Every finding on record at Goldwater Pontiac Nursing Home

Based on interview and record review the facility failed prevent misappropriation of narcotic medication for one of three residents (R1) reviewed for misappropriation on the sample list of four. Findings include:The facility's Abuse Prevention and Reporting Policy, revised 10/24/22, documents the facility affirms the right of residents to be free from misappropriation of property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. R1's Physician Order Sheet (POS), printed 8/25/26, documents an order for Morphine Sulfate Oral Solution 10 milligrams (mg) per 5 milliliters (ml), give 2.5ml by mouth every six hours as needed for severe pain. R1's Medication Administration Record, dated July 2026, documents an order for Morphine Sulfate Oral Solution 10mg per 5 ml, give 2.5ml by mouth every six hours as needed for severe pain. R1's Controlled Drug Administration Record, documents Morphine Sulfate 10mg/5ml solution, take 2.5ml by mouth every three hours as needed for pain. The quantity dispensed was 280ml. R1's Controlled Drug Administration Record documents Morphine Sulfate 2.5ml was given 43 times from 7/8/26 through 7/27/26 and the amount remaining was 172.5ml in the bottle. On 7/28/26, R1's Controlled Drug Administration Record documents 155ml remaining in the bottle. On 8/24/26 at 1:30pm, V1, Administrator, stated that it was reported to V1 that there was liquid morphine unaccounted for on 7/28/26. On 8/25/26 at 9:10am, V3, Director of Nursing, (DON), stated V3 was aware that a nurse saw a math error on R1's Controlled Drug Administration Record but the error was not reported to V3. V3 stated a discrepancy in the controlled substance count was identified by two nurses and reported to V3 on 7/28/26. V3 stated the nurses measured the morphine solution and corrected the count on the Controlled Drug Administration Record. V3 notified V1 about the discrepancy and began an investigation. On 8/25/26 at 12:42pm, V14, LPN (Licensed Practical Nurse), stated V14 noticed that there was a large amount of morphine solution missing from the bottle during V14 and V15's (LPN) narcotic count on the morning of 7/28/26. V14 stated V14 and V15 poured out the morphine solution and measured the medication together. V14 stated there was a 17.5ml discrepancy in the amount of morphine solution in the bottle and what the Controlled Drug Administration Record showed. V14 stated V14 reported the discrepancy to V3. On 8/25/26 at 3:22pm, V15, LPN, stated that V15 and V14 measured R1's morphine solution and corrected the amount remaining on the Controlled Drug Administration Record. V15 stated V14 reported the discrepancy to V3. On 8/26/26 at 9:00am, V3 state R1's morphine solution count correction was made by V14 and V15 but V3 did not count the medication at the time the discrepancy was identified. V3 stated that V3 and V12, Assistant Director of Nursing, measured R1's morphine solution on 7/29/26 and assumed the count that was on the Controlled Drug Administration Record was the same amount as V3 and V12 counted because V3 did not document anything different. V3 confirmed that 17.5ml of R1's morphine solution could not be accounted for. On 8/26/26 at 10:05am V1 confirmed that 17.5ml of R1's morphine solution could not be verified and accounted for.

Based on interview and record review the facility failed to report an allegation of misappropriation of narcotic medication to the State Agency for one of three residents (R1) reviewed for misappropriation on the sample list of four.Findings include:The facility's Abuse Prevention and Reporting Policy, revised 10/24/22, documents, when an allegation of misappropriation of resident property has occurred, the Department of Public Health's regional office shall be informed by telephone or fax. Within five working days after the report of occurrence, a complete written report of the conclusion of the investigation will be sent to the Department of Public Health. On 8/25/26 at 9:10am, V3, Director of Nursing, (DON), stated V3 was aware of a discrepancy involving R1's controlled medication administration record and controlled substance count. V3 stated two nurses identified a discrepancy and measured the remaining morphine solution, at which time 17.5ml of morphine solution could not be accounted for. V3 stated the nurses corrected the count on the Controlled Drug Administration Record and reported the discrepancy to V3 on 7/28/26. V3 stated V3 notified V1 of the discrepancy and initiated an investigation. On 8/26/26 at 10:05am, V1, Administrator, stated the facility did not report the controlled substance discrepancy to Illinois Department of Public Health. On 8/26/26 at 10:30am, V2, [NAME] President of Operations, confirmed the facility did not report the controlled substance discrepancy to Illinois Department of Public Health.

Based on interview and record review the facility failed to ensure medication orders were accurately verified, medications were administered in accordance with physician's orders, and controlled medications were accurately documented and accounted for. This failure affects one of three residents (R1) reviewed for medication administration on the sample list of four.Findings include:The facility's Medication Administration General Guidelines Policy, undated, documents 5. Five rights - right resident, right drug, right dose, right route and right time are applied for each medication being administered. 7. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in direction, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. Administration. 2. Medications are administered in accordance with written orders of the prescriber. Documentation. 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given.R1's Physician Order Sheet (POS), printed 8/25/26, documents an order for Morphine Sulfate Oral Solution 10 milligrams (mg) per 5 milliliters (ml), give 2.5ml by mouth every six hours as needed for severe pain.R1's prescription, issued and signed by V20, Advance Practice Registered Nurse, on 7/6/26, documents an order for Morphine Sulfate 10mg/5ml solution, take 2.5ml by mouth every three hours as needed for pain. R1's Controlled Drug Administration Record, documents Morphine Sulfate 10mg/5ml solution, take 2.5ml by mouth every three hours as needed for pain. The quantity dispensed was 280ml. R1's Medication Administration Record, dated July 2026, documents an order for Morphine Sulfate Oral Solution 10mg per 5 ml, give 2.5ml by mouth every six hours as needed for severe pain and documents Morphine Sulfate oral solution was administered 21 times from 7/8/26 through 7/27/26. Record review of R1's Controlled Drug Administration Record, documents R1's morphine sulfate was administered on 7/15/26 at 2:00 AM. 7/15/26 at 4:32 AM, 7/16/26 at 12:00 PM, 7/16/26 at 6:00 PM, 7/16/26 at 10:00 PM, 7/22/26 at 4:00 PM, and 7/22/26 at 8:00 PM. R1's MAR documents R1's morphine sulfate was administered on 7/16/26 at 4:21 AM, and 7/16/26 at 2:18 PM. On 8/24/26 at 12:34pm, V4, Licensed Practical Nurse, (LPN), stated V4 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/24/26 at 12:54pm, V5, LPN, stated V5 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/25/26 at 8:05am, V7, LPN, stated V7 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/25/26 at 8:06am, V8, LPN, stated V8 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/25/26 at 12:34pm, V13, LPN, stated V13 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/25/26 at 12:42pm, V14, LPN, stated V14 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. On 8/25/26 at 3:22pm, V15, LPN, stated V15 was not aware that the order on R1's MAR was different than the order on the Controlled Drug Administration Record. Record review of R1's MAR, dated 7/1/26 - 7/31/26, documents beginning on 7/8/26, R1's morphine sulfate was administered 21 times between 7/8/26 through 7/28/26. Only 7 of the administered 21 doses were documented on the Controlled Drug Administration Record. Record review of R1's Controlled Drug Administration Record, documents R1's morphine sulfate was administered 43 times between 7/8/26 through 7/28/26. Only 29 of the administered 43 doses were documented on the MAR. On 7/28/26 at an illegible time, R1's Controlled Drug Administration Record documents the amount of morphine solution remaining in the medicine bottle as 172.5ml and on 7/28/26 at 0550 documents the amount of morphine solution remaining in the medicine bottle as 155ml. On 8/25/26 at 9:10am, V3, Director of Nursing, (DON), stated V3 was aware that a nurse saw a math error on R1's Controlled Drug Administration Record but the error was not reported to V3. V3 stated a discrepancy in the controlled substance count was identified by two nurses and reported to V3 on 7/28/26. V3 stated the nurses measured the morphine solution and corrected the count on the Controlled Drug Administration Record. V3 notified V1 about the discrepancy and began an investigation. V3 denied knowledge of the morphine sulfate order discrepancy. V3 confirmed that there was a discrepancy between R1's morphine sulfate order on the MAR and what was delivered from the pharmacy. On 8/25/26 at 12:42pm, V14, LPN, stated V14 noticed there was a large amount of morphine solution missing from the bottle during V14 and V15's (LPN) narcotic count on the morning of 7/28/26. V14 stated V14 and V15 poured out the morphine solution and measured the medication together. V14 stated there was a 17.5ml discrepancy in the amount of morphine solution in the bottle and what the Controlled Drug Administration Record showed. V14 stated V14 reported the discrepancy to V3. On 8/25/26 at 3:22pm, V15, LPN, stated that V15 and V14 measured R1's morphine solution and corrected the amount remaining on the Controlled Drug Administration Record after identifying the discrepancy. V15 stated V14 reported the discrepancy to V3. On 8/25/26 at 2:41pm, V1 confirmed that R1's morphine sulfate was not accurately administered according to the physician's orders and accurately documented and accounted for.

Based on interview and record review the facility failed to promptly refund an overpayment of monthly charges for one resident (R2) of three residents reviewed for management of funds in a sample list of six. Findings Include: The facility's census documents R2 was admitted to the facility on [DATE]. At that time R2 was admitted to a private room with a shared bath. R2's signed contract with the facility dated 6/10/22 documents R2 was being charged for a semiprivate room with a shared bath. On 2/28/24 R2's representative paid $12,650.00 for R2's room and board. R2's Transaction Report documents R2's room and board was billed for that month at $9,920.00. The facility also provided a cancelled check signed by V13, R2's representative in the amount of $12,650.00. This supports the information on the Transaction report as above. This constituted an overpayment of $2,720.00. On 6/17/26 at 10:50AM V13, R2's representative stated I was not aware of the overpayment until I went to do the taxes, and I realized I had overpaid. I have repeatedly requested (R2's) overpayment be returned. The corporate people told me the facility made a mistake and undercharged me for the type of room (R2) is in. I have paid the amount I was billed every month since (R2) came to the nursing home. I have called the ombudsman. I was never notified of the of a rate increase. On 6/17/26 at 1:00PM V1, Administrator stated In May we did an audit of room rates and found two residents who had the wrong rate in the system. (R2) was one of those residents. I was told by corporate to apply the overpayment to the billing mistake made by our business office. The facility's resident funds policy revised 4/29/19 states. The resident may designate a representative to manage his/her personal funds. This policy further states The resident and/or representative are provided with a quarterly accounting report of his or her funds on deposit with the facility, and upon request.

Based on interview and record review, the facility failed to ensure timely post-fall assessment and physician notification, and failed to follow a physician order to obtain a post fall x-ray for two of six residents (R1 and R3) reviewed for falls on the sample of six.Findings include: 1.R1's Progress Note written by V2 Director of Nurses dated 5/27/2026 at 12:41 PM documents R1 experienced a witnessed fall on 5/27/2026 at approximately 5:56 AM while staff were assisting with activities of daily living in R1's room. The note documents R1 stated he was getting ready for breakfast, stood from his bed, lost his balance, and hit his head. The note further documents that neurological checks were initiated and that R1's physician and Power of Attorney (POA) were called at 11:15 AM. There was no documentation indicating successful physician contact or receipt of physician orders at that time. The note further documents R1 was assisted back to bed using a full-body mechanical lift and that physical and occupational therapy evaluations were requested. The Neurological Assessments Documentation from 5/27/2026 documents neurological checks were completed at 10:30 AM, 10:45 AM, 11:00 AM, 11:15 AM, 11:45 AM, 12:15 PM, 12:45 PM, 1:15 PM, and 5:15 PM.The facility's undated Neurological Assessment Policy, directs staff to complete neurological assessments following head injuries every 15 minutes for one hour, every 30 minutes for two hours, every four hours for 24 hours, and then every shift for 48 hours.R1's Risk Management Form completed by V2, Director of Nursing, documents R1 was with staff preparing for breakfast, stood from the bed, began walking with a walker, and fell. The form documents the physician was notified on 5/27/2026 at 11:24 AM and STAT (immediately) imaging was ordered.On 6/23/2026 at 12:16 PM, V1, Administrator, stated that V5 Agency Licensed Practical Nurse failed to report R1's fall to facility management and was no longer permitted to work in the facility.On 6/23/2026 at 1:02 PM, V2 stated V5, agency Licensed Practical Nurse, did not assess R1 following the fall and did not report the incident to V4, the nurse working the following shift. V2 stated V5 denied having knowledge of the fall. V2 further stated that R1 later informed V4 of the fall, and V4 reported the incident to V2 during the morning of 5/27/2026. V2 stated she then assessed R1, notified the physician and POA, and completed the facility's incident investigation. V2 further stated that R1 had attempted to get up from the floor following the fall and that V3 assisted R1 from the floor using a mechanical lift.On 6/29/2026 at 11:37 AM V3, Certified Nurses Assistant, stated that (on 5/27/26) R1 rang to get up. V3 reported she was assisting R1 with a gait belt while R1 was using a walker. V3 stated R1 removed one arm from the walker to wipe his nose, his foot slid out of his slipper, and he lost his footing. V3 stated she initially held the gait belt but released it as R1 was falling so she would not fall on top of him. V3 stated she did not recall whether R1 hit his head but confirmed that R1 hit his back. V3 stated she reported the fall to V5, agency nurse, who did not come to R1's room. V3 stated she then obtained assistance from V8, Certified Nurses Assistant, and both waited for V5 to respond. V3 stated she notified V5 a second time and V5 stated he was giving another resident medication and again did not come to the room. V3 stated that while waiting, R1 attempted to get up from the floor, and V3 and V8 transferred him with a mechanical lift. V3 stated R1 denied pain and was able to move his arms and legs. V3 stated she notified V5 again, and V5 stated he would pass it on in report. V3 stated she did not notify the other nurse in the building.On 6/29/2026 at 11:25 AM V14, Physician stated there should not be a delay in treatment, and if a resident is not on a blood thinner neurological checks would need to be completed for 72 hours. V14 also stated that contact with a provider should have happened immediately. V14 or the facility Nurse Practitioner could have been notified.2. R3's Progress Note dated 5/8/2026 at 9:00 PM documents R3 attempted to strike a staff member while staff were assisting him, resulting in both R3 and the staff member losing their balance. The note documents R3 landed on his right elbow and complained of pain to his right lower back following the fall.R3's Progress Note dated 5/9/2026 at 3:05 AM documents V11, Licensed Practical Nurse, assessed R3 and R3 complained of pain in the lower right rib cage area.R3's Progress Notes document R3's physician was notified on 5/9/2026 at 6:19 AM and provided an order for hip and rib x-rays. Documentation further shows (x-ray Company) was notified of the x-ray order on 5/9/2026 at 6:20 AM.Review of the medical record does not document the ordered hip and rib x-rays were completed.On 6/23/2026 at 12:51 PM, V2, Director of Nursing, stated the x-ray ordered to be completed in the facility was never performed. V2 further stated that if ordered x-rays cannot be completed in a timely manner, the physician should be notified for further direction and orders.

