Every finding on record at Heritage Health-Hoopeston

Based on observation, interview, and record review, the facility failed to sanitarily store respiratory equipment when not in use. This failure affects four residents (R5, R27, R40, and R74) out of five residents reviewed for respiratory care on the sample list of 41.Findings include: 1. On 5/19/26 at 2:17 PM, R27's Continuous Positive Airway Pressure (CPAP) face mask, with the supply tubing connected to the CPAP machine on top of the bureau, was inside the slightly open top drawer of R27's bedside bureau, unprotected from contamination due to other items in the drawer including a second older CPAP machine, 2 old used partially full concentrator humidifier bottles dated 7/9/25 and 7/17/25, and a box of electric shaver head replacements. R27's Medical Diagnoses List dated 5/20/26 documents R27 experiences medical conditions including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Shortness of Breath, Congestive Heart Failure, Anxiety, Hypertension, and Obstructive Sleep Apnea. On 5/20/26 at 1:28 PM, V3, Infection Preventionist, stated V3 expects the CPAP masks to be stored hanging up to dry after daily cleaning, or to be inside of a plastic bag or clean drawer, not inside of a drawer with other items in it. R27's Physician Order Sheet dated 5/20/26 documents daily CPAP care to include: After removing in the am, empty humidifier, rinse, and air dry. Rinse mask and tubing with tap water, hang to dry. 2. On 5/19/26 at 2:04 PM, R40's CPAP face mask, connected to the machine by hoses, was sitting on top of R40's bedside bureau, unprotected from contamination. R40 stated the CPAP face mask was the type that fits directly over R40's nose. R40's Medical Diagnoses List dated 5/20/26 documents R40 experiences medical conditions including Obstructive Sleep Apnea and Insomnia. On 5/20/26 at 1:28 PM, V3, Infection Preventionist, stated V3 expects the CPAP masks to be stored hanging up to dry after daily cleaning, or to be inside of a plastic bag or clean drawer, not on top of the bureau. R40's Physician Order Sheet dated 5/20/26 documents daily CPAP care to include rinsing with warm tap water and hanging to dry. 3. R5's Minimum Data Set (MDS) dated [DATE] documents R5 as moderately cognitively impaired. R5's Electronic Medical Record (EMR) documents R5's medical diagnoses as Chronic Pain, Chronic Obstructive Pulmonary Disease (COPD), Dementia and Chronic Heart Failure. R5's Physician Order Sheet (POS) dated May 2026 documents a physician order starting 3/24/26 to administer Arformoterol Tartrate Inhalation Nebulization Solution 15 micrograms (mcg)/2 milliliter (ml) orally via nebulizer two times per day related to Chronic Obstructive Pulmonary Disease (COPD). On 5/19/26 at 1:00 PM R5's Nebulizer mask was lying face down on R5's bed. On 5/20/26 at 2:45 PM R5's Nebulizer mask was lying face down on R5's recliner chair. On 5/21/26 at 9:00 AM R5's Nebulizer mask was lying face down on a pillow on R5's bed. On 5/21/26 at 8:50 AM V6 Registered Nurse (RN) stated V6 is R5's nurse routinely and normally 'just lays the mask on (R5's) bed or on top of (R5's) machine'. V6 RN stated R5's Nebulizer mask is 'never' put into a bag or stored in any way to prevent cross contamination. On 5/20/26 at 1:25 PM V3 Infection Preventionist (IP) stated Continuous Positive Airway Pressure (C-PAP) and Nebulizer masks should be air dried and then stored in a bag in between uses. 4. R74's diagnosis list (5/21/26) documents R74 has Chronic Obstructive Pulmonary Disease (COPD). R74's Physician Orders (5/20/26) documents the following orders: Albuterol Sulfate (bronchodilator) Inhalation Nebulization Solution, 2.5 milligrams/0.5 milliliters (mg/ml), 3 ml inhale orally via nebulizer two times a day for SOB (shortness of breath), wheezing related to COPD and Albuterol Sulfate Inhalation Nebulization Solution, 2.5 ml/0.5 mg, 3 ml inhale orally via nebulizer as needed (PRN) for SOB (shortness of breath), wheezing related to COPD may give twice a day PRN. This same record further documents cleanse nebulizer machine, change tubing/mask and bag and date every night shift every Sunday per protocol. R74's May 2026 Medication Administration Record documents R74 receives Albuterol nebulizer treatments at 5:00 a.m., and 4:00 p.m. On 5/19/2026 at 10:45 a.m., R74 was sitting in a recliner with R74's nebulizer machine, mouthpiece, and tubing sitting on top of R74's overbed table. R74 stated R74 receives nebulizer treatments twice a day via the mouthpiece. On 5/20/2026 at 1:56 p.m., R74's nebulizer machine, mouthpiece, and tubing were sitting on top of R74's overbed table. On 5/20/26 at 1:28 p.m., V3 IP stated R74's nebulizer mouthpiece and tubing should be cleaned after each use, placed in a bag, and not laying on the overbed table.

Based on interview and record review the facility failed to allow one (R62) resident to utilize their own Continuous Positive Airway Pressure (C-PAP) machine from their home environment out of one resident reviewed for resident rights in a sample list of 41 residents. Findings include: R62's undated Face Sheet documents R62 was admitted to the facility on [DATE]. R62's Minimum Data Set (MDS) dated [DATE] documents R62 as cognitively intact. R62's Physician Order Sheet (POS) dated May 2026 documents a physician order starting 4/1/2025 to assist R62 with placing R62's Continuous Positive Airway Pressure (CPAP) on at bedtime. Remove in the morning (AM) when awake. Settings minimum pressure 8, maximum pressure 13 and ramp per R62's preference. On 5/19/26 at 10:45 AM R62 stated staff told R62 that R62 cannot use R62's own C-PAP machine from home because 'they have a contract with the C-PAP company'. R62 stated there was nothing wrong with R62's home C-PAP machine and felt more comfortable with it. R62 stated R62 is not familiar with the facility provided machine and would like to have R62's own machine to use. R62 stated R62 does not understand why R62 cannot have R62's own machine and is being 'forced' to use the facility machine. On 5/20/26 at 2:20 PM V1 Administrator stated the facility has a contract with a respiratory company who will provide all of the C-PAP and Nebulizer machines for the residents. V1 Administrator stated it is easier for the facility to monitor the machines and if there is a problem with a machine then the facility can just call the company without having to try to determine which company the resident uses. V1 confirmed it could be considered a resident right's issue. The undated Illinois Long Term Care Ombudsman Program Resident Rights for people in Long Term Care Facilities pamphlet documents residents have the right to keep and use your own property.

Based on interview and record review the facility failed to follow their Antibiotic Stewardship policy for one (R2) resident out of one resident reviewed for Antibiotic Stewardship in a sample list of 41 residents. Findings include:R2's undated Face Sheet documents R2 admitted to the facility on [DATE] and readmitted on [DATE]. R2's Electronic Medical Record (EMR) documents R2's medical diagnoses as history of Urinary Tract Infection (UTI), Low Back Pain, Mixed Incontinence, Cystitis, Urgency of Elimination, Overactive Bladder and Chronic Pain.R2's Physician Order Sheet (POS) dated May 2026 documents a physician order starting 8/4/2025 and ending 8/4/2026 to administer Bactrim 400-80 milligrams (mg) half a tablet every Monday, Wednesday and Friday morning for recurrent Urinary Tract Infection (UTI) for 12 months.R2's Medication Administration Record (MAR) dated May 2026 documents R2 was administered Bactrim 400-60 mg on May 1, 4, 6, 8, 11, 13, 15, 18 and 20.On 5/21/26 at 2:00 PM V3 Infection Preventionist (IP) stated the facility Antibiotic Stewardship program's focus is to reduce the amount of time a resident is on an antibiotic and to not administer Antibiotics unnecessarily. V3 IP stated the facility follows McGeer's Criteria to determine if a resident has a Urinary Tract Infection (UTI) along with the results of a Urinalysis with Culture and Sensitivity (C&S). V3 IP stated administering long term antibiotics to R2 does not follow the facility Antibiotic Stewardship policy. The undated facility policy titled Antibiotic Stewardship documents the policy of this facility is to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and may create a reduction in treatment-related costs.

Based on observation, interview, and record review, the facility failed to complete an accurate Minimum Data Set Resident Assessment Instrument to include the use of non-invasive ventilators (CPAP, Continuous Positive Airway Pressure). This failure affects two residents (R27 and R40) out of five residents reviewed for respiratory services on the sample list of 41.Findings include: 1. On 5/19/26 at 2:17 PM, R27's Continuous Positive Airway Pressure (CPAP) face mask, with the supply tubing connected to the machine, was inside the slightly open top drawer of R27's bedside bureau. R27's Physician Order Sheet dated 5/20/26 documents for nursing staff to refill the CPAP machine with distilled water every night shift; CPAP Daily Care: After removing in the am, empty humidifier, rinse and air dry, rinse mask and tubing with tap water, hang to dry every day shift; and Apply CPAP at HS (hour of sleep), remove in am. CPAP pressure: 18 RAMP (setting that gradually increases air pressure as the patient falls asleep). R27's Care Plan initiated 3/11/25 documents R27 utilizes a CPAP related to Obstructive Sleep Apnea. R27's Minimum Data Set (MDS) Resident Assessments dated 12/9/25 and 2/24/26, Section O, document a coding for no non-invasive ventilators or CPAP use. On 5/20/26 at 2:36 PM, V5, Minimum Data Set Coordinator, confirmed R27 uses a CPAP machine and stated V5 was surprised R27's MDS was not coded for the use of the CPAP. V5 acknowledged answering no for the non-invasive ventilators disables the option to code for the CPAP. 2. On 5/19/26 at 2:04 PM, R40's CPAP face mask, connected to the machine by hoses, was sitting on top of R40's bedside bureau. R40's Physician Order Sheet dated 5/20/26 documents for nursing staff to apply the CPAP machine at night when R40 is sleeping and remove in AM, pressure settings 4-10; fill CPAP humidifier with distilled water every evening shift; CPAP daily care: Rinse humidifier, tubing and mask with warm tap water and hang to dry every day shift. R40's Care Plan initiated 1/5/26 documents a focus area for CPAP/ BIPAP (Bilevel Positive Airway Pressure) therapy. R40's Minimum Data Sets dated 1/11/26 and 4/14/26 Section O, document a coding for no non-invasive ventilators or CPAP use. On 5/20/26 at 2:36 PM, V5, Minimum Data Set Coordinator, confirmed R40 uses a CPAP machine and stated V5 was surprised R40's MDS was not coded for the use of the CPAP. V5 acknowledged answering no for the non-invasive ventilators disables the option to code for the CPAP.

Based on record review and interview, the facility failed to complete a significant change Minimum Data Set Resident Assessment for a resident with a significant decline in multiple areas of health status. This failure affects one resident (R11) out of one reviewed for activities of daily living on the sample list of 41.Findings include: R11's Minimum Data Set (MDS) Resident Assessment Instrument dated 12/31/25 documents R11 had a Brief Interview for Mental Status (BIMS) score of 3 out of a possible 15, indicating severe cognitive impairment. This same MDS documents R11 required moderate assistance from staff for bed mobility to roll from side to side, to go from lying to sitting position, from sitting to lying position, and from sitting to standing position. This MDS documents R11 required moderate staff assistance to accomplish a transfer from the bed to a chair, and from a chair to the shower. This MDS documents R11 weighed 146 pounds. This MDS documents R11's skin was free of pressure ulcers, and R11 had no behaviors of rejecting care. This MDS documents R11 was frequently incontinent of bladder and always continent of bowel. R11's MDS dated [DATE] documents R11 had a mild cognitive decline to a BIMS score of 1 out of a possible 15. This MDS documents R11 required maximum staff assistance to accomplish bed mobility to roll side to side, to go from sitting to lying, from lying to sitting, and from sitting to standing. This MDS documents R11 was dependent upon staff to accomplish a transfer from the bed to a chair, and from a chair to the shower. This MDS documents R11 weighed 130 pounds. This MDS documents R11 now had a stage 2 pressure ulcer on R11's left heel and was exhibiting behaviors of rejecting care. This MDS documents R11 was frequently incontinent of both bladder and bowel. Comparing these two MDS assessments, R11 experienced a mild cognitive decline, significant functional ability declines in six areas, significant weight loss, exhibited a new behavior of rejecting care, acquired a new pressure ulcer, and became incontinent of bowel. R11's Nurses Progress Notes dated 1/9/26, 1/31/26, 3/10/26 and 3/20/26 confirm R11 had experienced significant weight loss, with each note including an interdisciplinary team review. R11's Nurses Progress Notes dated 1/14/26 document R11 hitting and kicking at staff making R11 unapproachable. The 1/28/26 Nurses Progress Note documents R11 being combative with staff. R11's Nurses Progress Notes dated 2/19/26 documents a declination of a pharmacy recommendation to attempt a dosage reduction in R11's psychoactive medications due to ongoing behaviors and agitation. R11's Nurses Progress Notes dated 3/31/26 documents R11 developed an intact blister (stage 2 pressure ulcer) on R11's left heel. R11's Physician Order Sheet dated 5/21/26 documents in addition to the decline in cognitive, behavioral, and functional abilities, R11 required changes in both of R11's insulin prescriptions during the same period from 12/31/25 to 4/1/26. R11's long-acting insulin was changed from 13 units daily to 6 units daily on 1/15/26. R11's fast acting insulin sliding scale (insulin administered according to the level of blood glucose) was changed on 1/15/26 to half of the previous doses. R11's prior sliding scale was ordered by R11's physician as a blood glucose level of zero to 180 required no administration of insulin, a level of 181 to 230 required 2 units injection of insulin, 231 to 280 required 4 units, 281 to 330 required 6 units, 331 to 380 required 8 units, and 381 to 430 required 10 units. R11's new physician orders for fast acting insulin referenced the same glucose level ranges but 1 unit, 2 units, 3 units, 4 units, and 5 units for the incremental required doses, respectively. The current Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 Users Manual dated October 2025 documents on page 45: A significant change is a major decline or improvement in a resident's status that:1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting;2. Impacts more than one area of the resident's health status; and3. Requires interdisciplinary review and/or revision of the care plan. On 5/20/26 at 2:36 PM, V5, Minimum Data Set Coordinator, stated V5 triggers a review for a significant change if a resident has a fall or a significant decline. V5 confirmed R11 would qualify for a significant change MDS. V5 stated R11 is in therapy right now (staff intervention). V5 further stated V5 has a copy of the MDS User Manual. R11's current Care Plan documents new revisions in the time period between 12/31/25 and 4/1/26. On 3/25/26 to keep R11's fingernails short to avoid scratching R11's self. On 3/30/26 a revision to an existing intervention to place a censor pad alarm in R11's bed to alert staff when resident gets up by R11's self, check batteries at start of your shift. On 3/30/26 a new intervention to place R11's bed in the low position. On 1/6/26 a new intervention documenting R11 is on our 1:1 (one to one) program, R11 participates in sensory work with activity assistants, R11 excels the most when working with textures, taste and sound, we work with resident with spirituality, mental stimulation, self-help, creativity, games, socialization and sensory/cognitive stimulation.

