Every finding on record at Heartland Nursing & Rehab

Based on observation, interview, and record review the facility failed to implement interventions related to deescalating a resident's aggressive behavior for one (R1) of three residents reviewed for Quality of Care. This failure resulted in R1 being hospitalized for three days due to becoming physically aggressive with staff.The undated Facility Daily Census documents 53 residents in house.According to the Electronic Health Record (EHR) R1 has diagnoses including Hypo-Osmolality and Hyponatremia, Unspecified Dementia, Unspecified Severity, with Agitation, Type 2 Diabetes Mellitus without Complications, Personal History of Traumatic Brain Injury, Bipolar II Disorder, Schizophrenia, Unspecified, Auditory Hallucinations, Moderate Intellectual Disabilities, and Unspecified Psychosis not due to a Substance or Known Physiological Condition.R1's undated Care Plan documents R1 experiences hallucinations, had a level two Preadmission Screening and Resident Review (PASRR). Diagnoses include Schizophrenia and Bipolar Disorder. R1 is at risk for falls and elopement, requires some assistance with Activities of Daily Living (ADL's) related to Traumatic Brain Injury (TBI). R1 has the potential to demonstrate verbal and physical abusive behaviors and has poor impulse control with interventions to reduce stimuli, relocate to room, keep in calm setting and staff to walk away from R1 when R1 is displaying aggressive behaviors and not engage.R1's Clinical Census documents R1 was out of the facility on leave to the hospital from [DATE] through 7/7/26 and 7/9/26 through 7/17/26.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, walks with walker and needs set up/supervision for all Activities of Daily Living (ADLs). On 8/12/26 at 8:59AM, V4 (R1's) Guardian stated that on 7/4/26 after V4 had returned R1 to the facility, V4 received a phone call from V6 Certified Nursing Assistant (CNA). V6 CNA proceeded to tell V4 Guardian that V6 was standing outside of R1's room asking V4 if V4 could hear R1 screaming. V4 Guardian stated V4 could hear R1 cursing and yelling that R1 wanted to go to the hospital. V6 CNA made statements that R1 needed to go out to the hospital and when V4 Guardian agreed, V6 instructed V4 to tell R1's nurse V5 Licensed Practical Nurse (LPN). V4 Guardian demanded nurse be put on the phone immediately and stated V6 CNA took the phone to V5 LPN at that time. V4 Guardian stated V6 CNA had called from V6's personal cell phone. On 8/11/26 at 2:45PM, V5 Licensed Practical Nurse (LPN) stated that on 7/4/26 R1 had been out all day with V4 (R1's) Guardian. When R1 was returned to the facility by V4 Guardian, V4 told V5 LPN that R1 needed more briefs in R1's room and then left the facility. V4 Guardian did not mention any concerns with R1's breathing. V5 LPN stated that after getting R1 settled in R1's recliner, V5 left the facility for 20 minutes to pick up V5's lunch. Upon returning to the facility, V5 LPN overheard V6 Certified Nursing Assistant (CNA) on the phone with V4 Guardian discussing R1 needing to go to the hospital. V5 LPN stated that V6 CNA was speaking with V4 Guardian on V6's personal cell phone advising V4 that R1 needed to go to the emergency room (ER). V5 LPN proceeded to enter R1's room with V7 CNA to talk with R1 and attempt to calm R1 down as V5 has been able to deescalate R1's behaviors previously. R1 was screaming about how R1 needed soda before R1 went to the ER for R1's leg pain. V5 LPN asked R1 if V5 could give R1 pain medications as R1 had been out of facility all day without, and at that point, R1 grabbed V5 LPN by V5's arms, scratched V5's face, and attempted to shake V5 while screaming at V5. V5 LPN was able to get free of R1 and immediately exited the room and notified management on call.On 8/11/26 at 3:10PM, V7 CNA stated that on 7/4/26 V7 was in R1's room with V5 LPN when R1 attacked V5. V7 CNA stated V5 was attempting to calm R1 when R1 hit V5 without warning. V5 LPN immediately removed V5's self from the room. V5 LPN was very tearful about the incident. V7 CNA stated that R1 often has escalating behaviors surrounding phone calls or visits from daughter.On 8/12/26 at 10:25AM, V6 CNA stated that on 7/4/26 R1 had been out with family all day walking and about an hour after returning to the facility, R1 started screaming that R1 wanted to call R1's daughter and R1 wanted to go to the hospital because R1's leg hurt. V6 CNA stated that V6 dialed R1's guardian V4 for R1 but then spoke to V4 herself while R1 was yelling at staff in the background. V6 CNA stated that V4 Guardian did request for R1 to be sent to the hospital at which time V6 took the phone to V5 LPN so that V5 could facilitate the transfer. V6 stated V6 was using V6's own personal cell phone not the facility phone. V6 CNA stated that R1's agitation increased after phone call with V4 Guardian, and that V4 had commented V4 was probably the cause of R1's agitation.On 8/11/26 at 12:37PM, V2 Director of Nursing (DON) stated that R1 was out with R1's daughter all day on 7/4/26 and upon return, R1 started displaying behaviors related to not having R1's demands met immediately. R1 did not show any signs of physical or respiratory distress. R1 physically assaulted V5 Licensed Practical Nurse (LPN) resulting in R1 transferring to local hospital for safety per Police request. V4 Guardian was constantly updated throughout process.On 8/11/26 at 11:20AM, R1 was observed in rocking recliner in R1's room. Call light was at hand on recliner arm, R1 was well groomed and had appropriate footwear on. [NAME] was within R1's reach. R1 was pleasant and complimentary of staff.Facility Certified Nursing Assistant Job Description, undated, documents CNAs are to perform non-professional direct patient care duties under the supervision of nursing personnel, and to assist in maintaining a positive, physical, social and psychological environment for the residents. They are to report any changes with residents to their supervisors not directly to family of residents.

Based on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety. This failure has the potential to affect all 53 residents residing at the facility.The Long-Term Care Facility Application for Medicare and Medicaid form dated 1/26/26 documents 53 residents reside in the facility. On 01/27/2026 at 11:51 AM the facility's walk-in cooler was observed with a dark brown substance puddled onto the floor beneath a rack of raw meat. A large portion of meat wrapped in plastic was sitting on a cardboard box on the bottom shelf of the cooler with accumulating fluids on top of the box that were dripping down the side of the box. The walk-in freezer was observed with loose carrots and unknown debris on the floor.On 01/27/2026 at 11:53 AM V3 Dietary Manager stated the meat wrapped in plastic, located on bottom shelf, was pork and confirmed the accumulation of fluid on top of the box and identified it as drippings from the meat. V3 Dietary Manager verified the presence of the unknown brown substance accumulating on the floor of the walk-in cooler. V3 verified the presence of loose carrots on the floor as well as an unknown substance on the floor of the walk-in freezer and stated the floor in the cooler and freezer needed cleaned. The facility's Food Storage (Dry, Refrigerated, and Frozen) policy 2016 documents food shall be stored on shelves in a clean, dry area, free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety.

Based on interview and record review, the facility failed to have quarterly Quality Assessment Performance Improvement (QAPI) meetings and failed to ensure required staff members attended meetings. These failures have the potential to affect all 53 residents residing in the facility. Findings include: On January 28, 2026, V1, Administrator provided three sign-in sheets for the facility's Quality Assessment and Assurance (QAA) Committee dated 10/28/25, 7/17/25 and 3/14/25.On 1/28/26 at 1:15 PM V1, stated these are the only sign-in sheets I have for QAA meetings. The QAA sign in sheet dated 7/17/25 does not document V15 Medical Director's signature. The Facility undated policy titled Quality Assessment and Assurance Committee states The facility will have QA (Quality Assurance) meetings every quarter and the required attendance of the following members: Medical Director, Director of Nurses, Administrator and Infection Preventionist. V1, Administrator confirmed on 1/29/26 at 1:40 PM Yes, I can only find 3 QA meeting sign-in sheets. The last one dated 10/28/25 was my first meeting for QA since I am new. The Long-Term Care Facility Application for Medicare and Medicaid form dated 1/26/26 documents 53 residents reside in the facility.

Based on interview and record review the facility failed to implement a Legionella surveillance program. This failure has the potential to affect all 53 residents who reside in the facility.Findings Include:The facility's Long-Term Care Application for Medicare and Medicaid Services form dated 1/26/26 documents 53 residents residing at the facility.The facility's Safe Water Policy dated 2/1/24 states Maintenance Supervisor must be able to demonstrate sound knowledge and specific skills in service being provided. This may include the maintenance of water systems equipment/services such as: Water storage tanks, vessels, and connecting pipework above and below ground. Sanitary appliances and associated taps, thermostatic mixing valves, and other fittings. Fire Fighting Services.On 1/29/26 at 2:51PM V17, Maintenance Supervisor stated All I check is the water temperature in rooms. I am kind of new to this position and I don't know what to do to check for Legionella.On 1/29/26 at 2:30PM V1, Administrator verified no surveillance for Legionella was being done.

Based on observation, interview and record review the facility failed to ensure interventions for safe smoking were followed for three of 27 residents (R2, R43, R39) reviewed for accident hazards in a sample list of 27. Findings Include: R2's Care Plan documents an admission date of 07/08/2025 with the following diagnoses: Constipation, Tobacco Use, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Asthma, Gastric Ulcer, Presence of Right Artificial Shoulder Joint, Chronic Obstructive Pulmonary Disease, Generalized Anxiety Disorder, Dependence on Renal Dialysis, Depression, and Heart Failure. R2's Care Plan documents a focus area dated 7/09/2025 documenting the resident is a smoker with a goal of maintaining safety while following smoking protocol. R2's Smoking – Safety Screen dated 12/27/2024 documents R2 has been educated on smoking safety, that R2 uses a vape on occasion, and that R2 knows to turn her smoking materials into the nurse. The Safety Screen documents R2 lets staff know when she is going outside to smoke and when she comes back in the building. The Safety Screen documents there is potential for injury and R2 walks with a walker. R43's Care Plan documents an admission of 06/10/2024 with the following diagnoses: Hypomagnesemia, Thrombocytopenia, Gastro-Esophageal Reflux Disease Without Esophagitis, Depression, Acquired Absence of Right Leg Below Knee, Secondary Esophageal Varices Without Bleeding, Type 2 Diabetes Mellitus With Diabetic Neuropathy, Pancytopenia, Hypo-Osmolality and Hyponatremia, Diarrhea, Hyperkalemia, Essential (Primary) Hypertension, Type 2 Diabetes Mellitus With Hyperglycemia, Iron Deficiency Anemia, Chronic Kidney Disease Stage 3, Portal Hypertension, Reduced Mobility, Abnormalities Of Gait and Mobility, and Unsteadiness on Feet. R43's Care Plan focus area dated 07/07/2024 documents the resident is a smoker with a goal of maintaining safety while following the smoking protocol. R43's Smoking - Safety Screen dated 12/11/2024 documents the resident does not consider safety of others and could easily fall asleep and drop cigarette due to his diabetes problems and since he is an amputee he cannot respond as quickly as others to a fire situation. R39's Care Plan documents an admission date of 8/22/2025 with the following diagnoses: Anemia, Hypothyroidism, Gastro-Esophageal Reflux Disease Without Esophagitis, Retention of Urine, Hyperlipidemia, Antiphospholipid Syndrome, Essential (Primary) Hypertension, Presence of Functional Implant, Repeated Falls, and Type 2 Diabetes Mellitus. R39's Care Plan focus area dated 03/17/2025 documents the resident is a smoker with a goal to maintain safety while following smoking protocol. The facility's undated smoking policy documents residents are not allowed to keep cigarettes, electronic cigarettes, pipes, tobacco, lighters or any other smoking article in their possession. On 1/29/26 at 12:45 PM R2 was sitting in the outside smoking area, without staff present, lighting a cigarette with a personal lighter. R2 stated she always keeps her cigarettes and lighter on her person and comes outside to smoke often without staff present. On 1/29/26 at 12:53 PM R43 was sitting in the facility's smoking area smoking a cigarette without staff present. R43 stated he lit the cigarette with his own lighter he keeps on his person at all times and comes outside to smoke often without staff present. R34 was observed dropping a recently extinguished cigarette butt into his jacket sleeve. On 1/29/26 at 12:55 PM R39 was sitting in the outside smoking area, without staff present, lighting a cigarette with a lighter he removed from his jacket pocket. Once the cigarette was lit the lighter was observed being placed back into jacket pocket. R39 stated he keeps his own lighter and does not always have staff present when he goes outside to smoke. On 1/29/26 at 12:58 PM V11 Certified Nurse's Aide (CNA) confirmed the presence of residents smoking unattended in the facility's outside smoking area and stated several residents do not comply with the facility's rules regarding smoking and continue to obtain lighters in order to smoke whenever the residents' desire. On 1/29/26 at 12:40 PM V1 Administrator stated the facility has had some ongoing issues with several residents going outside to smoke without supervision. V1 Administrator stated several residents continue to obtain lighters and keep them on their person.

