Every finding on record at Grove of Fox Valley,The

Based on observation, interview and record review, the facility failed to ensure that a resident identified as dependent on for ADLs (Activities of Daily Living) was protected from sustaining burn injuries.This applies to 1 of 3 residents (R1) reviewed for resident injuries in the sample of 3.This failure resulted in R1 being transferred to the local emergency room on July 7, 2026 and then was transferred to the regional specialty burn center on July 8, 2026. R1 was admitted to the regional specialty burn center from July 8 through July 10, 2026 with 3% mixed thickness burns on the anterior trunk and left thigh.The findings include:R1 was originally admitted to the facility on [DATE], and was recently readmitted from the hospital to the facility on July 11, 2026. R1 had multiple diagnoses including cerebral infarction due to unspecified occlusion or stenosis of the left middle cerebral artery, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, anemia, type 2 diabetes mellitus, dysphagia following cerebral infarction, and burn of unspecified body region and unspecified degree (March 27, 2026), based on the face sheet.R1's Annual MDS (Minimum Data Set) dated July 1, 2026 showed that the resident was severely impaired with cognitive skills for daily decision making. The MDS showed that R1 had functional limitation in ROM (Range of Motion) to both sides of her upper and lower extremities and required maximum assistance from the staff for oral hygiene, upper body dressing, personal hygiene and for transfer from sitting to lying. The MDS showed that R1 required total assistance from the staff for toileting hygiene, shower/bathing, lower body dressing, for transfers from chair to bed and vice versa using sit to stand mechanical lift. The same MDS showed that R1 receives nutrition via feeding tube.R1's progress notes dated July 7, 2026 at 6:30 AM, created by V8 (RN, Registered Nurse) showed that at around 2:30 AM, the resident was observed scratching her left lower abdomen toward the groin area. Upon nursing assessment, the resident was incontinent. The previous dressing that was on the left lateral abdomen was soiled and one the of GT (Gastrostomy Tube) port was noted to be leaking. The progress notes documented that a universal valve was added for reinforcement and to cap off the GT port. It was further documented that R1's linens and brief were changed, and dressing to the left lateral abdomen was replaced.R1's progress notes dated July 7, 2026 at 11:30 AM, created by V3 (In- house NP) showed in-part, Patient seen today for acute follow-up after nursing noted new skin lesions involving the left lower abdomen extending to the left flank/back with a distribution similar to the patient's previous third-degree burn injury. Patient has a recent history of a full-thickness abdominal burn of unknown etiology that had healed and was recently evaluated during follow-up at (Regional burn Center). Today, recurrent skin changes were noted without any known trauma, thermal exposure, or identifiable cause. Given the recurrence in a similar pattern and unclear etiology, the patient will be transferred to the emergency department for urgent evaluation and further workup. Patient remains in no acute distress with stable vital signs. History is limited due to expressive aphasia. Continues PEG (Percutaneous Endoscopic Gastrostomy) tube feedings with aspiration precautions.R1's skin/wound evaluation dated July 7, 2026 at 11:53 AM, created by V5 (Wound care Nurse) showed that the resident was assessed with a newly developed open area on the left lower abdomen described as full thickness, measuring 3 cm in length x 29 cm in width x 0.1 cm in depth with scant amount of serous drainage, and with another newly developed open area on the left upper thigh described as full thickness, measuring 3 cm in length x 27 cm in width x 0.1 cm in depth with scant amount of serous drainage. The same wound evaluation documented that R1 was experiencing pain to the open wound identified on the left lower abdomen and left upper thigh.R1's progress notes dated July 7, 2026 created by V11 (RN) showed that the resident was sent to the local hospital at 12:08 PM for evaluation and treatment of the skin alteration. At 4:12 PM, V11 documented that she spoke to the nurse at the local hospital where R1 was sent to and was informed that R1 was in the process of being transferred to the regional burn Center for 3rd degree burn.R1's progress notes dated July 8, 2026 at 12:23 PM, created by V3 (In-house NP) showed that per DON's (Director of Nursing) update, the night shift nurse noted that R1's GT had malfunctioned and had leaked. Patient noted with scratching to abdominal area. The change in skin condition is caused by the G-tube leaking.R1's progress notes dated July 9, 2026 at 4:06 AM, created by V3 showed that an update was made to the V20 (Physician at the Regional burn Center). V3 documented, Explained to [V20] that the G-tube malfunctioned and was leaking causing the change in skin condition. Verbalized understanding.R1's regional specialty burn center admission records dated July 8, 2026 showed in-part under HPI (History of Present Illness), (Patient) is nonverbal and confused at baseline. Per nursing home summary, new onset skin lesions were found on (left lower quadrant) abdomen and upper leg this morning by staff at nursing home. Similar lesions occurred in March 2026 when her g-tube was leaking. (Patient) was seen itching and rubbing leg and abdomen) by nurses as well. The same records under Discharge summary dated [DATE] showed that R1 was admitted for evaluation and management of a 3% mixed thickness burn involving the anterior trunk and left thigh. The discharge summary showed in-part, The etiology of the burn was unclear on admission, but subsequent input from the nursing home nurse practitioner indicated that the injury was likely secondary to overnight leakage of (gastrostomy) tube drainage, resulting in caustic injury from gastric and bilious contents pooling in skin folds.R1's progress notes dated July 13, 2026 at 8:30 AM created by V3 showed in-part, Resident returned from (Regional burn center) following treatment for 3% mixed-thickness burns involving the left lower abdomen, left flank, and left upper thigh, secondary to PEG tube leakage with gastric contents causing skin injury.R1's progress notes dated July 13, 2026 at 10:28 AM, created by V4 (visiting NP wound specialist) showed in-part, Patient was sent to hospital on [DATE]) after staff noticed new areas of skin breakdown. Originally documented burns to proximal and distal abdomen have resolved on today's visit. Per hospital records, new areas seem to be burns due to gastric acid leaking from patient's G-tube. V4 further documented, These wounds possibly presenting this way because patient's abdominal fold and thigh are constantly touching while she is in chair. Patient has a hard time lying flat, and these areas are also touching while in bed. R1's addendum notes created by V4 on July 13, 2026 at 4:02 PM documented the new skin breakdown, identified as wound # 8 located on the left lower abdomen, with primary etiology of 3rd degree burn, staged as full thickness, measuring 2 cm in length x 28 cm in width x 0.1 cm in depth with calculated area of 56 square centimeters. The left lower abdomen burn had 100% slough with light amount of serosanguineous exudate. Another new skin breakdown was identified as wound #10 located on the left upper thigh, with primary etiology of 3rd degree burn, staged as full thickness, measuring 2.0 cm in length x 33 cm in width x 0.10 cm in depth with calculated area of 66 square centimeters. The left upper thigh burn had 100% slough with light amount of serosanguineous exudate.On July 13, 2026 at 11:40 AM, R1 was sitting in her wheelchair inside the room. R1 had dressing on the left lower abdomen, left flank and left upper thigh areas. V5 (Wound Care Nurse) provided treatment to the above-mentioned areas. V5 stated that the left flank wound was identified as a burn that R1 sustained on March 22, 2026 while at the facility. According to V5 the left lower abdomen and the left upper thigh wounds were also identified as a full thickness burn during R1's recent hospitalization on July 7, 2026. During the treatment observation of R1's left lower abdomen and left upper thigh, it was noted that both wounds had 100% slough and were linear in shape. V5 stated that V4 (visiting wound specialist NP) had earlier evaluated R1 and the newly identified full thickness burns on R1's left lower abdomen and left upper thigh were measured.On July 13, 2026 at 4:37 PM, V9 (CNA, Certified Nursing Assistant) stated that he was the assigned staff for R1 on July 6, 2026 during the afternoon shift from 2:00 PM through 10:00 PM. V9 stated that he provided incontinence care to R1 on July 6, 2026 at around 8:30 PM, and there was no GT (Gastrostomy Tube) feeding ongoing at the time as well as no leaking coming from the GT. According to V9, R1 had no wound on the left lower abdomen and left upper thigh when he provided the care to R1. V9 further stated that after he provided care to R1 at around 8:30 PM, he did not go back to R1's room for any additional care and left the facility at around 10:00 PM.On July 13, 2026 at 4:18 PM, V10 (RN) stated that he was the assigned nurse for R1 on July 6, 2026 during the afternoon shift from 3:00 PM through 11:00 PM. V10 stated that he administered R1's GT feeding at 4:00 PM and 9:30 PM, each feeding lasting for one hour. V10 stated that during the GT feeding administration, no leaking was observed, and no wound was observed on R1's left lower abdomen. V10 stated that he did not check for any skin alterations on the resident's thighs. V10 further stated that R1's GT had two feeding ports and had only used one during the feeding administrations. According to V10, after R1's GT feeding at 10:30 PM, he detached the GT feeding tube from the resident's GT site and placed a cap on the feeding port that was used. V10 stated that he made sure that both GT feeding ports were capped and were not leaking when he left R1's room.On July 13, 2026 at 3:14 PM, V7 (CNA) stated that she was the assigned staff for R1 on July 6, 2026 during the night shift from 10:00 PM through 6:00 AM of July 7, 2026. V7 stated that the first time she provided incontinent care to R1 during her shift was on July 7, 2026 between 1:00 AM and 2:00 AM. V7 stated that V8 (RN) assisted her with providing incontinent care to R1. According to V7 it was during that time that she noticed that R1's GT feeding port was uncapped and it was leaking. V7 stated that she noticed R1's left abdomen had redness/pinkish discoloration with small blood. Per V7, V8 cleaned R1's left abdominal area and GT site and applied dressing.On July 13, 2026 at 3:38 PM, V8 (RN) stated that he was the assigned nurse for R1 on July 6, 2026 from 11:00 PM through 7:00 AM of July 7, 2026. V8 stated that there was no report from the previous shift about any new skin alterations of R1 and there was no report of any GT concerns, including leaking. V8 stated that during the start of his shift, R1 was sleeping in bed. At 2:30 AM, during his rounds, he noticed that R1 was smelling of stool and needed care, so she informed V7 (CNA). V7 asked him to assist with R1's incontinence care because the resident at times could be combative and would be pushing the staff. V8 stated that when they removed R1's cover and gown, he noticed that the one of the resident's GT port was uncapped and was leaking clear liquid which he believed was gastric contents. Per V8, R1 was not connected to GT feeding at the time. V8 stated that he got a cap which he called a stop lock to cover the open port and proceeded to assist V7 with the incontinent care. According to V8, he changed the soiled dressing of R1's left flank area which was a burn injury identified previously. V8 stated that he also changed the soiled dressing on R1's GT site. During the same interview, V8 stated that he noticed that R1 had a white tissue formation along the left lower abdomen which for him appeared as an old scar because it felt hard compared to the surrounding skin. V8 described the white tissue formation as non-draining, approximately 1 cm in length and more than 5 cm in width. V8 stated that he did not see any skin alteration on R1's left upper thigh. On July 14, 2026 at 10:35 AM, V11 (RN) stated that she was the assigned nurse for R1 on July 7, 2026 during the morning shift which started at 7:00 AM. V11 stated that she did not receive any report about R1's GT leaking nor did she received report of regarding R1 having new skin alteration. V11 stated that during the morning medication pass (no time given) she was called by V6 (CNA) to come and check R1. V11 stated that she immediately went to R1's room and saw that the resident had whitish linear discoloration on the left lower abdomen approximately 1 inch in length and 6 inches in width. According to V11 she also saw redness on R1's left upper thigh area, but she could not give approximated measurement of the skin alteration. According to V11, V5 (Wound care Nurse) was called and had assessed R1. V11 also stated that V3 (In-house NP) was in the building and saw the skin alteration and gave the order to send R1 to the hospital for further evaluation and treatment. Per V11, the whitish linear discoloration on R1's left lower abdomen and the redness on R1's left upper thigh area were new. During the same interview, V11 stated that on July 7, 2026 before the end of her shift she called the local hospital where R1 was originally sent to, and she was informed by the nurse that R1 had a third-degree burn and was in the process of being sent to the regional specialty burn center for further management.On July 14, 2026 at 12:43 PM, V2 (DON, Director of Nursing)) stated that R1's first burn injury sustained on March 22, 2026 was likely due to contact with gastric contents per the NP of the regional burn center unit and was not likely due to hot beverage spill because R1 was on NPO (nothing per mouth) and was receiving gastrostomy tube feeding. According to V2, based on the facility's investigation of the second burn injuries sustained on R1's left lower abdomen and left upper thigh identified on July 7, 2026, the said burn injuries were sustained due to leaking of the gastric contents observed during the early morning of July 7, 2026 by V8 (RN). According to V2, the GT had leaked because one of the GT port was not covered, causing the gastric contents to leak out and pool to R1's skin. Additionally, V2 stated that R1 did not receive hot water baths on July 6 and July 7, 2026.On July 14, 2026 at 2:16 PM, V3 (In-house NP) stated that she was in the facility on July 7, 2026 at around 11:00 AM, when she was called by the nurse to assess R1's left lower abdominal area. Upon evaluation she noticed that R1 had a newly developed lesion on the left lower abdominal area which extended to the resident's left flank/back area. V3 described the lesion as two white marks almost on top of each other and were linear in appearance. V3 stated that R1's abdominal folds and abdominal area had excoriation. According to V3 the newly developed lesion on R1's left lower abdominal area appeared similar to the third degree burn injury that R1 sustained on March 22, 2026 on her left flank/back area, and because of this similarity she called R1's primary care physician (V21) to inform of the skin condition and they (V3 and V21) both agreed to send R1 to the hospital for further evaluation and treatment. V3 stated that she was informed by the facility that based on their investigation the newly developed burns on R1's left lower abdomen and left upper thigh identified on July 7, 2026 at the hospital were caused by R1's GT leaking, causing the gastric acid/contents to injure the skin. With the said information, she (V3) called V20 (Physician at the regional specialty burn center) to inform that the burn was caused by the gastric acid/contents from the leaking GT, to which V20 responded, It made sense. During the same interview, V3 stated that gastric contents are acidic and can cause burns, especially if the skin was exposed for some time. V3 stated that since R1 was [AGE] years old with fragile skin and had history of massive stroke, she (V3) cannot be certain how long of exposure it will take to burn R1's skin.On July 15, 2026 at 10:06 AM, V4 (visiting NP wound specialist) stated that she had monitored and treated R1's left flank/back area third-degree burn. V4 stated that the said burn was resolved as of July 13, 2026. V4 stated that she initially evaluated R1's newly identified third-degree full thickness burns on the left lower abdomen and left upper thigh on July 13, 2026. According to V4 the newly identified burns on R1's left lower abdomen and left upper thigh per hospital records seemed to be due to gastric acid leaking from the resident's GT. V4 stated that gastric acid is quite potent when exposed to a fragile skin such as R1's. Because of R1's old age and multiple comorbidities, it will not take long exposure time for the gastric acid to burn the resident's skin.

Based on observation, interview and record review, the facility failed to protect a resident dependent on staff for all ADLs (Activities of daily Living), from obtaining full thickness burns on the left side of her torso and partial thickness burns that extended from left upper back to top of the left thigh. This applies to 1 of 3 residents (R1) reviewed for wound care in the sample of 5. This failure resulted in R1 being transferred from the facility to the local emergency room on March 22, 2026, and then transferred to the regional specialty burn center. R1 was admitted to the regional burn center from March 23 through March 26, 2026, with 3% full thickness burns to the left abdomen/flank area with partial thickness burns surrounding the 2 areas of full thickness burn wounds from the left upper back to the left upper thigh. The Findings include:On April 17, 2026, at 4:02 PM, V18 (APN-BC, Advanced Practice Nurse, Board Certified from the Regional Burn Center) stated R1's burn injuries included 2 separate full thickness burn wounds on the left torso flank area and was surrounded by partial thickness burn wounds in a linear pattern of distribution from the left upper back to the left upper thigh. V18 stated the facility explanation of the burn injury being caused by a lotion or use of heparin did not explain the pattern or extent of the burn injury to R1. V18 explained due to R1's age ([AGE] years old) with R1's comorbidities, R1's skin was more fragile and much thinner than an average adult and R1's skin could be injured more easily. V18 stated the mechanism of injury would be contact.V18 stated due to R1 being NPO (Nothing by mouth) and having a gastrostomy feeding tube, there was less likelihood of R1's injury caused by a hot beverage spill and more likely due to contact with gastric contents or scalding from very, very, hot water temperature during bathing. R1's EMR (Electronic Medical Record) showed R1 was originally admitted to the facility on [DATE], and most recently readmitted to the facility on [DATE]. R1's record showed R1 had multiple diagnoses including cerebral infarction due to unspecified occlusion of the left middle cerebral artery with hemiplegia and hemiparesis affecting the right dominant side, dysphagia, type 2 diabetes, chronic diastolic congestive heart failure, and presence of unspecified burns. R1's MDS (Minimum Data Set) dated April 1, 2026, showed R1 was severely cognitively impaired and required substantial assistance with oral hygiene, rolling side to side in bed, and upper body dressing and dependent on staff for lower body dressing, bathing, toileting, and transfer and was fed by gastrostomy tube. On April 14, 2026, at 1:24 PM, V3 (R1's grandson) stated he had visited R1 on March 19, 2026, in the evening and had purchased an over the counter lotion for dry skin for R1. V3 stated he put R1's name on the bottle and left the bottle at the bedside in hopes staff would apply the lotion to R1's dry skin. V3 stated he did not apply the lotion but left the bottle at R1's bedside. V3 stated the next time he visited R1 was on Sunday March 22, 2026, in the afternoon. V3 stated when he arrived around 3:00 PM he was concerned because R1 was lying in bed and had not gotten up in the wheelchair which was unusual for R1. V3 stated he asked the facility staff why R1 was still in bed at that time in the afternoon and staff told him that R1 had been acting feisty and had not allowed staff to get R1 up that day. V3 explained R1 was not able to talk since R1 had the stroke but could communicate with gesture and facial expression. V3 stated he asked R1 why she had not gotten up that day and stated in response R1 turned her eyes away from him and V3 described he thought R1 was trying to express something was wrong but did not understand what R1 may be trying to say. V3 stated he left the facility around 4:00 PM when staff came to change R1's incontinence brief. V3 stated he received 3 calls after he left the faciity on March 22, 2026. V3 stated around 4:30 PM he received a voice mail message from a facility nurse that stated R1 had developed a rash on the left side of her abdomen but it was not serious. V3 stated the next call he received was around 7:30 PM from a different nurse who stated they were sending R1 to the emergency room per physician order due to the rash. V3 stated the next call he received was around 2:00 AM from the emergency room physician who stated R1 had 3rd degree burns to the left side of her abdomen but there was no explanation from facility staff as to how the burn injury had occurred. V3 stated on March 23, 2026, he spoke to the burn center physicians who had asked V3 how the burn injury had happened and V3 stated he had not been informed from the facility that R1 had sustained a burn injury and had only been told that R1 had a rash. V3 relayed that the physicians at the burn center had told V3 that the facility explanation of how the injury occurred was due to the lotion he had brought to the facility or a reaction from the use of heparin, that R1 had been receiving for months. V3 stated the burn center physicians told him neither of those explanations was the cause for the extent of the burn injury to R1. On April 17, 2026, at 9:04 AM, V19, (CNA) stated she was the caregiver for R1, on March 21, 2026, during the 10:00 PM to 6:00 AM shift. V19 stated it was the first time she had cared for R1. V19 stated she provided care to R1 without assistance and was unaware that R1 usually was provided care with 2 caregivers. V19 stated R1 refused to be repositioned and V19 had difficulty trying to change R1's incontinence brief. V19 stated R1 had a feeding tube that was leaking every time R1 attempted to provide care at 2:30 AM and 4:00 am. V19 stated she noticed the leaking liquid was dripping to the left side of R1's abdomen but was only able to wipe the liquid from the top of R1's abdomen. V19 stated she did not report the feeding tube leaking to the nurse because she thought the leaking was normal. R1's physician orders showed R1's enteral feeding orders initiated on January 8, 2026, was bolus feeding and flush scheduled for 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. There was no scheduled flush or feeding during the overnight shift. On April 15, 2026, at 2:37 PM, V7 (CNA) stated she assisted V6 (CNA) on March 22, 2026, around 4:00 PM, to change R1's incontinence brief. V7 stated R1 was lying on her left side when V7 came to change R1's incontinence brief. V7 stated R1 requires 2 staff during care due to R1 pushing at staff with both arms against staff and stated R1 was very strong. V7 stated she was on the left side of R1's bed and V6 was on the right side of R1's bed to change her. V7 stated as they turned R1 to position her on her back to change her, V7 noted the left side closure tab of the brief was wet, and when she removed the tab from the brief, she saw whitish and red discoloration of the skin on the left side of R1's abdomen and told V6 to go get the nurse. V7 stated she had never seen anything like that discoloration on the skin before. On April 15, 2026, at 2:54 PM, V6 stated on March 22. 2026, during the 2:00 PM to 10:00 PM shift, he was assigned to care for R1. V6 stated R1 required 2 caregivers when providing care and requested V7's assistance to change R1. V6 stated at the beginning of the shift, V3 was present and when V7 told V3 they were going to change R1, V3 ended his visit and left the room. V6 stated after they turned R1 from the left side to the back and V7 opened the brief, V6 stated V7 told him to go get the nurse right away. V7 stated he found V26 (Day shift RN) and V5 (Evening shift LPN) at the medication cart doing the change of shift count. V7 stated V26 and V5 came with him to the room. After looking at the discolored area on R1, V26 told V7 that R1 had a rash. V6 stated he had cared for R1 the day before, March 21, 2026, during the 2:00 PM through 10:00 PM shift and reported he did not see any skin discoloration or rash on the left side of R1's torso. V6 stated later in the shift, after dinner on March 22. 2026, V5 told V6 to prepare R1 to go to the hospital. On April 15, 2026, at 3:15 PM, V5 stated she was the nurse on March 22, 2026, 3:00 PM to 11:30 PM shift assigned to R1. V5 stated V26 informed V23 (NP-Nurse Practitioner for R1's attending physician) and sent a picture of the discolored area on R1's skin. V5 stated the area on R1's left abdomen and side had white and red discoloration with no blood present. V5 stated she received a call from V23 instructing V5 to send R1 to the hospital emergency room. V5 stated R1 was transferred to the local hospital emergency after ambulance transportation was arranged. V5 stated she notified V3 (R1's grandson) and V2 (Director of Nursing) of R1's transfer to the hospital. The facility provided documentation that showed R1 received bed baths and not showers and the last bed bath R1 had received occurred on March 19, 2026. On April 15, 2026, at 1:56 PM, V13 (CNA) stated she formerly worked at the facility and gave R1 a bed bath on March 19, 2026, during the day shift and was assisted by V15 (CNA). Both V13 and V15 stated the water used to bathe R1 was a comfortable temperature. On April 16, 2026, at 2:15 PM, V1 (Administrator) and V2 (Director of Nursing) reviewed images of R1's burn injury taken on March 22, 2026, at the local emergency room and images taken on March 23, 2026, at the regional burn center, and each stated they had not viewed images of R1's burn injury previously. V1 stated the facility was informed on Monday, March 23, 2026, by the regional burn center that R1 had sustained a burn injury in the facility. V1 stated she and V2 went to the room R1 had resided in and did not see a heating pad or were able to identify any source for R1's injury. V1 stated they started an investigation. V1 and V2 stated the only conclusion they reached was that R1's burn injury was caused by the over the counter lotion or administration of heparin. On April 16, 2026, at 2:35 PM, V23 (NP) reviewed image of R1's burn injury taken on March 22, 2026, from the local emergency room and identified the wounds as a third degree full thickness burn. V23 stated the image from the emergency room was very similar, the lighting may have been different, to the image she had received from facility on the evening of March 22, 2026, prior to ordering R1 be sent to the hospital. The facility submitted a report to the department (IDPH) dated March 27, 2026, identified as the final investigation report of injury of unknown origin to R1. The report showed 6. Harm sustained, if applicable: Describe any type of physical injury. Indicate if none. The facility's documented response was none. The facility's report concluded that R1's burn injury was caused by the over the counter lotion or the administration of heparin and implicated V3 had potentially applied the over the counter lotion to R1. The facility's report also showed that all staff interviewed denied applying the lotion or had knowledge the lotion was in R1's room. The facility's policy titled Hazards reviewed June 30, 2025, showed It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents.

