). X 20hrs. R50's Physician Orders, dated 2/20/25, documents, every shift Enteral - Medication Administration Flush: Flush with minimum of 30ml water before giving medications, flush with at least 5 ml between medications, and flush with minimum of 30 ml after all medications given. The policy Enteral Tube Feeding via Continuous Pump Procedure, undated, fails to document the procedure for using and labeling disposable tube feeding bags.

Based on interview and record review the facility failed to ensure resident's advance directives and physician's orders reflected resident's wishes for 2 of 3 residents (R41 and R58) reviewed for advance directives in a sample of 25. Findings include: 1. R41's Face Sheet, with original admitted [DATE], documents R41 has diagnoses of but not limited to chronic combined systolic (congestive) and diastolic (congestive) heart failure, chronic obstructive pulmonary disease with (acute) lower respiratory infection, atherosclerotic heart disease, and chronic atrial fibrillation. R41's Minimum Data Set (MDS), dated [DATE], documents R41 is severely cognitively impaired with a Brief Interview for Mental Status (BIMS) of 06 out of 15 and she is dependent on staff for most of her activities of daily living (ADLs). R41's Care Plan, not dated, documents Resident desires CPR be initiated in the event of cardiac arrest, resident wishes will be honored thru next review, Full Code/CPR, In the event of cardiac arrest, CPR will be initiated, and continue until EMS arrival to take over compressions, and/or physician gives order to stop compressions, if not effective, Provide information regarding Advance Directives upon admission. R41's Physician's Order, dated [DATE], documents R41 was a Full Code, and the order was discontinued and R41 was made a Do Not Resuscitate (DNR) on [DATE]. R41's Practitioner Order for Life-Sustaining Treatment (POLST), dated [DATE], documents R41's wishes are to be a DNR. R41's Updated Care Plan, print date of [DATE], documents R41 desires no life-prolonging measures in the event of cardiac or respiratory arrest as evidenced by advance directives/POLST form. 2. R58's Face Sheet, with original admitted [DATE], documents R58 has diagnoses of but not limited to Parkinson's disease and dementia. R58's MDS, dated [DATE], documents R58's is severely cognitively impaired and is dependent on staff for most of his ADLs. R58's Care Plan, with admitted [DATE], has no documentation of his advanced directive wishes. R58's Physician's Orders, dated [DATE], documents Full Code See POLST for medical interventions. R58's POLST, dated [DATE], documents R58 wishes to be a DNR. [DATE] 12:40 PM V1, Administrator stated the resident's physician's orders will document they are a full code until the doctor signs the POLST and then V13, Social Services will notify the nurse so the nurse can change it in the computer and then the nurse will pass it on to the V4, MDS coordinator so she can update the care plan. She said they must not have notified anyone of the updated POLST so they could change them in the computer, and they would get them changed right away. The facility's Advanced Directives policy, issue date of [DATE], documents Purpose: To provide guidance to staff on the expectation of respecting residents wishes with regards to Advance Directives and compliance with state and federal regulations. Policy: Advance directives will be respected in accordance with state law and facility policy. Responsibility: It is the responsibility of the Social Service department/Administrator to know the regulations/policies and ensure all appropriate staff are aware. Procedure: 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. If further documents 7. Information about whether or not the resident has executed an advance directive shall be prominently in the medical record. It also states 10. The Plan of Care for each resident will be consistent with his or her documented treatment preferences and/or advance directives. It further states 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical records and plan of care.

Based on observation, interview and record review, the facility failed to ensure medications are labeled and stored appropriately until they are administered for 4 of 4 residents (R4, R21, R23, R32) reviewed for medication storage in the sample of 34. Findings include: On 5/24/23 at 7:50 AM, V7, Licensed Practical Nurse (LPN), was observed doing the AM medication pass on the 100 and 200 Halls. When V7 opened the top drawer of the medication cart, there were three medication cups containing multiple pills and capsules. These cups were labeled with R4's, R21's, and R23's names, but no other identifying information or dates were written on the cups. There were two cups of clear fluid on top of the medication cart. 1. R4's Physician Order Summary dated 5/24/23 documents he takes the following medications in the morning: Fluoxetine 10 milligram (mg), Ergocalciferol 2000 units (u), Carbidopa-Levodopa 25-100 mg 2 tabs, Vitamin B12 1000 micrograms (mcg), Miralax 17 Grams (Gm), Aspirin 81 mg, Acetaminophen 325 mg 2 tablets, Odansatron 4 mg, and Trihexyphenidyl 1 mg. On 5/24/23 at 8:25 AM, V7 reviewed the medications labeled with R4's name. There were 10 pills in the cup. V7 identified the pills as Carbidopa-Levadopa 25/100 (2), Aspirin 81 mg (1), Odansatron 4 mg (1), Trihexyphenidyl 1 mg 1/2 tab, Vitamin B12 1000 mcg (1), Ergocalciferol 2000 u (1), and Tylenol 325 mg (2). V7 stated this was R4's morning meds. When pills were counted in the cup, there were 10 pills in the cup and V7 only identified 9 medications. When pills were compared to pills on R4's med cards and in stock medication bottles, the 10th medication was identified as Fluoxetine 10 mg and orders were all reconciled. V7 stated she thought she would recognize all of the pills and be able to identify what they were, but she was unable to identify the Fluoxetine until it was compared to his card of Fluoxetine. V7 also took a cup of fluid that looked like water off the top of the medication cart to give to R4. V7 identified this cup of fluid as R4's Miralax 17Gm. She stated the second cup of fluid was also Miralax in water for another resident to whom she still had to administer medications. These two cups of clear fluid had been sitting on the top of the medication cart since the start of the medication administration observation. 2. R21's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Sertraline 50 mg (1), Senna 8.6 mg (1), Miralax 17 Gm, Acetaminophen 325 mg (2), Apixaban 2.5 mg (1), Carvedilol 6.25 mg (1), and Isosorbide 20 mg (1). 3. R23's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Buspirone 5 mg (1), Sertraline 25 mg (1), Aspirin 81 mg (1), Seroquel 12.5 mg (1), Vitamin B12 500 mcg (1), Allopurinol 100 mg (1), Metoprolol Succinate 100 mg (1), and Ferrous Sulfate 325 mg (1). 4. R32's Physician Order Summary dated 5/24/23 documents she takes the following medications in the morning: Midodrine 2.5 mg (1), Allegra 180 mg (1), Carbidopa-Levadopa 25-100 mg (2), Senna 8.6 mg (1), Baclofen 10 mg (1), Entacapone 100 mg (1), Miralax 17 Gm, Vitamin D3 1000 u (1), Dulcolax 5 mg (3), Tylenol Extra Strength 500 mg (2), Lasix 20 mg (1), and B-Complex Tablet (1). On 5/24/23 at 8:20 AM, V7 stated, I'm not going to lie. I set the medications up for these residents when I first started my medication pass. I already signed them out on the MAR (Medication Administration Record) when I set them up. I will go back in and document any additional information, like a pain level or blood pressure, as soon as I get them. They are in the top drawer of the medication cart. I know we are not supposed to pre-set up medications, but if I didn't, I would be here forever doing my med pass. I do this every morning. If I had to leave and another nurse had to take over, and I had set a resident's medications up ahead of time, most of the other nurses know the residents and know their medication by sight. On 5/24/23 at 1:00 PM, V7 confirmed the second unlabeled cup of water containing Miralax that was sitting on the top of the medication cart this morning was for R32. V7 stated she had pre-mixed the Miralax when she set up the other medications to remind her to go down and administer R32's medications. V7 stated she did not need to label the cups containing Miralax with R4's or R32's names because Miralax is always the same dose so it doesn't matter which cup she gives them. On 5/24/23 at 9:10 AM, V1, Administrator stated, The nurses know they are not supposed to pre-set up any residents' medications. They should be checking the medication card against the order in the e-MAR (electronic medication administration record) and then give the medication at that time, not setting it up to give later. The facility's policy, Medication Administration, dated 1/11/10 documents, Objective: To provide accuracy during medication pass to assure quality care for residents. Policy: It is the policy of this facility to accurately administer medication following physician's orders. Procedure: 6. Compare label with MAR. Medications should be charted during the med pass in a consistent manner before moving on to the next resident.