Based on observation, interview, and record review the facility failed to administer medications timely and according to physician orders for three (R2, R40, R43) of fifteen residents reviewed for medication administration on the sample list of 27. These failures resulted in three medication errors out of twenty-five opportunities resulting in a 12% medication error rate. Findings include: On 1/27/2026 at 12:49 PM, V7, (Registered Nurse (RN)), administered both the scheduled dose of Insulin Aspart and the sliding scale dose of Aspart to R40 after the noon meal.R40's Physicians Order Sheet (POS) dated 11/19/2025 documents an active order for routine administration of Insulin Aspart before meals. Additionally, R40's POS includes an order dated 12/16/2024 for sliding scale Insulin Aspart to be administered before meals based on the resident's blood sugar reading.R40's Medication Administration Audit Sheet dated 1/27/2026 at 12:50 PM, documents that V7 (RN) administered R40's Insulin Aspart after the noon meal. On 1/27/2026 at 12:53 PM, V7, (RN), administered both the scheduled dose of Insulin Aspart and the sliding scale dose of Aspart to R2 after the noon meal.R2's POS dated 11/22/2025 documents an active order for routine administration of Insulin Aspart before meals. Additionally, R2's POS includes an order dated 11/22/2025 for sliding scale Insulin Aspart to be administered before meals based on the resident's blood sugar reading.R2's Medication Administration Audit Sheet dated 1/27/2026 at 12:53 PM, documents that V7 (RN) administered R2's Insulin Aspart after the noon meal.On 1/27/2026 at 1:09 PM, V7, (RN), administered both the scheduled dose of Insulin Lispro and the sliding scale dose of Insulin Lispro to R43 after the noon meal. V7 (RN) confirmed that R43's blood sugar reading was obtained at 11:15 AM and was 316. R43's POS dated 1/28/2026 documents an active order for routine administration of Insulin Lispro with meals. Additionally, R43's POS includes an order dated 7/28/2024 for sliding scale Insulin Lispro to be administered with meals based on the resident's blood sugar reading.R43's Medication Administration Audit Sheet dated 1/27/2026 at 1:09 PM documents that V7 (RN) administered R43's Insulin Lispro after the noon meal. On 1/27/2026 at 1:10 PM, V7, (RN), stated R2, R40, and R43's insulin was not administered according to the physician's order and agreed that the best practice is to administer medications exactly as ordered by the prescriber.On 1/29/2026, at 11:56 AM, V2, (Director of Nursing (DON)) stated all nurses are required to administer medications in accordance with the physician's orders and in a timely manner. The facility's Administering Medications Policy stated April 2019 documents that medications are administered in a safe and timely manner, and as prescribed. Additionally, this policy documents that medications will be administered in accordance with prescriber orders, including any required time frame.

Based on observation, interview, and record review, the facility failed to appropriately label nasal spray dispensers with the opened date for three (R1, R7, R48) of fifteen residents reviewed for medication administration on a sample list of 27. Findings include:On 1/28/2026 at 2:32 PM, the facility's North-South Medication Cart was inspected in the presence of V10, (Licensed Practical Nurse (LPN)). During the inspection R1, R7, and R48's nasal spray multidose dispensers were found without a documented date of opening.Review of R1's Physician's Order Sheet dated 10/02/2025 confirmed that R1 has an active order and is currently receiving Fluticasone Nasal Spray.Review of R7's Physician's Order Sheet dated 11/19/2025 confirmed that R7 has an active order and is currently receiving Fluticasone Nasal Spray.Review R48's Physician's Order Sheet dated 7/02/2025 confirmed that R48 has an active order and is currently receiving Fluticasone Nasal Spray.On 1/28/2026 at 2:35 PM, V10, (LPN), stated that any medication in a multi-dose container should be labeled with the date opened and discarded within 28-30 days of opening.On 1/29/2026 at 12:08 PM, V2, (Director of Nursing (DON)), stated the nurses should label all multi-dose containers upon opening.The facility's Administering Medications Policy dated April 2019 documents that medications are administered in a safe and timely manner and that when opening a multi-dose container, the date opened is recorded on the container.

Based on interview and record review the facility failed to monitor/ manage a gastrostomy feeding tube and report changes to the dietitian/physician for one (R52) of one resident reviewed for feeding tube in a sample of 27 residents. Findings include: R52's face sheet documents R52 was admitted to the facility on [DATE] with the following diagnoses: Urinary Tract infection, Dysphonia, Dysphagia, Epilepsy with Status Epilepticus, Status Post Gastrostomy, Left Hemiparesis, Left Hemiplegia, and History of Stroke, and was discharged to an acute care hospital 10/30/25. R52's Progress Note dated 10/29/25 at 6:00PM by V14, Licensed Practical Nurse (LPN) documents Nurse entered residents' room to give medications via g-tube (Gastrostomy Tube). Placement confirmed with stethoscope, nurse heard gurgling sound after pushing 5ml (Milliliters) of air through tube. 400ml of content was aspirated from g-tube. Nurse started continuous feeding at 60ml/hr (hour) after giving meds and flushing with 70cc (Cubic Centimeters) of water. On 1/29/26 at 2:00PM V14 stated I discarded the stomach contents. (R52) was complaining of abdominal pain. I did not call the doctor. R52' Daily Skilled Nurse's Note dated 10/30/2025 at 12:01PM by V7, Registered Nurse (RN) documents R52 requires the following skilled services PT (Physical Therapy) OT (Occupational Therapy) nursing observation and assessment and management of care plan. The reason (R52) requires skilled services is strengthening; pain management; PEG (Percutaneous endoscopic gastrostomy) tube management. (R52) is alert and has no memory problems. (R52) can recall A&O x4 (alert and oriented). (R52) does not have delusions, does not have hallucinations, and decision making is not impaired. Signs of delirium: none. Other cognitive concerns: none (R52) has the following sensory or speech issues: difficulty speaking. (R52) has the following indicators of a mood issue: none. (R52) has the following behavioral issues: none. (R52) has the following skin issues: PEG tube placed in abdomen. (R52) does not receive dialysis, is incontinent of bladder, is not on a toileting program for bladder incontinence, and does have a urinary catheter. (R52) is experiencing the following urinary issues: diarrhea. (R52) uses the following items to assist with bladder control: bed pan. Eating performance is tube fed. Swallowing observations with meals, snacks and medications: none observed. GI (Gastrointestinal) concerns are: NPO (Nothing by Mouth); complain of stomach pain, severe and acute. Bowel sounds are not assessed, has diarrhea, is incontinent of bowel, and is not on a toileting program for bowel incontinence. Apical pulse is regular, radial pulse is regular. (R52) is experiencing the following cardiovascular issues: none. (R52) has edema. Respiratory Status- (R52) is experiencing the following breathing issues: none. (R52) Does not have SOB (Short of Breath) while lying flat, Does not have shortness of breath on exertion, does not have shortness of breath or trouble breathing when sitting at rest. Lung sounds: Clear. (R52) does not have a cough and requires the following respiratory support none. Gait is not assessed, grasp is equal. Upper extremity movement: both sides are equal and movement is within normal limits lower extremity movement: both sides are equal and movement is within normal limits. Pupil response equal. (R52) has an infection. Additional comments: All meds given via PEG tube. R52's progress Note dated 10/30/2025 at 2:44PM by V7 documents Resident has complaint of abdominal pain, severe and acute all shift. Provider notified and requests that she be sent to (hospital) for evaluation and treatment. Resident and POA (Power of Attorney) agree with order and ambulance has been called for transport On 1/29/26 at 1:00PM when asked why she deferred an assessment of R52's abdomen, bowel sounds and did not address the insertion site of R52's new Gastrostomy tube, V7 stated Well she was in a lot of pain, and I didn't want to bother her too much. I guess I really should have done a better assessment. On 1/29/26 at 12:50PM V13, Registered Dietitian confirmed removing stomach contents during a gastric residual check could potentially cause fluid and electrolyte imbalance and is not the current standard of practice and given there was 400ML of residual the physician should have been notified. On 1/29/26 at 12:22PM V15, Medical Director verified given the new Gastrostomy tube a complete nursing assessment should have been done with specific parameters for how much residual is acceptable and when to notify the physician. V15 stated I would have consulted with the surgeon concerning whether or not to stop the tube feeding and how much residual is too much. R52's emergency room record from 10/30/26 documents an Xray was preformed and the gastrostomy tube was found to be in place. However, there was redness and drainage from the insertion site. The facility's policy Confirming the placement of feeding tubes revised November 2018 fails to address acceptable parameters of Gastric Residual volume and whether or not to return stomach contents to the resident.