Based on interview and record review, the facility failed to thoroughly investigate the circumstances surrounding an injury of unknown origin, in accordance with facility policy, when a resident dependent on staff assistance for all ADL's (Activities of Daily Living) sustained a burn injury to the left side of her body. This applies to 1 of 3 residents (R1) reviewed for wounds in the sample of 5. The findings include:The facility filed a final report dated March 27, 2026, regarding an injury of unknown origin sustained by R1. The report showed V1 (Administrator) was informed by V2 (Director of Nursing) on March 23, 2026, that R1 had been hospitalized for medical evaluation of redness and open area to her abdomen and redness to her left flank area. R1's MDS (Minimum Data Set) dated April 1, 2026, showed R1 was severely cognitively impaired and required substantial assistance with oral hygiene, rolling side to side in bed, and upper body dressing and dependent on staff for lower body dressing, bathing, toileting, and transfer and was fed by gastrostomy tube. On April 16, 2026, at 2:15 PM, V1 and V2 both stated they had not previously viewed images of R1's burn injury nor had discussed with the Health Care Providers at the regional burn center, where R1 was treated, the extent or most likely cause of the burn injury R1 had sustained while in the facility. The facility's final report showed V1 interviewed V23 (R1's Nurse Practitioner ) and V23 opined that heparin injections may cause hypersensivity or bruising on the skin and may cause chemical burns. V1 documented that R1's physician opined that an over the counter lotion that contained alpha-hydroxy acid may cause a chemical burn. The final report also showed that no staff interviewed applied the over the counter lotion to R1 and most were unaware the lotion was in R1's room. The facility's final report on a prescribed form, dated March 27, 2026, showed 6. Harm sustained, if applicable: Describe any type of physical injury. Indicate if none. The facility's documented response was none. R1's burn center record contained a Case Management Discharge Screening Evaluation dated March 24, 2026, showed that after obtaining information from the facility's hospital liaison that the likely cause of the burn injury was rash related or due to heparin use, the information was discussed with the burn service team. The Case Management note showed Per ongoing discussion with Burn Service, there is no circumstance in which (R1's) admitting injury can be confused with a rash nor would long-term Heparin injection cause a full thickness burn injury. On April 17, 2026, at 4:02 PM, V18 (APN-BC, Advanced Practice Nurse, Board Certified from the Regional Burn Center) stated R1's burn injuries included 2 separate full thickness burn wounds on the left torso flank area and was surrounded by partial thickness burn wounds in a linear pattern of distribution from the left upper back to the left upper thigh. V18 stated the facility explanation of the burn injury being caused by a lotion or use of heparin did not explain the pattern or extent of the burn injury to R1. V18 explained due to R1's age ([AGE] years old) with R1's comorbidities, R1's skin was more fragile and much thinner than an average adult and R1's skin could be injured more easily. V18 stated the mechanism of injury would be contact.V18 stated due to R1 being NPO (Nothing by mouth) and having a gastrostomy feeding tube, there was less likelihood of R1's injury caused by a hot beverage spill and more likely due to contact with gastric contents or scalding from very, very, hot water temperature during bathing. On April 17, 2026, at 9:04 AM, V19, (CNA) stated she was the caregiver for R1, on March 21, 2026, during the 10:00 PM to 6:00 AM shift. V19 stated it was the first time she had cared for R1. V19 stated she provided care to R1 without assistance and was unaware that R1 usually was provided care with 2 caregivers. V19 stated R1 refused to be repositioned and V19 had difficulty trying to change R1's incontinence brief. V19 stated R1 had a feeding tube that was leaking every time R1 attempted to provide care at 2:30 AM and 4:00 am. V19 stated she noticed the leaking liquid was dripping to the left side of R1's abdomen but was only able to wipe the liquid from the top of R1's abdomen. V19 stated she did not report the feeding tube leaking to the nurse because she thought the leaking was normal. V19 also stated she was interviewed during the investigation regarding the burn injury sustained by R1. V19 reported she informed the facility during the interview regarding R1's gastrostomy tube leaking during the shift worked on March 21, 2026. R1's physician orders showed R1's enteral feeding orders initiated on January 8, 2026, was bolus feeding and flush scheduled for 9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM. There was no scheduled flush or feeding during the overnight shift. The facility's final investigation report dated March 27, 2026, regarding an injury of unknown origin sustained by R1 contained an interview by V19. The investigation report did not include V19's statement regarding R1's gastric tube leaking during the overnight shift of March 21, 2026, prior to the burn injury discovered on March 22, 2026. The Facility's policy titled Care Guidelines for Accidents/Incidents dated February 1, 2026, showed Statement: The facility ensures the proper investigation and reporting of all accidents and incidents.Investigative actions: c. Assess the date, time location and circumstances surrounding the incident or accident .Injuries of unknown origin .Investigation must explore all possible risk factors /related circumstances related to the incident.

Based on observation, interview and record review, the facility failed to maintain urology recommendations for catheter changes, failed to prevent urinary tract infection, failed to change a catheter when needed, and failed to complete comprehensive assessment for indication of catheter use for residents with indwelling urinary catheter. This applies to 2 of 3 residents (R2 and R3) reviewed for catheter use in the sample of 5. The findings include:1. R2's EMR (Electronic Medical Record) showed R2 was admitted to the facility on [DATE], with multiple diagnoses including diabetes type 2, hemiplegia affecting the left non dominant side, benign prostatic hypertrophy, and chronic obstructive pulmonary disease. R2's MDS (Minimum Data Set) dated March 26, 2026, showed R2 was severely cognitively impaired and required assistance with ADLs including substantial assistance with eating, oral hygiene, personal hygiene and upper body dressing, and dependent on staff for toileting, bathing, lower body dressing, bed mobility and transfer. R2 had an indwelling urinary catheter for obstruction due to prostramegaly. R2's urology clinic progress note dated January 7, 2026, showed R2 had severe prostramegaly with an elevation at the base of the bladder and recommended catheter changes every 3-4 weeks at the clinic. The clinic progress note referred R2 to a urologist office closer to the facility for follow up care. On April 15, 2026, at 3:30 PM, V4 (LPN) stated while working the 2:00 PM -10:00PM shift on March 30, 2026, R2's sister approached V4 and complained R2's urine had a foul odor. V4 stated he changed the drainage bag and flushed R2's catheter with 50 cc normal saline. There was no physician order to flush the catheter. There was no documentation in R2's progress note on March 30, 2026. On April 14, 2026, at 3:08 PM, V17 (RN) stated while assigned to R2 on March 31, 2026, during the 3:00 PM-11:00 PM shift, V17 noted R2 had blood in the urinary drainage bag. V17 stated upon further assessment, R2 was complaining of pain in his genital area and V17 noted the securement device attached to the catheter was too taunt and causing pulling on the catheter. V17 repositioned the securement device, flushed the catheter, and obtained a urine specimen to be sent to the lab. V17 stated R2 expressed relief from the pain and there was no longer blood in the catheter after flushing and repositioning of the catheter. On April 15, 2026, at 3:08 PM, V4 also stated that on April 1, 2026, V4 worked the 2:00-10:00 PM shift and was assigned to care for R2. V4 stated R2's sister approached V4 and stated she wanted R2 sent to the hospital for a catheter change because she was unable to accompany R2 on an appointment to Chicago clinic for a catheter change. V4 contacted R2's Health Care Provider and received the order to transfer R2 to the hospital for a catheter change. V4 stated the next scheduled urology appointment was scheduled for April 21, 2026. R2 was transferred to the hospital on April 1, 2026, at 7:00 PM. V4 explained the day shift nurses make the follow up appointments. V4 stated the appointments that are scheduled are kept with the daily report. V4 stated he did not recall if R2 had a scheduled clinic appointment on April 1 and had no documentation to show past scheduled appointments. R2's progress note dated April 2, 2026, at 1:06 AM showed R2 was admitted to the hospital for cystitis and prostatitis. R2's progress note dated April 3, 2026, at 6:38 PM showed R2 was readmitted to the facility on antibiotics for a urinary tract infection. R2's EMR had no assessment completed for indication of indwelling urinary catheter use or ongoing assessment of need for use or plan for removal. On April 15, 2026, the facility was unable to provide a complete comprehensive assessment for catheter use upon request. R2's physician orders had no order to address catheter change. On April 15, 2026, at 10:35 AM, V2 (Director of Nursing) stated the last time R2's catheter was changed was January 27, 2026, in the local emergency room. V2 stated R2's next urology clinic appointment was scheduled for April 21, 2026. V2 stated R2 had a cystoscopy done on February 18, 2026, and was unsure if the catheter had been changed at that time. V2 was unable to provide documentation that R2 had catheter changes in the urology clinic every 3-4 weeks in accordance with the urology clinic recommendations, between January 27, 2026, and the next scheduled appointment on April 21, 2026. On April 14, 2026, the facility provided a list of residents who attended outside appointments from January 1 to April 14, 2026. R2 was listed as having attended appointments on January 7, 2026, and February 18, 2026. 2. R3's EMR (Electronic Medical Record) showed R3 was admitted to the facility on [DATE], with multiple diagnoses including cervical disc degeneration, adult failure to thrive, type 1 diabetes, uninhibited neuropathic bladder, and personal history of malignant neoplasm of the breast. R3's MDS (Minimum Data Set) dated March 10, 2026, showed R3 was moderately cognitively impaired and was dependent on staff assistance with ADLs including eating, oral and personal hygiene, bathing, dressing, toileting , bed mobility and transfer and dependent on staff for mobility. R3 had a sacral pressure ulcer stage 4 and an indwelling urinary catheter. On April 14, 2026, at 2:58 PM, R3 was observed lying in bed with indwelling catheter tubing that was cloudy in color and contained sediment. On April 15, 2026, at 10:00 AM, R3's catheter tubing appeared cloudy and contained sediment. V14 (LPN Wound Care Nurse) stated the catheter should be changed when the catheter stops draining or there is sediment in the tubing and added that catheter looks like it should be changed now. R3's physicians order dated March 4, 2026, showed to change the catheter and drainage bag when nonfunctioning. On April 15, 2026, The facility was unable to provide a completed comprehensive assessment for catheter indication of use and plan for removal of the catheter upon request. On April 15, 2026, at 10:35 AM, V2 (Director of Nursing) stated the expectation is for staff to change the urinary catheter when there are signs of obstruction, the catheter is not draining or there is sediment in the tubing. The facility's policy titled Indwelling Catheter dated June 30, 2025, showed 2. An indwelling catheter assessment will be filled out by the nurse.3. A physician's order will be obtained.4 A care plan for the use of the indwelling catheter will be made.9.An indwelling catheter may be changed PRN. Urine bag will be changed PRN.

Based on observation, interview, and record review, the facility failed to implement hand hygiene, wear PPE (personal protective equipment) when rendering care and handling linen. This applies to 5 of 5 (R59, R75, R22, R27, and R66) residents reviewed for infection control in sample 25. The findings include:. 1.R59's EMR (Electronic Medical Record) showed R59 was admitted to the facility on [DATE], with diagnosis of peripheral vascular disease, hypertensive heart disease, acquired absence of right leg below knee, anemia, and retention of urine. On 3/25/2026, at 8:58 AM V4 CNA (Certified Nursing Assistant) after applying for PPE (Personal Protective Equipment) entered room of R59 with supplies for incontinence care in hand. V4 Removed blanket, raised the bed to the appropriate height, and removed the soiled diaper. V4 used perineal wipes to clean resident in the front of perineal area. Turned residents to the side. Changed gloves did not complete hand hygiene and used perineal wipes to clean buttock area. V4 Changed gloves did not complete hand hygiene. Grabbed a clean diaper, bed pad, and fitted sheet. V4 removed soiled fitted sheet from half of the bed did not remove gloves did not complete hand hygiene. Applied clean fitted sheet, bed pad and diaper to other half of bed. V4 turned resident over to the alternate side removing soiled linen. V4 placed soiled linen on top of garbage can. V4 turned resident and applied clean sheet to the bed. V4 removed gloves, applied new gloves, did not complete hand hygiene. V4 removed PPE gown and gloves. Did not complete hand hygiene. Applied new gloves grabbed soiled lined took to soiled linen container in hallway without placing soiled linen in plastic bag for transport removed gloves did not complete hand hygiene. R59's care plan, dated 2/10/2026, showed R59 required EBP (Enhanced Barrier Precautions) related to left groin abscess. Interventions include: to change gown and gloves before caring for next patient. Ensure that gown and gloves are used during high-contact resident care activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. 2. R75's Electronic Medical Record (EMR) showed R75 was admitted to the facility on [DATE] with diagnoses including hypertension, diabetes mellitus, chronic kidney disease, paraplegia, and peripheral vascular disease. R75's Minimum Data Set (MDS) dated [DATE] showed moderately impaired cognition. The MDS further showed R75 is incontinent of bowel and bladder and requires total assistance with activities of daily living (ADLs), including perineal care. R75's care plan showed R75 is on Enhanced Barrier Precautions (EBP) related to an unstageable sacral pressure injury. On 3/25/2026 at 10:05 AM, V16 (CNA) was observed with R75 providing perineal care without wearing a gown. V16 did not perform hand hygiene before or after resident care. Following care, V16, while wearing the same soiled gloves, carried a bag of soiled linen into the hallway, opened the soiled utility room door, and discarded the items. V16 then removed gloves and did not perform hand hygiene. 3. R22's EMR showed R22 was admitted to the facility on [DATE] with diagnoses including multiple chronic ulcers of the lower extremities and atherosclerosis with ulceration. R22's MDS showed impaired cognition and incontinence of bowel and bladder. R22's MDS showed R22 requires substantial to total assistance with ADLs, including perineal care. R22's care plan dated 3/26/2025 showed R22 is on EBP related to multiple lower extremity wounds colonized with multidrug-resistant organisms (MDROs) as well as a left subclavian permacath (hemodialysis site). On 3/24/2026 at 10:40 AM, V18 (CNA) was observed with R22 providing perineal care wearing gloves only and without a gown. V18 did not perform hand hygiene before or after resident care. 4. R27's EMR showed R27 was admitted to the facility on [DATE] with diagnoses including osteoarthritis, atrial fibrillation, heart failure, diabetes mellitus, hypertension, major depressive disorder, and chronic kidney disease. On 3/25/2026 at 10:53 AM, V17 (CNA) was observed with R27 providing perineal care. Following care, V17 did not bag soiled washcloth and left them at foot of R27's bed, draped over the footboard and low air loss mattress pump. The soiled washcloths were observed to be in contact with R27's feet and bed linens. V17 then removed R27's soiled brief and did not place them in a bag. V17 then tossed the soiled brief across the bed over R27 toward the trash receptacle. The brief missed the receptacle and landed on the floor. V17 did not perform hand hygiene before or after resident care. 5. On 3/24/2026, at 11:22 AM V5 (LPN/Licensed Practical Nurse) walked in room with EBP sign on door to check blood sugar. V5 donned a pair of gloves, performed blood glucose check on R66. V5 failed to wash her hands after removing her gloves and before walking out of R66's room to touch the nursing cart. On 3/26/2026, at 8:57 AM V2 (DON/ Director of Nursing) said a EBP (Enhanced Barrier Precaution) sign hangs on the outside of the door with instructions for staff and visitors before entering. V2 said incontinence care is a high contact touch activity and staff should follow infection control practices. V2 said CNAs (Certified Nursing Assistant) should don PPE (Proper Protective Equipment) before entering room if EBP sign is posted on the door. V2 said if gloves get soiled during incontinence care the CNA should remove gloves and complete hand hygiene before applying new gloves. V2 said the CNAs should change gloves when going from dirty to clean and complete hand hygiene during incontinence care. V2 said the reason the CNA should perform hand hygiene after removing gloves is to minimize the risk of infection. V2 said dirty linen should be placed in a plastic bag and taken to dirty linen hamper. The CNA should remove gloves and perform hand hygiene. V2 said nursing staff should be doffing inside the room and preforming hand hygiene before coming out. The facility's policy title EBP Enhanced Barrier Precautions (EBP) dated of 9/16/2025, showed, purpose to reduce transmission of multi-drug-resistant organisms in the nursing home. EBP involves the use of gowns and gloves to reduce transmission of resistant organisms during high- contact resident care activities .1. The EBP requires the use of gowns and gloves during high contact resident care activities that provide opportunities to transfer XDRO's (Extensively Drug -Resistant) to staff hands and clothing. The facility policy titled Infection Prevention and Control dated 6/30/2025, showed the facility has established a policy to identify, record, investigate, control, test and prevent infections in the facility. 17. Hand hygiene must always be performed by staff before and after direct patient contact, and after each situation that necessitates hand hygiene. Alcohol-based hand rubs or hand washing for 20 seconds will be used.

Based on interview and record review the facility failed to have a process in place to ensure accuracy of a resident's personal blood glucose monitoring device and failed to accurately write parameters for a resident's blood pressure medication.This applies to 2 of 2 (R9 and R133) residents reviewed for quality care in the sample of 25.The findings include: 1.On 03/25/2026 at 2:05 PM, R133 stated he monitors his own glucose levels with his personal device and reports the result the nurse. R133 stated he has continuous glucose monitoring from a sensor attached to his skin that sends blood glucose levels to his personal cellular device. R133 stated he manages his device himself not facility staff. R133 stated the staff do not check his glucose levels with the facility device. On 03/25/2026 at 4:52 PM, V2 DON (Director of Nursing) stated R133 had not been assessed for using his personal glucose monitoring system. There is no physician order for R133 self-glucose monitoring. V2 DON stated the nursing staff should be utilizing the facility device to check and document R133's blood glucose levels. On 03/25/2026 at 5:45 PM, V20 RN (Registered Nurse) stated she and the nursing staff obtain R133's blood glucose levels from his device and document the results in the EMR (Electronic Medical Record). V20 stated R133 manages his own sensor and device, and the facility's nursing staff does not handle it. On 03/26/2026 at 12:35 PM, V5 LPN (Licensed Practical Nurse) stated the DON told her last night the nurses needed to start checking R133's blood glucose levels with the facility device. V5 stated she has no knowledge of how quality assurance monitoring is done on R133's device. V5 stated she did not know if R133 had been assessed for the competent use of his personal blood glucose monitoring device. V5 stated she did not know the name of R133's blood glucose monitoring device. V5 stated she did not have any instructions or policies for R133's blood glucose monitor device. On 03/26/2026 at 1:42 PM, V2 DON stated she was unaware the nursing staff were documenting the blood glucose reading from R133's personal device. V2 stated there is no facility policy for the use of R133 personal blood glucose monitoring system. V2 stated she did not have an instruction manual for R133's device and there had not been any staff training for R133's personal blood glucose monitoring device. R133's physician orders showed blood glucose to be monitored three times a day before meals. R133's current care plan states R133 is at risk for fluctuating blood glucose sugars due to diabetes mellitus. Interventions include blood sugar checks per physician's order. R133's MAR (Medication Administration Record) documents twenty blood glucose readings as sensors. The facility's policy Diabetes Management dated 6/30/25 showed it is the policy of this facility to provide optimal nursing care for diabetic patients to individualize teaching according to carefully assessed resident and family needs. Verify physician's order for this procedure. Follow the instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading. 2. R9's Physician Order Sheet (POS) showed an order dated 3/16/2026 for Metoprolol Succinate ER [Extended Release] oral tablet 24 hour 50 MG [milligrams] – Give 1 tablet by mouth one time a day. Hold if systolic blood pressure (SBP) greater than 110 or heart rate (HR) greater than 60. R9's Order Audit Report showed Metoprolol, prescription number 1459113, was dispensed on 3/17/2026 with directions to hold if systolic blood pressure greater than 110 or heart rate greater than 60. On 3/25/2026 at 9:10 AM, observation of R9's unit dose medication card (blister pack) labeled with prescription number 1459113 showed Metoprolol Succinate ER 50 MG tab with directions to give 1 tablet by mouth one time a day and to hold if systolic blood pressure greater than 110 or HR greater than 60. R9's Medical Professional Progress Note completed by V10 (NP-Nurse Practitioner) dated 3/17/2026 at 12:00 PM showed Continue Metoprolol ER – HOLD parameters noted.review order: likely should be hold if SBP < [less than] 110 or HR < [less than] 60.current order appears reversed). Under Medication Safety/Reconciliation Notes, V10 documented metoprolol hold parameters appear incorrect. Under Plan Summary, V10 documented clarify medication hold parameters and plan of care discussed with nursing staff. On 3/26/2026 at 11:00 AM, V10 (NP) stated she notified nursing staff and expected the order to be clarified. V10 stated the medication could be held when it should be administered, resulting in inadequate blood pressure or heart rate control. V10 further stated the medication could be administered when it should be held, placing the resident at risk for hypotension or bradycardia. On 3/26/2026 at 2:37 PM, V2 (DON-Director of Nursing) stated her expectation is that nursing staff carry out practitioner recommendations, including clarification of incorrect medication orders. V2 stated failure to carry out practitioner recommendations may result in medication errors and potential adverse effects to residents. The facility's policy titled Medication Pass (7/2/2025) stated it is the policy of the facility to adhere to all federal and state regulations with medication pass procedures.

