Every finding on record at Harmony Palos

Based on interview and record review, the facility failed to ensure that staff follow professional standards of practice when administering medication by failing to administer medication before documenting, failed to correctly document refused medication and failed to notify attending physician that a resident was refusing a particular medication. This failure affected one (R3) of five residents reviewed for nursing services.Findings include:R3 is [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history: Polyneuropathy unspecified, other specified disorders of muscle, type 2 diabetes with foot ulcer and other circulatory complications, cutaneous abscess of buttock, major depressive disorder, presence of cardiac pacemaker, venous insufficiency, hypertensive heart disease, etc. Minimum Data Set (MDS) assessment dated [DATE], section C (cognitive) documented a brief interview for mental status (BIMS) score of 15 for R3 indicating that resident is cognitively intact. Section GG (functional status) of the same assessment documented that R3 is dependent on staff for most Activities of daily living (ADL) needs.On 5/18/2026 at11:18AM, R3 was in his room, awake, alert and oriented, stated he has been at the facility for about 3 weeks, has issues with his medication, have complained that he does not want to take Jardiance, it makes him sick, but staff are still giving it to him. R3 said that removes it from the medication cup and refuses to take it. He added that he has not started therapy, he is being harassed by therapy though he told them that he is too sick to start therapy now.Review of active physician order for R3 showed the following Empagliflozin Oral Tablet 10 MG (Empagliflozin) Give 1 tablet by mouth one time a day for DM. Medication administration record for the month of May showed that the above medication is being signed as given at 9:00AM.On 5/18/2026 at 2:27PM V3 (RN) said that she is the assigned nurse for R3 today, she gave him all his medications, and he took them. Surveyor asked V3 if she is sure that resident did not refuse any medication and she said, Oh he refused his Jardiance, he said that it gives him some issue like upset stomach, I disposed the medication. Surveyor presented to V3 that she documented the Jardiance as given in resident's medication administration record (MAR). Surveyor asked V3 what the protocol is when a resident refuses medication and she said, we are supposed to mark it as refused and also notify the physician. Surveyor asked V3 why she did not mark the medication as refused or notify the physician and she said, I have not notified anyone yet, I was going to go back and fix the MAR, I always go back to finish my work.On 5/21/2026 at 11:30AM, V7 (LPN) said that she is familiar with R3, she took care of him for the first time on 5/16/2026, R3 refused his Jardiance, stating that he is allergic to it. V7 informed the DON about R3 refusing Jardiance and the DON said that R3 has reported the same thing to another nurse, the DON has reached out to his doctor who said that resident has been on that medication for a long time. V7 added that when a resident refuses any medication, it should be documented as refused in the medication administration record. Surveyor informed V7 that resident's medication (Jardiance) was documented as given on 5/16/2026 and she said, I am not sure that I went back and marked it as refused, I was confused with everything that went on that day.On 5/21/2026 at 11:16AM, V8 (Attending physician) said that he is familiar with R3, saw him when he first came to the facility and after he came back from the hospital. R3 complained about his pain management, he did not complain about Jardiance, V8 heard about Jardiance about a week ago, he told the staff who called him to hold the medication until he sees the resident again. V8 said that Jardiance has a lot of side effects, he was going to discuss with the resident and maybe switch to something else. V8 does not recall the name of the staff that called him regarding the Jardiance, he added that the expectation when a resident is refusing medication is to mark it as refused, not document it as given.On 5/21/2026 at 2:52PM, V2 (DON) said that R3 is newer to the facility but she is familiar with him, V2 does not know anything about R3 being allergic to Jardiance or refusing the medication, she became aware of it after surveyor brought it to their attention and the medication was discontinued. V2 added that the expectation from staff when a resident refuses medication is to call and notify the doctor, the medication should also be documented as refused in the MAR. Medication pass policy revised 7/2/2025 states in part: It is the policy of the facility to adhere to all federal and state regulations with medication pass procedures. Procedures 7. PO Meds: e. After medication is administered to each resident, sign MAR that it was given.On 3/21.2026 at 3:50PM, surveyor requested for facility policy on refusal of medication from V1 (Administrator) and she said that they do not have any policy on medication refusal.Job description for Registered Nurse (RN) and Licensed Practical Nurse (LPN) updated 12/1/2019 stated in part, summary/objective:In keeping with our organization's goal of improving the lives of our guests we serve, the Rn and LPN play a critical role in providing superior customer service and nursing care to all guests. The RN and LPN provide supervision of staff and will -------------------------------------------, following applicable laws, regulations, and established nursing policies and procedures. Essential functions: Provides quality nursing care to guests in an environment that promotes their rights, dignity and freedom of choice.

Based on interview and record review, the facility failed to protect resident's right to be free from abuse. This deficient practice affects one resident (R6) of three residents reviewed for abuse. This failure resulted in R6 having right leg shin bruising/hematoma.Findings Include:Facility Reported Incident to State Agency dated 3/22/26, reads in part: On 3/22/26 @ 8pm, R6 reported that V15 (CNA) kicked her in her leg and pulled her hair. V15 was removed from the building immediately. Notified attending physician, and emergency contact. Police Department was called and is in route.R6 is an [AGE] year-old female resident with diagnoses of Metabolic Encephalopathy, and Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety.On 5/6/26 at 9:30AM, observed R6 in bed watching television. R6 is alert and oriented and reported that on the day of the reported abuse, R6 entered the elevator, one person standing by the elevator control panel. The staff member flung her wheelchair and the staff member kicked R6 on her right leg. R6 stated she immediately reported the incident when R6 came out of the elevator. On 5/6/26 at 10:15PM, V12 (CNA) stated V12 heard R6 making allegations of abuse from other staff members but did not witness any physical abuse to R6 at that time. When R6 came back upstairs, out of the elevator V12 recalls seeing resident with her hair disheveled and messy after coming out of the elevator.On 5/6/26 at 11:00AM, V14 (Assigned Nurse for R6) stated V14 was called by the first-floor nurse to come and see R6 on the first floor and that R6 was upset and yelling. V14 went down and R6 reported to V14 that R6 was physically assaulted inside the elevator by V15. V14 stated she conducted a complete body assessment to R6 and noted a small red discoloration and slightly swollen area on R6's right leg shin area.On 5/6/26 at 11:30AM, V15 (CNA) stated that V15 does not recall if R6 was in the elevator. V15 stated that her mind was preoccupied when she went in the elevator due to some questioning by one staff member prior to V15's break. V15 used the elevator down to go downstairs and sit on her car for her break, then returned half an hour later and V15 was instructed to go wait outside and there was an allegation of abuse against her. V15 was asked if V15 recalls R6 riding the elevator with V15 and V15 stated To be honest, my mind was preoccupied with all the questions that was asked by my coworker that I did not notice if R6 was in the elevator or not. I spaced out. I do not recall any interaction with R6 in the elevator.On 5/6/26 at 11:56AM, V1 (Administrator) stated the abuse allegation was reported to her by V2 (Director of Nursing), V1 initiated the investigation and reported this allegation to State Agency. V1 stated that R6 reported to the nurse that a CNA kicked her and pulled R6's hair in the elevator. Described as big CNA and black female. Facility watched the video and observed V15 get in the elevator after R6 entered the elevator. R6 reported the staff was already in the elevator. And the video showed V15 came in after the R6 got in. First floor they exited @ 7:27PM CNA exited the elevator and walked towards the lobby. R6 did not exit the elevator until 35 seconds later after V15 exited. When R6 got out of the elevator, R6 calmly rolled down the hall, not frantic. Camera was not able to view what happened inside the elevator. Just CNA going inside the second elevator after R6 entered and then V15 leaving the elevator seconds later on the first floor.Shower sheet dated 3/22/26. Body diagram facing forward noted and documented that R6 to have right leg circled, described as bruise hematoma to shin.On 5/6/26 at 2:35PM V1 and V2 stated that there is no documentation they can provide that documented that R6 had any bruising or hematoma prior to this reported incident.Police Report dated 3/22/26 reads in part: Everything listed and described below including all conversation are in somebody and not verbatim please refer to body camera footage for more in depth and specific details. Any consistencies are unintentional.Local Police Department we're dispatching for the report of a battery through a patient by a staff member which reportedly happened an hour earlierUpon arrival V14 (Nurse), V14 informed the police that R6, who V15 described as being alert and oriented x4, explaining R6 had no Alzheimer's of psych issues, had alleged that R6 had been assaulted by a CNA. V14 said that upon checking R6, bruises were found on her were green in color, which V14 indicated they were fresh. V14 said the hematoma appeared to have grown larger since V14 first saw it. V14 also advised that R6 suffered redness to the back of her head, advising that R6 said her hair was pulled. V14 said these injuries were not on r6 prior to the incident. Police interviewed R6 and in summary: learned from R6, R6 being flung in her wheelchair. R6 described her as being pushed by the CNA in her wheelchair from the front of elevator to the rear elevator doors. R6 advised R6 then yelled at V15 (CNA) calling her Son of a b*tch. R6 advised V15 then turned around and V15 lifted her leg and kicked R6 on the leg. V15 also punched R6 in the face/head (forehead area). It is believed that this physical altercation took place inside the elevator. As later R6 described getting on the elevator on the 2nd floor and got off the first floor where R6 reported the incident to staff. R6 advised that R6 looked in the mirror, however she didn't notice marks on her face. R6 informed me that the marks to the back of her head were old, explaining that they did not occur from this incident. R6 explained that R6 doesn't bruise easy advising that based on her injuries, R6 must have been kicked hard.In the parking lot, found V15 and V15 stated she was informed that V15 was being accused of an abuse allegation. V15 upon returning on her break she was asked to leave. Police informed V15 of the allegation and V15 advised that she had no idea about any of that. On 5/6/26 at 11:56AM, V1 (Administrator) stated that video copy was sent to the police department link provided to facility. Per V1, video cannot be retrieved at this time. It was sent to the police provided link and if needed copy, the police may be able to provide it to State Agency surveyor.Abuse Policy with a revised date of 1/29/26 reads in part: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigation of allegation these guidelines include compliance with the (7) seven federal components of prevention and investigation.

Based on observations, interviews, and record reviews, the facility failed to implement fall care plan interventions for fall-risk residents. This applies to 2 of 3 residents (R4 and R8) who were reviewed for falls and injuries in a sample of 10.The Findings include:1.R4 is a [AGE] year-old male admitted on [DATE] with mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R4 was admitted with an admitting diagnosis including bipolar and a neoplasm of the tongue.On 5/5/26 at 10:05 AM, R4 was observed on his bed with no floor mat on his right side, and a folded floor mat was observed on his left side leaning against the bedside drawer.On 5/5/26 at 10:10 AM, V19 (Certified Nursing Assistant) entered R4's room and stated, I was about to give R4 a shower as today is his shower day. I will put the floor padding back after his shower.A review of the fall care plan documented interventions, including a floor mat on the right side of R4's bed.A review of the incident note dated 2/2/26 documented an unwitnessed fall with a right forehead bruise.A review of the health status note dated 2/3/36 documented that R4 had another fall and was found on the floor on 2/3/26 with no injury.2.R8 is an [AGE] year-old female admitted on [DATE] with severe cognitive impairment as per the MDS dated [DATE].On 5/6/26 at 9:55 AM, R8 was observed in her wheelchair, biking with a nonfunctioning chair alarm with her wheelchair. On 5/6/26 at 9:56 AM, V19 stated, The chair alarm is not working. It needs a new battery.On 5/6/36 at 10:08 AM, V20 (Restorative Director) replaced R8's chair alarm battery, and it started working.On 5/6/26 at 10:34 AM, V2 (Director of Nursing/ DON) stated that it was everyone's responsibility to test the chair alarm. Our staff is supposed to implement fall interventions to avoid further falls and injuries.A review of the fall log and health status note dated 4/23/26 documented a fall for R8 on 4/23/26 with no injury.A review of the fall care plan includes interventions, such as a chair alarm to alert staff when a resident attempts to get out of bed unassisted, so staff can assist the resident and prevent falls.A review of the Fall Occurrence policy, revised on 6/30/25, documents the policy statement: It is the policy of the facility to ensure that residents are assessed for fall risk, that interventions are put in place, and that interventions are reevaluated and revised as necessary.

Based on observation, interview, and record review, the facility failed to implement the fall care plan interventions in place for at-risk fall residents. This applies to 3 of 3 residents reviewed for falls in a sample of 6.The findings include:1.R3 is an [AGE] year-old female admitted on [DATE] with moderate cognitive impairment as per the MDS dated [DATE].On 3/31/26 AT 10:15 AM, R3 was on her bed with V9 (R3's Daughter) at her bedside. V9 stated, Nobody knows how R3 had a hip fracture. My mom doesn't walk, and we don't know how the injury happened. They didn't always have the bed alarm activated.On 4/1/26 at 9:15 AM, R3 was on her bed, and R3's bed alarm was not working. Upon notification, V10 (Restorative Nurse) checked the bed alarm and stated, We have to change the battery.On 4/1/26 at 9:50 AM, observed that R3's bed alarm was not working, with a new battery installed and not blinking. On 4/1/26 at 9:50 AM, V11 (R3's Nurse) checked the bed alarm and stated, The bed alarm is not working/blinking. I am going to change the whole alarm set. The problem could be with the padding, battery, or alarm system itself.On 4/1/26 at 10:07 AM, V11 had changed the whole bed alarm set and was working. V11 stated that the alarm should always be working, as R3 is at high risk of falls.A review of the R3's fall care plan interventions includes a bed alarm to alert staff when the resident attempts to get out of bed unassisted, so staff can assist the resident and prevent falls.2.R5 is an [AGE] year-old female admitted with severely impaired cognition as per MDS dated [DATE].A review of the fall risk assessment dated [DATE] documented that R5 is at risk for falls due to impaired cognition and impaired mobility.On 3/31/26 at 9:27 AM, observed R5 get out of bed, walk unsteadily, and go to the bathroom. The bed alarm was not going off.On 3/31/26 at 9:30 AM, V12 (Environmental Service Director) stated that the alarm should be set to go off when the resident gets up.A review of the R5's fall care plan interventions includes a bed alarm to alert staff when the resident attempts to get out of bed unassisted, so staff can assist the resident and prevent falls.3.R6 is a [AGE] year-old female admitted with severely impaired cognition as per MDS dated [DATE].A review of the fall risk assessment dated [DATE] documented that R6 is at high risk for falls due to impaired mobility, history of falls, and impaired cognition.On 4/1/26 at 9:40 AM, R6 was observed on an elevated bed with a bed remote hanging from the posterior side of the footboard and a call light touch pad inside the bedside drawer.On 4/1/26 at 9:43 AM, V13 (CNA) brought the call light touch pad accessible to R6.On 4/1/26 at 9:45 AM, V14 (Nurse) stated, R6 is on fall risk, and the bed should be in the lowest position, and the call light should be within his reach.A review of the R6's fall care plan interventions includes keeping the bed in a low position, keeping commonly used articles within easy reach, and reinforcing the need to call for assistance.A review of the facility presented the Fall Occurrence Policy (revised on 6/30/25), which states that it is the facility's policy to ensure that residents are assessed for fall risk, that interventions are put in place, and that interventions are reevaluated and revised as necessary.2. Those identified as high risk for falls will be provided with fall interventions.

Based on interview and record review, the facility failed to acquire and administer prescription medications to residents. This applies to 1 of 3 residents reviewed for pharmacy services in a sample of 6The findings include:R1 was an [AGE] year-old male admitted on [DATE], having mild cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. R1 was admitted with an admitting diagnosis including left femur fracture, Parkinson's disease, and bone density disorder.A review of the Physician Order Sheet (POS) documented that R1 was ordered with his hallucination medication Nuplazid 34 milligrams once a day, starting on 3/2/26.A review of R1's Medical Administration Record (MAR) for 03/2026 documents that R1 didn't receive his hallucination medication (Nuplazid) on 3/2/26, 3/3/26, and 3/4/26.A review of the POS indicates that the hallucination medication was discontinued on 3/4/26.On 4/1/26, the facility presented a statement from V4 (Registered Nurse for R1 on 3/4/26) stating that it was a clerical error that Nuplazid medication was administered on 3/4/26. The statement also documented that this medication was not available, was never administered to R1, and was discontinued by V5 (R1's attending Physician) on 3/4/26.On 4/2/26 at 3:45 PM, V7 (R1's concerned party) stated, I was staying with him most of the time. R1 was in need of his hallucination medications. But they didn't administer that during his stay with the facility.On 4/1/26 at 1:30 PM, V2 (Director of Nursing / DON) stated, We never administered R1's hallucination medication (Nuplazid). The resident was admitted on [DATE], and this is a specialty medication from the Veterans Affairs (VA) hospital. The nurse made a mistake by documenting that the medication was given to R1 on 3/4/26. We never received that medication. It was not given on 3/4/26.On 4/2/26 at 2:23 PM, V2 added, This is a specialty medication, and not all pharmacies carry this medication. Normally, we should get our medications from the pharmacy within 8 hours.On 4/2/26 at 3:00 PM, V5 (Pharmacist) stated, Nuplazid is not a specialty medication, but requires high-cost approval. We sent an email and voice message to V2 requesting this approval. We did not receive the approval, and hence it wasn't delivered to the facility.