Based on interview and record review the facility failed to implement fall interventions to prevent injury for one of three residents (R1) reviewed for falls on the sample list of three. These failures resulted in R1 sustaining a fall which led to a fracture of both the left ulna and left femoral neck. Findings include:The facility's Fall Assessment and Management Policy, revised June 2024, documents the facility will assess each resident's fall risk and implement interventions to decrease the residents' risk of falls and subsequent risk for injury.R1's Medical Diagnosis List, dated April 2026, documents R1's diagnoses including Alzheimer's Disease, Dementia with Agitation, Anxiety, and Chronic Pain.R1's Minimum Data Set, dated [DATE], documents R1 as severely cognitively impaired. R1 is dependent on staff assistance for transfers.R1's Care Plan, dated 7/1/25, documents R1 is at risk for falls related to confusion, and poor safety awareness. An intervention was added on 2/11/25 for staff to assist R1in transferring into his recliner when he is leaning in his wheelchair or appears tired.R1's Nurses Notes, dated 2/26/26, documents R1 was found on the floor, in the dining room, lying on his left side. V3 Registered Nurse documented R1 was lying on the floor in the dining room next to his wheelchair. R1's laptop cushion was sitting next to his wheelchair. R1 often falls asleep in his wheelchair. V3 recommended R1 be transferred to his recliner after meals to rest. At the time R1 did not complain of or show signs of any pain. R1's Interdisciplinary Team Note, dated 3/6/26, documents R1 was sitting in the dining room when staff heard his chair alarm sound. Staff responded and R1 was lying on his left side on the floor next to his wheelchair. R1 is wheelchair bound and needs staff assistance with all transfers. R1 was later sent to the emergency room for decrease in oxygen saturation. At the emergency room R1 was noted to have a fracture of his left wrist.R1's Hospital History and Physical, dated 2/27/26, documents R1 was admitted to the hospital for hypoxia and low-grade fever. During R1's evaluation, R1 complained of left wrist and left hip pain. R1's Left Wrist X-Ray results dated 2/27/26 documents R1 sustained an acute nondisplaced distal shaft fracture of the ulna related to an earlier fall at the facility. R1's Left Hip X-Ray dated 2/27/26 documents R1 also sustained an acute left femoral neck fracture.On 4/28/26 at 12:44 PM V3 Registered Nurse (RN) stated she was R1's nurse on 2/26/26 when he fell from his wheelchair in the dining room. V3 stated it was about shift change at about 2:00 PM when she heard R1's chair alarm sounding and she ran into the dining room to find R1 on the floor beside his wheelchair, lying on his left side. V3 RN stated she completed an assessment the best she could, and he did not complain of pain at the time. V3 stated at the time of the fall, R1 had removed his laptop cushion, which he often does, and fell forward from the wheelchair. V3 stated she had observed R1 prior to the fall, dozing off in his wheelchair in the dining room by the television. V3 confirmed R1 often begins to doze off in the wheelchair and without his laptop cushion he would easily fall forward, as he leans in his wheelchair. V3 confirmed staff should transfer him to his recliner if he is sleepy in his wheelchair to help prevent falls. On 4/28/26 at 3:18 PM V11 Assistant Director of Nurses confirmed R1 often falls asleep in his wheelchair and if staff noticed him doing so on the day of the fall, they should have transferred him into his recliner. V11 confirmed this is an intervention already on R1's Care Plan as a fall intervention and staff need to follow resident care plans and always implement fall interventions. V1 confirmed R1 sustained two fractures from the fall.

Based on interview and record review the facility failed to revise a care plan after an incident of resident to resident physical abuse. This failure affects one of three residents (R1) reviewed for abuse on the sample list of four. Findings include:The Facility Reported Incident Investigation dated 12/6/25 documents R1 hit R2 in the hall while they were talking to each other. The incident was witnessed by R4.R1's Medical Diagnosis list dated February 2026 documents diagnoses of Fibromyalgia, Dementia without Behavioral Disturbances, and Psychosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired, has physical/verbal behavioral symptoms one to three times a week, requires the use of a wheelchair for mobility, and requires substantial to maximum assistance for all activities of daily living. (ADL's). R1's Care Plan dated reviewed 1/27/26 did not address the incident of abuse which took place on 12/6/25 between R1 and R2. There were no problems or interventions on R1's care plan addressing abuse and hitting R2 in the arm. V3, RN ADON (Registered Nurse Assistant Director of Nurses) stated on 2/4/26 at 1:28 PM, (V5) Care Plan Coordinator is not here due to an emergency phone call she received; I will try to help with your questions. V3 reviewed R1's care plan on the computer and stated you are right no information about the incident on 12/6/25 is on the care plan. (V5) addressed the incident today before she had to leave. V3 stated we are to address issues of any type on the care plan as soon as we can when an incident happens. R4, stated in interview on 2/4/26 at 3:29 PM I saw what happened as I walked by (R1) and (R2) in the hall. (R1) raised her hand and smacked (R2) on the arm. They were arguing about something and (R1) became upset and hit (R2). V1, Administrator stated on 2/4/26 at 4:00 PM Yes I was told (R1's) care plan was not revised until today 2/4/26. Our policy states to revise the care plans as soon as possible after an event happens.

Based on interview and record review the facility failed to protect the resident's right to be free from physical abuse by another resident. This failure affects two of three residents (R1, R2) reviewed for abuse on the sample of four.Findings include:The facility's Abuse Prohibition policy with the revision date of 8/25/25 documents the facility affirms the residents' right to be free from abuse. The policy states that all residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. R1's Medical Diagnosis list dated February 2026 documents diagnoses of Fibromyalgia, Dementia without Behavioral Disturbances, and Psychosis. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired, has physical/verbal behavioral symptoms one to three times a week, requires the use of a wheelchair for mobility, and requires substantial to maximum assistance for all activities of daily living. (ADL's). R2's Medical Diagnosis list dated February 2026 documents diagnoses of Spinal Stenosis Lumbar Region without Neurogenic Claudication and Delusional Disorders. R2's MDS dated [DATE] documents R2 is severely cognitively impaired, has physical/verbal behavioral symptoms one to three times a week, requires the use of wheelchair for mobility, and requires substantial to maximum assistance for all activities of daily living. The Abuse Final Report dated 12/6/25 documents R1 and R2 were sitting in the hall talking and the conversation turned into a disagreement and R1 hit R2 on the arm. The Report documents residents were immediately separated and both residents were assessed for injuries and no redness or injuries were present. The Report documents the Power of Attorneys, Primary Care Physician and police were notified of the incident.R4 was a witness to the incident and R4 stated in interview on 2/4/26 at 3:29 PM I saw (R1) as I was walking by, (R1) raised her hand and smacked (R2) in the arm. The two were arguing about something and (R1) became upset with (R2) and hit him in the arm. Staff came and separated them immediately.V1, Administrator stated on 2/4/26 at 3:30 PM Yes, the incident took place.

Based on observation and interview the facility failed to maintain a homelike environment by failing to maintain linen in good condition. This failure affected two of twelve residents (R25, R33 ) reviewed for homelike environment on the sample list of 36. 1. On 7/27/2025 at 10:39 AM R25 stated the towels are worn and have frayed edges and holes. R25 held up a towel with worn, frayed edges and two washcloths with frayed edges on every side. R25 stated she doesn't understand why the staff don't get rid of the worn linen and instead provide linen that is in good shape for residents to wash up with. R25's Minimum Data Set (MDS) dated [DATE] documents R25 is cognitively intact. 2. On 7/28/25 at 8:06 AM R33 stated the edges of towels get frayed. There was a wet washcloth on bathroom sink with frayed, stringy edges. R33 held up another washcloth that had frayed edges with golf ball sized hole along edge. R33 stated he has seen worse than those and with such a nice place you would think they would provide nicer towels and washcloths. R33's Minimum Data Set (MDS) dated [DATE] documents R33 is cognitively intact. On 7/29/2025 at 1:20 PM there was three washcloths with frayed edges in the clean linen cart on north hall. On 7/29/2025 at 1:41 PM V4 Housekeeping Supervisor stated the facility outsources laundry services and when it returns clean the housekeeping staff put the clean linen in the storage room. When staff need more on the floor, they come to the storage room and get what they need. V4 confirmed staff should be throwing away linen that has frayed edges and holes. V4 stated he will educate staff to toss the worn linen and let him know it needs to be replaced.

Based on interview and record review the facility failed to investigate allegations of abuse and to implement protective measures following reported allegations of abuse for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents after allegations of abuse are reported to the (state surveying agency), the alleged incident will be investigated by the Administrator or designee and the results of the investigation will be reported to (state surveying agency). The Administrator is responsible for protecting the resident from retaliation during and after the investigation. When an employee is the alleged perpetrator of the abuse, the employee shall be immediately barred from any further contact with residents in the facility until the outcome of the investigation is determined. The facility's Abuse Tracking Log with last recorded entry as 5/5/24 does not document any allegations of abuse involving R1, R2, or R6. 1.) On 3/17/25 at 11:29 AM V26 (R2's Family) stated R2 often complained of unidentified staff squeezing R2 during cares, which has been reported to management and administration. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment, requires substantial/maximal assistance of staff for toileting and bed mobility, and is dependent on s staff for transfers. R2's active Care Plan documents R2 admitted to the facility on [DATE]. This Care Plan documents R2 has delirium or acute delusional episodes, makes untrue statements, and believes things have actually occurred despite reassurance from staff. This Care Plan does not identify what specific accusations or false statements R2 makes. On 3/17/25 at 1:17 PM V13 (Registered Nurse) stated within the last year R2 voiced complaints during night shift that a pregnant woman would come into R2's room at night and abuse R2. V13 stated V8 (Certified Nursing Assistant/CNA) was pregnant at that time but did not work on R2's hallway, and V8 was no longer allowed to take care of R2 after that. V13 stated V2 (Director of Nursing/DON) was aware of R2's accusations, interviewed staff and implemented using two staff for R2's cares. On 3/17/25 at 3:35 PM V2 stated staff have been using two people when providing R2's cares due to R2's history of making false statements. V2 stated R2 would say men were going into R2's room, but we had no men on staff. V2 stated R2 would speak in Spanish to R2's family saying unidentified staff were rough with R2, and both things were reported to V1 (Administrator). On 3/18/25 at 8:54 AM V22 (CNA) stated R2 has made allegations since June 2024 that men would come into R2's room and rape R2. V22 stated the nurses were aware, but V22 never reported this to V1 or V2. V22 stated the facility had one male CNA at that time who never took care of R2. On 3/18/25 at 9:13 AM V8 (CNA) stated V8 was not allowed to take care of R2 after R2 accused V8 of pinching R2 sometime in August 2024. V8 stated R2 also made allegations of rape during the night shift and in the hallways, and men weren't allowed to care of R2. V8 stated V1 and V2 were aware because they asked V8 questions about R2's rape statements. On 3/18/25 at 1:50 PM V1 confirmed the facility's abuse log did not include any abuse allegations involving R2 between January 2024 and March 2025 V1 stated V1 was not aware of R2's allegations of men going into R2's room, rape, or that staff are rough and pinching R2. V1 confirmed these allegations were not investigated and V8 was not placed on leave since an investigation was never completed. 2.) On 3/17/25 at 12:40 PM V28 (R1's Family) stated on 2/22/25 V28 called the facility and asked for R1's television (TV) channel to be changed. V28 stated V28 was on the phone and overhead a nurse come into R1's room, the nurse was snarky and yelled Ok (R1), I gotta change this TV because (V28) wants me to. V28 stated V28 called the facility and spoke to V13 (Registered Nurse), who confirmed V13 was the person in R1's room who changed R1's TV channel while V28 was on the phone with R1. V28 stated V28 reported this to V1 (Administrator) and V18 (Corporate Senior [NAME] President of Clinical Operations). R1's MDS dated [DATE] documents R1 has moderate cognitive impairment. On 3/17/25 at 1:17 PM V13 stated V28 called the facility and asked for R1's television channel to be changed. V13 stated V13 went to R1's room and changed the TV channel and R1 was on the phone at that time. V13 stated V13 might have been loud when talking to R1 but denied yelling at R1. V28 called back and insinuated V13 was being rude to R1 and V13 reported this to V2 (DON). On 3/17/25 at 2:43 PM V18 stated on 3/10/25 V28 contacted V18 and said that V28 had asked V13 to change R1's television channel and V28 asked V13 why V13 was rude and yelled at R1. V18 stated V18 spoke with V1 and V2, who had already addressed V28's concerns. On 3/17/25 at 3:35 PM V2 (DON) stated on the weekend of 2/22/25, V13 called V2 at home and said that V28 had called and asked V13 to change R1's television channel. R1 was on the phone with V28 when V13 went into R1's room to change the channel. V2 stated V13 said V28 called back and accused V13 of being rude, hateful, and yelling at R1. V2 stated V13 denied being rude/hateful or yelling at R1 and V13 stated that V28 later came in and apologized saying V28 has a hard time hearing on the phone. V2 stated V2 reported this to V1 on 2/24/25 and did not consider this an abuse allegation since R1's family never reported this and V28 apologized. On 3/17/25 at 3:20 PM V1 stated V1 was not aware that V28 alleged that V13 yelled at R1. V1 confirmed this was not investigated. On 3/18/25 at 1:50 PM V1 confirmed V13 was not placed on leave since this allegation was not investigated. 3.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment. On 3/19/25 at 9:04 AM V19 (CNA) stated on 1/18/25 R6 told V19 that another unidentified resident had hit R6. V19 stated this was reported to V1, it was looked into, and it was unfounded. On 3/19/25 at 11:48 AM V1 stated nothing had been reported that R6 alleged another resident hit R6. V1 confirmed this was not included on the facility's abuse log as being investigated.