Based on observation, interview and record review the facility failed to properly maintain a venous access device.This applies to 1 of 1 residents R94 reviewed for venous access devices in a sample of 25.Findings include:On 03/24/2026 at 11:03 AM, R94 displayed his left upper arm where his single lumen PICC (Peripherally Inserted Central Catheter) had been inserted. The PICC line was covered by a transparent film dressing and had a dried brown substance underneath it at the insertion site. The transparent film dressing was bubbled not in contact with his skin at the insertion site. The dressing was dated 3/16/26. R94 did not know the day or date of when his PICC line dressing had been changed. R94 stated he was getting IV (Intravenous) antibiotics twice a day.On 03/25/2026 at 4:52 PM, V2 DON (Director of Nursing) stated PICC line dressings are changed every seven days and as needed. The RN (Registered Nurse) assigned to the resident is responsible for maintaining the PICC line dressing. The PICC line dressing should have been changed when the dried brown substance was noted. If the dressing was placed on 3/16/26 it should have been changed on 3/23/26. Failing to change the dressing every seven days or when it is soiled and not secured places the resident at risk of developing a blood stream infection or if it is soiled and not secure the line may become dislodged placing the resident at risk for infiltration of fluids or medication. The nurses should not document a dressing change was done if it is not done.R94's TAR (Treatment Administration Record) documents the most recent PICC line dressing change as being completed on 3/22/26.R94's current physician orders include changing PICC line dressing every Sunday night shift.The facility policy Intravenous Therapy dated 6/30/25 states all midline catheter dressings are to be done every 7 days while following the procedure for dressing change of central lines. The outside of the dressing will then be labeled with dressing change date and time.

Based on interview and record review the facility failed to prevent a significant medication error.This applies to 1 of 1 residents R133 reviewed for significant medication errors in a sample of 25. Findings include:On 03/24/2026 at11:34 AM, R133 stated the prescriptions he was taking previously, he had not been receiving as they were ordered since admission to the facility. R133 stated the facility was provided with a list of the medications. R133 stated when he was at home his blood glucose was in a normal range. Since being in the facility his blood glucose readings have been too high.On 03/25/2026 at 4:35 PM, V22 QA (Quality Assurance) Pharmacist stated on 3/15/26 the pharmacy received an order for Metformin IR (Immediate Release) 500mg (Milligrams) twice daily. V22 stated the pharmacy assures there is no drug interaction for the list of medications submitted to them and they deliver the prescriptions. On 03/25/2026 at 4:09 PM, V23 Physician stated R133 was discharged from the hospital with orders. V23 stated he directed the nurse to continue and follow the hospital discharge instructions. V23 declined to answer how changes to R133's Metformin could impact his blood glucose levels.On 03/26/2026 at 12:07 PM, V2 DON (Director of Nursing) stated V19 RN (Registered Nurse) was the nurse that entered R133's metformin order incorrectly.On 03/26/2026 at 1:42 PM, V2 DON stated R133's blood glucose readings have stayed high since his admission to the facility.On 03/26/2026 at 1:59 PM, V19 RN (Registered Nurse) stated he entered R133's hospital discharge medication list and called them to V23 Physician. V19 stated he entered the regular metformin and not the extended-release metformin.R133's hospital summary of discharge medication includes metformin 500 mg 24-hour tablet take one tablet in the morning and one tablet in the evening.R133's Pharmacist MRR completed on 03/18/2026 states per hospital discharge, resident was to take metformin 500mg 24-hour one tablet two times a day. Resident now has an order for metformin 500 mg give one tablet two times a day. Please review, verify and update PCC as appropriate.R133's MAR (Medication Administration Record) shows he received nineteen doses of metformin 500mg over ten days from 03/16/2026 to 03/25/2026. R133's blood glucose from 03/15/2026 to 03/25/2026 ranged from 228 mg /dl to 458 mg /dl (Milligrams / Deciliter) The facility policy Verification of Physician Orders dated 7/3/25 states its purpose to reduce errors associated with misinterpreted verbal or telephone communications of medication orders or test results. A summary order to resume previous orders for medications shall not be accepted.

Based on observation, interview, and record review, the facility failed to provide timely incontinence care for residents that are dependent on staff assistance with activities of daily living (ADLs). This applies to three of seven residents (R1, R2, and R3) reviewed for incontinence care. The finding includes: R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed. R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated [DATE], shows R2 is cognitively intact (BIMS score 15/15) and dependent on staff for hygiene and incontinence care. The care plan dated April 25, 2025, directs incontinence care every two hours and as needed. R3, a [AGE] year-old admitted on [DATE]. R3's diagnoses included diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and diarrhea. The MDS dated [DATE], documents R3 as severely cognitively impaired and requiring extensive staff assistance for ADLs, including incontinence care. The care plan dated April 4, 2025, instructs provision of incontinence care every two hours and as needed. On April 25, 2025, at 11:00 A.M., R1 was observed with a saturated incontinence brief. V8 (CNA), at this time provided incontinence care to R1. V8 stated that incontinence care for R1, R2, and R3 (roommates) was delayed due to V7 (Certified Nursing Assistant /CNA) leaving the facility for personal reasons. V8 reported that incontinence care was subsequently provided to R2 at 10:30 A.M. and to R3 at 10:45 A.M. Both R2 and R3 were also found to have soaked incontinence briefs. During this time of observation, R1 stated that the last incontinence care and brief change were provided by V9 (CNA) during the night shift around 5:00 A.M. R2 and R3 similarly reported that their last incontinence care was also performed by V9 at approximately 5:00 A.M. On April 25, 2025, at 5:45 P.M., V9 validated that she had provided incontinence care for R1, R2, and R3 between 5:00 A.M. and 5:30 A.M. that morning. At 5:10 P.M. on the same day, V7 (CNA) stated that she was assigned to R1, R2, and R3 for the day shift starting at 6:00 A.M. on April 25,2025. V7 reported that although she began providing care to other residents, she did not provide incontinence care or brief changes to R1, R2, and R3 before leaving the facility at 9:30 A.M. At 11:30 A.M., (same day), V17 (R1's Power of Attorney) expressed concern, stating that it remains a concern that (R1) was not provided incontinence care and that his brief was not changed until 11:00 A.M., which happens almost daily. At 2:10 P.M., (same day) V18 (R3's Power of Attorney) stated that during her daily visits, R3 was often found soaked with urine and that staff would blame different shifts for the delay in care. The EMR (Electronic Medical Record) showed the following: -R1, a [AGE] year-old, admitted on [DATE]. R1's diagnoses included diabetes mellitus, other disease of anus/rectum, ulcerative colitis, major depression, neuropathy, and fractures of the 4th and 5th thoracic vertebrae. The MDS (Minimum Data Set) dated March 16, 2025, indicates R1 is cognitively intact (BIMS (Brief Interview Mental Status) score of 15/15) and requires staff assistance with ADLs, including incontinence care. The care plan dated March 24, 2025, directs staff to provide incontinence care every two hours and as needed. -R2, a [AGE] year-old, admitted on [DATE]. R2's diagnoses included right below-knee amputation, diabetes mellitus, peripheral vascular disease, gastroenteropathy. The MDS dated [DATE], shows R2 is cognitively intact (BIMS score 15/15) and dependent on staff for hygiene and incontinence care. The care plan dated April 25, 2025, directs incontinence care every two hours and as needed. -R3, a [AGE] year-old admitted on [DATE]. R3's diagnoses included diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease, and diarrhea. The MDS dated [DATE], documents R3 as severely cognitively impaired and requiring extensive staff assistance for ADLs, including incontinence care. The care plan dated April 4, 2025, instructs provision of incontinence care every two hours and as needed.

Based on observation, interview, and record review the facility failed to ensure accurate and timely accounting of controlled medications and failed to ensure that blister packs containing controlled medications are maintained intact to ensure safe and effective use of the medications. This applies to 5 of 5 residents (R23, R49, R52, R81 and R103) reviewed for controlled medications in the sample of 27. The findings include: 1. On January 7, 2025 at 10:44 AM with V13 (Assistant Director of Nursing), the Restorative Hall medication cart shift change accountability record for controlled substances showed that the first shift on and off nurses' initials for January 7, 2025 were not documented by both the in-coming and out-going shift nurses to ensure that all controlled medications were accounted at the start of the shift. Inside the controlled medication compartment, multiple controlled medications were observed including: - R49's blister pack of Pregabalin 25 mg (milligram), dispensed by the pharmacy on January 2, 2025 originally containing 30 tablets. The said blister pack of Pregabalin 25 mg had 28 tablets remaining that were intact and sealed (from #1 through #28). Review of R49's controlled drug administration record form for the Pregabalin 25 mg showed that there should be 29 tablets remaining in the blister pack. V14 (Registered Nurse) stated that she (in-coming nurse) and the evening out-going nurse completed the shift-to-shift narcotics/controlled substance count that morning and acknowledged that they did not sign the shift change accountability record for controlled substances for January 7, 2025. V14 stated that there was one missing Pregabalin tablet because she did not sign out on R49's controlled drug administration record form when she gave the resident's medication that morning during the medication pass. - R49's blister pack of Hydrocodone-APAP (Acetaminophen) 5-325 mg, dispensed by the pharmacy on June 4, 2024 originally containing 30 tablets. The said blister pack of Hydrocodone-APAP 5-325 mg had 30 tablets remaining that were intact and sealed (from #1 through #7, from #9 through #15, from #17 through #22 and from #24 through #30), while there were 3 additional tablets with broken seal at the back (#8, #16 and #23). V13 stated that the blister pack seal of any controlled medication should be kept intact to ensure its integrity and if the seal is broken the controlled medication should be wasted and witnessed by another nurse. 2. On January 7, 2025 at 11:10 AM with V13 the 500 Hall medication cart was observed with multiple controlled medications including: - R52's blister pack of Tramadol 50 mg, dispensed by the pharmacy on December 19, 2024 originally containing 30 tablets. The said blister pack of Tramadol 50 mg had 27 tablets remaining that were intact and sealed (from #1 through #27). Review of R52's controlled drug administration record form for the Tramadol 50 mg showed that there should be 28 tablets remaining in the blister pack. V15 (Registered Nurse) stated that there was one missing Tramadol tablet because she did not sign out on R52's controlled drug administration record form when she gave the resident's medication that morning at around 9:00 AM. Review of R52's medication administration audit report showed that the resident received Tramadol 50 mg on January 7, 2025 at 9:00 AM, administered by V15. - R103's blister pack of Alprazolam 0.25 mg, dispensed by the pharmacy on December 11, 2024 originally containing 30 tablets. The said blister pack of Alprazolam 0.25 mg had 25 tablets remaining that were intact and sealed (from #1 through #6 and from #8 through #26), while there was one (1) additional tablet with broken seal at the back (#7). - R23's blister pack of Oxycodone IR (Immediate Release) 5 mg, dispensed by the pharmacy on December 30, 2024 originally containing 30 tablets. The said blister pack of Oxycodone IR 5 mg had 29 tablets remaining that were intact and sealed (from #1 through #29). Review of R23's controlled drug administration record form for the Oxycodone IR 5 mg showed that there should be 30 tablets remaining in the blister pack. V15 who was the nurse on duty cannot explain why there was one (1) tablet of Oxycodone IR missing from the blister pack. Review R23's medication administration audit report showed that the resident received Oxycodone IR 5 mg on January 7, 2025 at 9:02 AM, administered by V15. - R23's blister pack of Lorazepam 0.5 mg, dispensed by the pharmacy on January 5, 2025, originally containing 30 tablets. The said blister pack of Lorazepam 0.5 mg had 30 tablets remaining that were intact and sealed (from #1 through #30). Review of R23's controlled drug administration record form for the Lorazepam 0.5 mg showed that there should be 29 tablets remaining in the blister pack. V15 stated that she gave one (1) tablet of Lorazepam 0.5 mg to R23 at around 9:20 AM that morning during the medication pass but cannot explain why there were still 30 tablets remaining in the blister pack. Review R23's medication administration audit report showed that the resident did not receive her Lorazepam 0.5 mg on January 7, 2025 during V15's shift. 3. On January 7, 2025 at 11:40 AM with V13, the 300 Hall medication cart was observed with multiple controlled medications, including R81's blister pack of Alprazolam 0.5 mg, dispensed by the pharmacy on December 12, 2024 originally containing 30 tablets. The said blister pack of Alprazolam 0.5 mg had eight (8) tablets remaining that were intact and sealed (from #1 through #5, #7 and from #9 through #10), while there were two (2) additional tablets with broken seal at the back (#6 and #8). On January 7, 2025 at 5:06 PM, V2 (Director of Nursing) stated that the nurse should immediately sign the controlled drug administration record form after the controlled medication was taken out of the blister pack or container to properly account the medication and to prevent discrepancies. V2 stated that the seal of the controlled medication blister packs should not be broken to ensure medication integrity. According to V2, if the controlled medication's seal has been broken it should be discarded/wasted and signed out by 2 nurses to prevent potential diversion of medication. During the same interview V2 stated that the incoming and the outgoing nurses should sign or initial the shift change accountability record for controlled substances to ensure that the narcotics/controlled substances are all accounted and documented. The facility's policy regarding Controlled Medications Count last reviewed and revised by the facility on July 26, 2024 showed, It is the policy of the facility to maintain an accurate count of Scheduled II controlled medications. The same policy under procedure showed in-part, 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying medication sheet indicating the medication is taken. 2. After administration of the controlled medication, the nurse will sign off the eMAR (electronic Medication Administration Record). 3. If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. The facility's policy regarding Medication Labels last revised on November 19, 2018 showed in-part under procedure, 7. Medication containers having soiled, damaged, incomplete, illegible, confusing, or makeshift labels are destroyed in accordance with the medication destruction policy.

Based on observation, interview and record review, the facility failed to provide a diet that includes the resident's diet preference. This applies to 1 of 1 resident (R137) reviewed for dining in the sample of 27. The findings include: R137's diagnoses on face sheet celiac disease, other seizures, difficulty in walking, not elsewhere classified, unspecified lack of coordination, acute respiratory failure, unspecified whether with hypoxia or hypercapnia. R137's admission MDS (minimum data set) dated December 12, 2024 included that R137 was cognitively intact. R137's diet order on Physician Order Summary included NAS (No Added Salt) diet, Regular texture, Thin liquids consistency, Gluten Free. R137's care plan revised on December 13, 2024 showed that R137 is at risk for alteration in nutritional status related to R137 is on a therapeutic diet. Interventions included to provide diet and supplements as ordered. On January 6, 2025, at 11:59 AM, R137 received room tray with chicken breast with no gravy, cooked carrots, a carton of 2% milk, 4 oz/ounce container of yogurt and a slice of white bread placed in a disposable sandwich bag. R137 stated They gave me a slice of white bread even though I am gluten free. I got celiac disease. R137 also added that it is not the first time he received regular bread. R137's diet card showed gluten free: no wheat, breads, etc. V9 (Guest Services) who was in the hallway was notified about resident concerns and she stated that she would in turn notify the dietary department of the same. On January 7, 2025 at 11:47 AM, R137 received a room tray served by V9. The tray included a meal of beef tips with no gravy, baked potato and Italian blend vegetables, 4 oz container of yogurt, and a dinner roll in a disposable sandwich bag. R137's diet card showed gluten free: no wheat, breads, etc. When asked if the roll was gluten free, V9 stated that she would have to have to ask the dietary department. On January 7, 2025 at 11:49 AM, V7 (Dietary Manager) stated that the dinner roll is not gluten free and that R137 should not have received it.

Based on interview and record review the facility failed to follow their policy for antibiotic stewardship to ensure residents received the appropriate antibiotic for an infection. This applies to 2 of 2 residents (R15 and R32) reviewed for antibiotic use in the sample of 27. The findings include: 1. The EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including hypertensive heart and chronic kidney disease with heart failure, neuromuscular dysfunction of the bladder, and stage four pressure ulcer of the sacrum. On January 8, 2025, at 11:34 AM, V4 (Infection Preventionist Nurse) said R15 was started on ciprofloxacin (antibiotic) on October 23, 2024, for a urinary tract infection. V4 said R15's antibiotic timeout was completed on October 26, 2024. V4 continued to say when she completes the antibiotic timeout, V4 is checking to make sure a provider has seen the resident since the antibiotic was started and writes a progress note about the antibiotic. V4 said she does not review the urine culture results as part of the timeout. V4 said R15's urine culture was resulted on October 26, 2024, and showed R15's urinary tract infection was resistant to ciprofloxacin. V4 continued to say R15's new antibiotic was not started until October 28, 2024. R15's Laboratory Results showed R15's urine culture results were reported to the facility on [DATE], at 9:47 AM. The results showed R15's urinary tract infection was resistant to ciprofloxacin. R15's Order Listing Report dated January 8, 2025, showed an order dated October 23, 2024, for ciprofloxacin 250 mg (milligrams), give one tablet by mouth every 12 hours for urinary tract infection for seven days. The report continued to show the ciprofloxacin was discontinued on October 27, 2024. The report showed an order dated October 27, 2024, for Fosfomycin oral pack 3 grams, give one packet by mouth one time a day every three days for urinary tract infection. R15's October 2024 MAR (Medication Administration Record) showed R15 received the first dose of Fosfomycin on October 28, 2024. The facility's October 2024's Infection List showed R15's infection occurred on October 23, 2024, and ciprofloxacin was started on October 23, 2024. The documentation continued to show a timeout was performed on October 26, 2024, but R32's antibiotic was not changed until October 28, 2024. The facility does not have documentation to show an antibiotic timeout was completed three days after the initial dose of antibiotic to ensure R15 was on the appropriate documentation. The facility does not have documentation to show a provider was notified of R15's urine culture results on October 26, 2024. On January 8, 2025, at 11:59 AM, V2 (DON/Director of Nursing) said when V4 conducts the antibiotic timeout, V4 should be reviewing the urine culture to ensure the resident is on the appropriate antibiotic. V2 said the antibiotic timeout should include V4 checking with the nurse practitioner that a resident is on the correct antibiotic for the infection. V2 continued to say the resident's nurse could also notify the nurse practitioner when laboratory results are received. V2 said a facility staff member should be notifying the nurse practitioner when laboratory results are received to ensure the correct antibiotic is being given to the resident. 2. R32's EMR showed R32 was admitted to the facility on [DATE], with multiple diagnoses including encephalopathy, chronic kidney disease, and acute respiratory failure. On January 8, 2025, at 11:34 AM, V4 said R32 was started on ciprofloxacin for a urinary tract infection on November 7, 2024. V4 said R32's urine culture results came back on November 10, 2024, but R32's antibiotics were not changed until November 11, 2024. V4 continued to say V4 completed R32's antibiotic timeout on November 10, 2024, and V4 did not look at the urine culture results. R32's Laboratory Results Report showed R32's urine culture results were reported on November 10, 2024, at 11:42 AM. The results showed R32's urinary tract infection was resistant to ciprofloxacin. R32's November 2024 MAR showed R32 started receiving ciprofloxacin on November 7, 2024. The MAR continued to show R32's antibiotic was changed on November 12, 2024. The facility's November 2024's Infection List showed R32's infection occurred on November 7, 2024, and ciprofloxacin was started on November 7, 2024. The documentation continued to show a timeout was performed on November 10, 2024, but R32's antibiotic was not changed until November 12, 2024. The facility does not have documentation to show an antibiotic timeout was completed three days after R32's ciprofloxacin was started to ensure R32 was on the appropriate antibiotic. The facility does not have documentation to show a provider was notified of R32's urine culture results on November 10, 2024. The facility's policy titled Antibiotic Stewardship Program Policy dated July 12, 2024, showed Policy Statement: The facility will comply with federal regulations in establishing an antibiotic stewardship program. Procedures . 6) Perform Antibiotic Timeout: Three days after the initial dose of antibiotic was started, a formal process of reassessment of the ongoing need for and choice of antibiotic is required to be performed by the clinical team an during this period, culture results is in already, and date such as resident's clinical response to antibiotic or alternative explanation for resident's status change is now available. Questions included in this process include: Does the resident have a bacterial infection that will respond to antibiotics? If so, is the resident on the most appropriate antibiotic, dose, and route of administration? .

Based on observation, interview, and record review, the facility failed to ensure that interventions were applied to provide comfort and prevent further worsening of resident's contracted hands. This applies to 2 of 3 residents (R17 and R41) reviewed for range of motion in the sample of 27. The findings include: 1). R17's face sheet showed her to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Congestive Heart Failure, Lack of coordination, Shortness of Breath, Chronic Kidney Disease, Major Depressive Disorder and Dementia. R17's Minimum Data Set (MDS) dated [DATE] showed R17 to be cognitively intact and that R17 required partial/moderate assistance for upper body dressing. R17's physician order dated September 26, 2024 showed the following: Apply rolled gauze to left hand contracture. On January 6, 2025 at 10:19 AM, R17 left hand was tightly closed and appeared contracted. R17 was not holding anything in her hand. On January 6, 2025 at 12:10 PM, R17 is lying in bed, her left hand was again observed tightly closed and appeared contracted and R17 was not holding anything in her hand. On January 7, 2025 at 10:10 AM, R17 stated she has received a bath already. R17's left hand was again observed tightly closed and appeared contracted and R17 was not holding anything in her hand. On January 7, 2025 at 2:46 PM, R17 left hand appeared contracted and she was not holding anything in her hand. R17 stated that no one has put anything in her left hand for a least week. R17 stated when carrot is used it does do some good. R17 stated she tried to put the carrot in her left hand but she couldn't. On January 7, 2025 at 3:29 PM, V18 (Restorative/RN) stated the R17 is being seen by restorative. V18 stated that R17 should have a role gauze in her left hand for treatment of the left hand contracture at all times except during ADL (Activities of Daily Living) care. V18 stated that the CNA's (Certified Nursing Assistants) should be applying the gauze. In R17's room, V18 uncovered R17 left hand and R17 did not have anything in her left hand. V18 tried to open R17 fingers on her left hand, and R17 screamed in pain. V18 stated that rolled gauze should be in R17 left hand. R17's left impaired mobility care plan as of January 7, 2025 at 3:20 PM showed the following: Pat dry and apply Roll wash cloth to bilateral hands. Then was changed the same day to the following: Apply Rolled Gauze/Kerlix to left hand, after AM ADL care, check skin, wash hand with warm water, Pat dry and apply roll gauze to bilateral hand. Apply all time. Change every morning. 2. R41's face sheet showed her to be a [AGE] year old female admitted to the facility on [DATE] with diagnoses that include Chronic Systolic Heart Failure, Weakness, Anemia in Chronic Kidney Disease, Hypertensive Heart and Chronic Kidney Disease, Quadriplegia, Major Depressive Disorder, Type 2 Diabetes, Dementia, and Personal History of Transient Ischemic Attack. R41's MDS dated [DATE] showed R41 to be cognitively impaired and that R41 required substantial/maximal assistance for upper body dressing. R41's physician order summary dated September 26, 2024 showed the following: Apply rolled gauze to right hand contracture. There was no mention of the left hand contracture. On January 6, 2025 at 10:17 AM, R41's left hand appeared contracted and closed. R41 was not holding anything in her left hand. On January 6, 2025 at 12:26 PM, R41 was not holding anything in her right or left hands. R41's left hand appeared contracted and closed. V19 (Licensed Practical Nurse) stated R41 needs a towel in her left hand. On January 7, 2025 at 2:35 AM, R41 was not holding anything in her left hand. On January 7, 2025 at 3:39 PM, R41 did not have anything in her left hand that appeared contracted. When surveyor asked R41 if anyone put a towel or anything in her left hand in the last couple days, R41 shook her head left to right, no. When R41 was asked how long has it been since she had placed anything in her left hand, R41 shrugged her shoulders. When asked has it been a while since she has had anything in her hand, R41 shook her head up and down, yes. V18 stated that R41 should have rolled gauze in her left hand. V18 tried to open R41's left contracted hand and R41 screamed in pain. R41's left impaired mobility care plan as of January 7, 2025 at 3:20 PM showed the following: Pat dry and apply Roll wash cloth to bilateral hand. Then was changed and read: Nursing Restorative Program as indicated, Apply Rolled gauze to left hand after AM ADL care and remove during meal and bedtime. On January 9, 2025 at 9:15 AM, V18 stated that R17 and R41's orders for rolled gauze to be placed in their contracted hands is a treatment to soften or loosen the contractures. V18 stated that having the gauze in the hand is also a more comfortable position for the resident's hands, and it helps to prevent worsening of the contractures.

