Every finding on record at Hope Creek Nursing & Rehab

Based on observation, record review and interview, the facility failed to give medications as ordered by the physician to two residents (R1 and R4) of three residents reviewed for medication pass. This failure resulted in four errors out of thirty- two opportunities for a 12.5% medication error rate. The (undated) facility policy, Medication Administration Guidelines, directs staff that medications will be administered following the seven rights of administration: Right Resident, Right Drug, right Dose, Right Consistency, Right Time and Right Route. 1) R4's current Order Summary Sheet, dated August 2026 includes the following medication, Hydrocodone- Acetaminophen Oral Tablet 5/325 MG Give one tablet by mouth every four hours as needed for pain. On 8/3/26 at 10:03 A.M., V3/Agency nurse prepared to administer medications for R4. V3/Agency Nurse withdrew one tablet of Hydrocodone- Acetaminophen 10/325 MG and placed it in a plastic medication cup. V3 entered R4's room and administered the medication to R4. 2) R1's current Order Summary Sheet, dated August 2026 includes the following medications, Cholecalciferol Oral Tablet 25 MCG (Micrograms) Give 1 tablet by mouth one time daily for supplement; Senna Plus oral Tablet 8.6- 50 MG (Milligrams) Give 2 tablets by mouth two times daily for constipation; Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG Give four capsule by mouth two times a day for mood disorder. On 8/3/26 at 10:26 A.M., V3/Agency Nurse prepared to administer morning medications for R1. V3 opened a stock bottle from the top drawer of the medication cart and poured two tablets Vitamin D 10 MCG (Micrograms), and one tablet Senna Plus into a plastic medication cup. V3/Agency Nurse then punched two capsules of Divalproex 125 MG into a plastic medication cup. V3/Agency Nurse then reached into the plastic medication cup with bare hands, withdrew the two capsules of Divalproex, opened them up and placed the powder in the first medication cup. V3/Agency Nurse crushed the rest of the medications, added applesauce and went to R1's room. V3 administered the medications to R1 and left the room. On 8/4/26 at 9:32 A.M., V2/Director of Nurses confirmed that R4 received the wrong dosage of Hydrocodone on 8/3/26. At that time, V2 also confirmed that R1 received the wrong dosage of Cholecalciferol, Senna Plus and Divalproex on 8/3/26.

Based on observation, interview and record review, the facility failed to ensure required fall interventions were in place for one of one resident (R1), reviewed for falls, in a sample of 5.The facility Fall Prevention and Management Program, dated (revised 5/5/2025) directs staff that the purpose of the (facility) Fall Prevention and Management Program is to provide appropriate interventions to prevent falls. This same program directs staff that the facility will provide fall prevention assessment (s) and implement interventions to prevent falls. R1's current Order Summary Sheet documents that R1 was admitted to the facility on [DATE] with [NAME] following diagnoses, Cognitive Communication Deficit, dementia, anemia, lack of Coordination and History of Fractured Pubis. R1's current Fall Risk Assessment, dated 1/16/2026 documents that R1 is at high risk for falls, and has a history of falls on 8/11/25 and 10/16/25. R1's current Care Plan, dated 7/29/25 documents that R1 is at high risk for falls due to decreased strength and endurance and generalized weakness. This same care plan includes the following interventions: A working and reachable call light and a bed in the lowest position. On 8/3/26 at 9:43 A.M., R1 was laying in bed, in his room. R1's bed was against the wall, and at thigh height. One fall mat was present to the open side of the bed. R1's call light was across the room, unable to be accessed by R1. On 8/3/26 at 10:26 AM., V3/Agency Nurse entered to R1's room, to administer morning medications. V3 administered the medications and left the room, not providing R1 with a call light to call for assistance. On 8/3/26 at 12:30 P.M., R1 remained in bed, in his room. R1's bed remained at thigh height. R1's call light was across the room, unavailable to R1. At that time, V4/Certified Nursing Assistant entered R1's room and stated R1 did not get up for the noon meal. V4 stated R1 rarely gets up and as R1 can be very combative. V4/CNA stated R1 had a history of falls. V4 then left the room without ensuring R1's call light was in reach. On 8/3/26 at 3:10 P.M., an observation was made of R1 with V2/Director of Nurses present. V2/DON confirmed R1's bed was not in a low position and R1's lack of a call light. At that time, V2/DON confirmed all residents should have access to a call light, to call for assistance. V2 also verified that R1 has a history of falls, R1's bed should be in the low position and R1 should have access to a call light.

Based on observation, interview and record review, the facility failed to provide grooming assistance for one of three residents (R1), reviewed for grooming, in sample of 5.The facility policy, A.M. Care, dated (reviewed) 01/2018 directs staff that A.M. care will be given to all residents daily and includes oral care, bathing, nail care and shaving. On 8/3/26 at 9:43 A.M., R1 was laying in bed, in his room. R1's bed was against the wall, and at thigh height. One fall mat was present to the open side of the bed. R1's eyes were opened. R1 was alert, but confused, unable to answer any questions. R1's face was unshaven with facial hair on cheeks, upper lip, and chin. R1's fingernails were long and jagged with caked, dark brown matter under the nails. [NAME] matter was smeared on the window curtain that rested on R1's bed. Additional brown matter was smeared on the wall near the curtain. A band-Aid was present to R1's left temple and a white self-adhering bandage was present to R1's left elbow. R1's call light was across the room, unable to be accessed by R1. On 8/3/26 at 12:30 P.M., R1 remained in bed, in his room. At that time, V4/Certified Nursing Assistant (CNA) entered R1's room and stated R1 did not get up for the noon meal. V4/CNA stated R1 rarely gets up as R1 can be very combative. V4/CNA stated R1 feeds himself and stated she finished feeding R1 his lunch. V4/CNA stated residents are supposed to get a shower twice weekly and stated she was unsure if R1 had received any showers in the past month. V4/CNA confirmed the brown substance on R1's wall and curtains was feces. V4 states (R1) plays in his poop. V4 also confirmed the caked brown matter under R1's fingernails and his facial hair. V4/CNA stated (R1) was hard to take care of., as he could be combative. At that time V4 left the room without ensuring R1's call light was in reach. On 8/3/26 at 3:10 P.M., during an observation of R1 with V2/Director of Nurses (DON) present,V2/DON confirmed R1's long facial hair, and dirty fingernails.

Based on interview and record review, the facility failed to prevent resident to resident abuse for one of three residents (R3), reviewed for abuse, in a a sample of 5.The facility policy, Abuse Prevention program, dated (revised) 01/2019 directs staff that it is the policy of the facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment and misappropriation of resident property. This same policy defines physical abuse as hitting, slapping, punching, kicking. R2's facility admission Record documents that R2 was admitted to the facility on [DATE] with the following diagnoses, Moderate Dementia with Behavioral Disturbances, Post- Traumatic Stress Disorder, Anxiety and Depression. R2' current care Plan, dated 2/6/26 includes the following Focus Areas: (R2) has a history of aggressive, inappropriate, attention-seeking and/or maladaptive behavior, but has demonstrated stability during the admission screening process & is therefore considered appropriate for admission. The history includes: Verbal or physical aggression. R2's Nursing Progress Notes, dated 2/12/26 document, (R2) hitting staff and attempted to hit another resident with a controller. Resident punching, kicking, clawing, attempting to bite, swinging chair controller at staff, and spitting on staff. All the time he was screaming for us to get out of his house. Attempts to redirect, offer comfort cares, all went unwanted. R2's Nursing Progress Notes, dated 3/20/26 document, (R2) redirected multiple times throughout this shift d/t hitting, kicking, screaming at family members and other resident's. Also refusing cares. No success with redirection. The facility Incident Report, dated 7/9/26 at 2:20 P.M. and signed by V2/Director of Nurses documents, Nurse noted alleged physical altercation between peers (R2 and R3). Per investigation and supporting documents, (R3) was witnessed to be propelling past (R2), while he was sitting in a recliner when he got into R2's personal space causing (R2) to become startled and defensive. (R2) rose up and contacted (R3)'s face. They were immediately separated from one another and assessments completed. No injuries were identified. R2 was placed on 1:1 supervision and was transferred to local emergency room for evaluation for new onset aggression. R2 returned with no new orders. Facility determines root cause to be related to R2's history of war flashbacks and being easily startled. New interventions include: R2 has remained on 1:1 supervision while being monitored for any signs/symptoms of aggression. Medications have been reviewed by facility doctor and psychiatric services. Family members have been at bedside/chairside to visit. R2's recliner was moved to create an ease of access pathway in the day area. On 8/4/26 at 9:12 A.M., V5/Certified Nursing Assistant (CNA) verified she had witnessed the physical altercation between R2 and R3 on 7/9/26. V5 confirmed the altercation occurred in the early afternoon and happened in the facility MDR/Activity Room. V5 states she witnessed R3 attempt to wheel past R2's recliner when R2 jumped up and hit R3 with a closed fist to the chin area. V5 states she immediately separated the two residents and V6/Licensed Practical Nurse who was in the area, responded right away. On 8/4/26 a review of V6/Licensed Practical Nurses' written statement documents, I was standing at the medication cart and heard (R2) say get out of my house. I looked up and (R3) was wheeling past (R2) in his wheelchair. (R2) stood up from his recliner chair and closed fist swung at (R3). I did not see contact made, but (V5/CNA) confirmed that (R2) did make contact with (R3)'s face.

Based on observation, interview and record review, the facility failed to ensure a call light was in reach for one of one resident (R1), reviewed for call lights, in a sample of 5.The facility policy, Call Lights: Accessibility and Timely Response, dated August 2025 directs staff that the purpose of this policy is to assure the facility is adequately equipped with a call light at each resident's bedside, toilet and bathing facility to allow residents to call for assistance. Staff will ensure the call light is within reach of resident and secured. On 8/3/26 at 9:43 A.M., R1 was laying in bed, in his room. R1's bed was against the wall, and at thigh height. One fall mat was present to the open side of the bed. R1's eyes were opened. R1 was alert, but confused, unable to answer any questions. R1's face was unshaven with facial hair on cheeks, upper lip, and chin. R1's fingernails were long and jagged with caked, dark brown matter under the nails. [NAME] matter was smeared on the window curtain that rested on R1's bed. Additional brown matter was smeared on the wall near the curtain. A band-Aid was present to R1's left temple and a white self-adhering bandage was present to R1's left elbow. R1's call light was across the room, unable to be accessed by R1. On 8/3/26 at 10:26 A.M., V3/Agency Nurse prepared to administer morning medications for R1. V3/Agency Nurse administered the medications and left R1's room, not providing R1 with a call light to call for assistance. On 8/3/26 at 12:30 P.M., R1 remained in bed. V4/Certified Nursing Assistant (CNA) entered R1's room and stated R1 did not get up for the noon meal. At that time V4/CNA left the room, without ensuring R1's call light was in reach. On 8/3/26 at 3:10 P.M., an observation of R1 and R1's room was made with V2/Director of Nurses (DON) present. V2/DON confirmed R1's lack of call light. At that time, V2/DON confirmed all residents should have access to a call light, to call for assistance.

Based on observation, interview, and record review, the facility failed to ensure the kitchen ceilings are free of dirt and debris. This failure has the potential to affect all residents residing in the facility with a current census of 162 residents.The Facility Resident Census Roster and Facility Matrix/802, dated 7/24/26, were reviewed. The Census Roster documented 162 Residents resided in the Facility. The facility policy, entitled Sanitation/Infection Control, document: the dietary manager is responsible for supervising all sanitation, and housekeeping procedures within the dietary department; monthly or more often as needed walls, ceilings, and shelves are clean thoroughly. Vents lights, cupboards, windows and screens are cleaned. On 7/24/26, at 9:00 a.m., during the kitchen tour, with V9/Dietary Manager, heavy dirt/debris was observed on the ceilings throughout the kitchen cooking/dish washing/food preparation/food serving areas. The dirt/debris was more prominent where ceiling vents are located. During tours, of the kitchen, V9 confirmed the ceiling is dirty and I assume maintenance [is responsible for cleaning ceilings/vents], but he [maintenance] has only been here for one week.

Based on observation, interview and record review the facility failed to maintain the resident call light system in working order for 4 of 5 residents (R1, R2, R8, R13) reviewed for call lights in the sample of 13.The findings include:1.On 6/15/26 at 9:25 AM, R1 and R2 were seated in bed in their room. R1's call light hung on the wall behind R1's bed. R1 stated, My call light hasn't worked in weeks. R1's call button was pressed. R1's call light was not functioning as it did not light up or beep. R2's call light hung on the wall behind R2's bed. R2 stated, My call light doesn't work either. Mine hasn't worked in a long time. R2's call button was pressed. R2's call light did not work as it did not light up or beep. At 9:36 AM, the call light in R1 and R2's shared bathroom was tested and found to be not working.On 6/15/26 at 10:37 AM, V13 Licensed Practical Nurse (LPN) stated that when a resident's call light is pressed, staff are alerted by the computer at the nurse's station on the unit. V13 stated the computer screen will show the room number of the resident needing assistance. V13 stated the computer screen will also beep until the resident's call light is answered. At 10:39 AM, R1's call light button was pressed. The computer monitor at the nurse's station was observed by the surveyor and V13 LPN. The monitor display did not show R1's call light was activated. The monitor did not beep. V13 stated, (R1's) light probably doesn't work. We need a new call light system. This happens a lot. If his call light was working, it would show up on the computer screen.On 6/15/26 at 11:43 AM, V18 Maintenance Director stated all facility staff are responsible for ensuring the call light system is in working order.2. On 6/15/26 at 10:15 AM, R13 stated that her call light was not working, she knew because she activated her call light last night and none of the staff responded. This morning R13 said she informed the nurse (V13 LPN) that her call light was not functioning. At 10:30 AM, V13 (LPN) confirmed that R13 reported that her call light was not working however she had not had a chance to check or to report the issue to Maintenance. V13 showed this Surveyor a monitor located in the Nurses station to show when residents call lights were on, their room number lights up in the monitor. This surveyor asked R13 to activate her call light. R8's (R13's roommate) call light was also pressed. The call light monitor in the Nurse station did not light up. The monitor did not show that R13 or R8's call lights had been activated. V13 said call light should be in good order so that staff can be notified of and respond to residents' needs.The facility's Call Lights: Accessibility and Timely Response policy (undated) showed, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on observation, interview and record review the facility failed to ensure residents that were dependent on staff with toileting were provided Activities of Daily Living (ADL) for 2 of 8 residents (R7 and R6) reviewed for ADL care in the sample of 13. The findings include:1.R7's electronic face sheet shows R7 has diagnosis that includes dementia with psychotic disturbances and anxiety.R7's facility assessment dated [DATE] shows R7 was always incontinent with bladder functions.On 6/15/26 at 9:52 AM, V4 (Certified Nursing Assistant-CNA) toileted R7 after breakfast. R7 was noted to be wearing 2 incontinent pads (double diapered) R7's incontinent pad was saturated with urine. V4 said she did not get up R7, (V5 CNA did). V4 stated R7 should not wear two diapers, R7 just needed to be toileted more often at least every two hours and as needed.R7's care plan dated 3/25/22 documents I have functional bladder incontinence r/t (related to) Dementia, Impaired Mobility, Physical limitations with intervention to include, Check the resident q (every) 2 hours and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes.2. R6's electronic face sheet shows R6 has diagnoses that include dementia and hypertension.R6's facility assessment dated [DATE] show R6 is always incontinent of urine. On 6/15/26 at 10:15 AM, V5 (CNA) toileted R6 after breakfast. R6 was noted to have 2 incontinent pads (double diaper) R6 was totally soaked with urine. V5 said R6 leaks when wearing only one incontinent pad. V5 said the Dementia Unit also gets to be too busy.R6's care plan dated 6/16/25 shows R6 has functional bladder incontinence related to Dementia toilet with appropriate staff assistance every 2 hours as needed.On 6/15/26 at 1:30 PM, V3 (License Practical Nurse-LPN) said applying two incontinent pad (double diaper) was not allowed at all the facility. The staff have been educated not to do these. {Double diaper} traps moisture, it causes infection and skin breakdown. If a resident has frequent urinary incontinence, the resident should be checked and changed more often rather than placing two incontinent pads. (Double diapers.)The facility Policy entitled Guidelines for Incontinence Care (undated) show, it is the policy of the facility to ensure that residents receive as much assistance as needed for cleaning the perineum and barracks after an incontinent episode or with routine daily care.

Based on observation, interview and record review the facility failed to provide a clean, comfortable, homelike environment for 1 of 5 residents (R1) reviewed for physical environment in the sample of 13.The findings include:R1's current care plan showed R1 had a colostomy in place to his abdomen. R1's colostomy allowed R1's stool to drain into a bag through a stoma (surgical opening) from R1's abdomen. On 6/15/26 at 9:23 AM, a moderate amount of a dried brown substance was noted on the handles of R1's walker. When R1 was asked what the substance was on his walker, R1 stated, That's poop. I tried to change the bag on my colostomy the other day. On R1's windowsill, directly next to his bed, dried stool was noted on a washcloth, a pair of scissors, and a box of colostomy bags. Multiple dried brown stains were noted on the privacy curtain next to R1's bed. When R1 was asked when his room was last cleaned, R1 stated, A guy (housekeeper) was just here this morning. He mopped and emptied my garbage. My stuff really needs to be washed down. That curtain has been dirty for a while. On 6/15/26 at 12:04 PM, V19 (Family of R1) stated, (R1's) room is filthy. I have come in and he has poop on his tables. That (privacy) curtain has been dirty for a long time. On 6/15/26 at 11:35 AM, V17 Housekeeping Director stated all resident rooms are to be cleaned daily which included wiping down resident tables, beds, chairs, and equipment. V17 stated privacy curtains should be assessed by housekeeping staff and replaced if soiled. The facility's Resident Room Cleaning and Sanitation policy (undated) showed, Resident rooms shall be cleaned and sanitized routinely and as needed to promote resident safety, comfort, dignity, and infection prevention. The policy showed resident nightstands, tables, and chair arms/handrails will be cleaned daily. The policy showed, Equipment visibly soiled with blood or bodily fluids shall be cleaned and disinfected immediately.

Based on observation, interview, and record review the facility failed to ensure Physician Progress Notes and orders were maintained with a resident's record and followed promptly. The facility failed to ensure accurate and complete monitoring of a surgical site was being completed. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 4.The findings include:On 4/12/26 at 9:48 AM, R1 was in bed on her back with head of bed elevated slightly. R1 had a gown on and incontinence brief. R1 had a healed surgical scar to the middle outer area of her right leg. R1 had a small abrasion above the surgical site that she stated was from the hinge brace. R1 stated she had surgery and then came to the facility. R1 said she had to go back to the hospital for another procedure because she had an infection to her leg.The Progress Note dated 2/24/26 for R1 stated she was asking about her antibiotic start date. A call was placed to the surgeon's office and the nurse said there wasn't one ordered. The wound nurse removed R1's immobilizer to look at the surgical site, replaced a couple of steri-strips that had been falling off. There was minimal serous drainage and light redness present. The area was cleansed, antibiotic order obtained and processed and R1 was to follow up on 2/27/26.The Physician's Progress Note from R1's visit to his office on 2/20/26 was not in the resident's record. The note was located by V2 Director of Nurses once the surveyor requested the document on 4/12/26. The Orthopedic Physician Progress Note dated 2/20/26 for R1 showed she was doing okay; continue the knee immobilizer; remain non-weight bearing on right lower extremity; leave steri-strips in place; follow up in one week for a wound check; and cephalexin 500 mg three times per day for seven days. This order was written on 2/20/26 but not located or processed by the facility until 2/24/26.On 4/12/26 at 12:20 PM, V2 Director of Nursing - DON stated the Orthopedic Physician Progress Notes dated 2/20/26 for R1 said to continue the knee immobilizer and leave steri-strips in place, follow up in 1 week for a wound check. No other wound care orders. R1 was started on cephalexin at that visit because he thought she had a cellulitis. V2 stated the visit was on 2/20/26 and the antibiotic wasn't started until 2/24/26 because they couldn't locate the paperwork. V2 stated R1 asked out her antibiotic and they didn't know anything about it, so V4 Wound Nurse called the doctor's office and the nurse there said one wasn't ordered. The nurse then called back later and said an antibiotic was ordered. V2 stated they later located the Physician Progress Note and got it ordered.On 4/12/26 at 12:42 PM, V4 Wound Nurse stated she put a note in R1's medical record on 2/24/26 about R1, the antibiotic and what happened. V4 stated R1 came up to her and asked about her antibiotic because the orthopedic physician said she was getting one. V4 stated she called the doctor's office, and his nurse told her that R1 was not placed on an antibiotic on 2/20/26 at her appointment. The nurse did not see it in the notes for R1. V4 stated she then looked around the facility and at the nurse's desk she found the Physician's Progress Note dated 2/20/26 for R1 with the antibiotic order. V4 stated she initiated the order for the antibiotic that day (2/24/26). The doctor's office also called back and said right before R1 was leaving the doctor's office he decided to put her on an antibiotic for cellulitis. V4 stated R1 had steri-strips in place after that visit and no dressing orders.On 4/12/26 at 2:27 PM, V1 Administrator stated the only way we could fix this issue was to follow up when they return and check for the paperwork, looking for the orders. If there isn't any paperwork, then we call and ask for the paperwork.The February 2026 Treatment Administration Record - TAR for R1 showed staff were monitoring a surgical site to R1's right leg. Leave surgical dressing in place until follow up unless dislodged or soiled, Notify medical doctor of any changes, signs or symptoms of infection every shift. Staff were signing off that this was being done; however, as of R1's 2/20/26 physician appointment she no longer had a dressing in place and had steri-strips. The March 2026 TAR for R1 up to 3/6/26 showed the same thing. R1's TAR's did not reflect the drainage or redness at R1's surgical site on 2/24/26. R1's medical record did not show any documentation of an infection to R1's surgical site.The hospital History & Physical/Discharge/Consult information dated 3/10/26 for R1 showed she was admitted to the hospital with purulent drainage from her surgical wound. R1 was admitted for a superficial wound infection. R1 was taken for an incision and drainage per orthopedics on 3/7/26, no deep tissue infection or abscess was found. R1 was started on antibiotics, and her cultures grew methicillin resistant staphylococcus aureus - MRSA.On 4/12/26 at 12:20 PM, V2 DON stated R1 was admitted to the hospital from her follow up orthopedic physician appointment for an incision and drainage to her surgical site. V2 stated R1 was re-admitted to the facility on [DATE] with dry dressings. V2 stated nurses are to monitor for any redness, drainage, and signs and symptoms of infection. On 4/12/26 at 12:55 PM, V2 DON stated they did not change the order on the TAR to show that R1's steri-strips along with the surgical site were being monitored. V2 acknowledged this should have been changed on the TAR.The facility's Conformance with Physician Medication Orders policy (no date) showed, all medications.shall be given only upon the written order of a physician. These medications shall be given as prescribed by the physician and at the designated time. A complete and accurate listing of current medication orders will be maintained on the resident's Physician Order Sheet.The facility's Change in Condition policy (May 2025) showed all facility staff must remain alert to changes in condition in all residents. Upon recognition of a change, appropriate nursing and medical interventions must be initiated promptly to address the residents' needs. The interdisciplinary team will ensure the change is assessed, documented, and communicated according to federal and state guidelines. All assessments, notifications, and interventions must be documented in the medical record. Include date, time, observed change, who was notified, recommendations, and outcomes.The facility's Skin Condition Monitoring policy (no date) showed it is the policy of the facility to provide proper monitoring, treatment, and documentation of any resident with skin abnormalities. Documentation of the skin abnormality must occur upon identification and at least weekly thereafter until the area is healed. Documentation of the area must include the following: size, shape, depth, odor, color, presence of granulation or necrotic tissue. Treatment and response to treatment.

Based on observation, interview, and record review the facility failed to ensure fall interventions were implemented for a resident who is at a high risk for falls. This failure resulted in R1 being found in her room, laying on the floor, sustaining a comminuted right humerus fracture requiring surgical interventions. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 8. The findings include: R1's Final Incident Report shows R1 is [AGE] year-old female, cognitively impaired. On 1/17/26 at 8:00 AM, R1 was found laying on the floor next to her bed with severe complaints of right arm pain. R1 was sent to the local hospital for evaluation. R1 sustained a right humerus fracture with surgical intervention.R1's Fall Risk assessment dated [DATE] shows she is HIGH risk for falls. On 03/20/26 at 10:07 AM, R1 was residing on the memory care unit. R1 was in her room sitting in her wheelchair. R1 was wearing an immobilizer to her right arm. R1 was alert to self and forgetful. R1 said she fell at a restaurant and could not recall the details regarding the fall. R1's room did not have signs posted to call and ask for help, there were no fall mats in her room, and there were no non- skid strips in front of her bed or in her bathroom. On 3/20/26 at 11:01 AM, V6 (Agency LPN) said on 1/17/26, she was passing morning medications and the aide reported that R1 was on the floor in her room. V6 said she entered R1's room and she was lying on the floor complaining of right arm pain. She called the paramedics and R1 was sent out to the local hospital. V6 said she thinks R1 was trying to get back in bed after breakfast. R1 is alert and forgetful, is a fall risk, has a history of self-transferring, and required one person assist with transfers. On 3/20/26 at 11:15 AM, V8 (Certified Nursing Assistant-CNA) said on 1/17/26, she heard yelling down the hallway. She found R1 laying on the floor in her room. I think she was trying to self-transfer from her wheelchair to her bed. R1 was complaining of pain to her right arm. The nightstand was behind her, and it appeared R1 fell backwards. V8 said R1's room was the last room at the end of the hall. V8 said she called for assistance when she found R1 on the floor. On 3/20/26 at 11:26 AM, V9 (Former CNA) said R1 was alert and oriented, she would always self-transfer and R1 was independent with transfers. (R1) was always independent. R1 would always say she didn't need help. R1 would normally eat in the dining room and go back to her to lay down. V9 said the last time she saw R1 was about 7:45 AM, self-propelling in her wheelchair going to her room. R1 was able to self-transfer, and she did not think to ask R1 if she needed assistance. V9 said they should check the electronic health record to check if the resident is a fall risk and how they transfer. V9 said she did not know R1 needed staff assistance with transfers. On 3/20/26 at 11:42 AM, V10 (CNA) stated, I don't think R1 was a fall risk. R1 always transferred herself, she always took herself to the bathroom. R1 was safe to self-transfer, and she did not use her call light assistance. V10 said and she does not remember if R1 had any falls prior. V10 said they should check the residents electronic record for the resident's transfer status and fall interventions. On 3/20/26 at 12:57 PM, V2 (DON) said she was on a leave absence from November 2025 to February 2026. The ADON (Assistant Director of Nursing) was reviewing the falls at that time. V2 said R1 fell in her room and sustained a right humerus fracture that required surgical intervention. When R1 returned, she was placed on the memory care unit for increased supervision. R1 is confused, had a history of falls and self-transferring. R1 would forget to ask for help, she thinks she can still do things on her own and forgets her limitations. Staff should assist her with transfers and required supervision for safety. R1 was not independent for transfers and required staff assistance. Staff should check the resident's electronic health records for their transfer status. When a resident transfers to a different room their fall interventions should follow them. R1 should still have fall interventions in place. On 3/20/26 at 2:05 PM, V1 (Administrator) said even he knows R1 is a fall risk, we have been working on falls as part of our of PIP (performance improvement plan) and educating staff to look on the residents Kardex or care plan if a resident is fall risk, how the resident transfers and ensuring fall interventions are in place. R1's current care plan initiated on 2/1/24 shows she is at risk for falls related to weakness, impaired gait and balance, requires assistance for bed mobility and transfers. Interventions include cues placed in room to ask and wait for assistance, non-skid strips at bedside, non-skid strips in front of toilet, low bed, call light within reach, and apply floor mats to right side of bed. R1's hospital records dated 1/26/26 show R1 sustained a communicated (bone has broken into more than two pieces) right humerus fracture from a mechanical fall. R1's Fall Prevention and Management Program Policy dated 5/2025 states, The purpose of our Fall Prevention and Management Program is to provide our residents with an interdisciplinary approach to assess risk for falls, provide appropriate interventions to prevent falls.