Based on observation, interview, and record review, the Facility failed to follow up on Registered Dietitian's (RD) recommendations for residents with significant weight loss and ensure RD recommendations are implemented in a timely fashion in 2 of 5 residents (R14, R48) reviewed for nutrition in the sample of 34. Findings include: 1. R14's Face Sheet documents R14 has diagnoses including chronic atrial fibrillation, obstructive sleep apnea, vitamin D deficiency, Barrett's Esophagus without dysplasia, essential (primary) hypertension, and age-related cognitive decline. R14's Minimum Data Set (MDS) dated [DATE] documents R14 was severely cognitively impaired, walked independently, and had no significant weight loss. R14's Care Plan dated 4/18/23 documents, I may be at risk for nutritional problems r/t (related to) age related cognitive decline. The Facility's Weight Losses list documents R14 as a resident who has lost weight. R14's Weight and Vitals Summary dated 5/25/23 documents R14 weighed 155.9 pounds on 4/11/23 and 146.2 pounds on 5/7/23. It documents this is a 9.7 pound or 6.2% weight loss in less than a month. R14's Progress Note dated 5/12/23 at 9:28 AM by V13, Registered Dietitian, documents, RD (Registered Dietitian) WT (Weight) OBS (Observation) note for (R14) who is triggering for significant (-9.7#; -6.2%) wt loss x 1mo (month). CBW (Current Body Weight) 146#; BMI (Body Mass Index) 22.2 underweight for age. Generally eats well on a regular diet. Meds (Medications) reviewed noting Seroquel was recently D/C'ed (discontinued), CPAP (Continuous Positive Airway Pressure) orders, No edema (fluid retention) or skin breakdown. Accuchecks (blood sugar checks) wnl (within normal limits) and rarely >110mg/dL (milligrams per deciliter). Suspect wt loss r/t new environment/routines, activity level; recommend adding house supplement at 60cc (cubic centimeters) TID (three times daily) until healthy BMI is achieved and maintained. Refer PRN (as needed). The Facility's Dietitian Referral - Recommendation Report dated and completed 5/12/23 documents R14's Nutritional Information is, Sig (significant) loss x 1mo (month), eats well, 93yo (year old), no edema, from (Assisted Living), skin intact. Recommendation: Add house supp (supplement) @ (at) 60cc (cubic centimeters) TID (three times daily). R14's Physician Orders dated 5/25/23 document Med Pass Supplement was not ordered until 5/25/23. On 5/25/23 at 8:15 AM, V1, Administrator, stated, (V13), Registered Dietitian, wrote her recommendations for (R14) on the communication form, but did not send us the actual recommendation form which is what we send to the doctor. 2. R48's Face Sheet Documents R48 has diagnoses including urinary tract infection, chronic obstructive pulmonary disease, major depressive disorder, gastro-esophageal reflux disease without esophagitis, repeated falls, essential (primary) hypertension, and difficulty in walking. R48's MDS dated [DATE] documents R48 was moderately cognitively impaired, required extensive on person assistance with bed mobility and transfer, did not walk over the previous 7 day period, and had lost weight without being on a prescribed weight-loss regimen. R48's Care Plan dated 4/27/23 documents, I may be at risk for nutritional problems d/t (due to) receiving a 2gm (gram) NA (sodium) regular diet r/t Dx (diagnosis) of HTN (hypertension) and having an unplanned weight loss on readmission. The Facility's Weight Losses form documents R48 is a resident who has lost weight. R48's Weight and Vitals Summary dated 5/25/23 documents weight of 153.9 pounds on 4/5/23 and 139.4 pounds on 4/21/23. It documents this is a 14.5 pound or 9.4% weight loss in less than a month. R48's Progress Note written 4/27/23 at 11:11 AM by V11, Dietary Manager, documents, Resident had a 11.3% weight loss on readmission compared to discharge weight of 154#'s on 4/5/23. Current weight as of 4/27/2023 is 139#'s with a BMI of 21.1. R48's Progress Note written 5/12/23 at 11:02 AM by V13, Registered Dietitian (RD), documents, RD WT OBS note: Significant wt loss b/t (between) 4/5 @ 153# and 4/21 @ 139#; noting (R48) was D/C'ed (discharged ) on 4/17, returning 4/21. CBW 5/8 138#; Sodium restricted diet ordered. Meds reviewed. Therapies ongoing, surgical incision noted. Continue to recommend liberalizing diet to regular and adding house supplement @ 60cc BID (twice daily). Rd will follow. Refer PRN. The Facility's Dietitian Referral - Recommendation Report dated and completed 5/12/23 documents R48's Recommendation as, Liberalize diet to regular. Add house sup (supplement) 60cc BID. Date Sent: 5/23/23. Refaxed 5/24/23. The form does not document a physician response. R48's Physician Orders printed 5/25/23 document, 2 GM NA diet. There was no supplement order or change in diet documented. On 5/25/23 at 8:15 AM, V1, Administrator, stated the reason they couldn't find R48's Recommendation Report before is because it was never signed off by the doctor and they had to fax it again it today. On 5/26/23 at 9:25 AM, V1, Administrator, stated she expects staff to follow up on dietary recommendations in a timely manner and follow the Facility's Dietitian Recommendation Process Policy. The Facility's Diet and Nutrition Care Manual 10th Edition, 2022, documents in the Preparing for Consultant Dietitian section, Review Dietitian's report, including sanitation from the prior month and develop plan of action to correct the identified problems. Follow up on Dietitian's recommendations and make sure that they are implemented in a timely manner. Inform Dietitian of any recommendations not completed or that the MD (Medical Doctor) has disagreed with. Documented in the Dietitian Recommendation Process section is, Policy: Dietitian recommendations will be completed in an organized and timely manner. If a recommendation is needed, the Dietitian will document in the medical record and complete a recommendation form. The Dietitian may make recommendations regarding resident care, which does not require a change in physician's orders. These recommendations will be documented. The Director of Nursing and the Food and Nutrition Services Manager are responsible for implementing these recommendations in their respective departments. The Dietitian will communicate with the Food and Nutrition Services Manager and Director of Nursing or other designate regarding documentation and recommendation. The Director of Nursing or designee will seek the physician's order changes in a timely manner. Responses should be obtained in 2-3 business days.

Based on observation, interview, and record review, the facility failed to provide safe transfers for 1 of 6 residents (R31) reviewed for accidents in the sample of 32. This failure resulted in R31 sustaining a laceration to the Right posterior calf requiring being sent to the emergency room and receiving 7 sutures. Findings include: 1. On 04/05/22 at 1:00 PM , V2, Regional Nurse, stated that V2 had received a call from previous Director Of Nursing (DON) reporting that when staff were transferring R31 to bed with partial mechanical lift and R31's legs became weak while still in the partial mechanical lift and moved over bed causing laceration to R31's right calf. V2 stated after the occurrence, maintenance looked at R31's bed and padded the bed frame, therapy to re-evaluate partial weight mechanical transfers, and R31 changed to a full mechanical transfer. V2 stated that the nurse is to be notified immediately if Certified Nursing Assistant (CNA) has to increase assistance for transfers. V2 stated that V2 would expect staff to increase transfer assistance if needed. On 4/5/2022 at 2:05PM, V8, Licensed Practical Nurse (LPN), stated that 2 CNAs were transferring R31 to bed with the use of partial mechanical lift and bumped R31's leg on the bed. V8 stated there was an area on the frame with sharp corners. V8 stated that R31 was already in bed when V8 assessed R31. V8 stated that V8 had to apply pressure to the laceration on R31's calf to stop the bleeding. V8 stated that R31 was sent to the emergency room and returned with 7 sutures. V8 stated that R31 has increased weakness in the evening. On 4/5/2022 at 2:10 PM, V9, CNA, stated stated that V9 was transferring R31 to bed with the partial mechanical lift and R31 started to sit prior to the sling being over the bed and bumped R31 leg on the bed. V9 stated that if a resident requires more assistance can go to a full mechanical lift On 4/5/2022 at 2:12PM, V10 ,CNA, stated that V10 was in R31's room to make sure R31 didn't fall during transfer. On 4/5/2022 at 2:18 PM, V7, Maintenance Director, stated that V7 was notified to pad R31's bed frame. V7 stated that V7 did not feel any sharp edges on the bed prior to padding the bed frame. R31's Minimum Data Set (MDS), dated [DATE], documents that R31 is severely cognitively impaired, requires extensive assistance and one person physical assistance for bed mobility, and transfers. R31's Interdisciplinary Resident Screen, dated 3/9/2022, documents R31 was changed to full mechanical lift on 3/8/2022, therapy deems as safest transfer to remain a full mechanical lift. R31's most current electronic face sheet documents a diagnoses to include contractures of right and left hand, and primary generalized [CONDITION(S)]. R31's Progress Notes, dated 3/8/2022 at 9:00 PM, document while staff were transferring R31 to bed they accidentally bumped R31's right calf on the metal bedframe causing a laceration. R31's notes document the laceration as approximately 4 Centimeter (CM) deep and R31 was sent to the emergency room . R31's Progress Notes, dated 3/8/2022 at 10:41 PM, document that R31 returned to the facility with 7 sutures to R31's right calf, an order for antibiotics for wound healing, and a [CONDITION(S)] was given in the emergency room . R31's Progress Notes, dated 3/22/2022, document sutures were removed and steri strips in place. On 4/5/2022 at 3:15PM, V2 stated that during transfers if resident has a changed, staff can be provided more assistance and that is what she would expect. On 4/6/2022 at 2:00PM, V14, Medical Director, stated if a resident receives a laceration during a transfer, of course, the transfer was an unsafe transfer. The Facility Safe Resident Handling Program Transfer and Bed Mobility Assessment Tool, revised 2/14/2018, documents caregivers should always do the safest transfer possible for both the resident and employee. It documents that Caregivers can always increase the level of assistance BUT can never decrease level of assistance. The tool documents If the level of assistance is increased, immediately notify the floor nurse so that the resident can be evaluated.