Based on observation, interview, and record review, the facility failed to provide specialized mattress for a resident with worsening acquired pressure injury wound in accordance with wound care practitioner recommendation and their policy. This applies to 1 of 4 residents (R54) reviewed for pressure injury wounds in the sample of 27. The findings include: R54's medical record showed R54 admitted to the facility on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction, presence of malignant neoplasm of the breast, presence of cardiac pacemaker, osteoarthritis of the hip, and bilateral nuclear cataract and open angle glaucoma. R54's MDS (Minimum Date Set) dated October 10, 2024, showed R54 was moderately cognitively impaired, and required assistance with ADL (activities of daily living) care including set up assistance with eating and oral hygiene, partial assistance with upper body dressing, personal hygiene and rolling right and left in bed, and substantial assistance with bed mobility, transfer, lower body dressing, toileting and bathing. R54's Braden risk assessment dated [DATE], showed R54 was at high risk for developing a pressure injury wound. R54's wound care progress note dated November 19, 2024, showed R54 had developed a pressure injury to the bilateral glute (upper buttock), assessed to be a stage 2 and measured 1.5 cm (centimeter) X 1.1 cm X 1 cm, with a surface area of 1.65 square cm. The wound base contained 10% epithelial tissue, and 90% granulation tissue. On January 8, 2025, at 10:03 AM, wound dressing change was observed on R54. V20 LPN (Licensed Practical Nurse/ wound care nurse) and V21 CNA (Certified Nursing Assistant) repositioned R54 to her left side on the bed and V20 changed the dressing to the bilateral glute. V20 described the mattress in use for R54 as a two-tone pressure redistribution mattress. V20 stated R54 needs more help repositioning now because she is weaker and could use a low air loss mattress. R54's wound bed contained slough and V20 validated the wound had progressed to a stage 3. R54's most recent wound care progress note dated January 2, 2025, showed R54's bilateral glute wound measured 1.3 cm X 1.1 cm X 0.01 cm with calculated surface area of 1.43 cm and was assessed to be a stage 3 pressure injury wound. The wound care progress note of January 2, 2024, also showed R54 would benefit from an alternating air/low air loss mattress for pressure redistribution. The facility's policy titled Skin Regimen and Treatment Formulary dated January 24, 2024, showed .Procedures .9. Residents with Stage III and/or IV pressure injuries will be placed in specialized air mattresses like Low Air Loss mattress with an incontinence brief only .

Based on interview and record review, the facility failed to follow a physician's order to obtain a referral for a Corneal Specialist. This applies to 1 of 1 resident (R77) reviewed for vision services in the sample of 27. The findings include: The EMR (Electronic Medical Record) showed R77 was admitted to the facility on [DATE], with multiple diagnoses including Parkinson's disease, chronic kidney disease, and type 2 diabetes. On January 6, 2025, at 10:20 AM, R77 said he has a hard time seeing and had a referral from the eye doctor but has not had an appointment made for him yet. On January 7, 2025, at 12:04 PM, V16 (Social Services) said she received an email from R77's POA (Power of Attorney) on December 19, 2024, requesting R77 have an appointment at a local eye clinic. V16 said she was out of the office until December 27, 2024, and on December 27, 2024, V16 notified V17 (R77's Nurse) to start the process to schedule the appointment for R77. V16 said she followed up with V17 today, and V17 had not started the process to schedule R77's appointment. An Eye Doctor note dated November 27, 2024, by V22 (Eye Doctor) showed Assessment and Plan, Diagnoses: Central corneal opacity, right eye. Care Plan: Consult with Corneal Specialist. R77's Order Summary Report dated January 7, 2025, showed an order dated November 27, 2024, for Refer to Cornea Specialist for scars on the right cornea by [V22]. As of January 7, 2025, at 12:00 PM, the facility did not have documentation to show R77 had an appointment scheduled for a corneal specialist. On January 8, 2025, at 2:32 PM, V2 (DON/Director of Nursing) said there should not have been a delay in R77 receiving a corneal specialist appointment. V2 continued to say R77's appointment should have been scheduled when the order was received in November.

Based on observation, interview & record review, the facility failed to place a thermometer in resident refrigerators, complete temperature logs, remove undated and expired items and keep refrigerators clean. This applies to 5 of 5 residents (R28, R32, R85, R90 and R110) in a sample of 31. Findings include: 1. On [DATE] at 11:55 AM R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator. V16 (CNA-Certified Nursing Assistant) witnessed these observations and agreed that there is no temperature log on the refrigerator and no thermometer inside. The refrigerator contained following food with no date: 1. Sandwich in ziplock bag - No date 2. Cups (2) with cucumber salad dated [DATE] 3. Steirofoam box with rice - no date 4. Stierofoam box with pureed beans - no date 5. Ziplock bag with cheese - no date On [DATE] at 2:00 PM, R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator. On [DATE] at 9:00 AM, R90's refrigerator had no thermometer in it and no temperature log on the outside of the refrigerator. Refrigerator was 'dirty' with dried up juice on the floor of the refrigerator. On [DATE] at 9:15 AM, V12 (LPN-Licensed Practical Nurse) stated, all refrigerators must have a thermometer to monitor the temperature inside the fridge so that the food remains edible. V12 stated, all food in the refrigerator must have an expiry date on it and all expired items must be discarded. On [DATE] at 10:20 AM, V2 (DON-Director of Nursing) stated, refrigerators need temperature logs to maintain the right temperature, so that food inside is preserved and edible. V2 (DON) stated, the refrigerator temperatures are checked and logged by the housekeeping staff. V2 stated, undated food must not be left in the refrigerator. On [DATE] at 12:30 PM, V1 (Administrator) stated, all refrigerators must have a temp log outside the refrigerator. V1 (Administrator) stated, all food inside the refrigerator must be dated and that any food that is not dated, must be thrown away because it cannot be determined how old the food is. 31327 2. On [DATE] at 10:18 AM, R28's refrigerator was inspected. There was no thermometer inside and there was no temperature log. Inside the refrigerator, there was bread, coke, sausage, mustard, and a plastic container with an unknown substance that was not labeled or dated. Inside the refrigerator, there were food stains. R28 stated, They (Staff) are supposed to take temperatures of the fridge, but I've never seen them. 3. On [DATE] at 10:40 AM, R32 was not in her room. Inside her fridge, there were tortillas, an onion, and one lemon. Her temperature log that was in a plastic sleeve taped to the side of the refrigerator was missing dates for ,d+[DATE], ,d+[DATE], ,d+[DATE]-,d+[DATE], ,d+[DATE]-,d+[DATE], ,d+[DATE]-[DATE]. 4. On [DATE] at 10:52 AM, R110 was lying in bed. Inside R110's fridge, there was no thermometer. Inside there was yogurt and milk. Her refrigerator did not have a temperature log posted on her fridge. R110 was unaware if the staff checks the temperature of her refrigerator. 5. On [DATE] at 11:45 AM, R85 was not in her room. The refrigerator temperature log was missing dates for ,d+[DATE], ,d+[DATE], ,d+[DATE]-,d+[DATE], ,d+[DATE], and ,d+[DATE] to ,d+[DATE]. For the month of February, they were missing dates for ,d+[DATE] to [DATE] and ,d+[DATE] to [DATE]. There was nothing completed for the month of March. Inside R85's fridge consisted of ,d+[DATE] pint cartons of reduced fat milk. Two cartons expired on [DATE], one expired on [DATE], one expired on [DATE], and the last one expired on [DATE]. Inside, there was half of a sandwich, soda, pudding, and bbq (Barbeque) sauce. On [DATE] at 1:48 PM, V2 (DON-Director of Nursing) stated, Housekeeping and the resident's assigned guardian angels (Staff) are supposed check the residents' personal refrigerators. Every fridge should have a thermometer and log sheet. On [DATE] at 2:04 PM, V1 (Administrator) stated, Housekeeping is supposed to do the refrigerator temperature log sheets. There should be thermometers in all resident refrigerators. They need to remove the expired items and they should be discarding the food items if there is no date. They also should clean the refrigerators if it's dirty. Facility policy 'Refrigerator and Resident Appliance Maintenance Service' dated [DATE] showed, 1. resident appliance eg. refrigerators are safe, clean and operable at all times. a. Refrigerator in resident room . 2. c. Temperature is maintained below 41*F (Fahrenheit) and above 32*F using a thermometer with +/- 3 degrees temperature variance. d. Proper labeling, storage and disposition of food items. e. Ensure proper dating and disposition of outdated food items including food brought by family and resident from the outside. Facility policy 'Food from the Outside Policy' dated [DATE] showed, 1) All food brought by visitors and family members from outside of the facility will be labeled with the date it was brought to the facility . 3) After ,d+[DATE] days, these food items will be discarded. 4) All undated food items will be discarded to ensure safety of the residents.

Based on observation, interview, and record review, the facility failed to secure a resident's oxygen cylinder. This applies to 5 of 5 residents (R2, R28, R32, R58, R110) reviewed for oxygen in a sample of 31. The findings include: On 3/14/24 at 11:30 AM, surveyor went to R28 and R58's room. R28 was lying in bed and R58 was being provided care by V18 (CNA-Certified Nursing Assistant). In between their bed and behind R28's wheelchair, there was a medium size oxygen cylinder on the floor that was unsecured. R28 was unsure of how long the oxygen cylinder was unsecured on the floor. When surveyor brought it to V18's attention, V18 stated, I didn't put it there. The oxygen tank should always be in a carrier. That's a big no no. I will find out who did that and I will try to find the carrier for that oxygen tank. I will take care of it now. On 3/14/24 at 11:35 AM, V17 (RN-Registered Nurse) stated, The portable oxygen tank should be in a carrier or bag behind the wheelchair. It should be secured when it's on the floor. It will most definitely combust if it falls and it will hurt the residents. R28 and R58's room is in between R32's room who has her own private room and R2 and R110's room, who both share a room. If R28's oxygen tank falls, it can cause a combustion which can put R58, R32, R2 and R110 at risk R28's face sheet shows diagnoses of chronic obstructive pulmonary disease and chronic respiratory failure with hypoxia. Oxygen 2 L (Liters)/ Minute via nasal cannula to maintain oxygen saturation level equal or above 92% every shift. Facility's policy titled Oxygen Storage (7/28/23) shows: Policy Statement: It is the policy of the facility to store oxygen safely and properly. Procedures: 1. Restrain or secure oxygen tanks at all times.

Based on observation, interview and record review, the facility failed to assess residents for self-administering medications and obtain physician orders to have medication stored in resident rooms. This applies to 4 out of 4 residents (R28, R32, R66 and R75) reviewed for self-administration of medications in a sample of 31. 1. R75's Admission Records documents she was admitted to the facility on [DATE]. Diagnoses includes metabolic encephalopathy, multiple sclerosis, seizures, and chronic kidney disease with dependence on renal dialysis. On 3/12/2024 at 11:04 AM, R75 had a medication cup full of pills. R75 said around 9:30 AM, she told the nurse she was not feeling well and will take her medication later. R75 said the nurse left her medication on her bedside table so she can take it later. On 3/12/2024 at 11:22 AM, V13 (RN-Registered Nurse) said she attempted to administer R75's medications around 9:30 AM. She said the medications that were in the medication cup were Ascorbic Acid 500 mg (milligrams), Carvedilol 12.5 mg, Colace 100 mg, Tecfidora oral capsule delayed release 240 mg, Divalproex Extended Release 250 mg, Eliquis 2.5 mg, Folic Acid 1 mg, Multivitamin, Renvela 800 mg and Sodium Bicarbonate 325 mg (2 pills). She said there were 11 pills in the cup. V13 said she left the medication by R75's bedside table because resident said she will take it later. V13 went to R75's room and counted and verified that there were 11 medications in the cup she left by R75's bedside table. On 3/12/2024 at 12:00 PM, review of R75's March 2024 POS (Physician Order Form) showed there is no order for R75 to self-administer medication. Review of assessments in the EMR (Electronic Medical Records) showed R75 does not have a Self-Administration Assessment. Self-Administration of medication assessment and order were obtained during Survey. On 3/14/2024 at 10:15 AM, V2 (DON-Director of Nursing) said she expects nurses not to leave medication at bedside because of safety concerns and to make sure that resident took the medication. 31327 2. On 3/12/24 at 10:18 AM, R28 was lying in his bed. On top of his bedside table there was an opened Budesonide and Formoterol Fumarate Dihydrate Inhalation Aerosol inhaler. R28 stated, The nurse brought it to me this morning and left it here. The nurse usually leaves it for me to take it and then leaves. He doesn't watch me. No one taught me how to do it. I already know how to take the inhaler. R28's POS (Physician Order Sheet) shows an order for Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG (Micrograms)/ACT-2 inhalations, inhale orally two times a day for shortness of breath. There was no order by the physician for the medication to be at the bedside. R28's electronic medical record was reviewed. There was no self-administration of medication assessment form. 3. On 3/12/23 at 10:40 AM, R32 was not in her room. On her end table there was a bottle of eye drops. On the label it shows Dextran 70, 0.1% Polyethylene Glycol 400, Povidone, and Tetrahydrozline HCL 0.05%. It was also noted to be in her bedroom on 3/13 and 3/14/24. On 3/14/24 at 11:28 AM, R32 who is only Spanish speaking was only able to tell surveyor that the medication belonged to her. She was unable to answer any more questions from surveyor. R32's POS was reviewed. There was no order for the medication and for it to be at the bedside. Review of her electronic medical record shows there was no self-administration of medication assessment form. On 03/13/24 at 3:17 PM, V2 (DON-Director of Nursing) stated, I think there's only resident here who can self-administer. They must have a physician's order for them to self-administer and have medications at the bedside. There should be a self-administration of medication assessment form and the nurse is to educate them and have the resident demonstrate how to use a medication to see if it's safe. 44387 4. On 3/12/24 at 11:08 AM, R66 was observed in bed in his room. R66 had a bottle of Nyamc 100, 000 Unit/Gram (Nystatin Topical Powder) on his bedside dresser. R66 said the powder belonged to him and he uses it. R66's current Physician Order Sheet (POS) shows order for Miconazlole Powder to apply transdermally. R66 did not have an order for Nystatin Powder or order to self-administer medications. R66's current care plan was reviewed; R66 was not care planned to self-administer medications. On 3/14/24 at 10:19 AM, V2 (DON) said residents would need to be assessed to see if they are capable of self-administering medications; after assessment, there needs to a physician order placed and it would be implemented in the resident's plan of care. Facility's policy titled Self-Administration of Medication (7/28/23) shows: Procedures: 1. The IDT (Inter-disciplinary Team) will assign a staff to evaluate a resident's ability to safely administer medication. A Self-Administration Evaluation will be filled out to determine capability. A return demonstration will be done to accurately evaluate resident's ability after the health teaching. 2. The resident may store the medication at bedside if there is a physician order to keep it at bedside. 3. The nurse on duty will document administration of medication in the MAR (Medication Administration Record). 4. The medication will be administered by the resident. 5. The resident's ability self-administer medication will be assessed regularly by the facility to coincide with the MDS (Minimum Data Set) assessment or any notable change in status.

Based on interview and record review, the facility failed to follow its advance directives policy. This applies to 2 of 10 (R40 & R14) reviewed for advance directives in a sample of 31. Findings include: 1. On 3/12/2024 at 2:56 PM, R40's EMR (Electronic Medical Record) review was completed and did not show an order indicating his advance directives. R40's EMR showed he was admitted to the facility on [DATE] and was receiving hospice services. R40 had an advance directive form dated 1/27/2021 indicating he was a DNR (Do Not Resuscitate) with selective medical treatment interventions. R40's Order Summary Report dated 3/14/2024 showed a physician order indicating DNR code status was entered on 3/12/2024 (during the survey). 2. On 3/12/2024 at 1:53 PM, R14's EMR review was completed and did not show an order indicating his advanced directives. R14's EMR showed he was admitted to the facility on [DATE]. R14's EMR did not show an advance directive form. R14's Order Summary Report dated 3/13/2024 showed a physician order indicating full code status was entered on 3/12/2024 (during the survey). On 3/13/2024 at 2:20 PM, V12 (Licensed Practical Nurse/LPN) said they enter a physician order in the residents' EMRs to indicate if they are full code or DNR to make staff aware of the residents' advance directives. On 3/13/2024 at 2:36 PM, V2 (Director of Nursing/DON) said a code status order is entered in the residents' EMRs and if needed the staff looks at the POLST forms to confirm advance directives. The facility's policy, titled Advance Directives with a revised date of 2/19/2024, showed Upon Admission: .2. Staff will provide the resident and/or representative with information regarding advance care planning which will address types of Advance Directives, treatment options and refusal of treatment. 3. Information will be reviewed and the resident and/or representative will be asked to sign and acknowledge that they have received the information on Advance Care Planning. 4. An Advance Directive form (as provided by the healthcare facility) shall be completed with resident and/or legal representative to verify treatment options as well as code status. 5. Appropriate information will be added to Physician Order Sheet (POS). 6. The resident's Advanced Directive choices/options shall be reviewed during the re-assessment and quarterly care planning process. 7. Discussion of Advance Directives and treatment options/refusals will be addressed in appropriate chart documentation as well as a care planned during the admission process, as indicated. 8. Staff will initiate choice discussion concerning the DNR option or Full Code .

Based on observation, interview, and record review, the facility failed to ensure R24 was free from physical restraint. This applies to 1 of 1 resident (R24) reviewed for physical restraints in a sample of 31. Findings include: The EMR (Electronic Medical Record) showed R24 was admitted to the facility on [DATE], with multiple diagnoses including multiple sclerosis, paraplegia, and functional quadriplegia. R24's MDS (Minimum Data Set) dated 1/01/2024 showed R24 required substantial to maximal assistance from staff for upper body dressing. On 3/12/2024 at 12:29 PM, R24 was sitting in her high-back wheelchair in the dining room with a seatbelt around her waist. On 3/14/2024 at 11:11 AM, V7 (Certified Nurse Assistant/CNA) and V8 (CNA) assisted R24 into her high-back wheelchair. V8 applied a push-button seatbelt around R24's waist area. R24 tried several times to release the seatbelt but was not able to, R24 said she could not do it because it was too hard. V8 said R24 sometimes could not release her seatbelt. On 3/14/2024 at 11:35 AM, V6 (Restorative Nurse) said there were no residents in the facility with the use of restraints. V6 said a restraint was any device that could restrict a resident, including a seatbelt if a resident could not physically release it. V6 said the use of restraints requires an assessment, consent, physician order, and care plan to monitor the resident. V6 said she was not aware of R24 using a seatbelt when up in her wheelchair. On 3/14/2024 at 11:59 AM, a review of R24's Active Order Summary Report did not show any order for a self-releasing seatbelt. R24's Restorative assessment form dated 1/02/2024 showed R24 had a limited range of motion to her bilateral wrists and hands and no evaluation for the use of a seatbelt device when up in wheelchair. The facility's policy, titled Restraints with a revised date of 7/28/2023, showed Policy Statement It is the facility's policy to ensure that each resident is not restrained for the purposes of discipline or convenience .Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets ALL the following criteria: A) attached or adjacent to the resident's body B) that the individual cannot intentionally remove easily, and C) restricts freedom of movement or normal access to one's body.

Based on interview and record review, the facility failed to follow a resident's plan of care for transfers for one of three residents (R1) reviewed for transfers on the sample list of three. This failure resulted in R1's foot getting stuck on the front of R1's wheelchair and R1's foot fracture. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE], with multiple diagnoses including cerebral palsy, fracture of right tibia, end stage renal disease, benign prostatic hyperplasia, and atrial fibrillation. R1's MDS (Minimum Data Set) dated May 26, 2023, showed R1 was cognitively intact. The MDS shows R1 required extensive assistance of facility staff for transfers between surfaces. R1's ADL (Activities of Daily Living) care plan dated November 17, 2022, showed, [R1] has an ADL self-care performance deficit and impaired mobility related to cerebral palsy, end stage renal disease, coronary artery disease, atrial fibrillation, anemia, and fracture of shaft of right tibia. The care plan continued to show multiple interventions dated August 22, 2023, including, [R1] requires extensive assist times two staff participation with transfers using [mechanical stand assist lift]. R1's x-ray dated August 25, 2023, at 6:47 PM, showed, .Nondisplaced acute oblique fracture distal diaphysis of the right tibia . A progress note dated August 25, 2023, at 9:00 PM, by V12 (Registered Nurse) showed, .This writer received results from [radiology company] that resident has a nondisplaced acute oblique fracture distal diaphysis of the right tibia. Resident denies pain or discomfort. Received a new order to send resident to [local hospital] per [V5 (Nurse Practitioner)] . On September 12, 2023, at 12:12 PM, R1 was sitting in his room at the edge of his bed. R1's right foot was in a controlled ankle motion boot. R1 said he must wear the boot because he broke his foot during a transfer. R1 said a couple weeks ago, a male CNA (Certified Nursing Assistant) picked him up to transfer him. R1 continued to say he informed the CNA he (R1) uses a mechanical stand assist lift. R1 said when the CNA transferred him, R1's foot got stuck and it broke. On September 13, 2023, at 2:45 PM, V3 (CNA) said he was caring for R1 on August 24, 2023, during the 2:00 PM to 10:00 PM shift, and this was V3's first time caring for R1. V3 continued to say R1 requested to be transferred from the wheelchair to his bed. V3 said he did not know R1's transfer status and did not look up R1's transfer status in the Electronic Medical Record (EMR) prior to transferring R1. V3 continued to say he used a gait belt and did a stand and pivot transfer with R1. V3 said as he was transferring R1, R1's foot got caught on R1's front wheelchair wheel. V3 continued to say when he placed R1 in the bed, R1 screamed out in pain. V3 said he touched R1's foot and R1 yelled in pain. V3 said he notified R1's nurse of the pain. V3 continued to say he knew he should have looked up R1's transfer status in the EMR, but V3 did not have time to look up R1's transfer status prior to transferring R1. On September 13, 2023, at 4:04 PM, V2 (DON/Director of Nursing) said at the time of R1's fracture, R1 was care planned to be transferred using a mechanical stand assist lift. V2 continued to say on August 24, 2023, V3 should have transferred R1 with another staff member using the mechanical stand assist lift. V2 said facility staff and agency staff can see a resident's transfer status in the EMR. On September 14, 2023, at 10:19 AM, V10 (Restorative Nurse) said prior to R1's leg fracture, R1 was to be transferred using a mechanical stand assist lift. V10 continued to say the mechanical stand assist lift requires two facility staff to transfer a resident. On September 13, 2023, at 3:27 PM, V11 (R1's physician) said it was definitely possible R1's improper transfer causing R1's foot to get stuck in his wheelchair caused R1's fracture. V11 continued to say it his expectation facility staff would transfer R1 in the safest manner using the way R1 had been assessed for transfer. The facility's policy titled Mechanical Lift Transfers dated July 28, 2023, showed, Procedures: . 5. There will always be two staff to assist resident. One staff will control the lift as the other will guide resident and support back and neck to transfer surface .