Based on observation, interview, and record review the facility failed to identify a pressure wound prior to becoming a stage 3 for a resident at risk for pressure ulcers (R1) and failed to ensure pressure relieving interventions were implemented for 2 of 3 residents (R1, R4) reviewed for pressure ulcers in the sample of 7.The findings include:1. R1's face sheet showed she was admitted to the facility 1/30/23 with diagnoses to include hemiplegia and hemiparesis, arthritis, secondary gout, hyperlipidemia, hypothyroidism, stage 3 chronic kidney disease, depressive episodes, Parkinson's disease, and pressure ulcer of left buttock. R1's facility assessment dated [DATE] showed she had severe cognitive deficits, was dependent on staff for most cares, and was at risk for developing pressure ulcers. R1's 1/15/26 Weekly Wound Evaluation showed, . Sacrum. Pressure Injury (In-House Acquired) . Stage 3. Length: 5 cm. Width: 1.5 cm. Depth: UTD (unable to determine) . R1's care plan initiated 7/31/24 showed, [R1] has the potential and actual impairment to skin integrity of the sacrum related to fragile skin, incontinence; Pressure area to sacrum (1/15/26) . R1's care plan initiated 2/15/23 showed, [R1] is at risk for skin breakdown related to hemiplegia/hemiparesis, impaired mobility. Assess for and provide appropriate pressure relieving devices. Assess for changes in skin condition each shift. On 2/22/26 at 9:35 AM, R1 was lying in her bed. R1's tan inflatable heel protector boots were observed to be under the edge of the dresser nearby R1's bed. R1's heels were lying directly on R1's air mattress. On 2/22/26 at 12:54 PM, R1 was receiving wound care by V6 (Wound Care Nurse). V8 CNA (Certified Nursing Assistant) was assisting V6 to position R1. R1 was lying in bed during care, she was observed to be wearing blue heel protector boots on both feet. V6 said R1 does not have any wounds on her heels. V6 said there is no order for R1 to wear heel protector boots, but she feels R1 should wear heel protector boots due to her condition and that is the reason the boots are in place. The tan heel protector boots were no longer under the dresser. V6 said she brought R1 new heel protector boots because her old ones were dirty. On 2/22/26 at 1:24 PM, V12 LPN (Licensed Practical Nurse/Treatment Nurse) said R1's sacral wound was identified when a CNA was getting R1 up for the day and told me she had a wound on her bottom. V12 said it is her understanding that the nurses should be documenting a weekly skin check. The reason to do weekly assessments is to make sure people aren't developing wounds and do to add more preventative measures. We would want to know about the wound right away so if the staff see breakdown happening, we will want to address it rapidly. V12 said she doesn't believe R1 wears heel protectors. On 2/22/26 at 2:57, V2 DON (Director of Nursing) said, . I would prefer the wounds be identified as soon as possible to prevent them from getting worse. I would expect her to have the low air loss mattress, heel protector boots. If she is bed bound, I don't think it would hurt her to wear hell protectors or have her heels floated. The facility's policy and procedure dated 5/20/23 showed, Guidelines for Preventative Skin Care. Guideline: It is the intent of the facility to provide residents with preventative skin care. to keep them clean, comfortable, well groomed and free from pressure sores. All residents will be provided a preventative pressure reducing mattress. Further, residents will have the results of their Braden Scale scores and Weekly Skin Assessments used as an indicator as to their specific Preventative Skin Care needs. Equipment: . 4) Heels Up or specialty order therapeutic boots. Procedure: Positioning pillows and/or specialty devices may be used between two skin surfaces or to slightly elevate bony prominences/pressure areas off of the mattress. Offloading must be provided as indicated to provide pressure relief. Heels Up or specialty ordered therapeutic boots may be used to protect heels on those residents identified as being high risk for potential skin breakdown. NOTE: Should a caregiver notice any alteration in a resident's skin to include a scratch, skin tear, bruise or discolorations, redness, rash, any broken skin or any other unusual observation will be reported immediately to the Charge Nurse for assessment and appropriate follow up. 2. On 2/22/26 at 11:13 AM, V6 (Wound Care Nurse) was at R4's bedside providing wound care to an unstageable wound to his coccyx. R4 was on an air mattress that was set to firm. R4 had a pressure relief cushion in his wheelchair that was flattened and torn with the foam inside coming out. V6 confirmed the cushion was worn and stated she would replace it. V6 stated the cushion was for pressure relief. V6 was asked to check R4's mattress and she stated it was set too high; it was set on firm and should be set to his weight. V6 asked R4 if he liked his mattress hard or wanted it soft and he seemed confused by what she was asking. On 2/22/26 at 1:00 PM, V2 Director of Nursing - DON stated if a resident has a pressure ulcer they will put a low air loss mattress, have a cushion to their wheelchair, and they may have boots to offload heels. The low air loss mattresses go off the resident's weight. V2 stated the cushions for pressure relief are checked by the wound nurse The Weekly Wound Evaluation dated 2/16/26 for R4 showed an unstageable pressure injury to his sacrum; 5 cm x 2.8 cm x 0.1 cm; moderate serousanguinous drainage present with a strong odor. Education was provided on the importance of off loading, verbalized understanding. Wound location changed from right buttocks to sacrum due to wound exacerbation. Low air loss mattress ordered. The Weight Documentation dated 2/9/26 for R4 showed a weight of 197 pounds. The Care Plan dated 1/19/26 for R4 showed the resident admitted with a pressure ulcer of the right buttock related to immobility. The care plan did not show pressure ulcer preventative measures/pressure ulcer relieving devices in place.

Based on observation, interview, and record review the facility failed to maintain a safe environment, provide adequate supervision, and implement necessary assistive interventions for three (R1, R2, and R3) of three residents reviewed for falls. These failures resulted in repeat falls or injury events, some with head trauma, lacerations, and hospitalizations. Findings include: The facility's Fall Prevention and Management Program revised 5/5/2025 documents the purpose of the Fall Management Program is to provide residents with an interdisciplinary approach to assess risk of falls and provide appropriate interventions to prevent falls. The facility will ensure that in an event a fall occurs, the fall will be investigated, appropriate treatment will be provided, and additional interventions will be implemented to prevent another fall from occurring as much as possible.1) R1's Hospital Discharge paperwork dated 8/5/25 documents R1 had a fall prior to admission. R1 was taken to local emergency room where R1 was admitted with a subdural hematoma and subarachnoid hemorrhage.R1's census line documents R1 was admitted to the facility on [DATE] for therapy.R1's current care plan did not include Fall Interventions on admission.R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and is dependent on facility staff for toileting.R1's Fall Risk assessment dated [DATE] documents R1 is high risk for falls.R1's Nurse Progress Note dated 8/21/25 at 4:25 AM, documents R1 was found sitting on the floor near her bed and was assisted by two unidentified staff members to the restroom after the fall. This note further documents R1 denied hitting her head and V12 (R1's Family Member) chose to not have R1 sent to emergency room for evaluation.R1's current care plan documents on 8/25/25 a Fall Care Plan was initiated for R1 to be toileted every three hours.R1's Toileting Task was not added to the Kardex (resident information) until 9/18/25 for staff documentation.R1's medical record does not contain documentation of when R1 was last toileted on 8/21/25.On 10/9/25 at 1:00 PM, V14 (CNA), stated staff use a sit to stand to transfer R1, and there is a sign at nurses' station that shows residents' transfer status. V14 further stated if it's not on the sheet then V14 just asks someone. V14 stated she does not know how to find transfer status in the electronic charting because they are often not updated. V14 confirmed she was not aware R1 was on a toileting schedule.R1's medical record does not contain documentation of when R1 was last toileted on 9/2/25. R1's Change in Condition Evaluation dated 9/2/25 at 11:56 PM, documents R1 was found on the floor in her room in front of the bathroom door with active bleeding to the back of her head. This note further documents there was dried blood on the floor next to R1 and by the side of R1's bed. R1 was sent to the local emergency room by ambulance.R1's emergency room Physician Notes dated 9/2/25 at 11:15 PM document R1 arrived at the local emergency room after an unwitnessed fall in the facility. R1 was found crawling on the floor near her window in her room. R1 had noticeable bleeding on the back of her head. R1 is also on Eliquis for previous blood clots. R1 has dementia.R1's Computed Tomography (CT) of Head Final Report dated 9/2/25 documents R1 has a small subdural hematoma along the right anterior falx measuring two millimeters (mm) and a right posterior scalp laceration/contusion.R1's Physician Final Report dated 9/3/25 documents R1 arrived at local emergency room after sustaining a fall and hitting her head. This note documents The CT scan of abdomen pelvis revealed a small intracranial bleed.R1's Nurse Progress note dated 9/3/25 documents R1 returned to the facility with a laceration of the head, subdural hematoma, and contusion to the right hip. R1 noted to have eight staples intact to back of head. R1's care plan documents on 9/3/25 R1's care plan was updated to rearrange the furniture and move the nightstand in the room to be further from the bedside On 10/9/25 at 9:01 AM, R1's nightstand was next to the head of the bed.On 10/9/25 at 10:03 AM, R1s current care plan documents on 10/9/25 care plan was updated to reflect R1 had an alteration in skin integrity related to laceration from fall on 9/2. This same care plan was also updated on 10/9 to reflect R1 has a potential for complications related to Subdural Hematoma that occurred on 9/2. R1's current care plan does not document R1s transfer status or R1s Activities of Daily Living (ADL) care plan. On 10/9/25 at 10:18 AM, V6 (Minimum Data Set/MDS Nurse) We (facility staff) have two people who do MDS / care plans. I went through R1's care plan this morning and noticed some things were not added. The other MDS nurse is newer and is on vacation, and I realized items needed to be added to R1's care plan today, so I added them. The Kardex is how staff see/document how residents transfer, toileting, eating, bathing, and dressing, and personal hygiene cares. It's hard to keep up on updating because it changes so much. V6 further stated that R1's care plan did not include her transfer status or activities of daily living (ADL) status until that morning. V6 acknowledged that workload and staffing (e.g. training a newer MDS nurse) contributed to the delays in updating care plans accurately and timely. V6 confirms that in order for CNAs to be able to chart in the tasks the care areas must be added to the care plan first. On 10/9/25 at 11:00 AM, V10 (Certified Nursing Assistant/CNA) stated that she began her shift around 10:00 PM on 9/2/25. Three female residents were still up in the dining area, and V7 (CNA) told them to go to bed. V7 asked V10 to assist with R1's roommate, who needed a shower. V10 reported, We were walking down the hallway and V7 said R1's roommate needed a shower, so we walked her to the shower room. V10 stated she was in the shower room with the resident when V7 left to get the resident's clothes. V10 heard V7 yell out for V8 (Licensed Practical Nurse/LPN), prompting her to open the shower room door. V10 observed R1 on the floor in her room, close to the door, bleeding from the back of her head. V10 stated she remained in the shower room to assist the resident she was with but heard V8 say, R1 was put to bed too early and may not have been toileted correctly. V10 described, R1 fell by her bed, which is where the dried blood was on the floor. I had to clean the blood up after I was done with the shower. There was a dried puddle of blood by the bed and droplets of blood leading to the door where R1 was sitting. There was also a blood spot on the chair that's used to prop the door open, but the chair had not been in place, so the door was closed. V10 stated, I'm pretty sure (R1) was on the floor for a while. V10 further stated she has worked at the facility since April of 2025 and feels that staff are not being trained properly on the floor and don't know where to find information on residents.V10 stated information on residents is often not on the electronic Kardex (resident information), and It makes it very hard to work here because we never know what's happening.V10 stated Sometimes I'm concerned about losing my license. V10 further stated she was not aware that R1 was on a toileting program. On 10/9/25 at 10:47 AM, V8 (LPN) stated that her shift was ending when V7 called her to R1's room at approximately 10:00 PM on 9/2/25. V8 found R1 sitting on the floor, bleeding from the back of the head. V8 said she did not know exactly what R1 was doing; R1 was not far from the bathroom. V8 added that R1 is not supposed to get up without help. V8 stated that staff had laid R1 down in bed, though she did not recall the time this was done. V8 further stated that approximately around 8:00 PM earlier, she checked on R1 and found her in bed, sleeping. On 10/14/25 at 9:25 AM, V9 (RN) stated that at the start of her shift (as a third shift nurse) staff entered R1's room and found her lying on the floor in front of the bathroom door, in a puddle of blood. V9 stated there was a trail of blood from the bed to the bathroom, as if R1 slid across the floor. The room door was closed when staff entered; V9 noted that the door does not reliably stay open unless pushed just right, and previously staff had propped the door open with a chair. V9 said she had never seen R1 attempt to get out of bed by herself. R1 was wet when found, but V9 expressed she could not determine what led to the fall or what R1 was doing at the time. On 10/9/25 at 12:16 PM, V12 (R1's Family Member), stated R1 had fallen and hit her head, and they sent her to emergency room and then transferred R1 to another hospital to monitor her brain bleed. V12 stated that the facility called me, but it wasn't until after they took R1 to the hospital. They told me (R1) had a fall and hit her head, nobody ever gave me any details other than she fell. (R1) now has hospice when she went back to the facility, they suggested Hospice.On 10/14/25 at 9:08 AM, V15 (Physician) stated they should have a care plan in place for all new admits because data shows new admits have a high risk for falls especially since R1 already had a history of falls. R1 should have had fall precautions in place upon admission and staff should have been aware of ADL needs. 2) R2's census line documents R2 admitted to the facility on [DATE].R2's Medical Diagnosis list documents R2 admitted with a Diagnosis of Dementia and Lack of Coordination.R2's Fall Risk evaluation dated 8/7/25 documents R2 is high risk for falls.R2's MDS dated [DATE] documents R2 is severely cognitively impaired.R2's Emergency Department Physician Notes dated 9/9/25 document R2 was sent to the local emergency room after facility reports R2 sustained an unwitnessed fall and was found lying on the ground. R2 is currently taking Eliquis as a blood thinner and reports left hip pain. R2's Fall Care Plan was not created until 9/10/25 when an intervention was added for gripper strips to be placed at R2's bedside, and to remind R2 to use call light for staff assistance.R2's current Kardex (resident information) does not contain Fall Interventions for R2. R2's Nurse Progress Note dated 10/1/25at 3:57 AM, documents R2 was found in bed with blood on his bed and on the floor with a laceration on R2s elbow that was actively bleeding. R2 stated he stood up and had fallen and hit his left elbow, left hip, and his head. R2 was sent to the local emergency room for evaluation of injuries. R2's Nurse Progress Note dated 10/1/25 at 4:41 PM, documents R2 returned to the facility with three sutures in his elbow for the laceration and no further orders.R2's current care plan documents Dementia Care plan, at risk for Bleeding related to Anticoagulant Therapy, and at risk for impairment to skin Integrity related to laceration was created on 10/9/25. R2's Fall risk care plan was created on 9/10/25, and ADL care plan was created on 10/14/25.On 10/14/25 at 10:30 AM, V16 (CNA), stated R2 often is impulsive and gets up on his own. V16 stated she worked on 9/9/25 and went into R2's room to get him ready for the day. V6 stated upon entering R2's room the floor was wet in urine with a wet adult brief on the floor and R2 was lying in bed naked. R2 told V16 that he had fallen in the night. V16 stated she let V17 (LPN) know what she had seen and what R2 told her.On 10/14/25 at 1:18 PM, V17 (LPN) stated V16 came to me on 9/9/25 and said R2 had told V16 he had slipped in urine and fallen on floor in the night. V16 cleaned R2 up and brought him to the dining room. V17 looked at R2 and assessed him, R2 said his shoulder and hip was injured and sore. V16 stated she had just found out someone she knew had been murdered and her mind wasn't where it should have been, there were residents trying to get up V16 was behind on her medication pass. V16 stated she sent R2 to the local emergency room and he came back to the facility later that day with no injuries. V16 stated she does not recall notifying the family. On 10/14/25l at 12:45 PM, V18 (R2's Family Member) stated the facility called on 10/1 to let V18 know that R2 needed to go to the hospital because his elbow was bleeding. V18 stated she also been told by family that R2's roommate is also peeing on the floor, which concerns me if that's happening, and R2 is falling. V18 stated she was not made aware of R2's fall on 9/9/25 and was not aware R2 was sent to the hospital for evaluation. V18 stated prior to R2's admission to the facility R2 had been declining and getting weak and was having a hard time walking and had fallen at home which is why R2 admitted to the facility. R2 needed therapy and increased care as his dementia was getting worse. On 10/14/25 at 1:00 PM, V6 stated that she was currently updating R2's care plan and this care plan should have already been updated. V6 confirms R2 should have had a fall risk care plan upon admission.3) R3's census documents R3 admitted to the facility on [DATE].R3's MDS dated [DATE] documents R3 is severely cognitively impaired. R3's Fall Risk Review dated 1/16/25 documents that R3 is at high risk for falls. Subsequent fall risk assessments on 4/27/25, 6/30/25, 7/6/25, 7/7/25, 7/11/25, 7/28/25, and 10/9/25 continue to document R3 as high risk for falls.R3's Change in Condition Evaluation dated 10/9/25 documents R3 was sitting in his wheelchair in the hallway next to the nurse's station and staff heard a noise and R3 was sitting on the floor.R3's Change in Condition Evaluation dated 7/28/25 documents R3 was found lying on the floor mat next to his bed and was bleeding from a small laceration on the left eyebrow. Adhesive strips were applied to the laceration. R3 stated he was trying to go to the bathroom.R3's Change in Condition Evaluation dated 7/11/25 documents R3 had an unwitnessed fall and was found by staff laying on the floor. Vitals on the report are dated 7/7/25.R3's Change in Condition Evaluation dated 7/7/25 documents R3 was found lying on the floor of the shower room on his back with knees bent and hands behind his head. R3 stated he walked.R3's Change in Condition Evaluation dated 7/6/25 documents R3 attempted to transfer self to the toilet and was found on the floor laying on the floor mat.R3's Change in Condition Evaluation dated 6/30/25 documents R3 had an unwitnessed fall and was found lying on the floor of the bathroom between the toilet and the sink. R3 stated he thinks he hit his head.R3's Care Plan documents that R3's toileting task was not added to the care plan or the Kardex (resident information) until 9/10/25.R3's current care plan does not contain documentation of new safety interventions nor ADL status after these falls.On 10/14/25 at 11:30 AM, R3 was in wheelchair sitting in the dining room. R3 is alert but confused.On 10/14/25 at 11:40 AM, V19 (CNA) stated R3 often slides out of his wheelchair so we put him in the dining room in a recliner chair, so he doesn't fall.10/14/25 at 12:13 PM, V6 stated these interventions were not put in the care plan on 8/26/25. V6 stated that she just put these in today on 10/14/25 and when they print V6 only included the initiation date. V6 Stated R3 needs a lot of help and is confused and has had a lot of falls. V6 Stated we used to train all staff upon hire regarding charting and how to find resident information and that stopped awhile back, but unsure why, we plan to restart again. V6 Stated these interventions should have already been on the care plan.On 10/14/25 at 12:45 PM, V2 (Director of Nursing) stated she was not aware that the care plans were not being updated. V2 further stated care plans are not really her area of expertise.

Based on observation, interview and record review the facility to ensure a resident's therapeutic diet was provided. This applies to 1 of 3 residents (R3) reviewed for diets in the sample of 7.The findings include:On 8/22/25 at 12:40 PM, R3 was in the dining room eating his noon meal. R3 was served one corndog, pasta salad, watermelon and cottage cheese. R3's neon colored diet card shows he is on regular diet, low concentrated sweets, no pork and double protein. R3 said he was served one corndog and should receive double protein.On 8/22/25 at 12:54 PM, V6 (Dietary Manager) said R3 is on regular diet, low concentrated sweets and no pork. V6 said the corn dogs are made with turkey and chicken. R3 should receive double protein with each meal and should have received two corn dogs. The cooks in the kitchen are new and she will in-service the staff to ensure residents receive their correct diet.R3's Physician Order Sheets dated through August 2025 shows his diet order is cardiac low concentrated sweets, provide 1/2 portion carbs and double proteins with meals and no pork.The facility's Therapeutic Diets undated Policy states, therapeutic diets are prepared and served as ordered by the attending physician.residents' trays will be clearly identified by a color-coded tray card, The tray card information is to include residents name, diet order and room number.

Based on interview and observation, the facility failed to ensure 1 of 4 residents (R1) in the sample of 7 reviewed for visitation rights were allowed to receive their chosen visitors.The findings include:On 8/22/25 at 11:37 AM, V4, Social Services Director, said V13 is R1's significant other/girlfriend. V4 said V13 is not allowed to visit R1 any longer. V4 said V13 calls the facility almost every day trying to come to the facility. V4 said R1's guardians, V9, would go back and forth about allowing V13 to visit R1. V4 said currently the decision to not allow V13 to visit has been made by the facility and the police.On 8/22/25 at 10:32 AM, V3, Receptionist, said V13 is not allowed to visit R1 at all. V3 said V4 came and told all the receptionists not to allow V13 to visit. V3 said she is supposed to ask V13 to leave and if she won't leave, they are supposed to get the police involved. V3 said V13 calls frequently and asks when she can visit again. V3 said she tells V13 to call V9. V3 said the electronic kiosk at the front desk even says, Access denied when V13 tries to check in to visit.On 8/22/25 at 12:35 PM, V1, Administrator, said V13 has not been in the facility since he has been the administrator (eight weeks). V1 said he just got caught up to speed on everything regarding V13 in relation to visiting R1 today since you (IDPH) came in and asked questions. V1 said he would never stop V13 from coming to visit R1. V1 said unless there is an order of protection, they cannot restrict a visitor. V1 said it's the resident's right to have visitors.R1's admission Record dated 8/22/25 shows V13 is his significant other.The facility was unable to provide any legal documents which prohibit V13 from visiting R1.The facility's Visitation Guidelines Policy (reviewed May 2025) shows the facility supports and encourages visitation for all residents in accordance with CMS federal regulations. Residents have the right to receive visitors. Any concerns, incidents, or restriction of visitation must be documented and reported to the Administrator.R1's current care plan provided by the facility does not address any restricted/limited visitation needs.

Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for one of 29 residents (R76) in a sample of 67. Findings include: R76 was admitted on [DATE] with diagnoses of Polyosteoarthritis, Restless Leg Syndrome, Essential Hypertension, Anemia, Osteoporosis, Depression, Fall, Spinal Stenosis and Orthopedic Aftercare and Contusion of Right Hip. post fall at home. R76's Progress Notes document on 6/3/25, R76 sustained a fall, was transferred to the hospital, was surgically treated for a left wrist fracture and returned to the facility with a left-hand brace and sling to arm, non-weight bearing to left upper extremity and pain medication. R76's medical record did not include a completed Significant Change in Condition Comprehensive Assessment/Minimum Data Set (MDS). On 6/26/25 at 1:00 PM, V15 (Care Plan and MDS Coordinator) stated a Significant Change in Condition Comprehensive Assessment/MDS had not been completed and should have been.

Based on interview and record review, the facility failed to correctly assess fall risks, develop a comprehensive care plan and implement intervention to prevent a fall with injury. This resulted in the resident sustaining a wrist fracture due to a fall because appropriate fall prevention interventions were not implemented timely for one of 29 residents (R76) in a sample of 67. Findings include: The Comprehensive Care Plans Guidelines policy dated 5/25 documents the comprehensive care plan will be developed within 7 days after the completion of the comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practical physical, mental and psychosocial well-being; any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her right to refuse treatment; the residents goals for admission, desired outcomes and preferences for future discharge; and resident specific interventions that reflect the resident's needs and preferences and align with resident's cultural identity. The Fall Prevention and Management Program policy revised 5/5/25 documents risk factors for falls include Arthritis, Thyroid Disorders, Urinary incontinence or urgency, Depression, Sleep Deprivation, Pain, Orthostatic Hypotension, Deconditioning from inactivity or acute/chronic disease/condition, Diuretics and Narcotics. Fall Risk Assessment includes history of falls, ambulation/elimination status, gait/balance, systolic blood pressure, medication use and predisposing diseases. Fall Prevention includes to identify risk factors, implement individualized approaches/interventions based upon resident risk. the Fall Prevention Strategies/interventions list may be used to identify appropriate intervention and interventions should focus on risk factors. A plan of care will be developed/updated to accurately reflect the resident's risk of falls and related prevention interventions. R76 was admitted on [DATE] with diagnoses of Polyosteoarthritis, Restless Leg Syndrome, Essential Hypertension, Anemia, Age-related Osteoporosis, Depression, Fall, Spinal Stenosis, Low Back Pain, Fibromyalgia, Lack of Coordination, Hypotension, Insomnia and Orthopedic Aftercare and Contusion of Right Hip post fall at home. R76's Minimum Data Set, dated [DATE] documents R76 had a brief interview for mental status score of 14 (little to no cognitive impairment); utilized a walker and/or wheelchair for mobility due to lower extremity impairment; required partial/moderate assistance (helper does more than half the effort) for hygiene, dressing/grooming, sit to stand, chair/bed to chair, toilet and tub/shower transfers; had occasional urinary incontinence and bowel continence; frequently experienced pain which interfered with sleep, therapy activities; rated pain at an eight (0-no pain, 10-worst pain); and was being administered an antidepressant, diuretic (medication to increase urine production) and opioid (narcotic pain medication) medication. R76's Rehabilitation Evaluation follow-up note dated 6/2/25 documents R76 was to be on Fall and Safety Precautions per facility protocol and to continue with Therapy Services due to gait/balance instability and physical deconditioning post fall at home. R76's Fall Risk assessment dated [DATE] documents a score greater than ten indicated the resident was at high risk for falls. R76 scored an eight and was a low risk for falls. The Fall Risk Assessment documented R76 was independent with ambulation, continent of bowel and bladder, gait and balance were within normal limits and had one to two health conditions which are inaccurate assessments when compared to the MDS/Comprehensive assessment dated [DATE]. R76's Progress Notes, Change in Condition Assessment/Evaluation and the Post Fall Investigation Report documented on 6/3/25 at approximately 2:15 AM, R76 attempted to self-transfer to bathroom due to the need to have a bowel movement and an unwitnessed fall occurred. R76 complained of left wrist pain with edema. R76's x-ray report dated 6/3/25 documented a left wrist fracture which was surgically repaired on 6/4/25. R76's care plan did not include fall prevention intervention until 6/3/25. The care plan did not include goals and interventions for the following areas identified on the comprehensive assessment until 6/24/25: Active Range of Motion Restorative Nursing Program to bilateral upper and lower extremity to prevent further decline in Range of Motion; Self-Care Deficit with impaired dressing and grooming and would benefit from a Dressing/Grooming Restorative Program due to impaired strength and endurance; Self-Care Deficit with Activities of Daily Living related range of motion deficit from left wrist fracture; placed in a supervised smoking program; risk for constipation; risk for complications related to Hypotension; at risk for altered tissue perfusion related to Anemia; alteration in sleep pattern related to Insomnia; risk for renal complications due to Chronic Kidney Disease; goals and interventions for Gastric Esophageal Reflux Disease and Depression; and had an Open Reduction Internal Fixation of the Left Distal Radius (wrist) and utilized a splint. The Rehabilitation Therapy note dated 6/9/25 documents She continues on hydrocodone-acetaminophen 5-325 TID (three times daily) until 6/14. She does not know what the plan is for her wrist post fracture. She continues with PT (Physical Therapy) and OT (Occupational Therapy) as ordered. They are working on dynamic balance tasks patient requires max cues to remain NWB (non-weight bearing) to LUE (left upper extremity). On 6/25/25 at 10:05 AM, R76 stated she thought she could get up and make it to the bathroom by herself and hurt her left wrist. R76 stated she had to have her wrist surgically repaired with hardware placed and this really set me back. R76 stated staff told her that she didn't need to use the call light and could use the bathroom independently. On 6/25/25 at 11:45 AM, V16 (Licensed Practical Nurse assigned to R76 on 6/3/25) was unable to state what R76's fall risk was or which precautions were implemented prior to the fall. On 6/26/25 at 1:00 PM, V15 (Care Plan and Minimum Data Set Coordinator) stated R76's care plan was not completed until 6/24/25 and should have been. On 6/26/25 at 2:45 PM, V2 (Director of Nursing) stated she was unaware the comprehensive care plan had not been completed until 6/24/25.