Based on interview and record review, the facility failed to thoroughly investigate falls and document a root cause for two of six (R1, R3) residents reviewed for falls in a sample size of six. Findings include:R1's Progress Note dated 5/27/2026 at 12:41 PM documents R1 experienced a witnessed fall on 5/27/2026 at approximately 5:56 AM while staff were assisting with activities of daily living in R1's room. R1's Risk Management Form dated 5/27/2026, completed by V2, Director of Nursing, documents R1 was with staff preparing for breakfast, stood from the bed, began walking with a walker, and fell. However, the Risk Management Form does not include a witness statement from V3, Certified Nurse Aide, who was identified as assisting R1 at the time of the fall. In addition, the form does not include documentation of the possible cause or root cause analysis of the fall.R3's Progress Note dated 5/8/2026 at 9:00 PM documents R3 attempted to strike a staff member while staff were assisting him, resulting in both R3 and the staff member losing their balance. R3's Risk Management Form completed by V10, Registered Nurse, does not include complete staff statements or documentation of the possible cause or root cause of the fall.The facility's Incident and Accidents-Illinois policy, reviewed 4/7/2019, states an incident/accident report is to include a full written statement and the possible cause of the incident.On 6/29/2026 at 2:48 PM, V2, Director of Nursing, verified that there was no documented root cause analysis identified on the Risk Management Form for either R1 or R3 following their falls. V2 also verified that there were no Fall Interdisciplinary Progress Notes documented in the electronic medical record for either resident. V2 provided the facility's Post Fall Huddle form, which includes designated sections for documenting the root cause of the fall. Review of the Post Fall Huddle forms for R1 and R3 document that the sections for root cause had been left blank.

Based on interview and record review the facility failed to protect a resident's right to be free from misappropriation of money for one of 10 residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM, R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. R86 stated R86 always keeps her purse in her closet but now is keeping it with her at all times. R86 stated there was only one time, over six months ago, when an unidentified person was going through R86's closet during the night and asked R86 how many pairs of jeans R86 had. R86's Nursing Note dated 7/28/25 documents R86 as alert and oriented to person, place, and time. The facility's investigative file of R86's allegation of misappropriation of money contained the following information: The Initial Abuse Investigation Report dated 7/1/25 documents on 7/1/25 at 3:00 PM R86's Family, V23, reported to V1 Administrator that $80.00 was missing from R86's room. The facility's Final Abuse Investigation Report dated 7/3/25 documents resident and staff interviews were conducted, and R86's room, laundry, and common areas were searched and were unable to locate the missing funds which would be replaced by the facility. This report documents R86 stated R86 never goes out to activities or the dining room, R86 is always in her room, and was unsure where the missing funds could have gone. R86's Cash Disbursement Forms dated 5/14/25 and 6/10/25 document R86 made a cash withdrawal of $50 on these dates from her resident trust fund account and was signed by both R86 and V10. On 8/19/25 at 12:51 PM, V1 Administrator stated R86 was not sure of the exact day that the money went missing. Stated R86 goes out on Mondays to get her hair done and R86 stated on Monday 6/30/25 R86 realized R86's cash was no longer in her purse. V1 stated R86's $80 was unable to be located.On 8/19/25 at 2:46 PM, V23 stated R86 went to get her hair done on 6/30/25 and didn't have money to pay. V23 confirmed R86 was missing $80. V23 stated R86 keeps money in her purse to pay for her hair appointments, and V23 knows that R86 did not misplace the money. V23 stated V23 believes someone took R86's money during the night while R85 was asleep. On 8/19/2025 at 2:07 PM, V10 confirmed R86 made $50 cash withdrawals on 4/2/25, 5/14/25, and 6/10/25. V10 stated the largest bill she gives out is a $20 bill and typically would give two $20 bills and one $10 bill. On 8/19/25 at 2:30 PM, V6 Licensed Practical Nurse confirmed R86's credibility. V6 also stated R86 is alert and oriented to person, place, time, and situation; has never been dishonest; and has no history of prior accusations or behaviors. The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents the facility affirms the resident's right to be free from misappropriation of property, which means the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review the facility failed to conduct a thorough investigation of an allegation of misappropriation of funds for one of ten residents (R86) reviewed for misappropriation of property in the sample list of 38. On 8/18/2025 at 10:40 AM R86 stated R86 thought her money was in her purse, but when she went to get her hair done there were only singles left, and the large bills were gone, which was $80. R86 stated R86 had gotten $40-$50 from V10 Business Office Manager and had some money left over from a prior withdrawal. R86 stated R86 keeps her purse in her room and does not leave her room, so the only time someone could have taken it was during the night when R86 was asleep. R86 stated the facility replaced the $80. On 8/19/25 at 9:30 AM R86 stated R86 is unsure what happened to her missing $80 but is certain R86 did not misplace it. R86 stated R86 always keeps her purse in her closet but now is keeping it with her at all times. R86 stated there was only one time, over six months ago, when an unidentified person was going through R86's closet during the night and asked R86 how many pairs of jeans R86 had. On 8/18/25 during general intermittent observations between 9:30 AM and 4:15 PM there were video surveillance cameras located throughout the 300 unit, including on R86' hallway. R86's Nursing Note dated 7/28/25 documents R86 as alert and oriented to person, place, and time. The facility's investigative file of R86's allegation of misappropriation of money contained the following information: The Initial Abuse Investigation Report dated 7/1/25 documents on 7/1/25 at 3:00 PM R86's Family, V23, reported to V1 Administrator that $80.00 was missing from R86's room. The facility's Final Abuse Investigation Report dated 7/3/25 documents resident and staff interviews were conducted, and R86's room, laundry, and common areas were searched and were unable to locate the missing funds which would be replaced by the facility. This report documents R86 stated R86 never goes out to activities or the dining room, R86 is always in her room, and was unsure where the missing funds could have gone. This report documents the floor nurse and nurse aides were interviewed but were not aware funds in R86's room but does not identify that video surveillance was reviewed or which specific staff were interviewed. R86's Cash Disbursement Forms dated 5/14/25 and 6/10/25 document R86 made a cash withdrawal of $50 on these dates from her resident trust fund account and was signed by both R86 and V10.On 8/19/25 at 2:46 PM, V23 stated R86 went to get her hair done on 6/30/25 and didn't have money to pay. V23 confirmed R86 was missing $80. V23 stated R86 keeps money in her purse to pay for her hair appointments, and V23 knows that R86 did not misplace the money. V23 stated V23 believes someone took R86's money during the night while R85 was asleep. On 8/19/25 at 12:51 PM, V1 Administrator stated R86 was not sure of the exact day that the money went missing. V1 stated R86 goes out on Mondays to get her hair done and R86 stated the following Monday (6/30/25) R86 realized R86's cash was no longer in her purse. V1 stated R86's $80 was unable to be located and it is hard to say if R86's money was lost in the facility or while out in the community. On 8/19/25 at 1:53 PM V1 confirmed the entire investigative file for R86's allegation was provided. V1 stated V1 did review video surveillance for night shift and interviewed staff but has no documentation of this. V1 stated since R86 wasn't able to identify a specific date that the money went missing, V1 didn't have a certain date to review video surveillance. V1 stated video surveillance is only kept for 30 days.On 8/19/2025 at 2:07 PM, V10 confirmed R86 made $50 cash withdrawals on 4/2/25, 5/14/25, and 6/10/25. V10 stated the largest bill she gives out is a $20 bill and typically would give two $20 bills and one $10 bill. On 8/19/25 at 2:30 PM, V6 Licensed Practical Nurse confirmed R86's credibility. V6 also stated R86 is alert and oriented to person, place, time, and situation; has never been dishonest; and has no history of prior accusations or behaviors. The facility's Abuse Prevention and Reporting-Illinois policy dated 10/24/22 documents the facility affirms the resident's right to be free from misappropriation of property, which means the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without the resident's consent. This policy documents the administrator, or designee will initiate an incident investigation, and will at a minimum attempt to interview the person who reported the incident, anyone likely to have knowledge of the incident, the resident, and any employees with whom the accused has regularly worked with.

Based on observation, interview, and record review, the facility failed to obtain physician orders for the use and care of a CPAP (continuous positive airway pressure) for one of two residents (R6) reviewed for respiratory care on the sample list of 38. On 8/18/2025 at 10:08 AM there was a CPAP machine on R6's desk in R6's room. R6 stated R6 is suppose to use it, but has had problems getting parts for it. R6 removed the filter from the machine to show the filter was dirty, covered in gray debris/dust. R6 stated R6 has talked to facility staff about needing parts for the machine. R6's Minimum Data Set, dated [DATE] documents R6 has severe cognitive impairment. R6's active physician orders and active care plan do not document the use or care of R6's CPAP machine as of 8/18/25. On 8/18/2025 at 3:54 PM V6 Licensed Practical Nurse stated R6 sleeps in her recliner and uses the CPAP machine, at least for the last five months that V6 has worked in the facility. V6 stated there should be physician's orders for use and care that would prompt to document on the Treatment Administration Record (TAR). V6 confirmed R6 did not have any physician's orders regarding the use of the CPAP. On 8/19/25 at 4:54 PM V21 Registered Nurse stated V21 works night shift and R6 has used a CPAP for about 5-6 months, R6 applies and cares for the machine herself. On 8/19/2025 at 12:08 PM V2 Director of Nursing stated CPAPs should be rinsed/washed on Mondays, and need filled with distilled water. V2 stated there should be physicians orders for use and documented on the TAR. V2 stated V2 would have to look at the facility's policy regarding changing filters on CPAPs. V2 stated V2 just found out about R6's CPAP yesterday and obtained orders for use/care. V2 stated it probably isn't care planned since we just found out about it yesterday. The facility's undated CPAP Therapy policy documents to verify physician orders, if ordered connect humidifier to CPAP unit, fill humidifier with distilled sterile water, and adjust the ramp to prescribed time if ordered. This policy documents to use a soft cloth and gently wash th3 mask or pillows with a solution of warm water and mild detergent, rings, and allow to air dry; wash/rinse/dry tubing as necessary; clean and inspect all components regularly. This policy documents that disposable filters should be replaced according to manufacturer's instructions, and reusable filters should be rinsed of dust and allowed to air dry. The User Manual dated 2021 for R6's CPAP machine, documents the device should only be used as instructed by a physician, including correct pressure settings, device configurations, and accessories. This user manual documents the device uses a reusable blue pollen filter that can be rinsed and includes an automatic reminder every 30 days to check and replace filters as directed.

Based on interview and record review the facility failed to prevent further abuse from occurring by allowing employees (V4 and V5 Certified Nursing Assistants) unrestricted access to residents following an abuse allegation. This failure has the potential to affect 36 residents (R1, R3, R4, R5, R7-R38) of 38 residents reviewed for abuse in the sample list of 38. Findings include: The facility's Abuse Prevention, Identification, and Reporting Program Policy and Procedure dated 9/10/19 documents employees will be immediately removed from work following an allegation of abuse/mistreatment and will not be allowed to return until the investigation results have been reviewed by the administrator. On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken. On 11/25/24 at 12:01-12:17 PM R6 stated R6 stated on 11/20/24 around 12:30 PM V19 Housekeeper said R1 wanted to speak with R6. R6 stated R1 told R6 that V4 and V5 were being very rough and abusive to R1. R6 stated R6 asked what R1 meant, and R1 said V4/V5 told R1 to turn and pulled on R1 while attempting to reposition R1 as R1 was holding onto the bed rail. R6 stated R1 said V4/V5 moved R1's legs back and R1 felt R1's back crack. R6 stated R6 reported this to V1 within 15 minutes and they went to speak to R1 together, and R1 said V4/V5 brutally hurt R1, they cussed R1 out, they were aggressive and mean to R1 as they jerked R1 around and yelled at R1. R6 stated R1's story changed and R1 denied the staff cussed at R1 when asked by V1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R6's MDS dated [DATE] documents R6 as cognitively intact. R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient. The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 (R1's Family Member) posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. This report documents V4 and V5 were suspended from work pending investigation results. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1 and V2 Director of Nursing spoke with V4 and V5 who stated that R1 refused to let go of the bed rail when they attempted to reposition R1, R1 was upset and started screaming at them, and R1 kicked them out of R1's room. V4's Time Card Report documents V4 worked on 11/20/24 from 5:57 AM until 9:59 PM, on 11/21/24 from 6:00 AM until 6:06 PM, and on 11/22/24 from 1:56 AM until 6:06 PM. V5's Time Card Report documents V5 worked on 11/20/24 from 5:57 AM until 6:13 PM. The facility's Daily Schedules dated 11/20/24, 11/21/24, and 11/22/24 document V4 and V5 worked on the Memphis (300) unit. The facility's Daily Census dated 11/24/24 document R1, R3, R4, R5, and R7-R38 reside on the 300 unit. On 11/25/24 at 11:14 AM V4 stated the Memphis unit is V4's primary unit. V4 stated around 6:00 AM on 11/20/24 R1's call light was on and R1 requested to be repositioned in bed. V4 and V5 assisted R1 with repositioning, but R1 wouldn't let go of the bed rail. V4 stated R1 needed to be scooted up in bed and V4 and V5 used a cloth pad to pull R1 up in bed. V4 stated R1 got upset with V4 and V5, you could just tell it in R1's voice that R1 was not happy with us. V4 stated V4 continued working and later that day the nurse told us that R1 no longer wanted V4 or V5 in R1's room, V4 and V5 went immediately to talk to V2 and that afternoon V1 spoke with V4 and V5 about the incident. On 11/25/24 at 11:25 AM V5 described R1's incident on 11/20/24 as described by V4. V5 stated R1 was not very happy with V4 and V5, and R1 said to V4/V5 that they were purposefully hurting R1, broke R1's back and ribs, and that R1's ribs popped. V5 stated V4/V5 stopped what they were doing, asked R1 how they could help, and exited the room to notify V11 Licensed Practical Nurse (LPN) of the situation. V5 confirmed V5 would consider R1's statements to be an abuse allegation. V5 stated that is why V5 reported to V11. V5 stated at 10:30 AM V11 said R1 no longer wanted V4 and V5 to provide R1's cares, and around 3:00 PM that day V1 and V2 discussed the incident and said this wouldn't be considered abuse that it would be considered a grievance. V5 stated V5 worked until 6:00 PM on 11/20/24 and received a call from V1 on 11/22/24 notifying of an abuse allegation and V5's suspension. On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated R1 denied being fearful of V4/V5 or that they intentionally hurt R1. V1 stated V1 interviewed V4 and V5 that day, who said that R1 would not let go of the siderail while they attempted to reposition R1. V1 stated on 11/22/24 at 7:08 PM V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident to the state survey agency at 9:47 PM. V1 stated on 11/22/24 R1 told V1 that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair. V1 confirmed V4 and V5 were not suspended until the evening of 11/22/24. V1 stated V1 felt R1's concerns on 11/20/24 was not an abuse allegation and that it was more of a customer service issue since V1 investigated and R1 said that it wasn't intentionally done to hurt R1 and R1 was not fearful. V1 was asked what would be the expectation of staff if during cares R1 voiced to staff that the staff were intentionally hurting R1, R1 broke R1's back and ribs, and R1's rib popped. V1 confirmed this would be considered an abuse allegation. V1 stated V4 and V5 should have stopped providing R1's care and reported R1's allegation to V1. V1 was not aware of R1's statements made during R1's cares and confirmed if R1's statements were reported to V1 on 11/20/24 V1 would have initiated the steps implemented on 11/22/24.