Based on observation, interview, and record review the facility failed to provide supervision for a resident with a history of falls while she was outside of the facility smoking and failed to have a plan in place for residents exiting the facility during inclement weather. These failures resulted in R55 exiting the facility unsupervised while the outside temperature was 14 degrees Fahrenheit (F) below zero and experiencing an unwitnessed fall. This applies to 16 of 129 residents (R55, R12, R64, R4, R5, R109, R77, R51, R50, R56, R21, R3, R47, R378, and R48) reviewed for safety and supervision. The Immediate Jeopardy began on 1/26/22 at approximately 7:00 AM when R55 exited the facility unsupervised and experienced an unwitnessed fall. The outside temperature at the time of the fall was 14 degrees Fahrenheit below zero. The Immediate Jeopardy was identified on 1/26/22. V1 (Administrator) was notified of the Immediate Jeopardy on 1/27/22. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/28/22, but noncompliance remains at a Level Two because additional time is needed to evaluate implementation and effectiveness of the in-service training. The findings include: R55's Face Sheet dated 1/26/22 showed diagnoses to include, but not limited to [CONDITION(S)], diabetes, [CONDITION(S)] (Stage 3), major depressive disorder, and dementia without behavioral disturbance. R55's Facility assessment dated [DATE] showed R55 had moderate cognitive impairment; required supervision with locomotion off unit; and required extensive assistance of two staff for bed mobility and transfers. R55's Care Plan initiated 8/15/20 showed R55 has a dementia diagnosis with interventions to include: Cue, reorient, and supervise [R55] as needed. R55's Care Plan initiated 6/3/20 showed R55 is at risk for falls related to unsteady balance, weakness, multiple medical conditions/diagnosis and medication. The interventions include: Remind and encourage resident to propel self on wheelchair in the middle of patio walkway as a safety precaution to prevent wheelchair imbalance and prevent a fall. R55's Medical Professional Progress Note dated 1/4/22 showed R55 was admitted on [DATE] and was previously hospitalized from 5/24/20 - 6/2/20 after suffering a fall at home and sustained a right humerus fracture. R55's Fall Risk Evaluation dated 10/9/21 showed R55 was a High Risk for falls with a score of 18 (a score of 8 or above = High Risk). The facility's Incident Report dated 7/7/21 showed, . At 9:10 AM on 7/7/21, a male resident told the writer that [R55] was on the ground [in the outside smoking area]. This same report showed R55 is oriented to person, situation and place, but had a lack of safety awareness . The facility provided an undated list of R55's falls. This list showed 3 falls since 2/4/21 and did not include the fall in the outdoor smoking area on 7/7/21 or the fall that occurred on 1/26/22 (again in the outdoor smoking area). R55's General Progress Note dated 1/26/22 showed, At 8:10 AM VP (Vice President) of clinical services overheard resident calling out for help and immediately responded. Upon approach, resident was noted sitting upright with both legs extended in front of her near the door of the patio/smoking area. Resident stated she was propelling her wheelchair to go back inside when she slid off from the wheelchair and landed on her buttocks . At 8:15 AM the resident was assisted back to the wheelchair with mechanical lift with 4 person assist and transported back to her room . A small abrasion was noted to right ring finger and redness to left knee . (According to timeandate.com the temperature at 7:52 AM was -14 degrees Fahrenheit) On 1/26/21 at 2:49 PM, V4 (Vice President of Nursing Services) said she was sitting at the nurses' station and heard someone calling for help around 8:10 AM. V4 said it was R55 yelling, Help me! V4 said R55 was sitting on her butt, just outside the door to the courtyard, with her wheelchair next to her. V4 said she did not see R1 fall. V4 said R1 was outside by herself. V4 said there were no residents or staff with R55 when she fell . On 1/26/22 at 10:02 AM, V5 (Licensed Practical Nurse - LPN) said R55 went outside this morning, in her wheelchair, and slid out of her chair. V5 said the staff had to use a mechanical lift to get her off the ground. V5 said he had not seen staff outside, supervising the residents, while they smoke. V5 stated, There isn't anyone monitoring their smoking. I am busy passing medications. At 3:17 PM, V5 said he saw R55 self-propel her wheelchair past him this morning around 8 AM. V5 said he asked R55 where she was going and she said to get coffee. V5 said he told R55, I hope you are not going outside. It's freezing. V5 said he went to administer medications and he did not see R55 go outside or fall. V5 said he does not have the authority to decide if the residents cannot go outside, but he would not have recommended it today. On 1/26/22 at 1:04 PM, V9 (Certified Nursing Assistant - CNA) said she was the CNA assigned to R55. V9 said most of the smokers will take themselves outside and they do not always tell the staff they are going outside. V9 said she did not know that R55 was outside this morning and had not seen her fall. V9 said she was coming from the [CONDITION(S)] center and V4 (Vice President of Nursing Services) had the door open and R55 was on the ground, outside. V9 said V10 and V11 (CNAs) assisted her with the use of the mechanical lift to get R55 off the ground. V9 stated, It could have been bad. She could have had frostbite because it was cold. V9 said when R55 came into the building her hands were cold and reddened. On 1/26/22 at 10:42 AM, R55 was seen unsupervised in the outdoor smoking area. (Approximately 3 hours after she fell outside in the same area.) At 10:42 AM, V6 (LPN) was seated at the nurses' station, across from the exit door to the outdoor smoking area. V6 said she was unsure of where R55 was at the time. V6 stood from the nurses' station and walked toward the dining room. V6 then pointed outside to R55 who was out on the patio unsupervised and smoking. (According to timeanddate.com at 10:52AM the temperature was 0 degrees Farenheit.) V6 said the staff do not go outside with the residents. V6 stated, It's cold outside, but they want to go out. V8 (Social Services) was seated inside the dining room, near the door to the outside smoking area, with his back to the door and windows. (V8 could not see R55 the way he was positioned.) On 1/26/22 at 10:44 AM, R55 entered the building and self-propelled her wheelchair to her room. R55 said, Ooh, its cold out there. R55 had frozen nasal drainage noted on her nostrils and her eyes were watering. R55 did not have gloves on. R55 stated, I fell outside this morning. R55 said she scraped her right knee and her right hand was hurting. R55 pointed to the inside of her right ring finger and a half circle abrasion was noted. R55 stated, I went over a big bump and I slipped out of the chair as I was reaching for the door, to come back in. I landed on my rear-end. No one was out there. I was out there 15 minutes. I had to bang on the door and yell to get their attention. They had to come out with the lift to help me up. I don't think anyone even saw me go out. R55 said the staff does not go outside with her when she smokes. R55 said she usually transfers herself and self-propels her wheelchair. R55 said she has had falls in the past. On 1/27/22 at 10:31 AM, V12 (Registered Nurse) said if a resident fell in the morning, then I would put them under close supervision to prevent another fall. V12 said it can be hard to see outside to the courtyard from the nurses' station. V12 said you would have to go into the dining room to see well. V12 said if a resident fell outside in the morning, then they should be in closer supervision that day. On 1/26/22 at 12:47 PM, R56 stated, Yes, I am a smoker. I go out on the patio by the dining room. It's the designated area. I can go out whenever; there aren't any designated times. R56 said staff do not go outside with him and never supervise smoking. R56 stated, We can go out whenever we want to. I have seen people fall outside. One of us will just go inside and let whoever is working know that someone fell outside. I don't have to tell anyone when I go out to smoke. R56's facility assessment dated [DATE] showed R56 was cognitively intact. On 1/25/22 at 10:15 AM, R47 said he smokes every couple of hours, no staff go out with him, and smoking is not supervised. R47's facility assessment dated [DATE] showed he is cognitively intact. On 1/26/22 at 11:02 AM, V7 (Nursing Supervisor) said the door from the dining room to the outside smoking area is always accessible to the residents. V7 said a staff member should go outside with the residents to observe for safety while they are smoking. On 1/26/21 at 1:37 PM, the outdoor smoking area was observed. The exit door had a keypad but the alarm had been disabled and the door was able to be opened without the alarm sounding. The area was a large, shoveled, concrete slab and there was a large metal grate just off to the side of the doorway which created an uneven surface. On 1/27/22 at 10:59 AM, V17 (Nurse Practitioner) said all kinds of problems could happen if a resident fell outside in -14 degree temperatures: they could develop frostbite, lose consciousness, or experience a fracture from the fall. V17 said it would all depend what happened. V17 said when the temperature is -14 degrees outside, we make recommendations for the residents not to go outside. On 1/27/22 at 9:45 AM, V1 (Administrator) said the facility has an open smoking policy. V1 said the door to the 300/400 courtyard is set to automatically unlock from 8:00 AM to 8:00 PM. V1 said she was not aware of a facility policy related to assessing for resident smoking outdoors in inclement weather. V1 was asked if -14 degrees would be considered inclement weather. V1 replied, I'm not sure what the temperature cutoff is for inclement weather. At 1:25 PM, V1` said the facility does not have a policy related to inclement weather and when residents are not allowed to go outside. V1 said the facility would try to follow any weather advisories. On 1/27/22 at 1:30 PM, V21, Medical Director said the facility should have a policy to assess for going outdoors in inclement weather. V21 said inclement weather in the winter would include below freezing temperatures, freezing rain, and gusting winds. V21 stated, I would consider -14 degree weather yesterday (1/26/21) to be an inclement weather concern. V21 said if a resident went outside unsupervised, and experienced an unwitnessed fall, then the resident could get caught in the extreme temperatures and they could get confused. V21 stated, I think good common sense prevails. V21 said if a resident was a high fall risk or experienced repeated falls, then it would not be a good idea to allow them to go outside unsupervised. The facility provided a list of residents who actively smoke dated 1/21/22 which showed 14 residents to include R12, R64, R4, R5, R109, R77, R51, R50, R56, R21, R3, R55, R47, and R378. On 1/28/22 the facility identified R17 and R48 as additional residents that actively smoke. The facility's Fall Occurrence Policy (revised 7/28/21) showed, It is the policy of the facility to ensure that residents are assessed for risk for falls and interventions are put in place to prevent them from falling. Procedure . 3. If a resident had fallen, the resident is automatically considered as high risk for falls . The facility's Smoking Policy (revised 7/28/21) showed, It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner . The Immediate Jeopardy that began on 1/26/22 was removed on 1/28/22 when the facility took the following actions to remove immediacy. To remove immediacy, the facility initiated the following steps: 1.On 01/26/2022, resident (R55) was immediately assessed after the fall and for signs and symptoms hypothermia. Fall Risk Re-evaluation was completed on 01/26/2022. R55 was seen and examined by NP on 01/26/2022 post fall. R55's care plan for smoking and fall risk were reviewed and updated to include supervised smoking schedule on 01/26/2022 during inclement weather. 2.Activity Staff and/or designees were immediately assigned to monitor residents that are smoking, residents capable of enjoying outdoor activities, and residents that may require supervision outside to ensure that residents are supervised during inclement weather such as on days in which temperature and/or condition extremes would present a danger to resident safety. Examples, include, but are not limited to, excessive heat or cold temperatures, high winds, lightening, snow/rain and icy conditions. Administration may set specific times for smoking and specific length of time outdoors during inclement weather and door will remain secured. 3.A facility-wide assessment of residents identified to be smokers and other residents capable of enjoying outdoor activities during inclement weather was immediately initiated on 01/27/2022 by (Social Service Designee) and will be completed on 01/28/2022. 4.A supervised smoking schedule was established for the residents between 8:00 am to 8:00 pm in the designated Smoking Space starting on 01/27/2022. 5.Education regarding supervised smoking schedule and other supervised outdoor leisure activities was initiated on 01/26/2022 to all residents provided by Guest Relations and Activity Director and/or other designees will be completed on 01/28/2022. 6.An emergency meeting conducted by Guest Relations and Activity Director with the Resident Council was held on 01/27/2022 to discuss the new supervised smoking schedule to promote resident's safety. 7.A facility-wide Fall Risk re-evaluation was immediately initiated by (Restorative Nurse)/designee on 01/27/2022 and will be completed on 01/28/2022 to ensure appropriate interventions for supervision during outside activities during inclement weather. 8.The facility created a policy to supervise residents enjoying leisure activities including smoking activities during inclement weather. 9.Facility-wide in-services regarding the policies on inclement weather initiated on 01/27/2022 by Interdisciplinary Team Members consisting of DON, ADON, Nursing Supervisor, SSD, Activity Director and Administration and will be completed on 01/31/2022. All staff currently on leave and vacation will be inserviced by the IDT upon return. No staff will be allowed to work until they completed the inservices. 10.Facility-wide in-services regarding the new supervised Smoking Schedule was initiated on 01/27/2022 by Interdisciplinary Team Members consisting of DON, ADON, Nursing Supervisor, SSD, Activity Director and Administration and completed on 01/28/2022. All staff currently on leave and vacation will be inserviced by the IDT upon return. No staff will be allowed to work until they completed the inservices. 11.New admissions and re-admissions that have history of smoking and active use of tobacco will be immediately assessed for Smoking Program by Social Service department to ensure that appropriate interventions are in place. 12.An emergency QAPI meeting was conducted together with the Medical Director, Administrator, DON, ADON, Nursing Supervisor, Regional Guest Relations, VP of Clinical Services, and SSD on 01/27/2022 at 7:00 pm to discuss the issues identified issues and put in place appropriate measures to prevent recurrence and the updated policies on Winter Emergency and Smoking Policy. 13.An emergency Security Committee meeting with the Social Service Designee, Administrator, Regional Guest Relation, Assistant Administrator and DON was held on 01/27/2022 to discuss issues identified and interventions put in place. Residents identified to be smokers will continue to be discussed on a weekly Security Committee meeting. 14.A QA audit tool was initiated on 01/27/2022 by Assistant Administrator and/designee to randomly observe residents that are smoking during various times 3x/week for 12 weeks to ensure that residents are provided with supervision during scheduled smoking including during inclement weather. All of the above will be discussed in the next QAPI meeting on February 9, 2022. II. Based on observation, interview, and record review the facility failed to complete a smoking assessment for a resident that smokes; and failed to provide smoking for a resident assessed as an unsafe smoker. This applies to 2 of 16 residents (R48, R56) reviewed for safety and supervision in the sample of 29. The findings include: 1.On 01/25/22 at 11:49 AM, R48 ambulated to his room with a steady gait. R48 stated, I do smoke. I'm trying to quit, so I haven't been smoking as much. We just go outside the dining room door (courtyard). I was just out there, but I only took a couple puffs. On 1/26/22 at 1:02 PM, R48 said, I had part of a cig this morning. I didn't smoke the whole cigarette because it was too cold. R48's Face Sheet dated 1/27/22 showed diagnoses to include, but not limited to: hypertension, heart failure, diabetes, major depressive disorder, chronic obstructive pulmonary disease ([CONDITION(S)]), gastro-[CONDITION(S)] reflux disease (GERD), arthritis, kidney failure and lung cancer. This document showed R48 was admitted to the facility. R48's EMR (Electronic Medical Record) did not contain a Smoking Program (Evaluation for Risk) document or a smoking care plan completed prior to 1/27/22 (20 days after admission). On 1/26/22 at 2:49 PM, V4 (Vice President of Nursing Services) said smoking assessments should be completed on admission and as needed. V4 said the purpose of the smoking assessments is to make sure ensure the resident's safety. On 1/27/22 at 12:46 PM, V8 (Social Services) said R48 was not on his list of active smokers. V8 stated, I haven't seen him go out. V8 said R48 sent him to purchase some cigarettes, but he was unable to complete the purchase. V8 stated, So, I didn't put him down as a smoker. He doesn't have a smoking assessment. I just assume, if I don't get them their cigarettes, they don't smoke. The purpose of the assessments is to determine safety. The facility's Smoking Policy (revised 7/28/21) showed, It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner . 2. On 1/26/22 at 12:47 PM, R56 stated, I am a smoker. I go out on the patio by the dining room. It is the designated area. I can go out whenever; there are no designated times. R56 stated staff do not go outside with him and there isn't any staff supervising smoking. R56 stated today was different than normal in regards to staff are monitoring smoking. R56 stated the patio door is kept unlocked and he go outside anytime he wants to. R56 stated, I have seen people fall outside. One of us will just go inside and let whoever is working know that someone fell outside. The Smoking Program (evaluation for risk) for R56 dated 11/17/21 showed, Dependent smoking program, facility will develop a smoking schedule with the resident. Resident is not considered a safe smoker and requires smoking management and supervision consistent with facility policy and may not have access to smoking materials outside of supervised smoking. On 1/27/22 at 11:56 AM, V20 (Restorative Aide) stated, R56 is on a supervised smoking program. I don't know if he keeps his cigarettes and lighter on him. I don't know. V8 from social services handles all of that. On 1/27/22 at 11:58 AM, V8 (Social Services) stated, I buy R56 his cigarettes but he is independent with walking so he can go smoke. We follow the smoking assessment. We also try to link it to community skills. We are supposed to follow the smoking assessment. R56's Care Plan dated 12/4/21 showed, The resident is a smoker and expresses the desire to smoke at this facility. The resident will demonstrate compliance with safe smoking policies as evidenced through the next review. Educate the resident concerning: where smoking may occur, times of smoking sessions, using ashtrays properly, not discarding ashes or butts on the floor, not lighting peers' cigarettes, not giving or trading cigarettes to peers, and the health and safety-related risks associated with smoking. The facility's Smoking policy (7/28/21) showed, Smoking is only permitted in designated areas. Facility staff may keep the residents smoking materials when not being used by the resident. Those that are assessed as unsafe smokers will be provided supervision during smoking. R56's Face Sheet dated 1/27/22 showed medical diagnoses including covid 19, major depressive disorder, wernickes [CONDITION(S)], anxiety, chronic pancreatitis, hypertensive heart disease, type 2 diabetes mellitus, long term use of insulin, panic disorder, alcoholic [CONDITION(S)], alcohol induced pancreatitis, other specified depressive episodes, and alcohol dependence with withdrawal unspecified. The Medical Professional's Progress Note dated 12/29/21 for R56 showed the patient has a history of alcoholism and wernicke's dementia. R56 needs frequent redirecting. R56 denies drinking alcohol. R56 has diabetes mellitus and can be labile. In house psychiatrist to follow up with patient as needed. Monitor blood sugar; abstain from alcohol. Redirect patient as needed.

Based on observation, interview, and record review the facility failed to ensure a resident was free from sexual and verbal abuse from a facilty staff member. This applies to 1 of 1 (R35) residents reviewed for abuse in the sample of 29. This failure resulted in the R35 experiencing fear for her safety and anxiety. The findings include: 1. R35's Face Sheet showed she was a [AGE] year old female with an admitted [DATE]. The Face Sheet showed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R53's Minimum Data Set (MDS), dated [DATE], showed she was cognitively intact with a Brief Interview Mental Status score of 15 out 15. The MDS showed she required extensive assistance of two people for bed mobility and transfers. The facility's investigation into an incident reported on 12/5/21 involving R35 and V29 Certified Nursing Assistant (CNA) showed, .allegedly (V29) Nurse Aide Boosted her up in bed and she felt that his (V29) face got too close and brushed her face . On 1/26/22 at 9:18 AM, R35 stated, He (V29) came in and said can I give you a hug. He (V29) then put his head on my chest, like by my breasts, then he(V29) kissed me on my head and I thought that was weird but I didn't know if he(V29) was just very friendly. He(V29) was an older gentleman and he (V29) had a wedding band on so I thought maybe he (V29) was just overly affectionate. Then it continued for days, where he (V29) would give me a hug, but put his head on my breasts. Then he started moaning when he did that and then the kisses started getting closer to my mouth. That was when I knew I had to stop it. I reported it to another CNA (V28). I reported it at night, and she (V28) said she (V28) had to go tell the nurse. The next day (V27 Admission Coordinator) came and talked to me and I told her (V28) the same story. Then some days later he (V29) came in my room . I was very scared when I saw him (V29) come in the room again. I was scared he (v29) was going to do something to me. R35 stated, during this time, when V29 entered the room, V16 R35's boyfriend had gone out to smoke a cigarette. R35 stated V16 returned to her room and V29 entered her room a second time. R35 stated V16 was very upset about this and told V29 to leave the room. R35 stated V16 left the room to find her nurse. R35 stated, I could hear the nurse yelling at him (V29) that he was not supposed to go in the room and she sent him home. I said, I don't want anyone to get fired especially around Christmas time but I did not want him (V29) in my room. The moaning really bothered me that was very inappropriate. Deep down I hoped they fired him because I don't know what he would do to someone that couldn't speak up for themselves. R35 stated, V14 Licensed Practical Nurse was the nurse who sent V29 home. On 1/26/22 at 2:46 PM, V14 stated, .When I went in (R35) said she doesn't know why that CNA (V29) was in the room and that he was not supposed to be in the room. The boyfriend (V16) said he was upset. (R35) said (V29) knew he was not supposed to be in her room because of what happened . V14 stated, I asked the CNA, because I knew he wasn't supposed to go there; I said why did you go in? If I was being accused of that stuff, I would not go in there just to protect myself from allegations, I would grab another staff member. He said the call light was on and he just went in to pick up a tray. V14 stated she was told by V15 (Licensed Practical Nurse, LPN) that V29 was not to go into R35's room due to a kissing incident with the CNA and the resident She told me something like he kissed her on the forehead and he was not supposed to be in there because of that. On 1/27/22 on 9:13 AM, V15 LPN stated she is a night nurse and worked on R35's unit. V15 stated she did not know V29 because he worked days. V15 stated, V28 CNA reported to her she did not want (V29) to be her CNA because something like he hugged her and kissed her on the forehead, but the patient does not want anyone to know because she doesn't want V29 to get in trouble and to lose his job . It was a very serious allegation .I endorsed it to (V14.) I told (V14) the same thing and that he (V29) should not be in the room because of the hugging and kissing issue . On 1/26/22 at 1:01 PM, V7 Nursing Supervisor when she spoke with R35, that's what the resident said, that there was hugging and kissing issues. On 1/27/22 at 10:10 AM, V1 stated she is the abuse coordinator. V1 stated it is not appropriate for staff to kiss a resident. On 1/27/22 at 12:52 PM, R35 stated I never mentioned anything like that; that he was repositioning me and he brushed up against me. I never minimized or changed my story to protect him (V29). I never said anything about him boosting me; I am too big (R35 weighs approximately 350 pounds) there is no way he is strong enough for him to reposition me. I never made an allegation that he repositioned me and he got too close to me; I only made the allegation about kissing and hugging. The facility's Abuse and Neglect policy (reviewed 1/17/22) showed an example of sexual abuse to be Implied or actual contact between a caregiver and resident of sexual nature. Any sexual behavior or relationship instigated by a staff member with a resident will be viewed as an allegation of sexual abuse . 2. R35's Face Sheet showed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R35's Minimum Data Set (MDS), dated [DATE], showed she was cognitively intact with a Brief Interview Mental Status score of 15 out of 15. The MDS showed she required extensive assistance of two people for bed mobility and transfers. R35's current room has a refrigerator stocked with miscellaneous drinks and snacks. On 1/26/22 at 8:55 AM, R35 stated, V22 Certified Nursing Assistant (CNA, R35 knew V22's first name, the facility later verified who the CNA was.) R35 stated V22 was in her room and as V22 was leaving the room she said, excuse me, I wanted something out of my fridge, then she started screaming. Yes, she was yelling loudly. My boyfriend heard her and he said what is going on. She said what do you want? I'm not doing anything for you it's time for me to go home. Then she said forget it; I'm leaving and she walked out the door. I did tell someone, but I don't remember who. I think it was one of the CNA's I really liked. That happened in my old room (R35 had a recent room change.) She (V22) did not get me what I wanted. I do need help to get stuff out of my fridge. R35 could not recall the exact date this occurred. On 1/26/22 at 9:08 AM, V16 R35's boyfriend stated the incident occurred in the evening, after R35 had returned from [CONDITION(S)]. V16 stated he was on the phone with R35 when the incident occurred and he could not hear the entire exchange; however, she was talking real loud and screaming; real loud and she was saying what do you want now? It was abusive and loud and then she said something about she was going to leave. On 1/27/22 at 10:10 AM, V1 stated I would expect the CNA to provide the resident with their request. It's not okay to yell at the resident and we strive to provide high quality customer service and to provide that assistance; that is why we are here. The facility's Abuse and Neglect policy (reviewed 1/17/22) showed verbal abuse includes but not limited to the use of oral, written, or gestured language. The policy showed examples of verbal abuse include yelling at residents.