Based on observation, interview, and record review the facility failed to maintain full mechanical lifts in safe/operable condition. This failure has the potential to affect eight of eight residents (R3-R10) reviewed for full mechanical lifts in the sample list of 10. Findings include:On 10/20/25 at 10:10 AM R3 was sitting on a full mechanical lift sling in her wheelchair. R3 stated yesterday the full mechanical lift wasn't working so V7 Certified Nursing Assistant (CNA) used the sit to stand lift to transfer R3 from her wheelchair into bed. R3 stated during the transfer R3 said Dear Jesus please don't let me fall. R3 stated there have been frequent problems with the full mechanical lift not working properly and yesterday the lift would not raise, it would only lower.On 10/20/25 at 1:02 PM R4 was sitting on a full mechanical lift sling in R4's room. R4 stated the staff had trouble getting the full mechanical lift to work this morning and had to go get another lift. At 1:17 PM V15 and V17 CNAs entered R4's room and used a full mechanical lift to transfer R4. V16 CNA went to use another full mechanical lift located in the alcove across the hall from R4's room. This lift contained gray adhesive tape around the housing compartment that covered the gear box and the lift would not raise when the handheld remote was activated. V16 stated the lift is not working properly, it won't raise and only lowers, and the adhesive tape has been there for a long time. V16 demonstrated that the emergency release function was broken, sliding up and down the shaft of the lift. V16 stated it has been like that for a long time and V14 Maintenance was aware of the lift issues. V16 stated the facility needs new lifts, they are always broken. V16 stated the facility has two full mechanical lifts which are used for currently eight residents.On 10/20/25 at 1:27 PM V15 CNA stated the full mechanical lift (referencing the lift in the alcove near R3's room) has been taped like that for at least the three years that V15 has been employed by the facility. V15 stated the emergency release has also been broken for quite a while, and V14 is aware. V15 stated V15 had to take the lift from the South hall since they discovered this morning that this lift was not working.On 10/20/25 at 1:28 PM V15 and V17 used the same full mechanical lift used for R4's transfer to transfer R3 from the wheelchair into bed. At 1:33 PM V15 and V17 stated the emergency release on this lift hasn't worked for quite some time. V15 demonstrated the emergency release did not function.On 10/20/25 at 1:37 PM V14 stated V14 has been the maintenance director since July and has not received any work orders for the full mechanical lifts. V14 stated there are no routine checks performed on the lifts for maintenance and functioning. V14 inspected the two full mechanical lifts that were on R3's/R4's hallway and confirmed the lift with the tape does not raise, and both emergency releases were not functioning. V14 took the remote from the other lift and attached it to the lift with the tape and used it to raise the boom. V14 stated it is a remote/cord issue. V14 stated the tape is used to keep the cover of the gear box in place, which was already there when he started working for the facility. V14 stated staff are to report mechanical lift issues to V14.On 10/20/25 at 2:28 PM V8 Minimum Data Set Coordinator provided a handwritten list of residents, R3-R10, who use the full mechanical lift.The facility's Using a Mechanical Lift policy dated July 2017 documents Test the lift controls. Ensure the emergency release feature works. If the mechanical lift is not deemed in working order, it shall be removed until repaired.The facility's Safe Lifting, Transferring and Movement of Residents policy dated July 2017 documents Maintenance staff shall perform routine checks and maintenance of equipment used for lifting to ensure that it remains in good working order.The User Manual for (full mechanical lift) dated 2023, provided by V1 Administrator, documents to use the hand pendant to raise and lower the boom and activate the emergency lowering device in the event of power failure or emergency. This manual documents to perform routine inspections of the lift and sling for cracks/damage, wear or fraying of straps or fabric, proper function of wheels and brakes, and condition of electrical cables and connections.

Based on observation, interview and record review the facility failed to properly transfer a resident (R3), for one of three residents (R3) reviewed for falls in a sample list of ten. Findings include:On 10/20/25 at 10:10 AM R3 was sitting on a full mechanical lift sling in her wheelchair. R3 stated R3 fell during a staff assisted transfer in July 2025 that resulted in right leg fracture. R3 stated since then R3 has received therapy, R3 can't use her legs to walk so she transfers with a full mechanical lift. R3 stated yesterday the full mechanical lift wasn't working so the Certified Nursing Assistant (CNA), V7, used the sit to stand mechanical lift to transfer R3 from the wheelchair into bed. R3 stated during the transfer, R3 said Dear Jesus please don't let me fall. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact and is dependent on staff for transfers. R3's active diagnosis list includes nondisplaced comminuted fracture of shaft of right femur, subsequent encounter for closed fracture with routine healing as of 7/23/25.R3's active Care Plan includes an intervention dated 10/16/25 TRANSFER: The resident (R3) requires Mechanical Aid Sling, (full mechanical lift) for transfers. PT/OT (physical/occupational therapy) is working with resident (R3) and this may change with their recommendation.On 10/20/25 at 10:56 AM V7 CNA confirmed V7 worked on R3's hall on 10/19/25. V7 stated sometimes one of the full mechanical lifts doesn't work and yesterday the lift on R3's hallway wouldn't go up. V7 stated V7 put in a work order request, but maintenance staff aren't in the facility on Sundays. V7 confirmed V7 used a sit to stand lift to transfer R3 on 10/19/25. V7 confirmed R3 transfers with full mechanical lift. V7 stated therapy staff have been working with R3 on two assist transfers to the commode.On 10/20/25 at 11:34 AM V13 Physical Therapy Assistant/Director of Rehab stated R3 continues on PT/OT and transfers with contact guard and minimal assist for stand pivot transfers in therapy. V13 stated floor staff should use a full mechanical lift for R3's transfers and R3 has not been approved to use the sit to stand lift.On 10/10/25 at 12:10 PM V8 MDS/Care Plan Coordinator confirmed R3's current transfer status is full mechanical lift and may adjust per therapy recommendation. V8 stated V8 needs to check with therapy on R3's transfer status since therapy staff have been working with R3 to stand and use the commode. V8 stated V8 has not received any recommendations from therapy to change R3's transfer status. The facility's Safe Lifting, Transferring and Movement of Residents policy dated July 2017 documents nursing staff and rehabilitation staff shall in conjunction assess each resident's needs for transfers assistance on an ongoing basis, and resident transfer needs will be documented in the care plan.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse by another resident. This failure affects one resident (R3) out of three reviewed for abuse on a sample list of eight. Findings include: R2's Medical Diagnoses list dated 8/20/25 documents R2 was diagnosed with Autism. Dementia. Anxiety, Insomnia, and Recurrent Depression. R2's Census Details of the same date document R2 had resided at the facility since 10/5/21. R3's Medical Diagnoses List dated 8/20/25 documents R3 was diagnosed with Dementia and Depression. R2's Census detail of the same date documents R3 had resided at the facility since 1/13/22. R2's Minimum Data Set, dated [DATE] documents R2 exhibits verbal behaviors such as screaming, threatening, and cursing, and physical behaviors such as hitting, kicking, pushing, grabbing, and scratching, directed at others which disrupt the living environment. This same Minimum Data Set documents R2 is independent in dressing and walking up to 150 feet. This Minimum Data Set documents R2's behaviors had worsened since the prior assessment dated [DATE]. R2's Minimum Data Set, dated [DATE] documents R2 exhibits physical behaviors directed at others, and other behavior such as hitting or scratching self, pacing, and rummaging, not directed at others. R2's Minimum Data Set, dated [DATE] documents R2 exhibited verbal behavior directed at others. R3's Minimum Data Set, dated [DATE] documents R3 had no exhibited behaviors and required staff supervision or assistance for all aspects of daily care. R2's Nursing Progress Note dated 6/24/25 documents R2 was up all night yelling, screaming, banging on room doors and exit doors, throwing a trash can, wandering in and out of other resident's rooms, and could not be redirected by staff. R2's Nursing Progress Note dated 7/7/25 documents R2 was in the hallway banging on the exit door, screaming dark outside repeatedly, and could not be redirected by staff. R2's Nursing Progress Note dated 8/7/25 documents after an allegation of abuse, (V2 Director of Nursing) watched a video recording of the incident to see R2 kicking another resident (R3) in the right lower leg repeatedly, an incident which prompted staff to send R2 to the emergency room for an evaluation. R3's Nursing Progress Note dated 8/7/25 documents R3 was in the dining room and without provocation, was kicked by R2 causing a small skin tear on R3's right shin. This note documents another resident (R4) had attempted to intervene in the incident which alerted staff to the incident who then intervened. The facility's List of Incidents dated for 6/26/25 through 8/20/25 documents an incident on 8/7/25 with R2 as the initiator of a resident-to-resident physical aggression and R3 being the recipient. The facility's Initial Report to IDPH dated 8/7/25 documents R2 and R3 involved in a resident-to-resident altercation. The facility's final report dated 8/13/25 documents R4 as the sole witness of the incident in the dining room, and video evidence of R2 kicking R3 in the lower leg. On 8/20/25 at 1:50 PM, R4 stated he had witnessed R3 seated in a wheelchair at a table in the dining room minding her own business, then R2 came up and kicked R3 in the leg, then R2 kicked R3 again and was laughing about it. R4 further stated R3 already had sores on her legs and R3's leg started bleeding again when R2 kicked R3. R4 then stated R2 kicked R3 again and he got up and said stop kicking her and that was when staff came and took R2 out of the dining room. R4 continued to state that there was not a lot of staff supervision in the dining room at the time because staff were bringing residents from their rooms to the dining room and then returned back to pick up other residents to bring to the dining room. R4 then stated R2 was back in the dining room the following day (8/8/25) and the staff supervision had not changed. R4 concluded by stating he had witnessed R2 walk up behind a resident (R6) about two and a half or three months ago and smack R6 in the back of the head when R6 wasn't doing anything, but there was no staff around at that time. R4's Minimum Data Set, dated [DATE] documents R4 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status, indicating R4 is cognitively intact. On 8/20/25 at 2 PM, V2, Director of Nursing, stated she had not seen the actual event but did watch the video from the dining room and did see R2 standing by the window, then walk over to R3 who was several tables away and kick R3. V2 stated she had known R2 and her family for about 40 years and thought R3 had some resemblance to R2's mother who R2 used to act violently towards. V2 further stated R2 was on the Autism scale and often acted like whatever she wants, she wants right now, like a small child. V2 stated she had not heard any kind of report about R2 smacking R6 in the head. On 8/20/25 at 2:15 PM, V3, Minimum Data Set Coordinator, stated she had watched the kicking incident between R2 and R3 on the camera. V3 stated she had known R2 and her family for a long time. V3 stated R2 used to be violent with her mother and had talked with R2's sister (V10) who had questioned if R2 was having some regression to an earlier age. V3 stated R2's behavior had been getting worse not just with the Autism but also with her Dementia. V2 stated she had not heard anything about any event between R2 and R6. On 8/20/25 at 2:20 PM, V1, Administrator, stated he had reported the incident initially on 8/7/25 and finally on 8/13/25. V1 stated he had watched the kicking incident between R2 and R3 on video and saw R2 walk up to R3 and kick R3. V1 made a kicking motion with his leg as he made this statement. V1 confirmed R4 was alert and oriented and accurate in his statements. V1 stated he had not heard any reports about R2 smacking R6 on the back of the head. On 8/20/25 at 2:20 PM, there was a purple quart-sized drinking mug on the windowsill of the business office with a broken raised edge in the drinking rim. There was a note affixed to the drinking mug which documented R2 had thrown the cup at a staff member (V4, Certified Nursing Assistant) and broke the mug.