Based on interview, observation and record review, the facility failed to provide complete and timely incontinent care for 4 of 6 residents (R2, R7, R21, R57) reviewed for incontinent care in the sample of 32. Findings include: 1. On 4/4/22 at 11:00 AM, V20, Certified Nurses Aide (CNA), transferred R7 from R7 wheelchair to the toilet using a mechanical lift. When R7 was raised to the standing position, R7's seat of R7 pants and R7 wheelchair cushion was wet with urine. R7 was transferred to the toilet and the soiled incontinent brief was removed. The brief was saturated with urine. V20 cleansed the peri area, rectal area and buttocks. V20 failed to cleanse the inner thighs and the back of the thighs. On 4/6/22, R7 remained in R7 wheelchair from 10:15 AM until 2:50 PM without being toileted or checked for incontinence based on 15 minute or less observation intervals. On 4/6/22 at 2:50 PM, V19, Licensed Practical Nurse (LPN), and V1, Administrator, transferred R7 from R7 wheelchair to the toilet using a partial mechanical lift. When R7 stood, the seat of R7's pants was saturated with urine. R7's wheelchair seat pad was also wet with urine. V19 removed R7's incontinent brief and it was saturated with urine. R7's buttocks was light red and intact. R7 was placed on the toilet and she urinated. V19 provided incontinent care for R7, placed a new incontinent brief and new pants on R7. R7 was transferred back to her wheelchair. On 4/6/22 at 3:52 PM, V1 stated that residents should be toileted or checked and changed at least every two hours. V1 also stated that she expects staff to provide complete incontinent care. R7's Face Sheet, print date of 4/6/22, documents R7 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R7's Minimum Data Set (MDS), dated [DATE] documents R7 is moderately cognitively impaired, requires extensive assistance from 1 staff member for toileting and is frequently incontinent. 2. On 4/6/22 at 11:05 AM, V24, CNA, and V21, CNA, entered R21's room to provide indwelling urinary catheter care. R21 was uncovered, V21 used a washcloth that had peri-wash on it and wiped the tip of the penis and then wiped the top side of the penis. V21 held onto the tubing at the insertion point and wiped down toward the collection device. V21 failed to wipe the bottom and sides of the penis, the pubic area, the groin or the scrotum. R21's Face Sheet, print date of 10/22/22, documents R21 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R21's MDS, dated [DATE], documents that R21 is severely cognitively impaired, requires extensive assistance of one staff member, and has a indwelling urinary catheter. 3. On 4/6/22 at 11:19 AM, V21, CNA, and V15, CNA, provided incontinent care to R57. R57's incontinent brief was removed. The brief was saturated with urine. V15 used a wet wash cloth with peri-wash to wipe R57's pubic area, with another washcloth wiped R57's left groin but only half way down. V15 failed to move R57 large scrotum and wipe all the way down the groin, with another washcloth wiped R57's right groin but only half way down. V15 failed to move the scrotum and wipe all the way down the groin. The area between the groin and scrotum was red and irritated looking with areas that had old cream that had been applied previously. V15 failed to wash the scrotum which was red and irritated. V15 then cleansed the penis. R57 was rolled over to R57 left side and R57 buttock and rectal area were cleansed. R57 was rolled over to the right side and the buttock was washed. R57's buttocks, sacrum and rectal area were very red and irritated. V15 stated she was finished and she covered R57 up. R57's Face Sheet, print date of 4/5/22, documents that R57 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R57's MDS, print date of 3/16/22, documents R57 is severely cognitively impaired, requires extensive assistance of two staff members for toileting and is always incontinent of bowel and bladder. 4. On 04/06/2022 at 4:15 PM, V10, CNA, cleansed R2's labia (both sides) and perineal area but did not cleanse R2's groin area or inner thighs. R2 was then rolled onto her left side. V17, CNA, did not cleanse R2's left buttock nor did she cleanse the back of R2's legs after cleansing R2's right buttock and rectal area. R2's Care Plan, dated 03/24/2020, documents Provide incontinence care after each episode according to facility protocol. R2's MDS, dated [DATE], documents that R2 was rarely or never understood, was totally dependent upon 2 staff members for toileting and hygiene, and was always incontinent of bowel and bladder. The facility's Resident Care Policy and Procedure, dated 11/2016, documents, Policy: Residents who require assistance from nursing staff to cleanse their perineal area will be cleansed in a manner that decreases the risk of transmission of infection and promotes skin integrity. It continues, For male genitalia-use gentle strokes from the head of the penis down shaft to the base of the penis, using a clean section of the washcloth or pre-moistened wipe with each stroke. It continues, Cleanse scrotum, using a clean section of the washcloth with each stroke. The facility's policy, Catheter Care -Male, dated 08/01/2005, documents, 9. Cleanse area of insertion of catheter into meatus using a clean washcloth prepared with soap and water or peri-care cleanser. Cleanse downward from top to bottom on one side, and then repeat on the other side using a clean washcloth.