Based on observation, interview, and record review, the facility failed to ensure two staff members assisted residents with bed mobility and toilet use. This failure resulted in R1 falling out of bed and sustaining bilateral femur fractures. This applies to 2 of 3 residents (R1 and R2) reviewed for falls in a total sample of 7 residents. The findings include: 1. According to the Electronic Health Record (EHR), R1 had [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], showed R1 needed extensive assistance of two people for bed mobility and bathing, and was totally dependent on two people for transfers and toilet use. The MDS showed R1 had impairment of the upper extremities on one side, and impairment of the lower extremities bilaterally. The MDS showed R1 weighed 182 pounds. R1 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 possible points, indicating (R1's) cognition was intact. A care plan showed R1 had Activities of Daily Living (ADL) self-care deficit related to limited mobility, with interventions including needing extensive assistance of two staff members for toileting and bed mobility. A Hospital X-ray report dated 05/10/2019, shows R1 had a [MEDICAL CONDITION] distal femur, likely a right proximal tibial fracture, and a left distal femur fracture with slight posterior displacement and mild impaction along the medial aspect. On 05/23/2019 at 11:00 AM, R1 said on 05/10/2019, V5, Certified Nursing Assistant (CNA), had been changing (R1) and was changing (R1's) sheets. V5 was standing on R1's right side as R1 was leaning to R1's right side, when V5 told R1 to roll over to the left side. R1's right hand was slightly contractured. R1 said R1 had very little use of R1's right hand to grasp anything, and could not hold the side rail very well with R1's right hand. R1 said R1 had to roll over a bump in the bed. The bump was the sheets and everything rolled up behind (R1's) back. Rolling onto R1's left side would have placed R1's left dominant hand underneath R1's side, leaving R1's right hand with limited range of motion free, but be unable to grasp the side rail with R1's right hand. R1 said R1 must have been positioned in bed closer to the footboard than R1 thought, because when R1 rolled over, R1 went right out of the bed without hitting the side rail. R1 said there was a partial side rail, but it didn't help because R1 was positioned lower than where the bed rail was at. R1 said when R1 fell out of bed, R1 hit the floor, first with R1's knees, then with the hips. R1 said the fall caused both femurs to be fractured. R1 said R1 was able to help turn R1 in bed, but there should be another person to be on each side so R1 wouldn't roll out of bed. R1 said prior to the fall there was usually two people to assist when turning R1 in bed, however, there were not always two people to assist on the weekends or the night shift, when there would only be one person. R1 said the bed was positioned pretty high; it was not in the low position when R1 fell . R1 said since the fall R1 has needed to take [MEDICATION NAME] for the pain, and also [MEDICATION NAME], but R1 continued to have leg muscle contractions (spasms) which were painful. R1 said the fall had limited R1's ability to help turn in bed. On 05/23/2019 at 1:06 PM, R1 said V5 had started to walk around the bed to the other side and (V5) probably didn't think (R1) would roll as fast as (R1) did. R1 said V5 definitely told R1 to roll, because R1 wouldn't have rolled unless V5 told R1 to. R1 said some of the CNAs will just say Let's go and R1 doesn't know what that means, so R1 will ask them, or wait for them to tell R1 what to do specifically. On 05/23/2019 at 1:25 PM, V7, Licensed Practical Nurse (LPN), said R1 always needed to have two people assisting with R1's care. V7 said the CNAs are paired with another CNA during the day shift and the evening shift. V7 said if the CNA needed to assist anyone who required a two person assist, then the CNAs are to find their partner and assist the person. V7 said R1 was alert and oriented to person, place, and time and had never been impulsive. V7 said R1 was a larger person with limited movement, and definitely needed two people to assist R1 with turning in bed, or it would be very dangerous. On 05/28/2019 at 11:24 AM, V5 said V5 had provided incontinence care to R1 alone, and was in the process of changing R1's bed linens. V5 had prepared and tucked the clean sheets under R1. After preparing the initial tuck, V5 was walking from one side of the bed to the other side of the bed, and R1 rolled over in bed without V5 telling R1 to roll over. V5 said prior to providing care , the head of R1's bed had been elevated so R1 had probably slid in the bed toward the foot of the bed. R1 was positioned more in the center of the bed than toward the head of the bed. V5 said during orientation, V5 had been trained to care for R1 using two people during bed mobility and incontinence care. V5 said this was the first time V5 had cared for R1 independently, and had no knowledge of what assistance R1 needed. V5 said the CNAs can find out the level of care needed by looking in the computer, or in the Kardex binder at the nurses station. On 05/28/2019 at 10:25 AM, V6, Doctor of Physical Therapy, said R1 had very limited mobility and probably couldn't turn in bed very well without assistance. On 05/28/2019 at 11:39 AM, V4, Restorative LPN, said the Kardex that the CNAs use was related to the residents care plans, and are updated when the care plan was updated. V4 said the Kardex binder included a weekly list of the residents and the type of mechanical lift assistance needed; transfer assistance of residents needing two or more people; and bed mobility assistance of two or more people. The Weekly Report dated 05/03/19, prior to R1's fall, shows R1 needed mechanical lift assistance, and bed mobility assistance of two persons. At 12:05 PM, V4 said R1 needed bed mobility lift assistance of two people only to lift R1 up in bed, but R1 was able to turn side to side with one person for R1's other care. V4 said prior to the fall, R1 was able to turn side to side with one person assistance. When asked to show where it documented R1's ability to turn side to side with one person assistance, V4 said it was in the care plan. The care plan history for bed mobility dated 07/20/2017, showed The resident requires two staff participation for toileting needs. No changes were made to the care plan until 05/10/2019, after R1's fall. The revision made on 05/10/2019 showed, The resident requires one to two staff participation for toileting needs especially with repositioning towards head of bed. Resident able to help during care by turning from side to side. (R1) able to hold on to side rails for mobility. Discontinued. V4 could not explain why the care plan revision dated 05/10/2019 showing R1 was able to assist with side to side turning with one person, was entered after R1's fall. On 05/28/2019 at 12:28 PM, V2, Director of Nursing (DON), and V3, Assistant Director of Nursing (ADON), stated after the fall R1 needed two person assistance for bed mobility and toileting, but prior to the fall R1 was able to be turned in bed and be toileted with one person assistance. When asked where it showed R1 was able to turn side to side with one person assistance, they said it showed it in the care plan. V2 and V3 also said therapy felt she could move side to side on R1's own, and would provide the therapy discharge summary to show documentation of therapy's recommendation. The ADL Self Care Performance Deficit Care Plan presented by V2 and V3, with a revision date of 05/23/2019, the entrance date of the investigation, and post fall date of 05/10/2019, included the revision R1 has bilateral BKA (Below Knee Amputation). Resident needs extensive assist of two with repositioning towards head of bed, but able to help reposition self from side to side. Per resident I can help myself on turning side to side. Uses bilateral siderails for mobility and repositioning. The Occupational Therapy Discharge Summary provided by the facility did not address R1's Bed Mobility or toileting ability, as they were not evaluated. A Restorative Quarterly assessment dated [DATE], showed R1 needed extensive assistance of two people for bed mobility, and was totally dependent on two people for toilet use. On 06/04/19 at 11:30 AM, V10, MD Orthopedic Surgeon, said V10 had not been given much information regarding (R1) ' s fractures from the facility, other than being told a staff member had been turning (R1) in bed, and was not told R1 fell out of bed. V10 said R1 was already at high risk for fractures, and it wouldn't take much impact or injury to cause the fractures. V10 stated, Yes the fractures were caused by an injury of the fall. According to V10, if R1's fractures don't heal in the next several months, the only option available would be to perform amputations higher above the fracture site. 2. According to the Electronic Health Record (EHR), R2 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE], showed R2 needed extensive assistance of two people for transfers and toilet use. The MDS showed R2 had impaired range of motion on one side of R2's upper and lower extremities, and was not steady moving on and off the toilet, needing staff assistance to stabilize. R2 had a Brief Interview for Mental Status (BIMS) of 15 out of 15 possible points, indicating (R2's) cognition was intact. A care plan showed R2 was at high risk for falling related to left [MEDICAL CONDITION] and left above knee amputation, with interventions including to always use two staff for safety during transfers and toilet use. The facility's Incident Log showed R2 had a fall on 04/21/2019. On 05/28/2019 at 9:53 AM, V8, CNA, said R2 was trying to reach the toilet paper in the bathroom. V8 said the toilet paper was on the left side of the toilet, which was on R2's paralyzed side. V8 said R2 stands with R2's one leg, and holds onto the bar or the wall for transfers. V8 said V8 was more there to support in helping R2 turn and guide R2 on and off the toilet. V8 said R2 was able to clean R2 up, and get on and off the toilet independently. V8 said V8 was alone with R2 and was usually alone. V8 said V8 would ask R2 if R2 needed more assistance from two staff members. V8 said the Kardex will let us know what kind of assistance the residents need. On 05/28/2019 at 10:25 AM, V6, Doctor of Physical Therapist, said R2 had trouble with pivoting because R2 was more unstable due to R2's left side paralysis. V6 said R2 was very impulsive, and didn't listen all the time. On 05/28/2019 at 12:28 PM, V2, (DON), and V3, (ADON), said R2 needed assistance of two people for toilet use. On 05/23/2019 at 4:04 PM, V2 (DON) said the facility does not have a policy regarding resident transfers, but they follow the resident's individual recommendation on the MDS and care plan for resident transfers.

Based on observation, interviews and record reviews, the facility failed to provide adquate monitoring/supervision to one resident (R23), who has a poor cognitive status with a history of frequent falls, failed to analyze each of R23's falls occurrence to ensure the application of appropriate safety interventions/measures, and failed to ensure safe technique was utilized during the transfers of two residents (R1 and R11) out of the sample of 24. This failure resulted in R23 having an avoidable fall and sustaining a Intracrainal Hemotoma. This applies to three out of eight residents (R23, R1 and R11) in a sample of 24 residents, who were identified at risk for falls. Findings include: 1. Review of R23's Face Sheet documented that R23 is a [AGE] year old male with [DIAGNOSES REDACTED]. Review of the facility's Accident Log documented that R23 experiened multiple falls in the facility. R23 fell on the following days: 12/10/2012, 12/14/2012, 01/03/2013, 01/05/ , 1/06/2013 and 1/16/2013. Review of the Incident Investigation Report, dated 1/16/2013, documented that R23: "fell when he was left in a room by himself and fell ... Nursing observation: Staff heard resident calling for help, noted resident sitting sideways with ...walker on the floor. Noted moderate amount of bleeding from head... Number of falls: past 60 days: 5... Physical Factors: poor safety jugement; behavior/cognitive factors; wandering/pacing... Probable Cause: wheelchair was in the way... Intervention: do not leave in room in wheel chair unattended... residents fell forward in ...walker and hit his forehead on floor causing a laceration to his forehead requiring 7 sutures..." Review of R23's Incident Investigation Report, dated 1/21/2013, documented the following: "Incident occurred on 1/21/2013 at 7 in the hallway... R23 fell while in ...walker on right side. R23 complained of pain in right arm and shoulder decreased ROM (Range of Motion)... Nurmber of Falls: past 30 days: 7 ...Physical Factors: behavior/cognitive factors; poor safety judgement... Probable Cause: resident leaned to the right side tipping the ...walker toward the right side... Intervention: do not leave in room in wheel chair/chair unattended." The director of nursing was interviewed 4/03/2013 at 2:12 PM. E2 said before R23 fell on [DATE] the intervention being used to keep R23 safe was to monitor him and not leave him alone in his room. E2 stated that R23 should have stayed in the common areas for monitoring. But, E2 said that a therapist left R23 alone in his room. E2 said that R23 was assessed by physical therapy for the use of the walker before he fell on [DATE]. However, E2 said another assessment was not completed after R23 fell from the walker on 1/16/2013. This lack of reassessment of the walker did not ensure it was safe for R23 to continued to use this device. The nurse who sent R23 to the hospital when he fell on [DATE] was interviewed on 4/02/2013 at 3:15 PM. E13 said that R23 could be combative, verbally abusive, so we kept a certified nurses aide with him. E13 could not recall what CNA was monitoring R23 when he fell . E13 said she recall that this CNA said she was following R23 but R23 fell . E13 said she came and saw R23 on the floor. E13 said she sent R23 to the hospital and later learned R23 had a serious injury. E13 stated, "It should not have happened, but you could not stop him for doing what he wanted to do." 2. On 3/26/13, E15 was observed to transfer R1 from his wheel chair to his bed. E15 grabbed R1 under both arms and and pulled him (R1) up and out of his wheel chair, bristly turned him around and placed him abruptly on the bed. E15 was observed wearing a gait belt around his (E15) waist. R1 made the statement "wait a minute. They are always in a hurry." A review of the facility' current minimal data assessment for R1 noted that R1 is to transfer with one assist. Also, R1 has been assessed to ambulate in room and hallway. During an interview with E2 (DON) on 3/28/13 at approximately 3:10 PM, E2 stated that staff are to use gait belts with all one assist transfers. A review of the facility's policy and procedure for transferring a resident noted that staff are to inform resident of the procedure, place a gait belt around the resident's waist, ask the resident to scoot to the front edge of the chair, make sure brakes are on, and assist the resident to stand and pivot around to the bed. 3. On 3/26/13 at 11:00 a.m. E16 (Restorative CNA) was observed transferring R11 from his bed to his wheel chair. R11 was noted sitting on a bed in a low position. E16 did not raise the bed to a higher position to make it easier for R11 to stand. E16 grabbed R11 under his left arm and grabbed the back of R11's pajamas, stood R11 into a standing position, and pivoted R11 into the wheel chair. E16 had a gait belt around her waist which she did not use to transfer R11. When E16 was asked why she did not raise R11's bed and use the gait belt prior to R11's transfer to the chair; no answer was given. Review of R11's admission face sheet showed R11 had admission [DIAGNOSES REDACTED]. Review of R11's CAA (Care Area Assessment) for falls dated 3/22/13 showed R11 was at high risk for falls. R11's MDS dated [DATE] showed R11 as an extensive, 2 person assist transfer. The facility's incident tracking log showed R11 had an unwitnessed fall in the facility's dining room on 3/13/13 and complained of pain to the right hip. R11 was sent to a nearby emergency room and was hospitalized with a suspected hip fracture although it was unfounded. Review of R11's plan of care addressing falls did not show the monitoring that should be done to prevent falls for R11. R11's care plan also did not show the type of transfer that should be performed on R11 such as 1 person, 2 person, mechanical lift, gait belt, etc ... Interview with E2 (Director of Nurses) on 3/28/13 at 3:00 p.m. noted E2 to say R11 should be transferred with a gait belt. Review of the facility's policy on Transfer Activities included steps in the procedure to: 1. Obtain assistance of another individual if necessary for safe transfer. 2. Place bed in position with the top of the mattress at the level of the wheel chair seat. 3. Apply transfer (gait) belt. 4. Hold the transfer belt from underneath, straighten your hips and legs slightly and lift the client to a standing position on the count of three. 5. Pivot on your foot farthest from the wheel chair and position the resident over the wheel chair seat. 6. Lower the resident into the wheel chair by fexing your hips and knees.

Based on observation, interview and record review the facility failed to consistently and accurately assess, monitor and implement pressure relieving methods to help prevent the development of pressure ulcers for 3 residents (R3, R7 and R24) at risk out of a sample of 24 residents. As the result of this failure, R24, who was admitted to the facility without pressure sores, developed an unstagable area to his left heel and a stage III to his right heel. This failure also resulted in R3 being admitted to the emergency room with a stage III pressure sore on buttocks and heel, the facility's staff was unaware of the opened areas. The findings include; 1. R24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R24 was assessed as totally dependent on staff for all levels of activities of daily living. Review of the facility's nurses treatment notes dated for 12/31/2012 noted R24 acquired bi-lateral heel wounds, with co-morbidity factors documented as dementia and incontinence. The right heel wound was assessed as 3.0 cm in length and 3.5 cm width, reddened area with black wound bed. The left heel wound measurement was recorded as 2.8 cm in length and 3.5 cm in width. Interventions that were documented "off-load, moon boots applied and follow up with the physician." By 2/13/13 both heels had progressed to unstagable. On 3/28/13 during an interview with E14 (treatment nurse), E14 stated that he was not aware of how R24 developed his heel ulcers. 2. Review of R3's Face Sheet was observed to have documentation that R3 is a [AGE] year old female, who was admitted to the facility originally on 12/24/2011. R3 has [DIAGNOSES REDACTED]. Review of R3's care plan documented that she had a potential for skin breakdown and it was a focus of concern in her care. But, the care plan interventions were general and not specific. Review of R3's recent Braden Scale Assessments, dated 3/27/2013 and 2/27/2013, documented that R3 is at risk for the development of pressure sores due to: immobility, moisture to skin, inadequate nutrition and friction and shearing. Review of R3's Wound Care Assessment Sheet documented that R3 developed opened wounds in the facility on the following dates: 10/03/2012 Stage II on Right Lower Buttocks 10/16/3012 Stage II on Outer Medial Buttocks 10/18/2012 Stage II on Right Outer Buttocks. No documentation found after 1/30/13 regarding R3's wounds and/or treatment in the nurses notes. Review of R3's Physician order [REDACTED]. R3's nursing note, dated 3/05/2013, documented that R3 was sent to local emergency room for care at 3 PM for abnormal labs. Review of R3's Hospital Face Sheet documented that R3 arrived at the hospital emergency roiagnom on [DATE] at 3:45 PM. Review of R3's History and Physical, dated 3/06/2013, from the hospital documented the following: "... Work up in the emergency room showed that... The patient (R3) was also found to have a stage III decubitus ulcer on her sacrum and another ulcer on her left heel. For all the above, the patient (R3) was admitted for further evaluation and management..." R3's son (Z2, Power of Attorney) was interviewed on 3/28/2013. Z2 stated that he was informed by the hospital's emergency room physician that his mother had a pressure sore on the buttocks and heel. During the initial tour on 3/26/2013. R3 was observed with dressings on her buttocks and left heel. R3 was observed to be cognitively impaired with dysphagia, and contractures. R3 was also observed to be dependent upon staff for incontinence care and to be turned and repositioned. On 3/27/2013 at 10:45 AM, the treatment nurse (E14) was observed changing R3's opened wound on the buttocks and left heel. E14 stated R3 had a stage III on the buttocks and unstagable on the left heel. E14 stated she was not aware that R3 had developed pressure sores until she returned from the hospital facility on 3/05/2013. E14 said that R3 has a history of reoccurring pressures sore developing in the facility, which healed and reopened. E14 described R3's pressures sores as being healed before she was admitted to the hospital. E14 said that R3's daughter-in-law told him that she was informed by the hospital that R3 had pressure sores, and her pressure was debride at the hospital. The nurse (E26), who sent R3 to the hospital on [DATE]. During an interview on 3/27/2013, E26 stated that R3's did not have any opened wounds when she was sent to the hospital on [DATE]. E26 said she did skin checks for R3 twice a week. R3's primary physician was interviewed on 3/28/13. Z1 said that R3's skin integrity was poor and she could start breaking down within 24 hours. Z1 agreed that R3 required close monitoring of her skin integrity. But, Z1 did not explain why the nursing staff did not have any orders for more frequent skin checks, so any pressure sore could be identified, assessed and treated. 3. On 3/22/2013 at 1:24 PM, the wound on R7's elbow and left foot were observed. E14 measured R7's elbow wound to be 0.4 cm x 0.5 cm. E14 said that R7's elbow wound was a stage III. E14 stated that R7's elbow wound developed in the facility. E14 said this wound was caused by her immobility and pressure from the arm rest of her wheel chair. E14 stated, "We start applying a pillow under her elbow, while in the wheel chair." However, E14 did not identify any preventive measures applied to prevent the pressure of her arm rest from causing a pressure sore. Review of R4's Face Sheet documented that R7 is a [AGE] year old female. R7 had [DIAGNOSES REDACTED]. Review of R7's care plan and wound care documentation did not address intervention for pressure of R7's elbow until her wound developed. Review of the facility's policy Prevention of Pressure Sore documented the following: "Any resident that is assessed as being at risk for skin breakdown will have specific preventative measures implemented and care planned... Equipment... elbow protector... Use elbow and heel protectors as necessary... Positioned to prevent pressure from medical devices such as tubes casts, braces, etc... Notify the POA... Pressure ulcer investigation completed upon discovery... " However this policy was not being followed in the care of the above resident's care.