Based on observation, interview and record review, the facility failed to implement fall interventions, document a fall in the medical record, perform safe and proper transfers, and thoroughly investigate falls for three (R1, R2, R6) of three residents reviewed for accidents in the sample list of 12. Findings include: The facility's Fall Assessment and Management Policy dated June 2024 documents the following: The resident's care plan will reflect specific needs and risk for falls and all staff who provide resident care will have access to the care plan and/or (electronic care report). Interventions will be based on the fall risk assessment and circumstances of each fall. The nurse will assess the resident following a fall and document on the resident's condition for 72 hours after the incident. The facility's Safe Resident Handling Program dated 3/18/18 documents the resident transfer status will be documented on the resident's plan of care and reviewed via the care plan time frames and as needed. This policy documents gait belts are required for transfers except when using a mechanical lift. 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment, has impaired range of motion affection one side upper and lower extremity, and is dependent on staff for transfers. R1's Care Plan dated 3/4/25 documents R1 had a stroke that affects R1's left side. R1's Fall Report dated 7/28/24 at 5:51 PM documents V13 (Registered Nurse/RN) was alerted that R1 was on the floor. V29 (Certified Nursing Assistant/CNA) was assisting R1 into the recliner with the sit to stand lift at the time of R1's fall. R1 was seated in the recliner and started to fall as V29 removed the stand lift. V29 lowered R1 to the ground. This fall is not documented in R1's medical record. On 3/19/25 at 10:34 AM V3 (Assistant Director of Nursing/ADON) stated falls should be documented in a nursing note and the fall report is part of risk management, which is not part of the resident's medical record. V3 stated the fall reports used to have a check box that needed to be marked in order for a nursing note to populate a note in the resident's medical record. 2.) R2's MDS dated [DATE] documents R2 has severe cognitive impairment, is frequently incontinent of bowel and bladder, and requires substantial/maximal assistance for toileting and is dependent on staff for transfers. R2's Care Plan dated 1/14/25 documents R2 makes accusatory statements and has behaviors of being aggressive and resistive with cares. R2's Fall Report dated 6/4/24 documents at 3:30 AM R2 was heard yelling that R2 needed to get up. R2 was found on the floor with her back against the recliner. There are no staff statements or interviews to determine when R2 was last observed or toileted prior to the fall. R2's Fall Report dated 2/8/25 at 6:23 PM documents staff alerted V30 (RN) that R2 was on the floor. R2 was found lying on the floor in front of R2's recliner. V20 (CNA) told V30 that V20 was assisting R2 into the chair, R2 lost balance, and V20 lowered R2 to the floor. V20 was reminded that R2 requires assistance of two for transfers due to behaviors and history of R2 sliding. On 3/18/25 at 4:31 PM V20 (CNA) stated R2 fell a few weeks ago when V20 was assisting R2 onto the toilet. V20 stated V20 transferred R2 by herself and did not use any assistive devices including a gait belt. V20 stated after the fall V20 was told that R2 was to have two staff for transfers and V20 was not aware of this prior to R2's fall. On 3/19/25 at 10:34 AM V3 confirmed R2 should have had two staff assisting for R2's sit to stand lift transfer/fall on 2/8/25. At 11:55 AM V3 reviewed R2's 6/4/24 fall investigation. V3 confirmed the 6/4/24 was unwitnessed and the fall investigation is not thorough and does not include staff statements or interviews to determine when R2 was last observed or provided incontinence cares prior to the fall. 3.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment, is frequently incontinent of bowel and bladder, requires substantial/maximal assistance of staff with transfers, and is dependent on staff for toileting. R6's Care Plan dated 5/16/24 documents R6 is at risk for falls and includes an intervention dated 2/11/25 for a nonskid mat in the wheelchair and recliner. R6's Care Plan dated 11/4/24 documents R6 has fractures of C7-T1, and C3-C5 related to a fall. R6's Fall Report dated 12/15/24 at 5:30 PM documents an unidentified (CNA) alerted V13 (RN) that R6 was found on the floor next to the bed in R6's room. R6 reported to the staff that R6 went to go to bed and R6's shoes started to slide. There are no staff statements or interviews documented to include R6's footwear at the time of the fall or when staff last observed R6 and provided toileting assistance prior to R6's fall. R6's Fall Report dated 2/6/25 at 5:00 PM documents R6 was found lying on the floor partially on R6's right side. R6 reported that R6 was trying to stand up to go to the bathroom, the floor was slick and R6 slipped. A nonskid mat was placed in R6's wheelchair seat as the post fall intervention. R6's Nursing Note dated 2/6/2025 at 5:20 PM documents R6's fall occurred in the dining room. There are no documented statements or interviews with staff to determine when R6 was last observed or provided toileting assistance prior to the fall. R6's Fall Report dated 2/24/25 at 2:10 PM documents R6 was heard yelling help from R6's room and was found lying on his right side in the doorway of his room. R6 was bleeding from cuts to the right eyebrow and right hand. There are no documented staff interviews or witness statements to identify when R6 was last observed by staff or provided toileting prior to R6's fall. On 3/18/25 between 11:39 AM and 12:15 PM R6 was sitting in a wheelchair in the dining room eating lunch. At 1:26 PM R6 was lying in bed asleep. R6's wheelchair did not contain a nonskid mat. V8 (CNA) stated R6 uses a bed alarm and V20 thought that was the only fall intervention that R6 uses. V6 stated V6 was not aware of R6 using a nonskid mat in the wheelchair and confirmed R6's wheelchair did not contain a nonskid mat. V20 stated fall information is kept in a binder at the nurse's station. This binder was reviewed with V20 and did not list a nonskid mat for R6. At 1:35 PM V13 (RN) stated V13 looks at the resident's care plan to determine fall interventions. V13 stated V13 did not realize that R6 was supposed to have a nonskid mat. On 3/18/25 at 2:21 PM V3 (Assistant Director of Nursing) stated the antiskid device was a post fall intervention and should still be in the seat of R6's wheelchair. On 3/19/25 at 11:55 AM V3 stated after R6's fall on 11/3/24 R6 has declined and requires staff assistance for all Activities of Daily Living. V3 confirmed R6's falls on 12/15/24, 2/6/25 and 2/24/25 were all unwitnessed and there is no documentation of when staff last observed R6 or provided toileting prior to each of these falls.

Based on interview and record review the facility failed to report allegations of abuse and timely report an injury of unknown origin to the facility's administrator and the state surveying agency for three (R1, R2, R6) of eight residents reviewed for abuse in the sample list of 12. Findings include: The facility's Abuse Prohibition policy dated 3/15/18 documents allegations of abuse must be immediately reported to the facility's administrator and the administrator will provide an initial notice of the allegation to the (state surveying agency) immediately after the allegation is known. This policy documents injuries of unknown origin, including significant bruises must be immediately reported to the charge nurse, Director of Nursing (DON) and Administrator. The charge nurse will document the nature of the injury in the resident's medical record, complete an incident report describing the injury and the circumstances of the injury, and notify the physician and resident's representative. Injuries of unknown origin will be reported to (state surveying agency) within 24 hours. The facility's Abuse Tracking Log with last recorded entry as 5/5/24 does not document any allegations of abuse involving R1, R2, or R6. 1.) On 3/17/25 at 11:29 AM V25 (R2's Family) stated the facility contacted V25 on the morning of 3/10/25 to report that R2 had a small bruise. V25 stated R2 was taken to the hospital by family on 3/10/25 and the emergency room physician thought the bruise looked to be five to seven days old. V25 stated V25 was given conflicting stories from the facility as to how the bruise occurred and V25 was told it was caused by a gait belt or a full mechanical lift. V26 (R2's Family) stated R2 often complained of unidentified staff squeezing R2 during cares, which has been reported to management and administration. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has severe cognitive impairment, requires substantial/maximal assistance of staff for toileting and bed mobility, and is dependent on s staff for transfers. R2's active Care Plan documents R2 admitted to the facility on [DATE]. This Care Plan documents R2 has delirium or acute delusional episodes, makes untrue statements, and believes things have actually occurred despite reassurance from staff. This Care Plan does not identify what specific accusations or false statements R2 makes. R2's March 2025 Medication Administration Record documents R2 receives Eliquis (blood thinner) 5 milligrams by mouth twice daily. R2's Nursing Note dated 3/7/2025 at 10:12 PM documents R2 had bruising on right side near breast that wrapped around R2's side. This note documents it appeared to be from the mechanical sit to stand lift sling. There is no documentation that this was reported to V2 (DON) and V1 (Administrator). R2's Nursing Note dated 3/10/2025 at 10:36 AM documents bruise under right arm measured 9.5 centimeters (cm) by 26 cm appears to be from sit to stand lift sling as bruise is same length as sling. The facility's Serious Injury Incident and Communicable Disease Report dated 3/11/25 documents the initial report of R2's bruise of unknown origin was submitted to (state surveying agency) on 3/11/25 at 1:42 PM, four days after the injury was initially found. On 3/17/25 at 1:17 PM V13 (Registered Nurse) stated within the last year R2 voiced complaints during night shift that a pregnant woman would come into R2's room at night and abuse R2. V8 (Certified Nursing Assistant/CNA) was pregnant at that time but did not work on R2's hallway. V8 was no longer allowed to take care of R2 after that. V13 stated V2 (DON) was aware of R2's accusations, interviewed staff and implemented using two staff for R2's cares. On 3/17/25 at 3:35 PM V2 (DON) stated staff have been using two people when providing R2's cares due to R2's history of making false statements. V2 stated R2 would say men were going in R2's room, but we had no men on staff. V2 stated R2 would speak in Spanish to R2's family saying unidentified staff were rough with R2, and both things were reported to V1 (Administrator). V2 stated R2's bruise was reported to nurse management on 3/10/25 and the bruise was purple, blue, and yellow in color. V2 confirmed yellow bruising would indicate the bruise was aging and not fresh. V2 stated V9 (Licensed Practical Nurse/LPN) documented in R2's nursing notes that the bruise was found on 3/7/25 and V9 did not report this to anyone. On 3/17/25 at 4:07 PM V3 (Assistant DON) stated V3 did not realize R2's bruise was considered an injury of unknown origin until after V18 (Corporate Senior [NAME] President of Clinical Operations) was notified, and then the injury was reported to (state surveying agency) on 3/11/25. On 3/18/25 at 8:54 AM V22 (CNA) stated R2 has made allegations since June 2024 that men would come into R2's room and rape R2. V22 stated the nurses were aware, but V22 never reported this to V1 or V2. V22 stated the facility had one male CNA at that time who never took care of R2. On 3/18/25 at 9:13 AM V8 (CNA) stated V8 was not allowed to take care of R2 after R2 accused V8 of pinching R2 sometime in August 2024. V8 stated R2 also made allegations of rape during the night shift and in the hallways, and men weren't allowed to care for R2. V8 stated V1 and V2 were aware because they asked me questions about R2's rape statements. On 318/25 at 4:45 PM V9 (LPN) stated on the evening of 3/7/25 V16 and V19 (CNAs) reported R2's bruise. V9 stated the bruise was purple and near R2's ribs and breast, R2 and the CNAs were not sure what caused the bruise. V9 stated V9 thought it might be caused from the stand lift. V9 stated V9 charted about the bruise but did not notify management. V9 stated V9 had not had any training on identifying and reporting injuries of unknown origin. On 3/18/25 at 1:50 PM V1 (Administrator) confirmed the facility's abuse log did not include any abuse allegations involving R2 between January 2024 and March 2025. V1 stated V1 was not aware of R2's allegations of men going into R2's room, rape, or that staff are rough and pinching R2. 2.) On 3/17/25 at 12:40 PM V28 (R1's Family) stated on 2/22/25 V28 called the facility and asked for R1's television (TV) channel to be changed. V28 stated V28 was on the phone and overhead a nurse come into R1's room, was snarky and yelled Ok (R1), I gotta change this TV because (V28) wants me to. V28 stated V28 called the facility and spoke to V13 (Registered Nurse) who confirmed V13 was the person in R1's room who changed R1's TV channel while V28 was on the phone with R1. V28 stated V28 reported this to V1 (Administrator) and V18 (Corporate Senior [NAME] President of Clinical Operations). R1's MDS dated [DATE] documents R1 has moderate cognitive impairment. On 3/17/25 at 1:17 PM V13 stated V28 called the facility and asked for R1's television channel to be changed. V13 stated V13 went to R1's room and changed the TV channel and R1 was on the phone at that time. V13 stated V13 might have been loud when talking to R1 but denied yelling at R1. V28 called back and insinuated V13 was being rude to R1 and V13 reported this to V2 (DON). On 3/17/25 at 2:43 PM V18 stated on 3/10/25 V28 contacted V18 and said that V28 had asked V13 to change R1's television channel and V28 asked V13 why V13 was rude and yelled at R1. V18 stated V18 spoke with V1 and V2, who had already addressed V28's concerns. On 3/17/25 at 3:35 PM V2 (DON) stated on the weekend of 2/22/25, V13 called V2 at home and said that V28 had called and asked V13 to change R1's television channel. R1 was on the phone with V28 when V13 went into R1's room to change the channel. V2 stated V13 said V28 called back and accused V13 of being rude, hateful, and yelling at R1. V2 stated V13 denied being rude/hateful or yelling at R1 and V13 stated that V28 later came in and apologized saying V28 has a hard time hearing on the phone. V2 stated V2 reported this to V1 on 2/24/25 and did not consider this an abuse allegation since R1's family never reported this and V28 apologized to V13. On 3/17/25 at 3:20 PM V1 stated V1 was not aware that V28 alleged that V13 yelled at R1. V1 confirmed this was not reported to (state surveying agency). 3.) R6's MDS dated [DATE] documents R6 has severe cognitive impairment. On 3/19/25 at 9:04 AM V19 (CNA) stated on 1/18/25 R6 told V19 that another unidentified resident had hit R6. V19 stated this was reported to V1, it was investigated, and it was unfounded. On 3/19/25 at 11:48 AM V1 stated nothing had been reported that R6 alleged another resident hit R6. V1 confirmed this was not included on the facility's abuse log as being reported to (state surveying agency) and confirmed it should have been reported.