Based on interview, observation and record review, the facility failed to report weight loss to the Physician and develop and implement interventions to prevent further weight loss for 2 of 9 residents (R34, R39) reviewed for weight loss in the sample of 33. This resulted in R34's severe weight loss of 8% in one month. Findings include: 1. R34's Admission Record, print date of 3/9/21, documents R34 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R34's Minimum Data Set (MDS), dated [DATE], documents R34 is moderately impaired for cognitive thinking and requires extensive assist of 1 staff member for feeding. R34's weight log, dated documents on 1/10/21, R34 weighed 136.5 pounds and on 2/10/21, R34 weighed 124.5 pounds. This was a severe weight loss of >8% in one month. R34's Nutrition Note, dated 2/25/2021, documents, Note Text: RD (Registered Dietician) WT (weight) Note: (R34) is experiencing significant (-12#; -8.8%) wt loss x 1/mo. ~143# from March - Nov; Dec and Jan wt 136#; Current BMI (body mass index) 25.1 remains wnl (within normal limits). Intakes varied, no changes to diet or meds. No [CONDITION(S)] or skin issues. Etiology of loss unclear, suggest re-weigh and then weekly wts (weights) to more closely follow, as poss (possible) nutl (nutrional) supplement may be needed. There was no documentation that R34 was reweighed. R34's Health Status Note, dated 3/11/2021, documents, Note Text: MD (V26, Medical Doctor) in to see resident. Received orders to get a weekly WT and fax to MD, Med Pass 90 cc (cubic centimeters) TID (3 times daily) with meals. This was 15 days after the RD note before R34's weight loss was addressed and any interventions were implemented. There was still no documentation that R34 had been weighed since 2/10/21. R34's Electronic Medical Record has no documentation that the Physician was notified of R34's severe weight loss before 3/11/2021. On 3/16/21 at 9:57 AM, V8, Dietary Manager, stated, If someone has a significant weight loss, they are reweighed. If it is a true weight loss, the Director of Nurses is notified and she notifies the doctor. I gather all the information relating to the resident medications, changes , food intakes, things like that and send it to the dietician. The dietician then makes recommendations. Then the nurses get it approved by the doctor. The process is usually pretty fast on our end, but sometimes it takes awhile for the doctor to approve the recommendations. On 03/17/21 at 11:12 AM, V26, Physician, stated, I would like the facility to notify me of weight loss when they realize it. 2. R39's Active physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] R39's Minimum Data Set (MDS), dated [DATE], documents that R39 requires supervision and setup only for eating. R39's Care Plan had the following interventions, all initiated on 12/26/2019, to address her nutrition: Diet to be followed as ordered; Encourage resident to eat at least 50% of all foods at all meals daily; Offer snacks in AM PM, and HS snack pass daily; RD (Registered Dietitian) to evaluate and make diet recommendations PRN; Refer to Speech therapist for swallowing evaluation; weight preschedule and record. Monitor and report significant change in weight to MD. R39's Care Plan Intervention, imitated on 1/20/20, to address her weight loss documents: Encourage food intakes at meal, offer substitutes for dislikes or food note eaten. R39's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R39's Care Plan Intervention, dated 3/24/20, documented Nutritional supplement per MD orders for weight management. R39's Electronic Record documents R39 had the following weights on the following dates: 5/10/20: 105 pounds (lbs) 6/5/20: 97.9 lbs 7/10/20: 98.3 lbs 8/10/20: 98.5 lbs 9/10/20: 98.1 lbs There is no documentation in R39's medical record that the facility implemented any new progressive interventions to address R39's weight loss from May 2020 to June 2020. R39's Weight Variance Assessment and Notification, dated 9/23/20, documented R39's physician was notified of R39's weight change. The Notification documented 60 ml-med pass supplement bid (twice daily). R39 had already been receiving a med pass supplement which was stated on 3/20/20. R39's Electronic Record documents R39's weights were as follows on the following dates: 10/10/20: 86.4 lbs 11/10/20: 89.3 lbs 12/10/20: 86 lbs 1/10/21: 83.7 lbs 2/10/21: 84 lbs R39's Care Plan Interventions, dated 10/21/20, documents Monitor weight and nutritional status and refer to RD PRN and Oatmeal and brown sugar at all meals daily. The intervention regarding referring to RD had also been implemented previously in the 12/26/2019 interventions. R39's Care Plan Problem, initiation date of 1/20/21, documented I'm receiving a regular easy to chew (mechanical) diet r/t (related to) problems chewing and swallowing. I have poor intakes of food and am at risk for nutritional deficient and further weight loss. The goal documented I will be encouraged to eat at least 50% of all food at all meals daily through next review; I will have no problems chewing or swallowing through next review; I will have no further weight loss and be encouraged to gain 1-2 #'s (pounds) through next review. The Intervention, dated 1/20/21 documents Magic cup with lunch and dinner daily. R39's Weight Variance Assessment and Notification, dated 1/27/21, documents a 10% weight loss in 180 days. The Physician signed the Assessment on 2/1/21 but did not recommend any progressive interventions to address R39's weight loss. R39's nutritional assessment, dated 1/28/2021, documents that R39 has had a significant weight loss. R39's assessment documents R39's ideal body weight range of 107-152#. R39's assessment documents regular mechanical soft diet, med pass 120 cc tid (three times daily), and magic cup after lunch and dinner. There were no other interventions noted to increase R39's nutritional intake or to monitor R39's more frequently. On 3/8/2021 at 12:25 PM, V15, Certified Nursing Assistant (CNA) offered R39 lemonade. R39 stated, I don't like lemons, I don't want that. V15 did not offer R39 a substitute. At 12:40 PM, R39 was served cooked cereal, peas, ground meat, sweet potatoes, and cake with frosting in brown plastic bowls. R39 was not served a magic cup. At 12:45 PM, R39 stated she was done. R39 insisted on leaving dining room. R39 had eaten a few bites of sweet potatoes, 100% of meat, no peas, a bite of cake, a few bites of cooked cereal, a couple bites of mashed potatoes, drank chocolate milk and none of the lemonade. None of the staff offer any substitutes to R39. R39's tray tag, dated 3/9/2021, documents easy to chew/mechanical, likes magic cup lunch and dinner/oatmeal with brown sugar all meals, adaptive equipment, curved spoon. On 3/10/2021 at 8:25 AM, R39 in the dining room in wheelchair for breakfast. R39 had Orange juice, milk, water. R39 was eating cooked cereal with brown sugar. Eggs, sausage, and gravy were on the plate. V15 added chocolate syrup to R39's milk. R39 fed herself with a fork, took a few bites of biscuits and gravy. 03/15/21 09:15 AM, V8, Dietary Manager, stated that R39 has had significant weight loss and that is why she now eats in the dining room. V8 stated that R39 has been eating in the dining room for approximately 2 weeks. V8 stated R39 is provided a magic cup every meal and she gets med pass. V8 stated the plan is to give magic cup every meal, oatmeal with brown sugar, and med pass. V8 stated that R39 does not eat well. R39's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/16/2021 at 12:10 PM, V1, Administrator, stated that R39 should have already been on weekly weights due to significant weight loss. V1 stated that offering different food choices would not be considered aggressive measures. The facility's Weight Management Policy and Procedure, dated revised 2/ , documents all residents will be monitored for significant weight changes to assure maintenance of acceptable parameters of body weight. The policy documents weights may be obtained more frequently than monthly if warranted based on resident condition or physician order. The policy documents the physician will be notified of any significant weight change and be made aware of any recommendations made by the dietitian.