Based on observation, interview, and record review, the facility failed to implement fall and accident prevention interventions according to a resident's care plan and physician orders. This failure affects one resident (R3) out of three reviewed for falls on the sample list of eight. Findings include: R3's Face Sheet dated 8/20/25 documents R3 had a legally established power of attorney. R3's Medical Diagnoses list of the same date includes Dementia, Major Depression, Hypertension, and Osteoarthritis of the Right Knee. R3's Census Detail of the same date documents R3 was admitted to the facility 1/13/22. R3's Physician order Sheet dated 8/22/25 documents R3 has physician orders to include non-skid strips on the floor in front of her recliner initiated 7/1/24, and to wear (cloth protective leggings) initiated 5/31/25. R3's Minimum Data Set, dated [DATE] documents R3 requires staff supervision and assistance for all aspects of daily living including hygiene, dressing, bathing, transfers, and transitioning between sitting and lying positions, and transitioning from sitting to standing. R3's Care Plan for fall prevention dated from 7/14/24 documents R3 is a fall risk. R3's fall prevention interventions include the area around R3's recliner needs to be kept free of hazards, and (non-slip material) is to be kept in R3's wheelchair seat, both dated as initiated 7/14/24. This care plan includes additional fall prevention interventions including for staff to keep R3's nurse call device in reach, initiated 10/11/24. This same care plan documents R3 is unaware of her safety needs, has Dementia, and often bumps into furniture which results in impaired skin integrity. The staff intervention for this accident problem area was for staff to place (protective leggings) on both of R3's legs for added protection, dated as initiated 5/31/25. There was a second intervention for R3 to have these protective cloth leggings and sleeves on both legs and both arms, dated as initiated 6/2/25. R3's Nursing Progress Note dated 8/20/25 at 8:15 PM documents R3 experienced an unwitnessed fall from bed with multiple bruises, abrasions, and was complaining of right knee pain. A second note on this same date at 8:55 PM documents R3 had swelling of the right knee and above the right eyebrow and was sent to the emergency department for an evaluation. R3's Nursing Progress Notes dated 8/21/25 at 1:09 AM documents facility nursing staff received an update from the emergency department personnel of R3's evaluation results indicating R3 had no fractures, no internal head bleeding, and had surgical glue applied to her right forehead and right knee. A second note on this date at 4:04 AM documented R3's return to the facility and R3 was able to tell nursing staff she had been to the hospital and saw her son but he had to leave because it was getting late, was responding appropriately to questions, told the nurse she had fallen and what injuries she experienced, the nurse noted additional bruising on R3's right elbow in addition to documenting the surgical glue on R3's right eyebrow and right knee. This note further documents R3 stated she was ready to go to bed and might sleep in. On 8/22/25 at 10:20 AM, R3 was seated in her recliner in her own room approximately four feet away from her bed. R3's nurse call light device was hanging from the light fixture on the wall above the left side of R3's bed approximately seven feet away from R3 and on the opposite side of the bed from where R3 was seated. There were no non-skid strips on the floor in front of R3's recliner. R3 was not wearing the protective leggings, nor the cloth protective arm sleeves. On 8/22/25 at 10:35 AM, V3, Minimum Data Set Coordinator, stated she was the nurse on duty and was taking care of R3. V3 stated R3 should have the non-skid material in her wheelchair seat and she personally tries to go around and make sure every resident has the material in their wheelchair seat because the residents will slip out of the wheelchair. V3 observed R3's wheelchair and confirmed the non-slip material was not in the seat. Likewise, V3 affirmed R3's nurse call device was hanging on the light fixture on the opposite side of the bed and was out of R3's reach. V3 stated R3 could hold the call light in her hand but would not realize what the device was to be used for, and R3 might accidentally push the button. V3 noted and confirmed there was not any non-skid strip on the floor in front of R3's recliner and stated that R3 had not attempted to stand up in months. On 8/22/25 at 11::25 AM, V2, Director of Nursing, stated the skin tear observed on R3's right lower leg was not from a resident-to-resident incident from 8/7/25 but rather was from when R3 fell out of bed on 8/20/25. V2 stated R3 often has wounds on both legs due to bumping into things when mobile in her wheelchair because she isn't aware of her own safety needs. V2 confirmed R3's fall on 8/20/25 was unwitnessed. V2 further stated she had personally gone around the facility to check for the non-skid strips for each resident who used them because there had been several residents who changed rooms and R3 was one of those residents. V2 nodded in confirmation that R3 was supposed to be wearing the protective leggings and protective sleeves.

Based on observation, interview, and record review, the facility failed to provide the services of a qualified director of food and nutrition services. This failure affects all 42 residents residing in the facility. Findings Include: On 12/10/24 at 9:55 AM, V5, Dietary Manager, was actively supervising and directing the food preparation and wares sanitation processes in the facility kitchen. At 11:50 AM and 12:08 PM, V5 was actively supervising and directing the meal service for lunch. On 12/10/24 at 9:55 AM, V5 stated she was the Dietary Manager. V5 further stated she had a (national company) cooking sanitation certificate. V5 continued to state she did not have a Certified Dietary Manager certificate (CDM, 6 to 9 month clinical nutrition curriculum), nor a Certified Food Protection Professional certificate (CFPP, CDM equivalent). V5 stated the facility utilized the services of a Registered Dietician one day per month on a consultant basis. V5 concluded by stating she did not meet the state requirements for a Director of Food Services nor meet the definition of a Dietetic Service Supervisor by stating she was not a graduate of a national dietetic school program, had no experience in education or employment prior to 1990, and had no qualifying military experience. On 12/10/24 at 10:10 AM, V6, Regional Dietary Representative, stated she, like V5, did not have a Certified Dietary Manager nor a Certified Food Protection Professional certificate. V6 stated she was currently enrolled in the Certified Dietary Manager course and that the ownership company would enroll V5 in the same course after approximately 30 days of V5's employment. V5 confirmed she would be enrolled in the course. On 12/10/24 at 10:10 AM, V5's certificate was on the wall in V5's office and documented V5 held a valid Certified Food Protection Manager certificate (one day training certificate for cooking sanitation). There was palatability, sanitation, lack of alternative menu items, lack of bedtime snacks, and potential contamination issues identified in the facility kitchen and meal services (reference F565 and F812). On 12/10/24 at 10:40 AM, V1, Administrator, stated, the facility used to employ a Certified Dietary Manager, but she was off work on a family medical leave of absence and is not going to return to work, so the facility hired V5 and would work on getting V5 trained and qualified. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain kitchen utensils to prevent potential contamination of food, and failed to prevent food contamination by storing utensils in bulk food containers. These failures have the potential to affect all 42 residents residing in the facility. Findings Include: On 12/10/24 at 10:15 AM, there was a metal, long handle measuring scoop located inside the bulk sugar bin. The handle of the scoop was in direct contact with, and partially buried by, the sugar. On 12/10/24 at 10:15 AM, V5, Dietary Manager, and V6, Regional Dietary Representative, both stated the scoop should not be left in the sugar. On 12/10/24 at 10:20 AM, there was a silicone blade spatula in a kitchen utensil drawer with a broken corner approximately three-quarters of an inch diagonal, exposing the granulated and rough internal material of the spatula. This granulated surface potentially would crumble off and contaminate food during preparation, and was not easily cleanable. On 12/10/24 at 10:20 AM, V5 removed the spatula from the drawer to indicate she would throw it away. The facility's Centers for Medicare and Medicaid Services Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24 documents 42 residents reside in the facility.

Based on interview and record review the facility failed to trend the facility's monthly infections. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: The facility did not provide an Infection Control Surveillance and Monitoring Policy and no documents were provided for how the facility trends monthly infections to prevent further infection throughout the facility. The facility has no documentation for the identified infections pattern/trend and interventions. On 12/10/24 at 02:10 PM, V2 Director of Nursing (DON) Infection Preventionist (IP) stated V2 has not kept up with a log for infections for residents, and only has October and November 2024, for infection logs and only for residents and not for employees. V2 stated V2 and does not complete any Quality Assurance (QA) on infections that reoccur. V2 also stated there has been no completed trending for the facility's infections. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.

Based on interview and record review, the facility failed to develop an infection prevention and control program that includes an antibiotic stewardship program and failed to review this policy annually. This failure has the potential to affect all 42 residents residing in the facility. Findings Include: On 12/11/24 at 10:40 AM, V2 Director of Nursing (DON) stated V2 has not completed an Antibiotic Stewardship Program for the facility. V2 stated there are no antibiotic protocols or a system to monitor antibiotics in place. The facility's Antibiotic Stewardship Program stated the purpose of the policy is to monitor antibiotic use of the residents. This policy has a date of 2/7/23, which has not been updated annually. The facility's The Long Term Care Facility Application for Medicare and Medicaid dated 12/10/24, documents there are 42 residents residing in the facility.

Based on observation, interview and record review, the facility failed to act on grievances from residents/family promptly, explain to residents how to file a grievance, inform residents where the survey book is located, and address lack of meal substitutes offered at mealtimes and not offering snacks at bedtime. This failure affects four of four residents (R3, R13, R21 and R25) reviewed for grievances in the sample list of 26. Findings include: On 12/11/24 at 10:00 AM, R3, R13, R21, and R25, all stated they can complain but that's as far as it goes. The residents stated staff say they will look into their concerns but the residents can not tell anything has been done. The residents stated they do not know about filling out a grievance form and they do not fill out grievances. The residents stated V9 Activity Director takes the complaints but then after that they do not hear anything more about it. The residents stated staff do not pass out snacks at bedtime and when asked about it they are only offered peanut butter and jelly (PBJ). The residents stated there is no anytime menu that they can see. The residents stated staff offer PBJ, grilled cheese, and cereal in the morning. The residents stated they have told V9 how bad the food is but nothing has changed. The residents stated meals are usually late and cold and breakfast is supposed to come at 7:00 AM and does not, that 12:00 PM lunch is late, and 5:00 PM supper is late. The residents stated they can not get hamburgers or hot dogs, and the potatoes are not done, and the fries are always cold and not done. The residents stated they have no idea where the survey book is located. On 12/12/24 at 11:13 AM V9 stated V9 does not write down the concerns of residents on the sheet for the council meetings. V9 stated V9 had V1 Administrator and V2 Director of Nursing come to resident council meetings, but does not document resident concerns or document speaking with the manager for the concern area or document the outcome. On 12/12/24 at 11:16 AM, V5 Dietary Manager, stated they have an always available menu that was posted but not now. V5 stated resident dislikes are put in a dining log and appear on meal tickets. V5 stated if residents don't like something we offer a second choice or always available menu. V5 stated at lunch today they have an alternative that they can choose from that is left over from the day before. V5 stated if residents don't like that they can choose off the always available menu. V5 stated this has been a consistent issue and V5 has only been here a few weeks so a couple of cooks have been choosing to offer a grilled cheese and PBJ only instead of using the always available menu. V5 stated these are issues they are fixing as well: cold food, food not tasting good, and late meals. V5 stated since V5 has been here they have been keeping temperature logs and they are better and V5 is re-tempting food herself. V5 stated serving times have been better but breakfast was late because there was no staff to take trays to the residents. V5 stated snacks at night were not happening so she stays to make sure snacks are available. V5 stated the snack issue was just brought to her attention maybe three days ago by V6 Regional Dietary. On 12/12/24 at 1:13 PM, with difficulty, the survey book was found by the front door in the corner with the name of the binder covered up by decor, not readily visible. This survey book has the surveys in it with survey dates of only 2022, no other years present On 12/12/24 at 1:20 PM V1 was shown where the survey book was located, Christmas decor blocked the view of the survey book entirely. V1 verified that the survey book surveys were not up to date with only 2022 surveys being present in the survey book. The facility's undated Grievance Policy documents the residents have the right to file grievances and concerns either written or verbally. A staff member may file a grievance on behalf of a resident. Grievances should be directed to the Administrator (Grievance Official) of the facility. The Administrator will immediately begin to address the grievance upon receipt, immediately discuss the issue with the individual and advise of an appropriate time frame to address the issue.