Based on interview and record review the facility failed to timely report an injury of unknown origin to the physician and resident representative. The facility also failed to report changes in medication orders to the resident representative for two (R1, R2) of six residents reviewed for changes in condition in the sample list of 12. Findings include: 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment. R1's Nursing Note dated 8/12/2024 at 9:58 AM documents new orders were received to stop Plavix. There is no documentation in R1's medical record that this new order was reported to V27 (R1's Family). On 3/19/25 at 10:42 AM V3 (Assistant Director of Nursing/ADON) stated V3 attempted to contact V27 the day R1's Plavix was discontinued, but V3 forgot to document that V3 left a message for V27. V3 reviewed R1's nursing notes and confirmed there was no documentation that V27 was notified of Plavix being discontinued. The facility's Guidelines for Physician Notification of Change in Resident Condition policy dated April 2019 documents resident's representatives, as appropriate, should be notified when there is a change in treatment such as discontinuing a form of treatment. 2.) On 3/17/25 at 11:29 AM V25 (R2's Family) stated the facility contacted V25 on the morning of 3/10/25 to report that R2 had a small bruise. V25 stated R2 was taken to the hospital by family on 3/10/25 and the emergency room physician thought the bruise looked to be five to seven days old. R2's MDS dated [DATE] documents R2 has severe cognitive impairment. R2's Nursing Note dated 3/7/2025 at 10:12 PM documents R2 had bruising on right side near breast that wrapped around R2's side. There is no documentation that this was reported to R2's family or physician until 3/10/25. R2's Nursing Note dated 3/10/2025 at 10:36 AM documents R2's bruise measured 9.5 centimeters (cm) by 26 cm. On 3/17/25 at 3:35 PM V2 (Director of Nursing/DON) stated R2's bruise was reported to nurse management on 3/10/25 and the bruise was purple, blue, and yellow in color. V2 confirmed yellow bruising would indicate the bruise was aging and not fresh. On 3/17/25 at 4:07 PM V3 (ADON) stated V3 found out about R2's bruise on 3/10/25. This bruise was found on the evening of 3/7/25 and reported to V9 (Licensed Practical Nurse/LPN). V3 stated V3 did not report R2's bruise to nurse management and V3 should have notified R2's family and physician the day the bruise was found. V3 confirmed R2's bruise was considered an injury of unknown origin. On 318/25 at 4:45 PM V9 (LPN) stated on the evening of 3/7/25 V16 and V19 (Certified Nursing Assistants/CNAs) reported R2's bruise. V9 stated the bruise was purple and near R2's ribs and breast, R2 and the CNAs were not sure what caused the bruise. V9 stated V9 thought it might be caused from the stand lift. V9 stated V9 charted about the bruise but did not report R2's bruising to anyone. V9 stated V9 had not had any training on identifying and reporting injuries of unknown origin. The facility's Abuse Prohibition policy dated 3/15/18 documents the charge nurse will report injuries of unknown origin to the resident's physician and family.

Based on observation, interview and record review the facility failed to label a refrigerated, plastic container of chopped onions and a refrigerated, plastic container of chopped tomatoes with any dates and failed to monitor temperature cooking times to ensure that food is being served safely. These failures have the potential to affect all 72 residents who reside in the facility. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 6/3/24 documents 72 residents reside in the facility. The facility provided Food Storage Chart dated 2/2022 documents that after a food item is opened, it will be covered, labeled, use by date will be put on, initialed and stored. On 6/3/24 at 9:10AM during the initial tour, chopped onions and tomatoes were stored in the refrigerator without any time or date label. On 6/3/24 at 9:11AM, V9 Dietary Manager said that the onions and tomatoes should have been dated when they were chopped and put into the refrigerator and now needed to be thrown away. Additionally, V9 Dietary Manager said that the onions and tomatoes would have been served today had the lack of dating not been brought to her attention. V9 stated All food has to be date labeled so that it isn't kept so long that bacteria grows and makes people sick. The facility provided Food Temperature Log for Meal Service sheet dated the week of 5/5/24 documents no temperatures taken for the week. The Food Temperature Log for Meal Service sheet dated the week of 5/19/24 documents no temperatures were taken for the supper meal service on 5/19/24 and 5/20/24. The Food Temperature Log for Meal Service dated the week of 5/26/24 documents no temperatures were taken for breakfast or lunch on 5/26/24 and no dinner temperatures were taken for the week. The Food Temperature Log for Meal Service Sheet dated 6/2/24 documents no temperatures were taken for supper on 6/2/24, no temperatures were taken for lunch or supper on 6/3/24 and no temperatures were taken for breakfast or lunch on 6/4/24. On 6/4/24 at 10:45AM, food was observed on the steam table. When asked for the cook temperatures from the oven, V21 [NAME] said that she didn't have them. V21 said We should, but we don't. They are supposed to be documented for every meal. On 6/4/24 at 2:00PM, V8 Dietary Manager said that cook times are to be monitored to ensure that food is cooked thoroughly, so that no one gets sick.

Based on observation, interview, and record review the facility failed to ensure medications were labeled with the resident's full name and opened dates, ensure medications were not used past the beyond use date, and discard medications for eight (R1, R6, R269, R62, R53, R59, R44, R9) of 18 residents reviewed for medication storage on the sample list of 42. Findings include: On 6/04/24 at 12:12 PM the C side medication cart was viewed with V15 Registered Nurse (RN). R1's Lispro insulin pen was labeled with an opened date 4/12/24 (past the beyond use date). R6's Basaglar insulin pen was not labeled with an opened date. There was a Novolog (Aspart) insulin pen that did not contain a resident's name, only R269's nickname, or an opened date. V15 verified the labeling of these medications. V15 stated the pen belonged to R269, and confirmed it was not labeled with R269's full name. V15 stated V15 thinks insulin is good for 30 days once opened. On 6/04/24 at 12:38 PM the A Wing medication cart was viewed with V16 RN. R62's Latanoprost (Xalatan) eye drop bottle was labeled with an opened date 4/16/24 (past the beyond use date.) The pharmacy label documented to discard six weeks after opening. V16 stated eye drops should be labeled with opened dates and discarded as labeled. The cart contained R53's Azelastine 0.05% eye drops. V16 stated R53 no longer resides in the facility. R59's Lispro (Humalog) insulin pen with opened date of 5/3/24 (past the beyond use date) was only labeled with R59's first name and last initial. R44's Aspart insulin pen was only labeled with R44's first name. V16 stated these insulin pens belonged to R59 and R44. R9's Basaglar insulin pen with dispensed date 5/16/24 was not labeled with an opened date. V16 stated R9 does not use insulin anymore, and discontinued medications should be returned to the pharmacy. V16 verified the labeling of these medications. On 6/04/24 at 1:02 PM V2 Director of Nursing (DON) confirmed medications should be labeled with resident's first and last names, and insulin and eye drops should be labeled with opened dates. V2 stated the facility follows the pharmacy's chart for when eye drops and insulin should be discarded once opened. At 1:20 PM V2 stated medications should be destroyed or returned to the pharmacy when a resident expires and R53's eye drops should have been destroyed since R53 expired. On 6/04/24 at 1:05 PM V3 Assistant DON viewed R6's and R269's insulin pen pharmacy labels, and stated R6's Basaglar pen was dispensed from pharmacy on 5/17/24 and R269's Novolog pen was dispensed on 6/6/23. R1's June 2024 Medication Administration Record (MAR) documents R1 receives Lispro per sliding scale three times daily. R6's June 2024 MAR documents R6 receives Basaglar 23 units every morning and 28 units every evening. R269's June 2024 MAR documents R269 receives Novolog per sliding scale three times daily. R62's June 2024 MAR documents R62 receives Latanoprost daily. R59's June 2024 MAR documents R59 receives Lispro per sliding scale three times daily. R44's June 2024 MAR documents R44 receives Aspart per sliding scale three times daily. R9's June 2024 MAR does not document an active order for Basaglar. R53's Census documents R53 expired on 5/29/24. The facility's pharmacy guide titled Medication with Beyond Use Dates dated September 2023 documents Once these products are opened or prepared, they must be used within a specific timeframe to avoid reduced stability, sterility, and reduced efficacy. All of these medications should be labeled in such a way that the Beyond Use Date is securely attached to part of the package and will not be discarded. Beyond use dating can be found in the products' package inserts, typically under the How Supplied/Storage and Handling section. This guide documents the stability for Admelog, Humalog, Novolog, and Basaglar pens as 28 days; and to discard Xalatan eye drops 6 weeks after opening. The undated (facility's pharmacy) Pharmaceutical Services Policy and Procedure Manual documents all resident medication labels should include the resident's name and discontinued/expired medications (that are not controlled substances) should be removed from active medication storage area and returned to the pharmacy. This manual documents when a resident expires, immediately return the resident's medications to the pharmacy for destruction.

Based on observation, interview, and record review the facility failed to administer medications as ordered and in accordance with manufacturer's instructions for three (R7, R270, R59) of 11 residents reviewed for medication administration in the sample list of 42. This failure resulted in four medication errors out of 25 opportunities, a medication error rate of 16%. Findings include: 1.) R7's June 2024 Medication Administration Record (MAR) documents Metamucil Powder 28.3 % (Psyllium) Give 12 gram by mouth in the evening for constipation Drink at least 8 oz (ounces) of cool liquid per dose scheduled daily at 4:00 PM. On 6/03/24 at 4:38 PM V13 Registered Nurse (RN) administered R7's medications including 1/2 teaspoon of Metamucil dissolved in water. The Metamucil label documented one tablespoon equals 12 grams. V13 confirmed 1/2 teaspoon of Metamucil was administered. On 6/04/24 at 11:48 AM V16 RN stated R7 receives Metamucil and the dose is 12 grams. V16 read the Metamucil label and confirmed one tablespoon is 12 grams. 2.) R270's June 2024 MAR documents to administer Humalog (insulin) Kwikpen 200 units per milliliter (u/ml) give 5 u subcutaneously before meals at 5:30 AM, 11:00 AM, and 4:00 PM, and three times daily per sliding scale 0-149=0, 15-200=2 u, 201-250=4u, 251-300=6u, 301-350=8u, and 351-600= 10 u. On 6/4/24 at 10:55 AM V15 RN stated R270's blood glucose was 317 and R270 will get 5 units of scheduled insulin and 8 units per sliding scale. At 11:01 AM V15 administered Humalog 13 units into R270's left upper arm and did not prime the pen prior to administration. There was no food at R270's bedside. R270 was served the noon meal in the dining room at 11:38 AM (over 30 minutes after receiving insulin.) On 6/04/24 at 12:12 PM V15 RN confirmed V15 did not prime R270's insulin pen prior to administration. V15 stated V15 was not aware that insulin pens should be primed. 3.) R59's June 2024 MAR documents Admelog (insulin) 100 u/ml give before meals at 6:00 AM, 11:30 AM, and 4:30 PM per sliding scale 151 - 200 = 2u, 201 - 250 = 4u, 251 - 300 = 6u, 301 - 350 = 8u, and 351 - 400 =10 u. On 6/04/24 at 11:09 AM V16 RN stated R59's blood sugar was 241. At 11:13 AM V16 administered Admelog 4 u into R59's abdomen. There was no food at R59's bedside. At 11:53 AM R59's noon meal was served (over 40 minutes after receiving insulin). On 6/04/24 at 1:37 PM V2 Director of Nursing stated short acting insulin should be given within 30 minutes before a meal. The facility's Medication Administration policy dated 1/11/2010 documents to follow physician's orders when administering medications and to compare the medication label with the MAR. The Humalog Highlights of Prescribing Information dated August 2023 and Admelog Highlights of Prescribing Information dated August 2023 document these medications are fast acting and should be administered within 15 minutes before a meal or immediately after a meal, and hypoglycemia (low blood sugar) is a possible side effect. The Humalog Kwikpen Instructions for Use dated July 2023 documents to prime (remove air) the insulin pen with 2 units prior to administration and repeat as needed until insulin is seen at the tip of the needle. These instructions document if the pen is not primed, too little or too much insulin may be administered.

Based on observation, interview and record review the facility failed to have orders, consents or assessments for R52 and R219, failed to complete an initial assessment for a soft waist restraint for R47 and failed to obtain a consent for a soft waist restraint for R55 for four of four residents (R47, R52, R55, R219) reviewed for restraints on a sample list of 42 residents. Findings include: The facility Restraint Program Policy and Procedure dated 11/10/15 documents that prior to the use of any restraint, each resident is assessed for potential alternative by using the restraint Pre-Restraining and Quarterly Evaluation. If a restraint is deemed appropriate, a consent will be obtained, a quarterly review of the restraint will be completed, the care plan will be updated and reduction attempts will be documented. 1.) R52's Minimum Data Set, dated dated dated [DATE] documents that R52 is severely cognitively impaired. R52's progress notes document that on 5/17/24, the body pillow was in use on R52's bed. R52's medical record does not document an order, a consent, or an assessment for a restraint or body pillow. On 6/3/24 at 12:18PM, R52 was laying in bed with a large body pillow tucked under the sheets from his waist to his toes, separating R52 from the edge of the bed with the body pillow. On 6/3/24 at 10:30AM, V10 Certified Nursing Assistant said that they use a body pillow to keep R52 from getting up and out of the bed. On 6/4/24 at 9:53AM, V3 Assistant Director of Nursing said that R52 didn't have an order for a body pillow, R52 shouldn't have a body pillow, that R52 can get up and out of the bed if he wants to and that the use of a body pillow could be considered a restraint. 40385 2.) On 2/3/24 at 9:14 AM and 9:51 AM R219 was lying in bed and one side of the bed was against the wall. The opposite side of the bed had a large body pillow positioned between the mattress and bed frame, which caused the foot of the mattress to be raised. R19 was confused and not interviewable. On 6/04/24 at 8:35 AM R219 was lying crossways in the bed, with feet hanging over the edge of the bed. There was no body pillow underneath of the mattress. On 6/03/24 at 9:51 AM V12 Certified Nursing Assistant (CNA) stated the body pillow is used because R219 tries to wiggle out of bed a lot, and a lot of times we find R219's feet hanging out of bed onto the floor. V12 confirmed the pillow is used to keep R219 in bed. V12 stated R219 is not able to remove the pillow. On 6/04/24 at 10:00 AM V11 CNA stated other staff were using the body pillow because R219 has a tendency to shift around in bed. V11 confirmed R219 is able to independently place R219's legs over the side of the bed. R219's Care Plan revised 5/30/24 documents R219's diagnoses include malignant neoplasm of stomach and liver, anxiety disorder, and restless leg syndrome. There is no consent, assessment, or order for the use of the body pillow restraint in R219's medical record. On 6/04/24 at 10:22 AM V3 Assistant Director of Nursing confirmed the use of the body pillow for R219 could be considered a restraint and V3 stated staff should not be using it. V3 stated there should be a physician's order, consent, and an assessment for restraint use. 37813 3. R47's Minimum Data Set (MDS) dated [DATE] documents R47 as severely cognitively impaired and uses a restraint while up in chair daily which prevents R47 from rising. R47's consent for restraint dated 7/20/24 documents a breakaway lap cushion was initiated for R47 related to poor safety awareness. There is no documentation of an initial assessment for this restraint. On 6/3/24 at 11:30AM R47 was observed in the front hall with the breakaway lap cushion in place to her wheelchair. 6/03/24 12:10 PM V22, R47's family member, stated (R47) can't remove the lap cushion herself. V22 stated (R47) was getting up on her own and face planted several times and I think (R47) needs the (Lap cushion). On 6/4/24 at 2:00PM V2, Director of Nursing stated We don't have an initial assessment for (R47) when we started using the (breakaway lap cushion). I think we must have just missed that. 32853 4.) R55's diagnosis list documents diagnoses including Dementia, Muscle Weakness, Muscle Wasting, Obesity, Anxiety and Depression. R55's Care Plan dated 7/10/24 documents R55 is at risk for falls due to weakness with an intervention of a soft lap cushion while in the wheelchair to remind her not to stand on her own. R55's Physician's Orders document an order for a soft lap cushion when in the wheelchair, remove during ADLs (Activities of Daily Living) and meals for diagnoses of Dementia, Lack of Safety Awareness and Frequent Falls. On 6/03/24 at 11:00 AM, R55 was in another resident's room sitting by their bed. R55 was in the wheelchair and had the soft lap cushion on her lap with both sides of the cushion threaded through the arms of the wheelchair (as designed). On 6/3/24 at 11:27 AM, R55 was in her wheelchair with the soft lap cushion across her lap with the sides of the cushion threaded through the arms of the wheelchair. On 6/3/24 at 12:09 PM, R55 was in her wheelchair in the dining room with the soft lap cushion on her lap with the sides of the cushion threaded through the arms of the wheelchair. On 6/4/24 at 8:38 AM, R55 was in her wheelchair sitting at the front desk with the soft lap cushion on her lap with the sides of the cushion threaded through the arms of the wheelchair. On 6/4/24 at 9:56 AM, R55 was in activities sleeping in her wheelchair with the soft lap cushion on her lap with the sides of the cushion threaded through the arms of the wheelchair. R55's medical record does not contain a consent for the soft lap cushion. On 6/04/24 at 12:26 PM, V2 Director of Nursing confirmed there was no consent for the soft lap cushion and V2 stated it was changed from a hook and loop closure belt to a soft lap cushion back in July 2023, because R55 kept taking off the hook and loop closure belt and kept trying to stand up from the wheelchair so they placed the soft lap cushion on her in the wheelchair.