Based on interview and record review, the facility failed to order and initiate contact isolation precautions for a resident (R4) while the resident was being treated for scabies for one out of three reviewed for infection control in a total sample of eight. Findings Include: R4 is a [AGE] year-old with the following diagnosis: dementia, Alzheimer's disease, and lung cancer. R4 was unable to answer questions due to mental status. On 3/7/26 at 1:24PM, V3 (CNA/Certified Nurses Assistant) stated R4 had a rash on the arms, chest, and back about a couple months ago. V3 reported residents that are being treated for scabies are put on isolation immediately, so they don't spread it to other residents or staff. V3 stated V3 was not aware R4 had been treated for scabies. V3 denied ever seeing R4 on isolation. V3 reported it is the nurse's responsibility to put in the orders for isolation and inform other staff. On 3/7/26 at 2:23PM, V4 (Former Wound Care Coordinator) stated the nurses will contact the physician for further orders if they think a resident has scabies. V4 reported residents should be put on contact isolation and moved to a room alone if they are being treated for scabies due to the condition being very contagious. V4 said, We have to put them on isolation or other residents will start to catch it.On 3/7/26 at 3:11PM, V8 (Medical Physician) stated if a resident is being treated with topical ointment for suspected scabies, then contact isolation should be ordered so it is not spreading to others. On 3/7/26 at 3:19PM, V9 (DON/Director of Nurses) stated residents that are being treated for scabies should be put on isolation and moved to a room alone. V9 reported V9 does not remember R4 being on any isolation over the last couple months. V8 stated the infection control nurse will document all types of isolation that has been used in the facility on a list so the facility can keep track of infections. A Physician note dated 1/13/26 documents R4 has a rash which is possibly scabies. Plan to treat with Permethrin cream and appropriate isolation. The Skin Alteration Nursing Evaluation dated 12/25/25 documents R4 had a scattered rash to both arms, chest, and stomach. Some scabbing was noted but R4 showed no sign of itching. The physician was made aware, and orders were carried out. No other skin assessments were provided during this investigation.The Physician Order Sheet was reviewed from 12/21/25 through present and there is no documentation of an order for contact isolation due to rash/scabies. The Medication Administration Record dated 01/2026 documents R4 was treated with permethrin cream for a rash on 1/14/26 and 1/22/26. The Infection Control Isolation Log for the last three months does not document R4 as having been isolation during this timeframe. The policy titled, Infection Prevention and Control, dated 05/29/20 documents, The facility has established a policy to identify, record, investigate, control, test, and prevent infection in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. Procedure.6. If the resident with infection needs transmisison0based precaution, the facility will provide the transmission-based precaution set required. 7. A transmission-based precaution set up will be provided outside the resident's room to provide Personal Protective Equipment (PPE) like gown and gloves to staff and visitors entering the resident's room.precautions to prevent Transmission of Infectious Agents and Transmission Based Precaution:.2. Contact Precaution- intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment.b. Use of gown and gloves is necessary for all interactions.

Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for accidents was free from accident hazards and received adequate supervision and assistive devices to prevent an avoidable fall. Specifically, the facility failed to ensure an agency CNA (V3) was oriented to R1's high fall risk status. This failure resulted in R1 sustaining a displaced humerus fracture, head laceration with active bleeding requiring sterile-strips, and facial contusions. R1 is an alert and oriented predominantly Polish-speaking [AGE] year old with diagnoses listed in part but not limited to type II Diabetes, Fracture of the Upper End of Right Humerus, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension, Anxiety Disorder and History of Falls. A facility incident report dated 9/12/2025 reads in part, On 9/12/25 while CNA (V3) was providing ADL (activities of daily living) care to the resident when the fall occurred the CNA had (R1) laying on her left side, the CNA had one hand on her rib cage area to stabilize the resident while she was washing her with the other hand when the resident started to roll out of the bed the CNA attempted to stop the fall but was unsuccessful. The CNA notified the nurse on duty. The nurse immediately assessed the resident. (R1) complained of pain to the right shoulder area and the nurse noted a laceration above the right eye. A cold compress was applied to the right eye. Nurse notified the doctor and orders were give to send out to the ED Emergency Department for evaluation. (R1) was sent 911 to hospital ED. (R1) returned from hospital ED with diagnosis of a fracture of the right humerus without any surgical interventions and a laceration above the right eyes and Steri-strips applied. During the investigation it was noted that the resident prefers to use the edge of the bed or the night stand to support herself for comfort during ADL care, and it was noted that she would benefit from a wide bed and siderails for support during care.A review of R1's care plans refutes facility's conclusion shifting blame to the resident as no documented evidence was found that R1 preferred to be at the edge of the bed or to use the night stand for support during ADL care and was not consistent with either the resident's interview and staff interviews. Care Plan dated 5/12/25 reads in part, (R1) is at high risk for falls due to history of falls, impaired mobility, weakness, comorbidities include Heart Failure, Hypertension, Hyperlipidemia, COPD, Respiratory Failure, Osteoporosis, Gout, Dementia, History of Deep Vein Thrombosis, Left humeral fracture. Interventions: Bed in low position, Encourage to transfer and change positions slowly, Frequent toileting, Have commonly used articles within easy reach. Low bed.On January 2, 2026 at approximately 10:40 AM, R1 was observed awake in bed and with the bed raised waist high and with no fall mats or other fall prevention measures in place. Two State Surveyors conducted an interview with R1 regarding her most recent fall. Because R1 is predominantly Polish-speaking, the state surveyor utilized the Polish-speaking surveyor to interpret and ensure accuracy. During this interview, R1 consistently stated that while the agency CNA (V3) was providing care, the CNA took her hands off the resident to reach for an item. The resident reported that because the CNA let go and there were no side rails in place, the resident rolled out of the bed and struck the floor. Furthermore, R1 did not mention any such preference to be at the edge of the bed while being changed or to use her nightstand as support.R1 said, I fell out of the bed when a CNA was changing my diaper. The CNA didn't hold me when she was changing me, and I rolled out of bed and fell. The bed was high up I think because I broke both my shoulders. My shoulder hurt a lot after the fall and they still hurt today. My hands hurt and shake too. I cannot hold things in my hands like I used to before the fall. They put up this bed railing (pointing to the rail) so maybe I won't fall now, but they never put it up before I fell.A post fall incident statement dated 9/15/25 taken by the facility's business office manager (V10) interpreted for R1 reads: Interview with R1 with staff member (V10) to translate stated, They were changing me when they turn me I went over the side of the bed and was on the floor. I wasn't reaching for anything. The bed is much more comfortable and I have more room to move yes I feel safer in this bed with the side rails.V4 LPN nurse on duty at the time of the incident confirmed in an interview on January 2, 2026 at 2:50 PM that upon entering the room immediately following the incident, R1 was on the floor with active bleeding from the head. V4 further stated that the Agency CNA never mentioned the resident reaching for anything at the time of the incident, which contradicts a later allegation made by the CNA that the resident's own actions caused the fall.On 1/2/26 at 2:50 PM V4 LPN said, I was training someone at the time of the incident and I was called to the room by V3 (Agency CNA) and the resident was on the floor and she had some bleeding while she was laying on her back. V3 told me that when she turned her (R1) over to clean her I think she turned her too far and so she fell out of the bed. 911 was called and I don't recall seeing a side rail. Of course if there were side rails, she may not have rolled out of the bed. The Agency CNA said that she just turned her as she was cleaning her. The aide didn't tell me anything about the resident reaching for anything at the bedside table. Surveyor asked about R1, V4 said, She was not a fall risk as she's never fallen out of the bed, so no she's not a fall risk. The whole time I've had her, she's never fallen. I was never told she was high risk for falls and she has never fallen in the room or anything like that. I know cognitively she is forgetful, but she is pretty with it. She speaks broken English but she understands me. I've never seen a communication board and have never had to use one for her.Furthermore, the (V1) Administrator's claim that a subsequent re-interview showed the resident preferred the bed in the lowest position was directly refuted by the consistent testimony provided by the resident to the two State Surveyors. R1 explicitly denied making any statement regarding a low-bed preference and maintained the fall was due to the CNA's failure to provide support. Medical records confirm the resident sustained a humerus fracture, head trauma with bleeding, and facial contusions as a direct result of this lack of supervision and lack of knowledge of resident's fall risk status and care needs.On 1/2/26 at 1:10 PM, V3 (Agency CNA ) stated it was her first time to care for R1 and admitted , No one told me anything about her history or that she was a high fall risk. She claimed the resident reached for an object, causing the fall however a statement R1 provided the nurse at the time, R1 denied reaching for anything and that she just rolled over because V3 did not keep her hands on her at all times to keep her from rolling out of the bed, nor were there any side rails for her to grab onto to prevent her from rolling out of the bed. On 1/2/26 at 1:10 PM, V3 Agency CNA, said, I haven't been back there awhile (referring to facility). My agency hasn't put me back there but I remember that incident. I was taking care of this lady (R1) and had her on her side. I had one hand on her shoulder and my other hand was cleaning her up because she had a massive BM (bowel movement). She (referring to R1) just reached for her bedside table or something on it. I don't know what she was reaching for to be honest. I think she just wanted some security or something but she just rolled over and fell off the bed. Surveyor asked about any bed rails, V3 said, No there were no rails on the bed for her to hold on to so I'm not sure why. I didn't understand her she didn't speak English. It was the first time I took care of her so I don't know if she ever fell before. Surveyor asked if anyone endorsed any information about R1's care needs to her, V3 said, No, no one told me anything about her. Like I said it was the first time I took care of her and no one told me anything about her and I didn't know if she was a fall risk. Surveyor asked if she had any training on fall prevention, V3 stated, No. I don't remember getting any.On 1/2/26 at 2:00 PM, V5 (Agency LPN) said, I'm her nurse today (Referring to R1) but I'm with Agency. All I can tell you is that she is alert oriented x 3 and she can make her needs known. I think family is involved too. Surveyor asked if R1 was at risk for falls, V5 said, No she's not a fall risk but yes I did hear about her falling awhile ago but I wasn't here when she fell. Surveyor asked about any facility in-service training, V5 said, I don't get any in-service training from here, my Agency does all that. (could not tell surveyor about fall preventative measures or fall prevention when asked about R1 as she did not consider the resident was a fall risk). Following the fall, R1 was transferred to the Emergency Department. Medical records from the hospital confirm the resident sustained a displaced fracture of the right humerus, multiple abrasions and a contusion to the left temporal region of the head. On 1/2/26 at 2:18 PM, V9 Nurse Practitioner wrote in part in the progress notes, Patient had a recent fall and returned back from the hospital on 9/22/25. FX of R (Fracture of Right )shoulder seen on imaging. patient has sling on now. patient has hematoma and bruising of Right eye and right side of face, CT head was negative according to records. Orthopedics consulted, pain management, and rehabilitation. Patient to follow up with ortho outpatient. Patient was stabilized and sent back to facility. V9 NP could not be reached for interview during this investigation. On 1/2/26 at 12:57 PM, Surveyor requested V1 administrator to provide a fall prevention policy but was provided instead with a Fall Occurrence policy. When requested for an actual policy and procedures that addressed fall prevention and how facility communicated this training to nursing staff, V1 said through email, That is the only policy. The Fall Occurrence Policy dated 6/30/25 reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions and reevaluated and revised as necessary. A fall Risk assessment form will be completed by the nurse or Falls Coordinator upon admission, readmission , quarterly, significant change and annually. Those identified as high risk for falls will be provided fall interventions. An Interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required MDS was done. If a resident had fallen, the resident is automatically considered as high risk for falls.

Based on interview and record review, the facility failed to implement the established comprehensive care plan for 1 of 3 residents (R1) to ensure safety during bed mobility and ADL (Activities of Daily Living) care and failed to communicate the resident's fall risk status. Specifically, facility staff failed to provide the required level of assistance and supervision mandated by the care plan, which led to a fall resulting in significant injury of a Humerus Fracture. A facility incident report dated 9/12/2025 reads in part, On 9/12/25 while CNA (V3) was providing ADL (activities of daily living) care to the resident when the fall occurred the CNA had (R1) laying on her left side, the CNA had one hand on her rib cage area to stabilize the resident while she was washing her with the other hand when the resident started to roll out of the bed the CNA attempted to stop the fall but was unsuccessful. The CNA notified the nurse on duty. The nurse on immediately assessed the resident. (R1) complained of pain to the right shoulder area and the nurse noted a laceration above the right eye. A cold compress was applied to the right eye. (R1) was sent 911 to hospital ED. (R1) returned from hospital ED with diagnosis of a fracture of the right humerus without any surgical interventions and a laceration above the right eyes and Steri-strips applied.R1 is an alert and oriented predominantly Polish-speaking [AGE] year old with diagnoses listed in part but not limited to type II Diabetes, Fracture of the upper end of Right Humerus, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension, Anxiety Disorder and History of Falls. Care Plan dated 5/12/25 reads in part, (R1) is at high risk for falls due to history of falls, impaired mobility, weakness, comorbidities include Heart Failure, Hypertension, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, Respiratory Failure, History of Deep Vein Thrombosis, Left Humeral Fracture. Interventions: Bed in low position, Encourage to transfer and change positions slowly, Frequent toileting, Have commonly used articles within easy reach. Low bed. R1's MDS (Minimum Data Set) dated 9/16/25 section GG for Functional Abilities/Self Care showed: Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. R1 was noted to be Dependent on staff to conduct this task. On R1's Care Area Assessments (CAA) Summary Section V of the MDS, R1 was triggered for Fall risk for every MDS assessment upon admission on [DATE] through current MDS. Review of R1's Care Plan revealed the resident was identified as a high fall risk and required extensive assistance of at least one staff member for bed mobility and incontinence care. However, on the date of the incident, V3 the agency CNA assigned to the resident failed to follow these interventions by removing her hands and physical support from the resident while the resident was in a side-lying position.On 1/2/26 at 1:10 PM, V3 Agency CNA, said, I haven't been back there awhile (referring to facility). My agency hasn't put me back there but I remember that incident. I was taking care of this lady (R1) and had her on her side. I had one hand on her shoulder and my other hand was cleaning her up because she had a massive BM (bowel movement). She (referring to R1) just reached for her bedside table or something on it. I don't know what she was reaching for to be honest. I think she just wanted some security or something but she just rolled over and fell off the bed. Surveyor asked about any bed rails, V3 said, No there were no rails on the bed for her to hold on to so I'm not sure why. I didn't understand her she didn't speak English. It was the first time I took care of her so I don't know if she ever fell before. Surveyor asked if anyone endorsed any information about R1's care needs to her, V3 said, No, no one told me anything about her. Like I said it was the first time I took care of her and no one told me anything about her and I didn't know if she was a fall risk. Surveyor asked if she had any training on fall prevention, V3 stated, No. I don't remember getting any.On 1/2/26 at 2:50 PM V4 LPN said, V3 told me that when she turned her (R1) over to clean her I think she turned her too far and so she fell out of the bed. 911 was called and I don't recall seeing a side rail. Of course if there were side rails, she may not have rolled out of the bed. The Agency CNA said that she just turned her as she was cleaning her. The aide didn't tell me anything about the resident reaching for anything at the bedside table. Surveyor asked about R1, V4 said, She was not a fall risk as she's never fallen out of the bed, so no she's not a fall risk. The whole time I've had her, she's never fallen. I was never told she was high risk for falls and she has never fallen in the room or anything like that. I know cognitively she is forgetful, but she is pretty with it. She speaks broken English but she understands me. I've never seen a communication board and have never had to use one for her.On 1/2/26 at 2:00 PM, V5 Agency LPN said, I'm her nurse today (Referring to R1) but I'm with Agency. All i can tell you is that she is alert oriented x 3 and she can make her needs known. I think family is involved too. Surveyor asked if R1 was at risk for falls, V5 said, No she's not a fall risk but yes I did hear about her falling awhile ago but I wasn't here when she fell. Surveyor asked about any facility in-service training, V5 said, I don't get any in-service training from here, my Agency does all that. (could not tell surveyor about fall preventative measures or fall prevention when asked about R1 as she did not consider the resident was a fall risk).