Based on observation, interview, and record review the facility failed to change, date and store oxygen tubing, humidifier bottles, nebulizer masks, and suctioning equipment in a sanitary manner for four of five residents (R4, R14, R34, R350) reviewed for oxygen in the sample list of 26. Findings Include: The facility policy Departmental Respiratory Therapy Prevention of Infection dated reviewed 4/27/24 documents the oxygen administration supplies consist of oxygen tubing and humidifier bottle. This policy documents to change the oxygen tubing cannula every seven days, and to discard the entire administration set up every seven days. 1. R34's Medical Diagnoses list dated December 2024 documents R34 is diagnosed with Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. R34's Physician Order Sheet (POS) dated December 2024 documents an order for oxygen per nasal cannula at three liters continuously. R34 also has an order for nebulizer treatments every four hours as needed. The oxygen tubing and humidifier bottle should be changed every Sunday night and stored in a plastic bag. On 12/10/24 11:54 AM R34's portable oxygen tubing was undated and hanging over the oxygen cylinder. R34's nebulizer tubing and mask were sitting on his bedside dresser. On 12/10/24 at 11:55 AM V8 (R34's Daughter) confirmed R34's oxygen tubing is never stored in a bag and neither is nebulizer tubing/mask. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R34's oxygen tubing and nebulizer mask and tubing should be changed, dated, and stored in a bag when not in use. 2. R350's Medical Diagnoses list dated December 2024 documents R350 is diagnosed with Pneumonia and Sepsis. R350's Physician Order Sheet (POS) dated December 2024 documents an order that R350 may suction herself using an oral plastic suction catheter. Nursing to empty out machine after each use and clean catheter by putting catheter in a cup of water and suck it up until it is clear. On 12/10/24 at 11:34 AM R350 stated she has been doing her own suctioning. Oral suction catheter appears dirty and is not covered. On 12/11/24 at 2:50 PM V2 Director of Nurses confirmed R350's suction catheter should be cleaned after each use and stored in a bag. 34058 3. On 12/10/24 at 10:10 AM, R4 was seated in an electric wheelchair in the North Hall wearing and utilizing oxygen from a portable tank mounted on the wheelchair through a nasal cannula tubing. R4's nasal cannula tubing did not have a date on it to indicate when it was last changed. On 12/10/24 at 10:12 AM in R4's room there was a room air concentrator with a humidifier bottle with a date written on the bottle of 12/1/24 to indicate the extension tubing was last changed on this date. There was a green plastic extension tubing connected to the humidifier bottle and the extension tubing had a piece of white tape with a date written on the tape of 11/17/24. There was a nasal cannula tubing connected to the green extension tubing with a piece of white tape on the cannula tubing of 11/17/24. There was a nasal cannula tubing on the seat of R4's recliner which was likewise dated 11/17/24. On 12/10/24 at 10:12 AM, R4 stated he had requested the nasal cannula and extension tubing be changed once per month instead of the once per week routine the nurses had been conducting. R4's Physician Order Sheet dated 12/11/24 documents a physician order for R4's oxygen tubing, humidifier bottle, and plastic holding bag to be changed weekly on Sunday nights. R4's historical Physician Order Sheets dating back through August 2024 document R4 began continuous oxygen therapy on 8/5/24. R4's Nursing Data Collection assessment dated [DATE] documents R4 had no oxygen use. R4 Nursing Progress Notes dated back through 8/1/24 do not document that any of the nursing staff providing care for R4 had spoken to R4 to inform him of any risks of changing the oxygen tubing monthly instead of weekly, or alternative sanitation procedures to changing the oxygen tubing every week. On 12/12/24 at 10:31 AM V2, Director of Nursing, and V3, [NAME] President of Clinical Operations, both stated they had not heard about R4 requesting to have his oxygen tubing changed monthly instead of weekly, and to their knowledge no one had spoken to R4 to inform R4 about infection control risks, or to explore other possible methods to sanitize R4's oxygen tubing such as soaking the tubing in soap and water, nor had anyone documented any of this. 35380 4. R14's undated Diagnoses list documents R14's diagnoses as Obstructive Sleep Apnea, Nasal Congestion, and Insomnia. R14's POS dated 12/13/24, documents oxygen at 3 liters per nasal cannula as needed for shortness of breath. On 12/10/24 at 10:20 AM, R14's oxygen tubing and water bottle were both dated 11/25/24. R14 stated he uses oxygen every night.

Based on Interview and record review, the facility failed to follow through with contacting Physicians for unaddressed Pharmacist recommendations, and failed to maintain documented evidence of Physician responses to Pharmacist recommendations. This failure affects four residents (R12, R16, R22, R26) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Registered Pharmacist Consultant recommendation recorded in R16's Nursing Progress Notes dated 11/25/24 documents a Pharmacist recommendation to conduct an abnormal involuntary movement scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R16's electronic medical record (EMR). As of 12/11/24 at 11:20 AM, there was likewise no record of an AIMS assessment conducted for R16 historically. 2. R22's Registered Pharmacist Consultant Report dated 1/25/24 documents, This resident currently has an order for the Antipsychotic Seroquel 25 mg every night at bedtime. This resident does not have an approved diagnosis to support Antipsychotic use in the elderly with Dementia due to a black box warning of increased risk of mortality. CMS (Centers for Medicare and Medicaid Services) approves Antipsychotic use with the following diagnoses: Schizophrenia, Bipolar Disorder, Huntington's Disease, and Tourette's Syndrome. Please provide an approved diagnosis or justification for use below. The physician response section was blank. R22's EMR did not include any documented evidence of a physician progress note nor any physician response to this Pharmacist recommendation. R22's Medical Diagnoses List dated 12/13/24 nor Physician Order Sheet dated 12/12/24 documented an approved diagnosis for R22's Seroquel, listed as prescribed for Anxiety, Irritability and Anger. On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated the consultant pharmacy review process is supposed to be that the Pharmacist does his reviews and makes a report, then he sends the report to the facility and to the doctor, then the doctor will address the recommendations when she is here. V2 and V3, [NAME] President of Clinical Operations, both stated R22's doctor is here every week. 20892 3. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder: Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. The start date for this medication was 7/1/24. On 10/27/24 V21, (Consultant Pharmacist) did a Medication Regimen Review (MRR) for (R26). V21 recommended a dose reduction of the psychotropic medications Trazodone 100 mg (milligram) two tablets at night, Fluoxetine 20 mg 4 tablets 80 mg daily , Seroquel 25 mg QD (every day) and Bupropion ER 100 mg BID (twice a day) due to self reported fall. This information was sent to V22, (Medical Director and R26's physician). V22 did not respond to the request until 11/19/24 on R26's Nursing home visit. V22 documented she did not want to do a drug reduction on any of the medications however no reason was documented. On 12/13/24 at 10:45 AM V2 Director of Nursing stated she does not receive the pharmacist recommendations from V21 because V21 emails them directly to V22. (R26) only had one MRR in her chart. V2 had to obtain the October visit from V22's office. 32172 4. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety. R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder. R12's Registered Pharmacist Consultant recommendation recorded in R12's Nursing Progress Notes dated 7/27/24, 8/26/24, 10/27/24, and 11/23/24 documents a Pharmacist recommendation to conduct an Abnormal Involuntary Movement Scale (AIMS) assessment to monitor for side effects of long-term Antipsychotic use. There was no documented evidence of a physician response, and no documented evidence of follow-up by the facility to obtain a physician response, in R12's electronic medical record (EMR). As of 12/11/24 at 12:00 PM there was likewise no record of an AIMS assessment conducted for R12 historically. On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year. The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record. The facility did not provide a policy regarding following pharmacy recommendations.