Based on observation, interview and record review the facility failed to complete a safe sit to stand mechanical lift transfer for one (R55) of four residents reviewed for falls in the sample list of 42. Findings include: R55's diagnosis list documents diagnoses including Dementia, Contracture of the Right Knee, Contracture of the Left Knee, Muscle Weakness, Muscle Wasting, Abnormal Posture and Obesity, Anxiety and Depression. R55's Physical Therapy Evaluation and Plan of Treatment signed on 12/18/23 documents R55's goals of therapy were to increase knee range of motion and strength to be able to continue to use the stand lift. On 6/3/24 at 12:10 PM, V5 Certified Nursing Assistant (CNA), V6 and V7 CNA students wheeled R55 into the central bathroom to assist R55 to the toilet. They removed the soft lap cushion and wheeled her close to the mechanical sit to stand lift. They placed her feet on the foot plate and placed the sling under her arms and around her back, and placed the loops of the sling in the hooks on the lift. They raised R55 with the mechanical sit to stand lift. They did not use the leg strap around her legs and R55's knees were not against the knee pad of the lift. R55's knees were at least six inches away from the knee pad. As they lifted R55, her elbows raised towards the ceiling and made a chicken wing look. R55's elbows were at more than a 45 degree angle up towards the ceiling and R55's legs were bent. R55 never came to a standing position in the lift. R55's knees were bent and she started sliding down in the sling as her elbows raised towards the ceiling. They moved her to the toilet and lowered her onto the toilet. V5 stated that R55 has been started on therapy again to assist with the mechanical sit to stand transfers. On 6/4/24 at 1:21 PM, V14 Certified Occupational Therapy Assistant/Therapy Program Manager stated that R55 was recently evaluated to restart Physical and Occupational Therapy. V14 stated that when using the mechanical sit to stand lift that staff should place the resident's feet on the foot platform, attach the sling around the resident, direct their hand placement on the handle bars and lift the resident. V14 stated that she assumed R55 could straighten her legs enough to be safe on the mechanical sit to stand lift since that is what they are using to transfer her. V14 stated that some residents have to use the leg strap and some do not. V14 stated that the resident's knees should be against the knee pad and their arms should not be chicken winging (elbows raising up) and that the elbows should be at the residents side, definitely not up like chicken wings. On 6/5/24 at 10:45 AM, V2 Director of Nursing stated that they do competency training with staff on all the mechanical lifts. V2 confirmed that the resident's knees are supposed to be against the knee pad, the resident's elbows should not be raised up and if there is a leg strap on the mechanical sit to stand lift they should use it on the resident's legs. The mechanical sit to stand lift instruction manual provided by V2 Director of Nursing on 6/5/24 documents when lifting the resident that the resident's knees should rest against the knee pad.

Based on observation, interview and record review the facility failed to shave two (R12 and R17) of two dependent residents reviewed for dependent activities of daily living on a sample list of 42 residents. Findings include: The facility provided A.M. (morning) Care procedure dated April 2009 documents that staff are to provide personal hygiene to residents in the morning. This includes providing assistance with shaving including a razor, shaving cream and a basin of warm water. 1.) R17's Functional assessment dated [DATE] documents that R17 is dependent for all activities of daily living. On 6/3/24 at 9:47AM, R17 had whiskers all over his face and neck, approximately 1/2 inch long. On 6/3/24 at 9:50AM, R17 said that he liked to be clean shaven and that he really misses that here. On 6/3/24 at 9:55AM, V17 Certified Nursing Assistant asked R17 if he would like to be shaved and he responded in the affirmative. On 6/5/24 at 9:35AM, R17 had beard growth of 1/4 inch. On 6/5/24 at 9:30AM, R17 said that he is unable to use his hands, and that he has to have assistance for anything that requires his hands to do. On 6/5/24 at 9:40AM, R17 said that he would like to be shaved, but that he hadn't been shaved for a couple of days. 2.) R12's Minimum Data Set, dated dated dated [DATE] documents R12 as cognitively intact. R12's care plan dated 12/2019 documents that R12 requires assistance with shaving. On 6/3/24 at 11:30AM, R12 was unshaven with hair approximately 1/4 inch long on his face and neck. On 6/5/24 at 9:38AM, R12 face remained unshaved and was approximately 1/2 inch long. On 6/5/24 at 9:39AM, R12 said that he likes to be shaved daily and that he doesn't get shaved daily. On 6/5/24 at 10:00AM, V4 Registered Nurse said that she would expect all residents to be shaved with morning cares.

Based on interview and record review the facility failed to obtain a level II PASRR (Preadmission Screening and Review) for one resident (R57) with Post-traumatic Stress Disorder (PTSD) of one resident reviewed for PASRR in a sample list of 42 residents. Findings Include: R57's Minimum Data Set (MDS) dated [DATE] documents R57 has an active diagnoses of PTSD and is cognitively intact. R57's Diagnoses list includes a diagnosis dated 6/30/23 of PTSD. There is no evidence in the medical record the facility obtained a Level II PASSR screening when they became aware of R57's diagnosis of PTSD. On 6/5/24 at 1:00PM V1, Administrator stated I was not aware that if the Level I PASRR did not indicate a Level II we had to get a level II in the event we became aware of a diagnosis of a serious mental Illness. V1 also verified that while the facility's policy for Care Plan Procedure does state the PASRR recommendations will be included in the initial Care Plan the facility does not have a policy specific to when to obtain a level II PASRR.

Based on interview and record review the facility failed to provide continuous supervision for a resident while taking a shower. This failure affects one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 falling in the shower sustaining fractures of the left upper and lower extremities. Findings include: R1's Facesheet dated 6/29/22 documents R1 is diagnosed with Alzheimer's Disease, Dementia with Behaviors, and [CONDITION(S)]. R1's care plan documents focus area of R1 receiving anticoagulant therapy initiated 2/25/20 revision on 2/1/22 with interventions to take precautions and avoid falls. R1's Fall Risk dated 4/5/22 documents R1 is at High Risk for falls in part due to R1's history of falls and altered mental status with which she overestimates abilities and forgets limits. R1's Minimum Data Set, dated dated dated [DATE] documents for showering, R1 requires physical help in part of bathing activities (showering) of at least one staff person. The Incident Report dated 6/21/22 documents on 6/16/22 R1 was in the shower when she fell and was found by a staff member. R1 was sent to the emergency room and was diagnosed with three fractures resulting from the fall. R1's Diagnostic X-ray Report of the Left Ankle dated 6/17/22 documents R1 sustained a comminuted non-displaced fracture medial malleolus. R1's Diagnostic X-ray Report of the Left Elbow dated 6/17/22 documents R1 sustained an avulsed fracture of the olecranon and a non-displaced radial head fracture. On 6/28/22 at 2:28 PM V5 Certified Nurses Assistant stated on 6/16/22 she helped R1 start her shower and then left the room for a few minutes. When she returned to R1's room, R1 was naked on the floor in front of the shower. V5 CNA stated she knew R1 was a fall risk and has Dementia and is forgetful. V5 CNA confirmed she should have stayed with R1 during the entire shower and supervised her instead of leaving the room. On 6/28/22 at 3:02 PM V3 Assistant Director of Nurses stated no resident should ever be left unattended in the shower. We completed in-service re-training after R1 fell in the shower. R1 should have been supervised in the shower at all times. V5 CNA should not have left her alone. V3 confirmed R1 is a high fall risk due to her overestimating abilities and forgetting limits and Dementia Diagnoses. On 6/29/22 at 12:19 PM V11 Medical Doctor stated R1 has Dementia and will often forget her limits and has poor safety awareness. R1 can appear cognitively normal but is very forgetful. V11 confirmed if staff would have stayed with R1 while she was in the shower, they could have potentially prevented her from falling which subsequently would have prevented the fractures.

Based on observation, interview, and record review the facility failed to administer [CONDITION(S)] medications as ordered for one (R56) of seven residents reviewed for accidents in the sample list of 35. This failure resulted in R56 having a [CONDITION(S)] that resulted in a fall with an elbow laceration that required sutures. Findings include: 1.) On 4/25/22 at 12:00 PM R56 was sitting in a wheelchair in the hallway, dropped R56's drink on the floor, and fell forward. Staff was called for assistance. R56 was unresponsive and was having a [CONDITION(S)]: R56's arms and legs were spastic and shaking, R56 was drooling and made a gurgling sounds, R56's eyes were rolled back. Staff transported R56 into R56's room. On 4/25/22 at 2:50 PM R56 stated R56 has a history of falling out of R56's wheelchair due to seizures, resulting in R56 being treated at the hospital. R56 was asked what the facility has done to keep R56 safe from injury during the seizures. R56 stated I'm just on heavy medications. R56's Care Plan dated 9/1/20 documents R56 has a [CONDITION(S)] disorder and includes an intervention to administer [CONDITION(S)] medications as ordered. R56's August 2021 Order Summary Report documents an order initiated on 1/20/21 to administer [MEDICATION(S)] ([CONDITION(S)] medication) 750 mg (milligrams) one tablet twice daily for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R56's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R56's Progress Notes document the following: On 8/8/21 at 8:17 AM R56's [MEDICATION(S)] was on order. On 8/8/21 at 7:09 PM R56's [MEDICATION(S)] entry documents Medication ordered; awaiting pharmacy. On 8/9/21 at 8:33 AM R56's [MEDICATION(S)] was unavailable. On 8/9/21 at 9:20 PM R56's [MEDICATION(S)] entry documents awaiting pharmacy. There is no documentation of any follow up with the pharmacy or that V15 Physician was notified of R56's missed doses of [MEDICATION(S)]. R56's nurses notes document: On 8/10/21 at 6:20 AM R56 was in R56's wheelchair, fell to the floor, and had a [CONDITION(S)]. R56 seized for 45 seconds to 1 minute. R56 had blood noted to both nostrils, an abrasion to the knee, and a 1 inch skin tear to the left elbow. R56 was sent to the emergency room and received two sutures to the left elbow. On 8/12/21 the IDT reviewed R56's fall and post fall interventions were to try and keep R56 safe and prevent injuries during seizures. R56's Hospital Summary dated 8/10/21 documents R56's Encounter diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/25/22 at 1:26 PM V4 Registered Nurse (RN) stated: R56 has a history of seizures. We monitor R56's [MEDICATION(S)] levels and adjust R56's [CONDITION(S)] medications. We count on the medication to keep R56 safe. On 4/27/22 at 11:50 AM V4 stated: V4 was working when R56 fell in August 2021. R56 had a [CONDITION(S)] and fell forward out of R56's wheelchair onto the floor. R56 was bleeding from the nose and had skinned up R56's elbow. R56 was sent to the hospital and received two stitches to the left elbow. We were out of R56's [MEDICATION(S)]. 8/9/22 was a Sunday, and we don't receive pharmacy deliveries on Sunday. We were waiting for pharmacy to deliver the medication. If a medication is unavailable we should notify the physician and document in the progress notes. On 4/27/22 at 12:00 PM V2 Director of Nursing stated V2 was not aware that R56 missed doses of [MEDICATION(S)] in August 2021, and there was no medication error report completed. V2 stated we are to notify pharmacy and have the backup pharmacy deliver medications when they are unavailable. V2 stated the physician should be notified if the medication is not obtained and doses are missed. V2 stated [MEDICATION(S)] is not in our convenience box of medications. V2 confirmed R56's nursing notes document [MEDICATION(S)] was not available and was awaiting pharmacy deliver on 8/8 and 8/9/21, and there is no documentation that V15 Physician was notified of the missed doses. On 4/27/22 at 12:23 PM V16 Pharmacist stated: The half life of [MEDICATION(S)] is 6-8 hours for instant release. R56 is on instant release [MEDICATION(S)]. If [MEDICATION(S)] doses are missed for 48 hours, V16 would be concerned about the patient having seizures and putting the patient at risk. The facility notified the pharmacy on 8/5/21 to request a refill of the [MEDICATION(S)]. We told the facility that we still had R56 discharged to the hospital in our system and would need updated orders in order to refill the medication. We did not receive R56's orders until 8/9/21. The last fill of the [MEDICATION(S)] was on 6/30/22, so that would have put R56 out of the medication roughly around 7/30/21. Usually the facility would let us know when they are out of a medication so that we can notify the backup pharmacy to have the medication delivered. V16 did not see any other documentation of communication from the facility regarding R56's [MEDICATION(S)] during 8/5-8/9/21. On 4/27/22 at 1:51 PM V15 Physician stated: V15 was unsure if the facility had notified V15 of R56's missed doses of [MEDICATION(S)] in August 2021. The facility should have had the backup pharmacy send the medication. The missed doses would be contributory to R56's [CONDITION(S)]. Seizures can result in a fall, and depending on the type of [CONDITION(S)] and if it affects the [CONDITION(S)] could result in death. V15 was unsure of the type of seizures that R56 has. The facility's Medication Administration policy dated 1/11/2010 documents: It is the policy of this facility to accurately administer medication following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication errors should be reported to the physician.