Based on interviews and record review the facility failed to prevent and protect cognitively impaired residents from physical abuse for 2 of 4 residents (R1, R4) reviewed for abuse in a sample of 7. This failure resulted in R1 wandering into R2's room, was then physically removed and led to R1 falling on the floor and sustaining head trauma and also resulted in R5 forcefully grabbing her roommate R4 by the hair and wrists that caused R4 to feel angry and scared of R5. Findings include: 1. Final incident report with incident date of 03/10/2025 indicated that, it is believed by staff witness [R1] entered [R2's] room and in turn pushed [R1] to keep him out of his room, which led to [R1] falling, however, [R2] was not observed by the staff at that moment. [R1] received a body assessment which revealed no abnormal findings and had no complaints of pain. R1's fall investigation report dated 03/10/2025 at 2:30 PM documented that R1 was allegedly pushed by another resident. R1 was wandering into R2's room as was allegedly pushed out of his room. R1 was observed on the ground and was unable to give a description. Description of immediate action taken documented a small, round, dark pink present to center occipital bone roughly the size of a dime and small amount of swelling noted. Injuries observed at time of incident indicated abrasion and swelling to top of scalp. Note within this same fall report dated 03/13/2025 indicated that R1 was up ad lib wandering per usual behavior, wandered into the doorway of a peer [R2], peer allegedly became agitated and allegedly pushed him. Root cause indicated wandering due to disease progression with nursing intervention to reduce wandering. (No further documentation was found related to R1's head trauma). R1's face sheet documented admitted [DATE] and a past medical history not limited to Alzheimer's disease, dementia, generalized anxiety disorder, weakness, hypertension, encephalopathy and depression. Face sheet indicated R1 is on comfort care. R1's care plan with date initiated of 07/21/2023 reads in part: demonstrates movement behavior and has been included in the elopement prevention program and has a wander guard in place; alteration in neurological status related to neuropathy, dementia and encephalopathy; impaired cognitive function or impaired thought processes related to Alzheimer's, dementia, anxiety, depression, neuropathy; history of falls and remains at risk for recurrent falls related to dementia, wandering and assistance needed with activities of daily living. R1's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 01/13/2025 indicated severe cognitive impairment with score of 03/15. Section GG for functional abilities indicated R1 requires partial to moderate assistance to walk 10 to 150 feet. Section I for active diagnosis indicated non-traumatic brain dysfunction. R1's Wandering Risk Scale dated 01/23/2025 indicated resident is a high risk for wandering. R1's screening assessment for aggressive and/or harmful behavior dated 03/13/2025 documented minimal risk for aggression. On 04/08/2025 at 9:28 AM, R1 was observed sitting in a recliner chair in the day area on the memory unit. R1 was alert to self and was not interviewable. R2's face sheet documented last admitted [DATE] and a past medical history not limited to alcohol abuse with alcohol-induced anxiety disorder, major depressive disorder, unspecified personality and behavioral disorder due to known physiological condition, unspecified mood [affective] disorder, anxiety disorder and adult failure to thrive. R2's care plan with date initiated of 07/21/2023 reads in part: demonstrates behavior symptoms concerning inappropriate personal boundaries due to cognitive impairment secondary to alcohol persisting dementia or a related dementia; demonstrates behavioral distress as manifested by verbally abusive behavior when agitated, use of profanity/racial slurs, demeaning statements, verbal threats and yelling at others, physically abusive behavior when agitated towards staff, attempting to push, shove, scratch, hit, slap, kick, grab, choke or otherwise harm staff (date initiated 09/19/2024); has current self-harmful ideation (thoughts) and/or behavior (date initiated 09/19/2022); displays conflictual, difficult behavior with other persons related to mental/severe mental illness, dementia of the Alzheimer's type, difficult time adjusting to life in long-term care facility, history of substance abuse, poor ineffective coping skills initiated on 03/13/2025 with interventions not limited to: physical stop sign to resident's door way and intervene when any inappropriate behavior is observed; stop sign on door to deter others from entering .to prevent unwanted interaction due to agitation or confusion, initiated on 03/14/2025. R2's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 12/31/2024 indicated severe cognitive impairment with score of 00/15. R2's psychiatric note dated 03/06/2025 (4 days prior to the incident with R1) indicated the resident was seen per staff request; increased agitation and aggression with plan to obtain urinalysis to rule out medical cause for behavior change and start sertraline [an antidepressant] and decrease mirtazapine [an antidepressant] due to ineffectiveness. R2's Medication Administration (Behavior Monitoring) note dated 3/10/2025 at 6:50 PM documented by V9 (Registered Nurse) reads in part, around [2:30 PM], resident pushed another male resident onto the ground because the resident accidentally wandering into his room. R2's screening assessment for aggressive and/or harmful behavior with effective date of 03/13/2025 documented a moderate problem with history or recent episode of aggressive/agitated behavior that includes aggression towards others. R2's trauma screening with effective date of 03/13/2025 documented history or presence of dysfunctional behavior and of mistreating others and showed significant trauma-related symptomology. R2's psychiatric note dated 03/13/2025 (3 days after to the incident with R1) indicated resident was seen per staff request for aggression towards peers after another confused resident walked into [R2's] room and [R2] pushed the resident to the floor. Note continued to document a plan to start donepezil (used to treat Alzheimer's disease/dementia) 5mg (milligram) by mouth at night for cognition and continue to taper mirtazapine due to ineffectiveness.dementia is worsening and unstable this visit. R2's active orders as of 04/08/2025 showed orders for behavior monitoring including verbal aggression with staff, agitation and aggression; alprazolam (an antianxiety medication) 0.25mg by mouth three times a day related to anxiety (03/27/2025); divalproex sodium tablet (a mood stabilizer) delayed release 250mg by mouth two times a day related to unspecified personality and behavioral disorder and mood [affective] disorder; donepezil hydrochloride 5mg by mouth at bedtime for dementia (03/14/2025); memantine hydrochloride 10mg by mouth daily related to unspecified personality and behavioral disorder; mirtazapine 30mg by mouth at bedtime related to major depressive disorder (03/14/2025); and sertraline hydrochloride 25mg by mouth daily related to major depressive disorder (03/11/2025). On 04/08/2025 at 9:24 AM, observed a white banner across R2's doorway that had a red stop sign in the middle of banner. R2 was in his room lying on the bed. When asked about the incident with R1, R2 said he came into my room, and I pushed him out. R2 did not recall whether this resident fell to the floor then repeated his previous statement, he came into my room, and I pushed him out. R2 did not answer any more questions asked by surveyor. On 04/08/2025 at 9:29 AM, V4 (Certified Nursing Assistant) said regarding the incident with R1 and R2, R1 went into R2's room and R2 pushed him out. V4 added that R1 had a bump on his head, then proceeded to show surveyor the area by patting the top and back of her head. V4 then said R1 either sits in the recliner chair in day area or wanders around the unit and gets anxious at times. V4 also said that R2 mainly stays in his room and doesn't let staff do a lot for him; he mainly goes out for smoke breaks and meals. On 04/08/2025 at 9:34 AM, V5 (Registered Nurse) said she was not working on the day of incident involving R1 and R2. V5 then said that R1 wanders throughout the day and R2 stays in his room. V5 added that R2 had no prior aggression, just likes to be alone. On 04/08/2025 at 11:13 AM, V1 (Administrator) said regarding incident with R1 and R2, that R1 was observed on floor outside of R2's room and there was suspicion that R2 pushed him because R1 wandered into the room. V1 added that the primary witness, V8 (Physical Therapy Assistant) saw R1 on the floor but didn't see R2 physically push him. V1 added that when he was informed about the incident, there were no apparent injuries found. V1 (Administrator) then said that R2 has no history of aggression with residents, but there have been prior staff concerns then referred surveyor to R2's progress note dated 03/03/2025 that indicated R2 had his hand on a nurse due to behaviors related to smoking. V1 added that V5 was the nurse involved. Informed V1 that during previous interview with V5 (Registered Nurse), she indicated that R2 had no prior aggression. V1 said he was unsure as to why V5 would make that statement because R2 was seen by psych that week due to this incident. V1 (Administrator) then said that R1 wanders, and his cognition is very low; staff try to supervise him and redirect as needed. Review of R2's progress note created by V5 (Registered Nurse) on 03/03/2025 at 11:23 AM documented that resident drew his fist back at nurses, cussing at [certified nursing assistant], staff told resident that he was not going out to smoke due to his behaviors On 04/08/2025 at 11:41 AM, V8 (Physical Therapy Assistant) said she was walking with another resident in the hallway near R2's room after 2:00 PM and had stopped at that resident's doorway which was across the hall and passed R2's room. V8 added that she saw what appeared to be, R1 being shoved from R2's doorway and into the hallway with force, then R2's door slammed shut. V8 (Physical Therapy Assistant) said R1 landed pretty hard and hit the back of his head on the ground. V8 said she did not see R2's hands physically push R1 out of the room. V8 (Physical Therapy Assistant) called for help because no one else was in the hallway at that time. V8 then said she opened R2's door and said to him, don't you put hands on anyone. R2 was in bed and did not respond. V8 then closed his door and at this time, an aide and a nurse were coming down the hallway. On 04/08/2025 at 1:07 PM, V2 (Director of Nursing) said she was not aware that R1 sustained any injuries after the incident with R2, and indicated there is no documentation that any injury was being monitoring. V2 then said she assumed nurses would assess resident's during neuro checks and if they found any injury, then they would document those findings. On 04/08/2025 from 1:22 to 1:31 PM, V9 (Registered Nurse) said that she documented an abrasion and swelling to the top of R1's scalp at the time of incident but now thinks they both were present prior to the incident with R2. V9 added that R1 had fallen in the past but couldn't recall any falls that occurred near the time of incident with R2. V9 (Registered Nurse) then said R2 is kind of [NAME] and can get agitated. She added that upon assessment, R2 was lying in his bed and was very agitated so she could only perform a quick body assessment on resident. On 04/08/2025 at 2:39 PM, V7 (Certified Nursing Assistant) said she was working on the memory unit on the day of R1 and R2's incident which had occurred around 3:00 PM. V7 said she was sitting in the dining/day area, and R1 was walking in the hallway like he always does when she heard a noise that sounded like someone fell . V7 (Certified Nursing Assistant) said she went down the hallway and saw R1 on the floor near R2's room and a therapy staff member (V8) were standing in front of another resident's room door who told V7 that R2 had pushed R1. V7 (Certified Nursing Assistant) then said that R1 had a bump to the back of his head with a small amount of blood present, that was not actively bleeding. V7 (Certified Nursing Assistant) added that after she was told what happened, she opened R2's door and he was standing in the middle of the room and didn't say anything but looked mad. V7 said she closed door then asked V8 to stay with R1 while she went to look for the nurse. V7 said when she returned to R1, a nurse was already there. V7 (Certified Nursing Assistant) then said that R2 can be aggressive to staff at times, shakes his fist at people, and doesn't like anyone coming into his room because he doesn't want to be bothered. V7 added that sometimes she is scared of R5. On 04/08/2025 at 2:53 PM, V10 (Agency Nurse) said she worked on the memory unit on the night shift after R1 and R2's incident and didn't recall being told about any head trauma. V10 said we did neuros [neurological assessments] on him; he didn't have any bruising. V10 then said she don't really recall the incident and ended the phone call. On 04/09/2025 at 1:50 PM, V1 (Administrator) said he did not identify or substantiate the incident with R1 & R2 as abuse because both residents have dementia and impaired cognition so there was no willful intent, and there was no concrete evidence or identification that R2 had pushed R1 out of his room. 2. Final incident report with incident date of 01/25/2025 at 8:47 PM documented that R4 and R5 were roommates on the memory care unit and were both in their room for the evening. Staff noted residents in the hallway and R5 had a hold of R4's hair then took a hold of R4's wrists. Staff intervened and R5 immediately released R4, residents were separated. R5 was placed on 1:1 supervision until transferred to the hospital for evaluation. Injuries non-apparent for both residents. New room assignment. R4's incident report dated 01/25/2025 initiated by V12 (Agency Nurse) documented that staff heard yelling and upon assessing situation, R4 told staff that her roommate (R5) pulled her hair; R5 was yelling at R4 and staff. R4's face sheet documented admitted [DATE] and a past medical history not limited to dementia, hypertension, atrial fibrillation and right femur fracture. Care plan with date initiated of 12/30/2024 documented impaired cognitive function or impaired thought processes related to dementia. R4's clinical census showed a room change from building 1-2 to 4-2 on 01/29/2025. R4's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 03/24/2025 indicated severe cognitive impairment with score of 02/15. R4's screening assessment for aggressive and/or harmful behavior dated 01/28/2025 documented minimal risk for aggression. R4's trauma screening with effective date of 01/28/2025 documented exposure to and an increased vulnerability to trauma. On 04/09/2025 at 11:53 AM, V13 (Certified Nursing Assistant) said R4 is easy to work with and she has not seen any aggressive behaviors from R4. On 04/09/2025 at 11:55 AM, R4 said regarding the incident with R5, I didn't do anything to her, she just came behind me and pulled my hair. R5 was visibly distraught during interview and said she was angry and scared of her then indicated that she wanted to press charges but knows that R5 has mental problems. R5's incident report dated 01/25/2025 initiated by V12 (Agency Nurse) documented that staff heard yelling and upon assessing situation, R5 told staff that her roommate (R4) hit her. Report indicated that R5 was confused and agitated/anxious. R5's face sheet documented admitted [DATE] and a past medical history not limited to depression, dementia, history of covid and edema. R5's care plan with date initiated of 11/04/2022 documented in part, demonstrates behavioral distress manifested by verbal behaviors when agitated and physical altercation with another resident; has displayed conflictual, difficult behavior with other persons manifested by getting defensive when other peers come into her room uninvited and my express the need to physically or verbally defend herself (initiated 11/16/2023); impaired cognitive function .becomes easily confused, overwhelmed, and disoriented (initiated 05/31/2024); problem with depressed mood that is evidenced by and not limited to fluctuations in mood, behavior, and affect .(initiated 05/31/2024). R5's progress noted dated 01/25/2025 at 11:13 PM documented by V12 (Agency Nurse) indicated that yelling was heard, and upon V12's assessment, she saw aides separating R5 and her roommate (R4). R4 said that R5 pulled her hair. R5 was yelling at R4 and staff. R5's psychiatry note dated 01/28/2025 reads in part, history of Alzheimer's dementia with behavioral disturbance. Visited acute on this day after an altercation with another resident. She (R5) was reportedly the aggressor and attacked her new roommate [R4]. Note also documented a plan to start divalproex sodium 125mg capsule by mouth two times daily for BPSD (behavioral and psychological symptoms of dementia. R5's screening assessment for aggressive and/or harmful behavior dated 01/28/2025 documented history or recent episode of aggressive/agitated behavior, history of abuse/neglect either as recipient or perpetrator including abusive and/or inappropriate sexual behavior. R5's trauma screening with effective date of 01/28/2025 documented history or presence of dysfunctional behavior (e.g., provoking, aggressive . abrasive/inappropriate behavior) but is documented as a minimal risk for aggression. R5's Brief Interview for Mental Status (BIMS) under Section C for cognitive patterns dated 04/01/2025 indicated severe cognitive impairment with score of 03/15. R5's active orders as of 04/09/2025 showed orders for behavior monitoring including agitation with peers, wandering, restlessness; divalproex sodium 125mg capsule by mouth two times daily for BPSD (01/31/2025); donepezil 10mg by mouth the evening for dementia; memantine hydrochloride 10mg by mouth two times a day for dementia. On 04/09/2025 at 11:50 AM, R5 was observed in her room, alert to self and was not interviewable. On 04/09/2025 at 12:06 PM, V11 (Certified Nursing Assistant) said R4 and R5 were roommates on the memory unit and indicated that R5 is normally confused. On day of incident, V11 said she was in the day area on the unit after supper when she heard someone yelling out for help. When she went down the hallway, V11 (Certified Nursing Assistant) said she saw R5 standing behind R4 in the hallway and R5 had a hold of R4's hair. V11 added that when she approached the residents and tried to redirect R5, she let go of R4's hair but then grabbed her by the wrists. V11 continued to redirect R5 in a calm manner, then R5 finally let go of R4's hair and they were separated. R4 was redirected to the day area. R5 was redirected back to her room; V11 stayed with R5 until she left facility via ambulance. V11 (Certified Nursing Assistant) added that during her 1:1 with R5, she seemed angry and was saying that R4 needed to go to jail. On 04/09/2025 at 1:38 PM, V12 (Agency Nurse) said the incident between R4 and R5 occurred after dinner. V12 said she was in the nurse's office on the unit charting when she heard some commotion and headed down the hall and could hear the aides saying, let her go. V12 (Agency Nurse) added that when she approached R4 and R5, they were standing in the hallway outside the doorway of their room and R4 was accusing R5 of attacking her. V12 said R4 was visibly upset and was assessed for any injuries with none found. She added that R5 was sent out because she was the aggressor and R4 was moved to another room on the unit, then was eventually moved to another unit because R4's son didn't feel comfortable with R4 staying on the unit. On 04/09/2025 at 1:50 PM, V1 (Administrator) said he did not identify or substantiate the incident with R4 & R5 as abuse because both residents have dementia and impaired cognition so there was no willful intent. V1 added that R5 grabbed R4's hair, but it was not stated that R5 pulled R4's hair and R5 had grabbed R4's wrists but did not push her. Abuse Prevention Program policy last revised 01/2019 reads in part: it is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. The following procedures shall be implemented when an employee or agent becomes aware of abuse or neglect of a resident, or of an allegation of suspected abuse or neglect of a resident by a 3rd party. Screen-Train-Report-Identify-Investigate-Protect-Prevent. Abuse and Crime Reporting policy last revised 01/2019 reads in part: this facility will not tolerate resident abuse or mistreatment or crimes against a resident by anyone, including staff members, other residents, consultants, volunteers, and staff of other agencies, family members, legal guardians, friends or other individuals. This policy will define how the investigation of abuse allegations and mistreatment, or crimes will be conducted and outline the process of reporting, investigating and arriving at a conclusion or disposition of the allegation. All personnel must promptly report any incident or suspected incident of resident abuse, mistreatment, neglect, or exploitation including injuries of an unknown origin . For the purposes of this policy, and to assist staff members in recognizing abuse, the following definitions shall pertain and is not limited to: physical abuse-hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on interview and record review the facility failed to provide timely incontinence care for one of one resident(R1), reviewed for incontinence care, in a sample of 3. The facility policy, Guidelines for Incontinence Care, dated 9/21/23 documents, It is the policy of the facility to ensure that residents receive as much assistance as needed for cleansing the perineum and buttocks after an incontinent episode or with daily care. Frequency depends on bladder diary results and/or routine minimal every two-hour checks as well as care planning. R1's facility Face Sheet documents that R1 was admitted to the facility on [DATE] with the following diagnoses: Polyneuropathy, Arthritis, Morbid Obesity, Major Depressive Disorder, Lymphedema and Dementia. R1's most recent Minimum Data Set Assessment, dated 10/11/24 documents that R1 is, always incontinent of bowel and bladder. R1s Care Plan in effect on 1/16/2025 documents, (R1) has a functional bowel and bladder incontinence r/t (related to) Impaired Mobility, Physical limitations, Obesity. Interventions include: Check (R1) every 2/hrs (hours) and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN (as needed) after incontinence episodes. On 1/27/2025 at 8:15 A.M., V4/R1's daughter stated she came to the facility on [DATE] at 11:45 A.M. for a care plan meeting for (R1). V4 further states she went to (R1's) room at approximately 12:15 P.M. and found (R1) lying in a urine saturated bed. V4 states urine was up to (R1's) shoulders, and down to (R1's) knees. V4 states (R1's) gown and all of (R1's) blankets were also urine saturated. (V4) states she put call light on to alert staff, after an unknown amount of time, walked to nurse's station where two nursing employees were seated and voiced concerns with (R1's) need for immediate assistance. The two employees came to room and then V3/Certified Nursing Assistant also came into room and was trying to apologize. V3/CNA states she had come into (R1's) room at 8:00 A.M. to change (R1) before breakfast, but R1 refused the assistance. V3/CNA then stated she had not had time to return to room to provide care for R1, until now. On 1/27/25 at 9:08 A.M., V7/Certified Nursing Assistant stated she frequently works 4100 hall and was present the day of the incident with R1. V7 further states she was one of the staff members who responded to R1's room. States R1 was fully saturated with urine from her shoulders to her knees and all bed linens were also saturated. States she was one of two staff that assisted in giving R1 a shower on that day. Does not recall any pressure wounds present on R1's buttocks on that day. On 1/27/25 at 10:12 A.M., V3/Certified Nursing Assistant (CNA) stated, I have been a CNA for the past seventeen years. I have worked at (facility) since September (2023). I have almost always worked on 4200. When I came in that day (1/16/25), I begged V9/Staffing Coordinator not to schedule me on that floor (4100) because I wasn't oriented to the floor, and I knew that hallway was heavy. I worked there once in November, and I told her not to schedule me there again without some orientation. Well, when I came in that day and was scheduled on 4100, I knew it was going to be a rough day. It's a very heavy hall with two person lifts on it. I started in on the hall, getting people changed and dressed and up for breakfast. By the time I got to (R1), it was 9:30 (AM) or so. When I walked in (R1's) room I said to (R1) I was there to change her and get her set up for breakfast. (R1) told me 'No, I don't want breakfast.' I don't want to be changed. I don't feel well. I want to see the nurse. I wasn't going to argue with (R1) so I told her I would let the nurse (V8/Licensed Practical Nurse) know. I left the room; I was super busy and had more residents to get to. By the time I came back (from break at 12:15 P.M.), my coworker met me at the door and told me (R1's) family member was very upset because I hadn't changed (R1). I was called and talked to about this (incident) and they sent me home for the rest of the day. I haven't been back to 4100 since. On 1/27/25 at 10:53 A.M., V2/Director of Nurses stated she was called to R1's room on 1/16/24 due to R1's daughter being upset about her mom not receiving incontinence care. V2 states R1 was saturated with urine from her shoulders to her knees and that all bed clothing and linens were urine soaked. On 1/28/25 at 8:22 A.M., V12/Certified Nursing Assistant confirmed she worked 4100 the night of January fifteenth (2025). V12 stated, (R1) was my patient that night. That's always the hallway I work. I last (provided incontinence care for R1) between 2 and 3 A.M. (R1) is always a full bed change. (R1) pees a lot. V12 confirmed she did not provide any additional incontinent care for R1 that night. On 1/28/25 at 8:37 A.M., V2/Director of Nurses confirmed the facility policy is to provide incontinence care for incontinent residents every 2 hours and as needed. V2/DON also stated that V3/CNA should have alerted nursing staff when R1 refused incontinence care.