Based on interview and record review, the facility failed to conduct psychotropic medication assessments, failed to maintain accurate documentation in psychotropic medication assessments, failed to conduct abnormal involuntary movement assessments for Antipsychotic medications, failed to obtain a time period duration for PRN (as needed) psychotropic medications, and failed to attempt gradual dose reductions for residents receiving anti-psychotic medications. These failures affect five residents (R12, R16, R22, R26, and R29) out of six reviewed for unnecessary medications on the sample list of 26. Findings Include: 1. R16's Medical Diagnoses list dated 12/13/24 documents R16 experiences medical conditions including Alzheimer's Disease and Dementia. R16's current Physician Order Sheet dated 12/13/24 documents R16 has physician orders for psychotropic medications including Sertraline (antidepressant) 25 milligrams (mg) daily, and Olanzapine (Antipsychotic) 2.5 mg daily. This same Physician Order Sheet documents R16 experiences additional medical conditions including Hallucinations and Paranoia, and Depression. R16's historical physician order sheets dating back to May of 2023 indicate R16 had been receiving these antidepressant and Antipsychotic medications routinely since that time. On 12/10/24 at 11:05 AM, V17, Certified Nursing Assistant, stated R16 is a risk for elopement and experiences hallucinations and paranoia. R16's Social Service quarterly assessment dated [DATE] documents R16 as taking one psychoactive medication listed as Memantine (N-Methyl-D-aspartate (NMDA) receptor agonist, not psychoactive) for Dementia. The Olanzapine and Sertraline are not listed. R16's four most recent Minimum Data Sets (MDS's) dated 11/22/24, 8/23/24, 5/24/24, and 2/29/24 each document R16 had not had any attempted gradual dose reductions for the Antipsychotic medication Olanzapine, nor were there any documented physician notes to indicate R16 would be clinically contraindicated to attempt a decreased dosage. R16's Assessments area of the electronic medical record (EMR) did not include any required quarterly psychotropic medication assessments. As of 12/11/24 at 11:20 AM, R16's EMR did not include any required abnormal involuntary movement scale (AIMS) assessments. On 12/12/24 at 10:35 AM, V2, Director of Nursing, stated she would look into the facility's former EMR system to check if any of R16's quarterly psychotropic medication assessments or AIMS assessments were located there. At this same time, V3, [NAME] President of Clinical Operations, stated she would likewise look into the facility's former EMR system for any of R16's assessments. As of 12/13/24 at 2:55 PM, neither V2 nor V3 had provided any historical documentation that these assessments had been completed for R16. 2. R29's current Medical Diagnoses Lists dated 12/11/24 document R29 experiences medical conditions including Major Depression. R29's current Physician Order Sheet dated 12/11/24 documents R29 has physician orders for Bupropion (antidepressant) 300 mg extended release daily. R29's EMR, including the Assessments area, did not include any required quarterly psychotropic medication assessments. On 12/11/24 at 1:40 PM, V2, Director of Nursing, stated the facility practice is to place the psychotropic medication assessments and AIMS in the assessments portion of the EMR. V2 further stated the Psychotropic medications assessments are supposed to be completed quarterly, and the AIMS every 6 months. 3. R22's current Medical Diagnoses list dated 12/13/24 documents R22 experiences medical conditions including Dementia, and Irritability and Anger. R22's current Physician Order Sheet dated 12/12/24 documents R22 receives psychotropic medications including Quetiapine (Seroquel, Antipsychotic) 25 mg every 24 hours PRN (as needed) for Anxiety, and Lorazepam (Antianxiety) 0.5 mg every 8 hours PRN for Pain related to Irritability and Anger, give prior to showers and (urinary) catheter changes. R22's historical Physician Order Sheet documents R22 had been prescribed the Antipsychotic medication Quetiapine on a daily basis through December 4, 2024 when the Olanzapine was changed to PRN. The Quetiapine ordered on a PRN basis did not include any stop date nor duration of time for the order. The Physician's Desk Reference 2024 documents Quetiapine is indicated for treatment of Major Depression (in conjunction with other antidepressant medications) and Bipolar Mania-Depressant Disorder. This same Physician's Desk Reference documents Lorazepam is indicated for the treatment of Generalized Anxiety Disorder. On 12/13/24 at 2:55 PM, V2, Director of Nursing, stated the facility nursing staff has had some discussions about making sure there are stop dates and durations for the PRN (as needed) psychotropic medications. V2 stated there are only two full time nurses at the facility so V2 spends a lot of her time working in the direct care aspect in the facility and that makes it difficult to keep up with paperwork. V2 acknowledged the requirement for PRN psychotropic medications to be limited to 14 days or there needs to be a physician evaluation and justification documented to continue use. 20892 4. The Physician's Order Sheet dated December 2024 documents (R26) takes the following medication for the diagnosis of Schizoaffective Disorder. Quetiapine Sulfate (Seroquel) tablets 25 mg (milligram) 1 tablet orally every day. Start date for this medication was 7/1/24. 12/11/24 (R26) chart did not have any AIMS (Abnormal Involuntary Movement Scale) assessment to review. When V2 was asked about (R26's) AIM's assessment at 11:20 AM, V2 stated I have to look and see if I can find it in the chart. V2 brought (R26's) AIM's assessment at 1:00 PM after it was completed. The assessment was dated 12/11/24 at 12:53 PM. V2 stated This is the only one I have. 32172 5. R12's Medical Diagnoses List dated December 2012 documents R12 is diagnosed with Dementia with Behavioral Disturbance, Major Depression, and Anxiety. R12's Physician Order Sheet dated December 2024 documents R12 is prescribed Risperidone (Antipsychotic) 0.25 milligram transdermal patch once daily related to psychosis with hallucinations, dementia with other behavioral disturbances, and anxiety disorder. R12 is also prescribed Sertraline (antidepressant) 50 milligrams daily related to major depressive disorder. On 12/12/24 at 12:20 PM V3 [NAME] President of Clinical Operations confirmed R12 has not had any AIMS assessments completed prior to 12/11/24 and no psychotropic medication assessments completed at all. V2 also confirmed there was no documentation of any attempted Gradual Dose Reductions in the last year. The facility's Psychotropic Medication Use policy dated December 2016 documents Psychotropic Medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and review. The need to continue PRN (as needed) orders for psychotropic medications beyond 14 days requires the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. The facility's Abnormal Involuntary Movement Scale policy dated 9/1/24 documents the AIMS assessment should be performed before starting Neuroleptic drug therapy and then repeated every six months. All information should be documented in the resident's medical record.

Based on observation, interview and record review the facility failed to supervise a resident while on the toilet (R1), failed to implement post fall interventions (R2) and failed to lock an unattended treatment cart (R2) for two of three residents (R1, R2) reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a 3 cm (centimeter) laceration and receiving 5 stitches in the emergency room . Findings include: The facility's Falls and Fall Risk, Managing policy with a revised date of March 2018 documents, Policy Statement Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident-Centered Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Monitoring Subsequent Falls and Fall Risk 4. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. 1.) R1's Minimum Data Set (MDS) dated [DATE] documents diagnoses including [CONDITION(S)], Alzheimer's Disease, Non-Alzheimer's Dementia, Anxiety, Depression and Unspecified Dementia with Behavioral Disturbances. This MDS documents R1 has moderately impaired cognitive skills. This MDS documents R1 requires extensive assistance (weight bearing support) of one person for transfers and toilet use and documents R1 is not steady, only able to stabilize with staff assistance, when moving from a seated to standing position and moving on and off the toilet. R1's Care Plan dated 2/27/22 documents to assist R1 with transfers and ambulation, to observe for unsafe actions and intervene and to assist to bathroom or commode as needed. R1's undated active Physician's Orders document orders for [MEDICATION(S)] (antidepressant) 50 mg (milligrams) every day with a start date of 8/13/21, [MEDICATION(S)] (antianxiety) 0.5 mg twice a day with a start date of 8/13/21 and [MEDICATION(S)] (antipsychotic) 0.25 mg twice a day with a start date of 9/13/21. The facility's Accident/Incident log documents R1 sustained falls on 2/26/22 (no injury), 4/10/22 (no injury) and 4/11/22 (deep laceration). R1's Incident Report printed on 4/18/22 documents on 4/11/22 at 4:50 AM, CNA (Certified Nursing Assistant) V7 sat R1 on the toilet and turned around to get R1's clothing and R1 fell off of the toilet seat and onto the floor. This report documents R1 sustained a deep laceration approximately 4 cm (centimeters) long to the right forehead and a ragged skin tear 3 cm long to the back of the right wrist. This report documents R1 was sent to the hospital emergency room for treatment. The investigation of the incident completed by V2 Director of Nursing documents the root cause of the fall was that V7 turned around instead of staying focused on R1. R1's emergency room documentation dated 4/11/22 documents, (R1) with h/o (history of) dementia brought from nursing home after (R1) fell off the toilet commode and hit right forehead causing laceration. emergency room Procedure Notes document, Wound Length: 3 cm, number of sutures, 5. R1's undated Resident Care Summary documents R1 is a two person assist, is confused and is incontinent of bowel and bladder. On 4/19/22 at 12:55 PM, V6 CNA stated they refer to the Resident Care booklet if they have questions on how to care for residents. At this time, V4 Restorative CNA stated that V4 is responsible for updating resident information in this booklet and CNAs are to look in the booklet for guidance on resident care. On 4/19/22 at 12:35 PM, V2 Director of Nursing confirmed regarding R1's fall on 4/11/22 that V7 got distracted after placing R1 on the toilet. V2 stated, preferably eyes should be on (R1) the whole time. On 4/19/22 at 2:27 PM, V11 R1's Physician stated R1's laceration was caused by falling from the toilet and hitting R1's head. 2.) R2's MDS dated [DATE] documents diagnoses including [CONDITION(S)], Heart Failure, Alzheimer's, non-Alzheimer's Dementia, [CONDITION(S)], Anxiety, Depression, Psychotic Disorder and Restlessness and Agitation. This MDS documents a BIMS (Brief Interview for Mental Status) score of 3/15 which indicates severe cognitive impairment. This MDS documents R2 requires limited assistance of one person for transfers and extensive assistance of one person for toileting. This MDS documents R2's balance is not steady when moving from a seated position to standing, moving on and off the toilet and walking. R2 is only able to stabilize with staff assistance. R2's Care Plan dated 8/9/21 documents R2 is at high risk for falls with a start date of 3/24/20 and interventions listed are anti-lock brakes on wheelchair dated 6/25/20, shoes or slipper socks on at all times dated 8/9/21, assist with transfers and ambulation dated 8/9/21, observe for unsafe actions and intervene dated 8/9/21. This care plan documents a fall on 11/1/21 and an intervention of anti tippers were added to R2's wheelchair. R2's undated active Physician's Orders document orders for [MEDICATION(S)] (antidepressant) 20 mg a day with a start date of 6/15/19, [MEDICATION(S)] Extended (antiseizure) 100 mg capsules, three capsules daily with a start date of 6/3/19, [MEDICATION(S)] (antidepressant) 15 mg daily with a start date of 8/21/20, [MEDICATION(S)] (antipsychotic) 0.5 mg twice a day with a start date of 11/30/20 and [MEDICATION(S)] (antianxiety) 0.5 mg twice a day with a start date of 1/24/20. R2's Incident Report printed on 4/18/22 documents on 3/26/22 at 7:42 AM, R2 stood up at the treatment cart from R2's wheelchair. The cart drawers nor the wheels were locked. R2 lost R2's balance and fell pulling the treatment cart on top of R2. R2 sustained five skin tears to R2's arms and a bruise and bump to R2's forehead and a scrape to the outer knee. R2's Nurse Progress notes document that this incident happed at 7:15 PM on 3/26/22 instead of in the morning. These Nurse's Progress notes document R2 was sent to the hospital and returned to the facility at 11:09 PM and x-rays were negative but R2 had a Urinary Tract Infection. R2's Narrative of Investigation documents the root cause to the fall on 3/26/22 was that R2 went up to the cart and the drawers were not locked and R2 tried to pull R2's self up and this caused the cart to tip and R2 fell , and the cart fell on top of R2. On 4/19/22 at 12:35 PM, V2 confirmed R2 fell because the treatment cart was unlocked. V2 stated the carts should be locked at all times. V2 stated that the treatment cart was left in the hallway unlocked and unattended when R2 pulled it over on R2's self. 3.) R2's Care Plan 11/1/21 documents R2 is to have anti tippers on the wheelchair and an intervention dated 8/9/21 to keep the call light in reach. On 4/18/22 at 11:22 AM, R2 was in R2's bed sleeping. R2's wheelchair was next to R2's bed. There was no anti tippers on R2's wheelchair and R2 did not have a call light plugged into the wall. There was an empty plug where the call light was supposed to be. On 4/18/22 at 1:15 PM, R2 was in the dining room leaning R2's head way back over the back of the wheelchair. R2 had anti roll back brakes on the wheelchair but no anti tippers on the wheelchair. On 4/18/22 at 1:03 PM, V6 Certified Nursing Assistant was taking R2 to the bathroom. V6 confirmed R2 did not have a call light in R2's room and V6 did not know why R2 did not have a call light. On 4/19/22 at 11:38 AM, there is still no call light in R2's room. On 4/19/22 at 12:35 PM, V2 Director of Nursing stated V2 was not aware that R2 did not have a call light. V2 stated that R2 should have a call light.