Based on observation, interview, and record review the facility failed to thoroughly investigate falls to identify the root cause and develop appropriate interventions, and failed to implement post fall interventions for six (R2, R9, R29, R41, R52, R56) of seven residents reviewed for accidents in the sample list of 35. The facility failed to implement safety interventions following seizures resulting in falls, this failure resulted in R56 falling and sustaining a left elbow laceration that required sutures. Findings include: 1.) On 4/25/22 at 12:00PM R56 was sitting in a wheelchair in the hallway, dropped R56's drink on the floor, and fell forward. Staff was called for assistance. R56 was unresponsive and having a [CONDITION(S)]: R56's arms and legs were spastic and shaking, R56 was drooling and made a gurgling sounds, and R56's eyes were rolled back. Staff transported R56 into R56's room. On 4/25/22 at 2:50 PM R56 stated R56 has a history of falling out of R56's wheelchair due to seizures, resulting in R56 being treated at the hospital. R56 was asked what the facility has done to keep R56 safe from injury during the seizures. R56 stated I'm just on heavy medications. R56's Minimum Data Set (MDS) dated [DATE] documents R56 is cognitively intact. R56's Care Plan dated 9/1/20 documents R56 has a [CONDITION(S)] and includes an intervention dated 2/15/22 to continue to try and provide a safe environment and prevent injuries during [CONDITION(S)] activity. R56's Care Plan dated 4/5/22 documents R56 is at risk for falls due to R56's [CONDITION(S)], and includes an intervention dated 3/7/21 to encourage R56 to notify staff when R56 feels a [CONDITION(S)] coming on so that staff can potentially be with R56 and provide a safe area. R56's Nursing Notes document the following: On 4/26/2021 at 8:00 AM R56 had a [CONDITION(S)], fell forward out of R56's wheelchair, and hit R56's face on the floor. R56 had a 1 cm (centimeter) laceration to the left eyebrow, and a 3 cm soft tissue injury to the right forearm. R56's nose was swollen, bleeding, and bruising. R56 was sent to the emergency room for evaluation. On 4/28/2021 at 1:03 PM the IDT (Interdisciplinary Team) discussed R56's fall. R56's fall was discussed with R56. R56 said R56 felt the [CONDITION(S)] coming on, but couldn't reach the call light in time to call for staff assistance. R56 was told it is ok to yell for help in an emergency situation. The root cause of R56's fall was the [CONDITION(S)], interventions continue per R56's plan of care, and provide safety during seizures. On 8/10/21 at 6:20 AM R56 was in R56's wheelchair, fell to the floor, and began to seize. R56 seized for 45 seconds to 1 minute. R56 had blood noted to both nostrils, an abrasion to the knee, and a 1 inch skin tear to the left elbow. R56 was sent to the emergency room and received two sutures to the left elbow. On 8/12/21 the IDT reviewed R56's fall and post fall interventions were to try and keep R56 safe and prevent injuries during seizures. On 2/14/22 at 7:05 AM R56 was found on the floor of R56's room, hallway under R56's bed. R56 had a [CONDITION(S)] and fell out of R56's wheelchair. On 2/15/22 the IDT reviewed R56's fall. The root cause of the fall was that R56 had a [CONDITION(S)] while in the wheelchair. The interventions were to obtain [MEDICATION(S)] level and Basic Metabolic Profile, and continue to try and provide a safe environment and prevent injury during seizures. There is no documentation that safety interventions were developed and implemented following R56's falls on 4/28/21, 8/10/21, and 2/14/22. R56's Hospital Summary dated 8/10/21 documents R56's Encounter Diagnoses were [CONDITION(S)] and left elbow laceration, and to remove R56's left elbow sutures in 10 days. On 4/25/22 at 1:26 PM V4 Registered Nurse (RN) stated: R56 has a history of seizures. We monitor R56's [MEDICATION(S)] levels and adjust R56's [CONDITION(S)] medications. We count on the medication to keep R56 safe. V4 confirmed no other safety interventions or [CONDITION(S)] precautions are used. On 4/27/22 at 11:50 AM V4 stated: V4 was working when R56 fell in August 2021. R56 had a [CONDITION(S)] and fell forward out of R56's wheelchair onto the floor. R56 was bleeding from the nose and had skinned up R56's elbow. R56 was sent to the hospital and received two stitches to the left elbow. On 4/27/22 at 10:31 AM V2 Director of Nursing (DON) stated R56's [CONDITION(S)] and fall interventions are that R56 takes [MEDICATION(S)] for seizures, and R56's [MEDICATION(S)] level is monitored. V2 stated R56 has been instructed to alert staff if R56 feels a [CONDITION(S)] coming on, and we try to have a safe area when R56 is seizing. V2 confirmed no safety interventions were developed/implemented after R56's seizures and falls. 2.) R9's MDS dated [DATE] documents: R9 has a Brief Interview for Mental Status score of 12, indicating R9 is at the higher range for moderate cognitive impairment. R9 requires extensive assistance of one staff person for transfers and toileting, and R9 is frequently incontinent of bowel and bladder. R9's Fall Investigation dated 3/21/22 documents: R9 was found on the bathroom floor at 2:50 PM. R9 was last observed at 2:20 PM sleeping, and N/A (Not Applicable) is listed as the last time R9 was toileted. Residents (R9) is alert with confusion. (R9) does not recognize (R9's) limitations. (R9) needs one assist for transfers and ambulation. Root Cause: Resident (R9) took self to the bathroom and lost balance and fell . Intervention: Alarm placed on bathroom door to alert staff to attempts at self transferring/toileting. R9's Care Plan dated 1/19/22 documents R9 is at risk for falls, and includes an intervention dated 3/22/22 for an alarm on the bathroom door to alert staff that R9 is attempting to self toilet. R9's Care Plan dated 1/26/22 documents R9 is incontinent of bowel and bladder, R9 wears incontinence briefs, and includes an intervention dated 1/26/22 to change R9's brief every shift and as needed. There is no documentation to assist R9 with toileting regularly. On 4/25/22 at 3:01 PM R9 stated staff had disconnected R9's bathroom alarm this morning when R9 was given a shower, and the staff must have forgot to turn the alarm back on. At this time R9's bathroom door was opened. There was an alarming device at the top of the door with a switch in the off position, and the alarm did not sound. R9's bathroom contained a shower. On 4/25/22 at 4:49 PM R9's bathroom door alarm was not turned on, and the alarm did not sound when the door was opened. On 4/26/22 at 8:10 AM R9 stated the staff never turned the bathroom alarm back on last night. R9's bathroom alarm switch was in the off position, and the alarm did not sound when the door was opened. On 4/26/22 at 10:50 AM V7 MDS Coordinator was in R9's room. V7 confirmed R9's bathroom door alarm was not turned on. On 4/27/22 at 1:15 PM V2 DON confirmed R9's fall investigation for the 3/21/22 fall does not document the last time R9 was toileted prior to the fall. V2 stated: R9 does require assistance with transfers and toileting, but R9 tries to self toilet and transfer at times. R9's post fall intervention was to use the bathroom door alarm. 3.) R41's MDS dated [DATE] documents R41 is cognitively intact, and requires extensive assistance of two staff for transfers and walking in R41's room. R41's Care Plan documents R41 is at risk for falls and has impaired balance. R41's Care Plan includes interventions to encourage R41 to have R41's feet elevated in the recliner, staff to check on R41 hourly and offer toileting, and to place the wheelchair in front of R41 when sitting in the recliner. R41's Fall Investigations document the following: On 3/2/22 at 9:30 PM R41 was found on the floor near R41's recliner. R41 said R41 was sleeping prior to the fall and did not know how R41 ended up on the floor. R41 had a bump to the ride side of the head with a gash 1.5 cm in length. R41 had a 5.5 cm by 2.5 cm skin tear. The intervention was to place the wheelchair directly in front of R41 when sitting in the recliner. On 3/4/22 at 8:15 AM R41 was found on the floor in between two recliners in R41's room. R41's right forearm skin tear reopened. R42 told staff that R41 was sleeping in the recliner and fell on to the floor. The intervention was to encourage R41 to elevate R41's feet when sitting in the recliner. There is no documentation that R41's wheelchair was in front of R41's recliner prior to the fall. On 3/4/22 at 2:15 PM R4 fell and had a laceration to the right ear. R41 was sleeping in the recliner and fell . There is no documentation that R41's wheelchair was positioned in front of R41 at the time of the fall. On 4/12/22 at 1:00 AM staff responded to R41's call light and found R41 sitting on the floor in front of R41's recliner. R41 often refuses to elevate R41's legs in the recliner. The fall intervention was staff were educated if R41 refuses to have R41's feet elevated when in the recliner, place the wheelchair directly in front of R41. The root cause of R41's falls is that R41 was sleeping and fell from the recliner. On 4/25/22 at 10:12 AM R41 was asleep in the recliner and R41's feet were not elevated. R41's wheeled walker was positioned in front of the recliner. On 4/26/22 at 1:42 PM R41 was asleep in the recliner and leaning to the left. R41's left arm was draped over the arm rest, and R41's feet were not elevated. R41's wheelchair was in the hall way, and R41's wheeled walker was not positioned in front of the recliner. On 4/27/22 at 8:21 AM R41 was asleep in recliner, and R41's feet were not elevated. R41's wheelchair was in the hallway, and R41's wheeled walker was near the bathroom door. R42 (R41's Spouse) stated: R41 prefers to sleep in the recliner. R41 has slid to the floor and fell forward out of the recliner. 4/26/22 at 1:44 PM V13 Certified Nursing Assistant (CNA) stated R41 refuses to elevate R41's legs while sitting in the recliner. V13 was asked what is done if R41 refuses to elevate R41's legs, and V13 replied nothing. On 4/27/22 at 1:15 PM V2 DON reviewed R41's fall investigations and confirmed R41's fall intervention for fall on 3/2/22 was to place the wheelchair in front of R41's recliner. V2 confirmed the wheelchair was not positioned in front of R41's recliner during R41's falls on 3/4/22 and 4/12/22. V2 stated: Staff were educated to position the wheelchair in front of R41's recliner after the fall on 4/12/22. R41's falls usually occur while R41 is sleeping in the recliner, and R41 refuses to elevate R41's legs. 4.) R52's Physician Orders dated 4/27/22 documents diagnoses including Dementia without Behavioral Disturbance, Urinary Incontinence, [CONDITION(S)], [CONDITION(S)] and Malnutrition. R52's Minimum Data Set (MDS) dated [DATE] documents R52 has moderately impaired cognition and requires extensive assistance of two staff for transfers and toileting and R52 does not walk. This MDS documents R52's balance during transitions is not steady and only able to stabilize with staff assistance with moving from a seated to a standing position, getting on and off the toilet and surface to surface transfers. R52's Care Plan dated 8/18/21 documents, Place alarm on bathroom door and make sure it is on when door is closed so that if I (R52) attempt to take myself (R52) to the bathroom the alarm will sound. R52's Fall Investigation dated 2/23/22 documents R52 was observed on R52's bottom in the bathroom next to the locked wheelchair. R52 received scratches on R52's back. No bleeding, bruising or swelling. The root cause documented for this fall is documented as, (R52) transferred self to toilet and lost balance while wiping. The intervention documented for this fall is, alarm on bathroom door changed out for louder alarm, education provided to staff to ensure it is activated at all times. On 4/27/22 at 11:40 AM, V2 Director of Nursing confirmed R52's bathroom alarm is suppose to be on, and confirmed that for R52's fall on 2/23/22 the bathroom alarm was not on and did not sound. V2 stated that staff should have been checking to make sure the bathroom alarm was on during rounds. 5.) R2's Physician Orders dated 4/27/22 documents diagnoses including [CONDITION(S)], Hypertension, [CONDITION(S)], Unspecified Dizziness and Giddiness, [CONDITION(S)] and Dementia with Behavioral Disturbance. R2's MDS dated [DATE] documents R2 has moderately impaired cognition and requires one person assistance to transfer and use the toilet. R2's balance during transitions documents R2 is unsteady and only able to stabilize with staff assistance with walking and turning around. R2's Care Plan dated 6/7/21 documents R2 is at risk for falls due to weakness and lack of safety awareness due to Dementia. This Care Plan documents an intervention dated 6/7/21 and revised on 12/2/21 for an alarm placed on the bathroom door to alert staff of resident trying to take self to the bathroom. On 4/26/22 at 11:10 AM, R2 was lying in bed and the bathroom alarm is turned off and the bathroom door is closed. On 4/27/22 at 7:49 AM, R2 was lying in R2's bed and the bathroom alarm is missing the cover to it exposing the batteries and the alarm is turned off. On 4/27/22 at 10:53 AM, V12 Certified Nursing Assistant confirmed R2's bathroom alarm was off and stated that V12 must have forgotten to turn it back on after R2's shower. On 4/27/22 at 11:40 AM, V2 confirmed R2's bathroom alarm is suppose to be turned on. 6. R29's Progress Notes dated 4/27/22 includes the following diagnoses: Dementia, Muscle Wasting and Atrophy, Difficulty Walking, Right Wrist Fracture, and [CONDITION(S)]. R29's Minimum Data Set (MDS) dated [DATE] document R29 is independent with Activities of Daily Living. R29's Care Plan includes the following: (R29) is at risk for falls related to weakness and confusion. (R29) had a recent fall that resulted in a bruise on right side of forehead, scalp laceration, right wrist Skin Tear, and Right wrist fracture. Date Initiated: 08/06/2021 Revision on: 03/31/2022. (R29) will resume usual activities without incident through the next review date Date Initiated: 08/06/2021 Revision on: 02/23/2022 Target Date: 05/30/2022 Assist (R29) to keep non-skid footwear on at all times while up Date Initiated: 08/06/2021 Education provided to allow staff to care for other Residents instead of attempting to provide assistance/care for her friends. Date Initiated: 03/18/2022 (R29) was educated that if she drops something to ask staff to pick it up Date Initiated: 02/21/2022 Make sure call light is always within reach Date Initiated: 08/06/2021. Please do not place bed all the way to the floor, as resident is independent it needs to be at proper height so that she can get to a standing position easily. Date Initiated: 02/15/2022 educate to use call light and ask for assistance. Staff is able to assist with adjusting bed to residents liking and safety. Date Initiated: 02/22/2022. R29's Progress Note dated 2/15/22 at 1:05AM documents (R29) found on the floor in the middle of the hallway in front of her room. Resident stated she was doing her hair and fell out of bed onto her head. During neurological assessment resident stated she was seeing double and was lightheaded. 911 was called. They departed facility at 12:43AM. Resident is documented as returning to facility without injury later 2/15/22. Facility's Full Occurrence Report dated 2/15/22 does not identify a root cause for R29's fall. R29's Progress Note dated 2/16/22 at 3:10PM documents (R29) in dining room for activities with Power of Attorney (POA). Reported that resident dropped tissue box under the table and bent over to pick it back up. Upon rising, resident lost balance and landed on buttocks. Resident's POA helped resident backup and into dining chair. Facility's Full Occurrence Report dated 2/16/22 at 3:10PM documents root cause as Bending over caused (R29's) balance to be off. Underlying causes for loss of balance were not assessed. R29's Progress Note dated 3/16/22 at 5:35PM documents (R29) observed on floor of (other resident's room). States she tripped on wheelchair leg and lost balance and fell . States she landed on her right buttocks. Denies injury or pain. Laying on back with head on pillow. Full Range of Motion to all extremities without difficulty. No redness or bruising to right buttock. Stood up with assist x 2 (staff members). Able to bear weight without difficulty. Taken back to room and resting in chair. Alert,oriented as before with occasional confusion. POA and physician notified. No new orders received. VS:98.1 91 16 144/72 with O2 sat 98%. Facility's Full Occurrence Report dated 2/16/22 does not identify a root cause for R29's fall. R29's Progress Note dated 3/30/22 at 1:35PM documents resident heard yelling for help in hallway. Resident found in hallway lying on right side on floor. Upon observation, laceration noted on right side of forehead, skin tear noted on right wrist. R29's Progress Note dated 3/30/22 at 4:40PM documents (R29) returned to the facility from emergency room at 4:20PM. Right wrist is fractured. Facility's Full Occurrence Report dated 3/30/22 at 1:40PM documents root cause as (R29) did not pick her foot up causing a stumble. Underlying causes for loss of balance or unsteady gait were not assessed. On 3/27/22 at 3:00PM V2, Director of Nursing stated that the root cause analysis needs to include underlying causes of falls not just circumstances surrounding falls and that a complete fall investigation requires a complete root cause analysis. The facility's policy Fall Assessment and Management revised April 2019 states Interventions will be based on the fall risk assessment,and the circumstances surrounding the risk for injury or actual injury or fall. Some examples may be: Fall related to gait or balance deficit, Falls related to confusion, Falls related to positioning problems, Falls related to toileting needs, Falls related to syncopal episodes, Falls related to environmental hazards, Falls related to sensory/perceptual problems, Falls related to poor judgement or knowledge deficit.