Based on observation, interview, and record review the facility failed to provide immediate post-fall care to one resident (R1) receiving anticoagulant therapy of three residents reviewed for falls with injury. This failure resulted in delayed treatment of a subdural hematoma. The facility also failed to safely turn and position one resident (R4) of three residents reviewed for accidents with injury. This failure resulted in R4 sustaining a nasal fracture. Findings include: Facility Employee Education Record/Falls and Anticoagulation: What You Should Know dated 11/18/24 documents: Key Points: Blood thinners, or anticoagulants, help prevent blood clots but can increase the risk of bleeding. Falling is a major reason why some people hesitate to take blood thinners. If you fall while on a blood thinner, contact your healthcare provider right away. Bleeding isn't always visible. You could bleed internally and not know it, and that's a significant concern. For example, we worry about brain bleeds when people fall and hit their heads- but if patients don't see blood, they might not realize that they're bleeding. If you fall while on a blood thinner: You should be assessed for bruising, and most importantly, for potential head trauma. Your doctor will want to know how you fell , what parts of your body were affected, and if you lost consciousness. Even if you think the fall was minor, you should call your doctor. Facility Policy/Post Fall Management Protocol (undated) documents: If fracture or head injury is suspected, Do Not Move resident, and advise resident not to move affected area, complete assessment. Neuro checks are completed for falls where the resident hit his head or if fall was unwitnessed and a head injury is demonstrated. Pain is assessed and addressed. Physician notification. Medications taken within the 24 hours before the fall; medications placing resident at risk. Neuro Check Flowsheet instructions: Neuro Checks should be completed for unwitnessed falls or fall in which head was hit. 1. Physician Order Summary Report dated 11/1/24 to 11/30/24 indicates R1 received the following anticoagulant medications: Aspirin 81mg (milligram) daily for Prophylaxis. Date initiated 8/16/24. Coumadin 3mg daily on Tuesday, Wednesday, Thursday, Saturday, Sunday related to Chronic Atrial Fibrillation and Coumadin 4mg daily on Monday, Friday related to Chronic Atrial Fibrillation. Date initiated 11/12/24. R1's Order Report also indicates Anticoagulant medication - monitor for discolored urine, black tarry stools, sudden severe headache, nausea/vomiting, diarrhea, muscle or joint pain, lethargy, bruising, sudden changes in mental status, or vital signs, shortness of breath, nose bleeds every shift for Monitor Anticoagulant Therapy. Date initiated 8/16/24. Incident Report indicates Incident Date: 11/16/24 and Time of Incident reported: 11pm. Report indicates R1 was found on the floor (in his room) on floor mat during routine cares. No evident injuries during initial assessment. Report indicates R1 began to have complaints of headache and nausea on 11/17/24 and was sent to the local ED (Emergency Department) for evaluation and treatment. Local Hospital ED (Emergency Department) Report dated 11/17/24 at 9:43pm indicates R1 Chief Complaint: Complaint of head and neck pain Pain scale 8. Fall from bed, had rolled off the bed during a bed change. Report indicates Onset: 11/16/24 and per EMS (Emergency Medical Services) R1 had an unwitnessed fall last night 11/16/24. (Facility) staff informed medics that R1 didn't tell them about the fall until today (R1) has a bruise to the right side of his head. Report indicates R1 is anticoagulated with Coumadin and currently bed-bound with left-side weakness from a prior stroke. Upon exam, R1 reports nausea and a very bad headache on the right side of his head. R1 states he fell last night while staff at the facility were rolling and changing him and stated he was unsure why they didn't have him evaluated at that time. Hospital Radiology/Head CT (Computed Tomography) dated 11/17/24 at 10:21pm indicates Findings: Acute large volume subdural hemorrhage with associated vasogenic edema and mass effect in the right cerebral hemisphere. 4mm (millimeter) of right-to-left midline shift. Reevaluation/Plan: Transfer to (a) University hospital for further evaluation and treatment. On 11/26/24 at 3:24pm V21, Hospital Social Worker stated that R1 was lucid and oriented when she spoke to him (on 11/17/24) and R1 stated he hit his head and rolled off the bed while being changed. On 12/3/24 at 10:30am V11, CNA (Certified Nurse Assistant) stated that at 10pm on 11/16/24 R1 was sitting on the edge of his bed when she did initial rounds. V11 stated at approximately 12am she was doing her check and change rounds when she found R1 and R1's bed wet with urine so she had to change R1 and his entire bed. V11 stated she did this by rolling R1 back and forth in his bed to get the wet linen out and the dry linen on the bed. V11 stated that R1 did not fall off the bed during care for R1. V11 stated R1 was lying in the bed when she was done, but she had to leave the room to get a top sheet and when she returned a few minutes later R1 was on the floor mat next to R1's bed. V11 stated that R1 told her that he rolled off the bed. V11 stated that she asked R1 if he was ok and R1 touched his head. V11 stated that the area on R1's head that he touched was like a carpet burn, about the size of a dime. V11 stated that she notified V10, RN (Registered Nurse) that R1 was on the floor and V10, RN and V13, CNA came into R1's room. V11 stated that V10 assessed R1, and all three staff got R1 back into bed. V11 stated she did not recall if V10 asked R1 if he had hit his head when he rolled off the bed. V11 stated that R1 stated that his head hurt and V10 gave R1 something for pain. R1's MAR (Medication Administration Record) dated 11/1/24 to 11/30/24 does not indicate any pain medication was administered to R1 on 11/16/24 or 11/17/24 by V10. On 12/3/24 at 9:20am V2, DON (Director of Nursing) stated that V10, RN no longer is employed at the facility. Multiple attempts were made to contact V10 by phone without success. On 11/27/24 at 1:34pm V13, CNA stated that she went in R1's room to help get R1 off the floor, R1 was mostly on the fall mat on the floor and R1's bed was in the lowest position it could go. V13 stated that she did hear V10 ask R1 if he hit his head. V13 stated I did see what looked like a quarter sized area of dried blood on (R1's) upper forehead - like at the hair line. No dripping blood. (V10 and V11) said (R1) had a skin condition and that it was not new. On 11/26/24 at 2pm V12, RN stated I was in the hallway passing meds near (R1) room (on 11/17/24) when I overheard (R1) tell someone he was on the phone with that he had a bad headache. I went into (R1's) room and asked him if he was ok and if he needed Tylenol. (R1) said 'yes' so I went to get some Tylenol and when I went back in, (R1) told me he fell the night before around 11pm. I didn't ask him how he fell , but he stated he fell out of bed and pointed to the top of his head. I saw an abrasion (larger than a fifty-cent piece) on the top-right side of (R1's head). V12 stated the area wasn't bleeding but noticeable. V12 stated that R1 did also complain of nausea and wanted to go to the hospital. V12 stated she then contacted V2, DON and was told to send R1 to the hospital. V12 stated, I did not get any report that (R1) had fallen the day before. V12 stated she was concerned when R1 told her he fell , because R1 is on Coumadin. V12 stated I just happened to overhear him complain about a headache later that evening, or I would not have known he fell . V12 stated If someone falls and they are on Coumadin - even if they say they are alright - they should be sent to the hospital. On 12/3/24 at 2:45pm V22, Physician/Medical Director stated that if he had been notified when R1 initially fell or was found on the floor, it would have been an immediate 'sendout' because he was on Coumadin and Aspirin. V22 stated time is critical in reversing the effects of the anticoagulants. R1 fell or rolled onto the mat next to his bed on 11/16/24 near midnight and was not sent to the hospital until 11/17/24 at approximately 9pm. V10, RN did not report that R1 had been found on the mat next to his bed, did not document that R1 had fallen until requested to do so by V2, DON on 11/17/24 and did not notify V22, Physician at the time of the fall. R1 was subsequently transferred from a local hospital ED to a University hospital from 11/17/24 to 11/27/24. 33970 2) The Facility's undated Fall Prevention and Management policy for documentation documents A. Fall is documented in the medical record 1. date and time 2. location and any facts necessary to describe the fall 3. assessment post fall 4. any injuries and care provided 5. notification of physician and family and 6. suggested documentation up to seventy-two hours after fall. R4's Fall Investigation dated 11/9/24 documents [AGE] year-old female, BIMS (Brief Interview for Mental Status) score of 4 (out of possible 15, indicating severe cognitive impairment) witnessed to slide/roll off the edge of her bed. Discoloration noted to head/face. Resident with daily anticoagulant use. Sent to ER (emergency room ) for (evaluation and treatment). R4's hospital record dated 11/9/24 documents CT (Computed Tomography) scan maxillofacial without contrast documents findings there is extensive soft tissue swelling surround the nose and anterior to the maxilla and right maxillary sinuses. I suspect nondisplaced fracture involving the nasal spine of the anterior maxilla at the inferior aspect of the nose. There are also possible bilateral nasal bone fractures with minimal displacement, although it is possible this appearance is due to motion. On 11/26/24 at 10:30 AM R4 had purple bruising to both sides of her nose and under her left eye. R4 also had bruising noted in the neck area. R4 did not recall falling, when asked about her bruises she stated, If you say they are there; I will believe you. R4's Admission Care Plan dated 10/30/2024 documents B. Function and Goals-Mobility: Bed Mobility 2 plus person physical assist. R4's Admission MDS (Minimum Data Set) assessment dated [DATE] documents GG. Function and Mobility-A. roll left and right: the ability to roll from lying on back to left and right side and return to lying on back on bed: 02. substantial/maximal assistance- helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. V4's (Certified Nurse Aid) written statement dated 11/9/24 documents that V4 was using an underpad to turn R4 in the bed when R4 attempted to reach out towards her bed side table. V4's statement documents I tried to grab her hips, but she slipped under my hands and fell on the floor on her right side face down. V6 (Certified Nurse Aid) written statement dated 11/9/24 documents I was down the hallway talking to the RN when other CNA (V4) hollered down and said she needed help. (R4) was on the floor. On 11/27/24 at 9:45 AM V2 (Director of Nursing) confirmed that R4 was performing bed mobility with just one assist and should have had two.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse and identify and investigate a potential allegation of abuse and protect resident from further abuse from R500, with a known history of verbal and physical aggression. These failures resulted in R500 verbally yelling and physically hitting R134 and shoving both R84 and R103 to the ground. R84 sustained a bleeding laceration to posterior head, facial bruising, and hospitalization requiring three staples to R84's posterior head. R103 experienced hip and knee pain, bruising, and hospital evaluation. R134 was hit in the face. These failures have the potential to affect all 35 residents residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/29/24, the facility remains out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, revised 3/1/21, documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This policy also documents Identification of Allegations/ Internal Reporting Requirements: Employees are required to immediately report and incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements. Employees without fear of retaliation may also independently report to the state survey agency any allegation of abuse, neglect, exploitation, or mistreatment of resident property, and to local law enforcement if they have a reasonable suspicion that a crime was committed. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports should be documented, and a record kept of the documentation. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. Investigation: All incidents, allegation or suspicion of abuse, neglect, exploitation, misappropriation of property, or crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON determines that there is an allegation or a reasonable cause for suspecting abuse, neglect, exploitation, misappropriation of property, or a crime against a resident, the Administrator or appointed investigator will investigate the allegation and obtain a copy of any documentation relative to the incident. This policy also documents Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. All personnel, residents, visitors, etc. (etcetera) are encouraged to report incidents of resident abuse, mistreatment or neglect or suspected abuse, mistreatment, or neglect, without fear of retaliation or retribution from facility or its staff. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This same policy also documents Procedure: Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate incident report and in the resident's medical record. This report shall be made immediately, but no later than two hours after the allegation is made. If the events that cause the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Crimes include but may not be limited to murder, manslaughter, rape, assault and battery, sexual abuse, theft robbery, drug diversion for personal use or gain, identify theft, and fraud and forgery. When an alleged or suspected case of abuse, neglect, exploitation, or crime against a resident is reported to the facility Administrator, the Administrator, or DON in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or significant injury to a resident will be reported within two hours of the incident. Any incident that involves a resident death will be called to the (State Agency) immediately. Abuse allegations involving one resident upon resident upon another resident will be reported to (the States Agency). The Diagnosis Report for R500, documents R500 admitted to the facility on [DATE] with a diagnosis of Schizoaffective Disorder. R500 was diagnosed with Obsessive Compulsive Personality Disorder on 7/15/24 and diagnosed with Bipolar and Metabolic Encephalopathy on 7/25/23. R500 was also diagnosed with Anxiety on 8/21/24 after readmitting to the facility on [DATE] from psychological hospitalization . The facility Psychiatric service report for R500, dated 6/5/24, documents R500 with a diagnosis of Dementia. This report documents R500 with auditory hallucinations and delusions and making false accusations of staff. Psychiatric History includes multiple psychiatric hospitalization s and multiple medication changes prior to facility admission. The current Care Plan for R500 documents the following: Focus areas with goals and interventions listed: R500 has chronic health conditions, behaviors, challenges, and co-morbidities that include Schizoaffective and bipolar disorder. R500 requires the support, services and structure of the care setting and is under the care of psychiatry and receives medications and illness management through psychological services and psychosocial group programming; R500 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming the unit; R500 uses antipsychotic medications r/t (related to) behavior management; R500 displays behavioral symptoms related to Bipolar Disorder; R500 has behavior problem r/t anxiety, depression, change in mood, self-isolation, false accusations, repetitive questioning, agitation, tearful episodes, cursing, decreased socialization, delusions, hallucinations, pacing, panic, paranoia, and verbal aggression; R500 has impaired cognitive function, becomes easily confused, overwhelmed and disoriented; and R500 had chronic psychiatric illness and determined to have ineffective coping modalities that include disorganized thought processes and mood patterns, delusions, hallucinations, difficulty meeting basic physiological/self-care needs, and having reduced insight and judgement r/t Schizoaffective disorder; and R500 displays conflictual, difficult behavior with other persons with symptoms of open conflict with or repeated criticism of staff and unprovoked expressions of anger towards staff and peer. Being verbally and physically aggressive with her peers. Interventions include: Teach and remind the resident to communicate his/her feelings, including anger and frustration through means other than hitting, touching or verbally abusing another person; R500 has rapid cycling and significant shifts in mood that include mania and depression that may last for several days r/t bipolar disorder with following symptoms of hallucinations, becoming easily agitated, irritated, disturbed, having illogical thinking, and paranoid delusional thoughts about others. Goal is for R500 to seek assistance when experiencing aggressive impulses and refrain from engaging in verbal threats and loud, profane language toward others. Interventions include: Monitor/record/report to MD (medical doctor) prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; and R500 has Behavioral Symptoms/Altercation with Roommate initiated on 4/4/24 as: R500 demonstrates behavioral distress related to: Ineffective coping mechanisms, bipolar disorder and Schizoaffective disorder. Problems are manifested by: Physically abusive behavior when agitated such as slapping or attempting to cause harm to a peer. The Behavior Monitoring Report for R500, dated 7/01/24 through 8/28/24 documents the following behaviors have been noted over the past 30 days: grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, scratching others, accusing of others, cursing at others, expressing frustration/anger at others, screaming at others, threatening others, entering other resident's rooms/personal space, disruptive sounds, repetitive motions, rummaging, agitated, anxious and restless, elopement and exit seeking, experiencing something not there, hoarding, neglecting self care, pacing, panic, refusing care, wandering and withdrawn/isolation. The Psychiatry Note for R500, dated 4/5/24, documents On 4/4/24 (R500) became agitated at her roommate (R134) for wandering on her (R500) side of the room and going through her (R500) belongings. When R500 attempted to take her belongings back, R134 raised their arms at R500 so (R500) struck (R134). R500 was sent to the local hospital for an evaluation and returned to the facility. On 8/27/24 at 2:47 pm, V2 DON (Director of Nursing) stated she does the Fall Investigations and V1 Administrator does the Abuse Investigations and there has only been one abuse allegation involving R500 and that was with R103. R500 is very territorial about her room and space and had just been at Geriatric psychological hospital for manic behavior, not for being aggressive. V2 DON stated That is the only incident she's had. There are no others. V2 DON stated R500 went out to the psychological hospital on 8/2/24 and just readmitted back to the facility on [DATE]. On 8/20/24 R500 pushed R103 and R103 fell to the floor. V2 stated both residents went out to the local the hospital for evaluations, returned with no injuries and R500 was placed on one-to-one staff monitoring when she returned from the hospital. On 8/27/24 at 3:15 pm, V1 Administrator stated he is the Abuse Coordinator but was not involved in the incident with R84 because he was not at the facility but was involved with the altercation between R500 and R103. V1 Administrator stated V2 DON (Director of Nursing) does all the fall investigations and did R84's investigation as a fall, it was not considered abuse and he is unaware of the incident being potential abuse. On 8/23/24 at 11:40 am, R500's door was closed, and V20 Transportation CNA was sitting outside of R500's room. Upon entering R500's room noted two mattresses on the floor with bed frames standing empty. R500 was lying on one of the mattresses and R500's personal items were randomly scattered on the other mattress on the floor. R500 stated she was not feeling very good, had recently been in the hospital, has lost weight, doesn't know why, and requested a soda to drink. 1. A facility Abuse Investigation for R500 and R134, dated 4/4/24, documents V38 CNA (Certified Nursing Assistant) heard noise and went into R500 and R134's room, (R134) had two bears and a flower in her hand. (R500) went and took the bears out of (R134's) hand. (R134) got upset and raised her hands in the air. (V38) got in between the two (R134 and R500) and tried to intervene and (R500) reached around and slapped (R134). V22 RN (Registered Nurse) witness statement documents (V22 RN) was standing at the nurses' station and was trying to get there asap (as soon as possible) because (V22 RN) was hearing a commotion. When (V22) got in the room (R500) was complaining about (R134) getting into (R500's) stuff. (R134) put her hands up in the air and (R500) slapped (R134). The local hospital ED (emergency department) Physician Notes for R500, dated 4/4/24, documents R500 is from (The Facility) and staff sent her (R500) in due to having an altercation with her roommate. The Final Abuse Investigation documents the facility is unable to substantiate this allegation as well as (R500) made contact with (R134); regardless that V38 CNA and V22 RN witnessed R500 hit R134. On 8/23/24 at 12:00 pm, V22 RN stated R500 has had some bizarre behaviors, is aggressive at times and there was an incident awhile back with another resident, her old roommate before she moved and R500 has been aggressive with the staff. 2. A facility Fall Investigation for R84, dated 8/20/24 at 12:23 pm, documented by V29 LPN (Licensed Practical Nurse) documents staff was in the dining room at lunch when someone (R500) was heard yelling on the hallway. V29 LPN asked V41 CNA to go observe the area. V41 CNA went to the hall and started to go down the hall and observed (R84) at the end of the hall. (R84) was observed falling backwards. V41 CNA was unable to assist (R84) d/t not being close enough. V41 CNA's statement is documented as: I was serving food. I heard someone yell. I went to observe the area and resident was at the end of the hall by (R500's) room. I observed the resident falling backwards and was unable to assist d/t not being close enough. The resident in the room had yelled, stepped back into her room and slammed the door. The local hospital ED (emergency department) Physician Notes for R84, dated 8/20/24, documents R84 presented to ED with a head injury. Chief complaint was an unwitnessed fall with wound to the posterior scalp and bleeding controlled at this time. CT (computed tomography) of the cervical spine and the head were completed with small left posterior scalp contusion without hemorrhage or fractures. On 8/28/24 at 10:45 am. the facility's Video Surveillance surrounding R84's on 8/20/24 at 12:23 pm incident viewed with V1 Administrator and V2 DON and shows R84 standing in R500's doorway area. R500 cannot be seen due to recession of R500's door. V41 CNA is seen walking down the hallway towards R500's door, and at approximately 15 feet from R500's door R84 is seen quickly and forcefully falling, hitting the back of her head on the floor. V41 CNA is then seen anxiously and rapidly moving in circles and about the hallway with arms flailing about. Other Staff members are then seen going down the hallway to assist. The Video Surveillance does not show R500 at the doorway due to the surrounding walls; however, there is some shadowing movement to the left upper exterior door frame area that quickly disappears while R84 is falling backwards. R84 does not appear to have stumbled backwards as the fall was so quick and forceful. R84's walker is also noted to move in the lower middle door area but does not fall over. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated R500 has had a lot of behaviors lately and over the past month or so and has been in and out of the hospital because of aggressive behaviors. V8 stated on 8/20/24 around 12:30 pm she heard R500 yelling and screaming and (V8) was approximately 15 feet from R500's room when R500 took both of her hands, grabbed R84 and like a bowling ball slammed R84 to the floor. She (R500) hulk smacked her (R84's) head and R84's head was gushing blood all over the floor. V8 stated she has never seen anything like that happen before, witnessed the entire incident and wrote a witness statement stating exactly what she saw and gave it to V29 LPN. V8 stated her statement was changed to reflect something other than what she saw. V8 stated V2 DON told (V8) she watched the camera, R84 had stumbled, and V2 DON needed V8 to stop telling people that R500 slammed R84 down. V8 stated she kept telling V2 DON what (V8) saw and that there was no stumbling or (V8) would have seen that. V8 stated she also told V14 ADON (Assistant Director of Nursing) what she witnessed. On 8/28/24 at 10:45 pm, V2 DON stated R84 was startled by R500 when R500 yelled and slammed her door and R84 stumbled back and fell . R84 never said she was pushed. V2 DON stated she heard rumors that were going around about R84 being pushed down the next day (8/21/24). V2 DON stated V41 CNA was telling everyone that she saw R500 push R84 down and was told to stop telling people that because the facility cameras do not show R500 pushing R84 down. When asked if the cameras show R500 not pushing R84 down or why V2 DON didn't investigate V41 CNA's allegation of abuse; regardless of when the allegation was made, V2 DON became irritated, raised her voice and stated R500 did not push R84 down, R84 stumbled and fell back. On 8/28/24 at 10:50 am, V1 Administrator stated the incident with R84 was reported to the State Agency as a fall and even if it was found to be abuse after investigating, he would not have resubmitted the incident as abuse, he would document it on the five day only. V1 also stated a abuse allegations with residents with dementia, confusion or one with a UTI (urinary tract infection) would not be considered willful abuse due to the resident not having the cognition to be willful and he would not report it as abuse. V1 Administrator confirmed the video surveillance did not show that there was or was not contact between R500 and R84 due to quality of video and positioning of camera. On 8/23/24 at 11:30 am, 12:01 pm, and 12:17 pm R84 was wandering the Dementia unit hallways with a wheeled walker and with a slow and steady gait. Bruising was noted to R84's right cheek and three staples to back of her head. On this same date at 12:18 pm, R84 wandered into another resident room. On 8/27/24 at 12:57 pm and on 8/28/24 at 10:09 am, R84 was pacing the hallways with a wheeled walker with a slow steady gait. On 8/27/24 at 1:10 pm, V33 CNA stated she and other nursing staff were in the dining room on 8/20/24 at noon assisting residents with lunch and heard R500 screaming, heard a big loud bump; like something hit on the floor, and then heard a door slam. V33 CNA stated R84 was down by R500's room, in front of R500's door and then just fell back. R500's room is at the end of the hall and the camera at beginning of hall. R500's room has an entryway so her door cannot be seen unless your closer to her room. V33 CNA stated V41 CNA told (V33) that she saw R500's hands push R84 down. V33 CNA stated R84's fall was an aggressive fall. A slower fall would not have caused that to her head. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R84 lost her balance and fell backwards, hit her head and had bruising from the fall, went to the hospital and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during shift change report, she was informed that on day shift R84 was walking with her walker, fell , and hit her head by R500's door, but doesn't know the details. V34 stated R500 was not on one-to-one monitoring at that time. 3. A facility Physical Abuse Investigation for R500 and R103, dated 8/20/24 at 4:40 pm, documents the Nurse heard loud screaming from around the corner in the hallway and Housekeeper in the hallway witnessed physical aggression from R500 towards R103. The victim (R103) had a fall to the floor as a result of R500's Physical Aggression. The investigation includes a statement for V39 and V40 CNA's documenting witnessing R500 yelling at R103 you stay away from me and then R500 pushing R103 to the floor. There is no witness statement from a Housekeeper included in investigation. R103 fell to the floor onto left side and complained of left hip and left knee pain. R103 and R500 were both sent to the local hospital for evaluation and treatment. The Change in Condition Evaluation for R500, dated 8/20/24 at 4:44 pm documents: R500's behavioral changes as physical and verbal aggression and a danger to self and others; Dangerous behavior as pushed peer and as a result of the physical aggression receiver of the aggression fell to the floor; Behavioral changes as resident moving furniture around and had made comment of being filthy and disgusting; and Resident has new orders to be on 1:1 supervision until further notice when she returns from ED (emergency department). The ED Physician Notes for R500, dated 8/20/24, documents R500 was recently discharged from local behavioral hospital yesterday (8/19/24), re- admitted to (the Facility) and altercation occurred (8/20/24) between R500 and another resident. The local hospital Emergency Department Provider Notes for R103, dated 8/20/24 documents the patient (R103) was in an altercation at (the Facility) on memory unit, was pushed hard and fell down and complained of left hip and left knee pain. On 8/28/24 at 10:45 am, the facility's Video Surveillance surrounding R103's 8/20/24 at 4:40 pm incident was reviewed with V1 Administrator and V2 DON and shows R103 and R500 at a table near the entrance of the hallway. R500 is seen standing facing R103 and appears to be talking to R103 and then R500 is seen quickly and forcefully grabbing R103 and shoving R103 towards the floor. R500 is then seen standing nearby while R103 is being assisted. On 8/23/24 at 11:48 am, R103 was in the dining room, standing next to a table talking to other residents. Between 11:50 am through 12:38 pm, R103 was walking independently around the dining room, sat in a stationary chair in the dining room, fed self lunch and at 12:38 pm remained sitting in the dining room. On 8/27/24 at 12:54 pm, R103 was pacing the hallways independently. On 8/30/24 at 2:30 pm, V3 Infection Preventionist assisted R103 with lowering her left pant leg. A large bruise measuring approximately 13 inches was noted to R103's left hip. V3 confirmed this was from R103's fall. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated on 8/20/24 around 4:35 pm she heard and witnessed R500 scream out at R103, grab R103 and throw R103 into the hallway wall, very forcefully. V8 stated after this incident R500 was put on one-to-one monitoring. V8 stated They should have done that after the first time and the second time wouldn't have happened. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R500 and R103 had a resident to resident altercation and both residents went to the hospital and came back and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during second shift R103 was walking and R500 pushed R103 down in the hallway. V34 stated she didn't see it happen but heard the staff talking about seeing R500 push R103 and stated, That's how I know. V34 CNA stated R500 and R103 went out to the local hospital and R500 was put on one-to-one monitoring when she returned from the hospital and had not been on one-to-one prior to that. On 8/23/24 at 11:35 am, V20 Transportation CNA was sitting just outside of R500's room. V20 stated V41 CNA had to leave for family emergency so (V20) was filling in to help with R500's one-to-one monitoring. V20 stated she transported R500 to a behavioral health hospital on 8/2/24 after R500 attacked the staff and was having bizarre behaviors. R500 screamed at the top of her lungs during the last hour of the ride but other than that she didn't have any behaviors. V20 stated R500 just came back here on 8/19/24 and had to be put on one-to-one a couple of days ago. The medical record for R500 documents another emergency room evaluation occurred for R500 on 8/26/24 due to aggressive physical behavior. The local hospital ED report for R500, dated 8/26/24, documents (R500) is a resident of (the Facility) and was apparently becoming quite aggressive with staff. Patient came flying down the hallway and pushed staff x (times) 2. She has no idea why she is in the emergency department, and has some unusual behavior at times and flaps her hands around stating that she is shaking all over. This report documents R500 is positive for agitation and behavioral problems. The Final diagnoses for R500 is documented as Behavior concern in adult and Aggressive behavior. The facility's Abuse log, dated 2024, documents one abuse allegation involving R500, dated 8/20/24 at 4:40 pm and does not include the allegation involving R134 or R84. The Immediate Jeopardy began on 8/20/24 at 12:23 pm when the facility failed to prevent, identify and investigate a potential allegation of abuse and protect residents from further abuse. V1 Administrator was notified of the Immediate Jeopardy on 8/29/24 at 11:28 am. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Investigation of both incidents were completed and reported to state survey agency and physician for R84, R103, and R500. 2. R84 was transferred to the hospital for evaluation. 3. R103 was transferred to the hospital for evaluation. No injuries were noted and R103 returned to the facility with no new orders. 4. R500 was placed on one-to-one supervision on 8/20/24. 5. R500 care plan was updated to include one-to-one supervision and again updated to include one-to-one supervision until the resident is deemed safe by psychiatry and/or nursing assessment. 6. R500 care plan was updated to include behavior monitoring Q (every) shift. 7. R84, R103, and R500 care plans have been updated to include one-to-one time with Social Services as needed to vent feelings. 8. Administrator in-serviced by Risk Management Consultant on 8/29/24 regarding Abuse Prevention Policy. 9. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff was initiated on 8/29/24. 10. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. Employees will not be allowed to work after 11:59 pm on 8/29/24 until they have completed the in-service. 11. QAA (Quality Assessment and Assurance) team members were in-serviced on the facility's Abuse Prevention Program policy and procedure by the Administrator on 8/29/24. 12. Social Services Director and/or designee will audit Trauma Screening assessments and Screening Assessments for Indicators of Aggressive and/or Harmful Behavior for all 35 residents with the potential to be affected by this alleged deficiency to ensure those assessments are current. Social Services Director/designee will ensure interventions are care planned for any residents assessed to be at risk. The audits will be completed by 11:59 pm on 8/29/24. 13. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during quarterly QA (Quality Assurance) meetings with medical director and address any concerns. 14. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during Morning QA meetings daily x 30 days on all new admits to assure compliance. 15. The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the facility QA Committee for follow up and review. 16. In-service training by Administrator/designee on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly x 3 by the DON or Administrator. 17. Administrator will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.

Based on observation, interview, and record review the facility failed to ensure residents were free from physical and verbal abuse and identify and investigate a potential allegation of abuse and protect resident from further abuse from R500, with a known history of verbal and physical aggression. These failures resulted in R500 verbally yelling and physically hitting R134 and shoving both R84 and R103 to the ground. R84 sustained a bleeding laceration to posterior head, facial bruising, and hospitalization requiring three staples to R84's posterior head. R103 experienced hip and knee pain, bruising, and hospital evaluation. R134 was hit in the face. These failures have the potential to affect all 35 residents residing in the facility's Dementia unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/29/24, the facility remains out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The facility's Abuse Prevention Program policy, revised 3/1/21, documents It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. This policy also documents Identification of Allegations/ Internal Reporting Requirements: Employees are required to immediately report and incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident they observe, hear about, or suspect to the Administrator if available or an immediate supervisor who must immediately report it to the Administrator. In the absence of the Administrator, reporting can be made to the DON (Director of Nursing). Any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment or crime against a resident is reported to a covered individual; covered individuals are notified annually of these reporting requirements. Employees without fear of retaliation may also independently report to the state survey agency any allegation of abuse, neglect, exploitation, or mistreatment of resident property, and to local law enforcement if they have a reasonable suspicion that a crime was committed. Such reports may be made without fear of retaliation. Anonymous reports will also be thoroughly investigated. Reports should be documented, and a record kept of the documentation. Upon learning of the report, the Administrator or in the absence of the Administrator, the DON shall initiate an incident investigation. Investigation: All incidents, allegation or suspicion of abuse, neglect, exploitation, misappropriation of property, or crime against a resident will be documented. Any incident or allegation involving abuse, neglect, exploitation, misappropriation of resident property, or crime against a resident will result in an abuse investigation. Once the Administrator or in the absence of the Administrator the DON determines that there is an allegation or a reasonable cause for suspecting abuse, neglect, exploitation, misappropriation of property, or a crime against a resident, the Administrator or appointed investigator will investigate the allegation and obtain a copy of any documentation relative to the incident. This policy also documents Protection of Residents: The facility will take steps to prevent mistreatment while the investigation is underway. Residents who allegedly mistreated another resident will be immediately removed from contact with that resident during course of investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches and placement, considering his or her safety, as well as the safety of the other residents and employees of the facility. All personnel, residents, visitors, etc. (etcetera) are encouraged to report incidents of resident abuse, mistreatment or neglect or suspected abuse, mistreatment, or neglect, without fear of retaliation or retribution from facility or its staff. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. This same policy also documents Procedure: Upon receiving reports of physical or sexual abuse, the Charge Nurse will immediately examine the resident. Findings of the examination must be recorded in a separate incident report and in the resident's medical record. This report shall be made immediately, but no later than two hours after the allegation is made. If the events that cause the allegation involve abuse or resulted in serious bodily injury, or not less than 24 hours if the events that cause the allegation do not involve abuse and did not result in serious bodily injury. Crimes include but may not be limited to murder, manslaughter, rape, assault and battery, sexual abuse, theft robbery, drug diversion for personal use or gain, identify theft, and fraud and forgery. When an alleged or suspected case of abuse, neglect, exploitation, or crime against a resident is reported to the facility Administrator, the Administrator, or DON in the Administrator's absence, will notify the following persons or agencies of such incident immediately. Any incident that involves crimes or significant injury to a resident will be reported within two hours of the incident. Any incident that involves a resident death will be called to the (State Agency) immediately. Abuse allegations involving one resident upon resident upon another resident will be reported to (the States Agency). The Diagnosis Report for R500, documents R500 admitted to the facility on [DATE] with a diagnosis of Schizoaffective Disorder. R500 was diagnosed with Obsessive Compulsive Personality Disorder on 7/15/24 and diagnosed with Bipolar and Metabolic Encephalopathy on 7/25/23. R500 was also diagnosed with Anxiety on 8/21/24 after readmitting to the facility on [DATE] from psychological hospitalization . The facility Psychiatric service report for R500, dated 6/5/24, documents R500 with a diagnosis of Dementia. This report documents R500 with auditory hallucinations and delusions and making false accusations of staff. Psychiatric History includes multiple psychiatric hospitalization s and multiple medication changes prior to facility admission. The current Care Plan for R500 documents the following: Focus areas with goals and interventions listed: R500 has chronic health conditions, behaviors, challenges, and co-morbidities that include Schizoaffective and bipolar disorder. R500 requires the support, services and structure of the care setting and is under the care of psychiatry and receives medications and illness management through psychological services and psychosocial group programming; R500 demonstrates movement behavior that may be interpreted as wandering, pacing, or roaming the unit; R500 uses antipsychotic medications r/t (related to) behavior management; R500 displays behavioral symptoms related to Bipolar Disorder; R500 has behavior problem r/t anxiety, depression, change in mood, self-isolation, false accusations, repetitive questioning, agitation, tearful episodes, cursing, decreased socialization, delusions, hallucinations, pacing, panic, paranoia, and verbal aggression; R500 has impaired cognitive function, becomes easily confused, overwhelmed and disoriented; and R500 had chronic psychiatric illness and determined to have ineffective coping modalities that include disorganized thought processes and mood patterns, delusions, hallucinations, difficulty meeting basic physiological/self-care needs, and having reduced insight and judgement r/t Schizoaffective disorder; and R500 displays conflictual, difficult behavior with other persons with symptoms of open conflict with or repeated criticism of staff and unprovoked expressions of anger towards staff and peer. Being verbally and physically aggressive with her peers. Interventions include: Teach and remind the resident to communicate his/her feelings, including anger and frustration through means other than hitting, touching or verbally abusing another person; R500 has rapid cycling and significant shifts in mood that include mania and depression that may last for several days r/t bipolar disorder with following symptoms of hallucinations, becoming easily agitated, irritated, disturbed, having illogical thinking, and paranoid delusional thoughts about others. Goal is for R500 to seek assistance when experiencing aggressive impulses and refrain from engaging in verbal threats and loud, profane language toward others. Interventions include: Monitor/record/report to MD (medical doctor) prn (as needed) risk for harming others: increased anger, labile mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; and R500 has Behavioral Symptoms/Altercation with Roommate initiated on 4/4/24 as: R500 demonstrates behavioral distress related to: Ineffective coping mechanisms, bipolar disorder and Schizoaffective disorder. Problems are manifested by: Physically abusive behavior when agitated such as slapping or attempting to cause harm to a peer. The Behavior Monitoring Report for R500, dated 7/01/24 through 8/28/24 documents the following behaviors have been noted over the past 30 days: grabbing others, hitting others, kicking others, pushing others, physically aggressive towards others, scratching others, accusing of others, cursing at others, expressing frustration/anger at others, screaming at others, threatening others, entering other resident's rooms/personal space, disruptive sounds, repetitive motions, rummaging, agitated, anxious and restless, elopement and exit seeking, experiencing something not there, hoarding, neglecting self care, pacing, panic, refusing care, wandering and withdrawn/isolation. The Psychiatry Note for R500, dated 4/5/24, documents On 4/4/24 (R500) became agitated at her roommate (R134) for wandering on her (R500) side of the room and going through her (R500) belongings. When R500 attempted to take her belongings back, R134 raised their arms at R500 so (R500) struck (R134). R500 was sent to the local hospital for an evaluation and returned to the facility. On 8/27/24 at 2:47 pm, V2 DON (Director of Nursing) stated she does the Fall Investigations and V1 Administrator does the Abuse Investigations and there has only been one abuse allegation involving R500 and that was with R103. R500 is very territorial about her room and space and had just been at Geriatric psychological hospital for manic behavior, not for being aggressive. V2 DON stated That is the only incident she's had. There are no others. V2 DON stated R500 went out to the psychological hospital on 8/2/24 and just readmitted back to the facility on [DATE]. On 8/20/24 R500 pushed R103 and R103 fell to the floor. V2 stated both residents went out to the local the hospital for evaluations, returned with no injuries and R500 was placed on one-to-one staff monitoring when she returned from the hospital. On 8/27/24 at 3:15 pm, V1 Administrator stated he is the Abuse Coordinator but was not involved in the incident with R84 because he was not at the facility but was involved with the altercation between R500 and R103. V1 Administrator stated V2 DON (Director of Nursing) does all the fall investigations and did R84's investigation as a fall, it was not considered abuse and he is unaware of the incident being potential abuse. On 8/23/24 at 11:40 am, R500's door was closed, and V20 Transportation CNA was sitting outside of R500's room. Upon entering R500's room noted two mattresses on the floor with bed frames standing empty. R500 was lying on one of the mattresses and R500's personal items were randomly scattered on the other mattress on the floor. R500 stated she was not feeling very good, had recently been in the hospital, has lost weight, doesn't know why, and requested a soda to drink. 1. A facility Abuse Investigation for R500 and R134, dated 4/4/24, documents V38 CNA (Certified Nursing Assistant) heard noise and went into R500 and R134's room, (R134) had two bears and a flower in her hand. (R500) went and took the bears out of (R134's) hand. (R134) got upset and raised her hands in the air. (V38) got in between the two (R134 and R500) and tried to intervene and (R500) reached around and slapped (R134). V22 RN (Registered Nurse) witness statement documents (V22 RN) was standing at the nurses' station and was trying to get there asap (as soon as possible) because (V22 RN) was hearing a commotion. When (V22) got in the room (R500) was complaining about (R134) getting into (R500's) stuff. (R134) put her hands up in the air and (R500) slapped (R134). The local hospital ED (emergency department) Physician Notes for R500, dated 4/4/24, documents R500 is from (The Facility) and staff sent her (R500) in due to having an altercation with her roommate. The Final Abuse Investigation documents the facility is unable to substantiate this allegation as well as (R500) made contact with (R134); regardless that V38 CNA and V22 RN witnessed R500 hit R134. On 8/23/24 at 12:00 pm, V22 RN stated R500 has had some bizarre behaviors, is aggressive at times and there was an incident awhile back with another resident, her old roommate before she moved and R500 has been aggressive with the staff. 2. A facility Fall Investigation for R84, dated 8/20/24 at 12:23 pm, documented by V29 LPN (Licensed Practical Nurse) documents staff was in the dining room at lunch when someone (R500) was heard yelling on the hallway. V29 LPN asked V41 CNA to go observe the area. V41 CNA went to the hall and started to go down the hall and observed (R84) at the end of the hall. (R84) was observed falling backwards. V41 CNA was unable to assist (R84) d/t not being close enough. V41 CNA's statement is documented as: I was serving food. I heard someone yell. I went to observe the area and resident was at the end of the hall by (R500's) room. I observed the resident falling backwards and was unable to assist d/t not being close enough. The resident in the room had yelled, stepped back into her room and slammed the door. The local hospital ED (emergency department) Physician Notes for R84, dated 8/20/24, documents R84 presented to ED with a head injury. Chief complaint was an unwitnessed fall with wound to the posterior scalp and bleeding controlled at this time. CT (computed tomography) of the cervical spine and the head were completed with small left posterior scalp contusion without hemorrhage or fractures. On 8/28/24 at 10:45 am. the facility's Video Surveillance surrounding R84's on 8/20/24 at 12:23 pm incident viewed with V1 Administrator and V2 DON and shows R84 standing in R500's doorway area. R500 cannot be seen due to recession of R500's door. V41 CNA is seen walking down the hallway towards R500's door, and at approximately 15 feet from R500's door R84 is seen quickly and forcefully falling, hitting the back of her head on the floor. V41 CNA is then seen anxiously and rapidly moving in circles and about the hallway with arms flailing about. Other Staff members are then seen going down the hallway to assist. The Video Surveillance does not show R500 at the doorway due to the surrounding walls; however, there is some shadowing movement to the left upper exterior door frame area that quickly disappears while R84 is falling backwards. R84 does not appear to have stumbled backwards as the fall was so quick and forceful. R84's walker is also noted to move in the lower middle door area but does not fall over. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated R500 has had a lot of behaviors lately and over the past month or so and has been in and out of the hospital because of aggressive behaviors. V8 stated on 8/20/24 around 12:30 pm she heard R500 yelling and screaming and (V8) was approximately 15 feet from R500's room when R500 took both of her hands, grabbed R84 and like a bowling ball slammed R84 to the floor. She (R500) hulk smacked her (R84's) head and R84's head was gushing blood all over the floor. V8 stated she has never seen anything like that happen before, witnessed the entire incident and wrote a witness statement stating exactly what she saw and gave it to V29 LPN. V8 stated her statement was changed to reflect something other than what she saw. V8 stated V2 DON told (V8) she watched the camera, R84 had stumbled, and V2 DON needed V8 to stop telling people that R500 slammed R84 down. V8 stated she kept telling V2 DON what (V8) saw and that there was no stumbling or (V8) would have seen that. V8 stated she also told V14 ADON (Assistant Director of Nursing) what she witnessed. On 8/28/24 at 10:45 pm, V2 DON stated R84 was startled by R500 when R500 yelled and slammed her door and R84 stumbled back and fell . R84 never said she was pushed. V2 DON stated she heard rumors that were going around about R84 being pushed down the next day (8/21/24). V2 DON stated V41 CNA was telling everyone that she saw R500 push R84 down and was told to stop telling people that because the facility cameras do not show R500 pushing R84 down. When asked if the cameras show R500 not pushing R84 down or why V2 DON didn't investigate V41 CNA's allegation of abuse; regardless of when the allegation was made, V2 DON became irritated, raised her voice and stated R500 did not push R84 down, R84 stumbled and fell back. On 8/28/24 at 10:50 am, V1 Administrator stated the incident with R84 was reported to the State Agency as a fall and even if it was found to be abuse after investigating, he would not have resubmitted the incident as abuse, he would document it on the five day only. V1 also stated a abuse allegations with residents with dementia, confusion or one with a UTI (urinary tract infection) would not be considered willful abuse due to the resident not having the cognition to be willful and he would not report it as abuse. V1 Administrator confirmed the video surveillance did not show that there was or was not contact between R500 and R84 due to quality of video and positioning of camera. On 8/23/24 at 11:30 am, 12:01 pm, and 12:17 pm R84 was wandering the Dementia unit hallways with a wheeled walker and with a slow and steady gait. Bruising was noted to R84's right cheek and three staples to back of her head. On this same date at 12:18 pm, R84 wandered into another resident room. On 8/27/24 at 12:57 pm and on 8/28/24 at 10:09 am, R84 was pacing the hallways with a wheeled walker with a slow steady gait. On 8/27/24 at 1:10 pm, V33 CNA stated she and other nursing staff were in the dining room on 8/20/24 at noon assisting residents with lunch and heard R500 screaming, heard a big loud bump; like something hit on the floor, and then heard a door slam. V33 CNA stated R84 was down by R500's room, in front of R500's door and then just fell back. R500's room is at the end of the hall and the camera at beginning of hall. R500's room has an entryway so her door cannot be seen unless your closer to her room. V33 CNA stated V41 CNA told (V33) that she saw R500's hands push R84 down. V33 CNA stated R84's fall was an aggressive fall. A slower fall would not have caused that to her head. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R84 lost her balance and fell backwards, hit her head and had bruising from the fall, went to the hospital and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during shift change report, she was informed that on day shift R84 was walking with her walker, fell , and hit her head by R500's door, but doesn't know the details. V34 stated R500 was not on one-to-one monitoring at that time. 3. A facility Physical Abuse Investigation for R500 and R103, dated 8/20/24 at 4:40 pm, documents the Nurse heard loud screaming from around the corner in the hallway and Housekeeper in the hallway witnessed physical aggression from R500 towards R103. The victim (R103) had a fall to the floor as a result of R500's Physical Aggression. The investigation includes a statement for V39 and V40 CNA's documenting witnessing R500 yelling at R103 you stay away from me and then R500 pushing R103 to the floor. There is no witness statement from a Housekeeper included in investigation. R103 fell to the floor onto left side and complained of left hip and left knee pain. R103 and R500 were both sent to the local hospital for evaluation and treatment. The Change in Condition Evaluation for R500, dated 8/20/24 at 4:44 pm documents: R500's behavioral changes as physical and verbal aggression and a danger to self and others; Dangerous behavior as pushed peer and as a result of the physical aggression receiver of the aggression fell to the floor; Behavioral changes as resident moving furniture around and had made comment of being filthy and disgusting; and Resident has new orders to be on 1:1 supervision until further notice when she returns from ED (emergency department). The ED Physician Notes for R500, dated 8/20/24, documents R500 was recently discharged from local behavioral hospital yesterday (8/19/24), re- admitted to (the Facility) and altercation occurred (8/20/24) between R500 and another resident. The local hospital Emergency Department Provider Notes for R103, dated 8/20/24 documents the patient (R103) was in an altercation at (the Facility) on memory unit, was pushed hard and fell down and complained of left hip and left knee pain. On 8/28/24 at 10:45 am, the facility's Video Surveillance surrounding R103's 8/20/24 at 4:40 pm incident was reviewed with V1 Administrator and V2 DON and shows R103 and R500 at a table near the entrance of the hallway. R500 is seen standing facing R103 and appears to be talking to R103 and then R500 is seen quickly and forcefully grabbing R103 and shoving R103 towards the floor. R500 is then seen standing nearby while R103 is being assisted. On 8/23/24 at 11:48 am, R103 was in the dining room, standing next to a table talking to other residents. Between 11:50 am through 12:38 pm, R103 was walking independently around the dining room, sat in a stationary chair in the dining room, fed self lunch and at 12:38 pm remained sitting in the dining room. On 8/27/24 at 12:54 pm, R103 was pacing the hallways independently. On 8/30/24 at 2:30 pm, V3 Infection Preventionist assisted R103 with lowering her left pant leg. A large bruise measuring approximately 13 inches was noted to R103's left hip. V3 confirmed this was from R103's fall. On 8/27/24 at 1:30 pm, V8 Anonymous Staff Member stated on 8/20/24 around 4:35 pm she heard and witnessed R500 scream out at R103, grab R103 and throw R103 into the hallway wall, very forcefully. V8 stated after this incident R500 was put on one-to-one monitoring. V8 stated They should have done that after the first time and the second time wouldn't have happened. On 8/23/24 at 11:58 am, V21 Restorative Nurse stated on 8/20/24, R500 and R103 had a resident to resident altercation and both residents went to the hospital and came back and That's all I know. On 8/27/24 at 1:00 pm, V34 CNA stated on 8/20/24, during second shift R103 was walking and R500 pushed R103 down in the hallway. V34 stated she didn't see it happen but heard the staff talking about seeing R500 push R103 and stated, That's how I know. V34 CNA stated R500 and R103 went out to the local hospital and R500 was put on one-to-one monitoring when she returned from the hospital and had not been on one-to-one prior to that. On 8/23/24 at 11:35 am, V20 Transportation CNA was sitting just outside of R500's room. V20 stated V41 CNA had to leave for family emergency so (V20) was filling in to help with R500's one-to-one monitoring. V20 stated she transported R500 to a behavioral health hospital on 8/2/24 after R500 attacked the staff and was having bizarre behaviors. R500 screamed at the top of her lungs during the last hour of the ride but other than that she didn't have any behaviors. V20 stated R500 just came back here on 8/19/24 and had to be put on one-to-one a couple of days ago. The medical record for R500 documents another emergency room evaluation occurred for R500 on 8/26/24 due to aggressive physical behavior. The local hospital ED report for R500, dated 8/26/24, documents (R500) is a resident of (the Facility) and was apparently becoming quite aggressive with staff. Patient came flying down the hallway and pushed staff x (times) 2. She has no idea why she is in the emergency department, and has some unusual behavior at times and flaps her hands around stating that she is shaking all over. This report documents R500 is positive for agitation and behavioral problems. The Final diagnoses for R500 is documented as Behavior concern in adult and Aggressive behavior. The facility's Abuse log, dated 2024, documents one abuse allegation involving R500, dated 8/20/24 at 4:40 pm and does not include the allegation involving R134 or R84. The Immediate Jeopardy began on 8/20/24 at 12:23 pm when the facility failed to prevent, identify and investigate a potential allegation of abuse and protect residents from further abuse. V1 Administrator was notified of the Immediate Jeopardy on 8/29/24 at 11:28 am. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. Investigation of both incidents were completed and reported to state survey agency and physician for R84, R103, and R500. 2. R84 was transferred to the hospital for evaluation. 3. R103 was transferred to the hospital for evaluation. No injuries were noted and R103 returned to the facility with no new orders. 4. R500 was placed on one-to-one supervision on 8/20/24. 5. R500 care plan was updated to include one-to-one supervision and again updated to include one-to-one supervision until the resident is deemed safe by psychiatry and/or nursing assessment. 6. R500 care plan was updated to include behavior monitoring Q (every) shift. 7. R84, R103, and R500 care plans have been updated to include one-to-one time with Social Services as needed to vent feelings. 8. Administrator in-serviced by Risk Management Consultant on 8/29/24 regarding Abuse Prevention Policy. 9. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff was initiated on 8/29/24. 10. In-servicing training by Administrator/designee on Abuse Prevention Policy with all staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. Employees will not be allowed to work after 11:59 pm on 8/29/24 until they have completed the in-service. 11. QAA (Quality Assessment and Assurance) team members were in-serviced on the facility's Abuse Prevention Program policy and procedure by the Administrator on 8/29/24. 12. Social Services Director and/or designee will audit Trauma Screening assessments and Screening Assessments for Indicators of Aggressive and/or Harmful Behavior for all 35 residents with the potential to be affected by this alleged deficiency to ensure those assessments are current. Social Services Director/designee will ensure interventions are care planned for any residents assessed to be at risk. The audits will be completed by 11:59 pm on 8/29/24. 13. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during quarterly QA (Quality Assurance) meetings with medical director and address any concerns. 14. QAA team will review the Trauma Screening assessments and Screening Assessment for Indicators of Aggressive and/or Harmful Behaviors during Morning QA meetings daily x 30 days on all new admits to assure compliance. 15. The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the facility QA Committee for follow up and review. 16. In-service training by Administrator/designee on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly x 3 by the DON or Administrator. 17. Administrator will enforce the interventions of plan of removal of immediacy and assurance of continued compliance.