Based on observation, interview and record review the facility failed to reassess pain regimen for 1 of 3 residents (R54) reviewed for pain in a sample of 33. This failure resulted in R54 continuing to experience pain with care and a physical decline in her function abilities. Findings include: R54's Care Plan, dated 2/26/2021, documents in part, I am on scheduled Pain medication Therapy r/t (related to) arthritis. Interventions Administer medication as ordered. Review for pain medication efficacy. Assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required. R54's Minimum Data Set (MDS), dated [DATE], documents R54 Receives routine pain medication and has non-verbal sounds (e.g., crying, whining, gasping, moaning, or groaning) and Facial expressions (e.g., grimaces, winces, wrinkled forehead, furrowed brow, clenched teeth or jaw) as indicators of pain. R54's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . C/O (complains of) increased pain, especially when attempting ROM (range of motion). Having some behaviors such as hollering out and grabbing at staff; possible d/t (due to) pain. Resident is unable to verbalize needs. R54's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Give 1000 mg by mouth three times a day for pain. Not to exceed 4G/day (grams per day). R54's Electronic Health Record (EHR) has no documentation of a pain flow sheet and reassessment of the effectiveness of R54's pain interventions. On 3/10/2021 at 12:55 PM, R54 was transferred from wheelchair to recliner with a sit to stand mechanical lift. V5, Certified Nursing Assistant (CNA), applied the sling around R54's back. Upon raising R54 to a standing position, the sling moved under R54's armpits and R54 gasped. R54 exhibited facial grimacing, wrinkling of her forehead, furrowed brow, squinting of the eyes, clinching of her teeth and stiffening of her neck and body. (R54) continued this until V5 placed her in the recliner. On 3/11/2021 at 1:50 PM, V5, CNA, performed range of motion with R54. R54 was lying on her back. When moving R54's shoulder, R54 was resistive and exhibited scowling of forehead, squinting of the eyes and stiffening of her neck. When performing ROM on her legs, R54 stiffened her body and kept leg stiff raising her head off the bed with each attempt to manipulate the knee joint. V5 attempted to manipulate R54's right hand. R54 drew her hand in pulling away from V5. R54's body stiffened and turned in towards V5. R54 began yelling out with a high pitch tone and stated enough. V5 stopped. 03/08/2021 1:49 PM, V24, CNA, stated R54 needs assistance from staff with activities of daily living. V24 stated, (R54) has contractures that causes her pain. (R54) does have behaviors and she yells out. Yells very loud. She has had a big change in the past year. On 3/10/2021 at 12:15 PM, V4, Licensed Practical Nurse (LPN), stated (R54) does have behaviors. She yells out when staff performs care. She has multiple contractures and these cause her pain. V4 stated, (R54) doesn't have pain medication and it's difficult to assess her pain. When you ask her a question, she will say 'No.' She is not able to tell you when she is in pain. So it makes it difficult. 3/10/2021 at 1:00 PM, V5, CNA, stated, (R54) yells out. She has a lot of pain because she is contracted. Her hands are the worst. That's when she yells out when we move her around especially her hands. This happens only when staff are performing care. It's worse when staff are moving her hands. She has contractures that causes her pain in her shoulders, hands and knees. She does have facial grimacing, gritting of teeth and stiffening of her body at times. When transferring her at the end of the day, she is stiff and it causes her pain when she moves. She has changed in the past year. She used to be able to hold on to the lift with her fingers. Now she doesn't hold on at all. 3/11/2021 at 3:23 PM, V6, LPN, stated that she has taken care of R54 and she does have pain. R54 takes routine pain medication. V6 stated normally they (nurses) would check back after the medication is given to make sure it works, but R54 doesn't have a flow sheet or a pain scale. On 3/15/2021 at 9:10 AM, V2, Director of Nursing (DON), stated, (R54) does yell out and become combative with care. This is because of R54's pain and she is receiving pain medication. It's hard to say with her if she is in pain or not. V2 stated the behaviors would decrease as how staff know the pain medication was effective. When asked how would you know more immediately? V2 stated, The nurses' check back to see if she is better. This would be documented in the chart. When notified of not finding this information in the chart, V2 stated we do have some documentation problems. On 3/16/2021 at 10:50 AM, V12, Nurse Practitioner, stated that she would expect the nursing staff to assess the effectiveness of the pain medication. V12 stated R54 has dementia and can't say she is pain. The medication was prescribed for a specific reason and behavior and if she continues to show that behavior then the pain medication would not be effective. V12 stated R54's pain medication was not effective. V12 stated R54's pain with her contractures have caused her decline. The Facility's Management of Pain Policy, dated 04/04/2012, documents, Our mission is to facilitate resident independence, promote resident comfort and preserve resident dignity. The purpose of this policy is to accomplish that mission through an effective pain management program, providing our residents the means to receive necessary comfort, exercise greater independence, and enhance dignity and life involvement. We will achieve these goals through: Aggressively assessing pain in non-verbal and cognitively impaired residents. Optimizing the residents' ability to perform activities of daily living. Preventing and minimizing anticipated pain when possible. Using non-pharmacological and complementary and Alternative Medicine (CAM) when appropriate. It further documents, Nursing Observation: Nursing observation is an important part of the pain assessment, especially in the non-verbal resident. Using the chart provided with the pain assessment, nursing will observe behaviors that may indicate pain in the non-verbal or cognitively impaired resident. Pain may be indicated when there are changes in the following: Facial expressions, Vocal behaviors, Body movements, Routines and Mental status. It also documents, Pain Flow Sheet: Initiate a pain flow sheet for all residents reporting pain regardless of the treatment (pharmacological and/or non-pharmacological). The pain flow sheet is completed each shift. The effectiveness of pain scale chosen by the resident or the behavioral indicators. (B)

Based on observation, interview and record review, the facility failed to implement fall precautions, provide supervision, provide a proper transfer and determine the root cause of repeated falls for 4 of 4 residents (R23, R44, R50, R10) reviewed for falls in the sample of 42. This failure resulted in R23 sustaining 3 broken ribs and R44 sustaining a laceration requiring staples. Findings include: 1. R23's Admission Record, dated (MONTH) 10, 2019, documents R23 was admitted on [DATE]. This Admission Record documents R23 has [DIAGNOSES REDACTED]. R23's Minimum Data Set (MDS), dated [DATE], documents R23 has a Brief Interview of Mental Status (BIMS) of 12 indicating R23 is moderately cognitively impaired. This MDS also documents R23 requires limited assistance of 1 staff member for bed mobility, transfer and locomotion on the unit. This MDS documents R23 is not steady but able to stabilize without staff assistance when moving from seated to standing, R23 is not steady and only able to stabilize with staff assistance for locomotion with the use of a walker. R23's MDS, dated [DATE], documents R23 has a Brief Interview of Mental Status (BIMS) of 10 indicating R23 is moderately cognitively impaired. This MDS also documents R23 requires limited assistance of 2 staff members for bed mobility, limited assistance of 1 staff member for transfer and locomotion on the unit. This MDS documents R23 is not steady but able to stabilize without staff assistance when moving from seated to standing, R23 is not steady and only able to stabilize with staff assistance for locomotion with the use of a walker. R23's Care Plan, dated 11/08/2018, documents, in part, Focus: I am at risk for falls r/t (related to) Gait/balance problems, hx (history) of falls, and hx of [MEDICAL CONDITION]. I need limited assist for transferring and toileting, walking with walker, locomotion in w/c. I am able to walk with one assist and walker in room and corridor. Intervention: Ensure that I am wearing appropriate footwear when ambulating or mobilizing in w/c (wheelchair). Date initiated: 08/09/2018, Educate me on safety reminders and what to do if a fall occurs Date initiated: 08/09/2018, Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Date initiated: 08/09/2018, Anticipate and meet my needs Date initiated: 08/09/2018. Ensure I am wearing well fitting shoes prior to getting up Date initiated: 1/26/2019. staff retraining on fall interventions date initiated 2/1/2019. Pressure pad to bed and chair date initiated 3/3/2019. R23's Fall Risk Assessment, dated 2/5/2019, documents R23's Morse Fall Risk Score of 80 indicating R23 is a High Fall Risk. There are no other Fall Risk assessments available for review. R23's Occurrence Report, dated 12/22/2018 at 02:15 AM, documents, in part, R23 had an unwitnessed fall while ambulating in his room which resulted in a 1.5 centimeter by 1.0 cm laceration to the center of his forehead. The Report Notes documented Resident stated he was attempting to ambulate to the bathroom