Based on interview and record review, the facility failed to ensure that 1 of 3 residents (R1) received care from staff with documented competency and training. Specifically, the facility assigned an agency CNA to provide direct care for R1 without first validating that the staff member possessed the necessary clinical skills or had been oriented to R1's specific safety needs, including fall risk status and required levels of assistance. As a result, the facility failed to ensure that R1 was provided care by a staff member with verified qualifications to perform the assigned duties. R1 is an alert and oriented predominantly Polish-speaking [AGE] year old with diagnoses listed in part but not limited to type II Diabetes, Fracture of the upper end of Right Humerus, Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, Hypertension, Anxiety Disorder and History of Falls. A facility incident report dated 9/12/2025 reads in part, On 9/12/25 while CNA (V3) was providing ADL (activities of daily living) care to the resident when the fall occurred the CNA had (R1) laying on her left side, the CNA had one hand on her rib cage area to stabilize the resident while she was washing her with the other hand when the resident started to roll out of the bed the CNA attempted to stop the fall but was unsuccessful. The CNA notified the nurse on duty. (R1) complained of pain to the right shoulder area and the nurse noted a laceration above the right eye. A cold compress was applied to the right eye. (R1) was sent 911 to hospital ED. (R1) returned from hospital ED with diagnosis of a fracture of the right humerus without any surgical interventions and a laceration above the right eyes and Steri-strips applied.On 1/2/26 at 1:10 PM, V3 Agency CNA, said, I haven't been back there awhile (referring to facility). My agency hasn't put me back there but I remember that incident. I was taking care of this lady (R1) and had her on her side. I had one hand on her shoulder and my other hand was cleaning her up because she had a massive BM (bowel movement). She (referring to R1) just reached for her bedside table or something on it. I don't know what she was reaching for to be honest. I think she just wanted some security or something but she just rolled over and fell off the bed. Surveyor asked about any bed rails, V3 said, No there were no rails on the bed for her to hold on to so I'm not sure why. I didn't understand her she didn't speak English. It was the first time I took care of her so I don't know if she ever fell before. Surveyor asked if anyone endorsed any information about R1's care needs to her, V3 said, No, no one told me anything about her. Like I said it was the first time I took care of her and no one told me anything about her and I didn't know if she was a fall risk. Surveyor asked if she had any training on fall prevention, V3 stated, No. I don't remember getting any.On 1/2/26 at 2:00 PM, V5 (Agency LPN) said, I'm her nurse today (Referring to R1) but I'm with Agency. All I can tell you is that she is alert oriented x 3 and she can make her needs known. I think family is involved too. Surveyor asked if R1 was at risk for falls, V5 said, No she's not a fall risk but yes I did hear about her falling awhile ago but I wasn't here when she fell. Surveyor asked about any facility in-service training, V5 said, I don't get any in-service training from here, my Agency does all that. A review of the facility-provided orientation documentation for the agency CNA V3 involved in R1's fall (dated 10/2024) revealed a perfunctory approach to training. Over two dozen training topics, including fall prevention and safety protocols, were marked only with a single continuous vertical strike-through line followed by the CNA's signature. The document lacked instructor initials for individual tasks, dates of specific competency completion, or any evidence that the CNA's skills were actually observed or validated by facility leadership. This failure to effectively verify the CNA's competency in safety protocols resulted in the staff member being assigned to care for a high-risk resident without confirmed knowledge of the facility's safety standards.On 1/2/26 at 12:57 PM, Surveyor requested V1 administrator to provide a fall prevention policy but was provided instead with a Fall Occurrence policy. When requested for an actual policy and procedures that addressed fall prevention and how facility communicated this training to nursing staff, V1 said through email, That is the only policy. The Fall Occurrence Policy dated 6/30/25 reads in part, It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions and reevaluated and revised as necessary. A fall Risk assessment form will be completed by the nurse or Falls Coordinator upon admission, readmission , quarterly, significant change and annually. Those identified as high risk for falls will be provided fall interventions. An Interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required MDS was done. If a resident had fallen, the resident is automatically considered as high risk for falls.The facility's training program failed to provide staff with a proactive fall prevention framework. A review of the facility's education modules revealed the absence of a fall prevention policy; instead, staff were only trained on a fall occurrence policy which detailed procedures to follow after a resident had already fallen. Consequently, the facility failed to ensure that the agency CNA was equipped with the necessary preventative competencies and safety protocols required to maintain the safety of R1 during high-risk for falls and ADL care.

Based on interview and record review, the facility failed to follow their Incident Reporting Policy. Facility failed to timely report (within 24 hours) a major injury from a known incident to IDPH (Illinois Department of Public Health). This deficient practice affects one resident (R1) of three residents reviewed for incident/accident. Findings Include: R1 is a [AGE] year old female resident, with diagnosis of but not limited to: Congestive Heart Failure, Pressure Ulcer Sacral Stage 3, Chronic Kidney Disease, Seizures, Lymphedema, and Pulmonary Hypertension. R1 has a BIMS of 8 (Moderate Cognitive Impairment). Facility Provided Initial Report to IDPH of this major injury on 5/13/25, reads in part: CNA (Certified Nursing Assistant) towards the end of providing peri-care to R1 in bed, on the last time that CNA turned R1 towards her, CNA inadvertently overturned resident's right leg. In the CNA's attempt to prevent R1 from rolling out of bed, CNA turned R1's leg back to bed preventing a fall. After peri care. R1 complained of right hip pain. Pain medication administered and provided relief. Attending physician who was in the building at the time was informed and gave orders for x-ray to the right femur and right knee. X-ray showed acute right intertrochanteric femoral neck fracture. Family was informed and advised for resident to be sent out to hospital, but family refused. Final report to IDPH, dated 5/17/25 reads in part: CNA inadvertently overturned resident's right leg. This resulted in R1 falling out of the bed and on to the floor. Currently R1 remains in the facility and pain management effective. Family decided for conservative management and non-surgical intervention due to R1's age. R1's care plan was updated to include assistive device in bed to assist resident with turning and repositioning. X-ray result dated 5/9/25 reported at 19:00, and shows that Right femur has a Lucency across the intertrochanteric femoral neck and lesser trochanter concerning for an acute intertrochanteric femoral neck fracture. Consider dedicated frontal and frog-leg lateral right hip radiographs versus a CT. On 6/17/25 at 11:10AM, V2 (DON) stated that on 5/9/25 V2 received a report from PT saying R1 is complaining of leg pain. V2 questioned staff on 5/9/25 and per CNA the resident rolled out of the bed half way. Right leg and the head was out of the bed. V2 also stated that on 5/9/25 Attending Physician ordered X-ray and then came back with fracture. V2 stated that V2 was not made aware of Fracture result until 5/13/25, and it was then reported to IDPH that day, which started V2's investigation. V2 stated that a fall incident or any known incident with major injury needs to be reported within 24 hours of finding the negative finding of x-ray result. Incident Reporting Policy with a revised date of 1/3/25, reads in part: It is the policy to ensure that all reportable incidents as stipulated in the Section 300.690 state regulation, are reported to the state agency. Any serious injury sustained by a resident that is not expected outcome of the disease process will be reported to IDPH Regional Office. As per IDPH clarification physical harm: does not include skin tear or bruise of something that can be covered by a band aid. Physical harm includes a fracture or blood flor not stopped by band aid or hospital treatment involves more than diagnostic evaluation. Therefore post ER (Emergency Room) evaluation that includes diagnostic evaluation only with subsequent findings of No injury do not have to be reported. The facility shall, by fax, phone, email, or directly through the IDPH Portal notify the Regulation Office within 24 hours after each reportable incident or accident. The facility shall send a narrative summary of each reportable accident or incident to the Department within seven days after the occurrence.

Based upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that staff turn/reposition residents safely, failed to ensure that staff report resident falls, failed to ensure that staff are aware of resident fall prevention interventions, failed to implement fall prevention interventions, failed to provide supervision, and/or failed to ensure that equipment was functioning properly for three of three residents (R1, R2, R3) reviewed for falls. These failures resulted in R1's (5/9/25) fall with sustained right acute intertrochanteric femoral neck fracture and pain rated 5/10. Findings include: R1 is [AGE] years old with diagnoses which include congestive heart failure, chronic kidney disease, lymphedema, and hypertension. R1's (3/1/25) fall risk assessment determined a score of 15 (high risk). R1's (5/28/25) functional assessment affirms resident is dependent on staff for rolling left and right. R1's (5/9/25) progress note (entered by V11/Agency Licensed Practical Nurse) states the aide witnessed resident attempting to roll off the bed, grabbed her by both legs and pulled her up into the bed. The resident complained of pain and Tramadol PRN (as needed) was given. The medical doctor was in the building and gives orders for an x-ray to the right femur and right knee. R1's (5/9/25) right femur x-ray states lucency across the intertrochanteric neck and lesser trochanter concerning for an acute intertrochanteric femoral neck fracture. R1's (5/9/25) Medication Administration Record affirms pain level was rated 5/10. R1's (5/9/25) final facility incident report (which is incongruent with the progress note) states the CNA (Certified Nursing Assistant) inadvertently overturned resident's right leg which resulted in the resident falling out of bed and on the floor. Residents care plan was updated to include assistive device in bed to assist resident with turning and repositioning [R1's comprehensive care plan - received 6/5/25 excludes an assistive device in bed]. R1's (5/28/25) BIMS (Brief Interview Mental Status) determined a score of 8 (moderate impairment). On 6/5/25 at 12:38pm, R1 was lying in bed however an assistive device (ie: side rails, trapeze) for turning and repositioning was not in place. Surveyor inquired about the (5/9/25) incident R1 stated I fell, they (staff) change your diaper and they tell you to roll go ahead keep rolling and that's when I fell on the floor. Surveyor inquired how staff responded when R1 fell R1 replied I think they (staff) just picked me (R1) up and put me back in bed, it happened so fast. Surveyor inquired if staff implemented anything after the (5/9/25) fall V5 (Family) responded There needs to be 2 people when changing her (R1). She (R1) can't move on her own. Surveyor inquired if side rails were placed on R1's bed V5 replied No, I don't see any. Surveyor inquired if R1 requires surgery for the 5/9/25 fracture V5 stated She's (R1) 95, the doctor recommended that and she said no due to her age, it was not in her best interest. On 6/5/25 at 12:52pm, V6 (CNA/Certified Nursing Assistant) entered R1's room to remove the lunch tray. Surveyor inquired about R1's fall prevention interventions V6 stated I help only the CNA to pull her (R1) up and to distribute the food and affirmed that she (V6) was unsure. On 6/5/25 at 1:09pm, V7 (CNA) affirmed that she's assigned to R1. Surveyor inquired about R1's fall prevention interventions V7 stated As of now, we (staff) roll her (R1) with a 2-person assist when we are changing her. She (R1) also has to have a bed all the way lowered [assistive device while in bed was excluded]. On 6/9/25 at 9:17am, V2 (Director of Nursing) presented V4's (5/9/25) witness statement as requested (due to inability to reach V4 via phone) which states during morning care on 5/9/25 when I was rolling the resident back over, her leg went over the edge. I grabbed her pant leg and the top of her shirt to prevent her from falling. She did touch the oxygen concentrator with her head, and I told the nurse. She never fell when I took care of her. Surveyor inquired about V4's statement (which was incongruent with R1's) V2 stated she (V4) said to me I (V4) was standing on the side of the bed and one of the legs went over too much so I grabbed her pant leg and shirt so she wouldn't fall out of bed. She said that she never fell out of the bed, but she did bump her head a little bit on the oxygen tank. She also said she (R1) did not complain of any pain. When I (V2) first went into the room (R1) did tell me she (R1) was having some pain. She (R1) was saying that it was taking two people to give her care during the initial contact but only (V4) was providing care so that didn't make sense what she (R1) was saying at that time. I (V2) went back to talk to her (R1) again when we figured out that there was a fracture, that's when (R1) tried to explain everything to (V3/Assistant Director of Nursing) she (R1) explained that she ended up on the floor and said that it took 2 people to get her off of the floor. I was unable to find anyone else that would have gotten her off the floor. On 6/9/25 at 1:31pm, surveyor inquired about R1's (5/9/25) incident V11 (Agency Licensed Practical Nurse) stated The CNA had me (V11) straighten her (R1) up in the bed because she was trying to fall out the bed. She (V4) told me she was trying to fall out the bed and she needed some help, so I (V11) went in there to help her. When I went down to that room the lady (R1) was in the bed. She (R1) said she was having some pain, so I gave her something for pain. V11 also affirmed that she was unaware that R1 fell on the floor. On 6/11/25 at 10:59am, surveyor inquired about potential harm to a resident if staff do not report to the nurse and/or physician that a resident fell and hit their head V13 (Medical Director) stated Multiple things can happen if we don't know about it. They (staff) should notify someone that something happened, if they (residents) fall they may require x-rays and we (staff) need to determine what happened. Falls can get fracture anywhere and if there's head trauma there's a risk of bleeding. __ R2's diagnoses include specified disorders of muscle and history of falling. R2's (3/20/25) fall risk evaluation determined a score of 5.0 (low risk). The facility incident log affirms R2 fell on 3/28/25, 4/1/25, 5/17/25, and 5/21/25. R2's (5/31/25) functional assessment affirms resident is dependent on staff for toileting and requires substantial/maximal assistance with chair/bed to chair transfer. R2's (3/20/25) care plan includes ADL (Activities of Daily Living) self-care performance deficit and impaired mobility related to generalized weakness and functional decline. Intervention: Transfer: substantial assist x1 staff participation and gait belt. R2's (5/31/25) BIMS determined a score of 15 (cognition intact). On 6/5/25 at 12:56pm, R2 was observed seated in a wheelchair. Surveyor inquired about R2's falls at the facility R2 stated It doesn't matter, what they gonna do? Surveyor inquired if the facility implemented something to prevent additional falls R2 responded They (facility) supposed to be getting me (R2) another wheelchair, but they haven't gotten one yet. Surveyor inquired how long R2 has been waiting for a new wheelchair R2 replied It's been long enough. On 6/5/25 at 1:35pm, the call light was activated (by R2). R2 stated I need somebody to come change me. V7 (CNA) subsequently entered the room, placed a gait belt around R2's waist and proceeded to transfer R2 by herself however R2 was unable to stand up straight (both knees were buckled) therefore R2 was quickly pivoted and plopped onto the bed. R2's pants were soaked with urine and the wheelchair seat was notably wet. On 6/11/25 at 11:45am, surveyor inquired if R2 can stand and/or transfer without assistance V14 (Restorative Nurse) stated He (R2) needs assistance for the transfer, he needs 1-person for assistance. If I'm not mistaken, he needs substantial assistance, technically we consider total dependence is 2-person but he is able to bear some weight and do couple steps. Surveyor inquired if R2 was supposed to receive a modified wheelchair V14 responded I haven't been notified of anything. The high back wheelchair would give him more support that would be helpful. I will go and speak with therapy about it. __ R3's diagnoses include cerebral infarction, cognitive communication deficit, and specified disorders of muscle. R3's (5/15/25) fall risk evaluation determined a score of 16 (high risk). The facility incident log affirms R3 fell on 5/21/25 and 5/23/25. R3's (5/19/25) functional assessment affirms resident is dependent on staff for sit to stand and chair/bed to chair transfer. R3's (5/15/25) care plan states resident has an ADL self-care deficit and impaired mobility, intervention: Transfer: partial assist x1 staff participation using gait belt and rolling walker. Resident is at high risk for falls, interventions: make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. R3's (5/21/25) incident report states CNA was cleaning up patient, left the room to find nurse. Other CNA observed patient on the floor next to his bed [the fall was unwitnessed]. R3's (5/19/25) BIMS affirms that cognitive skills for daily decision making are severely impaired. On 6/5/25 at 1:00pm, R3 was banging his cell phone on the bedside table repeatedly and yelling for help however staff did not respond. R3 was in a wheelchair adjacent the bed with a call light draped over his left arm (antecubital area) and not secured. R3 stated I need to get in bed. I'm worrying about getting in bed, I thought they (staff) were gonna put me in the bed it's been 20 minutes. How long does it take to get someone in bed? Surveyor inquired if R3 pressed the call light R3 responded I can't see the light where's it at? and was unable to find it. Surveyor inquired about R3's falls at the facility R3 replied I guess I was trying to get up. Surveyor inquired about staff response when he fell R3 stated They didn't pick me up right away, it a took a minute to get me up. I been calling for help a long time and I don't get it. On 6/5/25 at 1:06pm, V10 (Registered Nurse Orientee) affirmed that she's assigned to R3 and stated, He's a 2-person assist. Surveyor advised V10 that R3 requested assistance and we subsequently entered R3's room. R3 stated I need somebody to put me back in the bed. Surveyor inquired about the location of R3's call light V10 responded It's right there on your arm so he (R3) can reach it easily so it's available to him. R3 replied Yeah, but I can't see it and affirmed that he's visually impaired. V10 exited the room without providing R3 the call light and did not return - to assist R3 as requested. On 6/5/25 at 1:12pm, V7 (CNA) affirmed that she's assigned to R3. Surveyor inquired about R3's fall prevention interventions V7 stated We usually have the bed at the lowest position, and we have the bed alarm on. Surveyor inquired if R3 requires any additional fall prevention interventions V7 responded No however a chair alarm was observed on R3's wheelchair and provide call light access was excluded. Surveyor inquired about R3's call light V7 stated We usually have his call light attached to his gown. Surveyor inquired if there was a clip on R3's call light to secure it to his gown V7 reached for the call light cord (near the floor), moved the clip near the button and secured it to the gown. Surveyor inquired how R3 is transferred V7 replied He's a 2-people assist. We (staff) can help him stand and guide him to the chair. V8 (Infection Prevention Nurse) entered R3's room to assist with R3's transfer. R3's wheelchair was moved close to the bed however the wheels were not locked, a gait belt was not in use, and a rolling walker (as stated in the care plan) was not provided. As V7 was instructing R3 to stand up V9 stated Wait a minute, we should use a gait belt to get him up. V9 (Restorative CNA) subsequently entered the room placed a gait belt around R3's waist, then instructed him to push up from the chair and grab the walker. Surveyor inquired if the chair alarm (in use) sounded when R3 stood up V9 stated No. Surveyor inquired if R3's chair alarm was working V8 inspected R3's alarm and stated, Is this even on? The fall prevention program guidelines (revised 12/5/21) state a fall risk assessment shall be completed upon admission, re-admission, quarterly, significant change, annually, and after each fall. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited; to place call device within reach at all-times and respond to call light promptly. If a resident has visual defects, the location of the placement of the call light shall be verbalized to those residents. If a resident has any physical or fine motor skill deficiencies, the resident shall be fitted with the appropriate device. May utilize personal alarms when appropriate such as bed alarms, chair alarms and motion sensor alarms. Use of side rails may be considered as a safety measure, mobility aide for self-turning and repositioning. Provide assistance with activity of daily living to include toileting as needed. Use of gait belt and other appropriate transfer devices such as mechanical lifts. Ensure equipment is properly functioning and maintained.