Based on interview and record review the facility failed to immediately provide CPR (Cardiopulmonary Resuscitation) to one resident (R1) identified as having no Advance Directives and failed to follow their policy which documents that Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. The facility also failed to ensure all staff received training on the facility CPR Policy. On [DATE] at approximately 9:25am R1 was found unresponsive and without a pulse or respirations in his room by V7 (RN - Registered Nurse). V7 then left R1's room to make telephone calls to another nurse regarding R1's condition and to V2, (DON - Director of Nursing). This failure resulted in R1 not receiving Cardiopulmonary Resuscitation when found without a pulse and not breathing by V7, (RN) who left R1 and did not return to R1's room until V5, (RN) and V6, (LPN - Licensed Practical Nurse) had started CPR. This failure placed 59 current residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61) identified as having Advanced Directives indicating Full Code status at risk of not receiving immediate life sustaining treatment. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified to have started on [DATE] at 9:25am when R1 was found by V7 (RN) without a pulse or respirations and did not stay with R1 to initiate CPR. V1 (Administrator) was notified of the Immediate Jeopardy on [DATE] at 2:20pm. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level Two as the facility continues to monitor the effectiveness and training related to Advance Directives, code status, and initiation of CPR. Findings include: Facility Policy/Cardiopulmonary Resuscitation (undated) documents: It is the policy of (the facility) that Cardiopulmonary Resuscitation (CPR) shall be initiated and maintained by qualified staff in cases of recognized cardiac and/or pulmonary arrest to sustain or support a resident's cardiac and/or pulmonary function until advanced life support systems are available. Cardiopulmonary Resuscitation shall be initiated on all residents except those who have designated through advanced directives and/or have a specific physician order for DNR (Do Not Resuscitate), No Code or No CPR. Implementation of a code is as follows: Direct and non-direct care staff upon finding a resident non-responsive shall remain with that resident as is possible while signaling for assistance. The facility shall provide education to all employees regarding advance directives and the implementation of such. In servicing of advance directives policy and procedure shall be conducted annually. AHA (American Heart Association) Cardiac Arrest Treatment dated/reviewed [DATE] documents: If you think the person may be suffering cardiac arrest and you're a trained lay rescuer: Ensure scene safety. Check for response. Shout for help. Tell someone nearby to call 911 or your emergency response number. Ask that person or another bystander to bring you an AED (automated external defibrillator), if there's one on hand. Tell them to hurry - time is critical. If you're alone with an adult who has signs of cardiac arrest, call 911 and get an AED (if one is available). Check for no breathing or only gasping. If the person isn't breathing or is only gasping, begin CPR with compressions. Administer high-quality CPR. Push down at least two inches in the center of the chest at a rate of 100 to 120 pushes a minute. Allow the chest to come back up to its normal position after each push. Use an AED. As soon as it arrives, turn it on and follow the prompts. Continue CPR. Administer it until the person starts to breathe or move, or until someone with more advanced training, such as an EMS team member, takes over. Progress Note dated [DATE] at 5:34pm indicates R1 was admitted to the facility at 4:50pm with a gastric feeding tube and on dialysis. Note indicates R1 was receiving oxygen at 3L (liters). Physician Order Summary Report (POS) indicates R1 was admitted with diagnoses that included Congestive Heart Failure, Critical Illness Myopathy, Dilated Cardiomyopathy, Diabetes Mellitus, History of Prostate Cancer, Seizure Disorder, Encephalopathy, Dysphagia, Respiratory Failure. R1's electronic medical record did not contain Advanced Directives/Code Status. Progress Note dated [DATE] at 9:00am (documented by V5, RN - Registered Nurse) indicates V5 was called to come to building/Unit 2 by V7 (Charge Nurse). Note indicates V5 arrived and initially saw a resident on the floor in the dining room. Note indicates V5 was then sent to R1's room by V7 who stated that (R1) died . Note indicates V5 entered R1's room where family was present and noted R1 with no pulse and unresponsive. Note indicates V5 received a call at that time from V2 (DON - Director of Nursing) asking what was being done for R1. Note indicates V5 told V2 that she had just entered R1's room and did not know R1's code status but was instructed by V7 to start CPR. Note indicates another nurse (V6, LPN) arrived with the crash cart and began respirations for R1. Note indicates EMT's (Emergency Medical Technicians) arrived and took over CPR for R1. Progress Note - Clarification note dated [DATE] at 2:55pm indicates V5 was called to Unit 2 by V7, RN on duty related to an emergency. Note indicates V5 immediately responded to Unit 2 and upon arrival noted a female resident on the floor with a hematoma on her head. Note indicates as V5 went to assess the resident on the floor, the RN on duty (V7) informed V5 that V5 was needed down the hallway for a code. Note indicates V5 responded to R1's room where family was present and yelling and confirmed that R1 had no pulse or respirations. Note indicates the assigned nurse (V7) confirmed R1 was a full code and shortly thereafter V6 (LPN) arrived with the crash cart. Note indicates EMT's arrived and took over the code. On [DATE] at 1:45pm V7 (RN) stated that the night nurse told her in report that R1 had no code status identified, so R1 would be a Full Code. V7 stated I was in same hallway passing meds, (R1's) daughter came out of room to tell me R1 was dead. I immediately went into his room, and he had no pulse, no breathing. I left (R1's) room to call the house supervisor, she then called Code Pink. V7 stated she then called V2 (DON) and told her R1 did not have a POLST (Physician Orders for Life-Sustaining Treatment) and V2 said to start CPR. V7 stated she then went back to R1's room and V5 and V6 were placing the backboard under R1 and started CPR. V7 stated Sometimes we have to call the DON to find out what to do. On [DATE] at 9:10am V2, (DON) stated the first call she received was at 9:29am on [DATE] from V7, (RN) who reported The new guy is dead. V2 reported that V7 told her that R1 had no POLST and they are going to do CPR. After confirming phone calls were made I told (V5) to go back into the room to help the other nurses. On [DATE] V5 stated that she immediately responded to the Code called and arrived on Unit 2. V5 stated that V7 (RN) was standing by the nurse's station, did not appear to be on the phone and was not assisting a resident who was on the floor. V5 stated she asked V7 where was the Emergency? and V7 pointed toward R1's room. V5 stated R1 had no pulse, no respirations and she immediately started compressions. V5 stated she did not know why V7 left R1 to come out and make phone calls if she already knew R1 was a Full Code. V5 stated she would have stayed with the resident, started CPR and started yelling for other staff to come and help - make phone calls, etc. On [DATE] at 3:37pm V18 (Medical Director) stated that it's very hard to determine if the brief delay in initiating CPR lessened chances of survivability but of course the sooner starting the better. V18 stated staff should follow facility protocol as far as responding to CPR. On [DATE] V1 (Administrator) stated, We do not have signatures for (V5, RN) or (V7, RN -Agency staff) indicating that they received training on our CPR policy. All staff, including Agency staff should be familiar with our critical policies and I would say the CPR policy is critical. All licensed nurses should know how to respond and be familiar with CPR procedures. V1 confirmed that both V5 and V7 work regularly at the facility. On [DATE] the surveyor confirmed through interview and record review the facility took the following actions to remove the immediacy: 1. In-servicing by members of the Nurse Management team for licensed and certified staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated on [DATE]. 2. In-service by members of the Quality Assurance team for All staff on the facilities Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page was initiated on [DATE]. 3. DON/MDSC (Minimum Data Set Coordinator)/SS (Social Services) team members completed an audit of all residents' code status orders, POLST Forms and advanced directive care plans on [DATE]. This audit was repeated [DATE] with no inconstancies noted. A review of all new admits on [DATE] and [DATE] completed. 4. V7 has been removed from the facility's schedule and has not worked since the alleged deficiency. 5. All staff who have not received the above-mentioned in-service will by 11:00 PM on [DATE] or will be removed from the facility schedules until the in-servicing has been completed with a QAT (Quality Assurance Team) member. Quality Assurance Activities to assure the alleged deficient practice will not recur include: 1. In-servicing training by members of the Nurse Manager Quality Assurance Team on Advanced Directives, Cardiopulmonary Resuscitation, POLST Form, and Code Pink-Nurse Emergency Page with all staff will continue monthly for the next 3 months, then quarterly x 3 quarters. 2. DON/MDSC/SSD will complete an audit of all residents' code status orders, POLST Forms and advanced directive care plans monthly x 3 months then quarterly and PRN (as needed). 3. LNHA (Licensed Nursing Home Administrator) will enforce the interventions of plan of removal of immediacy.

Based on interview and record review the facility failed to develop a system to assess and evaluate residents for capacity to consent to sexual activity, failed to ensure two cognitively impaired residents (R1, R2) who engaged in a sexual act had the capacity to consent, and failed to prevent two cognitively impaired residents (R1, R2) who didn't have the capacity to consent, from engaging in a sexual act resulting in (R1) experiencing psychosocial harm as any reasonable person would be affected in a total sample of four resident reviewed for abuse. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 4/4/24, the facility remains out of compliance at a Severity Level Two as additional time is needed to evaluate the implementation and effectiveness of the removal plan including their Inservice Training and Quality Assessment oversite. Findings include: Facility Policy Abuse Prevention Program dated 3/1/21 documents: As part of the social history evaluation and MDS (Minimum Data Set) assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or who have needs and behaviors that might lead to conflict. Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental psychosocial well-being. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Sexual Abuse: Including, but not limited to, sexual harassment, sexual coercion, or sexual assault. Facility Assessment of Resident Capacity to Consent Sexual activity Policy (undated) documents: Purpose: To protect and ensure safety, health, and well-being of residents of (the Facility) who engages in sexual activity. Policy: It is the facility's policy to recognize and support each resident's right to engage in sexual activity, so long as the Facility is certain that there is consent among all parties to the sexual activity. This policy applies to all residents who are able to demonstrate consent by words and/or affirmative actions, even if the resident is non-verbal or is suffering from Dementia or some other cognitive deficit. Capacity to engage in sexual activity is defined as: I. The ability to understand information relevant to a decision to engage in sexual activity, and II. the ability to appreciate the reasonably foreseeable consequences of such a decision or lack of a decision. Capacity to consent to sexual activity has four key components: I. The ability to communicate a decision to engage in sexual activity. II. The ability to understand a decision to engage in sexual activity, consistent with an individual's values. III. The ability to appreciate the potential consequences of a decision to engage in sexual activity, including risks and benefits. IV. The ability to rationalize and reason the process utilized to reach the decision to engage in sexual activity, free from undue influence or coercion. Facility Incident Report dated 3/13/24 indicates on 3/13/24 at 1:00am V3, CNA (Certified Nurse Assistant) found R1 standing on the side of R2's bed with R1's penis in R2's mouth. Room Census Report indicates on 3/13/24 R1 and R2 were roommates at that time. Current MDS (Minimum Data Set)/BIMS (Brief Interview for Mental Status) indicate both R1 and R2 are severely cognitively impaired and unable to give consent. On 4/2/24 at 11:40am R1's spouse (V5) who visits R1 every day, stated prior to R1 becoming cognitively impaired, R1 was very cognizant of boundaries, never experimented sexually like that and he would have been devastated to have been found in that situation. V5 stated she absolutely believes R1 had no idea what he was doing or who he was doing it with. V5 stated (R1) is no longer a reasonable person, but when he was a reasonable person, this would have never happened. On 4/2/24 at 9:14am V11, R2's Family stated R2 was bisexual and would not have had any trauma related to this incident. On 4/2/24 at 3:15pm V1, Administrator stated that they concluded the investigation and found the sexual act between R1 and R2 was consensual. V1 stated that the facility does have an assessment to determine ability to consent for non-cognitive impaired residents, however it was not utilized due to R1 and R2's cognitive impairments. No assessment was completed to confirm R1 or R2's ability to consent to sexual activity was performed prior to the incident or after the incident. Consensual Sexual Relationship Agreement (undated) indicates the resident will be assessed by the professional staff to be alert, aware, coherent and capable of making decisions supporting their own choices and welfare. Agreement states residents are to be counseled regarding safe sex practices/behavior and to engage only with other residents who have decisional capacity AND consent to the relationship. On 4/2/24 at 3;21pm V12, Medical Director stated that with (BIMS) scores like that, neither R1 nor R2 would be able to consent. V12 stated R1 and R2 would not be able to understand the consequences of their actions due to their level of cognitive impairments. V12 stated the facility needs to focus on how to prevent this from happening in the future. The Immediate Jeopardy was identified to have started on (3/13/24) when R1 was found at R2's bedside with (R1's) penis in R2's mouth. . V1, Administrator was notified of the Immediate Jeopardy on 4/3/24 at 1:15pm. On 4/4/24 the surveyor confirmed through observation, interview and record review the facility took the following action to remove the immediacy. 1.Investigation of alleged abuse completed and reported to IDPH, alleged perpetrator and alleged victim's physician and resident representatives notified of alleged abuse. Investigation was initiated 3/13/24 and concluded 3/18/24. Initial Report was sent to IDPH 3/13/24 and Final Investigation Report was sent to IDPH on 3/18/24. 2. Both R1 & R2 were immediately separated by nursing staff and assessed for any signs of injury or trauma by Licensed Practical Nurse on 3/13/24. 3. Both R1 & R2 were sent to the local emergency room for evaluation on 3/13/24 and returned with no evidence of any injury or harm the same day. No new orders. 4. Both R1 & R2 were moved to two separate rooms in two separate hallways within the facility on 3/13/24. 5. The local police department was notified of the alleged incident on 3/13/2024. 6. R1 care plan has been updated to include one on one with staff times 7 days on 3/13/24 by SSD (Social Services Director). 7. R2 care plan has been updated to include Behavior Monitoring every hour x 7 days to assess for changes in mood/behavior post incident on 3/13/24 by Social Services Director. 8. R1 & R2 care plan has been updated to include 1 on 1 time with Social Services as needed to vent feelings. Facility SSD will continue to meet with R1 to assure R1 remains at baseline for mood and behavior on 3/13/24 by Social Services Director. 9. DON (Director of Nursing) and LNHA/(Licensed Nursing Home Administrator) were in-serviced on Assessment of Residents Capacity to Consent Sexual Activity Policy and Procedures by V13, Consulting Company CEO (Chief Executive Officer) on 4/3/24. 10. In-servicing by DON (Director of Nursing)/LNHA (Licensed Nursing Home Administrator) on Abuse Prevention Policy with facility staff was initiated 3/13/2024 and repeated 3/20/2024. Additional in-servicing regarding facility's abuse prevention policy will be completed by the Administrator or designee on or before 5:00 PM on 4/4/24. Any staff who has not been in-serviced on the facility's Abuse Prevention Policy by 5:00 PM on 4/4/24 will not be able to clock-in for work. 11. In-servicing training by Human Resources Director on Abuse Prevention Policy with facility staff will continue, and any remaining employees must be trained prior to reporting for work for their next scheduled shift. 12. QAT (Quality Assurance Team) members were in-serviced on Assessment of Residents Capacity to Consent Sexual Activity Policy and Procedures by the LNHA on 4/3/2024. 13. Social Service Director and Social Services Coordinator or designee will complete the Capacity to Consent Worksheet on all residents on or before 5PM 4/4/2024. 14.Social Service Director and Social Services Coordinator will complete the Capacity to Consent Worksheet on all residents going forward upon admission and quarterly. 15. In-service training by DON/LNHA on Abuse Prevention Policy with all staff will continue monthly for the next 3 months, then quarterly x 3 by the DON or Administrator. 16. LNHA will enforce the interventions of plan of removal of immediacy and assurance of continued compliance. 17. Quality Assurance (QA) Activities to ensure the alleged deficient practice will not recur include: -- QAT will review the Capacity to Consent Worksheet during quarterly QA meetings with medical director and address any concerns. -- QAT will review the Capacity to Consent Worksheet during Morning QA meetings daily x 30 days on all new admits to ensure compliance. -- QAT will review the Brief Assessment of Informed/Intimate Relationships during quarterly QA meetings with Medical Director and address any concerns. -- QAT will review the Brief Assessment of Informed/Intimate Relationships during morning QA meetings daily x 30 days on all new admits to ensure compliance. -- The facility will follow state and federal guidelines regarding Abuse Reporting by requiring reporting of all reports of abuse to be reported to the Regional Consultants and facility QA Committee for follow up and review.

Based on interview and record review, the facility failed to perform pressure ulcer treatments per order for one (R1) of three residents reviewed for pressure ulcers in a sample of five. This failure resulted in (R1) acquiring a Stage 4 pressure ulcer. Findings include: Facility Skin Integrity Guideline, undated, documents The purpose is to provide a comprehensive approach for monitoring skin conditions, decrease pressure ulcer and/or wound formation by identifying those patients/residents who are at risk, and implementing the appropriate interventions, and to promote healing of wounds whether admitted or acquired. R1's current care plan documents (R1) is at risk for skin breakdown related to impaired mobility with an intervention of monitor skin care daily, and assess for changes in skin condition each shift. (R1) has a pressure ulcer to her right heel related to immobility with an intervention of administer treatments as ordered and monitor for effectiveness, prevalon boots at all times, and the resident needs assistance to turn/reposition at least every two hours, more often as needed or requested. R1's Treatment Administration Record/TAR, dated 6/1-6/30/23, has no documentation R1 has a pressure ulcer, or is getting any skin treatments. R1's Weekly skin check, dated 7/18/23 and 7/25/23, documents R1 has no loss of skin integrity. R1's TAR, dated 7/1-7/31/23, documents Right heel cleanse with dakins solution cover with army battle dressing and wrap with kerlix daily, start date 7/28/23. This form has no documentation the treatment was completed on day shift on 7/28-7/30/23. R1's TAR, dated 7/1-7/31/23, documents Prafo boots while in bed every shift for wound care, start date 7/28/23. This form has no documentation the treatment was completed on day shift on 7/28-7/30/23. This form has no documentation the treatment was completed on evening shift on 7/29 and 7/30/23. R1's TAR, dated 8/1-8/31/23, documents Right heel cleanse with dakins solution cover with army battle dressing and wrap with dressing daily, start date 7/28/23. This form has no documentation the treatment was completed on day shift on 8/2/23. R1's Initial wound evaluation, dated 8/2/23, by wound physician documents Unstageable due to necrosis of the right lateral heel full thickness pressure wound 2x3.5x not measurable cm/centimeters. Identified 7/27/23. R1's Weekly skin check, dated 8/8/23, documents under Does resident have loss of skin integrity? Yes. R1's nurses note, dated 8/9/23, documents No dressing on foot when hospice CNA/Certified Nurse Aid did shower. R1's wound evaluation, dated 8/9/23, by wound physician documents Stage three pressure wound of the right lateral heel partial thickness pressure wound 0.6x1x0.1cm. Identified 7/27/23. R1's TAR, dated 8/1-8/31/23, documents Right heel cleanse with normal saline, cover with xeroform and island dressing daily every day shift for wound care, start date 8/4/23. This form has no documentation the treatment was completed on day shift on 8/10/23. R1's TAR, dated 8/1-8/31/23, documents Prafo boots while in bed every shift for wound care, start date 7/28/23. This form has no documentation the treatment was completed on day shift on 8/1, 8/2, 8/13, and 8/15/23. This form has no documentation the treatment was completed on evening shift on 8/13 and 8/16/23. R1's TAR, dated 8/1-8/31/23, documents Right heel skin prep daily every day shift for wound care, start date 8/11/23. This form has no documentation the treatment was completed on day shift on 8/12, 8/13, and 8/15/23. R1's wound evaluation, dated 8/16/23, by wound physician documents Stage three pressure wound of the right lateral heel full thickness pressure wound 2.5x4x0.4cm. Identified 7/27/23. R1's wound evaluation, dated 8/23/23, by wound physician documents Stage four pressure wound of the right lateral heel full thickness pressure wound 3x4x0.4cm. Identified 7/27/23. R1's TAR, dated 8/1-8/31/23, documents Santyl External ointment apply to right heel every day shift for wound care. Cleanse with normal saline, apply santyl to wound bed and cover with gauze island dressing daily. This form has no documentation the treatment was completed on day shift on 8/26, and 8/28/23. R1's wound evaluation, dated 8/30/23, by wound physician documents Stage four pressure wound of the right lateral heel full thickness pressure wound 2.8x4x0.4cm. Identified 7/27/23. R1's TAR, dated 9/1-9/30/23, documents Flagyl tablet apply to right lateral heel topically every day and night shift for pressure ulcer. Crush Flagyl and mix with betadine and apply to wound bed cover with gauze sponge and roll gauze twice a day. This form has no documentation the treatment was completed on day shift on 9/20/23. R1's TAR, dated 9/1-9/30/23, documents Low air loss mattress set to weight on bed every shift for pressure ulcer. This form has no documentation for evening shift for 9/2, 9/6, 9/10, 9/16, and 9/18/23. It also has no documentation for day shift on 9/20-9/22/23. R1's TAR, dated 9/1-9/30/23, documents Prevalon boots at all times every shift for wound care. This form has no documentation for evening shift for 9/2, 9/6, 9/10, 9/16, and 9/18/23. It also has no documentation for day shift on 9/20, and 9/21/23. R1's wound evaluation, dated 9/6/23, by wound physician documents Right heel stage four pressure injury in house acquired 3x4x0.4cm. Identified 7/27/23. Serous color, moderate amount, foul odor, wound red color with defined margins. Current interventions include betadine twice a day since 8/23/23, wheelchair cushion, and heel boots. R1's X-ray of the right foot, dated 9/9/23, documents (R1) has a worsening wound, rule out osteomyelitis. R1's weekly wound evaluation, dated 9/13/23 documents Right heel stage four pressure injury in house acquired 3x4x0.4cm. Identified 7/27/23. Serous color, moderate amount, foul odor, wound red color with defined margins. Current interventions include crush flagyl and mix with betadine twice a day and cover with gauze sponge since 9/13/23, pressure redistribution mattress, wheelchair cushion, and heel boots. R1's weekly wound evaluation, dated 9/20/23 documents Right heel stage four pressure injury in house acquired 4x4x0.4cm. Identified 7/27/23. Serous color, scant amount, no odor, wound red color with defined margins. Current interventions include crush flagyl and mix with betadine twice a day and cover with gauze sponge since 9/13/23, pressure redistribution mattress, wheelchair cushion, and heel boots. On 11/3/23 at 11:00am, V7 LPN/Licensed Practical Nurse/Wound Nurse stated I work Monday through Friday as the wound nurse. I am working the memory care unit today (1000 hall first floor) so the nurses are responsible for their own treatments if I am working the floor, and on the weekends since I don't work. On 11/7/23 at 12:35pm, V4/R1's POA/Power of Attorney stated (R1's) pressure ulcer went from a stage 1 to a stage 4 in a month because they did not do their job. On 11/7/23 at 2:22pm, V10 RN/Registered Nurse Hospice Compasses stated She was admitted [DATE] until 9/26/23. (R1) had wound orders in place but her wound was bad by the time we admitted her. On 11/7/23 at 3:05pm, V11 LPN MDS/Minimum Data Set stated I would expect the nurse to sign off the treatment plan when cares are completed. Sometimes they don't do that but if it is not charted it is not done in the nursing world. After you complete a treatment, you are to sign the form to show you did it. On 11/7/23 at 3:12pm, RN [NAME] of hope Hospice stated She was on hospice [DATE], to 9/7/23 when (V4- R1's) POA revoked. We struggled with getting the wound report from (facility) and our bath aid discovered no dressing on the foot (and the wound nurse had charted the dressing was changed) so our nurse came in and did the dressing change. Protocol is to remove the dressing and do the wound care, but they were having the wound care nurse doing the treatments at the (facility).