Based on record review and interview the facility failed to provide the necessary care and treatment to one of three individuals (R2) in the sample when they failed to recognize and address changes in intake and output and overall health. This failure resulted in a decline in physical condition for R2 and subsequent hospitalization during which R2 expired. FINDINGS INCLUDE: R2 is deceased and the resident's closed record was reviewed. On February 13, 2012 R2 was admitted from an acute care hospital to the facility with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. Review of Nurses Notes indicated that R2 was admitted to the facility with complaints of pain in the chest, back and legs. The resident chronically complained of pain and received [MEDICATION NAME] for the pain from [DATE] through and until [DATE]. R2 received the [MEDICATION NAME]es from [DATE] through [DATE]. On [DATE] R2 was assessed by Z1 (physician) for pain control and a new pain medication ([MEDICATION NAME] Patch) was ordered. On [DATE] R2 refused the ordered [MEDICATION NAME] (given for pain), stating that the patch wasn't effective in relieving her pain. On [DATE] R2 complained of a migraine headache. Z2 (physician) was notified and ordered Imetrix for the pain. R2 received Imetrix multiple times between [DATE] and transfer to the hospital on [DATE]. On [DATE] R2 is documented as having complained of blurred vision, continued pain and staff documented that the resident appeared to be weak. There is documentation on [DATE] that verifies the allegation that the resident wanted to go to the hospital. There was also a documented decrease in bowel sounds (staff had difficulty hearing bowel sounds in the left lower quadrant). The resident was documented as crying in pain. [MEDICATION NAME] one tab was given and resident response was monitored. At 5:00PM R2 stated that she hadn't had any relief from pain. The resident was "reassured" and Z3 (physician) was paged, but didn't answer. Staff paged Z3 several times,but he didn't answer; Z4 (Medical Director) was contacted, informed of situation and transferred R2 to the hospital. Staff also documents that R2's family member was contacted regarding the transfer. It isn't until [DATE] that staff documents a decrease in R2's appetite. On [DATE] staff documented the dinner intake as 25%, down from 100% on previous days. On [DATE] and [DATE] staff do not document R2's meal/liquid intake at all and on [DATE] staff documents that the resident ate 50% of her dinner. On [DATE] and [DATE] staff doesn't document the resident's meal intake at all. On [DATE] staff documents that R2 eats more than ,[DATE] of meals. On [DATE] R2 is documented as eating 25% at dinner and the appetite "remains poor..states her vision is so blurry... Resident appears weak." Staff continued on to document "No diarrhea this shift even though resident states that she is still having it." There isn't any verification of any physician or family having been notified of the resident's blurred vision or apparent weakness. There is not any documentation of a physician being notified of R2's decreased appetite until [DATE] when [MEDICATION NAME] (an appetite stimulant) was ordered. Nor is there any indication that staff notified Z8 (Registered Dietician ) of a decline in appetite. [DATE], R2 was transferred to the hospital. When asked to provide all Nutritional Assessments conducted for R2 between her admission to the facility on [DATE] and discharge [DATE] the facility provided a Nutrition Note for R2 dated [DATE] which assessed that the diet as served met ,[DATE]% of her estimated needs, that the resident was eating well, and a Nutrition Risk Assessment for R2 that was dated [DATE]. This date is dated three (3) weeks after R2 died . The information on the Risk Assessment is the same information as documented on the Dietary Assessment Note of [DATE] and fails to mention/assess the resident's poor oral intake and unplanned weight loss of 6.7 pounds between February,2012 admission and [DATE] discharge to the hospital. When the surveyor asked to speak with Z8, the facility stated that Z8 was no longer employed at the facility, that Z7 was the new Registered Dietician for the facility. When interviewed [DATE], Z7 Registered Dietician, stated that she would expect staff to notify her regarding a resident with diarrhea, that sometimes the diarrhea may be medication related or dietary related. Z7 stated that she would interview the resident. Z7 stated that the caloric and fluid requirements would need to be calculated and if the resident has diarrhea they As stated by Z9 "R2 was brought to the ER due to a change in mental status and was found to have severe [MEDICAL CONDITION] requiring pressors ( to increase blood pressure ) support...found to have a creat of 12.5...had quite significant diarrhea for the last few weeks and not eating well. Over last night only had 100 ml urine...virtually anuric on pressors." Z9's impression was 1). Acute [MEDICAL CONDITION] most likely prerenal, however anuric and on pressors. 2). Hypokalemia 3). Metabolic Acidosis most likely secondary to severe diarrhea 4). Septic Shock. Attachment 4. Mosby's Clinical Nursing, 3rd Edition, page 130, states that metabolic acidosis (decrease in PH and decrease in [MEDICATION NAME] levels) is caused by either the increase of fixed metabolic acids or through the loss of [MEDICATION NAME] in the body fluids and lists persistent diarrhea as a cause of [MEDICATION NAME] loss. Page 900 addressed Acute [MEDICAL CONDITION] and indicated that one category of [MEDICAL CONDITION] is prerenal and listed one cause as dehydration. On [DATE] at 2340 R2 was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. The resident was receiving intravenous (IV) fluids of D5W with 3 amps of NaHCO3 (sodium [MEDICATION NAME]). The physician progress notes [REDACTED]. On [DATE] at 10:15PM the ER Attending physician was asked to assess R2. The Attending physician pronounced R2 dead. The Death Certificate for R2 listed the initial cause of death as Acute [MEDICAL CONDITION] due [MEDICAL CONDITION] and Advanced [MEDICAL CONDITION].

Based on observation, interview and record review the facility failed to: (1) Prevent the development of pressure ulcers to two of two residents assessed for pressure ulcers (R5 and R6) in the sample of 24. (2) Failed to turn and reposition R 6 for more than two hours. (3) Develop and implement a repositioning plan for R 6. These failures resulted in the development of an avoidable facility acquired Stage II pressure ulcer on R 6's left buttocks and an avoidable facility acquired stage ll pressure ulcer on R5's coccyx. Findings include: 1). On 03-14-12 from 9:35 AM thru 11:35 AM, R 6 was observed in the dining room sitting in an adult reclining chair poorly positioned, leaning on the right side. At 12:30 PM R6's lunch tray served and R6 fed by the staff at 12:40 PM. From 9:35 AM thru 12:30 PM, R6 was not observed to be repositioned by the staff or offered fluids until lunch. Review of the facility weekly wound report dated 03-08-12 thru 03-13-12 reads: R 6 acquired a Stage II pressure ulcer on the left buttocks measured at 1.0 cm X 1.0 cm X 0.1 cm. This left buttocks pressure ulcer was initially noted on 02-13-12 as a Stage II. On 03-15-12 at 9:30 AM, R6 was observed in the dining room sitting on an adult reclining chair sleeping. At 10:06 AM, Z2(Hospice Aide) was observed giving R6 a shower, Z 2 stated " she (R 6) has a lot of BM in her diaper. " At 10:46 AM, skin assessment was requested. E7(The Treatment Nurse) stated " she currently has one Stage II pressure ulcer on her left buttocks. This is acquired in the facility; it was Stage II when it was first noted. " E 7 measured R 6's pressure ulcer at 1.0 cm X 1.2 cm X 0.1 cm. E 7 also stated " I can not tell you if the pressure ulcers are avoidable or unavoidable- only the doctors can do that. For her (R 6) she's totally dependent on staff for all of her activities of daily living. She's unable to reposition self; she needs to be repositioned by the staff. She's also incontinent of bowel and bladder. " There was no prevention plan developed for R 6 and this finding was confirmed by the Minimum Data Set/ Care Plan Coordinator (E 23) on 03-15-12 at 2:03 PM. E 23 presented the pressure ulcer care plan dated 11-09-11, this reads: " description of problem: The resident (R 6) does not have any pressure ulcers at this time: they are at risk for developing pressure ulcers related to assistance with activities of daily living and incontinence issues and primary mode of transportation is a wheelchair ...Will not develop care plan." On 02-14-12 a care plan for Stage II pressure ulcer on the left buttocks was developed. This plan of care was not individualized to address the specific needs of R 6. There was no repositioning plan developed to promote healing to R 6's ulcer. Review of R 6's Minimum Data Set (Minimum Data Set) dated 11-02-11 and 01-17-12 section M (skin conditions), MO 150 Risk of pressure ulcers. Is the resident at risk of developing pressure ulcers? R 6 was scored " 0 " NO. Review of R 6 ' s Braden scale from 11-14-11, 01-20-12 and 02-02-12 reads completely immobile- does not make even a slight changes in body/extremity position without assistance. Problem- Requires moderate to maximum assist to move. 2). Per wound report, R5 is identified by the facility to have acquired a pressure sore to the coccyx while in the facility. A review of the nurse's notation from 10/1/11 through 3/14/12 the facility indicates the following: The 10/8/11 nursing notation identifies redness to R5's groin area. On 12/8/11 the notation states: R5's skin is kept constantly moist related to perspiration, urine, etc. Dampness noted every time resident moved or turned. The 10/25/11 notation for friction /shearing states: R5 requires mod/max assist to move. R5 cannot lift without sliding on sheets. Skin is often, but not always moist. Linen must be changed at least once per shift. On 12 /21/11 nurses documents for R5's skin condition: R5 has excoriated buttock. On 12/27 nursing documents, R5 continues to have excoriation on buttock. The 12/30/11 skin notation documents: " noted an open area on coccyx measuring 1.0 cm x 1.0cm x 1.0cm to R5. From the interview with (E7) treatment Nurse conducted on 3/14/12, questioned how R5 developed the pressure ulcer. E7 presented a pressure ulcer investigation dated 12/30/11. The probable causative reasons for development of the pressure sore; the assessment is circled for incontinence, friction/pressure and change in nutritional status. A review of R5 ' s 10/17/ 2011 annual Minimal Data Set (MDS) under section M SKIN CONDITIONS, R5 is identified to be at risk for developing pressure sores. R5 does not have one or more unhealed pressure ulcers at stage I or higher.

1). Based on record review and interview, the facility failed to provide adequate supervision to prevent two residents (R10, R20) from falling repeatedly, including numerous falls in the dining room. This failure involved two (R10, R20) of seven residents reviewed for falls, out of a sample of 24. This failure resulted in one resident (R10) falling and sustaining a hip fracture on 11/11/11. The facility also failed to ensure interventions were implemented for one resident ( R20) out of seven reviewed for falls, out of a sample of 24. The facility also failed to document evidence of care plan revisions after falls for two residents (R10,R20) out of seven reviewed for falls, out of a sample of 24. Findings include: R10 is an [AGE] year old male with numerous [DIAGNOSES REDACTED]. His current MDS (minimum data set) of 3/26/12 scores R10 to require extensive one-person physical assistance (3/2) for bed mobility, transfers, ambulation and personal hygiene. The occurrence charting and fall investigation report dated 2/15/11-3/14/12 for R10 reflects the following falls: 9/22/11 occurrence charting- fall in dining room at 6:50 pm-resident stood up from chair and lost his balance. Fall investigation states staff unable to reach resident in time. Intervention listed on Fall Investigation states to not leave in room in w/c unattended. (Resident fell in dining room, not in his room). 9/26/11 occurrence charting states R10 observed on floor in room at 1:30 pm. This form indicates no witnesses. Fall investigation charting for this same date also indicates no witness and that an alarm was in place and sounding. R10 sustained 2 skin tears. The probable cause was listed as R10 climbed out of bed. There is no intervention listed. 9/30/11 occurrence charting states at 8:15 pm, R10 was found on floor after getting out of bed. The alarm was sounding. The occurrence form indicates there were no witnesses. R10 sustained bruising to the back of his head. Fall investigation charting indicates R10 has poor safety judgement and got out of bed without staff assistance. The intervention stated is to monitor R10 more often. There is no mention of how frequently to monitor, how this will be accomplished, who will do the monitoring or how this will be monitored. This intervention. does not appear on R10's current care plan dated 2/3/12. On 3/14/12 at 11:15 am, Z1 (consultant) stated they cannot provide former care plans on residents because of the computer system they use. They can only provide current care plans, which do not show previous interventions. 10/1/11 occurrence charting states R10 fell in the dining room at 10:55 am, while rising from his wheel chair. Only another resident (R1) is listed as a witness. Fall investigation charting for this incident states resident was found sitting on floor in dining room. Investigation charting indicates the alarm not in place. Probable cause states without staff assistance. Intervention is chair alarm. R1 stated R10 stood up from his wheel chair, lost his balance and fell , per fall investigation report dated 10/1/11. 11/4/11 occurrence charting indicates R10 fell in the dining room at 6:00 pm. The form indicates staff witnessed event. Fall investigation charting states resident suddenly stood up and fell to the floor. Staff was too late to stop fall. The form indicates the alarm was in place but did not sound. The intervention was the chair alarm cord was shortened. 11/11/11 Occurrence report indicates R10 was observed on the dining room floor at 7:29 pm. Witness listed as none. The report states R10 was rising without assistance. R10 complained of hip pain and was sent to the emergency room for evaluation. Fall investigation report states the chair alarm sounded and R10 had fallen to the floor before staff could reach him. Probable cause states R10 slid from the chair and has a history of falls. Re-admission nursing note from 11/18/11 timed at 1:47 pm reflects R10 was readmitted from the hospital with a surgical incision. Re-admission skin note from 11/18/11 at 4:27 pm reflects R10 was readmitted from the hospital with a [DIAGNOSES REDACTED]. 1/7/12 occurrence report indicates R10 fell in his room at 6:30 pm, sustaining a skin tear to his arm.. Documentation reflects R10 was attempting to stand from his chair when he fell . This documentation reflects no witnesses. There is no fall investigation charting for this event. 2/3/12 occurrence charting indicates R10 fell in the dining room at 3:05 pm when he stood up from his wheel chair unassisted. He sustained an abrasion to his forehead. This documentation indicates staff were witnesses. Fall investigation charting states R10 stood up and lost his balance. He claimed he wanted to go to the bathroom. Intervention:is to assist R10 to the toilet when needed and have R10 engage in activities. Incident Prevention Addendum for this event states R10 became agitated with another resident, stood up unassisted and fell . Wheel chair alarm had been in place. Resident's behavioral issues that were contributing factors include agitation and lack of safety awareness. 3/8/12 occurrence charting reflects R10 again fell in the dining room at 7:30 pm. This is described on this document as an unwitnessed fall. Staff assumed R10 was attempting to ambulate on his own. R10 sustained a scratch on his knee. There was no witness to fall. Fall investigation charting for this event states R10 had an unwitnessed fall in the dining room. R10's wheel chair alarm was not sounding because it was disconnected. Intervention listed on Fall Investigation states, "I will make it a point to check resident's chair alarms and if they are functioning and connected more often. Do not leave in room in wheel chair/chair unattended". Incident Prevention Addendum of the same date reflects the following: Wheel chair cushion restraint was not in place. Chair alarm wasn't connected. Nursing staff was inserviced on checking the alarm for function and to make sure it is connected appropriately. This documentation also reflects the alarm was in working order, but did not sound because it had been disconnected. Again, there is no description of how often R10's alarm will be monitored, who will do the monitoring or whether it will be documented or not. The same intervention of not leaving R10 unattended was listed in previous occurrence charting for R10's 9/22/11 fall.. R10 sustained a total of eight falls from 2/15/11 through 3/14/12. Of those, six falls occurred in the dining room. Of those six falls occurring in the dining room, there were no staff witnesses for four of those falls., 9/22/11 fall-no staff witness. 10/1/11-only witness a resident. 11/11/11-no witness. 3/8/12-unwitnessed fall. R10's current falls care plan dated 2/3/12 (2 submitted by facility with this date) reflects numerous interventions, including engaging R10 in activities, chair alarm, bed alarm, floor mat beside bed, assist with transfers, bed in low position, scheduled toileting, assisted ambulation and wheel chair cushion restraint. However, the only interventions dated are those of engaging R10 in activities, dated 2/3/12 and use of a wheel chair cushion restraint dated 2/3/12. Additionally, an intervention is dated for 3/9/12 includes revision of times for use of wheel chair cushion restraint. Neither of these care plan as submitted reflects revision of the care plan after each fall, with interventions specific to each of R10's falls. These care plans do not reflect interventions were initiated timely in relation to all of R10's falls. R20 is a [AGE] year old female with [DIAGNOSES REDACTED]. R20's current MDS scores R20 as a 3/2 for bed mobility, indicating R20 requires extensive assistance of one person for bed mobility. For locomotion on and off the unit, as well as dressing and eating, R20 is scored a 4/2, indicating R20 is totally dependent on staff for these activities. Occurrence reports and and Fall Investigation charting documents the following falls for R20: 6/11/11-Occurrence report documents R20 fell , was eased to floor by the nurse's station. Nursing note dated 6/11/11 at 10:37 am document R20 fell while self-ambulating, at 9:36 am. Witnesses were listed as staff. There is no specific intervention provided on either the occurrence report, the nursing note or the care plans for lack of safety awareness dated 1/16/12 or 2/24/12 , as all but 1 interventions are undated. 7/25/11-Occurrence report indicates at 7:25 am, R20 "eased to floor" and sustained a bruise below the left eye. Nursing note of that same date also reflect R20 was eased to the floor in the dining room. The note describes R20 as agitated. Care plans for falls/lack of safety awareness dated 1/16/12 and 2/24/12 contains no specific intervention related to this 7/25/11 fall, as all but 1 interventions are undated.. Witnesses are listed as staff. 8/23/11-Occurrence report of 8/23/11 reflects R20 fell at 6:10 pm, outside the entryway to the 1/2 wing dining room. Witness is listed as R20's family member. Nursing note from 8/23/11 at 11:43 am document R20 fell during assisted ambulation. R20 sustained a bump and an abrasion to her forehead. Care plans for lack of safety awareness dated 1/16/12 and 2/24/12 contains no specific interventions related to this fall, as all interventions except for 1 are undated. 10/15/11-Occurrence report indicates R20 fell in the dining room, witnessed by staff, at 10:50 am. Nursing note from 10/15/11 at 2:40 pm reflects R20 had been sitting in her wheel chair. R20 sustained a bruise to her upper buttock. Neither occurrence report, nursing notes or care plans dated 1/16/12 or 2/24/12 contain any specific intervention related to this fall, as all interventions except for one are undated. 10/21/11-Occurrence report reflects R20 fell at 7:30 am again in the dining room. There was no injury. Late entry nursing note dated 10/23/11 timed at 10:47 am indicates R20 was ambulating with assistance at the time of the incident. Neither the occurrence report, the nursing note nor the care plans dated 1/16/12 and 2/24/12 document any intervention specific to this 10/21/12 fall, as all but one care plan intervention is undated. 12/24/11-Occurrence report reflects a fall for R20 at 3:00 pm, again in the dining room. This report indicates R20 was being pushed in her wheel chair at the time. There was no documented injury. Witness is listed as staff. Occurrence charting for this same date timed at 8:26 pm states resident slid out of her wheel chair to the ground. Intervention listed as bed alarm, fall mats when in bed, pressure alarm, chair alarm, do not leave in room in w/c or chair unattended. Care plan for lack of safety awareness dated 1/16/12 and 2/24/12 documents several of these interventions, all of which are undated, which does not reflect revision after each fall. There is no indication when interventions were started (there is only one intervention that is dated, and the date of that intervention is 1/9/12). 1/8/12-Occurrence report documents a skin tear which occurred in the dining room. No specific information is provided. R20's care plan dated 1/16/12 states on 1/8/12, R20 slid out of her wheel chair. R20 sustained seven falls between 6/11/11 and 1/8/12. Of those incidents, six occurred in the dining room of the one/two wing and one occurred at the nurses desk, which is adjacent to the dining room. On 3/21/12 at 12:00 noon, E10 (Clinical Care Coordinator one/two Wing) stated due to the number of falls and unwitnessed incidents in the dining room, in January 2012, she began assigning CNAs (certified nursing assistants) to monitor the dining room on the evening shift, for 20 minute intervals on a rotating basis. This was initiated to provide better monitoring of the dining room. She stated she was aware R10 sustained another unwitnessed fall in the dining room as recently as 3/9/12. The care plans submitted for R20's falls, with a problem identified as no safety awareness and impaired judgement, are dated 1/16/12 and 2/24/12. The care plan dated 1/16/12 contains seven interventions: all but one intervention is undated. The only dated intervention is dated 1/9/12, which states to push R20 out of the unit to divert her attention. The other undated interventions include non skid pad on wheel chair, bed alarm on when in bed, bed in lower, locked position, floor mat on floor beside bed when resident in bed, provide max/extensive assistance of two persons to transfer bed/wheel chair/chair and offer sensory stimulation. The 2/24/12 care plan contains the same undated interventions. The failure to date interventions does not reflect a revision/updating of R20's care plan after each fall incident, with interventions initiated which are specific to the type of fall R20 sustained. This care plan does not reflect the timeliness of the interventions because they are not dated. There are no revisions apparent to the care plan after fall incidents with the exception of the intervention dated 1/9/12. 2). Based on observation record review and interview the facility failed to maintain water temperatures in resident bathrooms at safe temperatures. This has the potential to affect residents that the facility identified as being able to toilet and wash their hands independently. This applies to 3 residents (R3, R12, and R15) in the sample of 24, and 13 residents (R34, R51, R62, R65, R71, R76, R80, R82, R25, R110, R114, R122 and R123) in the supplemental sample. Findings include: On 3/13/12 the temperature of water at handwashing sinks taken on the 500 unit in resident room 506 at 11:15 am was 118 F.. Another water temperature at the sink in room R2 A on this unit was checked and initially measured 117.4 F; after 2 minutes when left to run for several more minutes the water temp was 119.5 F at 11:23 am. The 300 and 400 unit was checked for water temperatures at 11:45 am. In room 301 the temperature of the water at the sink was 122.1. F. At 11:55 am the water temperature measured in room 101 was 116.4 F. This was called to the attention of E1 the administrator at 12:00 noon on 3/13/12. E1 instructed E5 (facility manager) and E6 ( maintenance) to investigate the problem. Staff were not aware that the temperatures exceeded 110 F. On 3/14/12 at 3:40 pm E1 and E5 presented a copy of the mechanical rounds which documents various daily temperatures and systems check of items such as the boiler room, circulator pump and water temperatures in various rooms. This document has a space for each day of the week, including room water temperatures. From 3/12 to 3/16/12 the water temperatures in the rooms ranged from 101 to 110 F. From 3/ 5/12 to 3/9/12 the water temperatures in the rooms measured from 108 to 110 F. The form indicates water should not exceed 110 F in resident rooms. At this meeting E1 and E5 told a surveyor the facility purchased plumbing equipment on 2/3/12 for mixing valves. E5 explained there are three separate units each with their own mixing valves, one tank is for the 500 unit, one tank is for 100 and 200 units, and another tank for the 300 and 400 units. Since 2/3/12 they have had to adjust the valves on a daily basis