Based upon record review and interview the facility failed to revise a comprehensive care plan for three of three residents (R1, R2, R3) reviewed for falls. Findings include: R1's (5/9/25) final facility incident report states on (5/9/25) CNA (Certified Nursing Assistant) was providing peri-care to resident in bed, on the last time that CNA turned the resident towards her, CNA inadvertently overturned resident's right leg which resulted in the resident falling out of the bed and on to the floor. Residents care plan was updated to include assistive device in bed to assist resident with turning and repositioning. R1's (3/1/25) risk for falls care plan excludes the (5/9/25) fall and an assistive device in bed. On 6/10/25 at 11:48am, surveyor inquired if R1's comprehensive care plan includes an assistive device for turning and/or repositioning in bed (as stated on the 5/9/25 incident report) V3 (ADON/Assistant Director of Nursing) accessed R1's electronic medical record and responded No, she does not have side rails. __ R2's (5/21/25) incident report includes a fall. R2's (3/20/25) risk for falls care plan (received 6/5/25) excludes the (5/21/25) fall and preventive interventions entered on or after 5/21/25. On 6/10/25 at 11:59am, surveyor inquired about R2's (5/21/25) fall and preventive interventions - post fall V3 (ADON) stated The resident wanted to go to bed, and he (R2) asked the CNA to put him in the bed. The CNA went to go get diapers and the pad to put on the bed and he decided to slide onto the floor and try to crawl to the bed to get in there on his own. So, for the care plan intervention the staff need to visually check on him and make sure that his needs are met. Surveyor inquired when R2's fall care plan was last updated V3 responded That was supposed to have been um initiated on May the 21stand affirmed that R2's care plan was revised on 6/5/25 (survey entrance date). __ R3's (5/23/25) fall incident report includes Immediate Action Taken: bed rails will be added to bed, bed alarm and floor mats will be added. R3's (5/15/25) risk for falls care plan excludes the 5/23/25 fall and floor mats. On 6/10/25 at 12:10pm, surveyor inquired about R3's (5/23/25) fall and preventive interventions - post fall V3 (ADON) stated The patient have a pressure ulcer on his buttock area, and he tries to move around in the bed, I think he's also visually impaired. He rolled off the bed, so we applied side rails to help reposition himself in the bed. Surveyor inquired if floor mats were added to R3's care plan (as stated on R3's 5/23/25 incident report) V3 responded No, I don't see it on there. The fall occurrence policy (revised 7/26/24) states those identified as high risk for falls will be provided fall interventions. The falls coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary.

Based on interview and record review, the facility failed to implement effective fall interventions and supervision for a dependent resident assessed as a high risk for falls. This failure affected one resident (R2) of four residents reviewed for falls. This failure resulted in (R2) having a fall, being sent out to the emergency room , and sustaining a laceration to right eyebrow requiring 3 sutures. Findings include: R2 is a [AGE] year-old resident initially admitted to the facility on [DATE] with diagnoses including but not limited to: Functional quadriplegia, atrial fibrillation, bradycardia, and hypertensive heart disease with heart failure. R2's Minimum Data Set (MDS) section C0500 dated 2/18/2025 documents Brief Interview for Mental Status (BIMS) Score = 15 which suggests cognition is intact. MDS section GG0130 dated 2/18/2025 documents resident is dependent on staff for the following areas: eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygiene. Care plan with initial date of 2/20/2025 but revision date of 2/23/2025 documents Focus: R2 is high risk for falls due to weakness, functional decline, co-morbidities such as functional quadriplegia, DM-II (Diabetes Mellitus type 2), AFIB (Atrial fibrillation), hypertensive heart disease, HLD (hyperlipidemia), depression, anemia, BPH (benign prostatic hyperplasia) without UTI (urinary tract infection), neuropathy. Goal: R2 will be free of falls through the next review date. Interventions: I prefer to keep all needed items like water pitcher, tissue box, urinal, etcetera, within reach. o I prefer to keep the bed in the low position for safety. o I would like staff to keep furniture in locked position during transfers and nursing care. o Please make sure that my call light is within my reach and encourage me to use it for assistance as needed. I would like staff to address my needs with a prompt response to all requests for assistance. R2's Progress note dated 3/27/2025 documents: Note Text: Called Hospital to follow up patient status. Patient admitted diagnosis: head Laceration. Bed hold. R2's Progress note dated 3/27/2025 documents in part: Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Patient had a fall. He is on Eliquis 5 mg BID. Has wound on right eyebrow area. 2. This started on: 03/27/2025. 2f. Describe symptoms or signs: Had a fall incident today. Patient c/o (complaint of) pain in both arms. He also had a wound on right eyebrow. 8c. Is there any bleeding noted from the injury? Yes 8c1. If there is a bleeding, choose one of the following: Scant Recommendation: Appearance 1. Summarize your observations and evaluation: Patient has wound on right eyebrow area and c/o pain in both arms after a fall incident. He is on Eliquis 5 mg BID. He was sent to the hospital ER (emergency room ) via 911 for further evaluation and management. 3. Additional information on the change in condition: Patient was sent out to ER by 911. MD (medical doctor) and family were notified. R2's Progress note 3/27/2025 documents in part: Incident Summary: Summoned to patient's room by V8 Certified Nursing Assistant (CNA). R2 is observed lying on the floor by his bed. R2 is positioned on his stomach with face turned to left side. There's a chair close to R2's head. Assigned CNA (V8) said she was cleaning patient (R2) and left patient for a second to get more supplies as patient kept on passing stools. Before V8 CNA got back, she heard patient (R2) fell from the bed. R2 c/o (complains of) pain in both arms. Also, noted a wound on his right eyebrow area with small amount of bleeding. R2 remains alert and oriented x4. No loss of consciousness noted during the incident. Patient is on Eliquis 5 mg BID. 911 called for immediate transfer to ER (emergency room ). MD (medical doctor) and patient's family notified. R2's Hospitalist History and physical dated 3/27/2025 documents in part: The patient presented to the hospital after mechanical fall out of bed at nursing home. He got a laceration to his right eyebrow which was repaired in the ER. Tetanus was updated. Imaging was negative for any acute injury. Him and his sister stated there feeling that he is neglected at the current nursing home, and they would like to be placed any new nursing home. R2's Laceration repair procedure note from hospital dated 3/27/2025 documents in part: appropriate position and anesthesia around the laceration was obtained by infiltration using 1% lidocaine without epinephrine. The area was then cleansed using alcohol. The laceration was closed with 3-0 Prolene using interrupted sutures. There were no additional lacerations requiring repair. The wound area was then dressed with gauze. The patient's tetanus status was updated with a tetanus booster. Total repaired wound length 2.5 cm. Other Items: Suture count: 3 On 4/22/2025, at 9:39 AM, V8 (CNA) stated the night R2 had a fall, I was doing rounds. I went in to change R2. I was cleaning R2 up, he was on his side. R2 kept having a bowel movement. I asked if R2 was ok and went to the door because my linen cart was by the door. I went to grab more linen and R2 was on the floor. I had left R2 on his side, on the bed. R2 was comfortable on his side. R2 was laying on his side before I walked off and he was fine. R2 did not use any side rails. R2'a bed was not to the floor, but it was not high. I did not raise the bed to do care. I left the bed at the level it was in when I came in. R2's bed was about my hip level. R2 could move his one arm the right arm. R2 could move his legs a little bit but could not move them a lot. I can't even tell you how R2 fell . I know I left R2 in a safe position. R2 was laying on his side for a while as I was cleaning his back. My cart was right by the door, and everything happened so quick. By the time I came back in R2 was on the floor. I did not hear R2 fall. I just heard R2 tell me he was on the floor. R2 did not tell me he was slipping or anything. No one else was in the room when this happened. We do not carry radios or anything. There were three CNAs on that hall that night. I let the nurse know. I stepped to the door and called for V9 Registered Nurse (RN). We (V9 and I) cleared the way for the ambulance to come get R2. We (V9 or I) did not move R2 or put him back in the bed. The ambulance people came and got him off the floor. I did not realize R2 was bleeding until the ambulance came and picked him up. R2 was bleeding from his eye. I think it was the right side. R2 always complains of pain. R2 was not screaming or anything like it was something new. R2 pretty much just laid there talking normal. On 4/22/2025, at 11:29 AM, V9 Registered Nurse (RN) stated, I was working the night R2 had his fall at the end of March. I was at the nurse's station. My CNA (V8) was in the hallway. V8 said, can you come here. R2 is on the floor. V8 said, I was changing the patient and he kept passing stool and I left for a second and V8 said she heard him fall from the bed. When I walked in R2 was on the floor, so I called 911, I did not even move R2. Ambulance came right away within a few minutes. At first, I could not see if R2 was bleeding. R2's right side of his face was on the floor. When 911 got there I seen R2 had about an inch long cut on right eyebrow area that was bleeding a minimal amount. It was shallow. R2 was complaining of pain on the left arm. When I went in the room and seen R2 on the floor the bed was waist high. R2 did not have any bed rails on his bed or half rails that I know of. If I were to be changing the resident and needed more supplies, I would make sure the patient is on his back, the bed is lowered, and make sure resident is safe before I leave the room. I would explain to resident that I need to get supplies and I will be right back in a few seconds. On 4/22/2025, at 2:33 PM, V3, Director of Nursing (DON) stated, if a staff member was changing someone and needed more supplies the staff member could put on the call light and get help. In the situation with R2 the linen cart was right outside the door, I would not expect them (staff) to leave a resident to go all the way to the linen closet. I would expect staff to leave resident in a safe manner ensuring their safety before leaving them briefly for supplies. When asked what a safe manner would be V3 stated, a safe manner would be ensuring resident is not at the edge of the bed, put bed in low position, make sure call light was still in reach. When asked what position the resident should be placed in, V3 stated, I guess the position of the patient depends on the patient. When asked specifically for R2's situation as a quadriplegic what would the safest position be for R2 be, V3 stated R2 was a quadriplegic so his safest position would have been on his back. On 4/23/2025, at 11:25 AM, V1, Administrator stated, my expectation of staff when leaving a resident briefly to get supplies would be that they are left in a safe position. When asked what would constitute a safe position, V1 stated a safe position would be comfortable, center of the bed, and bed lowered. When asked what position the resident should be left in such as on side or on back, V1 stated the position the resident should be in would depend on their orders. Like if a resident has orders to turn every 2 hours, we would follow the doctors' orders. When asked what position should a resident be left in if the staff is just stepping away briefly to get supplies, V1 stated just for staff to step away briefly the optimal position could be on the back. When asked for this particular resident R2 who had quadriplegia and could not fully move legs, what would optimal positioning for this resident be if staff needed to walk away briefly to get supplies, V1 stated optimal positioning for this particular resident R2 would have been on his back due to his quadriplegia. If there is a fall, we do in servicing right away. I know we did in servicing for the date in question. Fall Prevention Program Guideline Policy with review date of August 5, 2022, documents in part: Policy Statement: Fall prevention program guidelines shall be implemented to promote safety of all residents in the facility. This program shall include measures to determine the individual needs of each resident by assessing the risks for fall and the implementation of evidence-based prevention interventions. Procedure 2. Safety interventions shall be initiated and implemented for each resident identified at risk for fall. 3. All assigned nursing personnel and facility staff shall be responsible for ensuring ongoing precautions are put into place and consistently maintained. 6. Interventions shall include staff, family and resident education, programs, purchase of equipment or other environmental-related alternatives to prevent the resident from falling. 7. An individualized evidence-based plan of care shall be created to reflect fall prevention interventions which could be but not limited to: h. Residents shall be observed to ensure the resident is safely positioned in bed or chair. Provide care as assigned in accordance with the plan of care. j. Education and communication of resident care to staff. m. provide assistance with activity of daily living to include toileting as needed. ADL (Activities of Daily Living) Care Guidelines Policy with reviewed date of August 5, 2024, documents in part: ADL care is provided for each resident in the facility in accordance to the resident's comprehensive assessment and care plan in order to identify, evaluate, and intervene to, maintain, improve or prevent and avoidable decline in ADL's. Interpretation and Implementation 2. Nurses and CNAs (certified nursing assistants) are trained in providing general/routine ADL care to the residents. The facility has an active program of restorative nursing services which is developed and coordinated through the resident's care plan. 4. ADL nursing care is performed daily for the residents based on the comprehensive assessment, plan of care, physician orders as well as ADL documentation on varios shifts. Such care may include as appropriate but not limited to: g. Incontinent care and bowel and bladder training as indicated; and i. Other ADL support and assistance in accordance to the restorative nursing assessment and/or comprehensive resident assessment