Based on observation, interview, and record review, the facility failed to provide supervision during a period of increased facility visitation where visitors were exiting the facility locked unit doors, when a daily pacing, agitated, cognitively impaired resident exited the facility through the Locked Unit doors. These failures resulted in R4 not being adequately supervised and exiting from the facility, through the locked unit doors, on 2/05/23 around 1:40 P.M. R4 was last observed by staff between 12:15 P.M and 12:30 P.M. Staff did not observe R4 exiting the building and were unaware that R4 had left the facility, crossed a busy two-lane road to a gas station to purchase cigarettes. R4 was found by a passerby lying in the road, approximately two blocks from the facility, after being observed falling multiple times, next to a major four lane highway with a posted speed limit of 45 MPH. The passerby (V15) drove R4 to the local (ER) emergency room where ER staff phoned facility staff, who were unaware that R4 was missing, approximately 30 minutes later to alert them of R4's location. R4 is one of twenty five residents (R4 - R28) residing on the facility first floor locked memory care unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 2/09/2023, the facility remains out of compliance at a Severity Level 11 as the facility continues to educate staff on elopement policies and procedures including Wanderguards (electronic monitoring device), perform elopement drills with utilization of Code Orange, and continue monitoring of compliance with follow up as part of the facility's QAPI (Quality Assurance and Performance Improvement) program. FINDINGS INCLUDE: The (undated) facility policy, Policy and Procedure Regarding Missing Residents and Elopement documents, It is the policy of this facility that all residents are provided adequate supervision to meet each resident's nursing and personal care needs. All staff will be trained upon orientation, missing resident in-service training will be conducted at minimum annually. Random elopement drills will be conducted at a minimum every 6 months. An 'At Risk List' shall be posted at each nurses' station and at the reception area. All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. R4's facility Admission Record documents that R4 was admitted to the facility on [DATE] with the following diagnoses: Disorganized Schizophrenia, Dementia and Tobacco Use. R4's Nursing Progress Notes, dated 10/19/2020 document, 2:30 P.M. (R4) arrived to facility at 2:30 P.M. by way of family vehicle. Resident alert with confusion. Noticeable involuntary hand movements. VA (Veteran's Administration) meds received in a box from family. Dark circles around his eyes unsure if there was a previous fall. Area appears to be healing. Skin dry and intact. Catheter noted on arrival. Resident was also noted with 200 cash that was immediately given to his brother that was still in the building. Brother also noted that the catheter was a new insert from the VA hospital. Resident noted with missing teeth and no dentures. Resident stated that he wears glasses but not sure where they are. Resident stated that he would like to be a DNR however not sure if he fully understands the concept. Bed placed in a low position and mats on both sides. Call light in place. Takes meds whole, general diet. R4's Wandering Risk Assessment, dated 10/19/2020 documents, (R4) is confused and may at some point exit seek, however (R4) is new to the facility and it's hard to determine that at this time. Based on the responses provided above, do you feel this resident is at risk for wandering, elopement, or getting lost. Yes: very likely to wander, elope, or get lost. No further Wandering Risk Assessments/Elopement Risk Assessments are present in R4's electronic medical record, until 5/31/22. R4's Nursing Progress Notes, dated 10/20/2020 document, Wanderguard placed on (R4's) right ankle. R4's Nursing Progress Notes, dated 4/06/2021 document, (R4) approached CNA stating that he removed his wanderguard off of his leg and flushed it down the toilet. CNA (Certified Nursing Assistant) asked resident why he removed the wanderguard and resident stated because he didn't want it. CNA told DON (Director of Nursing) and this charge nurse. This nurse called V26/ADON (Acting Director of Nursing) who states that facility is out of the wanderguards and to have staff be sure to monitor resident. R4's Nursing Progress Notes, dated 11/01/2022 document, (R4) alert with confusion, pacing hallways - bringing staff various items from room, gait unsteady at times, speech difficult to understand d/t (due to) mumbling, able to understand when spoken to and able to follow commands. Gray discoloration to face. Appears comfortable. Continent of Bowel and Bladder. Feeds self meals with no difficulties. R4's Nursing Progress Notes, dated 1/09/2023 document, (R4's) brother came to this nurse and asked if something happened with resident today. He stated that resident has called him several times wanting to leave here now. Resident has not made any complaints or accusations about anyone or anything today. I was in his room [ROOM NUMBER] minutes earlier to give him his medicine and he was lying, relaxed in bed watching TV. Brother took resident with him and stated he would call back in the morning. R4's Nursing Progress Notes, dated 1/29/2023 document, (R4) alert to self only with confusion per normal, up ad lib (as desired), pacing from room to nurses station all day shift, showing staff his possessions from his room, in good spirits, mumbles words, unable to understand what he says, took all meds well, ate all meals well, no agitation noted. R4's current Minimum Data Set Assessment, dated 12/02/2022 documents R4's Cognitive Status as 9:15 (moderate impairment) and R4's Activities of Daily Living, Ambulation as 1/1 (requires staff supervision). R4's current Physician Order Sheet, dated February 2022 includes the following physician orders, dated 1/13/2021: Wandering every shift, (R4) wanders at times; Hallucinations every shift and Clozapine (anti-psychotic) 50 MG (milligrams) by mouth in the morning, 100 MG by mouth at bedtime. On 2/06/23 at 10:15 A.M., R4 was up ambulating in the hallway from his room to the nurses' station and back. R4 appeared agitated. R4 was confused and unable to answer questions. When staff attempted to intervene and calm R4, he became increasingly agitated. Staff finally able to redirect R4 back to his room. On 2/06/23 at 10:35 A.M., V6/Licensed Practical Nurse (LPN) stated, I have been an employee here for the past sixteen years. Oftentimes, I work on this Unit. (R4) hasn't eloped before (the incident on 2/05/23), but he does wander the unit pacing and agitated. I have seen him at the Exit doors, looking outside. (R4) didn't have a wanderguard bracelet on, prior to his actual elopement yesterday, that I can remember. When (R4) returned from the ER (emergency room ) last night, they attempted to put one on him, but he wouldn't let them. Evidently, he has one in his shirt pocket. He keeps trying to hand it to me. I'm not sure why (R4) never had a bracelet on, he should have. On 2/6/23 at 11:02 A.M., V9/R4's Guardian stated, I have been (R4's) guardian for the past fifteen years. (R4) has had schizophrenia for many, many years. I take him to all his VA appointments. Previously he had been in a VA home in Iowa. I took him out of there because he was homesick, and I attempted to take care of him at my home. That didn't work out very well, so I placed him here. I live close by, and I visit him almost every day. He is a wanderer and a pacer. He is very anxious and paces constantly, usually from one door to another. I don't know if (R4) has ever tried to get out before, but I understand why he did on Sunday (2/05/23). When (R4) started the Clozapine many years ago, they told him he couldn't smoke. Well, smoking is the only pleasure (R4) has in life. I noticed he had been getting more and more agitated, so I bought him a pack of cigarettes, gave them to the nurse and asked if they take (R4) outside once a day for one cigarette. It seems to keep (R4) calm. Well, after his escape yesterday, I found out (R4) had been without cigarettes for the past three or four days. And that's exactly what (R4) did. (R4) walked right out of this building, through the front door and walked across that busy street and bought a pack of cigarettes. Then (R4) walked up to the busiest street around here, crossed the street and some lady found (R4) laying in the street and took him to the ER. I can't believe how (R4) walked out the front door. Other patients have bracelets on that won't let them out the door, but (R4) doesn't have one. I don't know why they never put one on him. At least (R4) wouldn't have been able to get outside and almost get hit by a car. On 2/6/23 at 11:20 A.M., V2/Director of Nurses (DON) stated, I have been the director of nurses here for the past six months or so. I don't recall (R4) ever attempting to elope before. I would think (R4) is at risk for eloping. (R4) is ambulatory, has a mental illness and paces frequently. I don't know why (R4) never had an elopement bracelet on before this. Maybe because (R4) never tried to escape before. I watched the video of (R4) leaving the building. It was around 1:40 in the afternoon. (R4) walked right out the front door. There was a couple in front of (R4), then (R4), then another person behind (R4). (V11/Receptionist) didn't recognize (R4) as a resident. When we talked to (V11) later that night, (V11) said she thought (R4) looked suspicious, so (V11) followed (R4) outside. (V11) saw (R4) go across the street and then (V11) went back inside and called one of the CNAs (Certified Nursing Assistants). They said no one was missing. It wasn't until the hospital called, 30 minutes or so (later) that we figured out it was (R4). At that time, V2/DON verified no Wandering Risk Assessments/Elopement Risk Assessments for R4 were completed between 10/19/20 and 5/31/22. On 2/06/23 at 11:29 A.M., V10/Licensed Practical Nurse (LPN) stated, I am the Restorative Nurse, but I just happened to volunteer for some over time, and I was the nurse on Sunday when (R4) eloped. We didn't even know (R4) was gone, until the hospital called and asked if we were missing a resident. I was in the middle of doing a 2 PM tube feeding. (R4) is usually very anxious and kind of agitated. (R4) likes to pace a lot. I heard (R4) walked right out of the locked door, behind some visitors. I don't know where the CNAs were when (R4) left. I know I was busy with other residents. I had someone fall around 1:00 (pm) and we had a lot of visitors in the Unit that day. On 2/06/23 at 1:41 P.M., V1/Administrator stated, (R4) doesn't have a care plan for elopement. (R4) didn't fit the criteria. At that time, V1/Administrator verified the facility had not followed its policy of having elopement drills every six months nor was list of residents at risk for eloping posted at the exits and each nurse's station. V1 also verified that V11/Receptionist had not attended the last facility in-service on resident elopement. On 2/06/23 at 2:04 P.M., V15/Concerned Citizen stated, (On Sunday-2/05/23) I was driving up the hill from (south of facility) and had driven by the (facility) when I saw (R4) walking. (R4) had shoes on, pants, a tee shirt, and a button-down shirt, that was unbuttoned. It was kind of cool out and it struck me as odd, as it was breezy outside. Also, I noticed (R4's) walk. (R4) walked with his head and chest out and his body was behind. I watched (R4) 'splat' on the road a couple of times. I mean (R4) fell , (R4) fell hard. I kept thinking (R4) had to be injured. Finally, the third time (R4) fell , (R4) was up to the frontage road, getting ready to cross that busy highway. When (R4) fell the last time, (R4) just laid on the road. I was terrified (R4) was going to get ran over by a car. It was a very busy on the road, cars go speeding by and run red lights all the time. I drove up to (R4) as (R4) was laying on the ground and asked (R4) if he was hurt. (R4) got up and came over to my truck and got in. My dog was in the front seat between us. I asked (R4) if he needed help and (R4) nodded yes. (R4) told me he wanted to go to Green Rock (town he lived in before his stay at the facility), but I could tell that wouldn't be a good idea. The only place I could think to take (R4) was to the ER (emergency room ). I live over by that way. (R4) never turned to look at me. (R4) stared straight ahead. I could tell something was wrong with (R4). (R4) shook and jerked the whole time and kept mumbling to himself. At one point (R4) lit up a cigarette and I told (R4) he couldn't smoke in my truck. (R4) didn't argue, (R4) threw it out immediately. I drove up to the ER and explained I found (R4) laying in the street. They could tell something was wrong with (R4) and got (R4) out of my truck and put (R4) in a wheelchair. They asked me for my name and telephone number, and I gave it to them, then I left. I was just trying to help. On 2/08/23 at 9:20 A.M., V20/Social Services Coordinator stated, I did (R4's) assessment for elopement in December 2022. (R4) only scored a 9, so (R4) wasn't considered high risk for eloping. I didn't do an elopement care plan for (R4). I rely on the nurses to guide some of my answers. I didn't know (R4) did not accept his nursing home placement. I thought (R4) was happy to be here. On 2/08/23 at 9:25 A.M., V2/Director of Nurses (DON) stated, The elopement risk assessment is completed by Social Services quarterly. The nurses do it on admission. I don't totally agree with the way (R4's) assessment was scored on 12/02/22. I think (R4) has always been at risk for eloping. (R4) fits the criteria due to his severe mental illness, dementia, agitation, and pacing. In my opinion, (R4) is at high risk for eloping. On 2/08/23 at 3:16 P.M., V11/Receptionist stated, I have been employed here for the past twelve years as a receptionist. On Sunday (2/05/23) I worked at the front reception desk from 8 AM until 7 PM. It was a busy day. We had a lot of visitors in the building. It was around 1:30 (P.M.) or so when another resident's spouse came up to me and said he saw a man with a blue shirt and pants on, that looked kind of odd, exiting the front door and wondered if it was a resident. I only saw the back of him. I went outside and I saw a man with a blouse shirt and pants on, walking down the hill, in front of the building, getting ready to cross the street to go to the gas station. The man was walking quickly. I came back inside and called the Unit on the first floor and (V23/Certified Nursing Assistant CNA) answered the phone. I didn't think it was a resident because any resident that lives back there has an alarm bracelet on that sounds when they come through the double doors, and I hadn't heard any alarm when (R4) came through. When (V23/CNA) answered, I asked (V23) if there had been a visitor back there with a blue shirt and pants on. She told me yes, one had been in the dining room, but he was no longer there. I went back outside and told the resident's spouse that (R4) wasn't a resident. So, he left. It wasn't until the hospital called around 2:05 (P.M.) asking if we were missing a resident, that we realized there was a problem. (R4) had left the building and was in the emergency room . At that time, V11/Receptionist verified she had not attended the yearly in-service on resident elopement in August 2022. On 2/09/23 at 10:57 A.M., V23/Certified Nursing Assistant (CNA) confirmed she worked in the unit on 2/05/23. At that time, V23/CNA stated, It was a nice day outside and we had a lot of visitors in the unit that day. At one time, I saw a man in the dining room with a blue shirt and blue pants on, so when (V11) called and asked me, I told her the man had left. (R4) was his normal self that day. He always paces back and forth and gets very agitated at times. There were three of us (CNAs) on Sunday and at 1:30 in the afternoon, we were taking turns, taking a break, and assisting other residents. No one saw (R4) go through the locked doors. On 2/09/23 at 11:22 A.M., V24/CNA verified she worked the locked unit on Sunday. V24/CNA stated, It was a busy day on Sunday (2/05/23), we had a lot of visitors. I saw (R4) that day. (R4) was his usual self, pacing up and down the hallway. I didn't see (R4) go through the locked doors that afternoon. I was helping another resident, at that time. On 2/09/23 at 11:54 A.M., V 25/CNA verified she was working the unit the past Sunday (2/05/23). V25/CNA stated, I don't recall anything different with (R4) on Sunday. (R4) paces all the time. I didn't see (R4) leave through the locked doors. I can't remember exactly what I was doing at that time. R4's Emergency Department (ED) Report, dated 2/05/23 at 2:07 P.M. documents, Time seen 2:07 P.M. [AGE] year old male presents to the ED. A bystander was driving when she found the patient on the ground on the side of the road. It is unknown where he was found but she picked him up and transported him here to the ED and left her number if we have further questions. Patient is oriented X (times) 1 and states he has fallen a couple of times and has scrapes and bruises. Patient is a resident at (facility) memory care unit. (Facility) was called and confirmed. It is unknown when they (facility) last saw him today. Health Status: Skin: Abrasion of left knee, ecchymosis of right thigh. Disposition: Medically cleared. (V2/Director of Nurses) called and states the last time they saw (R4) was around 1:50 P.M. R4's Nursing Progress Notes, dated 2/05/23 at 9:20 P.M. document, (R4) returned to this facility via medics, brother accompanied (R4) via private vehicle. (R4) agitated upon arrival. Medications given. Per brother's request a shower was given with skin checks completed. Three 1 CM (centimeter) circular red areas on top of right knee noted. 2 X 1 circular abrasion noted to right hip. The Immediate Jeopardy was identified to have begun on 2/05/23 when R4 exited the facility through the Locked Unit doors, walked across the street to buy cigarettes, and was found lying at the side of the road approximately two blocks from the facility, after being observed falling multiple times, next to a major four lane highway with a posted speed limit of 45 MPH. V1/Administrator and V2/Director of Nurses were notified of the Immediate Jeopardy on 2/09/23 at 3:45 P.M. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R4 was reassessed for elopement risk by the Charge Nurse on 2/05/2023. On 2/05/2023, Wanderguard placed on resident with resident being non-compliant. Wanderguard placement compliance occurred on 2/07/2023 per physician's order. Social Service Coordinator updated care plan on 2/06/2023 related to elopement on 2/05/2023. 2. On 2/05/2023 - 2/06/2023, Social Services and nursing management team re-assessed all current residents for elopement risk All residents who have cognitive impairment with behaviors of agitation and pacing were reviewed for elopement risk. Residents who meet criteria will be assessed by the IDT based on such assessments, the team will determine the appropriateness for the placement of a wanderguard with MD (Medical Doctor) orders. Additionally, all residents identified as high risk for elopement were immediately assessed by V26/ADON and social services for interventions to address their high risk for wandering to include placement of wanderguards and care plan updates related to elopement. List of residents at risk for elopement is posted at the reception area and all nurses station and will be updated by social services team. Residents will be assessed for elopement risk on admission, readmission, quarterly and with significant change. Missing person drills were conducted on all 3 shifts initiated on by Administrator/designee on 2/06/23 through 2/08/23 and will be conducted quarterly by Administrator/Designee. Administrator/designee will ensure that the facility utilizes Code Orange in the event of a missing person and follow its policy. 3. Administrator immediately educated receptionist to include validation of people leaving the facility on 2/05/2023. HR (Human Resource) Director/designee educated all remaining receptionists on 2/06/2023 and 2/07/2023. On 2/05/2023, Administrator immediately initiated education on missing person policy and to utilize Code Orange in event of a missing person and to follow missing policy procedure when there is concern for a missing person. Staff were educated to recognize residents at risk for elopement and interventions needed for high-risk residents. On 2/08/2023, Administrator initiated staff education to monitor the locked exit doors during periods of increased facility visitation. 4. On 2/09/2023 the Administrator educated Social Services team on identifying residents with cognitive impairment with behaviors of agitation and pacing. Monitoring for compliance related to this will be conducted by the Social Services Director or designee with oversight from the Administrator 7 days weekly. This monitoring will be done X 4 weeks. It will include various shifts as well as some weekend days. Afterwards, this monitoring will continue 3 days weekly for a period of not less than 6 months to ensure ongoing compliance. After that, random monitoring will occur ongoing. Any concerns will be addressed and if found the resident will be placed on the High Risk for Wandering List with the Interdisciplinary Team evaluating the resident(s) for a wanderguard bracelet. 5. On 2/05/2023, Administrator/designee began education of all staff on Missing person policy- to include prevention of missing residents and procedure for the response to missing person. Staff who were not present for the initial in-service and agency staff are required to be educated prior to beginning of their next scheduled shift at the facility. 6. On 2/09/2023, the Administrator/DON/Designee initiated all staff education to review residents with cognitive impairment with behaviors of agitation and pacing for elopement risk. Staff who were not present for the initial in-service and agency staff are required to be educated prior to the beginning of their next scheduled shift at the facility. 7. HR Director/designee will ensure that staff will be trained on missing person policy upon hire, quarterly and annually. This was initiated by HR/designee on 2/06/23 and is ongoing for all new staff upon orientation. 8. On 2/08/2023, Administrator/designee began education to all staff regarding monitoring the locked exit doors during increased numbers of visitors. Staff who were not present for the initial in-service and agency staff are required to be educated prior to the beginning of the next scheduled shift at the facility. 9. On 2/06/2023, social services ensured that an updated list of residents at risk for elopement was posted at the reception area and at every nurses' station. 10. On 2/09/2023, Regional Director of Operations in-serviced administrator on the risks, severity, and prevention of elopement for facility residents. 11. All monitoring done by facility staff as well as by Regional Team staff (RDO/RNC) will be presented to the QAPI Committee at their weekly meetings. Any concerns will have been addressed. However, any patterns will be identified. If indicated, an Action Plan will be written by the QAPI Committee. Any Action Plan will be monitored weekly by the Administrator until resolved. 12. A member of the Regional Team, (RDO/RNC), will attend the QAPI meetings either in person or remotely for a period of not less than 3 months to serve as additional oversight, reference, and support. Note: When the facility is placed back into substantial compliance, QAPI meetings will go to monthly.

Based on observation, interview and record review the facility failed to prevent the development of pressure wounds for one resident (R1) of three residents reviewed for incontinence care. This failure resulted in R1 acquiring a Stage 2, Stage 4 and two Deep Tissue Injuries. Findings include: Facility Policy/Skin Integrity Guideline dated 2011 documents: To provide comprehensive approach for monitoring skin conditions To decrease pressure ulcer and/or wound formation by identifying those patients/residents at risk, and implementing appropriate interventions Patients/Residents will be assessed or observed for skin breakdown as necessitated by change in condition. The interdisciplinary plan of care will address problems, goals, and interventions directed toward prevention of pressure ulcers and/or skin integrity concerns identified. Patients/Residents will be observed by the CNA (Certified Nurse Assistant) daily for reddened/open areas, edema of feet or sacrum. Changes will be reported to the licensed nurse and documented. Initiate positioning schedule to meet individual patient/resident needs and minimize concentrated pressure to skin as indicated by the individualized care plan. Care plan is to be implemented, evaluated and revised based on the needs of the resident. If patient/resident is refusing or choosing not to receive treatment, review risks, benefits and alternatives. Re-evaluate and attempt other interventions. Treatment Protocol for Reddened, Denuded Areas: Protect from moisture, pressure and further injury Current Physician's Order Report Summary indicates R1 was admitted to the facility 1/7/23 with diagnoses that include Left Humerus Fracture, Heart Disease with Pacemaker, Defibrillator and Heart Valve Replacement and Obesity. Initial/Admission Skin assessment dated [DATE] and Weekly Skin Check dated 1/11/23 indicates no alteration in skin on R1's buttocks or coccyx. Progress Note dated 1/15/23 at 8:49 am indicates a small open area noted to R1's coccyx approximately 0.3 cm (centimeters) circular in size, R1 repositioned off buttock, refusing to get out of bed at this time. Note indicates dressing applied and wound NP (Nurse Practitioner) notified. Progress Note dated 1/17/23 indicates V7, Wound NP attended and examined R1, orders received and noted. Wound NP Report dated 1/17/23 indicates R1 was assessed on that date and found to have scattered denuded areas, large erythema to buttocks and coccyx associated with incontinent dermatitis; open wounds left and right buttocks. Report Assessment Note: New onset of multiple areas to buttocks/coccyx; multiple comorbidities; history of non-compliance. Refer to wound flow sheet for specific measurements and assessments. Due to noncompliance - these areas have a high potential for decline related to incontinence of stool and urine. Weekly Wound Evaluation dated 1/17/23 indicates rash on R1 coccyx, scattered area of erythema (redness), wound margins defined Incontinent Dermatitis. On 1/18/23 at 11:15am V9, LPN (Licensed Practical Nurse) administered wound care to R1's coccyx wound. At that time R1 was noted to have a large area of red denuded skin across his buttocks/coccyx and several open areas of various size as well as one oval shaped wound covered with black tissue. Two open areas were noted under R1's scrotum. V9 stated R1 just moved to this unit yesterday and his notes only indicated one small open area and incontinent dermatitis. V9 stated she would notify V7, Wound NP of the identified open areas. On 1/19/23 at 3pm V10, LPN stated she did not physically round with V7, Wound NP (on 1/17/23) and only documents the wound assessment from the sheet given to her by V7. V10 stated We still don't have V7's dictated report from 1/17/23. Weekly Wound Evaluation, completed by V10, dated 1/17/23 was completed based solely on handwritten notes from V7. No facility staff visualized, assessed and/or documented on R1's wounds on 1/17/23. On 1/19/23 at 4pm V2, DON (Director of Nursing) stated they do not get V7's full dictated report until several days after V7 rounds. V2 stated facility staff do not round with V7 (V7) rounds with his own nurses and they've only just left the handwritten notes. V2 stated they currently do not have a designated wound care nurse - floor nurses do the treatments. On 1/18/23 at 4pm V7, Wound NP stated when he assessed R1 on 1/17/23 at the facility R1 was full of stool and he told the staff they needed to keep R1's skin clean in order to prevent further skin breakdown. V7 stated the combination of R1's skin being moist, wet and pressure was the perfect storm for a rapid decline in R1's skin. V7 stated he told facility staff they cannot put R1 in a chair and leave him up all day. V7 stated that given R1's age, comorbidities, weight and noncompliance (R1) is going to be hard to heal. V7 stated he is aware R1 was transferred to another facility (today) and will be seeing R1 at the receiving facility in the morning (1/19/23). V7's Wound/Skin Consult to Eval/Treat Report dated 1/19/23 indicates R1 transferred to another facility (on 1/18/23). Assessed coccyx/buttocks incontinence dermatitis wounds appear to be related to pressure this assessment. Right buttock to coccyx pressure ulcer Stage 4/proximal coccyx pressure ulcer Stage 2/new onset multiple wounds. Presents with wound to scrotum trauma related to undergarment/right ischium DTI (Deep Tissue Injury)/traumatic wound to left and right knee/right heel with blanchable erythema/left heel DTI. Wound Assessments as follows: 1) Right buttock to coccyx: pressure ulcer Stage 4; 4.5cm x 4.9cm x 0.1cm, 50% black slough 2) Proximal coccyx: pressure ulcer Stage 2; 1.0cm x 0.6cm x 0.1cm 3) Right ischium Deep Tissue Injury: 3.1cm x 1.0cm x 0.1cm 10% purple black, erythema large, slough 80% yellow 4) Scrotum traumatic wound: 1.2cm x 0.8cm x 0.1cm 5) Right heel: mild to moderate blanchable erythema 6) Left heel Deep Tissue Injury: 0.7cm x 1.0cm x 0cm deep purple Report indicates R1 was transferred to receiving facility (on 1/18/23) and were not acquired at the receiving facility. No wound care plan was initiated after identification of a new skin impairment on 1/15/23.