Based on interview and record review the facility failed to timely notify a resident representative and physician of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38. Findings include: The facility's policy Physician-Family Notification - Change in Condition dated 11/13/18 documents the facility will notify the resident's representative and physician when there is an accident involving the resident that results in injury and has the potential for requiring physician intervention, when there is a significant change in the resident's health, mental, or psychosocial condition, or when there is a need to alter treatment significantly. On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 Certified Nursing Assistants were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken. V7 (R1's Family Member) stated R1 reported this incident to V7 on the morning of 11/22/24, a few hours later V7 posted this allegation on (social media platform) and then the facility contacted V7 about the incident. R1's Minimum Data Set, dated dated dated [DATE] documents R1 as cognitively intact. R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient. There is no documentation in R1's medical record that this allegation was reported to V20 Medical Director/V21 (R1's Physician) and V7 prior to 11/22/24. The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. This report documents R1's family and physician were notified. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1's typed notes dated 11/22/24 document R1 told V1 that during the incident R1 felt a pop in her ribs, V1 offered to have x-rays done, V1 asked V12 Licensed Practical Nurse to assess R1 for injury, and V1 notified V7 to schedule a meeting to discuss R1's concerns. R1's Nursing Note dated 9:59 PM documents R1 was assessed and had no injury and no complaints of pain, V7 was notified, and a message was left for V21 to return call. R1's Nursing Note dated 11/22/24 at 10:01 PM documents V20 was notified of R1's abuse allegation and obtained new order for x-ray of right ribs. On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated V1 was out of the facility on 11/21/24, V1 followed up with R1 on 11/22/24, and at that time R1 reported that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair on 11/22/24, so V1 asked a nurse to assess R1. V1 stated on the evening of 11/22/24 V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident and the nurse notified the physician that night.

Based on interview and record review the facility failed to timely notify the administrator, state survey agency, and local law enforcement of an allegation of abuse for one (R1) of 38 residents reviewed for abuse in the sample list of 38. Findings include: The facility's Abuse Prevention, Identification, and Reporting Program Policy and Procedure dated 9/10/19 documents employees are required to immediately report any potential/actual abuse or mistreatment that they observe, hear about, or suspect to the facility's Administrator. This policy documents the Illinois Department of Public Health will be notified within several hours of the reported allegation, not to exceed 24 hours, and other external agencies will be notified such as local/state law enforcement as indicated based on the nature of the allegation, physical injuries, and as required per state/federal regulations. On 11/25/24 at 10:03-10:20 AM R1 stated last Wednesday (11/20/24) R1 needed repositioned in bed, V4 and V5 Certified Nursing Assistants were rough and R1 felt R1's back and ribs pop when V4 and V5 jerked R1 over in bed. R1 stated V4 and V5 yelled at R1 too. R1 stated R1 reported this to an unidentified nurse that evening. R1 stated R1 had right side pain since the incident, x-rays were completed around midnight last night, and nothing was broken. V7 (R1's Family Member) stated R1 reported this incident to V7 on the morning of 11/22/24, a few hours later V7 posted this allegation on (social media platform), and then the facility contacted V7 about the incident. On 11/25/24 at 12:01-12:17 PM R6 stated on 11/20/24 around 12:30 PM V19 Housekeeper said R1 wanted to speak with R6. R6 stated R1 told R6 that V4 and V5 were being very rough and abusive to R1. R6 stated R6 asked what R1 meant, and R1 said V4/V5 told R1 to turn and pulled on R1 while attempting to reposition R1 as R1 was holding onto the bed rail. R6 stated R1 said V4/V5 moved R1's legs back and R1 felt R1's back crack. R6 stated R6 reported this to V1 within 15 minutes, they went to speak to R1 together, and R6 said V4/V5 brutally hurt R1, they cussed R1 out, they were aggressive and mean to R1 as they jerked R1 around and yelled at R1. R6 stated R1's story changed and R1 denied the staff cussed at R1 when asked by V1. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R6's MDS dated [DATE] documents R6 as cognitively intact. R1's Concern/Compliment Form dated 11/20/24 documents R1 stated V4 and V5 were being mean, had bad attitudes, and moved R1 in a rough fashion. This form documents staff were re-educated on customer service and to remember to be nice, smile, and be patient. The facility's initial report to the Illinois Department of Public Health dated 11/22/24 documents on 11/22/24 at 7:08 PM V7 posted on (social media platform) an allegation of abuse of R1 by V4 and V5 and the post was sent to V1 Administrator. V1's electronic mail dated 11/22/24 at 9:47 PM documents V1 submitted the initial report of R1's abuse allegation to the state survey agency. There is no documentation that this allegation was reported to local law enforcement. V1's typed notes dated 11/20/24 documents that afternoon R6, resident council president, reported to V1 that R1 said V4 and V5 were rude to R1, expected R1 to do things for herself, and were rough when they repositioned R1 in bed. This note documents V1, V10 Social Services Director, and R6 spoke to R1 who voiced the same concerns as reported to R6. V1 and V2 Director of Nursing spoke with V4 and V5 who stated that R1 refused to let go of the bed rail when they attempted to reposition R1, R1 was upset and started screaming at them, and R1 kicked them out of R1's room. On 11/25/24 at 11:14 AM V4 stated around 6:00 AM on 11/20/24 R1's call light was on and R1 requested to be repositioned in bed. V4 stated V4 attempted to use a cloth incontinence pad to reposition R1, but the pad pulled out from under R1, so V4 went to ask V5 for assistance. V4 stated V4 and V5 were on each side of R1's bed and attempted to turn R1, but R1 would not let go of the bed rail. V4 stated R1 was afraid of falling, but we explained to R1 that we wouldn't let her fall, and we were able to get the cloth pad underneath of R1. V4 stated R1 needed to be scooted up in bed and V4 and V5 used the cloth pad to pull R1 up in bed. V4 stated R1 got upset with V4 and V5, you could just tell it in R1's voice that R1 was not happy with us. V4 stated R1 is sensitive and has a history of back problems. V4 stated later that day the nurse told us that R1 no longer wanted V4 or V5 in R1's room and V4 and V5 went immediately to talk to V2. V4 stated that afternoon V1 spoke with V4 and V5 about the incident. On 11/25/24 at 11:25 AM V5 described R1's incident on 11/20/24 as described by V4. V5 stated R1 was not very happy with V4 and V5, and R1 said to V4/V5 that they were purposefully hurting R1, broke R1's back and ribs, and that R1's ribs popped. V5 stated V4/V5 stopped what they were doing, asked R1 how they could help, and exited the room to notify V11 Licensed Practical Nurse (LPN) of the situation. V5 confirmed V5 would consider R1's statements to be an abuse allegation. V5 stated that is why V5 reported to V11. V5 stated V5 has received abuse training and confirmed abuse allegations should be reported to V1. V5 stated V11 said to use two staff for R1's cares. V5 stated at 10:30 AM V11 said R1 no longer wanted V4 and V5 to provide R1's cares, and around 3:00 PM that day V1 and V2 discussed the incident and V5 was told this wouldn't be considered abuse, that it would be considered a grievance. On 11/25/24 at 11:42 AM V11 LPN stated R1 was upset on the morning of 11/20/24, but V11 was unsure of the specifics other than R1 stated R1 didn't like it here. V11 asked V4 and V5 to talk to R1 and they said they were using two staff for R1's cares and were going to talk to V2. V11 stated later that day another resident (R6) went into R1's room to speak with R1. V11 stated V4 and V5 did not report to V11 anything involving R1 that day. On 11/25/24 at 12:43 PM V13 Certified Nursing Assistant stated on 11/20/24 at 6:00 PM R1 told V13 R1 had a problem with the dayshift Certified Nursing Assistants that day, R1 said R1's right side hurt because the staff had pulled on R1, and R1 was still hurting the next day. On 11/25/24 at 2:02 PM-2:20 PM V1 Administrator stated around 2:00 PM on 11/20/24 R6 said R1 reported V4 and V5 were rude to R1, expected R1 to do things for herself, and they were rough with R1. V1 stated V1 spoke with R1 and R1 reported the same things that R6 told V1. V1 stated R1 denied being fearful of V4/V5 or that they intentionally hurt R1. V1 stated V1 interviewed V4 and V5 that day, who said that R1 would not let go of the siderail while they attempted to reposition R1. V1 stated V1 was out of the facility on 11/21/24, V1 followed up with R1 on 11/22/24, and at that time R1 wanted to know why V4 and V5 weren't terminated. V1 stated at that time R1 reported that during the alleged incident R1 felt a pop in her ribs and was unable to shampoo R1's hair on 11/22/24, so V1 asked a nurse to assess R1. V1 stated on 11/22/24 at 7:08 PM V1 received a copy of V7's social media post alleging abuse of R1, and that is when V1 reported the incident to the state survey agency at 9:47 PM. V1 stated V1 did not notify the local law enforcement, V1 should have, and V1 will do that today. V1 stated V1 did not report R1's concerns on 11/20/24 because V1 felt at that time there was no abuse allegation and that it was more of a customer service issue since V1 investigated and R1 said that it wasn't intentionally done to hurt R1 and R1 was not fearful. V1 was asked what would be the expectation of staff if during cares R1 voiced to staff that the staff were intentionally hurting R1, R1 broke R1's back and ribs, and R1's rib popped. V1 confirmed this would be considered an abuse allegation. V1 stated V4 and V5 should have stopped providing R1's care and reported R1's allegation to V1. V1 was unaware that R1 made these statements during R1's care. V1 confirmed if R1's statements were reported to V1 on 11/20/24, V1 would have initiated the steps that were taken on 11/22/24.

Based on observation, interview and record review, the facility failed to provide behavioral health services to maintain the highest practicable mental well-being for a resident diagnosed with major depression. This failure affects one of two residents (R53) reviewed for behavioral health services on the sample list of 30. This failure resulted in R53 being tearful, visibly shaking, and expressing despair. Findings Include: R53's ongoing diagnosis listing documents the following diagnoses: Vascular Dementia without Behaviors, Anxiety Disorder and Major Depression. R53's May 2024 Physician Order Sheets documents an order for Lorazepam {Benzodiazepine} topical gel 1 mg (milligram) per ml (milliliter) to the inner wrist or other hairless area prn (as needed) every every 4-6 hours for anxiety or agitation but does not have any medication orders for R53's diagnosis of major depression. On 5/14/24 at 11:21 AM, R53 was sitting up in a wheelchair in the doorway of R53's room. R53 became tearful and began to shake when talking about having to come to the long term care facility. R53 stated R53's family told R53 that R53 was not taking care of R53's self or dog, so they initially put R53 into an assisted living facility and now R53 is in long term care. R53, while still crying, explained R53's family sold everything that R53 owned stating, I have nothing now. R53 stated, they tell me (R53) I'm adjusting but I don't feel I am adjusting, I just want to run away and keep running and running with no place to go. R53's Care Plan dated 3/25/24 documents R53 has a psychosocial well-being problem related to R53's medical diagnosis of Anxiety Disorder and Major Depressive Disorder with interventions that include: allow R53 time to answer questions and to verbalize feelings perceptions, and fears as needed; Assist/encourage R53 to set realistic goals; Encourage participation from R53; Increase communication between R53/family/caregivers about care and living environment; and explain all procedures and Treatments, Medications, Results of labs/tests, Condition, All changes, Rules, and options. This Care Plan also documents R53 is on hospice and will work cooperatively with the hospice team to ensure R53's spiritual, emotional, intellectual, physical and social needs are met. R53's medical record does not contain any documentation that R53 is obtaining any behavioral health services to assist R53 in coping with R53's depression. On 5/15/24 at 10:30 am, V10 SSD (Social Service Director) stated any resident who takes any type of psychotropic medication is referred to behavioral health services upon admission, or when started on medication however R53 was not do to being on hospice and hospice wanting to manage their own medication. At this time, V10 explained that when R53 was admitted to the facility, R53 was unresponsive and non-verbal however R53 has improved so much, R53 is being taken off of hospice. V10 was not aware of R53 being severely emotionally about being at the facility and R53's recent events. On 5/15/24 at 11:00 am, V10 stated V10 completed a PHQ (Patient Health Questionnaire) - 9 on R53 and stated R53 scored a 12, which indicates possible depression. V10 stated that V10 called V32 (R53's POA (Power of Attorney)) after completing the assessment to see if it was okay for R53 to be seen by behavioral health services and V32 gave permission and actually stated that R53 had been taking an antidepressant for depression prior to being placed on hospice. The facility's Hospice Service Agreement dated 11/3/23 documents the facility will furnish to the individual who is both a resident of Facility and a patient of Hospice, all of those services which Facility normally would have provided in the absence of Hospice Program, as provided for the Facility's policies, procedures, and protocols as required by State and Federal Law and agreements with the resident and the resident's family.