Based on interviews and record reviews the facility failed to follow their policy and procedures for care planning and fall prevention by not implementing previously established fall interventions based on all available information for a resident readmitted to the facility with a history of repeated falls and by not implementing personalized fall interventions or ensuring all available sources of information were utilized to identify and implement effective fall interventions for a resident who was admitted to the facility after being hospitalized from a fall that resulted in multiple significant injuries. This failure applies to two of four residents (R7 and R56) reviewed for falls and resulted in R56 experiencing a fall that resulted in a thigh bone fracture. Findings include: R7 is an [AGE] year-old male with a diagnoses history of Metabolic Encephalopathy, Right and Left Side Pain from Back to Legs, and restless leg syndrome who was admitted to the facility 07/23/2024. R7's admission hospital records dated 02/21/2024 documents he had a history of frequent falls, he was admitted to the hospital after a fall at home, he had previous hospital admissions related to falls in the last few years, he has severe lumbar spine fusion and complains of pain, per family member he has been having more frequent falls as of late, and can be transferred to rehabilitation; the plan for recurrent falls included recommendation of subacute rehab; IDT (Interdisciplinary Team) recommendations also included Bed/Chair alarms, caregiver within arm's reach when out of bed, establish a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, and minimizing overnight disruptions. The facility's Fall Log reviewed 11/18/2024 documents R7 had falls on 10/22 at 11:40 AM and 10/26 at 9:25 PM R7's progress note dated 10/23/2024 documents a certified nursing assistant made writer aware that R7 was observed sitting on the floor. Writer and staff went into resident's room to assess resident. Resident stated he was trying to move to the other bed because his bed had a hole in it, and he slid down on the floor. R7's Fall Risk Management assessment dated [DATE] documents his bed alarm was going off in his room, staff immediately responded, and he was observed lying on the floor; R7 reported he didn't fall but slipped off the bed as he was trying to go to the other bed. R7's Current care plan initiated 07/23/2024 documents he is at risk for falls related to a history of falls, potential medication side effects, poor safety awareness, disease process such as acute respiratory failure with hypoxia, sepsis, aspiration pneumonia, cognitive impairment, acute metabolic encephalopathy, Coronary Artery Disease, Benign Prostatic Hyperplasia, chronic Urinary Tract Infections, Hypertension, Diabetes Mellitus, Acute Kidney Injury, and A fibrillation. R7's care plan interventions did not include Bed/Chair alarms, caregiver within arm's reach when out of bed, establishing a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, or minimizing overnight disruptions. R7's Bed alarm intervention was not implemented until 10/22/2024 and the intervention of frequent rounding and asking if he needs assistance or toileting were not implemented until 10/26/2024. R56 is a [AGE] year-old male with a diagnoses history of Cirrhosis of Liver, Emphysema, Non-traumatic Brain Hemorrhage, Stage 4 Chronic Kidney Disease, Sarcoidosis, Epilepsy, Hepatic Encephalopathy, History of Falling, Multiple Fractures of Ribs, and Bone Disorder who was admitted to the facility 07/12/2024. The facility's Fall Log reviewed 11/18/2024 documents R56 had a fall with injury 07/12/2024 at 10:39 PM. R56's Admission Summary progress note dated 7/12/2024 documents patient has arrived at facility via stretcher around 2pm. Writer noted upon assessment patient has multiple bruises all over the body, left ear sutures, and bruising around left eye. Patient is currently in bed, with bed in the lowest position, call light within reach, ice water at bedside; at 11:03 PM it was documented that Writer was notified by certified nursing assistant of patient being on the floor. Upon assessment the writer observed the patient sitting upright at the bedside, as the writer asked the patient what happened his nose started to bleed. The patient had pain rating 10/10 with limited range of motion to the left leg, the patient was extremely confused. Facility Incident Report dated 07/18/2024 documents R56 had an unwitnessed fall 07/12/2024 at 10:10 PM and was admitted to the hospital with an acute right femoral shaft fracture; On 07/12/2024 at approximately 10:10 PM a certified nursing assistant observed patient sitting on the floor of his room, he was observed by nurse sitting upright on his buttocks on the floor by his bed, he was observe with minimal bleeding from nose and was unable to move his right leg, when asked what happened he reported he was trying to get up and use the bathroom, he did not activate the call light for assistance, he was last seen by the nurse before the incident at approximately 9:35 PM sleeping in bed with his call light in reach and bed in the lowest position. On 11/18/24 01:29 PM V26 (Family Member) stated, R56 fell when he first came to the facility, and she doesn't think they did the proper intake when he was admitted . V26 stated, the facility didn't get enough information about R56's needs. V26 stated, R56's other roommates had a better intake process and were better accommodated. V26 stated, she doesn't know how R56 fell but his bed was not equipped with sensors or railings, and his room was far back in the facility at the very end. V26 stated, after R56 fell they added railings to his bed, moved his room closer to nurses station, and added a motion sensor to his bed. V26 stated, when R56 fell he fractured his femur (thigh bone) and hasn't been able to receive therapy. V26 stated, R56 has been discouraged and depressed, has become withdrawn and believes a lot of it has to do with the injury. R56's medical records did not include any information obtained from V26 (Family Member) on the day he was admitted regarding his needs based on his risk of falls and history of falls. R56's hospital report dated 07/24/2024 documents he was recently admitted to the hospital from 06/29/2024 - 07/12/2024 for traumatic subdural hematoma and sub arachnoid hemorrhage (bruising and bleeding near the brain), nasal bone fracture, abnormally low blood cells post bone marrow biopsy and having subsequent worsened confusion. R56's Minimum Data Set section for Functional Abilities dated 07/12/2024 marked as completed at 3:11 PM documents he required supervision and touching assistance with bed mobility and substantial/maximal assistance with transfers. The facility's census report documents when R56 was admitted on [DATE] his room was located in an area that was not close to the nurses station and when he was readmitted to the facility on [DATE] he was placed in a room right outside the nurses station area. R56's physician order history documents 2 quarter side rails to aide with bed mobility and transfers were not ordered until 07/24/2024. R56's Current care plan initiated 07/12/2024 documents he is a high risk for falls due to traumatic subdural hemorrhage, calculus of kidney, stroke, acidosis, right ankle joints and right foot, stage 3 Chronic Kidney Disease stage, sarcoidosis, epilepsy, acute kidney failure, insomnia, and right hip fracture with interventions implemented 07/12/2024 including ensure that his frequent visitors are aware of the use of assistive and adaptive devices; he has periods of forgetfulness and would like staff to frequently reorient him to his surroundings; he would prefer to keep all needed items like water pitcher, tissue box, urinal, etc., within reach; he would prefer to keep the bed in the low position for safety; he would like Physical Therapy and Occupational Therapy to evaluate and treat him as ordered to increase his strength and mobility and prevent further falls; and he would like staff to provide him with a safe environment: even floors, free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; side rails as ordered, and handrails on walls. R56's care planned interventions of a bed alarm to alert staff when he attempts to get out of bed unassisted, or so staff can assist him and prevent falls and the two quarter side rails to aide with mobility and transfers were not implemented until 07/24/2024. R56's care planned interventions of reminding him to ask for assistance; reorienting him on how to use the call light, and if necessary, toileting him to prevent unassisted attempts to go to the toilet were not implemented until 11/09/2024. On 11/20/24 at 1:02 PM V2 (Director of Nursing) stated, initial fall assessments are done upon admission. V2 stated, if a resident has a known history of falls on admission based on information obtained from the resident, the resident's family, or the hospital this information would be including in the admission's assessment. V2 stated, any information obtained from those sources should be included on the admission or baseline care plans. V2 stated, any past medical history of fall interventions should have been incorporated in R56's care plan once he was readmitted to the facility in July 2024. V2 stated, he believes V26 (Family Member) was present and interviewed when he was admitted to the facility and possibly any available information regarding falls would have been obtained from her. On 11/21/24 at 10:33 AM V32 (Physician) replied, yes when asked by surveyor if fall interventions should be personalized to R56's needs. V32 stated, he saw R56 soon after his arrival prior to his fall and V26 (Family Member) was at bedside at this time. V32 stated, he believes there was some concern with R56's neurological status related to his sarcoidosis, and this may have led to him attempting to get out of bed. V32 stated, R56 suffers from a rare illness, and it may have been difficult to anticipate his particular needs and the appropriate precautions needed to be implemented prior to him coming to the facility for the first time. V32 stated, fall interventions are a personalized approach for each patient and should be tailored to the debilities that each patient comes with. On 11/21/24 at 11:32 AM V1 (Administrator) stated, the room R56 was located in on admission is not right near the nurses station and is towards the end of the hall. V1 stated, room R56 is currently located in is closer to the nurses station and is right outside of it. On 11/21/24 at 12:29 PM V2 (Director of Nursing) stated, R56's bed rails were not in place when he fell [DATE]. V2 stated, bed rails would not be added until an assessment is done, and consents were given. V2 stated, there was no reason rails could not be applied for R56 on admission, however there was no indications if bed railings were needed or not for R56 and no information was provided by V26 (Family Member) of him needing bed railings. V2 agreed it is not necessary for V26 to initiate the use of bed railings, and railings could be used for mobility or if the staff noticed that the patient was struggling with positioning however there was nothing indicating this during the brief amount of time R56 was admitted prior to his fall. The facility's Fall Occurrence Policy received 11/21/2024 states: It is the policy of the facility to ensure that residents are assessed for risk for falls and that interventions are put in place. A Fall Risk Assessment form will be completed by the nurse or the Falls Coordinator upon admission. Those identified as high risk for falls will be provided fall interventions. An interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required Minimum Data Set was done. If a resident had fallen, the resident is automatically considered as high risk for falls. Therefore, the nurse does not have to fill out the Fall Risk Assessment to determine if the resident is high risk for falls or not, after the resident had fallen. The Falls Coordinator will add the intervention in the resident's care plan. The interventions will be reevaluated and revised as necessary. The facility's Care Planning Policy received 11/21/2024 states: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Based on the State Operations Manual F656 regulation a comprehensive care plan must be developed after the comprehensive assessment of the resident. The baseline care plan at a minimum should include initial goals based on admission orders, physician orders, and therapy services.

Based on observation, interview, and record review, the facility failed to follow their policy and procedures for preparing food under sanitary conditions by not using hand hygiene, when necessary, not sanitizing surfaces after cleaning them, not ensuring appliances were adequately dried or free of surface contamination after cleaning and before use, and not ensuring hair restraints were worn properly. This failure applies to all 96 residents in the facility. Findings include: Kitchen On 11/19/24 from 10:30 AM - 11:30 AM Observed while taking temperature of seasoned rice observed V28 (Cook) doff and don gloves without performing hand hygiene then prepare pureed taco meat, observed V27 (Food Service Director) and doff and don gloves while performing tasks in the food prep area without performing hand hygiene. Observed V29 (Night Cook) doff and don gloves while performing hand hygiene while performing tasks in the food prep area then handle clean dishware. Observed V28 doff and don gloves multiple times without performing hand hygiene while preparing and temping food, handling containers with food in them, and handling clean dishware. Observed V28 with hair exposed from the back of her hairnet while preparing food and performing other kitchen tasks and V30 (Dietary Aide) with hair exposed from the sides of her hairnet while assisting with preparing meal trays. Observed V28 use a soapy towel to clean the food prep table where the food processor was located, the food prep table near the stove, and a beverage cart and not sanitize after cleaning. Observed V28 wash and clean the food processor equipment, then immediately puree vegetables in it with a noticeable amount of water remaining on the inside and outside of the food processor and the lid. 11/20/24 01:43 PM V27 (Food Service Director) stated, when staff remove gloves, they should wash their hands before donning new gloves. V27 stated, staff should sanitize a surface immediately after cleaning it with the soapy water. V27 stated, when the food processor can't be air dried during constant use because the temperature of the food will go down if air dried when in between use after being washed. V27 stated, the food processor should be left for a minute or two to allow some water to drain from it before reusing after cleaning it. V27 stated, any water left in the food processor after cleaning will change the consistency for the puree, and there could be contamination from the water. V27 stated, all hair should be covered when underneath a hairnet because hair can contaminate food. The facility's Kitchen Policy received 11/20/2024 states: The facility will comply with state and federal regulations in operating facility's kitchen. Hair restraint is required except for those who are bald. Staff will wash hands after handling soiled items. The facility's Hand Hygiene Policy received 11/20/2024 states: Hand hygiene is important in controlling infections. Hand hygiene consists of either hand washing or the use of alcohol gel. The facility will comply with the CDC (Centers for Disease Control and Prevention) Guidelines in regard to hand hygiene. Hand hygiene using alcohol-based hand rub is recommended during the following situations: After removing gloves.

Based on observation, interview, and record review the facility failed to follow their policy and procedures for comprehensive care planning by not ensuring care plans, and personalized care planning interventions were implemented as needed based on grievances, resident's past medical history, and comprehensive assessments. This failure applies to four of four residents (R7, R16, R45, and R56) reviewed for care planning. Findings include: R7 is an [AGE] year-old male with a diagnoses history of Metabolic Encephalopathy, Right and Left Side Pain from Back to Legs, and restless leg syndrome who was admitted to the facility 07/23/2024. R7's admission hospital records dated 02/21/2024 documents he had a history of frequent falls, he was admitted to the hospital after a fall at home, he had previous hospital admissions related to falls in the last few years, he has severe lumbar spine fusion and complains of pain, per family member he has been having more frequent falls as of late, and can be transferred to rehabilitation; The plan for recurrent falls included recommendation of subacute rehab; IDT (Interdisciplinary Team) recommendations also included Bed/Chair alarms, caregiver within arm's reach when out of bed, establish a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, and minimizing overnight disruptions. The facility's Fall Log reviewed 11/18/2024 documents R7 had falls on 10/22 at 11:40 AM and 10/26 at 9:25 PM R7's Current care plan initiated 07/23/2024 documents he is at risk for falls related to history of falls, potential medication side effects, poor safety awareness, disease process such as acute respiratory failure with hypoxia, sepsis, aspiration pneumonia, cognitive impairment, acute metabolic encephalopathy, Coronary Artery Disease, Benign Prostatic Hyperplasia, chronic Urinary Tract Infections, Hypertension, Diabetes Mellitus, Acute Kidney Injury, and A fibrillation. R7's care plan interventions did not include Bed/Chair alarms, caregiver within arm's reach when out of bed, establishing a toileting schedule and ADL (Activities of Daily Living) routine, non-skid socks, use of bedside commode, shades up during the day, lights off and shades down at night, or minimizing overnight disruptions. R7's Bed alarm intervention was not implemented until 10/22/2024 and the intervention of frequent rounding and asking if he needs assistance or toileting were not implemented until 10/26/2024. Resident #16 R16 is an [AGE] year-old female with a diagnoses history of Recurrent Severe Major Depressive Disorder, Overactive Bladder, who was admitted to the facility 12/12/2023. On 11/18/24 at 11:29 AM R16 stated sometimes they don't like to get her up with the mechanical lift and she must wait. R16 stated she was waiting for someone to get her out of bed, get her dressed, and place her in her chair. R16 stated she was supposed to be up in her chair by 11 AM. R16 stated sometimes they don't get her up until later. Observed R16 still in her bed wearing a gown. R16 stated she would prefer to be up and dressed. On 11/18/24 at 12:19 PM Observed staff getting R16 out of bed and dressed. R16's current care plan documents she has a self-care deficit in ADL's (Activities of Daily Living) and Impaired Mobility related to weakness, functional decline, and comorbidities such as Urinary Tract Infection, A Fibrillation, Hyperlipidemia, Hypothyroidism, and a personal history of venous thrombosis. R16's is on a dressing/grooming program. Interventions include requiring total dependence for transfers using a mechanical lift with two-person assistance and does not include a get up schedule. On 11/19/24 at 1:20 PM V24 (Family Member) stated, the aides tell R16 she's too heavy to put in a sling. V24 stated, months ago she reported this to V3 (Assistant Director of Nursing) and things would improve temporarily, then later she reported these issues to V2 (Director of Nursing). V24 stated, yesterday on 11/18/2024 she texted V25 (Assistant Administrator) about R16 not being out of bed yet at around 12:20 PM and he informed her they were finally getting her out of bed soon after. V24 stated, sometimes R16 calls her on the weekend and reports she's still in bed at 6PM. V24 stated, if R16 is changed at 9AM and needs to be changed again at 11 they tell her they just changed her. V24 stated R16 prefers to be gotten out of bed at 11 AM so she won't be in this situation. V24 stated, staff complain about getting R16 out of bed because she's heavy to put in the mechanical lift. V24 stated, R16 is told on the weekends we're short staffed, we'll be back, and they don't return, and she is left unchanged for hours. Grievance form dated 09/30/2024 documents V24 expressed concerns regarding R16 requesting to be placed on a get up schedule. Grievance form dated 11/19/2024 documents concerns were reported concerning R16 being gotten out of bed before lunch. On 11/20/24 at 1:36 PM V2 (Director of Nursing) stated, a get up schedule should be part of R16's care plan and the staff should have her up by 11 AM or 11:30 AM from what he can recall. Resident #45 R45 is a [AGE] year-old male with a diagnoses history of Partial Paralysis following a Stroke, Dementia, and History of Falling who was admitted to the facility 09/16/2024. On 11/18/24 11:00 AM Observed R45 left hand contracted. R45 stated, he cannot use his left hand. V33 (Family Member) stated, she was told the facility won't provide therapy services for R45 hand because his insurance won't cover it. V33 stated, R45 has multiple medical insurances, and she isn't sure why some form of therapy services isn't covered for him. R45's Admission Restorative assessment dated [DATE] documents he is experiencing functional decline, and he needs to be referred to Physical Therapy and Occupational Therapy for further evaluation. R45's Physician progress note dated 10/5/2024 documents he has a contracture of the hands. R45's Current care plan documents he requires assistance with ADL's (Activities of Daily Living) such as bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting, co-morbidities such as hemiplegia/hemiparesis (partial paralysis), and dementia with interventions including Skilled Rehabilitation Therapy evaluation and treatment as indicated; he would like staff to refer him to Physical and/or Occupational Therapy as ordered by the physician to evaluate his current condition/status and recommend appropriate interventions to improve my functional ability. R45's current care plan does not include treatment for his left-hand contracture. R45's Current physician orders include an order effective 11/19/2024 for being seen 1 time by Occupational Therapy for evaluation only for left hand splinting needs and recommendations and an evaluation for a splint. On 11/20/24 at 1:29 PM V2 (Director of Nursing) stated, the MDS (Minimum Data Set) coordinator usually reviews care plans to ensure they are complete and agreed that R45's care plan should include care for his contracture. V2 stated, R45 should have been evaluated for a hand splint much sooner than 11/19/2024 based on his medical history and admission's restorative assessments. Resident #56 R56 is a [AGE] year-old male with a diagnoses history of Cirrhosis of Liver, Emphysema, Non-traumatic Brain Hemorrhage, Stage 4 Chronic Kidney Disease, Sarcoidosis, Epilepsy, Hepatic Encephalopathy, History of Falling, Multiple Fractures of Ribs, and Bone Disorder who was admitted to the facility 07/12/2024. On 11/18/24 01:29 PM V26 (Family Member) stated, R56 has been discouraged and depressed, has become withdrawn and believes a lot of it has to do with the injury he sustained when he fell at the facility on 07/12/2024. V26 stated, R56's condition and being in and out of the hospital a lot playa a role and they had not been providing him with any social services to address this. V26 stated, R56 has sarcoidosis, and this has affected his mood. R56's Admission Minimum Data Set, dated dated dated [DATE] documents his mood status included having little interest or pleasure in doing things; feeling down, depressed, or hopeless; sleep disturbances, feeling tired or having little energy, appetite disturbances, having negative feelings about himself, having trouble concentrating, and having communication disturbances for a period of several days. R56's current care plan does not include a plan or interventions for his mood. The facility's Care Planning Policy received 11/21/2024 states: It is the policy of the facility to ensure that all care plans including base line care plans are in conjunction with the federal regulations. Based in the State Operations Manual F656 regulation a comprehensive care plan must be developed after the comprehensive assessment of the resident. The baseline care plan at a minimum should include initial goals based on social services. After the comprehensive assessment (state/federal - required Minimum Data Set) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days.