Based on record review and interview the facility failed to implement care planned fall interventions to prevent a fall for one of three residents (R11) reviewed for falls on the sample list of 13 residents. R11 fell and sustained a displaced spiral humerus (arm) fracture when staff failed to utilize two staff for a transfer and failed to implement nonskid floor strips. Findings include: R11's undated Face Sheet documents an admitted [DATE] and diagnoses of: COVID-19 on 11/9/21, Acute Embolism and [CONDITION(S)] of Deep Veins of Right Lower Extremity and [CONDITION(S)] Right Lower Limb on 11/4/21, Closed Displaced Spiral Fracture of Right Humerus on 11/16/21 and History of Falling and Difficulty in Walking. R11's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 5 out of 15 possible points indicating severe cognitive impairment. This same MDS documents R11 as requiring extensive assistance of two staff for transfers, bed mobility, dressing, toileting and personal hygiene. R11's Care Plan intervention dated 10/11/21 documents R11 requires two staff for transfers when R11 has acute illness. This same Care Plan intervention dated 6/30/20 documents R11 is to have non-skid strips on floor. R11's Fall Scale assessment dated [DATE] documents Fall risk score of 75 indicating R11 as a high fall risk. R11's Physician Order Sheet (POS) dated November 1-30, 2021 documents a Physician order dated 11/4/21 for [MEDICATION(S)] 500 milligrams (mg) twice a day for seven days and again on 11/13/21 twice a day for three days for Right Lower Extremity [CONDITION(S)]. This same POS documents a Physician order dated 11/4/21 for [MEDICATION(S)] 100 mg twice a day for seven days and again 11/13/21 twice a day for three days for Right Lower Extremity [CONDITION(S)]. R11's Nurse Progress Note dated 11/16/21 at 4:40 AM V32 Registered Nurse (RN) documents dependent pitting [CONDITION(S)] in Right Lower Leg and gait is unsteady and balance is poor. R11's Hospital Medical Record dated 11/16/21 documents Patient (R11) stated was being transferred at facility and was dropped by (V31). Complains of pain to right shoulder. Obvious deformity. This same Hospital record documents X-Ray impression: Oblique Fracture of the Proximal Right Humerus and Widening of the Right Acromioclavicular (AC)joint suggesting mild AC joint injury. R11's Final Report to Illinois Department of Public Health (IDPH) dated 11/18/21 documents (R11) was diagnosed with COVID-19 on 11/9/21 and has had increased weakness since getting COVID-19. (R11) has not been able to ambulate and staff has been assisting with transfers into wheelchair. (R11) went to stand up with staff assisting and (R11) feet started to slide out, (V31 Certified Nurse Aide (CNA)) put (V31) forearm under (R11) right arm as (R11) was sliding and that is when (V31) heard a pop sound and lowered (R11) to the floor. Due to right arm pain and no range of motion in right arm, (R11) was sent to the local emergency room for evaluation and treatment. (R11) was noted to have a Closed displaced Spiral fracture of shaft of Right Humerus. On 11/20/21 at 11:15 AM R11 stated the girl (V31 CNA) was trying to get me up when my feet slipped out from underneath me. She (V31) grabbed me to keep me from falling on the floor. (V31) grabbed me under my right armpit and that's when we (V31, R11) heard a loud pop noise. Oh, it hurt so bad. I couldn't move my arm. R11 stated they (facility) didn't do anything wrong but let me fall and break my arm. On 11/20/21 at 3:20 PM V29 Nurse Practitioner confirms R11 was being treated with antibiotics for newly diagnosed Right Lower Extremity [CONDITION(S)] which began on 11/4/21 and was diagnosed with Right Lower Leg DVT (Deep Vein [CONDITION(S)]) on 11/6/21. V29 confirmed that R11 was diagnosed with COVID-19 on 11/9/21. V29 stated COVID-19, [CONDITION(S)] and a DVT are acute illnesses. On 11/20/21 at 2:00 PM V3 Assistant Director of Nurses (ADON) stated (R11) was diagnosed with COVID-19 on 11/9/21 and moved to another room on the COVID-19 unit. We (facility) did not make sure the non-skid strips were on the floor. We (facility) missed it. The non-skid strips should have been on the floor. (R11) fall could have been prevented. V3 confirmed R11 was recently diagnosed with Right Lower Extremity [CONDITION(S)], Right Lower Extremity DVT and COVID-19. V3 confirmed (R11) Care Plan documents R11 needs the assistance of two staff for transfers when acutely ill and that (R11) did not have two people assisting (R11) on 11/16/21 during this incident. On 11/20/21 at 12:40 PM V31 Certified Nurse Aide (CNA) stated I (V31) was trying to get (R11) out of recliner chair to go to the bathroom. (R11) was on COVID-19 unit because (R11) was positive for COVID-19 at that time. (R11) was supposed to have the non-skid strips on (R11) floor but when (R11) had to change rooms to go the the COVID-19 unit nobody put the strips down in (R11) new room. There were no non-skid strips in (R11) room on COVID-19 unit. When (R11) tried to stand (R11) feet slipped out from under (R11) so I (V31) put one hand on the gait belt and put (V31) arm under (R11) right arm to keep (R11) from falling further. That's when we (V31, R11) heard the pop sound. It was awful. If (R11) had the no skid strips or if (V31) had some help (R11) wouldn't have fallen and gotten hurt. I (V31) broke (R11) arm trying to keep (R11) from falling. I (V31) feel terrible about it all. V31 CNA stated I knew (R11) didn't have the no-skid strips on the floor and should have gotten help but transferred (R11) by myself (V31) anyway.