Based on interview and record review, the facility failed to operationalize their Infection Prevention and Control Program by failing to track infections and conduct infection surveillance. These failures affects one resident (R13) and has the potential to affect all 80 residents residing at the facility. Findings Include: 1. The facility Infection Surveillance, Tracking and QA (Quality Assurance) Reporting Policy dated 2/14/18 documents the facility will identify, monitor, track and report infections and monitor adherence to infection control practices. Infection surveillance for compliance may include but is not limited to: review of laboratory/microbiology reports and results, observing for trends and monitoring to ensure appropriate precautions were initiated as appropriate. Infection Tracking includes but is not limited to: completing Infection Tracking Log for all residents with an infection and/or treated with antibiotics, track physician antibiotic prescribing practices as appropriate, monitor for trends by unit/location, clusters of same infection types/organisms, outbreaks, and employee illnesses. On 5/15/24 at 1:00 PM, V24 (Infection Preventist) provided the Infection Control/resident list documentation that does not include trending and infection surveillance, outbreak investigation and surveillance also remain incomplete with missing data entries for type/location of infection, infectious organism, and if isolation was required or not. The facility resident list report dated 5/14/24 lists 80 residents residing at the facility. 42702 2.) R13's physician orders dated 5/13/24 document that R13 is to be in strict contact and droplet isolation for Norovirus. R13's progross notes dated 5/14/24 at 1:14 AM documents strict isolation for Norovirus. On 5/13/24 at 12:30 PM, only a sign for enhanced barrier precautions was on R13's door. On 5/14/24 at 9:30 AM, only a sign for enhanced barrier precautions was on R13's door. R13's Minimum Data Set, dated dated dated [DATE] document R13 as cognitively intact. On 5/14/24 at 9:32 AM, R13 stated, I'm not on any isolation that I'm aware of. I went out to my restaurant yesterday to make the pies. The girls don't wear any gowns when they come in here. Last night I wasn't feeling good and I threw up. On 5/15/24 at 9:30 AM, R13's door signage included a sign for contact isolation and to see the nurse before entering. On 5/15/24 at 11:50 AM, V3 Assistant Director of Nursing said that R13 should have been on contact isolation as of 5/13/24. On 5/15/24 at 11:30 AM, V24 Infection Preventionist stated that she was doing education with staff regarding how they should handle isolation in the future.

Based on observation, interview and record review the facility failed to ensure that residents are treated with respect and dignity. This failure affects three (R76, R43, & R66) of twenty four residents reviewed for dignity on the sample list of 30. Findings include: The facility's Dignity policy dated 11/28/12 documents, The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. This policy also documents that maintaining a resident's dignity should include refraining from practices demeaning to residents. 1. On 5/14/24 at 10:42 AM, R76 stated that V25 Certified Nurse's Assistant asked her if she had pooped right in the hallway in front of everyone. R76 stated she felt embarrassed by V25 asking her this out in the hallway. R76 stated she told V26 Licensed Practical Nurse about it. On 5/15/24 at 11:38 AM, V26 stated that R76 did report to her that V25 asked her if R76 pooped in the hallway. V26 stated it is not appropriate to ask that in the hallway and that she should have asked her in the room. 34201 2. R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has severe cognitive impairment. On 5/13/24 at 12:35 PM, R43 was sitting in the lounge area eating lunch, by R43's self, away from all other residents who were in the dining area. At this time, V3 ADON (Assistant Director of Nursing) / Licensed Practical Nurse stated V3 is unsure why R43 is in the lounge area by R43's self other than the fact that R43 likes to tool around and take food off of other resident trays. R43's Care Plan dated 4/23/24 does not document that R43 takes food from other residents and is to sit by R43's self. 49492 3. 05/13/24 11:55 AM R66 Urinary drainage bag observed hanging on the right side of the bed at the foot of the bed, visible from doorway/hallway. No dignity/cover bag observed. 05/13/24 1:15PM R66 Record review indicate a diagnosis of Neuromuscular Dysfunction Of Bladder indicating the need of an indwelling urinary catheter to drain the bladder. 05/14/24 09:00 AM R66 Urinary drainage bag hanging on the foot of the bed at the right side, uncovered/not placed in dignity bag at this time visible from the doorway/hallway. 05/14/24 09:05 AM R66 states staff just hang the bag from the bed and leave. R66 states he has had the indwelling urinary catheter for a long time due to not being able to empty his bladder on his own. R66 states a doctor told R66 has sign and symptoms of Multiple Sclerosis and will always have the need for a catheter going forward. 05/16/2024 09:18 AM V2 and V3 both state that all nursing staff should be putting all urinary collection/drainage bags inside a dignity bag unless being drained to protect resident dignity and privacy.

Based on observations, record reviews, resident and staff interviews, the facility failed to complete a self-administration of medication assessment for one of one resident (R29), reviewed for self-administration of medication. Findings Include: 05/15/24 09:15 AM R29 was observed with a medication cup on the bedside table with several unidentified medications still inside. R29 was observed with eyes closed resting in a recliner at this time. 05/15/24 09:20 AM R29 room door under constant observation from 09:15 AM until V12 (Registered Nurse) returned to nurses station at 09:20 AM. V12 then accompanied this surveyor to R29's room. V12 looked at the medication cup located on bedside table and picked it up from the bedside table concealing it in her left hand. V12 then aroused R29 by shaking R29's right hand/speaking loudly over the television and asked R29 why R29 did not take his medication. V12 was asked if V12 left the medication cup containing the medications at the bedside, V12 stated V12 left a calcium tablet at the bedside but did not leave this medication cup with medications in it. 05/15/24 09:25 AM V2 (Director of Nursing) stated nurses are not supposed to leave medications at the bedside, the nurse is supposed to watch the residents take the medications. 05/15/24 09:30 AM Clinical Physician Orders record review does not contain a physician order for medication self-administration. 05/15/24 09:40 AM R29 Standard Assessments record review does not contain an assessment for medication self-administration. 05/15/24 09:45 AM R29 Care Plan review indicate to Administer medications as ordered and to monitor/document for side effects and effectiveness by the License Practical Nurse (LPN), or Registered Nurse (RN).

Based on interview and record review, the facility staff failed to report allegations of abuse to the Abuse Coordinator for one of three residents (R44) reviewed for abuse on the sample list of 30. Findings Include: R44's MDS (Minimum Data Set) dated 3/14/24 documents R44 has severe cognitive impairments. R44's Nursing Progress Notes document the following: 5/11/24 at 3:34 am by V27 RN (Registered Nurse) - R44 expresses frustration toward staff members, refusing care, and accusing CNAs (Certified Nursing Assistant's) of punching R44 in the gut. Upon inspection, R44 had no bruising or redness to indicate a punch to the gut. 4/27/24 by V28 LPN (Licensed Practical Nurse) - R44 was sitting out in the living room on the wing. There was another resident (unidentified) talking to a stuffed animal. R44 started yelling at that resident, Shut up .you need to comb your hair .When staff told resident that we don't talk like that, R44 said F*** you b****. When staff educated R44 that if R44 was going to talk like that, R44 could go to R44's room because that isn't nice to talk to people that way, R44 then stated to the other resident, stop yelling or I'll hit you in the head. Staff kept R44 away from other residents as R44 walked R44's self back to her room. R44 was raising R44's middle finger and saying f*** you to the staff. On 5/13/24 at 1:27 PM, V1 Administrator stated V1 has not had any allegations of abuse reported to V1. On 5/15/24 at 1:08 PM, V1 stated V1 was not aware of the above allegations as nobody reported them to V1. V1 explained staff have all been inserviced many times therefore should be aware of what needs reported and explained, this should have been reported. On 5/15/24 at 2:09 PM, V28 stated on 4/27/24 R44 was lashing out, yelling and threatening to hit another resident (unidentified) . V28 stated, sometimes R44 just gets up in a bad mood and lashes out and takes it out on others but then at other times, R44 is as sweet as pie. V28 stated V28 has been instructed on what constitutes as abuse and what needs reported and explained V28 thinks that R44 was just angry. V28 stated R44 went back to R44's room when instructed to do so, if (R44) kept doing it {yelling and threatening}, I (V28) would have reported it. On 5/16/24 at 4:22 PM, V2 DON (Director of Nursing) with V1 present stated that V2 counseled V27 that R44's allegations that R44 was hit in the stomach should have been reported to V1 immediately. The facility's Abuse Prevention and Reporting Policy dated 4/14/22 documents abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal, sexual, physical and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Employees are required to report any incident, allegation or suspicion of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property they observe, hear about, or suspect to the administrator immediately, or to an immediate supervisor who must them immediately report it to the administrator.

Based on interview and record review, the facility failed to accurately code the Minimum Data Set for three of 24 residents (R29, R43, R53) reviewed for Assessments on the sample list of 30. Findings Include: 1) R43's MDS (Minimum Data Set) dated 2/28/24 documents R43 has limited ROM (Range of Motion) to both bilateral upper and lower extremities. R43's Care Plan dated 4/23/24 does not document any limited ROM. On 5/13/24 at 1:57 PM, V3 ADON (Assistant Director of Nursing) / LPN (Licensed Practical Nurse) stated R43 does not have any limited ROM. On 5/14/24 at 3:05 PM, V5 LPN stated R43 has full ROM to all extremities but does have some weakness in the legs. On 5/15/24 at 10:45 AM, V29 MDS Coordinator stated R43's MDS was completed prior to V29 starting at the facility so V29 is not sure why it is coded the way it is but verified that it is coded incorrectly as R43 does not have any limited ROM. 2) R53's May 2024 Physician Orders documents an order dated 3/25/24 to admit into hospice care for comfort measures only. R53's Care Plan dated 3/25/24 documents R53 is on hospice. R53's MDS (Minimum Data Set) dated 3/29/24 does not document that R53 is receiving hospice care. On 5/14/24 at 11:18 AM, R53 confirmed R53 was placed on Hospice after having a small stroke but has improved so will be coming off of hospice. On 5/15/24 at 11:23 AM, V29 MDS Coordinator confirmed R53's MDS is coded incorrectly due to not having hospice care marked and stated it should have been. 49492 3) 05/13/2024 09:50 AM V1 states there are no residents currently receiving dialysis in the facility. 05/15/24 09:20 AM V12 (Registered Nurse) stated R29 has a left forearm fistula (Dialysis access port) but R29 has never had dialysis. R29 states R29 has not had dialysis and does not want dialysis at this time. 05/15/24 09:25 AM V2 (Director of Nursing) and V3 (Assistant Director of Nursing) review Minimum Data Set (MDS) for R29. R29 MDS Section O dated Tue [DATE] at 09:19:21 AM is marked (documented) Yes, R29 as having dialysis while a resident. V2 and V3 agree that R29 has never had dialysis while a resident in this facility and the MDS was completed incorrectly. V2 states R29 had the left arm fistula placed in January 2024 but has not had dialysis performed. V2 states the left arm fistula has never been accessed.

Based on observation, interview, and record review the facility failed to assist with shaving and nail care for two (R12, R69) of twenty four residents reviewed for activities of daily living on the sample list of 30. Findings include: 1. R12's care plan dated 12/18/23 documents that R12 has a self care performance deficit. This documents that R12 needs supervision with touch assistance for personal hygiene. This care plan also documents an intervention for staff to check nail length and to clean nails as needed. On 5/14/24 at 10:30 AM, R12 was sitting in the hallway in a wheel chair. R12's face was partially shaved. R12's neck and cheeks had an over growth and sides of face. R12 stated that he shaved himself and that he did the best he could. R12's fingernails were jagged and had an accumulation of a black substance underneath them. On 5/15/24 at 11:36 AM, R12 was sitting in the hallway. The sides of his face and neck continued to have an overgrowth of facial hair. R12 stated he did the best he could to shave his face. R12 stated he likes to be clean shaven but needs help and can't do it by himself. R12 fingernails remained jagged and continued to have an accumulation of a black substance underneath them. On 5/16/24 at 2:00 PM, V1 Administrator stated that R12 does require assistance with shaving and the staff should help him. 2. R69's care plan dated 4/19/23 documents R12 has a self care performance deficit related to weakness. This care plan documents R12 requires extensive assistance of one staff member for assistance with personal hygiene. On 5/13/24 at 12:20 PM, R69 was sitting at the dining room table. R69 had one quarter inch growth of facial hair. When asked if growing a beard, rubbed face and stated no, just waiting for someone to cut it or me, anybody will do, what are you doing now, can you do it?