unassisted when he slid and lost balance landing on floor. The Report documented he was wearing only socks when the incident occurred. The Report documented Root cause: Other, inappropriate footwear Recommendation: Slipper socks worn at night Remind and encourage to use call light. R23's Occurrence Report, dated 1/26/2019 at 07:30 AM, documents, V19 witnessed R23 fall in his room. The Report documented R23 sustained a skin tear to the back of his right hand which required steri-strips. The Report documented Resident was being assisted out of bed by CNA. Resident wearing slipper socks. As CNA assisted resident into a sitting position on the bed he began to slide out of bed, CNA was unable to prevent the fall, but was able to lower resident safely to the floor, landing on his buttocks. Resident did hit his hand on bed frame as he slid onto floor causing a skin tear. Footwear: Slipper-socks. The Report documented the root cause as inappropriate footwear with recommendations for staff to assist resident to wear well fitted shoes before getting up. R23's Care Plan was not updated with the recommendation made from Occurrence Report dated 1/26/19. R23's Occurrence Report, dated 2/1/2019 at 10:20 PM, documents, R23 fell while ambulating in his room. The Report documented he was wearing normal socks. The Report documented he was found on the floor in the sitting position with his feet in front of him and sustained no injuries. The Report documented R23 stated he slipped while getting out of bed. The Report documented Conclusion: Resident is alert and orientated x 2, he requires limited assist with transfers and ambulation, he is frequently non-complaint with safety, transferring and ambulating without calling for assistance. Current fall intervention is for him to wear slipper socks while in bed. Staff retraining assistance. Current fall intervention is for him to wear slipper socks while in bed. Staff retraining will be given to follow current plan of care. Root cause: Staff did not follow plan. Recommendation: Staff retraining on following fall interventions. R23's Occurrence Report, dated 2/4/2019 at 3:40 PM, documents, R23 fell while in his resident Bathroom. The Report documented he sustained no injuries and was alert and oriented times 2. The Report documented Resident self transferred to the bathroom without calling for assistance, well fitted shoes on. resident being monitored for cold s/s (signs and symptoms) with increased weakness. The Conclusion of the Report documented Resident is alert and orientated x 2, he requires limited assist with transfer and ambulation with wheeled walker. He is non-complaint with safety, transferring and walking without calling for assistance. He is noted to have cold symptoms, SOB (shortness of breath), clear nasal drainage. Root cause: Other, possible underlying medical condition Recommendation: Chest X-ray and labs to rule out underlying medical condition. The Report did not document how staff were to provide increased supervision or any other interventions to prevent R23 from future falls. R23's Care Plan was not updated with any interventions to address his non-compliance or how staff were to prevent him from future falls. R23's Occurrence Report, dated 3/3/2019 at 8:20 PM, documents R23 fell while taking himself to the bathroom. The Report documented he sustained a laceration to his left brow measuring 3 cm by 1.5 cm and a skin tear to his right forearm measuring 2 cm by .5 cm. The Record documents CNA called nurse into residents room Resident noted lying on right side in bathroom with wheelchair at bathroom door. Arm and legs folded inward to middle torso. Resident facing toilet feet outside doorway. Sent to ER (emergency room ) for evaluation due to laceration and elevated pulse. Resident Statement of what happened: Resident stated he needed to go to the bathroom and lost balance. The Report Conclusion documented Resident is alert and orientated x 2 with confusion, he has poor safety awareness. He requires limited assist with transfers and ambulation with use of wheeled walker. He was attempting to take himself to bathroom without calling for assistance, lost balance and fell . Due to noncompliance with safety, pressure pad alarm will be applied while in room. Root cause: Other, Non-compliant with safety. Recommendation: Pressure Pad alarm while in room. R23's Occurrence Report, dated 4/8/2019 at 3:45 AM, documents, R23 had an unwitnessed fall in his room while ambulating to the bathroom unassisted. The Report documented he sustained an abrasion to his right lower back measuring 15.2 cm by (x) 1.2 cm, a skin tear to his right upper arm measuring 5.2 cm x 2.3 cm, a skin tear to his right ear measuring 6.2 cm by 6.1 cm and an abrasion to his mid left back measuring 3.1 cm by 3.1 cm. The Report documented Resident noted supine on floor with head against dresser, walker in front of him, call light off, alarm sounding, gripper socks on, res (resident) stated he was attempting to go to the bathroom on his own. Assessed by nurse, pain noted with ROM (range of motion), MD (medical doctor) updated and gave orders for X-ray, abrasion. Resident Statement of what happened: 'I'm going PEE'. Conclusion: Resident is alert with confusion. He is non-complaint with safety. He requires limited assist with transferring and ambulation with use of wheeled walker. Root cause: Other, Resident non-complaint with safety. There were no documented recommendations on this Report. R23's Right Ribs X-ray, dated 4/8/2019, documents, in part, Impressions: Anterior Lateral right eight, ninth and 10th rib fractures. On 4/11/2019 at 11:50 AM, V1, Administrator, stated, Yes, it seems like his real root cause of falls is related to footwear and trying to get up and go to the bathroom. On 4/11/2019 at 12:11 PM, V2, Director of Nurse (DON), stated, Fall risk assessments should be completed upon admission and annually. V2 also stated, The cause of his falls is footwear and trying to go to the bathroom. The facility policy and procedure Fall Assessment, Risk Identification and Management Policy, dated 3/20/2012, documents, in part, It is the policy of the facility to assess each resident's fall risk upon admission. Procedure: I. Initial Assessment and Planning A. Upon admission/ readmission, a Fall Assessment will be completed based on the initial admission nursing assessment and the resident history. B. Each resident will be assessed using the MDS upon admission, quarterly and with any significant change assessment. c. The potential for injury will be care planned when appropriate, based on the results of the Fall Assessment. The interdisciplinary care plan will be individualized to reflect the specific needs and risks factors of the resident. E. Fall occurrence will be monitored by the Quality Assurance team. II. Resident Falls c. Care Planning after a fall 1. A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regard to future interventions, and resident specific risk factors. III. Interventions to manage falls A. Intervention will be based on the resident assessments and the circumstances surrounding the risk for injury or actual fall. 2. R44's current Electronic Health Record (EHR) documents [DIAGNOSES REDACTED]. R44's MDS dated [DATE] documents R44 is cognitively impaired and requires extensive assistance of two staff members for toileting. R44's Care Plan dated 5/17/17 documents R44 is at risk for ADL self-care performance deficit and requires extensive assist with toileting. R44's Care Plan 2/26/19 Fall intervention documents Stay with resident during toileting. R44's Fall assessment dated [DATE] documents R44 is a high risk for falling R44's EHR Health Status Note documents, 2/26/19 11:01: Called to resident room and was updated by V2, Director of Nursing and V5, Licensed Practical Nurse, resident had fallen, and they had just gotten her back into bed. Large laceration noted to right side of head, pressure applied. Call placed to 911 @ this time. Fall 2/27 lac to head staples (2). R44's Occurrence Report dated 2/26/19 documents R44 fell in R44's bathroom while ambulating and sustained a laceration to the right side of scalp and sent to the emergency room for evaluation due to head trauma. Notes documents (R44) noted on right side on bathroom floor with head against doorframe. Laceration noted to right temporal lobe, pressure dressing applied to control bleeding, assessed by nurse, neuro checks initiated and within normal limits (WNL) for this resident. Level of Consciousness (L[NAME]) per baseline, no pain with Range of Motion (ROM). (R44) sent to the ER for evaluation due to head trauma. R44's statement: I was ready to get up. The Report Conclusion documents (R44) is alert and oriented to self, with poor safety awareness. (R44) requires limited to extensive assist with transfers, ambulates short distances with wheeled walker and assist. (R44) attempted to get up unassisted in the bathroom and was noted on the floor with laceration to right temporal. Assessed by nurse and sent to ER for evaluation. The Report documents Recommendation: Staff to remain with resident during toilet. On 04/11/19 at 09:22 AM V2, DON stated R44 had to go to bathroom and had a bowel movement in pants. V2 states V5 went to grab washcloths from R44's room and left R44 in the bathroom alone. V2 stated V5 had the door open and could visualize R44. V2 stated R44 needs assistance for toileting of 1 or may use sit to stand, just depends on what is offered or if R44 is not cooperating. V2 stated that R44 has been assessed for extensive assistance of 2 staff members for toileting on the MDS. On 04/11/19 at 11:36 AM, V5 stated she was taking care of R44 when she fell on ,[DATE]. V5 stated she went