Based on record review, and interview, the facility failed to supervise two residents (R1 and R2) while on a toilet / bedside commode. These failures resulted in R1 falling and sustaining a Left [MEDICAL CONDITION]. R1 and R2 are two of six residents reviewed for falls in the sample of six. Findings include: 1. R1's Face Sheet documents R1 was admitted to the facility 6/16/17. (R1 is currently hospitalized ) R1's Physician order [REDACTED]. R1's Medication Administration Record [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents the following: Moderate Cognitive Impaired - decisions poor; cues and supervision required. The same MDS documents R1 is not able to stabilize without staff assistance to move on or off toilet, stand from seated position, and requires extensive staff assistance with transfers and ambulation. R1's Care Plan dated 12/14/18 documents the following: I have a high risk for falls. I will have no injury from falls from 12/19/18 - 3/19/19. R1's Fall Risk Evaluation dated 12/13/18 documents a total score of 14, with a score greater than 10 representing High Risk. The same Fall Risk Evaluation documents R1 has had three or more falls in the last three months. A facility report titled Incident Log dated (MONTH) (YEAR) through (MONTH) 2019 documents R1 fell on [DATE], 12/24/18, 12/30/18, 1/3/19, 1/15/19, 1/31/19, 2/28/19 and 3/16/19. R1's Fall Management - Post Fall Assessment Tool (included Resident Incident Reports) document R1 has had falls on the following dates: 11/25/18, 12/24/18, 12/30/18, 1/3/19, 1/15/19, 1/31/19, 2/28/19 and 3/16/19. All the above-mentioned falls Fall Management - Post Fall Assessment Tool (Resident Incident Reports) reports document the investigation were completed and R1 sustained no major injuries, until 3/16/19 fall with left [MEDICAL CONDITION]. R1's Resident Incident Reports dated 3/16/19 at 12:30 am documents by V3, Registered Nurse / RN and V6, Licensed Practical Nurse / Fall Investigator as follows: R1 fell in the bathroom. V3 observed the fall. R1's Resident Incident Report included an attached statement written by V3. The attached statement documents the following: I (V3) pottied (taken to the toilet) (R1). While she (R1) was on the toilet (R2), across the hall, was on the commode and stood up to transfer herself (R2). I (V3) was torn between the two residents. (R1 was sitting (on the toilet), not fidgeting so I hurried across the hall and sat (R2) on (R2's) bed. As I was returning to (R1's) room I witnessed (R1) falling to her left side. I couldn't be in both places at the same time. (V4, Certified Nursing Assistant / CNA) was on the north hall at the time. (R1) did not hit her head. (R1) fell mainly on her left arm. (R1) did not complain of pain. (V4, CNA) and I put her (R1) to bed and her (R1) fell asleep and didn't to stir the rest of the night while I was there (working till 3:00 am). R1's Nurse Progress Note dated 3/16/19 at 7:24 am, signed by V2, Director of Nursing / DON documents the following: Resident (R1) rested quietly until this time. (V9, CNA) CAN started to get her (R1) up and ready for the morning and when (V9) CAN went to swing resident's legs over to the side of the bed the resident (R1) moaned and yelled out 'that hurts'. (V9) called for nurse (V2, DON) to come to the room. During assessment resident (R1) complained of left thigh / knee pain when the (R1's) leg was palpated. Resident (R1) would not flatten her legs to check for rotation or shortening. Resident (R1) is unable to flatten her legs normally. When (R1's) arms were palpated resident complained of pain as well. Whenever resident (R1) was touched she would say it hurt and then make comments that didn't make sense like 'it came down the straw'. The (R1's) left knee area was warmer to touch than the right (knee). No redness, swelling or bruising noted. (V10) paged at 7:25 am. (V17, R1's Family Member) notified of incident and does want an X-Ray done. Resident (R1) remains in bed currently. Personal alarm and floor alarm on. Call light within reach. R1's Nurse Progress Note dated 3/16/19 at 8:21am documents V8 Physician was on call for V10, Physician and gave orders for R1 to be sent to the emergency room for evaluation and treatment. R1's Hospital Diagnostic Radiology Report (X-Ray) dated 3/16/19 at 11:01 am, documents the following: X- Ray Hip 2 or Greater Views Left and Pelvis. Findings: Diffuse Osteopenia. Mild [MEDICAL CONDITION] changes to both hips. Mildly displaced left intertrochanteric femur fracture ([MEDICAL CONDITION]). R1's Hospital Emergency Documentation dated 3/16/19 documents the following: Emergency Department Course; discussed with the patient (R1) that she does have a [MEDICAL CONDITION]. She (R1) is going to require hospitalization and orthopedic surgical treatment. 2. R2's POS dated (MONTH) 2019 document the following Diagnoses: [REDACTED]. R2's Fall Risk Evaluation dated 12/29/18 documents R2 is at high risk for falls, score 16. Total score of ten or above represents high risk. R2's Resident Incident Report dated 9/23/18 documents R2 self-transferred while going to the bathroom. R2's Care Plan updated 1/17/19 documents the following: I (R2) have weakness with unsteady on feet. I become anxious when I have difficulty breathing due to [MEDICAL CONDITION]. Assist with transfers and toileting. I have a risk for falls, as evidenced by impaired balance during transitions. fell in room [ROOM NUMBER]/7/18, 1/17/18, 1/22/18 fell responding to bladder needs, 3/14/18 slid out of wheelchair, 3/26/18 fell in room, 4/18/18 fell in room, 4/19/18 fell in room, 4/29/18 observed fall in hallway, 7/16/18 hallucinating and wheel chair brakes not locked, 7/29/18 up without assist and fell , 9/23/18 left alone in bathroom by CAN (unidentified). The same care plan documents the following fall prevention interventions: seat alarm, bed alarm, and motion sensor floor alarm, and educate staff to never leave resident alone in bathroom. R2's Minimum (MDS) data set [DATE] documents R2 has severe cognitive impairment, requires limited physical staff assistance with transfer, extensive staff assistance with toileting, and cannot steady herself without staff assistance walking, transferring, toileting, or moving from seated to standing position. On 3/19/19 at 2:40 pm V3 stated the following: We have four halls with about fifty residents all together. We only have one nurse and usually two CNA's at night, sometimes three. Most of the time that is enough on nights. The night (R1) fell and broke her hip, the CNA's were both busy working down other halls. We had all been trying to encourage (R1) to let us get her ready for bed. (R1) finally agreed. I was taking (R1) to the bathroom when (R2) put on her call light. I transferred (R2) to (R2's) bedside commode and clipped (R2's) personal alarm on her shirt. I then went back across the hall (leaving R2 unsupervised) and transferred (R1) to the toilet. (R2's) alarm went off so I knew she wanted off the bedside commode. Both (R1 and R2) are high risk for falls so I went immediately to assist (R2) (leaving R1 unsupervised). As soon as I got (R2) to the side of the bed, I could see across the hall that (R1) was getting off the toilet by herself. I watched R1 fall to the floor. I left (R2) sitting on the side of the bed (unsupervised). I forgot to put her personal alarm back on (R2's Care Plan intervention). I was torn between the two residents both (R1 and R2 are) at high risk for falls with history of falls. (R1) had stood up from the toilet so I hurried to her but did not get there soon enough to prevent her fall (with left [MEDICAL CONDITION]). (R1) did not hit her head. I should not have left her on the toilet alone. Hind sight is 20 - 20. I should have finished toileting (R2) before putting (R1) on the toilet. I assessed (R1) and (R1) was bleeding from two skin tears on her left arm. (R1) did not complain of pain when I checked her legs. (R1) did not show any signs of rotation or discoloration to her hip. I transferred (R1) back onto the toilet and put on the call light. (V4, Certified Nursing Assistant) responded and stayed with (R1) while I went to get supplies to dress (R1's) skin tears. I left (R1's) room and went back to (R2's) room. I lifted (R2's) legs back into bed and put (R2's) personal alarm back on. I should not have left her (R2) unattended either and should have made sure her alarm was on when I had to leave her to help (R1). I am so glad (R2) didn't fall too. I was so torn between who to help. I got the dressing supplies, cleaned and dressed (R1's) skin tears. (V4) and I (V3) put (R1) in bed. (R1) did not complain of pain. (R1) slept the rest of my shift (until 3:00 am). On 3/19/19 at 3:00 pm V2, Director of Nursing (DON) stated the following: I came in at 3:00 am on 3/16/19, the night (R1) had her fall, that resulted in the [MEDICAL CONDITION]. (R1) was asleep when I came in and continued to sleep without signs of restlessness or discomfort. Around 7:00 am (V9, Certified Nursing Assistant) CNA was getting her (R1) up for breakfast. (R1) complained of left knee and thigh pain so (V9, CNA) left (R1) in bed and reported to me (V2, DON). I (V2, DON) assessed (R1), who could not flatten her legs to assess for shortening or rotation. (R1) continued to complain of pain in (R1's) left leg, left knee and left arm when I palpated these areas. The doctor's office was called (V10's, R1's Physician). (V8, Physician) was on call for (V10, R1's Physician) and called back with order to send (R1) out to the hospital for X-Rays). R1 was admitted to hospital with a left [MEDICAL CONDITION]. I expect all staff to stay with residents when toileting. This should not have happened. (R1) should not have been left on the toilet. R2 should not have been left on the bedside commode. (V3, Licensed Practical Nurse) should have completed (R2's) care before starting (R1's) care. (R2) should have been put back to bed and (R2's) alarm should have been on before (V3, LPN) initiated (R1's) care. This would have most likely prevented (R1's) fall that night. On 3/20/19 at 10:20 am V10, Primary Care Physician stated the following: (R1's) left [MEDICAL CONDITION] was caused by the fall (3/16/19). I was not informed that (R1) was left unattended on the toilet. The fall likely could have been prevented if (R1) was not left by herself. (V8, Physician) was on call Saturday and sent (R1) to the hospital as soon as he was informed of the pain post that fall. The facility Fall Prevention and Management Policy and Procedure dated (MONTH) 8, (YEAR) documents the following: Each resident must be assessed on admission, quarterly and any changes in condition for potential risk for falls to take preventative approach. Discussions regarding the acceptable level of risk must be based on individual assessment with input from resident and/or resident's representative and interdisciplinary team. Purpose: 3. Provide appropriate strategies and interventions directed to resident environmental factors and staff. The facility policy Safety and supervision of Residents dated (MONTH) (YEAR) documents the following: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility- wide priorities. The same policy documents: Individualized, Resident -Centered Approach to Safety, 3. The care team shall target interventions to reduce individual risk related to hazards in the environment, including adequate supervision and assistive devices.