Based on observation, interview and record review, the facility failed to ensure a pressure ulcer wound treatments was completed as ordered, implement pressure relieving interventions and prevent potential cross contamination of the wound for two of five residents (R13, R51) reviewed for pressure ulcers on the sample list of 30. Findings Include: The facility's Pressure Ulcer Prevention Policy dated 1/15/18 documents specialty mattresses such as a low air loss, alternating pressure, etc mattress may be used as determined clinically appropriate. Specialty mattresses are typically used for resident who have multiple stage 2 wounds or one or more stage 3 or stage 4 wounds, and use a pressure reducing pad in chairs of all types to protect bony prominence's for residents. 1) On 5/13/24 at 11:29 AM, V3 LPN (Licensed Practical Nurse)/ADON (Assistant Director of Nursing) stated that R51 has a chronic stage four Pressure Ulcer to the Sacrum. On 5/13/24 at 11:36 AM, R51 was sitting up in a wheelchair with a gel pressure cushion seat at the dining room table. R51 had a mechanical lift sling under R51 and between R51's buttocks and the gel pressure cushion. On 5/14/24 at 8:25 AM, R51 was sitting up in a wheelchair with a gel pressure cushion seat but also had a mechanical lift sling between R51's buttocks and the gel pressure cushion. At this time, R51's bed had a regular mattress on it. R51's Wound assessment dated [DATE] documents R51 has a stage four pressure ulcer to the sacrum measuring 0.3 cm (centimeters) by 0.5 cm by 0.9 cm. R51's May 2024 Physician Orders document the following order to the Coccyx wound - cleanse with wound cleanser pack with indoor gel to wound bed place small piece of calcium alginate with silver over the top of the wound bed then cover with a thick absorbent pad and secure in place daily. If iodoform gel is not available, may use honey. R51's Care Plan dated 5/8/24 documents R51 has a pressure ulcer to the sacrum with interventions that include: educate family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, follow facility policies/protocols for the prevention/treatment of skin breakdown, monitor nutritional status and serve diet as ordered, monitor intake and record, monitor/document/report PRN (as needed) any changes in skin status: appearance, color, wound healing, signs of infection, assist with repositioning approximately every two hours, pressure relieving/reducing mattress on bed and pad in chair, encourage/assist to use the bathroom every two hours and PRN in an attempt to reduce incontinent episodes, complete treatment as ordered. On 5/14/24 at 10:19 AM, V2 DON (Director of Nursing) and V8 CNA (Certified Nursing Assistant) donned gowns and entered R51's room to provide wound care. At this time, V2 DON stated R51 is on EBP (Enhanced Barrier Precautions) due to having a pressure wound. Both V2 and V8 washed hands and donned gloves. R51 was lying in bed on a regular mattress. V8 rolled R51 to left side and V2 removed R51's wound dressing to the sacrum which consisted of a small piece of thick absorbent dressing that had a small amount of yellow drainage on it. No calcium alginate was on the wound as ordered. The wound to the sacrum presented as a stage four pressure ulcer. V2 measured the wound and reported the measurements as 0.6 cm by 0.4 cm by 1.1 cm. After cleansing the wound appropriately, V2 applied the iodoform gel to the wound base, then pulled a pair of scissors out of V2's uniform pocket to cut the silver calcium alginate and thick absorbent pad, before placing them over the wound. V2 confirmed V2 used scissors from V2's pocket and did not clean them prior to using them and stated, V2 had already cleansed the scissors with bleach wipes prior to placing them in (V2's) pocket. At this time, V2 also confirmed the dressing that V2 removed from R51 did not contain the ordered silver calcium alginate. V2 also confirmed that R51 was on a regular mattress and should be on an alternating pressure air mattress and explained that is V2's fault because V2 thought R51 was already on one. On 5/14/24 at 1:34 PM, R51 was sitting up in the wheelchair with the mechanical lift sling under R51 and between R51's buttocks and pressure relieving cushion. On 5/14/24 at 1:53 PM, V5 LPN stated R51 has had the same wound the entire time and even though it is sometimes documented as the coccyx and other times as sacrum, it is the same wound. On 5/15/24 at 4:20 PM, V2 confirmed that sitting on a transfer sling could interfere with pressure relieving interventions when up in the wheelchair. 42702 2.) R13's care plan dated 5/23/24 documents a risk for pressure ulcer development due to weight, mobility, bowel incontinence, and fragile skin. R13's Minimum Data Set, dated dated dated [DATE] documents R13 is cognitively intact. R13's care plan dated 5/2/24 documents that R13 is dependent on two staff, requiring the mechanical lift, for toileting needs including catheter care and incontinence care. R13's care plan dated 5/6/24 documents to report any changes in skin status. R13's bowel and bladder record dated 5/11/24, 5/14/24 and 5/15/24 documents bowel movements on these dates. On 5/14/24, R13's medical record does not document any current wounds or wound treatment. On 5/14/24 at 10:41 AM, R13 said that she has wounds that come and go on her buttocks and legs and that she feels like there is one there now and has been for several days. On 5/15/24 at 12:00 PM, V2 Director Of Nursing assisted R13 to roll onto left her left side to complete pericare. An open stage two pressure ulcer the size of a quarter was on R13's right buttock. On 5/15/24 at 12:30 PM, V17 Certified Nursing Assistant (CNA) stated that she provided pericare/catheter care to R13 this morning and that R13 had an open wound, but that they wiped barrier cream over it and didn't tell anyone. On 5/15/24 at 1:56 PM, V2 said that based on how the wound looks, she would guess that it had been open for a few days and that the CNA's should have reported it.

Based on observation, interview and record review, the facility failed to thoroughly assess a resident's risk for falls, implement appropriate safety interventions to prevent further falls, provide a safe, non-hazardous shower environment, failed to follow the facility policy for bathing, and failed to use an appropriate chair for transporting/moving a resident from one location to another for one of six residents (R2) reviewed for falls on the sample list of six. Theses facility failures resulted in R2 falling out of a shower chair while being relocated, while in the shower chair, to a dry/non-slick environment. This fall resulted in R2 sustaining a closed displaced fracture of the posterior arch of the first and second cervical vertebra, an open fracture of the nasal bone, bilateral closed fractures of the maxilla and a traumatic [MEDICATION(S)] hematoma. R2 passed away seven days later from a traumatic head injury and fall, as documented on R2's death certificate. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on [DATE]. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to thoroughly assess a resident's risk for falls, implement appropriate safety interventions to prevent further falls, provide a safe, non-hazardous shower environment, follow the facility policy for bathing, and use an appropriate chair for transporting/moving a resident from one location to another. On [DATE] at 3:28 pm, V1 Administrator and V2 DON (Director of Nursing) were notified of the Immediate Jeopardy situation. While the immediacy was removed on [DATE], the facility remained out of compliance at the Severity Level 2. The facility is in the process of evaluating every resident's fall risk and shower assessments and updating resident care plans to ensure appropriate fall/safety interventions are in place, and inservicing staff on shower chair assessments, updated bathing policy, and transfer safety. The facility has installed safety belts on all shower chairs. Findings Include: R2's [DATE] Physician Orders document the following Diagnoses: Brief [CONDITION(S)], [CONDITION(S)] with Hallucinations, Adult Failure to Thrive, Dementia with Behavioral Disturbances, and History of Falls. These orders also document PT (Physical Therapy) and OT (Occupational Therapy) as indicated. R2's MDS (Minimum Data Set) dated [DATE] documents R2 has severe impaired cognition, has physical and verbal behaviors ,d+[DATE] days a week, is totally dependent of staff for bathing, and has a history of falls. R2's Care Plan dated [DATE] documents R2 is at risk for falls due to confusion, gait/balance problems, impaired safety awareness and a history of falls. This Care Plan also documents R2 has 'repetitive physical movements. R2's Progress Notes document the following falls: [DATE] - R2 lunged forward while sitting in R2's wheelchair and landed on the floor. [DATE] - CNA (Certified Nursing Assistant) was propelling R2 in a wheelchair when R2 lifted (R2's) feet, tucked {the} top half of {R2's} body in a forward motion and fell to floor. [DATE] - CNA was wheeling R2 in a shower chair, out of door of shower room into an open area to transfer R2 into a wheel chair when R2 leaned forward and fell out of shower chair and hit R2's head on the door frame of the bathroom, landing on the floor on R2's right side. R2 was noted to be bleeding from the bridge of the nose and nostrils. R2's Hospital History and Physical dated [DATE] by V28 Hospital ER (emergency room ) Physician documents R2 presented to the ER after a fall at the nursing home. R2 was sitting in a shower chair while taking a shower and R2 moved and slipped forward onto R2's face. R2 has a large frontal contusion with a puncture wound laceration to the upper bridge of the nose with mild bleeding, and superficial abrasions to the left knuckles between the 4th and 5th digit as well as the lateral aspect of the 2nd digit. V28 documents X-rays and a CT (Computerized Tomography) was preformed and revealed the following: closed displaced fracture of the posterior arch of first cervical vertebra, closed nondisplaced fracture of the second cervical vertebra and traumatic [MEDICATION(S)] hematoma without loss of consciousness, open fracture of the nasal bone, and bilateral closed fracture of the maxilla. R2 was then sent to a Trauma Center due to the extent of R2's injuries. R2's Hospital Discharge Summary from the Trauma Center dated [DATE] by V29 Trauma Center Physician documents, R2 was found deceased on [DATE] {7 days after the fall} at 1:26 am after being brought in to be evaluated by the Trauma Team after sustaining a ground level fall at a skilled nursing facility. R2 was found to have bilateral maxillary sinus fractures, nasal bone fractures, C2 odontoid fracture, [MEDICATION(S)] hematoma of C3, T1, T8, T11 and compression fractures. R2's Death Certificate [DATE] documents R2's cause of death as Traumatic Head Injury and Fall. On [DATE] at 5:30 am, V6 CNA stated V6 was at the nurses station on [DATE] when V9 CNA was giving R2 a shower. V6 stated V6 responded to the shower room call light to find R2 had slid sideways in the shower chair. V6 explained V6 helped V9 readjust R2 in the shower chair and then stayed with V9 to help finish up R2's shower. V6 stated V9 was sliding on the wet shower room floor so V6 and V9 removed R2, in the shower chair to the middle of the room, got R2 dried off and R2's gown on. V6 explained the floor was slick because it was wet so they were moving R2 into another room, attached to the shower room, which was approximately 20 ft away to transfer R2 from the shower chair into R2's wheelchair. V6 stated V6 opened the door and then turned away to grab the wheelchair as V9 was pushing R2 in shower chair and then heard V9 say ugh, as I heard a thud. V6 stated V6 turned around to see R2 lying on the floor, with R2's nose bleeding. V6 and V9 summoned the nurse, V10 LPN (Licensed Practical Nurse), who then called V7 RN (Registered Nurse) to also come and assist. V6 stated facility staff left R2 on the floor until the ambulance arrived, applied ice to R2's forehead due to the immediate swelling, then R2 left for the hospital. V6 explained the wall that R2 hit R2's head on was concrete with tile over it. V6 stated R2 was hollering out in pain. V6 explained R2 had issues with lunging forward when up in the wheelchair, so staff always kept a close eye on R2. V6 stated the shower chair did not have any safety belt or lap bar on it. V6 also stated we {staff} don't transport residents in the shower chair typically but we will move them in the chair from the shower to the pre-shower room due to the floor being wet. On [DATE] at 5:48 am, V7 RN confirmed V7 had been called over to assist with R2's fall on [DATE]. V7 stated when V7 responded, V7 found R2 lying on R2's right side in the pre-shower room with a nasty 3 cm (centimeter) x (by) 3 cm bump to (R2's) forehead and a cut/puncture area to the bridge of (R2's) nose. V7 explained that R2 moved to try and straighten R2's self out and then yelled out in pain. V7 stated the staff reported that R2 had slipped out of the shower chair but (R2) does have a tendency to lean forward. V7 stated the shower chairs do not have a safety belt but that is actually one of the things V7 suggested to the DON (Director of Nursing) and Administrator, because V7 thinks that would have helped. On [DATE] at 5:55 am, V8 CNA stated R2 has a known behavior of rocking back and forth when sitting up in a chair. On [DATE] at 7:41 am, V1 Administrator provided a list of additional parts that could be purchased for the facility shower chairs, that included a seatbelt and lap bar but stated the shower chairs do not have those. I (V1) don't think they were ever purchased. R2's medical record contained a PT screening from [DATE] with recommendations for foot pedals on the wheelchair when propelling R2 and dumping the back of the wheelchair to keep R2's shoulders over hips to reduce (R2) lunging forward out of the chair. There is no screening from OT in R2's medical record. On [DATE] at 11:50 pm, V19 PT confirmed V19 screened R2 in February after R2 had fallen from R2's wheelchair. V19 stated V19 recommended dumping the wheelchair which means lowering the back of the wheelchair by a couple of inches to ensure R2's shoulders aren't in front of R2's hips so that R2 sits in good alignment. V19 stated V19 doesn't assess for shower safety, that is something OT would do. On [DATE] at 12:50 pm, V20 OT stated V20 has never evaluated R2 so V20 can't make any recommendations or suggestions of what V20 would have recommended to keep R2 safe in the shower. On [DATE] at 1:40 pm, V1 stated the facility policy says to refer to therapy after the second fall so if we ordered PT to screen (R2), OT would have been ordered too The facility Fall Policy dated [DATE] documents, the resident's environment will remain free from accidents and hazards as possible; and each resident will receive adequate supervision and assistance devices to prevent accidents. Any ambulatory resident who has had two falls within the last 30 days or less will be screened by therapy. On [DATE] at 2:03 pm, V10 LPN confirmed V10 was R2's assigned nurse on [DATE] when R2 fell out of the wheelchair, hitting R2's head on the wall. V10 stated staff had brought R2 into the open room before the shower room to transfer R2 from the shower chair to the wheelchair when R2 reportedly stiffened up, leaned forward and fell out of it. V10 explained, that was a known behavior R2 had, and R2 had done it often in the last couple of months, which resulted in R2's previous falls. On [DATE] at 2:34 pm, V1 stated even though R2 had behaviors of lunging forward when up in a wheelchair, R2 never had those behaviors while in the shower chair. R2 had always used the upright/standard shower chair, without incident so V1 didn't think to use any additional safety attachments for the shower chair, plus those recommendations would have come from OT after OT screened R2 {which did not happen}. The facility Bath, Shower/Tub Policy dated February 2018 documents that after the bath/shower is given, staff are to dry the resident off from head to waist, then assist them out of the shower chair, apply a towel to the shower chair seat then have the resident sit back down, and finish drying the resident bottom half of the body. On [DATE] at 9:04 am, V9 CNA stated V9 CNA was showering R2 on [DATE] and that the shower floor and shower room floor were both very slick, due to being soaking wet with water since this was the third shower that was given that night. V9 stated V9 did not dry the floor between showers. V9 explained that after R2's shower, V9 dried R2 off and placed a gown on R2 before moving R2, in the shower chair, but did not place a dry towel on the shower seat for R2 to sit on. V9 stated V9 was sliding all over the place so V9 and V6 were moving R2, in shower chair, to the room that was attached to the shower room, before transferring R2 from the shower chair to the wheelchair. V9 stated V9 was pushing the chair with both hands and had (V9's) foot holding the door open for (V6) to bring the wheelchair through when (R2) lunged forward and fell , hitting hard. (R2) had immediate swelling to (R2's) face. V9 stated R2 leans and lunges all the time. On [DATE] at 12:36 pm, V9 stated V9 and V6 had dried R2 off and placed a gown on R2 prior to moving R2 into the room next to the shower room but had not placed a towel under R2 per the facility Bath, Shower/Tub Policy. V9 stated that not just the shower floor gets slick but so does the entire shower room floor, that is why V9 was relocating R2 to a dry area. On [DATE] at 1:40 pm, the shower room in the spa has a shower with a plastic bottom with built in grips. On the shower rail, there were 3 extra shower anti-slip grips. The shower floor when dry is not slick but after turning the water on, it was slick. Water ran out of the shower into the shower room causing the shower room floor to become slick as well. On [DATE] at 2:10 pm, V22 Maintenance Director confirmed the shower floor and shower room floor both can get slick when they are wet, which was reported to V22 after R2's accident. On [DATE] at 2:35 pm, V31 Director of Sales and Marketing/Supplier stated shower chairs are not intended to be used as a transport chair. On [DATE] between 10:45 am - 3:30 pm, the surveyor confirmed through interview, record review and observation that the facility took the following actions to remove the Immediate Jeopardy: 1.) Fall Assessments were completed by V2 DON and V21 Care Plan Coordinator for all residents between [DATE] - [DATE]. A copy of each assessment was provided by V1 Administrator for review. 2.) Shower Assessments were completed by V2 and V21 for all residents on [DATE] and again between [DATE] - [DATE]. A Copy of each assessment was provided by V1 for review. 3.) Inservice/Education was provided to all nursing staff between [DATE] - [DATE] regarding Shower Chair Assessments, the updated Bathing Policy which includes ensuring the floors are dried after each shower with the use of towels and squeegee, and Transfer Safety by V1 Administrator, V2 DON and V21 Care Plan Coordinator between [DATE] - [DATE]. This was verified by interview with V17 LPN (Licensed Practical Nurse), V35 CNA (Certified Nursing Assistant), V30 CNA, V25 CNA, V36 CNA, V37 RN (Registered Nurse) and V38 CNA. 4.) All resident Care Plans and Kardex's were updated to reflect all resident current needs and safety interventions and were verified to be in place by V21 between [DATE] - [DATE]. 5.) Binders were placed at each Nurses Station on [DATE] that indicate which shower chair is required for each resident by V21, which was verified by observation on [DATE]. 6.) Audits of the shower rooms were completed by V1 and V2 on [DATE] and [DATE] to ensure proper safety equipment is in each shower room. On [DATE], each shower room had squeegee's in place and safety belts were on each shower chair.