to get R44's some new linens and R44 took a step and hit her head on the door frame. V5 stated that R44 was alone in the bathroom. V5 stated staff routinely got R44 up with 1 assist and thinks R44 might have been a 2 assist due to behaviors. V5 stated she knows not to leave resident to get linens and take them in with her now. 3. R50's face sheet dated 2/26/19 the following [DIAGNOSES REDACTED]. R50's MDS dated [DATE], documents R50 requires extensive assistance of two staff members for transfers. BIMS 14 and cognitively intact. R50's Care Plan dated 3/6/19 does not address the number of staff required for transferring R50. R50's Occurrence Report dated 3/24/19 documents V25, CNA called for help due to resident sliding out of sit to stand. The occurrence report documents one (1) staff was in assistance at the time of the fall. On 04/11/19 at 10:12 AM during an interview, V25 she stated when assisting R50 on 3/24/29 with the sit to stand that he slipped after applying lotion. V25 stated she was the only one assisting him when this fall occurred. R50's Occurrence Report dated 4/4/19 documents V29, CNA was transferring R50 when the transfer lift battery stopped working and V29 was unable to get R50 onto bed. The occurrence report states only one (1) staff was in assistance at the time of the fall. 04/11/19 10:40 AM V2, DON stated it depends on R50's abilities as they change. V2 stated R50 may only need one assist during the day but may need a mechanical lift in the evening because R50 is weaker. When asked how would the staff know this if it is not written in the care plan , V2 did not have a direct response but did state I understand.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and failed to provide safe transfers to prevent falls for 6 of 10 residents (R1, R2, R5, R7, R9, R11) reviewed for falls in the sample of 15. This failure resulted in R2's fall from bed and sustained a right humerus fracture requiring hospitalization , R1's fall from a sit to stand mechanical lift sustaining a possible fracture of L1 and head hematoma requiring hospitalization , and R7's fall and sustained a right hip fracture requiring surgery with hospitalization , and a second fall with an acute minimally displaced fracture trochanter proximal right hip and requiring right hip surgery. Findings Include: 1. R2's Electronic Health Record (EHR), with the most recent date of 5/27/17, documents diagnoses, in part, Unspecified fracture of shaft of right humerus, [DIAGNOSES REDACTED], muscle wasting and atrophy, and recurrent Depressive Disorders. R2's Minimum Data Set (MDS), dated [DATE], documents R2 having a Brief Interview Mental Status(BIMS) of 6, indicating severe impairment, and is dependent on staff for all transfers. The MDS further states R2 has functional limitations in range of motion to the lower extremities. R2's Care Plan, dated 2/9/17, documents R2 is at risk for falls related to paralysis of lower extremity due to polio, is non-weight bearing, needs a mechanical lift for transfer, is on a diuretic related to edema to bilateral extremities, and is at risk for falls related to diuretic therapy. Care Plan further documents R2 is dependent for all Activities of Daily Living (ADLs) and needs 2 assist with ADLs, including bed mobility. The Facility's fall risk scale entitled, HH Fall Scale, Morse V.1a, dated 2/2/2017, documents R2 as being high risk for falling. The Facility's report to Illinois Department of Public Health on 3/17/17, documents in part, (R2) is 281 pounds. The staff was turning the resident in her bed when her leg slipped off the bed. (R2) sent to emergency room . Final Report: Interviews indicate staff was completing a bed bath with (R2). (R2) carries the majority of her weight in her lower extremities. The resident's leg slid over the right side of the bed. The weight of her leg continued to pull resident to the floor. The X-ray reports indicated (R2's) right humerus was fractured. (R2) was admitted with a right humerus fracture for surgical repair. The Report was dated 3/17/17 at 5:08 AM. The Occurrence Report, dated 3/17/2017 at 5:24 AM, documents in part, res (resident) noted on floor on Right side of bed on Right side Right arm under res assisted to bed per 5 workers using (mechanical) lift 1/2 SR(side rails) up X (times) 2. The Operative report, dated 3/18/17, documents in part, Procedure Performed: ORIF (Open Reduction Internal Fixation) right humeral shaft fracture. On 6/15/17 at 3:00 PM, E1, Administrator, stated while the Kardex stated R2 was an assist of 1, the Care Plan at the time stated she was an assist of 2, and it is the expectation, for the staff to follow the Plan of Care, which at the time of fall was 2 assist for bed and bathing. E1 further confirmed only 1 staff member was assisting R2 at the time of injury. On 6/14/17 at 2:53 PM, E6, Certified Nurses Aide (CNA), stated she has been employed at the facility for [AGE] years and R2 has always been an assist of 2 people. E6 stated she would not bath nor transfer R2 prior to the fall and presently without 2 staff members. On 6/15/17 at 9:39 AM, E10, CNA, stated he has used 2 because I wouldn't feel comfortable, doing care and/or transfers with R2 without 2 staff members, including prior to the fall and after R2's fall. On 6/14/17 at 1:33 PM, Z1, R2's husband, stated that prior to the fall, R2 always used her right hand/arm predominately to eat and do daily living of activities. Z1 further stated R2 was able to use the trapeze prior to the fall, and is unable to do so now due to the fracture sustained from the injury, and doubted R2 would be able to use the trapeze in the future to assist with bed mobility. On 6/15/17 at 10:08 AM, regarding the circumstances of R2's fracture, Z2, R2's Physician, stated he expects staff to follow the plan of care for residents, including R2. 2. R7's EHR, dated 5/31/17, documents the following Diagnoses: [REDACTED]. The MDS, dated [DATE], documents R7 having impairment in Cognitive Skills for Daily Decision Making, indicating severe impairment, and requires extensive assist with staff for all transfers. The MDS further states R7 having impairment in R7's lower extremities. R7's Care Plan, dated 5/1/2017, documents in part, R7 is at risk for falls related to gait/balance problems, decreased safety awareness, history of falls with injury, fracture of the right hip, and is WBAT. The Facility Occurrence Report, dated 4/9/2017 at 3:50 PM, documents in part, resident (R7) was noted on the floor. C/O (complained of) right hip pain. Witness Statement. (Staff) was walking down the hall toward the sounding alarm. (R7) on the floor. The Progress Note, dated 4/9/2017 at 16:44 (4:44 PM), documents in part, (R7) noted on bedroom floor attempted to ambulate self. Alarm sounding. The Facility's Report to Illinois Department of Public Health, dated 04/09/17, documents in part, (R7) sustained a fracture from a fall. MD (Medical Doctor) and POA (Power of Attorney) notified. Sent to St. Francis ER (emergency room ) for treatment. Final report to follow. R7's Hospital report, dated 4/10/17, documents in part, Fracture of femoral neck, right. Assessment & Plan: Postop day 1 status [REDACTED]. The Facility's Occurrence Report, dated 12/15/2016 through 6/13/2017, documents R7 having the following falls: 3/19/17 at 10:30 AM, 3/30/27 at 11:45 AM, 4/9/17 at 3:50 PM, 4/18/17 at 2:00 PM, 4/18/17 at 4:40 PM, 4/28/17 6:00 AM, 5/4/17 5:20 PM, 5/25/17 3:00 PM, and 6/11/17 at 8:15 AM. The Facility's Time Line of Falls, undated, documents the facility initiating R7 having the following interventions: 3/19/17 grippy socks on when in bed; 3/30/17 if restless, get up in dining chair and offer snacks; 4/18/17 documents low bed, mats to floor at 2:00 PM; 4/18/17 for fall at 4:40 PM pressure alarm on at all time; 5/4/17 anti-rollbacks on wheelchair; 5/25/17 nurse to update MD on abnormal labs. MD to review pain medication for possible reduction; 6/11/17 when standing up and down, take resident for ride in wheelchair around the facility. The facility did not provide additional interventions for the 4/9/17 fall, and the interventions on 4/28/17 is the same interventions provided for the 4/18/17 fall, which includes to continue pressure alarm on at all time, and does not include any new interventions for the 4/28/17. The Facility's Report to Illinois Department of Public Health, dated 5/25/17 and 5/30/17, documents R7 sustained a fall on 5/25/17 as her alarm was sounding and staff observed R7 on the floor near her low bed. Staff further observed (R7) having difficulty bearing weight on her right leg. R7 was sent to the ER for treatment. The report further states, R7 sustained a right hip arthroplasty and an acute minimally displaced fracture trochanter proximal right hip. Per hospital physician, surgery is not typically indicated. The Follow-up Report, dated 5/29/2017 at 11:58 AM, states in part, (R7) was in bed and attempted to get self out of bed and what it appears to have happened was resident tripped over mat and fell . Res(resident) sent to ER for eval (evaluation). Resident returned from ER with bed rest and weight bearing as tolerated. On 6/13/17 at 11:10 AM, R7 is lying in a low bed with mats next to side of bed. Pressure alarm tab in view. On 6/15/17 at 8:25 AM, R7 is sitting in a high back wheelchair with anti-tippers and alarm tab attached to chair. On 6/15/17 at 9:00 AM, E1 stated R7 has had multiple falls with multiple interventions, and facility is a restraint free facility. E1 further stated Hospice is screening resident and what the facility has provided in the documentation entitled Time Line of Falls is all the interventions done for R7. On 6/16/17 at 1:45 PM, E2, Director of Nursing (DON), stated the physician reduced R7's medications as follows for the 5/25/17 fall: On 5/18/17 reduction in Norco 5-325 mg (milligrams) from four times per day to 7.5-325 mg to three times per day. On 5/27/17 Norco 5-325 mg from four times per day to three times per day. On 5/30/17, MD further reduced medication, Norco 5-325 from three times per day to twice daily. 