Based on interview and record review, the facility failed to investigate and determine a root cause analysis of a fall, failed to implement fall interventions, and failed to provide supervision during toileting to prevent a fall for one of five residents (R120) and failed to monitor a personal safety monitoring device for a resident identified as high risk for elopement for one of two residents (R341) reviewed for accidents/incidents in the sample of 64. As a result of this failure R120 fell in the bathroom after being left unattended on the toilet on 05/03/22, and was subsequently transferred to a local hospital and diagnosed with a left femoral neck fracture. Findings include: 1. The facility's Incidents/Accidents/Falls policy (undated) documents the following: It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management. The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated and resolved. The facility will create a data base related to incidents/accidents as part of the QAPI (Quality Assurance Process Improvement) process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent recurrences when possible. It will be part of the QAPI (Quality Assurance and Performance Improvement- monthly meeting) Agenda. R120's Fall Risk Reviews (dated 04/05/22, 04/11/22, and 05/07/22) all document scores greater than 10, indicating R120 is at high risk for falls. R120's Minimum Data Set Assessment (dated 05/16/22) documents in Section C, Cognitive Patterns, a Brief Interview for Mental Status score of 1, indicating severe cognitive impairment. This same assessment documents in Section G, Functional Status, that R120 requires extensive assistance (resident involved in activity, staff provide weight-bearing support) with two+ persons physical assist with toilet use. R120's current care plan documents the following fall prevention intervention: Anticipate and meet the individual needs of the resident. R120's Fall Investigation (dated 2/8/22) is blank and does not document the following: a root cause analysis was determined, a care plan review was conducted or new fall prevention intervention was implemented. On 06/30/22 at 10:10 AM, V19 (Minimum Data Set Assessment Coordinator) stated that R120's fall on 2/8/22 was never investigated, and therefore, a root cause of R120's fall was not determined. V19 stated R120's care plan was not reviewed and a new fall prevention intervention was not implemented after R120's 2/8/22 fall. R120's current care plan has no mention of R120's 2/8/22 fall. R120's Fall Investigation (dated 4/5/22) documents R120 was found on the fall mat next to her bed. On 06/30/22 at 10:14 AM, V19 (Minimum Data Set Assessment Coordinator) stated, it was found that (R120's) air mattress was not set correctly. It was not set to the correct weight that correlates with what R120 weighs, which may have caused her to roll out of bed. The mattress should have been set to (R120's) current weight at that time. R120's Fall Investigation (dated 04/20/22) documents R120 fell while attempting to stand unassisted in the dining room. On 06/30/22 at 10:18 AM, V19 (Minimum Data Set Assessment Coordinator) stated the fall prevention intervention to obtain a [MEDICATION(S)] level was ordered after R120's 04/20/22 fall, and V19 stated it was never completed. R120's Fall Investigation (dated 05/03/22) documents that R120 had an unwitnessed fall and was found on the floor in the bathroom next to the toilet, and was sent to a local hospital for evaluation. This same investigation documents that R120 was left unattended by a staff member after being placed on the toilet, and was on the floor once staff returned. R120's local hospital medical record (dated 05/03/22) documents R120's results of a CT (Computed Tomography) scan of R120's pelvis as follows: Nondisplaced linear subcapital femoral neck fracture. On 06/30/22 at 10:24 AM, V19 (Minimum Data Set Assessment Coordinator) stated R120 is a 2:1 assist, and staff should have never left her alone on the toilet. On 06/30/22 at 2:00 PM, V29 (Licensed Practical Nurse) stated she was the nurse working at the time of R120's 05/03/22 fall. V29 stated, (R120) should not be left alone on the toilet. She is a high fall risk. She even wears a helmet, which should have been the first clue not to leave her unattended. I immediately educated the CNA (Certified Nursing Assistant) after she left her alone. I told her this cannot happen on a dementia unit, and (R120) is just too busy and impulsive of a person to leave alone in the bathroom. (R120) is a person that you just can't leave alone. 2. The facility's Policy and Procedure for Personal Safety Monitoring Devices for Residents at Risk of Elopement (dated 08/12/2011) documents the following: All residents shall be assessed for behaviors that place them at risk of elopement utilizing an elopement risk assessment upon admission, quarterly, annually and upon significant change of condition. The primary care physician for all residents identified of being at risk of elopement will be notified and an order will be obtained for a personal safety device. The order for the personal safety device will be written on the Physician's Order Sheet in the resident's medical record. The personal safety device will be applied to the resident according to resident needs. Devices may be applied to any extremity. Residents dependent on wheelchairs for transportation may have devices applied to the chair. A plan of care will be developed for all residents identified to be at risk for elopement. All personal safety devices and exit door alarms will be tested daily to assure that each device and door alarm are functioning properly. R341's Wandering Risk Scale (dated 06/12/22) documents a score of 11, indicating R341 is a high risk for wandering. R341's Elopement Risk Review (dated 06/12/22) documents a score of 16, indicating R341 is a high risk for elopement. R341's Progress Note (dated 6/13/22) documents the following: (R341) is very confused and angry that she is here. She keeps asking to call the police because we are holding her hostage. Easily redirected for a few minutes. She is also exit seeking every chance she gets. (Personal Safety Monitoring Device) in place to left ankle. On 06/30/22 at 09:25 AM, R341 was sitting at the table in the dining room with a group of residents participating in a bingo activity. An unidentified staff member was providing assistance with the activity. An personal safety monitoring device was in place around R341's left ankle. R341's current Physician's Orders do not have an order for a personal safety monitoring device in place. R341's current care plan has no mention of R341's personal safety monitoring device. R341's Medication Administration Record and Treatment Administration Record (dated 6/12/22 - 6/30/22) have no mention of any monitoring of 341's personal safety monitoring device. On 06/30/22 at 10:00 AM, V2 (Director of Nursing) confirmed that R341's medical record has no record of monitoring R341's electronic personal safety monitoring device. V2 also confirmed that R341's current care plan has no mention of R341's personal safety monitoring device and stated, (R341) should have a care plan for this. On 06/30/22 at 12:00 PM, V1 (Administrator) stated that standard practice for an elopement risk is to obtain a physician's order, document daily checks of the personal safety monitoring device on the MAR (medication administration record) or TAR (treatment administration record), and a care plan should be in place noting the elopement risk and personal safety device. V1 confirmed that none of the above mentioned has been completed since R341's admission to the facility on [DATE].

Based on interview and record review, the facility failed to properly transfer one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 receiving nine staples to the right side of her head. Findings include: The facility's Mechanical Lift Transfer (Full size/Hoyer Type Lift) documents the following: Purpose: To assure that all residents that are assessed to require total assistance in transfer are transferred safely with no injury to resident or care handler. The operating of the lift requires a minimum of two trained operators. Slings are to be used with their respective mechanical lifts with the appropriate size per patient and weight capacity. Check patients sling size in point of care and mechanical lift weight limit on the mechanical lift prior to using the mechanical lift on a patient. Choose the appropriate sling to be used to transfer the resident per POC (plan of care) Staff using the sling will visually inspect for loose stitching, bleached, torn, cut, and/or frayed to prevent resident injury. The lift slings should be inspected by staff using the sling before and after use for wear and tear. Slings that are unsafe to use could result in injury and should not be used. The facility's fall incident report dated 5/6/2022 at 9:57 pm documents the following: Nursing Description: Nurse (R3, LPN, Licensed Practical Nurse) was called to resident's room at 7:15 pm, (R1) was laying on the floor on right side, resident was vomiting on floor and CNA was holding towel to back of head. Nurse immediately called 911. Nurse got on floor in front of resident and spoke to her, resident was alert, residents pupils were pinpoint, nurse took over holding pressure to back of right side of residents head. Resident had a head wound that was bleeding (mechanical lift) was still sitting around resident. Staff stated to nurse that they were lifting resident to transfer her to bed and she fell out of (mechanical lift). (R1) told nurse 'it broke.' (R1) was alert and talking with nurse until ambulance arrived. (R1) did complain of mid back pain. (R1) was sent to (local hospital). MD (medical doctor) contacted about (R1) being sent to the emergency department. Administrator and DON (Director of Nursing) aware it broke. This same form documents the following under a section titled witnesses. I (R4, CNA, Certified Nursing assistant) was putting (R1) back to bed. I was in the back, (R5, CNA) was in the front. I (R4) tried to save her (R1) from falling out but I couldn't save her from falling. I (R5, CNA) was going in to assist with transfer. As we were lifting (R1) at the time we thought she flipped back out of sling due to sling being wrong size and shower sling placed by first shift. Later it snapped off (mechanical lift). Nurse (R3, LPN, Licensed Practical Nurse) was immediately notified and while nurse was assessing I called supervisor to notify of injury. The facility's final report documented the following: Incident date: 5/6/2022. Brief description of Incident: (R1) had a witnessed fall by two staff members. Immediate Action taken: Upon assessment the nurse noted (R1) with bleeding to the back of her head. (R1) was stabilized and had minimal complaints of pain until EMS (emergency medical service) arrived. (R1) left facility in stable condition. (R1) was sent to the ER (emergency room ) for evaluation and kept overnight for observation. (R1) returned from hospital with sutures to the back of her head and care plan updated. Conclusion: Upon investigation, resident was being transferred by staff and was unable to complete transfer. (R1) was sent to the ER for evaluation. She (R1) was kept overnight for observation and returned to the facility the next day with sutures to the back of her head. Resident (R1) care plan updated and pain is being managed. R1's current care plan documents the following: initiated 9/13/2021, I (R1) am dependent with 2 staff members as I require full staff performance and support for transfers. I may use a (mechanical lift), sling size extra large to provide a full staff transfer. Requires 2 staff members to operate (mechanical lift) and to complete the transfer. R1's ED (Emergency Department) physician notes dated 5/6/2022 document the following: The patient (R1) presents with mechanical fall. (R1) is a [AGE] year old female presenting to the ED via EMS (Emergency Medical Service) from a (facility), after a 2 to 3 ft mechanical fall that occurred PTA (prior to arrival). (R1) was in a (mechanical lift). She flipped out of the lift and fell to the floor. (R1) hit her head. She was vomiting on the scene. She did not have LOC (loss of consciousness). (R1) has a bleeding laceration to the right side of her head. She has associated mid back pain and headache. (R1) has left sided LE (lower extremity) pain, but states that this is chronic. This same form documents the following: Laceration repair, Laceration 4 cm (centimeters) in length. Scalp: right, shape: linear, depth: superficial, details: bleeding, skin closure: 9 staples. R1's Physical Therapy and Occupational Therapy notes dated 5/9/2022 document the following: (R1) had a fall during a (mechanical lift) transfer. (R1) received a head laceration requiring 9 staples. She is complaining of back and shoulder pain. Cognition-follows directions=two- step; oriented to Person, place, time, purpose and caregivers; safety awareness=intact; new learning capacity=intact. On 5/23/2022 R1 was lying in bed, blankets pulled over her body to her neck. R1 was alert and oriented, answering questions and communicating adequately. R1 stated a Caucasian dark haired CNA was going to transfer her a couple weeks ago after dinner from the chair to bed. R1 stated she told the CNA that she better get some help and the CNA stated she could not find anyone else but reassured R1 she could do it. R1 stated when the CNA lifted her in the mechanical lift the strap broke and she hit her head. She stated she is doing pretty good now. R1 stated 2 to 3 staff always transfer her with the mechanical lift and she has never had just one CNA use the mechanical lift. On 5/23/2022 at 12:04 pm V2, DON, (Director of Nursing) stated she was notified of R1's fall the evening of 5/6/2022. V2 stated R3, LPN (Licensed Practical Nurse) was the nurse caring for R1. V2 stated R1 was vomiting and her head was bleeding/ V2, DON stated she instructed staff not to move R1 and apply pressure to her head. V2 stated R1 fell out of the mechanical lift, was sent to the emergency room , kept overnight for observation and returned to the facility with sutures in her head. V2 stated R1 was in a mechanical lift and fell out. V2 stated that all slings for the mechanical lifts were pulled and inspected. V2 stated staff training was completed on the use of mechanical lift and slings after R1's fall. V2 stated V5, CNA (Certified Nursing Assistant) reported to her that after R1's fall she noticed a strap was broken on the sling. V2 stated initially V5, CNA thought the sling was the wrong size for R1. V2, DON stated the root cause of R1's fall on 5/6/2022 was sling malfunction and the intervention was staff educations.

Based on observation, interview and record review the facility failed to thoroughly investigate two falls, including one fall with a head injury for one resident (R2) of three residents reviewed for falls. This failure resulted in R2 receiving a subdural hematoma and a laceration requiring sutures. Findings include: Current Physician Order Sheet indicates R2 was admitted to the facility 10/18/21 with diagnoses that include Cerebral Infarct, Diabetes Mellitus and [CONDITION(S)] with Urinary Suprapubic Catheter. Comprehensive assessment dated [DATE] indicates R2 is cognitively intact and transfers with limited assist of one staff; Fall Risk Review dated 12/31/21 and 2/1/22 indicates R2 is high risk for falls. On 2/16/21 at 10:10am R2 was sitting in a motorized recliner chair. At that time R2 stated that (on 2/1/22) he was asleep in his recliner chair and woke up as the recliner chair was raising up and before he could get it to stop, it threw him forward out of the chair hitting his head on the window ledge and falling on the floor. R2 stated that he went to the hospital and was told he has a small brain bleed as well as a laceration. R2 stated his leg was pressing against the recliner chair remote control while he was sleeping and he couldn't turn it off before he fell . R2 stated that he usually falls out of motorized scooter, not the chair. Nurse Note dated 2/1/22 at 4:16pm indicates R2 was combative with staff while trying to get resident off the toilet and into his wheelchair. Note indicates (R2) basically slid down the wall onto the floor receiving an abrasion to the top of his head and on right lateral elbow. Nurse Note dated 2/1/22 at 9:19pm indicates R2 was found on the floor of his room with a large gash located on the front right side of his head and due to the size of the lump and amount of bleeding (R2) was sent to the ED (Emergency Department) for eval and treatment. Nurse Note dated 2/2/22 at 2:45am indicates R2 returned from ED with diagnosis of subdural hematoma, Urinary Tract Infection; sutures intact to right frontal lobe. No fall investigation was completed for R2's fall in the bathroom. Fall investigation (for fall requiring hospital treatment) did not identify root cause analysis of fall, did not give a description of the fall occurrence, did not identify interventions to prevent future falls in this manner and did not include interviews from staff, R2, or R2's roommate who was in the room at the time of the fall. Fall Incident conclusion only addresses R2's return from the hospital, subsequent wounds from fall and to remind R2 to use the call light. On 2/17/22 at 9:20am V2, DON (Director of Nursing) stated that she did the investigation of R2's fall. V2 stated they didn't identify R2 sliding to the floor in the bathroom while having behaviors toward staff as a fall so no investigation was done. V2 stated that when she interviewed R2 about the fall that required hospital treatment, R2 was really upset and didn't say anything about the recliner chair. V2 acknowledged that she didn't really know how R2's fall occurred even after reading her own incident investigation. V2 acknowledged the documentation should be better and the investigation should be more thorough. Attempts to interview V8, LPN (Licensed Practical Nurse) who was R2's assigned nurse on 2/1/22 were unsuccessful. Facility Policy/Incidents, Accidents, Falls (undated) documents: The nurse responsible for the oversight and care of the resident will complete an incident/accident report. When possible, a descriptive statement(s) will be obtained from the resident and/or any witnesses. All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Note: Each fall needs a new intervention rolled out. Some occurrences will require a more extensive investigation process. These include but are not limited to: Falls with significant injury Disruptive/Combative Behavior resulting in harm

Based on observation, interview and record review the facility failed to quarantine a COVID-19 positive resident, place the COVID-19 positive resident and the exposed roommate on transmission based precautions, failed to follow transmission based precautions for a COVID-19 resident and failed to ensure staff wore required PPE (Personal Protective Equipment) while in the facility during a COVID-19 outbreak. The facility also failed to prevent a COVID-19 positive staff member, with symptoms, from providing direct resident care in building four. The facility also failed to have a facility specific COVID-19 surveillance plan, policy and procedure. These failures have the potential to affect all 126 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the Immediacy was removed on 1/12/2022, the facility remains out of compliance at a Level 2 to complete additional staff training and quality assurance efforts to ensure compliance is maintained. Findings Include Facility Infection Control: COVID-19 Contract Tracing reviewed 1/2021 documents The contact tracing policy has been created to provide guidance when an exposure to COVID-19 has occurred and to ensure that infection prevention practices are taken. Testing is recommended for all close contacts of confirmed or probable COVID-19 patients. Those contacts who test positive (symptomatic or asymptomatic) should be managed as a confirmed case and move to Red Zone. 1. Facility COVID-19 testing spreadsheet dated 1/5/21, documents 1/5/22 at 1:10 AM, (R11) Result: Positive. On 1/5/22 at 10:15 AM, V16, Infection Preventionist (IP), stated (R11) was the only resident that tested positive. She was put in quarantine and is being moved to the red zone in building three. (R22) tested negative, so she is going to remain in the room under quarantine. On 1/5/22 at 10:56 AM, observation of R11 and R22's room. R11 remains in original room in building four with R22. R11 has not been moved to building three (Red ZONE). There are no isolation signs posted outside or on the door to the room. There is a sign posted outside the room that reads Green Zone: Standard Precautions. PPE Required: Surgical Mask or KN95, Universal Precautions. On 1/5/22 at 11:00, V14, Licensed Practical Nurse (LPN), observed in R11 and R22's room providing resident care with N95 mask and eye protection on with no other PPE. On 1/5/22 at 11:02 AM, V14, LPN, verified there are no isolation signs posted outside of R11 and R22's room and stated I don't know if (R11) is supposed to be in isolation or not. I know she tested positive for COVID, but I'll have to ask about the isolation. On 1/5/22 at 11:03 AM, V22, Certified Nursing Assistant (CNA), observed placing isolation sign outside of R11's room that reads Yellow Zone: Transmission Based Precautions. PPE Required: N95 Mask, Face shield, Single Gown - with each encounter, gloves (hand hygiene donning and doffing). V22, CNA, stated I was given the sign to post for (R11)'s isolation, but didn't get it posted. That's what I'm doing now. On 1/5/22 at 11:07 AM, V14, LPN, stated I just checked and I was supposed to wear the full PPE because (R11) is in isolation for COVID. V14, LPN, verified the Yellow Zone sign outside R11's room identifies the correct PPE she was to wear when entering R11's room. On 1/5/22, V14, LPN, continued providing direct resident care on Unit 4-1 the remainder of her 6:00 AM to 2:00 PM shift. On 1/5/22 at 1:17 PM, V16, IP, verified R11 tested positive on 1/5/22 at 1:10 AM, but was not moved to the red zone until after 11:30 AM. V16, IP, also stated (R11) should have had a red zone sign and not a green or yellow zone sign posted outside due to the positive COVID-19 result. On 1/6/22 at 2:40 PM, V17, LPN, observed conducting rapid COVID-19 tests on residents. V17, LPN, stated If there's a test that comes up positive, I would immediately shut the residents door, place an isolation sign on it, notify the nursing supervisor and then get the resident moved to the red zone. On 1/6/22 at 2:46 PM, V2, Director of Nursing (DON) stated Once we identify a positive COVID-19 results, the resident should be moved to the red zone within an hour, but ideally within 15 minutes. 2. The facility's COVID-19 tracking log for employees dated 12/31/21 at 10:00 PM, documents V21, CNA, tested positive for COVID-19. V21's Positive COVID-19 Test form dated 1/1/22, documents Symptoms: Yes, headache, body sore/ feel weak. Date symptoms started: 12/31/21. Nursing schedule dated 12/31/21, documents V16, CNA, worked in building four from 10:00 PM to 2:00 AM. On 1/4/22 at 10:52 AM, V21 CNA, stated I came into the facility on the night of 12/31/2021, around 10:00 P.M. and punched in. My nose was a little stuffy and I was tired, but I didn't think I had COVID. I did my (rapid test) and left it lay next to the time clock and went to the floor I was assigned, building 4, second floor. The shift supervisor was at the back door when I came in, but she left. I heard she was working a floor. I didn't wait to see my test results before I went to the floor. Around 2:00 in the morning (1/1/22), I came back down to the time clock to sign out for my break, and I saw my positive test. I called the supervisor and punched out and went home. On 1/5/22 at 2:32 PM, V16, Infection Preventionist (IP), stated I found out (V21, CNA) tested positive for COVID-19 on 12/31/21. I was told she had worked the floor from 10:00 PM till 2:00 AM while positive when I came into work Monday morning (1/3/22). All the residents exposed to the positive staff member were tested for COVID-19 on 1/5/22. The staff are responsible for screening themselves when they come in and the supervisors and staff are responsible for the COVID-19 testing. I have the employee screening right here for 12/31/21 and unfortunately (V16, CNA) didn't fill out the COVID screening when she came in. She also didn't wait for her rapid test results before going to work in building four. 3. On 1/5/22 at 12:56 PM, V18, CNA, observed carrying meal trays through the dining room. V18's N95 mask is down around her neck exposing her mouth and nose. V18's eye protection is propped up on top of her head and not over her eyes. V18, CNA, then stopped at the table where R14, R15, and R16 are sitting eating lunch and talking to residents and V20, CNA. On 1/5/22 at 1:00 PM, V20, CNA sitting at a table with R23, R24 and R25. V20, CNA, is assisting R25 with his meal. V20's, CNA, N95 mask is down around her neck exposing her mouth and nose with her eye protection propped up on top of her head not covering her eyes. On 1/5/22 at 1:17 PM, V16, IP, verified V18, CNA and V20, CNA are required to wear the N95 mask covering their mouth and nose along with eye protection and stated Because we're in a COVID-19 outbreak status, the staff are required to wear the N95 mask and eye protection at all times when in resident care areas. The only time they're allowed to take it off is when they're in the breakroom or office. 4. On 1/6/22 at 9:30 AM, record review of facility COVID-19 surveillance plan, and COVID policy and procedures. Facility does not have a policy on employee or resident screening for COVID-19, COVID-19 positive resident assessments, response to a COVID-19 outbreak or a policy on the required PPE during a COVID-19 outbreak. On 1/6/22 at 10:00 AM, V16, IP, stated I was given the CDC (Center for Disease Control) guideline and was told that's what we use for response to a COVID outbreak. We don't have a policy that specifically states what we do when we have an outbreak or what PPE is required. Because the CDC guidelines change so often we can't be updating the policy every week, so we just print out the guidelines and follow them. On 1/7/22 at 10:50 AM, V16, IP, stated We don't have a policy on employee or resident screening. We go by the current CDC guidelines. When a resident has COVID-19, we just put in a general order of what needs to be done, but there's no policy on it. Facility Midnight Census Report dated 1/3/22 and verified by V2, DON, documents a 126 residents residing in the facility on 1/3/22. The Immediate Jeopardy was identified On 1/11/2022 at 10:00 A.M. The immediate Jeopardy began on 1/5/22 when the facility failed to quarantine a COVID-19 positive resident and place the COVID-19 positive resident and the exposed roommate on transmission based precautions. On 1/11/2022 at 9:59 A.M.,V2/Director of Nurses was notified of the Immediate Jeopardy. On 1/12/21 at 11:30AM, the surveyor confirmed through interview and record review the facility took the following actions which were initiated on 1/5/21 and completed on 1/12/21 to remove the Immediate Jeopardy situation. * The COVID positive resident was moved to the facility COVID Unit. * All staff, currently working on 1/5/2022 were In-Serviced on wearing the proper PPE while caring for COVID positive residents. * The exposed room mate was placed on appropriate Transmission based Precautions. * Education, provided immediately by Director of Nurses and Infection Preventionist including: Positive Residents placed in Quarantine or on Transmission based Precautions immediately after identification of a positive COVID-19 test; Staff educated on policy and procedures for potential resident and roommate exposure; Dedicated staff are assigned to the COVID-19 Unit; Personal Protective Equipment education to all staff, residents and vendors while in facility; Education of facility staff on the COVID-19 Plan and Testing Protocols. All staff will be educated on the above concerns and education will continue until every employee is In-Serviced. This will be completed by 1/12/22. *Outside vendors will be educated on PPE requirements and Transmission based Precautions before providing care to residents. Initiated 1/11/22 and will continue. * Agency staff will be educated before providing care to residents on all above concerns and will continue daily, prior to beginning of their shift. * Facility Infection Preventionist and Director of Nurses will continue to be able to communicate changes to staff and residents as it relates to the COVID-19. The Director of Nurses and Infection Preventionist Nurse will have clear understanding of the facility policy and procedure as it relates to COVID through the direct education of the Regional Nurse Consultant.

Based on interview and record review, the facility failed to implement additional fall interventions to prevent a fall for one of three residents (R3), reviewed for falls, in a sample of 25. This failure resulted in R3 falling from a bed and sustaining a cervical fracture, head injury, cardiorespiratory collapse and hospitalization at an out of state trauma center. FINDINGS INCLUDE: R3's (Hospital) Discharge Summary, dated [DATE] documents that R3 was discharged from a local hospital with the following diagnoses and physician orders: T9 (Thoracic) Spinal Cord Injury with subsequent Paralysis, Traumatic Right AKA (Above the Knee Amputation), [CONDITION(S)] on Hemodiaylsis, Wounds with Chronic Osteomylitis, Acute on Chronic [CONDITION(S)] and Deconditioning. Physician orders include: Admit to facility; Up with assist; Physical and Occupational Therapy. R3's (Hospital) Fall Risk Assessment and Interventions, dated [DATE] include the following: Requires assist or supervision for mobility, transfers and ambulation. Side Rails x 2. Transfer with assist/device. R3's (Hospital) Physical Therapy Notes, dated [DATE] document, Anticipated Discharge to Rehabilitation Unit, Skilled Nursing Facility. (R3) will require skilled therapy in a facility able to provide [CONDITION(S)] and IV (Intravenous) antibiotics. Anticipated Treatments/Needs: Basic activities of daily living, Bed mobility training, Therapeutic exercises, Transfer training. Functional Mobility Details: With use of (side) rails, (R3) able to roll bilaterally independently. R3's (Facility) Admission Screen, dated [DATE] and signed by V4/Registered Nurse documents, Arrived via stretcher. admitted from hospital. Alert, oriented to person, place, situation. Mobile per wheelchair. Side Rails (both sides). R3's Progress Notes, dated [DATE] and signed by V4/Registered Nurse document, (R3) arrived via ambulance form (local) hospital. Alert and oriented X 4. (Person, Place, Time, Situation). (Mechanical lift) for transfers. Side rails for assisted movement and repositioning. R3's (facility) Physical Therapy Evaluation and Plan of Treatment document, dated [DATE] documents, Physical Therapy evaluation: Short Term Goal (R3) will safely perform bed mobility task with moderate assist with use of side rails. Long Term Goal (R3) will safely perform bed mobility tasks with stand by assist with use of siderails in order to get in/out of bed. Underlying Impairments: Balance deficits, Decreased functional activity tolerance, Muscle disuse/atrophy, Unilateral weakness and Sensation impairments. R3's (Medical Supply) Order, dated [DATE] at 11:36 A.M. documents, Deliver a forty two inch bariatric bed frame and forty two inch bariatric mattress for (R3), per request of V27/Central Supply Clerk. No bed rails to this facility. R3's (Medical Supply) Order, dated [DATE] at 3:27 P.M. documents, (V5/Assistant Director of Nurses) said they (facility) can't have (bed) rails (on R3's bed). At 3:37 P.M., the order documents, (Side) Rails refused. R3's Progress Notes, dated [DATE] at 7:56 P.M. and signed by V4/Registered Nurse document, (R3's spouse) called over the phone and stating (R3) needed help. I immediately went down to assess the situation and noted (R3) on the floor with his bed in high position. (R3) was laying on the floor with his head toward the foot of the bed and his leg underneath the bed. (A) viable knot noted to the top of (R3's) head with a tinge of blood. (R3) started throwing up, denies pain. (R3) was unable to tell me how he fell . (R3's spouse) notified of situation and Paramedics called. Upon transferring (R3) to the gurney, (R3) lost consciousness. (R3) was transferred to (local) Hospital. Fall occurred at 7:30 P.M. R3's ED (Emergency Department) physician Notes, dated [DATE] at 8:28 P.M. document, (R3) presents following an unwitnessed fall from bed. Tonight (R3) was talking to (R3's spouse) on the phone and suddenly she heard (R3) yell. (R3) reports he did hit his head. CT (Computerized Tomography) of the left lower extremity. Findings: Significant worsening of the left lower extremity since prior CT. The left femur is now shattered with multiple moderately displaced fractures throughout it's length. Nondisplaced fracture of the left inferior pubic ramus. CT of the cervical spine. Findings: Fracture through the right articular pillar of the C3 that does not appear to involve the vertebral artery foramen. Notes 9:09 P.M. (R3) (cardiac) rhythm is reading V(ventricular)-tach ([CONDITION(S)]) on the monitor. Amidodarone (antiarrhythmic medication) given. (R3) will be transferred by (helicopter) to (ouf of state) Trauma Center. Condition is critical. On [DATE] at 11:45 A.M., V2/Director of Nurses (DON) stated, I remember (R3). I know there were some problems with (R3's) bed and bed rails. (R3) was a paraplegic from a previous car accident and had no control from the waist down. I know (R3's spouse) wanted bed rails (on R3's bed), but (V8/Former Administrator) wouldn't allow them. I think we finally got a trapeze for (R3's) bed. R3 was definitely at high risk for falls. I don't know why we never placed bed bolster on his bed or used fall mats beside his bed. On [DATE] at 12:00 P.M., V5/Assistant Director of Nurses (ADON) stated, I was the acting DON (Director of Nurses) when (R3) was admitted to the facility. (R3's spouse) was upset, because she said (R3) had side rails on (R3's) bed at home and while (R3) was in the hospital to help him reposition himself in bed and to prevent him from falling out of bed. (R3) was a paraplegic and had no control over his lower body. He also had a right leg above the knee amputation and had the joint in his left hip removed. If (R3) got too close to the edge of the bed, (R3) couldn't stop himself from falling. (V8/Former Administrator) would not let us add side rails to (R3's) bed. (V8) said they were against our policy. His bed was specialty bed and came from (Medical Supply Company). (R3) didn't have bed bolsters, a low bed or fall mats next to his bed. I don't know why we didn't have them for (R3). On [DATE] at 4:30 P.M.,V10/Medical Supply Sales Representative stated, I am the representative that services the facility. We received a call from them on December sixteenth for a forty two inch mattress and an a bedframe. The facility refused to allow us to bring the standard bed rails that came with the bed. And at 5:16 P.M., V10 further stated, If a resident is at risk for falling from the bed, we are able to offer a bed bolster which is simply an elevated lip that goes all around the mattress or fall mats to place on the floor to lessen the impact from a fall. The facility did not request any of these additional products. On [DATE] at 09:49 A.M., V11/Medical Supply Quality Assurance Director stated, If a resident is at risk for falls, we would recommend a facility place bed bolsters on a bed, use a high/low bed which keeps the bed closer to the floor and fall mats on either side of the bed to lessen impact in the case of a fall. On [DATE] at 1:15 P.M., V5/Licensed Practical Nurse/Restorative Nurse stated, (R3) was a paraplegic and an [CONDITION(S)]. When (R3) was first admitted to the facility, (R3) was in a bed with rails on either side so (R3) could reposition himself. (R3) also said he felt safer, because if (R3) would get too close to the edge of the bed, (R3) would fall out. (R3) was unable to stop himself, once (R3) started falling. (R3) was high risk for falls, but we were instructed by the former administrator, to take the side rails off of (R3's) bed. We ordered (R3) a larger bed and put a trapeze on it so (R3) could reposition himself. (R3) did not use bed bolsters on (R3's) bed or fall mats on either side of his bed. On ,d+[DATE]//22 at 1:44 P.M., V6/Registered Nurse stated, I was the nurse that admitted (R3). (R3) was alert and oriented. (R3) had been in a car accident a number of years ago and was a paraplegic and an [CONDITION(S)]. When I admitted (R3), (R3's) bed had two rails on either side that (R3) could use to reposition himself. At some point, (R3) was put in a different bed that didn't have rails. (R3) had a trapeze (R3) could use to reposition himself. (R3's) new bed didn't have bed bolsters or fall mats. I worked the night of [DATE]. I had been in (R3's) room about fifteen minutes prior to (R3's) fall. (R3) wanted some cough drops and was talking to (R3's spouse) on (R3's) cell phone. The head of (R3's) bed was up and (R3) had the TV (television)on. (R3's spouse) called the nurse's station around 7:30 and said while she was talking to (R3), (R3) yelled that (R3) was falling and then the phone went silent. I ran to (R3's) room and found (R3) laying between the wall and (R3's) bed. (R3's) leg was twisted under the bed. (R3's) catheter tubing was stretched tight. (R3) was calm, but (R3) couldn't tell me how (R3) had fallen. (R3) was bleeding from (R3's) head. (R3) was a paraplegic and couldn't feel anything from the waist down. (R3) was laying on (R3's) side. I didn't move (R3). I yelled for a CNA (Certified Nursing Assistant) and called 911 for an ambulance. They were here quickly and transported (R3) to the hospital. I called the ER later that night and they told me (R3) had cardiac arrested and they revived (R3) and sent (R3) by helicopter to (an out of state trauma center.