Based on observation, interview and record review, the facility failed to ensure post fall interventions were in place for one of three residents (R2) reviewed for falls on the sample list of five. This failure resulted in R2 having a fall that resulted in a 3 centimeter forehead laceration that required sutures. Findings Include: R2's Fall Risk assessment dated [DATE] and 6/21/21 both document R2 is at high risk for falls. R2's MDS (Minimum Data Set) dated 6/21/21 documents a BIMS (Brief Interview for Mental Status) as a 7, which indicated severe cognitive impairments. This MDS documents R2 is independent with bed mobility and requires supervision for transfers. R2's Progress Notes dated 2/8/21 documents at 8:00 am, R2 ambulated to nurses desk, reporting I (R2) need a band-aid. I (R2) rolled out of bed and got this, pointing to R2's right jawline where a 3.0 cm (centimeter) x (by) 3.0 cm purple bruise is present, with 0.5 cm x 0.2 cm x 0.1 cm V-shaped skin tear at the center of the bruise. When R2 reported the fall, R2 stated I (R2) don't know what happened. I (R2) didn't know where I (R2) was and just rolled out of bed. New intervention: scoop edge mattress placed on bed. R2's Progress Notes dated 9/13/21 documents R2 yelling out for help from R2's room. Upon entering R2's room, R2 was noted to be laying on floor on R2's tummy, diagonal to the bed. There was a significant amount of blood under R2's head. R2 was repositioned to be able to assess where the bleeding was coming from and R2 was found to have a large laceration and hematoma above the left eye. R2 stated R2 swung feet over the bed, stood up and fell forward on the floor. R2 was sent to the hospital for evaluation. R2's Hospital Notes from V11 dated 9/13/21 documents R2 had a fall while getting out of bed, and struck R2's head on the ground. R2 sustained a 3 cm gaping left suprorbital laceration with associated large skin avulsion requiring sutures. R2's Care Plan dated 9/14/21 documents R2 is at risk for falls related to impaired balance/gait and cognition/safety awareness, with interventions for a scoop mattress to have been implemented after R2's 2/8/21 fall, and to replace call don't fall signs in room and bathroom from current signs to ones on bright paper which was to have been implements after R2's 9/13/21 fall. On 9/21/21 at 3:15 pm, R2 had a regular mattress on R2's bed. There was a white sign in R2's room with red writing on the wall next to the head of bed, and in the bathroom next to the toilet and call light that documents don't stand without help. There was another white sign with black writing on it at the foot of the bed that documents please call-don't fall. On 9/22/21 at 8:00 am, R2 was lying in bed, on a regular mattress. The same white signs were on R2's walls. On 9/22/21 at 9:50 am, V9 RN (Registered Nurse) and V13 CNA (Certified Nursing Assistant) both confirmed that R2 does not have a scoop mattress. V13 stated V3 ADON (Assistant Director of Nursing) was just asking a couple of days ago if the facility had any spare scoop mattresses. On 9/22/21 at 10:05 am, V3 stated if R2's care plan says R2 is to have a scoop mattress, then R2 should have one. V3 stated V3 was on the unit the other day and told staff if a scoop mattress was not on R2's bed, they {staff} needed to put one on. V3 stated R2 had a scoop mattress at one point and doesn't know what happened to it, unless it didn't move with R2 when R2 had a room move. V3 also stated V2 DON (Director of Nursing) was going to change out the white safety signs in R2's room to bright colors. V3 stated V3 is unsure why that didn't happen. R2's ongoing census documents R2 moved rooms on 5/21/21. On 9/22/21 at 11:46 am, V18 (R2's Family) stated V18 voiced a concern on 9/16/21 during their care plan meeting regarding R2's fall and the fact that R2 did not have a scoop mattress, which R2 is suppose to have. V18 stated R2 had a scoop mattress in R2's previous room but has not had one since being in R2's new room.

A. Based on record review and interview, the facility failed to apply foot pedals to a wheelchair, to provide a safe transport of a resident (R25) when leaving the facility in the facility van. This failure resulted in R25 sustaining a right distal femur and patella fracture, which required emergency treatment, overnight hospitalization and a leg cast. R25 is one of four residents reviewed for accidents/falls on the sample list of 35. B. Based on observation, interview and record review the facility failed to provide supervision to prevent a resident from wandering, impacting six of eight residents (R30, R38, R24, R29, R50 and R13) reviewed for resident to resident altercations on the sample list of 35 residents. Findings include: A. R25's Local Hospital Discharge Summary dated 12/12/20 documents R25 was being discharged to this skilled care facility after an episode of [CONDITION(S)] that resulted in a fall at home which caused R25 an Iliac Wing (Pelvic) fracture. R25's Face Sheet confirms R25 was admitted to the facility on [DATE]. R25's Minimum Data Set (MDS) to dated 2/8/21 (prior to incident of 3/30/21) documents R25's BIMS score as 14/15 (no cognitive impairment), uses a wheelchair for mobility, does not ambulate, and required physical staff assistance of one person for transfers. On 6/3/21 at 1:25 pm R25 was laying in bed. R25 stated I (R25) suffered a fracture to my (R25) right leg from being pushed by (V5, Transportation Assistant) in her wheel chair. R25 pulls back the blankets on her bed to show R25's right leg. R25 had a full length, thigh high immobilizer brace on R25 right leg. R25 stated I did not have foot peddles on my wheelchair at the time. The transportation person (V5) was pushing my wheel chair without the foot pedals on. My (R25) foot went under the wheelchair. I (R25) have to wear this brace now. My doctor says it will likely not heal completely, as I am getting a little older. I likely will never be able to walk again. I had a cast on (right leg) initially. This happened about two months ago, I don't know the actual date. R25's Health Status (Nursing) Note dated 3/30/21 at 9:00 am documents R25 went out of the facility for a follow-up appointment with the dentist (unidentified). R25's Health Status (Nursing) Note dated 3/30/21 at 11:13 am documents R25 returned from the dentist appointment. The facility incident investigation includes a signed statement dated 3/31/21, signed by V5, Transportation Department Assistant documents the following: I (V5, Transportation Department Assistant) transported (R25) to her (R25) Dentist appointment, (V6, Dentist), (local address and phone number) on March 30, 2020 at 9:00 am. As we (V5 and R25) were going into her (R25's) appointment, (R25) dropped her (R25's) foot, stopped holding her (R25's) legs up. Which stopped the wheelchair from it's forward motion, up the handicapped (wheelchair accessible) ramp. (R25) has never used foot rest in the year that I (V5, Transportation Department Assistant) I have been doing Transportation at (the facility name). (R25) said her leg hurt and was pointing just below her (R25) knee. She (R25) asked the receptionist (unidentified at the dentist office) for Tylenol (pain medication). I (V5, Transportation Department Assistant) said no (to R25), she (unidentified receptionist) cannot give you (R25) anything (resident first name used). Then (R25) asked and received an (elastic) bandage. I (V5, Transportation Department Assistant) left to go do another transport. Upon my (V5, Transportation Department Assistant) return to (facility name), I (V5, Transportation Department Assistant) informed Nurse (V7, Registered Nurse) of what happened and got footrest from (R25's) room. When I (V5, Transportation Department Assistant) returned to pick (R25) up at her appointment, she (R25) was in the waiting room (at the dentist office). When we (R25 and V5, Transportation Department Assistant) got back to (facility name), stopped at the nurses desk, as I (V5, Transportation Department Assistant) always do upon returning from appointments. (R25) asked (V7, Registered Nurse) for some Tylenol. The facility investigation report, had an undated, handwritten witness statement by (V8, Certified Nursing Assistant/CNA) that documents the following: Transport (V5, Transportation Department Assistant) took resident (R25) to (R25's) room. (R25) complained of pain in knee. Reported to nurse (V9, Licensed Practical Nurse/ LPN). (V9, LPN) told CNA (V8,CNA) to put a warm blanket on (R25's) knee. At 6:00 pm, (R25) could not bear weight, had to use (mechanical stand lift) for transfer. R25's Health Status (Nursing) Note dated 3/31/21 at 05:39 am, documents the following: Resident (R25) complained of right knee pain 10 out of 10 (on a scale of one to ten, ten being the worst pain). Unable to bear weight on right leg. Bruising noted on knee. (V10, Nurse Practitioner) notified, awaiting orders (physician). R25's Health Status (Nursing) Note dated 3/31/21 at 09:10 am, documents the following: X-ray ordered of right knee including distal and lateral femur AP, two views, each scheduled through (private X-ray service) for today. R25's Health Status (Nursing) Note dated 3/31/21 at 1:02 pm, documents the following: (private X-ray service) here to do X-ray. R25's Health Status Note nurses note dated 3/31/21 at 1:35 pm documents the following (V10, Nurse Practitioner) here (in facility) reviewed X-Ray results, new order to transfer to (local hospital) due to distal fracture of right femur. R25's ED (Emergency Department) to Hospital Admission/ Discharge Summary Physician Progress Note dated 3/31/21-4/1/21 signed by (V11, Physician) documents the following: Hospital course: Shows matter (?), further evaluation management of right distal femur fracture. Pain controlled, on oral antibiotics with minimal IV (intravenous) analgesics (pain medication) required. Orthopedic surgery (unidentified person) was consulted, who ordered additional CT (Commuted Tomography) imaging. Recommended non operative management. Short leg cast placed by Ortho (Orthopedic) with instructions for outpatient follow-up. The same ED (Emergency Department) to Hospital Admission/ Discharge Summary documents the following Right Femur X-Ray results 3/31/21: There is a displaced and impacted fracture through the distal femoral metaphysis (end plate of the bone). This is likely comminuted (multiple fragments) There is approximately once centimeter posterior displacement of the distal fragment. No fracture of proximal to mid femur. Stable arthritic changes in the right hip. Diffuse vascular calcifications. Moderate to severe [CONDITION(S)] in the knee. The same ED (Emergency Department) to Hospital Admission/ Discharge Summary report documents: Impression: Acute, impacted, commuted and displaced through the distal metaphysis (end plate of the bone). The same ED (Emergency Department) to Hospital Admission/ Discharge Summary documents the following results of a CT of R25's Right knee results dated 4/1/21 findings: Twisting injury comparison to Radiograph (X-Ray) 3/31/21. The same CT documents Injury on wheelchair. Impression: 1. Acute comminuted displaced [MEDICATION(S)] fracture of the distal femoral diaphysis as described. No intercondylar extension. 2. Acute nondisplaced vertically oriented fracture of the mid- patella (knee cap triangular bone). V5, Transportation Department Assistant's Verbal Discipline Report dated 4/2/21 documents the following: Please back patients on/off the platform for the lift in the van (facility transportation vehicle). Always use foot pedals on wheelchair for transports. On 6/3/21 at 3:27 pm V2, Director of Nursing stated (R25) was taken by our previous transportation staff, (V5, Transportation Department Assistant), to a dentist appointment. (V5, Transportation Department Assistant) had not put wheelchair pedals on (R25's) wheelchair before leaving. (R25) should have had foot pedals on her wheelchair before being taken out of the facility. Our expectations for safely transporting residents in a wheelchair, requires staff to put wheelchair foot pedals on when taken residents out. V2 confirmed (R25's) right leg fracture could have been prevented had the facility protocol been followed. On 6/4/21 at 9:30 am V2, DON and V1, Administrator confirmed R25 was transported without wheelchair pedals on R25's wheel chair which resulted in R25's fractures (right knee and femur. V2, DON also stated (V5, Transportation Department Assistant) was not following safe transfer procedure when taking R25 out of the facility which caused these preventable fractures. V1, Administrator nodded in agreement. V2, DON also stated (R25) and should have always had her foot pedals on the wheelchair. I do not have a written policy, but all staff have been educated. Moving forward, they (staff) all know residents being pushed in or outside the facility in their wheelchair should have the foot pedals on at all time. The Fall policy revised 3/20/18 states The resident's environment will remain free from accidents and hazards as possible; and each resident will receive adequate supervision and assistance devices to prevent accidents. B. The Care Plan updated 5/26/21 documents R30 has the potential to be physically, verbally and sexually aggressive with staff and that R30 has the potential to be physically aggressive with other residents related to dementia. The Care Plan also documents R30 has a history of grabbing female staff members inappropriately and that R30 is severely cognitively impaired. On 6/3/21 at 10:40 am V17 and V19 Certified Nurses Aides (CNAs) transferred R30 from the toilet to the wheel chair. After being assisted into the wheel chair R30 reached out and touched V17's buttock with R30's hand and then R30 propelled R30's self to the door. The Nurses Note dated 4/27/21 states (R30) wandering in wheelchair going into other resident's room. The Nurses Note dated 5/7/21 states (R30) went into another resident room inside doorway cussing at another resident. Resident was removed from the room and redirected to lounge area. The Nurse Note dated 5/17/states Resident (R30) up since 4:30 (am) wandering in wheelchair into unoccupied rooms, opening outside doors and setting off alarm and yelling help me disturbing other residents. Resident wandered up to female resident (R50) sitting in common area numerous times kicking resident's feet and upsetting other resident (R50). (V1 Administrator) contacted regarding kicking. Currently sitting in recliner with attempts to have staff member constantly supervise when not assisting other staff members. The Nurses Note dated 5/18/21 states (R30) Awake and up since 3:00 am. Wandering hallway in wheelchair and attempting to enter others' rooms. Cursing at staff and combative when re-directed. Hits staff and spitting on floor. The Nurses Note dated 5/22/21 states (R30) wandering in wheelchair into other resident's room, calling staff[OBSCENITY] s and saying I'll kick the s**t out of you. Told by female resident he had pulled the covers off her feet and was touching her feet. Another female resident states is he running around? This is ridiculous. The Nurses Note dated 5/23/21 states (R30) wandered in wheel chair, needing very frequent redirection to not wheel himself near other residents or into other residents' rooms. The Nurses Note dated 5/25/21 states (R30) wandering in wheelchair from beginning of night shift until put down for bed at 9:00 PM. Resident opening outside doors and setting off alarms, digging in garbage can and kicking it over, going into female resident's room and touching her feet. Resident hit this nurse in the arm as I walked by him, spitting on the floor, touching sterilizer and moving isolation carts around making it difficult for staff to get work done as he was needing constant attention. The Nurses Note dated 5/27/21 states (R30) wandering hallways in wheelchair since (6:30 PM) and requiring constant supervision. Attempting to go into others' rooms, getting into garbage, moving furniture around in unit living room, calling staff names and making inappropriate sexual comments to staff and attempting to touch staff. Staff walked with resident in hallways, pulling (R30) out of others' rooms. The Nurses Note dated 5/28/21 states Resident (R30) then placed in (R30's) wheelchair and roamed unit yelling help me and attempting to enter others' rooms. The Minimum Data Set (MDS) dated [DATE] documents R38 is cognitively intact. On 06/02/21 at 09:43 AM R38 stated two or three weeks ago while she was sleeping in her recliner R30 came in her room and pulled her blanket and socks off and told her she had big feet. R38 stated she was startled. R38 stated R30 has tried to get into her room at other times and staff have pulled him out. The MDS dated [DATE] documents R24 is cognitively intact. On 06/02/21 at 10:18 AM R24 stated R30 came into her room and she told him to leave but before he left he tickled her feet. R24 stated he gets away from them every now and then. The MDS dated [DATE] documents R29 is moderately cognitively impaired. On 6/3/21 at 9:00 am R29 stated R30 has been in her room three or four times. R29 stated sometimes (R30) gets away from them. R29 stated R30 roots through her dresser drawers and the basket on her table. R29 stated she does not like it when R30 comes in her room. R29 stated her room is supposed to be private. The MDS dated [DATE] documents R13 has severe cognitive impairment. On 6/3/21 at 9:20 am R13 stated R30 has been in her room three times. R13 stated (R30) is getting to be a problem. R13 stated she has complained to the staff two or three times and she is at the point where she just yells at him when she sees him at her door. R13 stated last night R30 tried to come in her room and she yelled at him and he left. On 6/3/21 at 9:25 am V17 CNA stated If there is a door open (R30) will go in and if staff are with another resident they can't watch him. On 06/03/21 09:58 AM V19 CNA stated R38 reported to V19 that R30 was in R38's room and touched R38's feet. V19 stated R30 used to have a one to one care giver but that ended in March or April 2021. V19 stated V19 does not understand why R30 no longer has a one to one caregiver to supervise him. On 6/3/21 at 11:00 am V16 Registered Nurse (RN) stated they try to watch R30 but if they have to leave him to care for another resident he zooms off down the hallway. On 6/3/21 at 12:15 PM V15 RN stated V15 has seen R30 in other residents' rooms and R30 gets angry when they try to redirect him out of other residents' rooms. V15 stated R30 has been in R13's room and other residents (R38 and R24) have also complained to V15 that R30 has pulled blankets off them and played with their feet. V15 stated R30 has to be watched constantly but staff have other things to do. V15 stated R30 has made sexual comments to staff and has tried to touch V15's buttocks. On 06/02/21 at 02:36 PM V2 Director of Nurses stated V2 knew R30 was wandering into other resident's rooms but V2 did not know the extent of the problem. On 06/03/21 at 12:11 PM V1 Administrator stated R30 used to have a one to one caregiver but V1 was told by risk management that that is not a service the facility provides. On 06/04/21 at 08:38 AM V1 Administrator stated R30's one to one caregiver was discontinued in April (2021). V1 stated V1 believes the reason for the one to one caregiver for R30 was the way he interacts with the staff and due to his wandering into other residents rooms. V1 stated V1 does not know what interventions were put in place to manage R1's behaviors after the one to one caregiver was discontinued. (B)