Based on observation, interviews and record reviews, the facility failed to implement the use of personal protective equipment during provision of care on residents in isolation rooms; failed to change soiled gloves during ADL (activities of daily living) care; and failed to prevent contamination of urinary catheter and bag by keeping it off the floor for four (R15, R71, R101 and R112) of four residents in the sample of 46 reviewed for infection control. Findings include: R15 is an [AGE] year-old, male admitted in the facility on 10/22/24 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; and Chronic Viral Hepatitis C. On 11/18/24 at 11:39 AM, V16 (Certified Nurse Assistant, CNA) was observed providing ADL care on R15. V16 was observed wearing the same pair of gloves when she started wiping R15's face, neck, upper back, lower back and when cleaning the genital area. She (V16) was also wearing the same pair of gloves when she put on his (R15) new gown, new incontinent brief, and clean bed linens. R71 is a [AGE] year-old, male, admitted in the facility on 09/23/24 with diagnoses of Obstructive and Reflux Uropathy, Unspecified; Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms and Personal History of Malignant Neoplasm of Prostate. POS (Physician Order Sheet) dated 09/24/24 recorded: Indwelling Catheter. On 11/18/24 at 10:45 AM, R71 was observed propelling his wheelchair in the hallway. R71 has an indwelling urinary catheter in placed. His urine bag was not inside privacy bag. The urine bag was observed being dragged to the floor as his wheelchair moves. On 11/19/24 at 12:41 PM, R71 was observed in his room; eating lunch while sitting in wheelchair. His indwelling urinary catheter bag was observed covered in front, not in a privacy bag, and was touching the floor. The catheter tubes were in between his legs, and on the floor. On 11/19/24 at 12:45 PM, V11 (Registered Nurse, RN) was asked regarding R71 and catheter care. V11 replied, His indwelling urinary catheter is the one that has an attached front cover. This doesn't cover the whole urine bag. The indwelling catheter should not be touching the floor as he moves the wheelchair. The tube should not be on the floor as well to prevent contamination and for infection control. R101 is a [AGE] year-old-male, admitted in the facility on 10/31/24 with diagnoses of Unspecified Dementia, Unspecified Severity, Without Behavioral disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety; and Gastrostomy Status. On 11/18/24 at 12:23 PM, V21 (Podiatry Assistant) and V22 (Podiatrist) were observed inside R101's room, putting aside a blue pad with trimmed toenails. V21 stated they just finished cutting his (R101) toenails. V21 and V22 were observed not wearing gowns. R101 is on EBP (enhanced barrier protection) due to presence of gastrostomy tube. V21 and V22 were also not observed wash their hands before leaving his (R101) room. V21 and V22 went directly to R112's room. R112 is an [AGE] year-old, male, admitted in the facility on 11/15/24 with diagnoses of COVID 19 (Coronavirus 19). R112's care plan dated 11/15/24 recorded: Requires (droplet/contact) precautions related to COVID infection - Interventions: Initiate proper precaution; Observe isolation precautions as clinically indicated; Use appropriate protective equipment; Utilize proper handwashing technique. POS dated 11/18/24 documented: Maintain at all times. Strict contact/droplet isolation precautions due to an active infection. On 11/18/24 at 12:25 PM, V21 and V22 were observed going into R112's room without wearing gown, N95 mask, eye wear or face shield; and started cutting his (R112) toenails. No handwashing was observed on V21 and V22 prior to contact with R112. On 11/20/24 at 11:31 AM, V23 (Infection Preventionist) was asked regarding infection control. V23 replied, For residents on enhanced barrier precautions, gowns and gloves are worn prior to entering room and while providing care such as assistance with ADLs (activities of daily living) and trimming nails. Hand hygiene/handwashing should be done before and after contact. During provision of morning/care incontinence care, staff wears gloves and change when soiled making sure not contaminating clean items with soiled items. Gloves are changed when visibly soiled; when putting on clean gowns; in between residents. Droplet precautions - mask and goggles/face shields/eye wear are to be used when providing care. For COVID, staff must wear gown, gloves, N95 and eye wear/face shields. Facility's policy titled Infection Prevention and Control dated 6/6/24 recorded in part but not limited to the following: Policy Statement The facility has established a policy to Identify, Record, Investigate, Control, Test, and Prevent Infections in the facility. The facility will also maintain a record of incidents and corrective actions implemented for the identified infection. Procedures: 17. Hand hygiene will 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. Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precaution: 1. Standard Precaution - based on principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membrane may contain transmissible infectious agents. Infection prevention practices include hand hygiene, use of gloves, gown, or mask depending on anticipated exposure, and safe injection practices. PPE is used depending on anticipated exposure to blood, body fluids, mucous membranes, non-intact skin, or potentially contaminated environmental surfaces or equipment. 2. Contact Precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment. b. Use of gown and gloves is necessary prior to room entry. Face protection may be necessary if performing activity with risk of splashing or spraying (Standard Precaution). 3. Droplet Precaution - intended to prevent transmission through close respiratory or mucous membrane contact with respiratory secretions. b. Eye protection, and mask should be worn for close contact with the resident. If there are infectious material that can be transmitted through contact, then gloves and gown should also be used. 5. Enhanced Barrier Precaution (EBP) a. Involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDROs as well as residents with wounds and/ or indwelling medical devices. Facility's signage posted by the door (resident room) documented in part but not limited to the following: Droplet Precautions Everyone must: Clean their hands, including entering and when leaving room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. Enhanced Barrier Precautions Providers and staff must also: Wear gloves and gown for the following high-contact resident care activities: providing hygiene. Facility's policy tiled Urinary Catheter Care dated 8/19/24 stated in part but not limited to the following: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control 2. b. Be sure the catheter tubing and drainage bag are kept off the floor. Facility was requested to present policies related to infection control during ADL care but unable to provide one.

Based on observation and interview the facility failed to follow their policy to ensure multidose vials of insulin were dated when vials were first accessed for two residents (R14 and R5) and failed to safely dispose of seven expired bottles of house stock medications. This failure has the potential to affect 38 residents residing on the second floor. Findings include: On 11/19/24, at 10:53 AM, Surveyor asked V8 Registered Nurse (RN) to review second floor low-end medication cart. Surveyor observed a previously accessed insulin pen of Toujeo Solostar (insulin) 300 unit/ml injection that showed an order date of 10/30/2024. Insulin pen was not dated when it was opened or dated for when to discard on the pen or the bag it was in. This insulin pen had an expiration date of 8/31/2026 and was for R5. V8 (RN) verified the pen had previously been accessed and that it did not have a date on the insulin pen of when it was accessed or when it should be discarded. Surveyor observed the following: 5 house stock medications bottles expired in the same medication cart: Oyster shell Calcium 500 mg stock bottle with expiration date of 10/2024 Niacin 100 mg stock bottle with expiration date of 08/2024 One daily multivitamin stock bottle with expiration date of 08/2024 Magnesium Oxide 400 mg stock bottle with expiration date of 06/2024 Stomach Relief 525 mg liquid stock bottle with expiration date of 10/2024 V8 (RN) was asked by surveyor to verify expiration dates on above 5 bottles. Dates were verified by V8 (RN). Surveyor observed V8 (RN) throw the 5 expired stock bottles dated prior to 11/2024 in trash bin on the low-end medication cart for second floor. On 11/19/24, at 11:20 AM, Surveyor asked V8 (RN) to review second floor middle medication cart. Surveyor observed a previously accessed insulin pen of Toujeo Solostar 300 unit/ml insulin glargine injection pen. Insulin pen was not dated when it was opened or dated for when to discard on the pen or on the bag it was in. This insulin pen had an expiration date of 8/31/2026 and was for R14. V8 (RN) verified the pen had previously been accessed and that it did not have a date on the insulin pen of when it was accessed or when it should be discarded or on the bag it was in. Surveyor observed the following: 2 house stock medications bottles that had already expired in the same medication cart: Niacin 500 mg stock bottle with open date of 3/6/24 that had an expiration date of 10/2024. Niacin 100 mg stock bottle that had expiration date of 08/2024. V8 (RN) verified the expiration dates and discarded the 2 expired bottles of stock medications dated prior to 11/2024 in trash bin on middle medication cart on second floor with surveyor present. On 11/19/2024, at 11:43 AM, V3 Assistant Director of Nursing (ADON) stated, insulin pens should be dated when opened. I am not sure how long they are good for once opened. I will get back to you. On 11/19/24, at 11:57 AM, Surveyor went back up to second floor and observed the discarded stock medication bottles were still in the trash bins in both medication carts on second floor. On 11/19/24, at 12:01 PM, V3 (ADON) stated, insulin pens/vials once opened are good for 28 days. Regarding discarding expired medications, we remove them from out of circulation and I will have to check with how we get rid of them. On 11/19/24, at 12:17 PM, V3 (ADON) stated, stock medications that are expired should be discarded in drug buster or sent back to pharmacy. It would be unacceptable to discard medication bottles of stock meds that are expired in the trash bin on the med carts. V3 (ADON) provided surveyor with census per medication cart for second floor residents. On 11/19/24, at 1:30 PM, Surveyor called V7 Pharmacist consultant. V7 stated, to dispose expired medications the facility should follow their policy for disposing of medications. Toujeo Solostar insulin pens should be dated when opened and are good for 56 days. They should also be labeled with the expiration date of the 56 days. On 11/19/24, at 03:39 PM, V2 (DON) stated, regarding insulin pens, they should be dated the first time they use them. All insulin pens are good for 28 days after first use. We do not put a discard date on the insulin pens. Regarding destruction of any expired medications, anything that is not able to go back to the pharmacy we use the drug buster to destroy in house. If a nurse throws medications/bottles of medications in the trash bin on the medication cart, that is not acceptable. Someone else could get them such as another resident and cause harm. We also do not want them to get into the garbage supply for contamination issues, etc. Medication Storage, Labeling, and Disposal Policy with revision date of 8/16/24 documents: Policy Statement: It is the facility's policy to comply with federal regulations in storage, labelling, and disposal of medications. Procedures 3. Medications will be stored safely under appropriate environmental controls. 4. Medications will be secured in locked storage areas. Medication Pass Policy with revision date of 08/16/24 documents: Medication Labeling: 1. All opened medication vials in the refrigerator should be labeled with the date when it was opened and discarded within 28 days of opening except for Levemir insulin which can be discarded 42 days after opening and Xalatan eye drops which can be discarded 6 weeks after opening. 2. Follow pharmacy recommendation as to when the medication should be discarded after opening. 3. Insulin vials are to be discarded within 28 days after opening, except for Levemir insulin which are to be discarded 42 days after opening.

Based on observation, interview, and record review the facility failed to follow their policies for restorative nursing program services by not ensuring a resident received the necessary treatment and services to prevent further decline in physical functioning for a resident with a contracture. This failure applies to one of one resident (R45) reviewed for rehab and therapy services. Findings include: Resident #45 R45 is a [AGE] year-old male with a diagnoses history of Partial Paralysis following a Stroke, Dementia, and History of Falling who was admitted to the facility 09/16/2024. On 11/18/24 at 11:00 AM Observed R45's left hand contracted. R45 stated, he cannot use his left hand. V33 (Family Member) stated, she was told the facility won't provide therapy services for R45 hand because his insurance won't cover it. V33 stated, R45 has multiple medical insurances, and she isn't sure why some form of therapy services isn't covered for him. R45's Admission Restorative assessment dated [DATE] documents he is experiencing functional decline, and he needs to be referred to Physical Therapy and Occupational Therapy for further evaluation. R45's Current care plan initiated 09/16/2024 documents he requires assistance with ADL's (Activities of Daily Living) such as bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting, co-morbidities such as hemiplegia/hemiparesis (partial paralysis), and dementia with interventions including Skilled Rehabilitation Therapy evaluation and treatment as indicated; he would like staff to refer him to Physical and/or Occupational Therapy as ordered by the physician to evaluate his current condition/status and recommend appropriate interventions to improve my functional ability. R45's current care plan does not include treatment for his left-hand contracture. R45's Physician progress note dated 10/5/2024 documents he has a contracture of his hand. R45's Current physician orders include an order effective 11/19/2024 for being seen 1 time by Occupational Therapy for evaluation only for left hand splinting needs and recommendations and an evaluation for a splint. Occupational Therapy Evaluation and Treatment Encounter Reports dated 11/19/2024 document R45 has a contracture of his left hand, he was referred by his primary physician in order to be evaluated for need of splint for his left hand and he could benefit from application of splint to prevent further limitations from occurring which could possibly cause skin break down and difficulty with proper hygiene of hand. On 11/20/24 at 1:33 PM V2 (Director of Nursing) stated, R45 should have been evaluated for a hand splint much sooner than 11/19/2024 based on his medical history and admission's restorative assessments. V2 stated, if not evaluated timely there could be further deterioration of the hand and worsening of contraction and disuse of the hand. The facility's Restorative Nursing Program Policy received 11/21/2024 states: It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. If the assessment shows the resident needs therapy, then therapy should be provided. Nursing and Restorative Services may include the following: Contracture Management: Splint. Nursing and restorative services shall be reflected in the resident's individualized care plan consistent to the completion of the resident comprehensive assessment.

Based on observation, interviews and record review, the facility failed to assess and evaluate a resident for self-administration of inhalers and eyedrops; and failed to obtain physician's order for eyedrops for one (R10) of one resident in the sample of 46 reviewed for medications. Findings include: R10 is an [AGE] year-old, male, admitted in the facility on 08/16/24 with diagnoses of Other Pulmonary Embolism Without Acute Cor Pulmonale; Chronic Obstructive Pulmonary Disease (COPD), Unspecified; Chronic Respiratory Failure with Hypoxia; and Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. MDS (Minimum Data Set) dated 08/19/24 Section C recorded R10 has BIMS (Brief Interview for Mental Status) score of 12 which means moderate impairment in cognition. On 11/18/24 at 10:09 AM, R10 was observed in room, in bed, watching television. A Combivent inhaler was observed placed on bedside table. R10 was asked if he is self-administering the Combivent inhaler. R10 stated, I use it when I feel like it. Two 10 ml (milliliters) bottles of eye drops were placed on nightstand. R10 was again asked if he is using the eyedrops. R10 stated, I use it twice a day. POS (Physician Order Sheet) dated 08/16/24 recorded: Combivent Respimat Inhalation Aerosol Solution 20-100mcg/act (microgram per actuation) 1 spray inhale orally every 4 hours for COPD when awake. There was no recorded physician order for eyedrops. R10's care plans documented: 08/17/24 - At risk for altered respiratory status/difficulty breathing related to COPD, Chronic Respiratory Failure with Hypoxia, OSA (Obstructive Sleep Apnea) Administer medication/puffers as ordered. Monitor for effectiveness and side effects. 08/16/24 - At risk for alteration in respiratory functioning related to COPD, Chronic Respiratory Failure with Hypoxia, OSA: Administer oxygen and other medications and respiratory treatments as ordered. On 11/19/24 at 11:17 AM, V2 (Director of Nursing) was asked regarding R10's self-medication administration. V2 replied, R10 is not supposed to be self-administering medications and no medications should be left at bedside. There is no order and there is no assessment. Facility's policy titled; Self-Administration of Medication dated 6/6/24 stated in part but not limited to the following: Policy It is the policy of the facility to ensure that resident's right to self-administer medications is observed. A resident who requests to self-administer medications will be assessed to determine if resident is able to safely self-medicate. Procedures: 1. The IDT (interdisciplinary team) will assign a staff to evaluate 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. Facility's policy titled Physician Orders dated 8/16/24 documented in part but not limited to the following: Policy Statement It is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance with the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS.

Based on interviews and record review, the facility failed to consistently monitor, assess, and implement pressure relieving interventions to prevent the development of facility acquired pressure ulcers. This affected one resident of three (R1) residents reviewed for pressure ulcer prevention. This failure resulted in R1 developing a stage 3 pressure sore to the coccyx area, and a stage 2 pressure sore to the left buttocks. Findings include: Review of R1's medical record notes R1 was admitted to this facility on 1/25/23 with diagnoses including: severe sepsis with shock related to UTI (urinary tract infection) and pneumonia, malaise, acute respiratory failure with low oxygen levels, chronic obstructive pulmonary disease, heart failure, dementia, and diabetes. R1 was discharged to home on 2/6/23. Review of R1's admission skin assessment, dated 1/25/23, notes no skin breakdown or reddened areas identified. Review of R1's POS (physician order sheet), dated 1/26/23, notes an order for an air mattress for skin integrity. On 2/10/23 at 10:50am, R1's family member stated that on the day of R1's discharge from facility, family member was cleaning R1 and saw wounds on R1's coccyx and buttocks. R1's family member stated when she got R1 home and removed his socks she observed a large blood blister on his right heel. R1's family member stated that facility did not notify her of these wounds. On 2/10/23 at 2:37pm, V4 (unit manager) stated that on 2/6/23 V4 was informed that R1's family member found wounds on R1's sacrum and left buttocks. V4 stated V4 was asked to assess these wounds. On 2/14/23 at 9:50am, V5 (wound care nurse) stated V5 performs a head-to-toe skin assessment on newly admitted residents. V5 stated that V5 informed staff that R1 required an air mattress because R1 did not move much. V5 stated R1 did not receive air mattress during his stay. V5 denied being made aware of any skin breakdown on R1's coccyx and left buttock. V5 stated R1 had a scabbed area on right heel that V5 observed on 1/26/23. V5 stated she applied a foam dressing to R1's heel and changed every three days. V5 stated when residents are discharged home with wounds, the discharge instructions will note orders for wound care treatments. On 2/14/23 at 12:00pm, V10 (nurse) stated V10 provided care to R1 on 2/6/23. V10 stated R1's family member provided most of the care for R1 during his stay. V10 stated sometimes family would ask for staff assistance. V10 stated on 2/6, R1's family member asked V10 for assistance with turning R1. V10 stated family member was standing facing R1's back when he turned and observed wounds on coccyx and left buttocks. V10 stated there was some drainage observed from the wounds. V10 stated V10 informed V9 (unit manager) of R1's wounds. V10 denied contacting R1's physician for treatment orders. V10 stated R1's family member informed V10 that V10 was previously a wound care nurse and requested a calcium alginate dressing for R1's wounds. V10 stated V10 cleaned R1's wounds and applied calcium alginate dressing per family's request. V10 stated V10 also gave R1 some extra dressings for home use. Review of R1's medical record, dated 2/6/23, V10 RN noted new opening noted at coccyx 0.5cm (centimeters) width x 1.5cm length x 0.2cm depth. Review of R1's medical record, dated 2/6/23, V4 (unit manager) noted V4 was asked to assess the new wounds on R1. R1 has a stage 3 pressure ulcer on the coccyx area and a stage 2 pressure ulcer on the left buttocks. Review of R1's care plan, dated 1/26/23, R1 is at risk for alteration in skin integrity related to impaired mobility. Review of this facility's skin care treatment policy, revised 7/28/22, notes charge nurses must document in the nurse's notes and/or the wound report form any skin breakdown upon assessment and identification. Furthermore, topical skin treatment must be obtained from the resident's physician.