A. Based on record review and interview, the facility failed to conduct thorough investigation into falls to determine the root cause and failed to implement alternate interventions to prevent recurring falls for one of seven residents (R14) reviewed for falls, in the sample of 15. These failures resulted in a fall with facial lacerations and cerebral contusion, requiring hospital treatment. Findings include: According to the physician's orders [REDACTED]. The Minimum Data Sets (MDS) for 5/5/11 and 7/15/11 assess R14 with memory problems, severe to moderate cognitive impairment respectively, behaviors of physical and verbal abuse and rejecting care, requiring extensive assist for ADLs (activities of daily living), and history of falls. The Care Area Assessment (CAA) for Cognitive Loss/Dementia dated 5/5/11 states that R14 "has had a significant decline in her cognitive status. her short-term memory has become more impaired. . . ." The CAA for ADLs states that R14 has "poor sitting balance, she tends to slide down in her w/c. She is unable to stand by herself {due to} poor standing balance. Resident will not remember that she cannot transfer herself and will try to do it herself at times." The CAA for Falls also states that R14 is "unaware of safety issues" and attempts self-transfer at times. The 7/11 POS included the undated order, "May place in geri chair with tray for safety PRN (as needed) May use reclining geri chair with tray when unable to sit upright/balance in w/c (wheelchair) slides and endangering self/fall risk least restrictive. . . ." The Physical Restraint assessment dated [DATE] notes severe pitting edema as a medical symptom for use, and also "sliding forward in w/c - attempting self transfer. . .has no safety awareness." Other interventions listed as "attempted prior to restraint use" include "w/c, recliner in room, 1:1 activities." The Care Plan last reviewed on 5/11/11 states to "Discourage independent transfers. Bed/chair alarm. {check} for safety when alarm is activated. . . . does attempt to transfer self independently in/out of bed. . . . .Encourage to sit {up} straight in w/c - has tendency to scoot down in chair. . ." Nurses Notes and the incident log from 2/11 to present list falls either out of bed or out of the chair on these dates: 2/18/11, 3/7/11, 3/29/11, 4/3/11, 4/13/11, 4/24/11 (times 2), 5/1/11, 6/4/11, 6/28/11, and 7/12/11. The Unusual Occurrence Reports and Fall Investigation Worksheets for these falls show limited investigation. These reports indicate "What action can be taken to prevent a reoccurrence?" and follow-up as follows: 3/7/11 - "encourage res (resident) to use call light/ask for assistance;" 3/29/11 - was found on the floor in the bathroom, had "increased confusion," and an alarm was placed at that time; 4/3/11 - R14 again found on the floor in the bathroom between the toilet and the wall. R14 stated she "was getting off the toilet and lost balance. . ." The action taken is to "Be sure to use fall alarm when in w/c. Continue to remind res to ask for assistance." 4/13/11 - R14 attempted to transfer self to bed and staff responded to alarm sounding. 4/24/11 - at 3:45pm R14 was found on the floor at the foot of the bed, with no alarm sounding. The alarm was applied and at 4:10pm, staff responded to the alarm sounding on R14 on the floor in the bathroom. At that time R14 was "placed in g/c (geri-chair) for safety. Res has difficulty understanding and does not use call light." 5/1/11 - staff responded to the alarm when R14 fell out of the wheelchair in her room while "folding blankets and moving them to her recliner. . ." The action is to "monitor" and the Root Cause Analysis states that R14 "appeared to have lost balance - at {times} leans too far forward - and fell ." 6/4/11 - staff responded to the alarm and found R14 "on knees next to low bed. . ." No action taken was indicated and there was no Fall Investigation Worksheet. 6/28/11 - R14 was again found on her knees by her bed and had been in the wheelchair prior to the fall. The alarm was not attached and "res removed" was on the investigation worksheet. The action was "reminders - alarm in place." On 7/12/11 at 1:50am, Nurses Notes and the Unusual Occurrence Report state, "staff heard res call for nurse. Found res sitting on floor next to bed. . . ." Again the alarm was not on. The action taken was to "continue with low bed and alarm attached. . .Remind to use call light for assist." The root cause for this fall was "confused/forgetful - unaware of safety issues. . ." On 7/12/11 at 10:00am, Nurses Notes state the following: "Housekeeper heard a loud BOOM and someone yelling. Pt (patient) found lying face-down in common area near dining room. A visitor (witness) stated she (R14) tried to stand up from her w/c and fell strait forward landing directly on her face. Large amount of bleeding from nose and mouth. . . . C/o (complains of) pain in nose and mouth. . . .Small chip out of top DL' (left) incisor. . . Upper lip. . .lower lip with small lacerations. . . Soft tissue swelling present nose and upper lip. ." R14 was sent to the hospital. The History and Physical dated 7/12/11 notes, "swollen bridge of the nose. . .upper lip and lower lip lacerations and. . .swelling . . ." The CT (computerized tomography) notes "left frontal lobe cerebral contusion." Nurses Notes and physician's orders [REDACTED]. The Nurses Notes, Unusual Occurrence Report, Investigation Worksheet, and interview with Z2 (witness) on 8/10/11 at 12:00pm, all indicate that there was no alarm sounding or attached at the time of R14's fall on 7/12/11. There was no evidence of thorough investigation or interviews with witnesses or staff. Also, through all the prior incidents, there is no evidence of any other interventions or devices attempted to prevent or reduce falls, other than the alarm and to remind R14 to use the call light. On 8/10/11 at 11:45am, these incidents were discussed with E3 (Director of Nursing) and what alternative devices or interventions were tried with R14. E3 stated she thought they had tried a lap cushion but R14's "stomach was too big." B. Based on interview and record review the facility failed to report and conduct investigations into incidents of resident to resident inappropriate sexual behavior for one of six residents (R15) reviewed with behaviors in a sample of 15 and one supplemental resident(R17). Staff failed to develop and implement individual behavior plans to prevent repeated behaviors. These failures resulted in repeated sexually inappropriate behavior by R15 and R17 toward R29, R28, R27, R14, R13 and R18; and placed R6, R25 and R30 at risk of inappropriate sexual contact. R6, R13 and R14 are three of the 15 sampled residents. R18, R25, R27, R28, R29 and R30 are supplemental residents. Findings include: 1. The July 2011 Physician order [REDACTED]. The Minimum Data Sets ((MDS) dated [DATE] and 7/2/11 state R15 has no cognitive deficit and is independent with locomotion on/off the unit. a. E17, Certified Nurse Aide(CNA) stated on 8/10/11 at 4:10pm that when R15 was first admitted to the facility (4/2/11) he would rub residents' shoulders as if to "calm" the resident. E17 stated during the night one time "when everyone was out of the dining room except (R29), I saw him(R15), he had is hand between her(R29) legs." E17 stated she did not remember reporting the incident to anyone, but thought E18, RN (Registered Nurse) was with her. E17 was unable to identify the date the incident occurred. The Physician Note dated 3/30/11 states that R29 has a [DIAGNOSES REDACTED]. The Nurse's Notes dated 5/2/11 to 6/13/11 do not document any incident with R15. b. E17, CNA stated on 8/10/11 at 4:15pm that R15 would also sit in the hall by R28's room. E17 stated R15 would go into R28's room, but we "never caught (R15) doing anything. One day she(R28) ran into another room." E17 stated this happened with R15 "a lot." E17 stated that E14, LPN(Licensed Practical Nurse) was aware of R15's behavior. E15, CNA, stated on 8/10/11 at 4:25pm that staff first thought R15 was comforting residents by holding their hands. E15 stated that R15 would follow R28 "up and down the hallway." E15 stated that "a family member said that (R15) had his hand up (R28's) shirt." E15 stated she reported the incident to one of the nurses, maybe E14, LPN. E15 stated she heard about the last incident (7/2/11) involving R15 and R14. E14, LPN, stated on 8/10/11 at 4:05pm that when R15 was first admitted "we thought he was comforting them-confused female residents, by the third or fourth day he was here" we knew we had to watch him(R15). E14 stated the first incident occurred approximately within the second week after R15 was admitted [DATE]). E14 stated she heard in shift report that "staff saw (R15) putting his hand on her(R28) upper leg. Also (R15) would try to get his hand up their shirt(R28)." E14 stated that R15 "tried to get close to (R28)." The August 2011 POS states R28 has a [DIAGNOSES REDACTED]. c. E14, LPN, stated on 8/10/11 at 4:05pm that "When staff were busy in rooms with (other) residents, (R15) would prowl, aware of female residents that were relaxed-confused, (would) find (R15) going in their rooms, or sitting outside their (room), especially (R28 and R27)." E14 stated R15 "tried to put his hand up (R27's) shirt." E14 stated she did not witness the incident with R27, but heard staff talking about it. The July 2011 POS states that R27 has a [DIAGNOSES REDACTED]. The Nurse's Note dated 5/12/11 at 12:00pm documents that R27 went into another resident room and "wheeled up to a male visitor and attempted to pull his pants off. Crying 'Please give me some.' Kept trying to unbutton trousers and pull down...." E14, LPN, stated on 8/10/11 at 4:05 pm that she reported the incidents to E20, Former Director of Nursing(DON) and was told to "put him(R15) on a watch." d. The Unusual Occurrence Report dated 7/2/11 at 2:15pm states that R15 "approached a confused resident(R14) in the dining room (both ...in wheelchair). Place his hand on her knee, when he started to advance his hand under her dress and up her thigh, CNA intervened and separated residents." R15's Nurse's Notes dated 7/2/11 at 2:15pm state, "Noted sitting in doorway of room......(R27, R26) looking around. When staff approached....wheeled self out of doorway, then into dining room.....and proceeded to place his hand on (R14's) knee. When (R15) started to advance hand under dress and up thigh was stopped by CNA. Immediately wrote on (communication)board, 'Don't tell. It's my last chance. I'm sorry'......." The MDS dated [DATE] states that R14 has moderate cognitive impairment and behaviors of resisting care. R14's Nurse's Notes dated 7/2/11 do not document the incident with R15.. e. R15's Nurse's Notes contain the following entries: 5/10/11 at 1:30am--"Had to be redirected multiple times (related to) attempting to contact with female resident...."at 6:30pm---".....saw (R15) and a female resident in hall kissing..."; 5/15/11 at 7:30am-"sitting outside a female resident door..." at 9:00am "....staff noticed (R15) writing something on his communication board to a female resident.......staff approached to see what he wrote on the board was 'you want me to go down your pants'......(R15) jerked board away......" ; 6/12/11 at 11:50pm-"...(R15) going into 2 residents rooms...." ; 6/17/11 at 7:20am "...redirected away....then sat outside female resident room....". E16, Abuse Prevention Coordinator, stated on 8/11/11 at 1:00pm that she does not know when the first incident with R15 and a female resident occurred or who the female resident was. E16 stated she did not know who R15 was kissing on 5/10/11. E16 stated the two residents documented on 6/12/11 was R27 and R26. E16 stated the incident documented on 5/15/11 with the communication board and R15 writing to a female resident about getting in her pants was R28. E16 stated she did not know when R15's Physician was notified, but a Psychiatric Evaluation was done shortly afterward. E2, DON, stated on 8/11/11 at 1:15pm that she knew R15 was here for a short time when his behaviors started, but does not know which resident he was "going after" or kissing. E2 stated she knew R15 was going toward certain residents' rooms, but does not know which resident. The Psychiatric Evaluation dated 5/18/11 states, "(R15's)...Able to communicate on a message board and seems to understand and answer questions generally appropriate......(R15) has been acting out sexual behavior towards confused, elderly female residents. He waits until night or the staff is not looking and then seeks out these females, also making sexual comments on his board, attempting to make sexual advances as well.....Able to print answers...give correct month and year, gives me two to one day off as far as a day and the date, does write the reason he is here, because of his inappropriate behavior......Clearly from his brain damage he has a somewhat disinhibited type of behavior.....understands the nature of it but it is unclear whether he really sees this as right or wrong.....reasonable to ....decrease and stop the Celexa......Another possibility.... might be using Depakote...to see if this would help with some of the impulsive behavior, although his behavior appears more purposeful than impulsive, but at this point medications probably may not have a significant effect other than those options. More of a behavioral and restrictive program to restrict and redirect his behavior would be most appropriate." The Care Plan dated 6/29/11 does not identify the sexually inappropriate behaviors R15 was having or identify any interventions for staff to follow. There is no behavior or restrictive program identified on the Care Plan to redirect or restrict his inappropriate sexual behavior. E2, DON, stated on 8/11/11 at 1:15pm that the Care Plan for R15 does not identify his behaviors or have any behavior/restrictive program in place. E2 stated staff were doing 15 minute checks for R15 and he had 1:1 talks with E16. E3, DON, stated on 8/15/11 at 12:40pm there are no Unusual Occurrence Reports or investigations for the incidents with R15 being sexually inappropriate with R27, R28 or R29. E3 stated there is no investigation of the incident on 7/2/11 with R15 being sexually inappropriate with R14. 2. The July 2011 POS states that R17 has [DIAGNOSES REDACTED]. The MDS dated [DATE] and 7/19/11 state R17 has memory/cognitive problems, behaviors, and requires extensive assist with transfer, dressing and hygiene. The Care Plan dated 7/20/11 states that R17 has "inappropriate sexual episodes" with the following interventions: "Provide privacy when needed-Pull curtain...close door. Be firm and direct to discourage behavior during ...care" ; "Place items in left hand to discourage...from grabbing staff during care" ; "Ignore sexual remarks" ; "Do not sit near female residents during activities" and "1:1 supervision at all times when out of room for exercise." The Care Plan does not address that the privacy curtain is pulled to keep R17 from seeing wandering female residents in the doorway, that R17's bed was moved because of an incident with R13 on 5/19/11 or that R17 had a history of [REDACTED]. a. E14, LPN, stated on 8/10/11 at 4:05pm that approximately 2 1/2 to 3 months ago during a storm warning, R17 was out in the hall. E14 stated, "(R17) went to (R13) and brought his hand between her shirt and tried to lift her shirt. E14 stated she then moved R17 to a different location, away from R13. E14 stated the incident occurred prior to the one on 5/19/11. E14 stated she did not report the incident to anyone, just told the staff to watch R17. The Unusual Occurrence Report dated 5/19/11 at 1:00pm states that R13 was found in a male resident's room(R17). "(R17) was in bed and (R13) was next to his bed and (R17) had his hand in (R13's) pants.....(R13) has confusion and could not explain what occurred..." E24, CNA, stated on 8/10/11 at 1:30pm, "I was walking down the hall and heard (R13) yelling 'Stop, Stop'. (R13) was in (R17's) room. (R17) was in the first bed(by door) and (R13) was wheeled up to the bed (in wheelchair). (R17's) good hand was in her pants. (R13) was in the wheelchair-her pants were up, (R17's) hand was down in her pants and brief, she(R13) was hollering stop. I asked (R17) why would you do something (like this)--(R17) said I don't know. (R17) gets perverted with us at times-inappropriate, have never seen him do it (with another resident)." When asked how she thought R13 got into R17's room, E24 stated, "I think she(R13) went to the exit door to look out and (R17) said 'Come here' and she(R13) would come to him(R17). (R17) got her(R13) close enough to get ahold of her." E24 stated staff now pull the privacy curtain so R17 can't see out the door of the room and staff also moved R17's bed over by the window, so it's farther from the door. E16, Abuse Prevention Coordinator, stated on 8/10/11 at 11:25am that she did not do anything with the incident involving R17 and R13 which occurred on 5/19/11. E16 stated that incident(5/19/11) was the only one she was aware of with R17 and R13. E16 stated she did not do an investigation of the incident. E16 stated that R17 has a history of fondling cognitively impaired female residents when he was more mobile, and out at meals he would pull his penis out, which is why R17 only has supervised time out of his room. E16 stated R13 is able to propel herself in the wheelchair and staff try to keep R13 in the common area so they can keep an eye on her. E26, CNA, stated on 8/10/11 at 4:00pm that staff try to redirect other confused residents from going into R17's room. E26 stated confused female residents which have tried to wander into R17's room are R6, R25 and R30. E26 stated that R30 thinks R17 is "her husband." The July 2011 POS states that R13 has a [DIAGNOSES REDACTED]. The Care Plan dated 5/25/11 identifies that R13 self propels her wheelchair throughout the hallway. The Care Plan does not address the incident on 5/19/11 between R13 and R17, or the need for supervision of R13 to prevent a reoccurrence. E25, CNA stated on 8/10/11 at 1:50pm that she is R13's primary CNA during the day. E25 stated she was not aware of the incident which occurred on 5/19/11 between R13 and R17. b. The Nurse's Notes dated 6/5/11 at 10:00am state, "(R17) out of room, in w/c....(R17) sitting in hallway by nurse and another male resident(R18). (R17) wheeled over to male resident(R18) and attempted to stick his hands down (R18's) pants. Nurse intervened and separated (patients), stating 'What are you doing? He's a man not a woman!' (R17) stated, 'Get me a woman then!' (R17) immediately tried to wheel back toward male resident(R18) reaching for his pants......." E19, RN, stated on 8/11/11 at 10:30am that R17 "grabbed the elastic waistband of (R18's) pants and pulled on it(waist band) and tried to get his hands in (R18's) pants." E19 stated that R17 "tried, but did not get his hand actually in (R18's pants). I intervened as I saw it happen." When asked if she filled out an unusual occurrence report, E19 stated, "No report (was filled out) because (there was) no contact." E19 stated she does not think she needed to fill out an occurrence report and is not sure if she reported the incident to anyone or not. E2, Assistant Administrator, and E3, DON, stated on 8/15/11 at 12:40am that they did not think an Unusual Occurrence Report needed to be filled out or an investigation done as E19 intervened. The undated facility Abuse Policy contains the following information: "Events such as unexplained bruising.....on residents, occurrence patterns and trends that may constitute abuse will be monitored and the direction of the investigation will be determined by......Monitoring residents involved in occurrences with other residents by keeping them separated from each other if needed." "Investigation: All unusual occurrences will be addressed by......Completing the unusual occurrence form.....Investigating each incident completely....." "Protection........ Resident to Resident abuse: separating these residents as much as possible without seclusion, care planning to resolve issues, monitoring by staff." C. Based on observation, record review and interview the facility failed to provide secure storage for cleaning chemicals to prevent accidental resident exposure, (R6, R30, and R36) and failed to supervise the dining room to prevent resident access to potential burn hazards from the hot coffee machine and the hot steamtable. (R7, R25). R6 is one of fifteen sampled residents, R30, R36 and R25 are supplemental residents. Findings include: 1. On 8/08/11 at 3:00 pm the lower cabinet in the main living room area was unlocked. A spray bottle of grill cleaner and bleach water was stored in the cabinet. Cognitively impaired residents R6 and R30 were seated near by. 2. On 8/08/11 at 3:10 pm the door to the bathing room on the Middle Hall was open. A wall cabinet with a key in the lock was noted to be open. A spray bottle of Bleach was stored on a shelf in the cabinet at eye level. 3. On 8/09/11 at 12:20 pm residents were eating in the South Dining room . The steam table and coffee was turned on and there were no Dietary or Nursing staff in the dining room with the residents. On 8/09/11 at 1:30 pm cognitively impaired residents R7 and R25 were alone in the South Dining Room. R7 was ambulating and R25 was seated. R7 stated that she was out of sorts , someone took her name sign off of her room and they kept telling her she was in the wrong room. There were no staff present to prevent resident access to the hot steamtable and coffee machine and pots. The steam table was on and the metal on the side was very hot to the touch. A thermal label registered 150 degrees F. Hot coffee in glass pots measuring 182 degrees Fahrenheit (F.) was on the counter on burners of the coffee machine. 4. On 8/11/11 at 10:30 am an unattended Housekeeping cart was parked on the South Wing Corridor outside of room 43 which was near the bird aviary. The Housekeeper was not present in the room, nor in the hallway to supervise the cart and chemicals. Cognitively impaired residents R30 and R36 were seated by the aviary. The chemical storage compartment door was open and there were spray bottles of cleaning chemicals inside. There was a red bucket of liquid on top of the cart and a mop bucket with liquid on the Housekeeping cart. Housekeeper E23 then came out of the South Dining room to the cart. E23 stated she had been in the dining room putting a wet floor sign out. E23 identified the liquid in the red bucket and the mop bucket as the facility house disinfectant.