Based on observation, interview and record review, the facility failed to complete pressure ulcer treatments as ordered, prevent cross contamination of the pressure ulcer, assess and measure the pressure ulcer weekly, implement pressure relieving interventions and failed to notify the Physician and Registered Dietician of worsening pressure ulcers for two of three residents (R1 and R4) reviewed for pressure ulcers. This failure resulted in R1 and R4's wounds doubling in size and progressing to an unstageable pressure ulcer. Findings Include: 1.) On 3/23/21 at 3:20 pm, R1 was lying in bed flat on R1's back, on a regular mattress and stated R1 has a blister or something on (R1's) butt that hurts, and it needs something done to it. R1's MDS (Minimum Data Set) dated 3/8/21 documents R1 is alert and oriented, requires extensive assistance with bed mobility and transfers, and is at risk for pressure ulcer development. R1's Weekly Wound Tracking Worksheet dated 3/10/21 documents, R1 has a open area to R1's bottom measuring 0.5 cm (centimeters) by 0.6 cm by UTD (unable to determine) that is covered 100 percent with epithelial tissue. This note does not document the exact location, the type or description of open area. The facility Weekly Wound Tracking Worksheet dated 3/23/21 documents R1's Pressure ulcer as a stage II to the left gluteus measuring 1.2 cm by 1 cm by UTD. R1's medical record does not contain any additional wound measurements or descriptions. R1's March 2021 POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/23/21 at 3:25 pm, V9 LPN (Licensed Practical Nurse), R1's scheduled nurse, stated V9 does not do the treatments for V9's assigned residents. V9 stated the facility normally has a float nurse that does them but that there was miscommunication as to who was going to do it today, it will either be V17 RN (Registered Nurse) or V18 RN. On 3/23/21 at 3:55 pm, V9 LPN and V13 CNA (Certified Nursing Assistant) entered R1's room. R1 did not have a dressing covering R1's pressure ulcer to the left buttocks, and was incontinent of stool. R1 has two pinpoint open areas that scabbed over and a larger area underneath that is red and scabbed {measuring 1.2 cm by 1 cm according to Weekly Wound Tracking}. V9 confirmed R1 did not have the ordered dressing in place and stated, it was due to the miscommunication earlier in the shift as to who was going to complete it, and not sure how long R1 had been without a dressing. V13 CNA provided incontinent care to R1 with a disposable wipe, wiping over the entire buttocks, including the pressure ulcer three times, with the wipe that was soiled with stool and contaminating the wound. V13 stated at 1:30 pm when V13 provided cares to R1, R1 did not have a dressing on the wound. V9 and V13 adjusted R1 in bed and V9 again stated that V18 RN would be completing R1's treatment later. R1's March 2021 TAR (Treatment Administration record does not document R1's treatment as being completed on 3/12/21, 3/19/21, or 3/22/21. On 3/24/21 at 9:30 am, R1 was lying in bed, slightly on right side when V24 RN and V25 entered R1's room to complete the ordered dressing change. R1's incontinence brief was saturated with urine and had stool in it. V24 donned gloves and removed the soiled dressing to reveal, 2 scabbed pin point open areas to the left buttock and the larger pressure ulcer that is now 100 percent covered in white slough. V24 changed gloves but did not perform hand hygiene, then proceeded to clean the pressure ulcer and surrounding tissue with 4x4 gauze and wound cleanser. V24 then sat the used/contaminated 4x4 used to cleanse the wound, on the clean surface next to the bordered foam dressing. Without performing hand hygiene or changing gloves, V24 then applied hydrogel to the wound (2 pin point areas and 1 larger area covered in white slough) V24 confirmed covered in slough, and not able to see the wound bed. V24 then applied the new foam dressing. On 3/24/21 at 9:40 am, V24 RN confirmed V24 did not perform hand hygiene and stated, I (V24) should have brought alcohol {hand gel} in with me. I (V24) knew I (V24) was missing a step. V24 also confirmed she sat the soiled 4x4 gauze used to clean R1's wound on the clean surface next to the new sterile dressing, potentially contaminating the new dressing. On 3/24/21 at 12:14 pm, V30 Physician stated V30 was aware of a small open area that they were using hydrogel on, but had not been notified that it was deteriorating, and should have been. The main thing for healing wounds, is to keep the wound clean and free of infection, off load the area and good nutrition. V30 stated if the wound is getting worse, R1 needs to off load the pressure to the area in order for it to heal, and with R1's non-compliance at times, an air mattress would be a alternative that the facility could try to relieve that pressure. V30 also stated that whatever the RD (Registered Dietician) recommended would have been put into place to help with the nutritional needs for wound healing. Ultimately though, if you don't get rid of the pressure, the wound will not heal. On 3/24/21 at 1:38 pm, V29 RD stated V29 found in R1's notes that R1 had a new open area on R1's bottom but did not have actual information on the type or stage of the wound. Based on R1's intake history, and the wound being new, V29 did not feel R1 needed any extra recommendation. V29 stated, had I (V29) received wound measurements, like I (V29) use to get from ((V20) Previous DON, Director of Nursing)) I (V29) would have seen the wound was deteriorating and recommended liquid protein, extra protein at a meal, protein snacks and/or oral nutritional supplements. Good nutrition will definitely contribute to wound healing. On 3/24/21 at 3:30 pm, V2 Acting DON stated wounds are to me assessed and measured weekly. V2 stated V2 was aware that was not being done but that V2 is trying to do V2's job; care plans and working the floor, then also trying to assist with DON duties. V2 also stated that V2 was not able to find a policy on wound assessments, wound treatments, or on unstageable pressure ulcers. The facility Hand Washing and Gloves Policy dated 7/30/15 documents, hands must be washed after removal of gloves. The facility Hand Sanitizer Policy dated 3/6/20 documents, hand sanitizer should be used after contact with blood, body fluids, or contaminated surfaces. 2.) On 3/23/21 at 3:35 pm, R4 was lying in bed on R4's back, on a regular mattress, and stated R4 has a bony butt and might have an open area. R4's Weekly Wound Tracking Worksheet dated 3/2/21 documents R4 has a sacrum wound measuring 0.5 cm (centimeters) by 0.5 cm by 0.1 cm that is covered with 100 percent epithelial tissue. R4's medical record does not contain any additional wound measurements or descriptions until 3/23/21. R4's Weekly Wound Tracking Worksheet dated 3/23/21 documents R4's coccyx/sacral wound has deteriorated and is now an unstageable pressure ulcer measuring 2 cm by 1 cm by UTD (unable to determine). On 3/24/21 at 1:22 pm, V29 RD (Registered Dietician) stated V29 reviewed R4's pressure ulcer on 3/3/21, and recommendations were made. V29 stated V29 was reviewing facility wounds again on 3/17/21 and when V29 asked for the wound reports, V29 was informed that they were not available and hadn't been completed due to V20 Former DON (Director of Nursing) no longer working at the facility. V29 stated had V29 known R4's wounds were worsening, V29 would have recommended enhance potatoes and cereals to give R4 more protein, along with a liquid protein supplement wound healing. V29 stated, good nutrition would contribute to wound healing. On 3/24/21 at 3:30 pm, V2 Acting DON (Director of Nursing) stated wounds are to me assessed and measured weekly. V2 stated V2 was aware that was not being done but that V2 is trying to do V2's job; care plans and working the floor, then also trying to assist with DON duties.