Based on interview and record review the facility failed to have interventions in place to address the behaviors of a resident pulling out a tracheostomy tube and inner cannula for one resident (R2) reviewed for accidents and incidents in a total sample of 6. This failure resulted in R2 pulling out the tracheostomy tube and being found unresponsive, CPR was initiated and R2 was pronounced deceased in the facility. Findings Include: Respiratory Therapy Note dated [DATE] documents that R2 was being admitted to the facility for rehab and reconditioning. R2's history documents that the resident was hospitalized on [DATE] after a fall where the resident sustained a subdural hematoma requiring a left craniotomy and craniectomy. R2 was placed on a ventilator and a trach and feeding tube was placed. R2 was weaned off the ventilator, decannulated and sent to acute rehab on [DATE]. On [DATE] R2 suffered tracheal stridor and cardio-pulmonary arrest. R2 was transferred back to the hospital, tracheal stenosis was noted, and a new trach was placed. Upon admission to the facility on [DATE] R2 was noted with a 28% aerosol trach collar in place with oxygen at 5 liters. R2 had no signs of respiratory distress, and all vital signs were stable. Trach care and suctioning done every shift and as needed. Social Service Note dated [DATE] documents that R2 has a Brief Interview for Mental Status Score of 13 out of 15 indicating that the resident is cognitively intact. R2 is calm and cooperative and communicates with clear speech as English is the resident's primary language. The resident is her own responsible party. R2 has no history of delusions or hallucinations. R2 ambulates via wheelchair and requires assistance with ADLs. Nurse's Notes dated [DATE] documents that nurse arrived to perform suctioning. Nurse observed R2's removable inner cannula on the bedside table. R2 was asked why she removed the inner cannula and stated because she did not need it. R2 educated on the importance of having the inner cannula in place. Cannula cleaned; suctioning performed but Nurse had trouble putting the cannula back in place. Once the cannula was inserted R2 had complaints of shortness of breath. R2's aerosol trach collar applied and the resident still had complaints of shortness of breath. Nebulizer treatments done with no relief. Normal saline applied to the trach and suctioning done. Nurse removed a thick mucus plug with suctioning and resident no longer had troubles breathing. Vitals were stable, resident reeducated on leaving the inner cannula in place and verbalized understanding. Nurse's Notes dated [DATE] documents that at 10:37am the nurse entered the resident's room to give medications and noted that R2 was unresponsive. The nurse noted that the resident did not have a pulse and did not have respirations. R2's trach collar was in place but the tracheal tube and inner cannula had been removed from the stoma and was found in bed under the resident's covers. The nurse reinserted the tracheal tube and inner cannula and initiated CPR. The paramedics were called and R2 was pronounced deceased at 11:16am. The Death Certificate documents that the cause of death was acute respiratory insufficiency and mucus plug of the tracheal tube. On [DATE] at 12:30pm V3 (Respiratory Therapist) stated, The resident was admitted to the facility with a trach that required maintenance after having a thyroid surgery where a partial tumor resection was done. The maintenance included suctioning, breathing treatments, cleaning out the cannula and this was the responsibility of the nursing staff when I'm not here. I work Monday through Friday during the day and I round ,d+[DATE] times per shift on all my residents. The resident was receiving humidity through the aerosol trach collar to maintain the airway. The resident was not on a ventilator and only required about ,d+[DATE] liters of oxygen. R2 did have a history of pulling out the trach, she had done this before at another facility. R1 did pull out the inner cannula while here and I went in and educated the resident on the importance of keeping that inner cannula in place. The resident did not give a reason why she pulled out the inner cannula but she did verbalize understanding after education was complete. On [DATE] at 2:35pm V5 (Nurse) stated, I was coming back to the resident's room to give medications. The CNA was in the room with her so I went to take care of another resident and came back later. When I came back the resident was lying on the bed with her legs hanging out of the bed looking straightforward at the TV. R2 didn't respond to me when I spoke to her and that was abnormal because she talks with the trach. I asked if she was ok, she didn't respond so I assessed her and there was no pulse and she was not breathing. I called a code blue and initiated CPR. R2 had the aerosol collar on but it was loose. The trach was sitting on the opening of the ostomy site. The CNA was in the room with the resident providing care 10 minutes prior to this incident. A couple of days before this happened, R2 was with family and I was called in the room because the resident was having trouble breathing. R2 had the collar covering the neck but she was asking to be suctioned. That's when I noticed the inner cannula was not in, it was on the bedside table. I had trouble getting the inner cannula back in, I called the supervisor and had to use saline to get it in. Education was done on not pulling it out because it causes mucus plugs. The resident said she pulled it out because she didn't need it. I notified the supervisor and the nurse practitioner. I don't recall any new interventions being put into place. I just tried to monitor the resident every hour or so. On [DATE] at 2:40pm V6 (Nurse Practitioner) stated, R2 was stable. She had the aerosol trach collar and was not on oxygen. The resident pulled the trach out over the weekend and that call would've gone to the on-call person, but there were no new interventions put into place. R2 was on nebulizers and getting suctioned as needed. R2 was alert and oriented x 3 and able to make her needs known. R2 did pull out the trach at another facility and there was a previous incident of the resident taking out the inner cannula. The care plan was reviewed and documents that R2 has a risk for respiratory impairment related to the presence of a tracheostomy. Staff is to monitor for signs of respiratory distress, suction and provide trach care based on physician's orders and as needed. There was no care plan or updated interventions in place to address the behavior of the resident pulling out the trach tube.

Based on observation, interview and record review the facility failed to ensure staff provided weekly wound assessments and performed daily treatment orders for resident with an unstageable pressure ulcer injury. This failure resulted in R5's wound becoming infected and admitted to the local hospital with [CONDITION(S)]. The facility failed to ensure a protective dressing was in place for a resident with a stage 4 pressure ulcer injury to the sacrum. This applies to 2 of 7 residents (R5, R6) reviewed for pressure ulcer injuries in the sample of 7. The Findings Include: 1. R5's face sheet showed she is an [AGE] year-old female admitted to the facility on [DATE]. R5's admission assessment dated [DATE] showed she has sacrum pressure ulcer measuring 7 cm (centimeters) x 9 cm. The Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The same progress note showed treatment orders to cleanse with normal saline, triad (wound dressing) to the peri wound, Thera-honey to the wound bed and cover with calcium alginate and cover with foam dressing daily. The Skin & Wound Evaluation report dated 12/7/21 to 12/28/22 showed no assessments were performed. The Wound physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's Skin and Wound assessment dated [DATE] (the next assessment performed 10 days later) documents her unstageable sacrum pressure ulcer measuring 5.1 cm x 6.9 cm. The same report showed her wound is deteriorating. R5's nursing note dated 1/23/22 documents R5's sacral wound appeared necrotic with black slough and increased drainage. R5's sacral wound has gotten worse with a noticeable odor. R5 was sent out to the local hospital for wound evaluation R5 was admitted to the local hospital with [CONDITION(S)] (infection that has reached the bone). R5's Treatment Administration Record (TAR) for December 7, 2021, and January 22, 2022 showed her orders include to apply triad (wound dressing) to the sacrum then apply Thera-honey to the wound bed and cover the wound bed with calcium alginate and cover with foam dressing every day shift every other day. (the treatment order should be daily, not every other day). R5's TAR showed her treatment orders were not performed 29 days out of 45 days. On 2/25/22 at 9:37 AM, V3 (RN) said the facility does not have a wound nurse and the floor nurse's do the treatment orders as much as possible. V3 said it's not good for the resident's, sometimes we don't have time to do the treatment orders. V3 said she has notified management regarding this concern, it's frustrating. On 2/25/22 at 12:52 PM, V2 (Director of Nursing) said we do not have a wound nurse. The nurse's should provide the wound treatments and follow the physician treatment orders. On 2/25/22 at 5:28 PM V10 (Wound Nurse Practitioner) said if a resident's wound is not changed it can build up bio film in the wound bed causing an infection and could progress into [CONDITION(S)]. V10 said the facility does not have a wound nurse and she only follows the resident if the facility provides a staff member to round with her. V10 said there are times she does not assess a resident's wound if the facility does not provide a staff to make rounds with her. 2. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .S.) dated through February 2022 shows R6 is an [AGE] year-old male with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The P.O.S. shows orders to cleanse the sacrum with normal saline, lightly pack undermining with calcium alginate and Thera-honey and cover with a foam dressing. R6's Skin & Wound Evaluation Report dated 2/19/22 shows he has a stage 4 sacrum pressure ulcer measuring 3.5 cm x 1.5cm x 1.3cm and tunneling at 5.5 cm. On 2/25/22 at 9:43 AM, R6 was lying in bed. V3 (RN) assisted R6 to his side and pulled down his incontinent brief. A mid-size round open deep area was observed on his sacrum without a dressing in place. V3 said it's open, not covered. V3 said no one reported to her R6's dressing was off. R6's Treatment Administration Record (TAR) shows orders to cleanse the sacrum, pack with calcium alginate and there-honey and cover with a foam dressing. The TAR shows no treatment was provided for 5 days out of 25 days. The facility does not have a pressure ulcer injury policy in place.

Based on interview and record review the facility failed to have two staff members perform a two person transfer using the mechanical lift while transferring a resident to avoid a fall with injury. This applies to one of three residents (R1) reviewed for accidents in a sample of three. As a result, R1 sustained a right hip fracture and required surgery to repair it. Findings include: R1 is [AGE] year old admitted to facility with [DIAGNOSES REDACTED]. Facility Incident Report completed on 10/14/16 at 3:30 a.m. documents E4 (RN) registered nurse was called to R1's room and noted right thigh/hip swollen and (RLE) right lower extremity shorter than (LLE) left lower extremity. R1 complained of pain if touched. Z3 (attending physician) made aware, order to transfer R1 to (ER) emergency room . Z1 (family) not answered the phone. On 11/22/16 at 3:00 p.m. E4 (RN) registered nurse stated E5 (C.N.A) certified nursing assistant transferred R1 by self, just pivoted resident to bed and was supposed to be a two person mechanical lift transfer. E5 urged R1 to go to bed. R1 did not fall. At 3:30 p.m. E5 stated I transferred R1 to bed, who told me to be careful because the leg was twisted. I just took R1 from wheel chair and pulled resident who told me had leg twisted before I moved resident. I was supposed to use mechanical lift for R1; I didn't know, it was my first time taking care of R1 and I did not ask. You must have two people and use the machine to transfer R1 and patients like R1. Facility Minimum Data Sheet (MDS) documents on 10/26/16 under section G - functional status: B. Transfer 3/3 - extensive assist, two + person physical assist. Facility Care Plan documents on 10/10/16 under: Focus: Requires assistance/potential to restore function for transferring from one position to another related to disease process contusion of right knee. Goal: Will be transferred by staff without injury and will be able to transfer with assistance two persons. Interventions: Transfer using a mechanical lift. Therapy evaluation and therapy as ordered Transfers: Provide two persons for supervision/physical assist. On 11/23/16 at 10:30 a.m. E2 (RN) stated They are educated to use two staff assistance with mechanical lift. E5 did not follow the two person transfer; they should follow resident kardex to ensure resident safety. On 11/22/16 at 12:30 p.m. R1 stated They twisted my leg here, it hurt. Facility Mechanical Lift policy dated 1/14 documents as being advisable to have two staff members present to stabilize and support the patient. R1's Local Hospital Orthopedic Trauma Surgery Operative Note documents 10/15/16 at 1:20 p.m. Pre-operative Diagnosis: [REDACTED]. Right peri-implant femoral shaft fracture. 2. Right lower extremity infection. Post-operative Diagnosis: [REDACTED]. Right peri-implant femoral shaft fracture. 2. Right lower extremity infection. 3. Right distal femoral shaft non union secondary to implant failure. 4. Right supra-condylar femur non union secondary to infection. Procedure: 1. Irrigation and debridement right femur. 2. Removal of hardware right femur. 3. Open reduction internal fixation right femur.

Based on interview and record review the facility failed to monitor the effectiveness of interventions and modify interventions for one resident (R1) and failed to supervise one resident (R2) in a sample of three residents reviewed for falls. These failures resulted in R1 sustaining a left hip fracture and blunt head injury after falling and R2 falling from toilet. R1 died three days later as a result of this fall. Findings include: Review of R1's medical record (Medical Diagnosis) notes R1 with [DIAGNOSES REDACTED]. R1's most recent MDS (Minimum Data Set) of 8.24.16 notes R1's BIMS score (Brief Interview for Mental Status) as 2 or severely impaired. R1's previous BIMS (8.14.16) was 4 or severely impaired. Review of facility's Incident/Accident Reports and R1's medical record (Progress Notes) notes R1 had multiple falls without injury (8.10.16, 8.17.16, 8.25.16, 9.1.16, 9.12.16, 9.13.16) and one fall with injury (9.16.16, left hip fracture). -8.10.16: Found sitting on knee on floor. Resident stated family member pushed (R1). No one was in the room with resident. -8.17.16: readmitted from hospital. At 2:15 PM resident was found sitting on floor with back towards bed, gown was laying on floor next to R1. Family member came to visit and informed staff R1's confusion had increased while at the hospital and R1 kept attempting to get up as well. -8.25.16: Confused, re-directed multiple times to sit in wheelchair. Taken to room to watch television and drink fluids after returning from therapy. Staff heard resident calling out for help and found resident on floor near bed. -9.1.16: Staff heard resident calling for help and found resident laying on the floor at the south end of R1's bed, laying on left side in front of wheelchair. Resident last seen three minutes prior to fall sitting outside R1's room, was alert but confused. -9.12.16: After breakfast, R1 got up from wheelchair and fell to floor. Resident was agitated. -9.13.16: Found on floor laying on back. -9.16.16: fell from wheelchair while in hallway by nurse's medication cart while nurse was in another room passing medications to another resident. Staff got resident out of bed earlier and placed in wheelchair because R1 was restless and attempting to get out of bed. R1 was transferred to hospital for low blood pressure (,[DATE]) and low SpO2 (88%). Resident was admitted with [DIAGNOSES REDACTED]. Additional review of R1's medical record notes R1 was found on the floor on 8.22.16, however no incident report was found. R1's fall care plan was reviewed. The careplan was initiated on 8.10.16 after R1's initial fall. Interventions included: Reinforce need to call for assistance. R1's cognitive status (as noted above) was severely impaired. No interventions were initiated after R1's falls of 8.17.16, 8.25.16 or 9.1.16. E2 (Director of Nursing, 10.25.16 at 1:37 PM) said in part, the expectation is that care plans should be updated after each fall. R1's death certificate lists R1's immediate cause of death as blunt force injuries of left hip due to fall. Review of R2's medical record (Medical Diagnosis) notes R2 with [DIAGNOSES REDACTED]. R2's most recent MDS (Minimum Data Set) of 8.8.16 notes R2's BIMS score (Brief Interview for Mental Status) as 7 or severely impaired. R1's transfer score is,[DATE] (extensive assistance/two+ persons physical assist). Review of facility's incident/accident reports notes R2 fell without injury on 9.8.16. E7's (LPN-Licensed Practical Nurse) statement, obtained by E2 (DON-Director of Nursing), notes in part E7 assisted R2 to the toilet; when finished, instructed R2 to wait while E7 got help. When E7 returned, R2 was on the floor. The facility's conclusion states: Resident requires 2 person assist which is in (R2's) Kardex. Resident tried to get up from the toilet & fell to floor. Facility to ensure resident is not lift by herself while on the toilet. Review of R2's Fall(s) document (9.8.16) notes in part the following: B. Physical Performance Limitations 1. Difficulty maintaining sitting balance 3. Difficulty maintaining standing position 4. Impaired balance during transitions. D. Diseases & Conditions 22. Muscle weakness 31. Impulsivity or poor safety awareness 37. Other dementia 38. Anxiety disorder Review of progress note related to the incident (9.8.16 at 9:44 PM written by E7) states in part: Resident attempt to go to bathroom in 202A. Resident taken to (R2's) room. Stated (R2) needed to go to bathroom right away. Assisted to bathroom, pt. (patient) stood, placed on toilet, resident urinated, wiped clean by myself. (A)ttempted to put back in wheelchair, stated I feel like I'm gonna have a bowel movement; resident tried to get up by pulling on the wire, unable to carry all (R2's) weight, I asked (R2) to stay on the toilet seat while I quickly asked for help, pt.stated understanding and said yes; when I returned to the bathroom, pt. was already seen on the floor. E7 (10.25.16 at 11:33 AM) said in part, E7 got ready to get R2 off of toilet, R2 pulled on E7's arm to get up; E7 got R2 back on toilet seat and told R2 to stay there while E7 went to get CNA (Certified Nursing Assistant). The CNA went into the room and found R2 on the floor. The CNA told E7 that patient is a two person assist and stated, Did you know that? I didn't know the resident good. I was in orientation. It was my first or second day on the unit.