3. The EHR, with the most recent date of 6/22/16 for R11 documents diagnoses, in part, [DIAGNOSES REDACTED] and Hemiparesis following nontraumatic subarachnoid hemorrhage affecting left dominant side, Heart Failure, [DIAGNOSES REDACTED], Chronic Pain, Localized Edema, Cerebrovascular Disease, Major Depressive Disorder. The MDS for R11, dated 4/25/17, documents R11 with a BIMS score of 6, indicating severe cognitive impairment, and is totally dependent on staff for transfers. The Care Plan, dated 5/8/2017, documents R11 has a history of falls with potential for further falls, is dependent on staff of 2 assist with bed mobility, transfers, and is non-ambulatory, and uses a mechanical lift for transferring. The Care Plan further documents R11 has a cognitive deficit with impaired decision making. On 6/14/17 at 9:45 AM, R11's wheelchair was approximately 3 feet from the bed. E9, CNA, applied the lower half of the sling to R11's mechanical lift. E10, CNA, applied the upper half of the sling to the mechanical lift. E10 raised the controls from the mechanical lift as E9 held onto R11's lower half of the sling. As E10 moved the mechanical lift from the wheelchair towards the bed, E9 released her hands from the sling, moved the wheelchair away from the mechanical lift, leaving no control over R11, as she swung freely above the chair. E10 proceeded to move the mechanical lift to the bed, and E9 then placed her hands onto the sling and guided R11's feet toward the bed. R11 was then lowered to the bed. On 6/16/17 at 10:00 AM, E2 stated she recently did one-on-one inservicing and now the facility must have hands on with a mechanical lift. The Facility's Fall Assessment, Risk Identification And Management Policy, revised 3/20/2012, documents in part, Policy: It is the policy of this facility to assess each resident's fall risk on admission. It continues, Procedure: B. Each resident will be assessed using the Minimum Data Set (MDS) upon admission, quarterly, and with any significant change assessment. The policy continues, E. Fall occurrence will be monitored by the Quality Assurance team. F. The Fall Assessment may address assessment of factors. It also documents, III. Interventions to manage falls. A. Interventions will be based on the resident assessment and the circumstances surrounding the risk of injury or actual injury or fall. 4. The MDS, dated [DATE], identifies R1 to have a BIMS score of 7 - severe cognitive impairment, and relies on one staff for transfers and ambulation. The Care Plan, dated 5/16/12, documents R1 has a history of falls with potential risk for further falls due to receiving antipsychotic and antidepressant medication, requires limited assist with transfers, and ambulation with wheeled walker. The goal is to have no serious injury related to falling through the next review. Interventions include to ambulate in room with one assist in part. The Care Plan does not reflect any falls as occurring. The Restorative Program Care Plan identifies R1 as being on a transfer program since 9/29/16 with the goal for R1 to transfer with verbal cues, SBA (stand by assist), and use of wheeled walker safely by next quarterly eval (evaluation.) The Progress Notes, dated 5/15/17, document R1 was transferred to the hospital for pneumonia and returned to the facility on [DATE]. The Occurrence Report of 5/31/17 at 7:30 AM documents R1 was ambulating with E4, CNA, and was lowered to the floor. The report documents a walker was in use and the root cause was documented as no fault. The recommendation made at the time of the fall is sit to stand (mechanical) lift used for transfers. There is no documentation that R1 was reassessed upon her return from the hospital to determine if her level of care/assistance needed was the same as before or if it increased due to her weakened condition in an effort to reduce falls. The Occurrence Report of 6/3/17 at 11:55 AM documents R1 was being transferred in the bathroom via a sit to stand mechanical lift. The report documents R1 fell to the ground during the transfer and sustained head trauma at the center side of back of head (hematoma.) The report document the root cause as due to resident action or internal risk factors. The recommendations was for R1 to use a total body lift for transfers. The Progress Notes, dated 6/3/17 at 12:10 PM, documents R1 was complaining about her head hurting following the fall and an ambulance was called to transport to the emergency room for evaluation. At 14:16 (2:16) PM on 6/3/17, the progress note document R1 has a possible L1 fracture and a large head hematoma. On 6/15/17 at 10 AM, E2 stated R1 returned to the facility (on 5/23/17) in a weakened condition from the pneumonia, but was still a wheel walker transfer and ambulation at that time. Regarding the fall on 5/31/17, E2 stated R1 was lowered to the floor by E4 when she got weak on her way back from the bathroom. Regarding the fall on 6/3/17, E2 stated R1 lifted her arms and slipped right out of the sling that was applied about R1's waist causing her to fall to the floor. E2 stated she complained about her head hurting and was sent to the hospital for evaluation. E2 stated she had a possible fracture of L1 and a head hematoma. The June 2017 Physician order [REDACTED]. On 6/15/17 at 2 PM, E4 stated on 5/31/17, she was ambulating R1 back to her chair from the bathroom when her knees gave out. E4 stated she had a gait belt about R1's waist and lowered her to the floor. E4 stated she was also the one transferring R1 with the sit to stand when she slipped out of the sling. E4 stated she applied the sling about R1's waist and lifted her up from the toilet when R1 suddenly brought her left arm over the sling. E4 stated she sat R1 back down on the toilet, moved R1's arm back over the strap and cued her to grasp the handle bars of the lift and lifted her up again moving her out of the bathroom. E4 stated she had R1 approximately 6 inches from the toilet when R1 brought her right arm over the sling strap then her left, falling through the waist band of the sling to the floor. On 6/15/17 at 2:50 PM, Z3, Manufacturer representative of the lift used on R1, stated once staff apply the sling about a residents' waist, the strap should be pulled snug as they are lifted up from a sitting position as you get slimmer as you stand. Z3 also stated the resident should be weight bearing and able to grasp the bars when lifted up to standing position for the lift to be safe. On 6/16/17 at 10:30 AM, E2 stated the facility had just inserviced staff on all forms of transfer approximately 1 month ago and stated that they were trained to pull the waist belt snug as they lifted the resident off from a sitting position. E2 agreed that R1's overall function has decreased, but that her transfer ability has decreased since her fall from the sit to stand. On 6/14/17 at 10:12 AM, R1 was in her wheelchair in her room with a sling under her. E16 and E17, CNAs entered R1's room with the full body mechanical lift. The CNAs attached the sling straps to the machine. E17 ran the controls as E16 was standing by R1's bed. E16 reached over and grabbed R1's sling at the top in the middle of her back and as R1 swung over toward the bed, guided her feet about to the foot of the bed. Neither staff had control of R1 as she dangled from the sling moving from the wheelchair to the bed. 5. The MDS, dated [DATE], identifies R9 as having short/long term memory deficits with severe cognitive impairment and is dependent on two staff for transfer. The June 2017 POS documents R9 is a full body mechanical lift for transfers. The Care Plan, dated 3/21/17, documents R9's Focus area as at risk for falls due to unaware of safety needs, gait/balance problems in part. The goal is to sustain no serious injury through the next review with interventions for staff not to leave in room unattended, and up with mechanical lift. On 6/13/17 at 12:15 PM, E16 and E15 entered R9's room to get him up for meals. R9 had a sling under him and the CNAs attached the sling to the lift arms of the full body lift. R9's wheelchair remained approximately 6-8 feet away from the bed. R9 was lifted from the bed. E15 used the controls of the machine and E16 guided R9 toward the chair and turned him around to enable them to set him down in his wheelchair. Neither CNA had control of R9 from the rear as they moved him across the room. On 6/13/17 at 3:44 PM, E18 and E19 entered R9's room to get him up for supper. After hooking the sling straps to the lift arms, E18 controlled the lift as E19 grabbed R9's feet as they moved him approximately 8 feet across the room to his wheelchair. Neither CNA had control of R9 in the sling. 6. The POS, dated 06/01/17, documented R5 had the following diagnoses, in part as, Alzheimer's Disease, history of falling with a burst fracture and Anxiety. The MDS, dated [DATE], documented R5 was cognitively intact and required limited assist on one staff for transfers and ambulation. The Care Plan, dated 04/20/17, documented R5 was identified as being high risk for falls requiring gait belt with one assist. It also documented R5 had a weak gait and uses a wheelchair for locomotion. On 06/13/17 at 11:45 AM, E16, CNA, transferred R5 by holding her under the left arm as R5 stood up from the reclining chair to transfer to the wheelchair. No gait belt was applied for the transfer.