Based on interview and record review the facility failed to ensure a safe transfer using the appropriate equipment to avoid a serious injury (Left Humerus and Rib Fractures) for one of 8 residents (R14) reviewed for falls/injuries in a sample of 15. The injuries to R14 were the result of an improper transfer causing harm to R14. Findings include: The facility Resident Incident Report dated 9-27-17 documents an incident for R14 on 9-13-17 at 6:10pm with an injury. (E3), Certified Nurses Aide (CNA) came to (E4), Licensed Practical Nurse (LPN), and reported a bruise on left upper arm. (E4) went and evaluated (R14). (R14) did not act like she was in pain until movement with left arm. Noted a purple bruise approximately 9.8 centimeter (cm) long and 11.0 cm wide. Noted swelling in left upper arm and left shoulder. On 10-27-17 at 10:25am E4 confirmed her Nurses Note she recorded about R14 when she documented on 9-13-17 at 10:47pm that Z2, (R14's Nurse Practitioner) was called by E4, who left a voice mail at 6:36pm. At 6:48pm Z2 called back indicating she was out of town for a conference and will address (on 9-14-17). Director of Nursing was Notified. (Mobile X-ray service) was called approximately 7:00pm for x-ray and will come (9-13-17). Nurses Note dated 9-14-17 at 9:09am documents the x-ray that was obtained from the mobile x-ray service revealed a fracture. Z4, R14's Primary Care Physician was notified and an order to send to emergency room for evaluation and treatment was obtained at 12:30am (9-14-17). The Radiology Report from the local Hospital dated 9-14-17 at 3:29am for R14 documents comminuted left humeral diaphysis fracture is identified. Fracture of the left eighth rib is also seen on the left side. E3's written statement on 9-14-17 around 2:30 pm (on 9-13-17) I laid (R14's) chair flat and put pillows at the foot and all around the sides. I put my left arm underneath her shoulders and my right arm under her legs and placed her into the chair. (R14) showed no signs of pain. Roommate was in room. Put (R14) into the hallway outside of room when covered up. R14's Minimum Data Set ((MDS) dated [DATE] documents R14's transfer ability as totally dependent on staff with assist of 1 staff. All of R14's Activities of Daily Living (ADL's ) were documented as R14 being totally dependent on staff with assistance of 1 staff. On 10-27-17 at 8:10am E1 Administrator confirmed R14's Care Plan documented R14 was a Mechanical Lift Transfer with assist of 2 staff. E1 stated all of our Mechanical Lift Transfers are with assist of 2 staff. R14's ADL Functional/Restorative Record dated 7-18-17 identifies Adaptive equipment to include for R14 Mechanical Lift and under transfers 2 assist. On 10-27-17 at 8:10am E1 stated when we investigated the transfer, we reenacted (the transfer) to have (E3) transfer (cradle lift) another CNA of the same size and height as (R14). And (E3) did the transfer several times, no bruising or redness was noted, this CNA stated it did not hurt her left arm, but (E3's) hand was located on the same place as the bruising on (R14's) arm. It's the only thing we can think of that could have cause (the bruise/fracture). We discussed it with (Z2) and she reviewed the time line and all the investigation at the Quality Assurance Meeting. (Z2) determined that with (R14's) long term declining nutritional health it didn't take much for the bone to break. At this time E1 continued to state (R14) was a mechanical lift transfer and (E3) said she knew (R14) was a mechanical lift but thought she could do the cradle lift. We did determine it was an improper transfer and (E3) was disciplined, retrained and has returned to work.

Based on interview and record review staff failed to report allegations of abuse committed by a staff Certified Nursing Assistant (CNA) against R6. As a result this allegation was not investigated and the CNA was allowed to have continued resident contact. On a subsequent occasion this same CNA was verbally abused R4. R6 and R4 are two of four residents sampled for abuse out of a total sample of six. Findings include: E17, CNA signed a statement dated January 7, 2011. It reads as follows: "...I came on duty at 6:00 AM this morning. As I got to my desk I heard this hateful voice talking to a resident (R4) telling him to stay in the damn bed. I waited for a few minutes to make sure, then the night aide (E14) (CNA) came down the hall and said you best help me with this son of a [***] ...I went into that resident's room and told the resident that it was okay, and he said thank God you are here. After helping that aide with this resident, I then went to another night shift aide and asked if there were ever issues with this aide in question, and that aide told (me) she was not going to get involved. It was around 6:20 (AM) then, and I reported the incident to the nurse (E15, Licensed Practical Nurse, LPN) and she told me to let the director of nursing know when she got here. When the Administrator arrived today at 6:45 (AM), I immediately told her the situation, she asked if I told the charge nurse and I told her yes. She then asked me if the aide was still in the building and I told her no..." E17 confirmed by telephone on 2/4/2011 at 2:20 PM that she had made the statement, E17 said, "...It was awful, the resident (R4) was scared to death...Tears were running down his face and he was laying across the bed...it was scary...When I reported to the nurse she said it is verbal abuse..." E15, LPN stated on 2/16/2011 at 11:00 AM by telephone that she was told of the allegation of abuse. E15 stated..." Yes, I was the charge nurse. E17 said one of the aides said something vulgar about a resident - I only heard what one of the CNAs said. I don't pay attention to third party conversations. I was giving report and so I did not go to look for that (the accused) CNA. I thought she was gone but I was not sure.." A facility time reporting sheet for E14 documented that she clocked out at 6:36 AM on 1/7/2011. E19, CNA stated by telephone on 2/4/2011 at 2:45 PM that she was witness to the abuse on 1/7/2011. E19 stated,"... I was the day shift relief. I heard her (E14) call him (R4) a son of a [***] to his face. She told him he was on her last nerve. She also said to him she was not going to put up with his[***] I did report this to the night shift nurse..." R4 was asked his recollection of the January 7, 2011 incident on 2/16/2011 at 1:00 PM. R4 stated he remembered something that happened awhile back but could not remember any specifics. R4 stated he thought the girl had sugar diabetes. E1, Administrator on 2/17/2011 at 12:45 PM stated that E14 was terminated for this incident. She stated E15 should have clocked E14 out immediately. She stated E14 should not have been allowed free access to the residents in the building. The facility investigation into the 1/7/2011 abuse allegation contained an interview with E18, CNA that was signed by E1, Administrator and that read as follows: "... I questioned co-worker (E18) about (E14), asking her if she had ever heard (E14) be verbally abusive or abusive in any way to any of the residents. (E18's) response was that she had heard her (E14) yelling at the resident in room one, that she wasn't in the room with them, she could just hear her yelling at him..." E18 stated by telephone on 2/4/2011 at 1:00 PM that, "..the resident in room [ROOM NUMBER] was (R6)." E18 stated this happened some weeks back. E18 stated that E14 was getting irritated about R6's getting out of bed. "It was not a nice voice. I felt it was uncalled for - she (E14) was verbally abusive, I think at other times too. I was irritated and uncomfortable at the incident. I think I made a comment to the nurse, but did not formally report the incident. I don't know why I didn't report it..." R6 was asked his recollection of any incidents where staff were not nice to him. R6 stated he remembered awhile back one of the girls cussed at him but he did not remember who. He also stated he did not tell anyone. E1, Administrator stated on 2/4/2011 at 2:50 PM that she was unaware of the incident with (R6). E2, Director of Nursing stated on 2/4/2011 at 3:00 PM that she was unaware of the incident with (R6).

Based on interview and record review, staff failed to report allegations of verbal and emotional abuse committed by a staff Certified Nursing Assistant (CNA) against R6. During another witnessed abuse R4 was verbally abused by the accused CNA. The witness CNA failed by allowing the abuser continued contact with R4 and failing to go directly to the charge nurse and report the abuse. The charge nurse failed by not immediately locating and suspending E14; as a result she failed to protect R4 and all other residents in the facility from further risk of abuse. R6 and R4 are two of four residents sampled for abuse out of a total sample of six. Findings include: E18 CNA was interviewed by telephone on 2/4/2011 at 1:00 PM. E18 stated she had heard R6, being abused by E14 CNA but had failed to report the incident. E18 stated, "..the resident (who was being abused) in room [ROOM NUMBER] was (R6)... This happened some weeks back... (E14) was getting irritated about his (R6's) getting out of bed. It was not (E14 was not using) a nice voice. I felt it was uncalled for - she (E14) was verbally abusive, I think at other times too. I was irritated and uncomfortable at the incident. I think I made a comment to the nurse, but did not formally report the incident. I don't know why I didn't report it..." In a signed a statement dated January 7, 2011. E17, CNA stated : "...I came on duty at 6:00 AM this morning. As I got to my desk I heard this hateful voice talking to a resident (R4) telling him to stay in the damn bed. I waited for a few minutes to make sure, then the night aide (E14) (CNA) came down the hall and said you best help me with this son of a [***] ...I went into that resident's room and told the resident that it was okay, and he said thank God you are here. After helping that aide with this resident, I then went to another night shift aide and asked if there were ever issues with this aide in question, and that aide told (me) she was not going to get involved. It was around 6:20 (AM) then, and I reported the incident to the nurse (E15, Licensed Practical Nurse, LPN) and she told me to let the director of nursing know when she got here. When the Administrator arrived today at 6:45 (AM), I immediately told her the situation, she asked if I told the charge nurse and I told her yes. She then asked me if the aide was still in the building and I told her no..." E17 confirmed by telephone on 2/4/2011 at 2:20 PM that she had made the statement, E17 said, "...It was awful, the resident (R4) was scared to death...Tears were running down his face and he was laying across the bed...it was scary...When I reported to the nurse she said it is verbal abuse..." E15, LPN stated on 2/16/2011 at 11:00 AM by telephone that she was told of the allegation of abuse. E15 stated..." Yes, I was the charge nurse. (E17) said one of the aides said something vulgar about a resident - I only heard what one of the CNAs said. I don't pay attention to third party conversations. I was giving report and so I did not go to look for that (the accused) CNA. I thought she was gone but I was not sure.." A facility time reporting sheet for E14 documented that she clocked out at 6:36 AM on 1/7/2011.

Based on interview and record review the facility failed to have an abuse policy that explicitly states they will immediately investigate all allegations of abuse. In addition staff failed to effectualize other parts of the facility abuse policy by failing to immediately report the abuse of R6 and of R4. Also, staff failed to protect R4 and other residents of the facility after an allegation of abuse was reported. R6 and R4 are tow of four residents reviewed for abuse in the sample of six. Findings include: The facility Abuse Prohibition Policy reads as follows: "...D. Identification: ...Once alleged abuse is determined, an investigation will be conducted..." E1 Administrator stated on 2/17/2011 at 2:00 PM that the policy should read that as soon as an allegation of abuse is reported it will be investigated. In addition the policy states, "...E. Investigation: The Administrator and/or Director of Nurses will be notified immediately of any alleged abuse..." E1 stated on 2/17/2011 at 2:00 PM that staff failed to follow policy by failing to immediately report two allegations of abuse. Also, the policy states, "...Any employee suspected of committing the above will be removed from direct patient care immediately..." In paragraph "...F. Protection: Appropriate action will be taken in order to protect a patient from harm during the investigation. As noted in E.2, any staff accused of patient abuse or neglect will be suspended pending the results of the investigation..." E1 stated on 2/17/2011 at 2:00 PM that staff failed to follow policy by failing to suspend E14 immediately.

Based on record review and interview the facility failed to check the nurse aide registry before allowing the employee to work as a nurse aide for 3 of twenty direct care staff checked. In addition the facility failed to initiate an employee criminal background check on two of twenty records checked. Findings include: A review of employee hiring records on 3/24/2011 show the following: 1. E19 Certified Nursing Assistant (CNA) was hired on 7/22/1991. The employee records show the Nurse Aide Registry was not checked until 3/24/2011. 2. E20 CNA was hired on 7/10/2009. The emplyee records show the Nurse Aide Registry was not checked until 12/14/2009. In addition there was no criminal background check initiated. 3. E21 CNA was hired on 5/4/2010. As of 3/24/2011 E21 was not shown to have passed her proficiency test and to be certified as a nurse aide. 4. E18 CNA was hired on 8/8/2005. The employee records show the criminal background check was not initiated as of 3/24/2011. E1, Administrator, confirmed on 3/24/2011 that the employee records were accurate. E1 also confirmed that E18, E19, E20, and E21 provided direct care to residents during the period of non-compliance with criminal background checks and registry checks.