Based in interview and record review, the facility failed to follow the comprehensive pain guidelines, assess the effectiveness of pain medication 1 hour after administration and failed to administer an additional dose as ordered for 1 of 3 residents (R1) reviewed for pain in the sample of 12. This failure resulted in R1's pain being assessed as 10 out of 10 on the numeric pain scale more than 4 hours after the administration of pain medication, R1 did not receive another dose of medication when it was due, and no additional orders were received to manage R1's pain. Findings include: On 4/26/16 at 2:30pm, R1 stated she asked several times to make her [MEDICATION NAME] scheduled every 6 hours just like it was at home, instead of as needed. R1 would ask for pain medication but it would still take staff several hours to bring it to her. R1 stated she did not receive [MEDICATION NAME] every 6 hours and would lay in bed in excruciating pain until the nurse would bring the medication more than 6 hours later. On 5/2/16 at 9:45am, Z6 (Family) stated R1 would ask for pain medication and did not get it as often as she could. Closed record documents R1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Physician order [REDACTED]. March 2016 Medication Administration Record [REDACTED]. March 2016 Controlled Substance Record for [MEDICATION NAME], March [DATE], and Nurse Progress Note 3/22/16 all document R1 received 1 tablet [MEDICATION NAME] at 2:30am on 3/22/16; 3/22/16 6:50am follow up pain scale is documented as 10 out of 10 pain scale and medication was ineffective. March 2016 MAR indicated [REDACTED]. R1 was able to get 1 tablet of [MEDICATION NAME] at 8:30am, but did not receive it until 9am. The nurse progress notes do not document communication with the physician that R1's pain medication regimen is ineffective and R1 rates the pain at 6:50am 10 out of 10 on the pain scale, more than 2 hours before the medication is given. March POS documents [MEDICATION NAME] was changed to scheduled doses every 6 hours on 3/25/16 after the nurse called the physician regarding ineffective pain management 3 days later. Minimum Data Set 3/26/16 documents R1 receives a scheduled and as needed (PRN) pain medication regimen; R1 has frequently experienced pain or hurting over the last 5 days; R1 has had to limit the day-to-day activities because of pain; over the last 5 days R1 rates her worst pain as a 10 on the 0-10 pain scale. Pain Care Plan initiated on 3/20/16 documents R1's pain goal is 0 on the numeric 0-10 scale and one intervention is to notify physician if pain frequency/intensity is worsening or if current [MEDICATION NAME] regimen has become ineffective. On 4/27/16 at 1:20pm, E2 (Nurse Supervisor) stated pain medications are given as ordered. Nurses assess a patients level of pain when giving pain medication and document the level in the computer. After a dose is given, the computer will prompt a follow up pain assessment in 1 hour. The nurse reassesses the effectiveness of the dose given. If the pain medication is ineffective, the nurse calls the physician for orders to manage the pain. On 5/3/16 at 11:20am, E13 (Director of Nursing) stated nurses track the effectiveness of pain medication 1 hour after it was administered. Staff are to call the physician if the dose was ineffective, can get a change in dose, frequency or another medication to help manage the pain better. On 5/5/16 at 9:55am, E21 (Nurse) stated R1 received pain medication as ordered. E21 would consider a pain medication dose ineffective if the patient was awake and still complaining of pain. E21 stated ice packs or other interventions may be helpful to manage pain. If pain medication is ineffective, E21 stated the doctor may need to be called for a change in orders. E21 stated not to wait until next dose is due; the Physician should be called right away if the patient did not get relief from the last dose. E21 stated she does not recall what happened on 3/22/16 regarding R1's pain medication administration, does not know why she did not call the physician when R1 stated her pain was 10 out of 10, or why she waited until 9am to give another dose of [MEDICATION NAME] when it was due at 8:30am. On 5/9/16 at 10:20am, Z2 (Physician) stated that if R1 complained of pain 10 out of 10 and a dose of [MEDICATION NAME] was available, the nurse should have given it right away. Z2 stated that he was not notified about R1's ineffective pain management; if he had been notified, he would have changed the frequency, changed the [MEDICATION NAME] to scheduled instead of as needed, increased the dose, or added another medication. Z2 stated the [MEDICATION NAME] was changed to scheduled every 6 hours, but is not sure when. Pain Practice Guide - Identify the last dose of medication and the amount given to the patient prior to admission and when the next dose is due to be given. Verbal Descriptor Scale - the patient is asked to identify how much pain they are having by choosing a descriptor from no pain (0) to horrible pain (10). If a patient has evidence of pain or a condition with recurring episodes of pain, the physician is notified to obtain orders for pain medication. Pain evaluation is also completed before and after PRN medication administration. The interdisciplinary team designs the patient's care plan to focus on all of the patient's issues including those associated with pain symptoms. A measurable goal is developed and a target date established. Approaches are selected based on patient's preferences and past history of successful pain relief. Patients with a score of 4-7 twice in a seven day period or who had one score of 8, 9, or 10 are reported to the physician for possible treatment adjustment.

Based on interview and record review, the facility failed to follow their gait belt policy and care plan for transfers, for 1 of 3 residents (R1) reviewed for transfers in a sample of 3. This failure resulted in R1 falling face first to the floor, R1 was transported to the hospital and assessed and treated for [REDACTED]. Findings include: R1 was admitted to the facility 2/5/2012. A review of the plan of care initiated 2/6/2012 notes to "use gait belt to facilitate safe transfer". A review of R1's minimum data set ((MDS) dated [DATE], section G/Functional Status notes that R1 requires "extensive assistance from staff for balance and transfers and that staff are required to provide weight bearing support, one person physical assist". According to the facility incident report dated 10/31/2012, R1 was being assisted by facility staff Z2, Certified Nurse Aide (CNA), while ambulating. R1 was about to be transferred from the wheelchair to the bed, as the certified nurse aide locked the wheelchair R1 leaned forward fell hitting her forehead on the floor. Interview with R1 on 11/28/2012 at 10:30 AM, R1 stated, "was walking in my room and the girl (Z2) let loose of the gait belt and I fell forward on the floor on my face; this happened about three weeks ago." Review of Z2's written statement as interviewed by E5, Registered Nurse-PM Supervisor (RN) on 10/31/2012 at 9:00 PM denotes "I (Z2) started walking patient (R1) with walker after gait belt placed on patient, we walked from patient room to nursing station. I was holding patient gait belt and pulling wheelchair. Then we came back to patient room. And what happened? She (R1) walked with her walker to her bedside, she said she was ready to sit. Patient (R1) was standing with her walker I locked wheelchair and she (R1) grabbed wheelchair and she started sitting, but she leaned forward and fell to the face on floor. I was standing on right side of the patient (R1) and wheelchair. I did not grab the resident nor did I grab the gait belt in time. It was very unexpected. Did you hold gait belt on patient? I did not have time, it was so quick ." E2, Minimum Data Set Coordinator stated on 11/28/2012 at 11:10 AM that R1 needed extensive assist by one person. E2 stated the gait belt helps staff to provide support to the resident when they are transferring a resident. On 11/28/2012 at 12:15 PM, E5 (RN) stated, "I was on the first floor when the second floor nurse calls me that a resident fell in her room. I went to second floor and found patient (R1) on the floor next to the bottom of her bed lying on her left side." E5 stated she instructed staff to call 911 immediately and not to move R1 but monitor R1 until paramedics arrive. E5 stated she asked Z2 what happened, and Z2 explained that R1 wanted to sit in her wheel chair and she was standing behind R1's wheel chair and locked the wheel chair. Then Z2 explained that she walked around the wheel chair while R1 was sitting down but did not have time to grab belt before the resident fell . E1, Administrator stated on 11/28/2012 at 9:40 AM that the CNA (Z2) was suspended on first day of the fall, during the investigation. E1 stated it was determined Z2 did not use the gait belt and was fired. Review of Z2's employee discharge notice dated 11/2/2012 denotes previous warning: "yes". Describe the action that made it necessary to prepare this notice; "Failure to follow facility policy and procedure regarding transferring patients using gait belt. 10/31/2012 while transferring a patient (R1), gait belt was on but employee was not holding belt, patient leaned forward and fell to floor". Review of the facility gait belt policy denotes "to safely and effectively transfer or ambulate a patient Equipment: Gait Belt, ambulate by maintaining hold on belt, lower into chair by grasping belt at patient's left and right side and bending knees as sitting occurs." According to R1's hospital record dated 10/31/2012, a Computed Tomography (CT) scan indicated extensive left sided frontal and periorbital hematoma, edema and a non-displaced right C1 lateral mass fracture. Z1, Medical Doctor, stated on 11/28/2012 at 11:20 AM, " (R1) is alert and oriented, no question about that, she is with it. (R1) can be demanding at times and is attention seeker. Has history of Depression but the subdural hematoma that (R1) sustained is from the fall when she hit her head. However the fracture is hard to say."

A.) Based on interview and record review the facility failed to implement interventions and thoroughly investigate falls to prevent injury for one (R7) of 24 residents this resulted in an introchanteric fracture. Findings include: R7 was admitted on [DATE] from a hospital. Nursing admission progress note indicate the reason for admission and past medical history included status [REDACTED]. On 11/24/11 R7 got up without assistance and fell per the incident report. R7 incurred a right intertrochanteric fracture requiring surgical repair and returned to the facility 12/2/11. Per nursing progress notes dated 11/24/11 E6 was found on the floor with the alarm sounding very low. On 12/5/11 at 12am, per nursing progress note documentation, R7 was noted attempting to get out of bed at rounds and reassessed at 12:40am sleeping in no distress. On 12/5/11, per nursing progress notes and incident reports, R7 was found on the floor with the alarm sounding at 3:45am. An x-ray was completed 12/5/11 with results showing an old right intertrochanteric fracture without significant healing. A care plan initiated 10/30/11 included an intervention for fall prevention. This care plan shows interventions revised 11/4/11 and 12/5/11. Per the incident report dated 11/24/11 the facility investigated the fall and the intervention completed in response to the fall was to send E7 to the emergency room . R7 returned to the facility on [DATE] and the care plan show no other interventions until 12/5/11. On 12/6/11 at 6:50am, Z1 (family) was bedside. An interview with Z1 indicated Z1 was staying the night with R7 due to R7 falling the previous night and Z1's concern that R7 keeps falling and concern as to why the facility is not able to prevent the falls. The Fall Practice Guide policy indicates: 1) The approach for fall interventions are clear, specific and individualized for the patients needs. 2) Regardless of the interventions that are put in place a key factor to success is the timely review of the interventions as patient's condition and needs change. 3) Patient falls are traced by time, location and causative factors. The data is reviewed to identify any trends. 4) During a change in condition or fall occurrence, the interdisciplinary care plan teams reviews the patient's most current Falls RAP to determine if the patient's present condition or status has changed and therefore requires the completion of a new off-cycle Falls RAP. If the current Falls RAP still describes the patient accurately, then a narrative summary of the patient's condition and circumstances surrounding the event are documented in the patients clinical record. The care plan is revised s clinically indicated to meet the patient's current needs. As a result of the facilities failure to thoroughly investigate the cause of the falls and place preventative measures, R7 sustained a fracture.

Based on observation, interview and record review, the facility failed to implement its abuse protocol for 3 of 4 residents (R1, R2, R3) reviewed for abuse in a sample of 8 residents. This failure resulted in R2 receiving multiple skin tears. Findings include: 1. During a tour of the facility ' s 2nd floor unit with E4, (Assistant Director of Nursing) ADON on 8/5/11 at 10:45am, R1 was observed in bed with visible bruises on her left arm, left leg and what appeared to be a fading bruise of the right peri-orbital area. E4 stated that R1 requires extensive assist from staff for all ADL ' s (activities of daily living) and that the peri-orbital bruising is " always like that. " E4 went on to say that R1 has experienced a recent decline in condition. A Patient Transfer Form dated 7/19/11 shows R1 was readmitted to the facility on that date. An undated Nursing Admission Evaluation shows no applicable skin related risk factors, however, skin assessment diagram reveals multiple areas of skin alterations including a bruise of left upper arm. Nursing notes dated 7/20/11, 7-3 shift, describes " an old bruise to her R (right) medial upper arm and lump noted " , with no reference to left upper arm bruise. There were no further documentation regarding bruising in the nurses notes dated 7/21/11 through 8/5/11. The facility utilizes Skin Worksheets which are completed by the certified nurses aids (CNA ' s) during residents ' showers and or baths. R1 ' s Skin Worksheets dated 7/16/11 through 8/3/11 ( five sheets) shows " old bruise " on right upper arm (7/30/11) and " bruises " to right upper arm (8/3/11). There was no documentation found regarding the left arm, right leg and right peri-orbital bruise observed by surveyor. 2. During a tour of the facility ' s 2nd floor unit with E4, Assistant Director of Nursing (ADON) on 8/5/11 at approximately 10:50am, R2 was observed in her room, sitting in a wheelchair. R2 ' s arms were not visible due to a sleeve-like garment on both arms. E4 stated that R2 has very fragile skin and wears geri-sleeves on all four extremities. R2 was observed with an open wound on the left arm which E4 describes as an old skin tear. There were multiple areas of bruising on R2 ' s right arm. E4 stated that the geri-sleeve help to prevent skin tears as R2 ' s skin tears even during transfer to bed. There were multiple areas of bruising and skin tears observed on R2 ' s bilateral lower extremities. On 8/5/11 at approximately 1:50pm, Z2, Family Member, was visiting with R2 and told surveyor he (Z2) was not aware of any bruising or skin tears on R2 ' s body. Z2 went on to say that he would discuss this with R2 ' s assigned power of attorney. Z2 asked R2 if staff is rough with her during care. R2 responded " they need to be rough with me. I ' m too lazy. " Surveyor addressed this comment made by R2 with E1, Administrator, on 8/5/11 at 4:30pm. There was no response from E1. This concern was again addressed with E1 on 9/6/11 at 2:30pm. E3, Director of Nursing, presented surveyor with written documentation on 9/6/11 at 3:30pm, of an interview she conducted with R2 which states R2 denies mistreatment from staff. There was no evidence that an investigation was conducted. R2 ' s care plan dated 4/15/11 shows [DIAGNOSES REDACTED]. R2 requires 2 person mechanical lift for transfer. Facility ' s Incident Report log for the period of February to August 2011, shows no incident reports being completed nor investigation done regarding R2 ' s skin condition. Nursing notes dated 7/1/11 through 8/5/11 shows 4 incidences of skin tear, 7/13/11, 7/15/11, 7/23/11, 8/4/11. There was no evidence provided to support these occurrences being investigated. R2 ' s Skin Worksheet dated 7/2/11 through 8/3/11 (6 sheets) does not reflect the presence of these incidences. 3. R3 ' s Minimum Data Set ((MDS) dated [DATE] shows a [AGE] year old resident with a [DIAGNOSES REDACTED]. An incident report dated 5/17/11 states R3 was " noted with bruising to both metacarpal hands also small skin tear noted between lt. (left) 4th and 5th finger. " The incident report was missing all staff signatures and contained incomplete data regarding care provided to R3 following the discovery of the injuries. The report faxed to the State agency on 5/18/11 states " Confused resident alleged ' staff beat me up. ' Investigation initiated. Staff suspended. " A follow up report to the State agency dated 5/20/11 states " Investigation complete. Abuse cannot be substantiated. " Z1, Family Member, told surveyor during a telephone interview on 8/5/11 at 9:00am, that an unidentified certified nurse ' s aide (CNA) reported to her (Z1) that 2 CNA ' s grabbed R3 ' s hand too tightly during care, causing bruising of both hands. The facility Investigation Report dated 5/17/11 shows E5, Certified Nurses Aid (CNA), and E6, CNA were the individuals caring for R3 when the alleged abuse occurred. During an interview with E5 on 8/31/11 at 3:40pm, E5 stated that she was a new employee at the time, assigned to take care of R3 with the assistance of E6 to perform a 2 person assist transfer. R3 became very combative (biting, spitting, scratching) during transfer from bed to wheelchair on 5/17/11 because she, R3, did not want to get out of bed. E5 stated that R3 bruises easily and that no bruising occurred as a result of this transfer. E6, CNA, told surveyor during a separate interview on 9/1/11, that R3 has a history of accusing staff of being abusive and exhibiting verbal and physical behaviors to staff and residents. According to E6, R3 cries a lot, throws food and knives at other residents during meal times in the dining room. E6 also stated that all the CNA ' s are scared to work with R3 as a result of this behavior. These behaviors, according to E6, are evident on a daily basis; all employees are aware of it but nothing has been done about it. R3 ' s Care Plan dated 5/6/10 includes interventions to address behaviors of hitting, swearing, attempting to bite staff, falsely accusing staff, pinching, banging eating utensils on the table during meals. These behaviors continue and there is no evidence that these interventions have been revised. Surveyor requested documentation that these behaviors have been addressed by social services. There was none presented and none found in the clinical record. MDS dated [DATE] and 8/3/11 states R3 exhibits no behaviors. Facility ' s Abuse Policy dated 4/21/06 addresses " catastrophic reactions " which it defines as ' reactions or mood changes of the patient in response to what may seem to be minimal stimuli, e.g., bathing, dressing, toileting, etc. and can be characterized by weeping, blushing, anger, agitation or stubbornness. " The Policy states that such reactions should be addressed to prevent negative patient outcomes. During an interview with E1, Administrator, on 9/1/11 at approximately 11:30am, Surveyor asked E1 how are residents who exhibit undesirable behaviors monitored and protected from potential behavior-related abuse. E1 stated that it is the nurse managers ' responsibility to monitor the provision of direct care. Residents are also frequently asked about their care. E1 went on to say that family members are encouraged to report any concerns to staff. E1 agreed that, for ' difficult ' residents, an approach that may be effective would be to assign the same staff to these residents to foster good relationship between staff and resident. E1 stated that the occurrence of skin tears in the facility is likely due to residents picking at their own skin and the facility applies geri-sleeve to those residents. E1 stated that all occurrences of bruise of unknown origin are investigated under the abuse protocol. E1 also stated that all personnel receive training on abuse prohibition. Facility abuse protocol was reviewed and states that all injuries of unknown origin, reports of abuse, neglect or mistreatment will be investigated and reported to the state agency as required.