Based on observation, interviews and record review facility failed to: 1) Supervise and ensure the safety of 1 of 1 sampled residents (R2), with a acute mental status change on 12/31/11. R2's mental status progressively declined over a 7 hour period with increasing agitation, confusion, repetitive disrobing and un-safe repetitive independent ambulation. R2 also wandered out of his room and into other residents' rooms, upsetting the other residents. Over the course of this 7 hour time frame the night shift staff had increasing difficulty re-directing R2. This lead to R2 becoming physically aggressive with a staff member during re-direction that resulted in physical injury to that staff member. While R2 was exhibiting agitated, aggressive and destructive behaviors, the nursing staff failed to monitor, supervise and obtain timely medical evaluation and treatment. When R2 was observed exhibiting violent aggressive behaviors of banging objects against the wall with such strength as to dent the walls, the nursing staff closed the resident's door and left him un-supervised in his room. When the staff returned to the nursing station R2 climbed out of his unsecured bedroom window. 2) Secure "70%" of resident room windows on the 500 unit (currently occupied by 26 residents), to prevent the windows from opening more than 6 inches, as per facility protocol. 3.) Failed to adequately supervise and initiate interventions to address exit seeking behaviors for 1 of 8 residents (R1) identified by the facility as "At risk for exit seeking / Unit Wanderers". 4.) Failed to follow facility's " Elopement / Unsafe Wandering" policy by not completing an elopement risk assessment on admission for 1 resident that did not reside on the Secured Unit, that were later identified as at risk for elopement , ( R1). These failures resulted in R2 eloping from the facility through an unsecured window and being found naked, lying on the ground, with multiple bleeding abrasions all over his body. R2 was log rolling erratically back and forth in the northbound lanes of a 4 lane heavily traveled roadway. This roadway is located approximately one city block south of Interstate 88 entrance ramps. In addition, staff witnessed multiple passersby using their cell phones to record R2 while he was lying in the street. The outside air temperature on the morning of 12/31/11 in Aurora, Illinois was 25 degrees Farenheit, (excluding the windchill factor). These failures also resulted in R1, a [AGE] year old resident with severe cognitive impairment and an un-steady gait, on 01/29/12 to exit the facility alone and without her wheelchair, crossing a heavily trafficked large parking lot and entering an apartment building across the parking lot. An Immediate Jeopardy was identified on 02/08/12. The Immediate Jeopardy began on 12/31/11 when R2 eloped from the facility.. Although the Immediate Jeopardy was removed 02/08/12 at 4:30 PM, the facility remains out of compliance at a severity level 2 due to the need to implement and evaluate their removal plan. Findings Include: 1) R2 was admitted to the facility on [DATE] at 4:30 PM from an acute care hospital with [DIAGNOSES REDACTED]. R2 was assessed on admission as 5 foot 11 inches tall and 310 pounds. The Facility's Incident Investigation Reports and Nurses notes included the following: On 12/31/11 R2 experienced an acute mental change at approximately 4:30 AM. The resident was frequently monitored and no incidents noted until approximately 7:45 AM when the resident was exhibiting new behaviors. The nurse immediately went to notify the physician (MD) and obtain orders to send R2 out to the emergency room (ER), for an evaluation. Upon returning to the room within three minutes, the nurse noted R2 was not in the room and the window was open. Staff found R2 in front of the facility on the ground. R2 was assessed and noted with abrasions to the face and legs. No other injuries noted. Paramedics on site and assisted R2 to the ambulance, then to the ER. R2 was admitted to the hospital for Acute Mental status changes. Per interview with hospital staff, R2 experienced acute mental status changes with hallucinations that could have been related to his status [REDACTED]. R2's medical record included: - 12/28/11 Hospital discharge records noted R2 was experiencing altered mental status for three days prior to admission to the acute care hospital after sustaining a fall with a head injury. R2 developed frontal lobe pain and was taking anti-coagulant medication at home. (R2 was admitted to the hospital 12/26/11). - 12/29/11 psychological evaluation includes the following: R2 admits to having visual hallucinations (seeing people), confusion and altered mental status. Alert and oriented times one, cooperative, decreased judgement, decreased insight and short term memory problems. diagnosed with [REDACTED]. This psychological evaluation was prompted due to R2's exhibited behavior changes. Nurses progress notes: - 12/28/11 alert and oriented times 3 (time, place and person), mental status appears normal, left sided weakness from a prior CVA, no loss of range of motion (ROM), ambulates to bathroom and has slight tremors at times. - 12/29/11 5:30 PM R2 is confused and oriented times one. Requires 2 assist with transfers to wheel chair. - 12/30/11 5:51 PM Confused with spouse. - 12/30/11 10:02 PM Becoming upset at his wife, accusing her of having an affair and playing games with him. Wife denies any truth to R2's statements. R2 was calmed down but required a lot of re-focusing. - 12/31/11 11:36 AM R2 climbed out his bedroom window at 8 AM. R2's mental status was normal then increased agitation and confusion. R2 was in his room one moment beating on the wall with a planter, then climbed outside through the window. - 12/31/11 (note: appears to be a late entry) 11:49 AM At 11 PM R2 in bed sleeping with no complaints. 1 AM R2 noted in his bathroom, he had ambulated there himself, escorted resident back to bed. 4:05 AM R2 found in another resident room bumping into wheel chair and furniture. R2 escorted back to his room. A short time later R2 kept getting out of bed and attempted to ambulate without assist, staggering with obvious un-steady gait and requiring physical assist to get back to bed. After E4 left R2's room R2 started exhibiting aggressive behaviors toward a staff member (E6 nurse aide), grabbing E6's arm and refusing to let her go. E4 had to help free E6 from R2's grasp and E6 sustained bruises from this incident. E4 called Z2 (R2's doctor), and obtained orders for Haldol 5 mg injection to be administered now. "7:45 AM resident was noted in his room with the planter banging it on the wall as in trying to break through it, resident was not able to be redirected by writer so another emergency call was placed to Z2 for permission to send to emergency room due to increased agitation and possible danger to staff and residents in the general area. After Z2 gave order to send R2 to the hospital, writer went back to resident's room not more than 3 minutes had past, when it was discovered that resident got out of his room via window." E4 ran outside to Farnsworth street in case R2 made it that far and R2 was spotted on the ground in the nude, rolling around in the middle lane of Farnsworth street log rolling himself in the path of oncoming traffic. E4 ran into the street waving his hands up in the air to stop the flow of traffic and keep R2 from being run over. R2 was removed from the street after covering his body with E4's coat with much difficultly due to R2 not helping to stand up on his feet, with assistance of multiple staff. 911 arrived once R2 was removed from the street and to the safety of the grass area. R2 was immediately transported to the hospital. R2's medical record included only one Elopement Risk assessment dated [DATE], (after this incident). During 02/08/12 interview, E1 said R2 was not assessed for Elopement Risk on initial admission because he was just admitted for rehab therapy on the short term rehab unit (500 wing). R2's 01/04/12 Elopement Risk care plan includes that resident previously eloped from facility and had a catastrophic reaction to psychotropic medication (Haldol). During a 02/08/12 9 AM interview, E4 said on 12/31/11 at about 1 AM R2 was found up in bathroom, unassisted and with unsteady gait. E4 assisted R2 back to bed and had a conversation with resident about his past occupation. R2 was alert, cooperative and calm. Then at 4 AM R2 was found in another resident's room, "messing" with peers wheelchair and touching the walls. R2 was initially resistant to leaving this other resident's room which caused this other resident to become upset. R2 was unsteady walking and leaned heavily against my body while ambulating to a wheelchair, acting as if he could not walk. R2 was alert and oriented and communicative at this time. Shortly after returning R2 to his bed, while in the nursing station, E4 heard E6 (R2's nurse aide), calling out "Let me go", from down the hall. E4 witnessed R2 firmly grasping E6's arm and E6 was saying "Don't squeeze so hard". E4 ran to assist E6 and when R2 saw E4, R2 started acting like he could not stand without physical assist. E4 said that E6 was assisting R2 to bed when he grabbed her arm. E6 sustained bruises to the arm from this incident. E6 stayed with R2 while I went back to the nursing station to call MD. The MD ordered an injection of Haldol be given. R2 said he wanted the shot. R2 remained in bed after the Haldol was administered until about 7:45 AM. At 7:45 AM E4 heard a loud banging noise, like construction was going on, coming from R2's room. Upon inspection of the noise, R2 was observed grasping a planter with two hands and banging it against the wall causing dents. E4 said that he was a little scared that R2 might hit him with the planter but was able to get the planter away from R2 and assist him back to bed in a sitting position. R2 would not verbally respond when spoken to and just starred at E4. E4 left R2 alone in his room to return to the nursing station and call R2's MD. E4 said that E6 was working with another resident at the time R2 was banging the planter on the wall and he was not sure if E6 even heard it. The resident in the room next to R2's room was upset and yelling about all the noise that R2 was making. Upon E4's return to R2's room , E4 pushed the door open, felt a cold wind and noticed R2 was gone. E4 did not think R2 got out the window because the resident was so large and had an un-steady gait, but E4 did not see R2 leave his room or walk past the nursing station. E4 left R2's room and proceeded to the exit door yelling for co-workers to assist in finding R2. E7 (nurse aide) followed E4 outside the facility, across the parking lot toward the street. R2 was observed naked, log rolling back and forth on the ground into traffic in the northbound lanes of Farnsworth street. E4 ran into the street, holding his arms up in the air to halt traffic and then placed his jacket on top of R2 because people were using their cell phones to take pictures of him. R2 had scrapes and abrasions all over his body that were bleeding. E4 said that he thinks that if he and E7 had not gotten to R2 when they did, R2 could have been hit by one of the cars that were trying to go around stopped vehicles. In addition, E4 said throughout that night R2 would frequently remove all his clothes and needed frequent redirection to reapply his gown. During a 02/08/12 12 PM interview E7 said that she was R2's 12/31/11 6 AM-2 PM assigned nurse aide. E7 said on 12/31/11 upon arrival ,when she received her assignment for that shift, E7 was notified R2 was agitated and his door was closed. E4 told E7 to not go in R2's room because of him being agitated. E7 said she did not go into R2's room at all that shift. E7 said that around 8 AM or a little after, while passing breakfast trays, E4 asked her to follow him outside. E7 observed R2 rolling around back and forth, on the ground in the northbound lane of the street. There was oncoming northbound traffic E7 said she did not hear R2 banging on the walls and did not know anything was going on with the resident until E4 asked her to go outside with him. E7 also said it wasn't until later that shift, after R2 was transported to the hospital, that she was notified R2 had a confrontation with the night shift nurse aide (E6). E7 said she had worked with R2 on prior shifts and he never exhibited any behavior problems before 12/31/11. During a 02/08/12 12:20 PM telephone interview, E6 said she was R2's assigned nurse aide 12/30/11 11 PM - 12/31/11 7:00 AM shift. E6 also said that on 12/31/11 R2 was acting different from the prior two nights. R2 usually is quiet, sleeping or watching his television at night without any behaviors. On 12/31/11 at approximately 5:00 AM, E6 saw R2 walking at a rapid pace in the hall with an un-steady gait. E6 called for E4 to assist getting R2 back to bed. R2 just sat on the bed so E4 told me to keep an eye on him. I was in the hallway and another resident called me to his room for assistance, so I went. When I returned to the hallway E6 saw R2 quickly exiting his room again. R2 grabbed E6's arm with one hand and attempted to hit E6 with the other hand. R2 was trying to push me out of the way as he tried to exit his room. I yelled for E4 to come help me, which he did. E4 told R2 to stop and go back to his bed. R2 is a big man. E4 returned to the nurses station and E6 stayed in the hall in front of another resident's room to watch for R2 leaving his room. E6 stayed out of view of R2. E6 said she did hear R2 banging on the walls and getting agitated and saw E4 come to R2's room. E6 said that she left the facility to go home at 7:30 AM, prior to his elopement incident. During a 02/08/12 2:45 PM telephone interview, E9 (nurse), said she was R2's 12/31/11, ( 7 AM-3 PM) assigned nurse. On 12/31/11 during morning report, E4 told her that R2 was going in and out of other residents' rooms during the night. R2 required a medication to calm him down. During this change of shift report E4 and E9 heard a banging sound coming from R2's room. E4 and E9 went to check on the noise and entered R2's room. R2 was observed to be very confused and banging a fake planter against the wall. E4 and E9 both left R2 alone in his room and closed his bedroom door. E9 said the nurses went back to the nursing station to call R2's MD. 3-4 minutes later E4 returned to R2's room and found the resident missing. R2's 12/31/11 Hospital Record includes: R2 was hospitalized [DATE] through 01/04/12 with [DIAGNOSES REDACTED]. The 12/31/11 History and Physical included that R2 developed extreme agitation, broke glass window, ran out and was found in the street without any clothes and with bruises all over his body. R2's 01/01/12 Neurological consult report included that "etiology of R2's bizarre behavior at nursing home 12/31/11 is not entirely clear. However, it does not seem to be any acute process. The patient does have a history of Depression and was some paranoid because apparently he got some IM injection in his buttock area for anxiety, the patient did not like it and he broke the window. R2 reported he did it on purpose and he broke the window and jumped out of the window from the rehab and found naked without any clothes in the street." Further review of facility's investigation of R2's 12/31/11 elopement incident validated that facility protocol for resident room window securing included : All resident room windows are to be secured with a screw into the window frames to prevent the window from sliding open more than 6 inches. During 02/03/12 9:15 AM interview, E5 (Maintenance Director), said that on 01/01/12 he was directed to complete an audit of every resident room window for screw placement , so the windows are not able to slide open more than 6 inches. E5 said that he found 70% of the short term rehab resident rooms did not have a screw in the window frames to prevent them from fully opening. E5 also said this unit had been remodeled about a year ago and when it was remodeled they forgot to put in the screws in 70% of the rooms' windows. E5 further said that R2's room did not have a screw in the window frame, allowing the window to slide wide open on 12/31/11. During this survey there was 26 residents residing on the short term rehab unit. 2) According to the medical record R1 is a [AGE] year old female who was admitted to an unsecured unit at the facility from the acute care hospital at 5:30pm on 01/20/12. R1's admission [DIAGNOSES REDACTED]. Nurses notes documented during a head to toe assessment at 12:32 AM (01/21/12) that R1 appears confused, speech is normal, alert, oriented to person. 12:33 AM, alert and awake, oriented to person, disoriented to time, place, balance difficulty. 12:44AM , able to ID need to void-sometimes, able to use call light, sometimes, able to ask to go to toilet, sometimes. Diagnoses: [REDACTED]. 12:46 AM, confused at all times. 01/22/12: 11:18 AM follow up incident, fall at hospital prior to admission to this facility, no apparent injury. 01/24/12- Skilled Nursing Observations - Mood, chronic behavior, repetitive behavior. Confused, often easily reoriented. Packs her belongings and asks for a cab to leave nightly. 01/24/12- Social Service Assessment -Admission (completed by nursing) - Behavior: Patient often confused. Patient puts on clothing in multiple layers and states she needs to " take a leave of absence or call a cab." Easily redirected and reassured. Patient aware of how to turn off bed alarm. Monitored closely. Re-educated of need to call for assistance when getting up. According to the Initial 24 hour Incident Investigation Report completed by E1 (Administrator), on 01/29/12 at approximately 6:15pm nurse could not find resident to administer her medication. Staff conducted search and resident was found at 7:00 PM in the next building in her old apartment. The apartment ( an assisted living facility) is located next door to the facility approximately 300 yards away. The area between the two buildings consists of parking lots for both facilities. A busy roadway is also nearby to the west of both facilities. Included in the Initial 24 hour Report under "known facts at this time" E1 documented, " This resident did not exhibit any wandering concerns to staff during her stay here." E1 was asked on 02/07/12 if a formal risk assessment was completed for R1 upon admission. E1 stated the assessment was not completed because R1 was admitted to the facility for therapy from the hospital and was expected to return to her apartment in Assisted Living. E1 further stated R1 was not considered an elopement risk. Review of E1's full investigation report including staff written statements noted the following: E11 (nurse) documented in her statement written on 01/29/12 she went to the dining room to give R1 her medication at approximately 6:10 PM. R1 was not in the dining room and E11 continued to search the unit. E11 then went to the front desk and noticed an empty wheelchair with an alarm attached. E11 asked E12 (receptionist) if she had seen R1. E12 stated a woman matching R1's description had come to the front desk with her purse and stated someone was picking her up. E12 (receptionist) documented in her statement of 01/29/12 an older lady in a wheelchair came up to the lobby at about 6:30 PM and asked if she could leave the wheelchair here so she could go out to her car. She had her purse and keys in her hand. I figured she was a visitor who was borrowing the chair while she was visiting someone. The alarm on the wheelchair went off but I didn't know why and asked her if she knew why. She told me she didn't know and thought it would go off by itself. I thought maybe that was the only available chair not thinking this was a resident since I had not seen her until tonight. E12 was interviewed by phone on 02/10/12 at 11:30 AM. E12 stated she has worked at the facility since 2006. She was trained as a receptionist in basic office skills. E12 further stated the facility kept a book at the front desk of names and pictures of residents who are identified as wanderers. Those residents are from units 1 and 2. They also wear wandering bracelets on their wrists. If a known wanderer tries to leave the building I was supposed to stop them and call a nurse or CNA (Certified Nurses Aide). On 01/29/12 R1 came up to the desk in a wheelchair. She was dressed well, she had a purse and keys in her hand and spoke very well. She didn't look familiar to me. I didn't see a bracelet on her. She asked if she could leave the wheelchair at the door because she was leaving by car. She stood up and didn't appear to have too much trouble walking, she was just a little unsteady so I just thought she had borrowed the chair while she was visiting someone.. An alarm went off when she got up. I didn't know why it was alarming or anything about chair alarms. R1 told me she didn't know why the alarm was going off but it would shut off. R1 then left the building. She wasn't in the wanderers' book and they didn't tell me what a chair alarm was for until after all this happened. The facility's policy on Elopement / Unsafe Wandering Risk Assessment (revised and effective 01/03/12) was reviewed. Specific Procedure / Requirements include the following: 1. The Elopement / Unsafe Wandering Risk Assessment will be completed on admission (within 7 days), quarterly and as needed for a change in resident status. NOTE- If the resident is identified as an elopement risk prior to admission or during the current stay, immediate interventions should be implemented. 2. If a new admission or a current resident exhibits behaviors such as; exit seeking, history of exit seeking, wanting to go home or unsafe wandering into hazardous areas the facility should immediately: A. Place the resident in the secured unit. B. Update the wanderer's book with the resident's picture and demographic information. C. Alert the MD and POA (power of attorney) of the behaviors. D. Place a electronic wandering device alarm or (equivalent) bracelet on the resident. E. Place on 1:1 program if exit seeking behaviors are extreme and the resident cannot be easily re-directed. F. Complete the Elopement Assessment. On 02/07/12 E1 confirmed that none of the interventions listed on the elopement assessment policy had been implemented for R1 prior to her elopement from the facility on the evening of 01/29/12. R1 was not assessed until after her elopement and then placed on the secured unit. R5, R6 and R7 who all reside on the unsecured unit are not new admissions were not assessed for wandering/elopement and appropriate interventions until 02/08/12. On 02/08/12 at 3:05PM E1(Administrator), E2 (Director of Nursing) and E3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed the facility took the following actions to remove the immediacy: Facility's removal plan with a completion date of 02/09/12 includes: Identifying other residents at risk for elopement. 1) 100% of Elopement risk assessments were reviewed and/or completed for all residents that did not reside in the secured unit 02/08/12 and care plans up-dated to include electronic wandering alert device use and picture placement at reception area. 2) All windows were assessed and /or ensured that they could not open more than 6 inches on 01/01/12. 3) The elopement risk binder was revised on 12/31/11 and again on 02/08/12 4) All facility department heads (including DON, ADON and Social Service Director), were inserviced by Chief Clinical Officer on 01/03/12 and again 02/08/12 by the DON regarding: - Facility policy on completing elopement assessments. - The requirement that resident room windows should not open more than 6 inches. - Residents identified as elopement risk should be placed in the secured unit if they meet the criteria set forth in facility's secured unit screening tool. The proper interventions will be put in place for residents who are at risk for elopement that do not meet secured unit admission criteria. - Monitoring residents with medical and mental condition changes and exit seeking behaviors. 5) Beginning 02/08/12, 100% of all licensed nurses and certified nurse aides will be inserviced by the DON or ADON before they are allowed to work on the floors regarding: - Facility's Change of Condition Policy and Procedure - Resident Crisis Management Policy and Procedure - Facility's Emergency Contact Priority List. - Facility's Missing Resident Policy and Procedure. - How to manage residents with aggressive behaviors. 6) The Social Work Consulting group will work with the Social Service staff, Activity staff and department heads on identifying all residents with behaviors, proper behavioral interventions, care planning and behavioral programming. 7) Starting 02/09/12 the nursing department will review the 24 hour change of condition report and observe for any new behaviors and that proper interventions were implemented. 8) Starting 02/09/12 the nursing department will complete chart review for all new and re-admissions to ensure that the Elopement Risk Assessments were/are completed. Any new or re-admissions that are identified as an elopement risk will be placed in the secured unit for safety. 9) Monitoring : - The Department Heads will review all QA tools to ensure that all listed examples were completed for any resident identified. Any discrepancies noted will be immediately corrected. Further education and QA modification will occur if further discrepancies are noted. This process will continue daily until substantial compliance is obtained. At that time the QA committee will review this process and revise the schedule per the recommendations of the committee. The Administrator and DON will monitor for continued compliance. - Social Work Consultation Group will continue to work with the facility staff on managing residents with aggressive behaviors monthly upon scheduled visits. From these visits further staff education needs will be identified and formal inservicing will be arranged. The formal consultation report will be completed and submitted to the Regional Vice President and Chief Clinical Officer for review. The Administrator and DON will monitor for continued compliance. - The maintenance director will conduct random rounds to ensure that all resident room windows do not open more than 6 inches. Rounds will be completed so that every resident room window is checked at least monthly. The Administrator and DON will monitor for continued compliance. - The Regional Vice President and /or Chief Clinical Officer and/or Corporate representative will conduct periodic visits to the facility to ensure that this QA plan is being followed as set forth and to provide further guidance and education. - The QA committee will monitor this program for effectiveness. Any new incidents that occur will be reviewed to ensure the policy was followed. Any discrepancies noted will be identified and new interventions will be implemented as determined by the QA committee. - The Medical Director has reviewed facility's policy and procedures related to this event. The facility sought the Medical Director's consultation for this plan of "abatement". The Medical Director will assume the care for any patient whose primary care physician does not respond in the event of an emergency. The Medical Director will continue to visit at least monthly to provide support, guidance and education to ensure the staff are properly trained to provide appropriate care to residents. The Administrator and DON will be responsible for compliance.