Failures at this level required more than one deficient practice statement. A. Based on record review and interview the facility failed to implement a targeted fall prevention intervention and failed to assess for the safe use of an electro-mechanical lift chair for R5 prior to a fall that resulted in R5 sustaining a hip fracture; the facility failed to provide a safe transfer for R6 and R10. These failures affect two of four residents (R5, R6) reviewed for falls on the sample of eight residents and one resident (R10) on the supplemental sample. B. Based on observation, record review and interview the facility failed to maintain hot water accessible to residents at handwashing sinks at a safe temperature to prevent burns for four (R1,R2, R6, R7) residents on the sample of eight reviewed for environment and five ( R3, R4, R14, R10, R15) residents in the supplemental sample. Findings include: a) 1) R5's physician's orders [REDACTED]. The POS also documents [REDACTED]. R5's Fall Risk assessment dated [DATE] documents R5 is at high risk for falls. R5's Care Plan documents R5 is at high risk for falls related to history of falls and history of vertigo. R5's care plan documents a fall prevention intervention on 9/23/15 for R5 to have a personal alarm at all times. R5's Transfer Lift assessment dated [DATE] documents R5 is able to stand for four (4) seconds unassisted. R5's Minimum Data Set ((MDS) dated [DATE] documents R5 was cognitively intact and independently ambulatory with use of a walker. R5's MDS dated [DATE] documents R5 had moderate cognitive impairment and required the assistance of one staff for transfers and ambulation. Z1's (R5's physician) notes dated 11/1/15 documents .vascular dementia .very confused to time or place . R5's Incident Note dated 11/15/15 at 6:30 am documents Resident (R5) was found lying on floor. Head to toe assessment performed with findings of left leg pronation and report by resident of left leg pain . The note documents R5 was transferred to the hospital by ambulance. R5's The Story of My Fall dated 11/15/15 documents (R5) stated (R5) was getting up from recliner back to bed. The report documents Alarm not on resident (R5). On 8/21/16 at 1:08 pm E6, Certified Nursing Assistant (CNA), stated E6 stated E6 found R5 on the floor (on 11/15/15) with R5's electric lift recliner in the up position and R5's alarm was not sounding. E6 stated R5's left leg hurt. E6 stated R5's alarm was not in place and was supposed to be. On 8/21/16 at 2:15 pm and 8/23/16 at 2:02 pm E4, Licensed Practical Nurse (LPN), stated R5 had a fall on 9/23/15 and R5's fall prevention intervention was to have a personal alarm at all times. E4 stated when R5 fell on [DATE], R5 did not have the alarm on. E4 stated R5 was to have the alarm on at all times to alert us when R5 is getting up. E4 also stated E4 was not aware of any assessment for R5's safe use of an electric recliner. R5's Medical Record did not have an assessment for R5's safe use of an electric recliner nor was there any documentation of R5's ability or inability to safely use the electric recliner. On 8/23/16 at 3:30 pm E2, Director of Nursing, and E4 confirmed that assessments are not performed for residents that have an electric lift recliner and there is no policy/procedure regarding the use of lift recliners. On 8/23/16 at 9:20 am E11, Physical Therapy Assistant, stated R5 had alarms because (R5) was prone to get up by herself. R5's Progress Notes dated 11/15/15 at 9:07 am documents Spoke with (hospital) ER (emergency room ) nurse res. (resident, R5) being admitted to (hospital) DX (Diagnosis): FX (Fracture) Left hip. R5's Hospital Report dated 11/15/16 documents R5 was hospitalized for [REDACTED]. On 8/23/16 at 2:20 pm Z1, Physician stated from what I can tell from the notes R5 did sustain the hip fracture from a fall at the facility on 11/15/15. The Fall Policy dated 8/21/14 documents The resident's environment will remain free from accidents and hazards as possible; and each resident will receive adequate supervision and assistance devices to prevent accidents .Interventions will be listed on care plan and individualized to each resident according to risk after each fall .Possible interventions .Body/pressure alarms. a) 2. On 8/22/16 at 11:00 am the door to R6 and R10's room was closed. E10 Certified Nurse Aide (E10) responded to the knock on the door stating it was alright to enter the room. R6 was at the bedside in a reclined geriatric chair. R10 was seated at the bedside in a wheelchair. Both R6 and R10 had mechanical lift slings beneath them. E10 stated that she had just finished transferring R6 from the bed to the geriatric chair and R10 from the bed to the wheelchair with the full mechanical lift that was in the room. E10 confirmed that she had transfered R6 and R10 by herself using the lift. E10 stated alot of times she operates the lift alone. E10 stated the facility policy is to use two staff for mechanical lift transfers. E10 stated I forgot to ask (E2, Registered Nurse/Director of Nurses) to help me with the transfers. On 8/22/16 at 11:15 am E2 confirmed that mechanical lift resident transfers were to be done utilizing two staff. E2 stated (E10) should have asked me to help her with the transfers. R6's quarterly MDS dated [DATE] identified R6 had severe cognitive impairment and required total assistance of two staff for transfers. R6 is assessed as non ambulatory. The Care Plan dated 7/20/16 stated that R6 was at high risk for falls related to cognition, history of falls, and being non ambulatory. R6 also has a Right Above the Knee Amputation.The care plan states The resident requires a mechanical lift (total) with two staff assistance for all transfers. R10's MDS dated [DATE] documented R10 had moderate cognitive impairment and required extensive assist of two staff for bed mobility and transfers. R10's care plan dated 6/18/16 for transfers stated The resident requires the use of the mechanical lift for all transfers, except for toileting with a staff assist of two .(R10) is resistive to care at times, toileting. R10's Transfer assessment dated [DATE] also stated a total lift with two staff members was required. E10 stated on 8/22/16 at 11:10 am that E10 was one of a few CNAs who can use the lift by herself. The facility Mechanical Lift Policy dated 1/18/13 states the purpose was To transfer a resident who is unable to transfer independantly safely from the bed to chair, chair to commode or toilet, or chair to bed. These residents are not able to stand independently or may be unsteady and require assistance from a mechanical lift and staff Procedure: 1. Identify need of resident needing a mechanical lift and which lift is appropriate: sit to stand lift or total lift. 2. 2 staff members with transfer with a total mechanical lift b) 1. On Sunday 8/21/16 at 9:45 am the hot water at R7's bedroom handwashing sink was 117 degrees Fahrenheit (F.). The water was very hot to the touch. R7 was not present at the time. R7's 6/6/16 quarterly Minimum Data Set (MDS) documents R7 has severe cognitive impairment , and is independent in ambulation and activities of daily living (ADLs). R7 was independently ambulatory through out the day in the building on 8/21 at 8:50 am, 10:40 am, and 4:00 pm. 2. On 8/21/16 at 9:50 am the hot water at R4's handwashing sink was very hot to the touch and measured 118 degrees F. The sink was equipped with a single faucet that is adjusted to the left (hot) or right (cold) to adjust the temperature. R4 stated at that time, The water is hot! I know it! 3. On 8/21/16 at 9:55 am the hot water at R2's handwashing sink measured 117 degrees F. R2 was not in the room at the time. R2's MDS dated [DATE] assesses R2 as having severe cognitive impairment and requires extensive assist for ADLs. On 8/22/16 at 9:00 am the hot water at R2's sink measured 116 degrees F. On 8/22/15 at 9:30 am R2 propelled his wheelchair slowly down the hall. 4. On 8/21/16 at 10:00 am the hot water at R14's handwashing sink measured 117 degrees F. On 8/22/16 at 9:05 am the hot water was 117 degrees F. R14 stated I know it's hot, I know how to mix it. 5. On 8/21/16 at 10:05 am the hot water at R15's handwashing sink measured 117 degrees F. R15 was laying in his bed. R15 stated I get plenty of hot water if I want it. R15 stated he is able to propel himself in the wheelchair to get to the sink. 6. On 8/22/16 at 9:00 am the hot water at R1's handwashing sink measured 117 degrees F. R1 stated at that time Sometimes it get real hot right away and other times you have to wait, I know how to adjust it. 7. On 8/21/16 at 9:55 am the hot water at the sink shared by R6 and R10 measured 116 degrees F. R10 stated she is capable of accessing the handwashing sink when in her wheelchair. R10's quarterly MDS dated [DATE] documents R10 has moderate cognitive impairment. 8. On 8/21/16 at 10:20 am the hot water at the sink in the C wing shower room measured 115 degrees F. Certified Nurse Aide E6 stated at that time the water gets very hot at some of the resident handwashing sinks but not all of them. E6 stated a night shift aide checks the hot water temperature of the shower and writes it on the log in the shower room. 9. On 8/22/16 at 8:55 am the hot water at the public restroom near the dining room measured 117 degrees F. and was very hot to the touch. R7 was independently using the public restroom on 8/22/16 at 8:30 am and on 8/21/16 at 10:00 am. On 8/21/16 at 10:50 am the hot water temperatures were discussed with E5 Housekeeper/Activity Director, who stated she is responsible for checking hot water temperatures at resident handwashing sinks on the morning shift and the afternoon and evening shifts during the week Monday-Friday. E5 does not work weekends. E5 had a August 2016 Water Temperature Sheet for Handwashing Sinks. The documentation showed that on 8/1-5, 8/8-12, 8/15-19, and 8/21/16 the morning temperatures were taken at R8's bedroom sink and the afternoon temperatures were checked at R3's room. All were recorded between 103-104 degrees F. E5 confirmed she monitors hot water at the same two sinks each day. E5 stated she was told the water is all on the same line so the temperatures should be the same. E5 stated she took the temperature this morning at (R8's) room was 103 F. On 8/21/16 at 10:55 am E5 used the facility digital thermometer and compared it to the surveyor's digital thermometer under running water. E5 was only placing the very tip (1/4 inch) of the thermometer probe in the water instead of emersing the probe to the sensor notch 1/2 inch into the water stream. When E5 fully immersed the probe the thermometers were within a half degree of each other. E5 used her thermometer and confirmed that the hot water at R8's sink was 115 degrees F., E5 stated the water was too hot the range was 90-110 degrees F. E5 stated the difference in temperatures must be that E5 lets the water run for a while first and then only was putting the very tip of the thermometer in the water. On 8/22/16 at 9:00 am -9:15 am E5 accompanied the surveyor and confirmed that hot water at resident sinks for R1, R2,R7, R8 and R14's rooms were between 116-118 degrees F. On 8/22/16 9:50 am E8 Maintenance Director stated that the hot water to resident rooms is provided by a boiler located in the boiler building. E8 stated he documents the hot water temperature at the mixing valve during the weekdays which runs between 115 and 125 degrees F. E8 stated by the time the water reaches the resident rooms the temperature should be below 110 degrees F. E8 stated the nursing and housekeeping staff check the water temperatures at the resident room sinks and the shower. E8 was not aware that E5 was only checking two rooms on the wing. E8 stated that different rooms should be tested each day when monitoring hot water temperatures. E8 was informed that the water temperatures were elevated (116-118 degrees F.) on 8/21/16. E8 stated he did not work on Sunday 8/21/16. On 8/22/16 at 10:00 am the gauge after the mixing valve for the boiler was reading 125 degrees F. E8 stated I came in (8/22/16) this morning and made an adjustment to the mixing valve. It could take several hours for the water temperature to come down. The facility policy Water Temperatures on Bathing Units dated May 2003 states Water temperatures shall be between 100 degrees and 110 degrees Fahrenheit. Any temperatures recorded outside of this range shall be reported to the Maintenance Department .If the temperature is outside of the above range by more than 2 degrees (such as 112.5 degrees) notify maintenance immediately by activating the maintenance pager Intent: To make sure that water temperatures remain within proper ranges, so that resident's comfort and safety is assured. E8 Maintenance Director stated on 8/22/16 at 3:00 pm stated policy just addresses bathing locations however the same parameters apply to handwashing sinks.

Based on record review and interview, the facility failed to provide adequate supervision for one of three residents sampled for falls (R1), by failing to maintain use of the gait belt throughout ambulation and transfer, resulting in a fall. This fall caused a fracture of the humerus. Findings include: According to admission records and the current physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] also lists a [DIAGNOSES REDACTED]. The MDS states R1 is only able to stabilize with human assistance. The facility listed R1 as interviewable. The Occurrence Report dated 4/3/12 stated the following: "Aid was walking resident with gait belt and walker, following with w/c (wheelchair); Res. (resident) walking to DR (dining room) table for breakfast. Became distracted and tripped over her own foot, fell forward onto left side (hit head on table and possible floor also). Resident states she heard loud cracking in the left upper arm when she hit the floor. .. ." R1 was sent to the hospital where she was found to have a fracture of the left proximal humerus, according to the Orthopedic follow-up notes dated 4/1/12. The Occurrence Report states that the incident was probably caused by "Resident distracted while walking to dining room to sit down for breakfast; distracted and stopped paying attention to her walking." The Care Plan Intervention on this report was to "Remind to stay focused on walking while walking res." On 4/12/12 at 8:40 a.m., R1 was in the room in the wheelchair with a sling on her left arm. R1 was alert and oriented. R1 stated regarding the incident that she was walking to the dining room with her walker with E4 (Certified Nurse Aide/CNA) following behind her and pushing the wheelchair. "I told her (CNA) I couldn't go any further, but she said to try a little further. The next thing I know the floor was coming up and I was on my face. I heard a crack in my left arm. . . .I had a gait belt on but she (CNA) wasn't holding on to it" R1 stated that the doctor told her the break was "too high up" to do surgery so she has the sling. R1 states the fracture "is a real setback", she had been able to use the bathroom and do hygiene more by herself. Now R1 has to use a mechanical lift and is in therapy again. Z1 (friend) stated on 4/12/12 at 10:30 a.m. after the incident he asked E4 what happened and E4 said, " I felt so bad because I couldn't grab her belt in time." The written statement by E4 states that E4 ". . .heard {R1} sigh. I said; "You're almost there. Do you want to keep going? She didn't answer just kept walking. We got to the table . I asked her if she wanted to sit in a chair or her wheelchair. So I let go of the gait belt and prepared to brace the wheelchair. . ." At that time, E8 (dietary staff) poured coffee at her table. R1 "called out for {E8} to leave the coffee pot, taking a step forward instead of sitting down. Distracted and in a hurry, she tripped over her own feet." Other written statements by E9 (CNA), E7 (nurse), and E3 (nurse) state that they heard E4 "yell" and call out R1's name prior to the fall. E8's statement said that R1 was walking with her walker and E4 was "pushing the wheelchair behind her." On 4/12/12 at 10:50 a.m., E4 confirmed her written statement that she did offer R1 the opportunity to stop and sit down. E4 stated that she was holding the gait belt as they were walking, and pulling the wheelchair behind. Then when at the table, E4 confirmed that E4 let go and was not holding on to the gait belt at the time of the fall. The approach for R1's Restorative Program Lookback Documentation for the Walk to Dine program for 1/12 and 2/12 states, "Ambulate 25 feet to dining room at meal time with walker, gait belt and stand by assist. Increase distance as tolerated." On 4/12/12 at 2:00pm, E2 (Director of Nursing) stated that this means that staff would hold on to the gait belt as stand by assist for walking and transfers. E2 stated that she was not aware that E4 had let go of the gait belt. E2 thought that R1 had just tripped over her feet. The current POS confirms that R1 now is transferred by mechanical lift. Nurses notes and POS dated 3/21/12 also indicate that R1 developed two open areas on the left buttock. Facility policy/procedure for gait belts, dated 3/1/10, states that "Gait belts are to be used on every transfer unless medically contraindicated. . . .grasp belt at residents back and to the side - stand as close to resident as possible. If resident begins to fall, do not try to prevent the fall. Guide the resident to the floor by bending your knees. . ."