Based on observation, interview, and record review, the facility failed to ensure a fall intervention was in place for one of three residents (R1) reviewed for falls in the sample of three. This failure resulted in R1 sustaining a fall out of bed and subsequently receiving an open head injury that required sutures. Finding include: The facility Fall report for R1, dated 2/20/21, documents R1 had an Unwitnessed fall on 2/20/21 and the Staff found resident (R1) laying on right side of floor next to bed. No floor mats noted at the scene .Educated staff on importance of using her floor mats. R1's bed was in lowest position, no floor mats on the floor at time. This report documents a laceration to (R1's) face. The facility's initial fall investigation, dated 2/20/21, documents (R1) observed laying on right side of the floor, rolled out of bed. 4 cm (centimeter) open area noted to right eyebrow/temple area .MD (Medical Doctor) notified and orders received to send to ER (emergency room ) for evaluation. (R1) returned from ER with sutures to rt (right) eyebrow. The current Care Plan for R1, documents a new fall intervention was added on 8/20/20, after R1's 8/20/20 fall onto the floor as: Bedside floor mats placed to prevent fall-related injury. The facility Cheat Sheets form documents R1 is to have bedside fall mats in place next to her bed. On 2/24/21 at 10:20 am, R1 was sitting in a wheel chair in the dining room with her head bent down, eyes closed, and was nonverbal. R1 had red and purple discoloration to the right lateral temporal region of her head, below her right eyebrow that extended down towards R1's right cheekbone with 11 sutures in place. On 2/26/21 at 10:37 am, V2 DON (Director of Nursing) confirmed R1 fell out of bed onto the floor and did not have fall mats on the floor to each side of her bed at the time of the fall, and should have. V2 also stated we call them Cheat Sheets and the staff use the Cheat Sheets which list fall interventions that should be in place.

Based on record review, interview, and observation, facility staff failed to implement fall precautions (floor mats) for one resident (R1), of three residents reviewed for falls with injuries, in a total sample of three. This failure resulted in R1 falling on the floor, after rolling out of bed, and sustaining a [MEDICAL CONDITION] which required closure with 5 staples. FINDINGS INCLUDE: R1's electronic medical record, Nurse's Note, dated 7/10/2019, at 3:08 p.m., written by V3/Restorative Director, documents, Resident found on the floor at bedside at 1500 (3:00 p.m.) with contusion to the back of the head with significant bleeding. V4/Medical Doctor's office notified and orders obtained to send to ER (emergency room ) for eval(uation) and treatment. emergency room document, entitled (Hospital Name) ED, dated 7/10/2019, V6/Physician Assistant documents, (R1); Reason for Visit Fall [MEDICAL CONDITION]; ED Course Lac(eration) Repair 7/10/2019 8:00 p.m.; Location: Scalp; Scalp location: L(eft) parietal; Length (cm (centimeters)): 2; Depth (mm (milli-meter)): 5; Repair method: Staples; Number of staples: 5. R1's Care Plan History document, dated 7/25/2019, documents, Hi-low bed and mats 1/15/2019. On 7/25/2019, at 12:00 p.m., V2/Director of Nursing, confirmed during the investigation, of R1's fall with scalp laceration, V5/Certified Nursing Assistant admitted V5 failed to place R1's floor mats next to R1's bed after assisting R1 to lay down in bed. Additionally, V2 confirmed V5's failure, to place the floor mats next to R1's bed, resulted in V5 being suspended as there would have been a high probability of (R1) not receiving a [MEDICAL CONDITION]. On 7/25/2019, at 12:40 p.m., R1's left parietal laceration is approximately one-inch long; staples removed; edges well approximated; and no signs of infection.

Based on interview and record review, the facility failed to monitor daily weights for one of one resident (R1), reviewed for daily weights in a sample of three. This failure resulted in repeated hospitalization s for R1 and eventual death. FINDINGS INCLUDE: The facility policy, Weight Policy, dated (revised) 6/17/14 directs staff, It is the policy of this facility that weekly weights are to be obtained at the time of the resident's shower. In the event a resident refuses their shower, the weight is still required. Weights are to be taken on all new admissions within the first 72 hours of admission and then weekly thereafter for 4 weeks, then monthly. Additional weights shall be taken at the discretion of the nursing staff, food service director, or physician. R1's facility Admission Record, documents that R1 was admitted to the facility on [DATE] from a local hospital, after being hospitalized for [REDACTED]. R1' facility New Admission/Readmission CNA (Certified Nursing Assistant) Checklist, dated 12/4/17 documents R1's weight as 151.3 pounds. R1's Physician Transfer Order Report, dated 12/4/17 includes the following Diagnoses: [REDACTED]. Also included are the following prescribed medications: [REDACTED]. This same document includes the following physician orders: Follow up with (V6) Cardiologist on (MONTH) 7, (YEAR); Heart Health Diet; Activity as tolerated. Also included in My Action Plan- Heart Failure is the following instructions: Weight daily, Check for swelling in hands, legs, feet and stomach, Call Physician if greater than a 3 pound weight gain in one day or a 5 pound weight gain in one week. R1's facility Nursing Admission form, dated 12/4/17 documents, [MEDICAL CONDITION]-none. R1' Admission Care Plan includes the following Focus and Interventions, Cardiac (R1) has [MEDICAL CONDITION], Hypertension and Coronary [MEDICAL CONDITION]. (R1) has chest pain at times and [MEDICAL CONDITION] to BLE (bilateral lower extremities). Daily weight. R1's Progress Notes document on 12/7/17, (R1) out with daughter to appointment at CVM (Cardio Vascular Medicine). Returned to the facility with no problems. N.O. (New physician's orders [REDACTED]. (R1) also to keep legs elevated when at rest. Daughter (also) reports (R1) is to wear TED (Anti-Embolism Stockings) hose daily. On 12/16/17 at 7:15 P.M., R1's Progress Notes document, (R1) complains of dyspnea. Lungs coarse with scattered wheezes. Weak, non-productive cough. Orders received to send to ER (emergency room ) for evaluation and treatment. R1's facility Weights and Vitals Summary includes the following daily weights for R1 for 12/5/17 through 12/16/17: (MONTH) 9th-148 pounds, (MONTH) 11th-144 pounds. There are no weights documented for (MONTH) 5, 6, 7, 8, 10, 12, 13, 14, 15 or 16. R1's hospital emergency room report, dated (MONTH) 16, (YEAR) documents R1's weight in the emergency room as 153 pounds. This same ER report documents R1's Pro-BNP (Brain Natriuretic Peptide) as 2,675 (Normal Range 5-450 pg/ml) (picograms/milliliter). (At any age, a pro-BNP value of <300 pg/ml excludes Acute [MEDICAL CONDITION].) R1's Physician Transfer Order Report, dated 12/22/17 documents the following Diagnoses: [REDACTED]. This same document includes the following physician orders: Weight yourself without clothing at the same time each day. Call (the) Physician with a sudden weight gain, 2 pounds in a day or 5 pounds in a week. R1's facility Monthly Weight Sheet documents R1's weight on readmission as 145 pounds. R1's Care Plan Conference Report, dated 1/11/18 documents, Family present. Concerns with swelling ([MEDICAL CONDITION]). Not being weighed daily. R1's facility Weights and Vitals Summary includes the following daily weights for R1 for (MONTH) 23, (YEAR) to (MONTH) 11, (YEAR): 1/2/18= 158 pounds and 1/4/18= 157 pounds. There are no weights documented by facility staff for (MONTH) 23, 24, 25, 26, 27, 28, 29, 30, 31 or (MONTH) 1, 3, 5, 6, 7, 8, 9, 10 or 11. R1's Progress Notes, dated 1/17/18 document, (R1) to be seen in ER. R1's hospital emergency room Report, dated 1/17/18 at 5:14 P.M. documents, (R1) presents to the ED (Emergency Department) for shortness of breath, and extremity swelling that began 4-5 days ago. R1's weight is 163 pounds (18 pound weight gain). Pro-BNP is 3,467. Active Problems: Acute combined systolic and diastolic [MEDICAL CONDITION] with accelerated hypertension. Patient is in fluid over load. R1's hospital Internal Medicine Report , dated 1/18/18 documents, (R1) with a [MEDICAL CONDITION] ejection fraction (volumetric fraction of blood ejected from a ventricle of the heart with each heart beat; a measure of the pumping efficiency of the heart) of 55-60% in (MONTH) (YEAR). Presents from a (local) nursing home with shortness of breath and lower extremity swelling. R1's hospital General Cardiology Progress Note, dated 1/21/18 documents, Current weight 140 pounds. Plan: Acute on chronic combined systolic and diastolic heart failure. Repeat Echo (Echogram) revealed newly diagnosed decreased LVEF (left ventricular ejection fraction) of 35-40%. (R1) is discharging to Hospice. No follow up is needed at this time. R1's facility Progress Notes, dated 1/21/18 document, (R1) returned to the facility at this time via ambulance for comfort and end of life care. On 2/3/18 these same Progress Notes document, (R1) pronounced dead at 4:45. Family at bedside. On 3/5/18 at 2:20 P.M., V4/Registered Nurse stated, I was (R1)'s full-time day shift nurse. (R1) was not on daily weights. (R1)'s grand daughter requested that we weigh (R1). (R1) had gained more than twenty pounds. I don't know why (R1) didn't get weighed everyday and the doctor notified. On 3/5/18 at 2:30 P.M., V5/Registered Nurse stated, I was the second shift nurse for (R1). I don't remember if (R1) was a daily weight. I don't think (R1) was. On 3/5/18 at 2:40 P.M., V2/Director of Nurses stated, The Physician order [REDACTED]. The (physician) orders are supposed to be placed on the medication administration record. Some (facility) units have weight books, or the chart. We also use a weight record form. The physician is supposed to be notified of any weight gain. (R1) was not a daily weight. We had a care plan meeting with the family and they were concerned because of (R1)'s weight gain and [MEDICAL CONDITION]. I don't know why the staff didn't follow the transfer orders for (R1). On 3/6/18 at 9:00 A.M., V6/Cardiologist stated, If (I) order a resident to have daily weights, it is to monitor for fluid over-load. (I) expect daily weights to be done and to be notified of established parameters of weight gain.

Facility failures resulted in four deficient practices: A. Based on observation, interview, and record review the facility failed to assess side rails for entrapment risk prior to use for one of six residents (R11) reviewed for side rails in the sample of 29. This failure resulted in R11's head becoming entrapped between the side rail and the mattress. The facility continues to use the same unsafe side rail despite R11's previous entrapment and subsequent fall from the bed. Findings Include: This failure resulted in an Immediate Jeopardy. The facility policy, Restraint Free, review date of 12/20/16 documents, Prior to the use of any side rails, a bed mobility assessment must be conducted by a therapist or licensed nurse. The resident must be able to demonstrate that they are capable of using them for bed mobility. If side rails are utilized, they must be fitted appropriately to the bed. R11's Nurse's Notes, dated 3/16/17 at 4:15 A.M. document, Res (resident) (R11) found saying, 'Help Me!' in bedroom. (R11) found with knees on floor wrapped in blanket and with head wedged between side rail and mattress. (R11) states (R11) needed to use the restroom. (R11) assisted up, redness noted to left ear. ROM (Range Of Motion) WNL (within normal limits). Neuros (neurological checks) started. No other injuries noted. These same Nurse's Notes document at 4:20 A.M., Intervention: bed sensor pad for safety. R11's admission sheet documents R11's date of admission to the facility as 08/01/15. Physician order [REDACTED]. R11's Minimum Data Set (MDS) Assessment, dated 3/7/17 documents R11's Cognitive Status as Severely Impaired. This same assessment documents R11's Balance During Transitions, Surface To Surface Transfer (transfer between bed and chair or wheelchair) as a 0 (steady at all times). R11's current Care Plan, dated 6/4/2017 documents, Focus: (R11) is at risk for falls related to confusion, medication use. (R11) is independent with bed mobility and ambulation with supervision. R11's most recent quarterly Side Rail Assessment, dated 6/7/17 documents, R11 (has) an alteration in safety awareness due to cognitive decline. And (Has) a history of falls. This same document does not address entrapment risk or appropriate alternatives attempted. On 6/7/17 at 9:58 A.M., in regards to the 3-16-17 incident, E3/Restorative Nurse stated, (R11) was yelling, ' I have to go to the bathroom!' and 'Help Me!' E4/Licensed Practical Nurse found (R11) with (R11)'s head wedged between the side rail and the mattress. (R11) has two 1/2 rails due to altered safety awareness, a history of falls and difficulty with balance. We do not have an assessment that describes other alternatives tried before the use of the side rails. E2/Director of Nurses further stated on 6/7/17 at 12:45 P.M., Our side rail assessments do not include risks for side rail entrapment. Our side rails are alittle out-dated. On 6/7/17 at 12:40 P.M., with E5/ Maintenance Director present, R11's bed had a mattress with two, loose, oblong half rails attached to both sides of R11's bed. These same side rails had two bars positioned vertically with an opening in the middle. When the rails were raised to the up position, they extended approximately 18 inches above the mattress. There was a gap between the mattress and the bed rail that was 3-4 inches between the mattress and the bottom of the side rail, and increased to 7 inches at the top of the side rail. Both the left and the right rail were loose and wiggled with slight movement. This wiggling increased the space to seven inches at the top of the side rails. On 6/7/17 at 12:25 P.M., while in R11's room, assessing R11's bed frame, mattress and side rails, E2/Director of Nurses stated, There is a potential for (R11)'s head to get caught in that gap (between the mattress and bed rail). Those are the same bed rails that were there when (R11) got (R11)'s head caught. E20/ Licensed Practical Nurse confirmed these same side rails have been on R11's bed since February 2017. On 6/7/17 at 2:45 P.M., E4/Licensed Practical Nurse stated, (On 3/16/17) I was at the med (medication) cart at the nurse's station and I heard (R11) yell, 'Help Me!' (R11) had (R11)'s head and left arm stuck between the bed rail and the mattress. The rails were kind of loose. (R11) was stuck. (R11) was unable to move. I called for another CNA (Certified Nursing Assistant) and the two of us were able to release (R11)'s hand and (R11)'s head popped out. The side rails are the same ones on (R11)'s bed now. They are large, oblong ones that are very wiggly. R11's Nurse's Notes document on 5/14/17, (R11) found sitting on floor next to bed with back resting against side of bed. Right leg extended out with left knee bent and sheet noted wrapped around left ankle and foot. (R11) states, 'I slid right down the bed.' On 6/7/17 at 7:55 P.M., R11 was lying in bed sleeping. Two 1/2 side rails were in the up position. An approximate seven inch width gap was present between the mattress and the side rail. On 06/08/17 R11 was unable to remember the entrapment incident. The Immediate Jeopardy was identified on 06/12/2016 at 1:00 P.M The Immediate Jeopardy began on 03/16/17 at 4:15 A.M. when the facility failed to assess the risk of entrapment and continued to use the same side rail with the same gap between the mattress and the side rail after R11 became entrapped in the gap between the mattress and side rail . The facility Administrator was notified of the Immediate Jeopardy on 06/12/17 at 1:30 P.M. While the immediacy was removed on 06/12/17, the facility remained out of compliance at a severity level 2 as the facility is in the process of monitoring it's plan of care. The surveyor confirmed through interview, observation and record review that the facility took the following actions to remove the Immediate Jeopardy: -An assessment of R11's side rails by the Administrator, Director of Nurses and Assistant Director of Nurses will be performed to evaluate the continued use of R11's side rails. Time frame for completing is 6/12/17 at 3:00 P.M. - A facility Bed Rails Risk Assessment will be developed by the Administrator, Director of Nurses and Assistant Director of Nurses to determine the safety of side rails and to help eliminate entrapment risk for all residents. Time frame for completing is 6/12/17. - A bed rail/entrapment assessment will completed on all residents with side rails by the Unit Nurses and monitored for completion by the Unit Managers. Time frame for completing is 6/13/17 by 11:59 P.M. B. Based on observation, interview, and record review the facility failed to assess for entrapment, obtain informed consent and document alternatives tried before the initiation of side rails for 23 of 29 residents, R3,R7, R8, R9, R10, R11, R13, R15, R19, R20, R21, R23, R24, R25, R26, R27, R29, R31, R33, R34, R35, R36 and R57, reviewed for side rails in the sample of 29. 1.) On 6/7/2017 at 10:00AM R7's bed had bilateral horizontal quarter size bed rails with two metal vertical rods inside the rail on both left and right side of the bed. The siderails were in the upper position. R7's Side Rail Assessment, dated 4/27/2017, documents that R7 is currently using the side rails for positioning and support, and that siderails are indicated and serve as an enabler to promote independence. R7's siderail assessment has no documentation of assessing for the risk for entrapment. There is no documentation that any interventions were attempted prior to the initiation of R7's siderails. The current medical record did not contain an informed consent for the use of the siderails. On 6/7/2017 at 11:00AM E2/DON (Director of Nurses) stated, We have not done any consents for the use of the siderails, and I don't see any interventions done prior to using the siderails for this resident (R7). 2. On 6/7/2017 at 3:00PM R33's bed had bilateral vertical mini siderails on the left and right side of the bed. Both siderails were up and in place, and the right siderail had the call light monitor in the middle of the rail. R33's Side Rail Assessment, dated 6/7/2017, documents that R33 is currently using the siderails for positioning and support. This same assessment documents that siderails are indicated to provide safety and serve as an enabler to promote independence. R33's siderail assessment has no documentation of assessing for the risk for entrapment. There is no documentation to show that any interventions were attempted prior to the initiation of R33's siderails. R33's current medical record did not contain an informed consent for the use of the siderail. 3.) On 6/7/2017 at 10:15AM R29's bed had bilateral one half horizontal siderails to the left and right side of bed. The siderails were in the upper position. R29's siderails have three metal vertical rods on the inside of both rails. R29's Side Rail Assessment, dated 4/27/2017, documents that R29 is currently using the siderails for positioning and support, and that siderails are indicated and serve as an enabler to promote independence. R29's siderail assessment has no documentation of assessing for the risk for entrapment. There is no documentation to show that any interventions were attempted prior to the initiation of R29's siderails. R29's current medical record did not contain an informed consent for the use of the siderail. 4. On 6/8/2017 at 12:35PM R57's bed had bilateral horizontal one half siderails to the left and the right side of R57's bed. Both siderails were in the upper position and R57's call light was wrapped around the left siderail. R57's Side Rail Assessment, dated 4/22/2017, documents that R57 is currently using the siderails for positioning and support, and that the siderails are indicated to provide safety. This same assessment documents that siderails are indicated and serve as an enabler to promote independence. R57's siderail assessment has no documentation of assessing for the risk of entrapment. There is no documentation to show that any interventions were attempted prior to the initiation of R57's siderail. R57's medical record did not contain an informed consent for the use of the siderail. 5. R11's Minimum Data Set (MDS) Assessment, dated 3/7/17 documents R11's Cognitive Status as Severely Impaired. This same assessment documents R11's Balance During Transitions, Surface To Surface Transfer (transfer between bed and chair or wheelchair) as a 0 (steady at all times). R11's current Care Plan, dated 6/4/2017 documents, Focus: (R11) is at risk for falls related to confusion, medication use. (R11) is independent with bed mobility and ambulation with supervision. R11's most recent quarterly Side Rail Assessment, dated 6/7/17 documents, R11 (has) an alteration in safety awareness due to cognitive decline, and (has) a history of falls. This same document does not address entrapment risk or appropriate alternatives attempted. R11's current medical record did not contain an informed consent for the use of the side rails nor any documentation of alternatives tried before the initiation of the side rails. On 6/7/17 at 12:40 P.M., with E5/ Maintenance Director present, R11's bed had a mattress with two, loose, oblong half rails attached to both sides of R11's bed. These same side rails have two bars positioned vertically with an opening in the middle. When the rails are raised to the up position, they extend approximately 18 inches above the mattress. There is a gap between the mattress and the bed rail that is 3-4 inches between the mattress and the bottom of the side rail, and increases to 7 inches at the top of the side rail. Both the left and the right rail are loose and wiggle with slight movement. This wiggling increases the space to seven inches at the top of the side rails. 6. R20's current Minimum Data Set, dated dated [DATE] documents R20's bed mobility as, Limited Assistance and balance during surface-to-surface transfers as Not steady, but able to stabilize without staff assistance. R20's current Care Plan, dated 5/9/17 documents, Focus: (R20) is at risk for falls related to an actual fall on 12/30/16. (R20) is stand-by-assist for transfers. R20's most recent, quarterly Side Rail Assessment, dated 5/5/17 documents, (R20) has an alteration in safety awareness due to cognitive decline. And (has) a history of falls. This same document does not address entrapment risk or appropriate alternatives attempted. R20's current medical record did not contain an informed consent for the use of the side rails nor any documentation of alternatives tried before the initiation of the side rails. On 6/7/17 at 10:30 A.M., R20's bed had a 1/2 side rail present to each side of the bed. These rails extended from the head of the bed to the middle of the middle of the bed. When the rails are raised to the up position, there were two vertical bars positioned with a seven inch gap between them. 7. R24's current Minimum Data Set, dated dated [DATE] documents R24's bed mobility as, Limited Assistance and balance during surface-to-surface transfers as Steady at all times. R24's current Care Plan, dated 5/2/17 documents, Focus: (R24) is a fall risk and is impulsive and will attempt to stand and transfer self. R24's most recent, quarterly Side Rail Assessment, dated 5/3/17 documents, (R24) has an alteration in safety awareness due to cognitive decline. And (has) a history of falls. This same document does not address entrapment risk or appropriate alternatives attempted. R24's current medical record did not contain an informed consent for the use of the side rails nor any documentation of alternatives tried before the initiation of the side rails. On 6/7/17 at 11:00 A.M., R24's bed had a 1/2 side rail present to each side of the bed. These rails extended from the head of the bed to the middle of the middle of the bed. When the rails are raised to the up position, there were two vertical bars positioned with a seven inch gap between them. 8. R35's current Minimum Data Set, dated dated [DATE] documents R35's bed mobility as, Limited Assistance and balance during surface-to-surface transfers as Steady at all times. R35's current Care Plan, dated 2/6/17 documents, Focus: (R35) is at risk for falls related to an actual fall on 2/6/17 and 2/8/17. (R35) is independent for transfers. R35's most recent, quarterly Side Rail Assessment, dated 6/7/17 documents, (R35) has an alteration in safety awareness due to cognitive decline. And (has) a history of falls. This same document does not address entrapment risk or appropriate alternatives attempted. R35's current medical record did not contain an informed consent for the use of the side rails nor any documentation of alternatives tried before the initiation of the side rails. On 6/7/17 at 11:30 A.M., R35's bed had a 1/2 side rail present to each side of the bed. These rails extended from the head of the bed to the middle of the bed. When the rails are raised to the up position, there were two vertical bars positioned with a seven inch gap between them. 9. R25's Side rail assessment, dated 6/6/17, documents that R25 has alterations in safety awareness due to cognitive decline. R25's side rail assessment has no documentation of assessing for R25's risk of entrapment, nor of any interventions were attempted prior to the initiation of the side rails. R25's care plan, dated 3/14/17, has no documentation addressing the use of R25's bilateral half side rails. R25's physician's orders [REDACTED]. R25's Behavior Monitoring Record, dated 5/2017, documents that R25 has a history of behaviors of verbally abusing, refusing cares, Insomnia, and Depression. On 6/6/17 at 9:30 a.m., R25 was lying in bed with bilateral half side rails up. E9 (Registered Nurse) directed R25 to grab R25's right side rail to assist with turning during wound care. R25 was able to grab the side rail and with the assist of one turned to R25's right side. R25's side rails had six vertical bars and four horizontal bars with multiple openings large enough for an extremity to go through. 10. R26's Side rail assessment, dated 6/8/17, documents that R26 is comatose, semi-comatose, obtunded, or has fluctuations in level of consciousness, and has alterations in safety awareness due to cognitive decline. R26's side rail assessment has no documentation of assessing for R26's risk of entrapment, nor of any interventions were attempted prior to the initiation of the side rails. R26's physician's orders [REDACTED]. R26's Fall risk assessment, dated 5/24/17, documents that R26 scored a twelve putting R26 at a high risk for falls. R26's Care plan, dated 6/2/17, documents that R26 has impaired cognition function and impaired thought processes. The care plan also has no documentation addressing R26's use of R26's bilateral half side rails. On 6/5/17 at 11:40 a.m., R26 was lying in bed with bilateral half side rails up. E18 (Registered Nurse) directed R26 for R26 to grab onto the left side rail to assist with turning. R26 was able to grab onto the side rail and turn to R26's left side with the assist of one. R26's bilateral half side rails had four vertical bars and four horizontal bars with openings large enough for an extremity. 11. R31's Side rail assessment, dated 4/28/17, documents that R31 receives medications which would require increased safety precautions. R31's side rail assessment has no documentation of assessing for R26's risk of entrapment, nor of any interventions were attempted prior to the initiation of the side rails. R31's physician's orders [REDACTED]. R31's Care plan, dated 5/5/17, has no documentation addressing the use of R31's bilateral half side rails. On 6/8/17 at 11:00 a.m., R31 was lying in R31's bed with bilateral half rails up. R31 turned herself to her left side using the side rail on R31's left side. R31's half side rails were rectangular shaped with two vertical bars and one horizontal bar with openings large enough for an extremity. 12. On 6/7/17 at 12:55 p.m., R8 was lying in R8's bed with R8's bilateral half rails up. R8 was demonstrating uncontrollable tremors to R8's bilateral hands. E19 (Licensed Practical Nurse) directed R8 to grab R8's right side rail to assist with turning. R8 grabbed the right side rail with R8's left hand and with minimal assistance was able to turn R8 to his right side. R8's Brief Interview Mental Status, dated 2/6/17, documents that R8 had a score of five signifying that R8 has severe cognitive impairment. R8's Care plan, dated 2/13/17, has no documentation addressing the use of R8's side rails. R8's side rail assessment, dated 4/7/17, documents that R8 is comatose, semi-comatose, obtunded, or has fluctuations in level of consciousness, and has alterations in safety awareness due to cognitive decline. R8's side rail assessment has no documentation of assessing for R8's risk of entrapment, nor of any interventions were attempted prior to the initiation of the side rails. R8's Fall risk assessment, dated 4/7/17, documents that R8 has a score of 14 signifying that R8 is at a high risk for falls. R8's physician's orders [REDACTED]. R8's Behavior Monitoring Record, dated 5/2017, documents that R8 has a history of delusions. 13. On 6/5/17 at 9:45a.m., there was a metal oblong, 3/4-length side rail attached to the upper portion of R9's bed on the left side, against the wall. This side rail had a horizontal division bar between the top and bottom of the side rail, leaving an approximate 3 inch open space above and below the bar. On the right side of R9's bed was a rectangular, half-length white metal side rail, approximately 20 inches wide and 12 inches high. This rail had no division bars, leaving an open area of approximately 18 inches wide by 12 inches high. R9's Side Rail Assessment, dated 4/30/17, does not include an assessment for entrapment risks. R9's clinical record does not include an informed consent for the use of side rails or alternatives attempted prior to the implementation of the side rails. 14. On 6/5/17 at 9:50a.m., there were bilateral, plastic, oblong, half-length padded side rails with 3 division bars each, spaced approximately 3 inches apart, attached to the upper portion of R15's bed. R15's clinical record does not include an informed consent for the use of side rails or alternatives attempted prior to the implementation of the side rails. R15's Side Rail Assessment, dated 5/14/17, does not include assessment for entrapment risks. 15. On 6/5/17 at 1:45p.m., there were bilateral hard plastic, half-length side rails attached to each side of the upper portion of R21's bed with three division bars present on each rail, spaced approximately 3 inches apart. R21's clinical record does not include an informed consent for the use of side rails or alternatives attempted prior to the implementation of the side rails. R21's Side Rail Assessment, dated 4/28/17, does not include assessment for entrapment risks. 16. On 6/5/17 at 1:45p.m., there were bilateral oblong, quarter-length side rails attached to the upper portion of R23's bed. These side rails had two division rails approximately 3 inches apart. R23's Side Rail Assessment, dated 6/7/17, does not include assessment for entrapment risks. R23's clinical record does not include informed consent for the use of side rails or alternatives attempted prior to the implementation of the side rails. 17. On 6/7/17 at 12:20 PM, R10's bed contained 2 oblong 1/2 side rails on both sides of the bed with 2 horizontal bars which created a 6-7 inch gap in the middle of the 2 bars. R10's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of the side rails. R10's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 18. On 6/7/17 at 9:58 AM, R13's bed contained 2 oblong, 1/4 size Siderails on both sides of the bed. These side rails contained 1 vertical bar in the middle with approximately a 2-3 inch gap and one horizontal half bar in the middle with a 1-2 inch gap. R13's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of the side rails. R13's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 19. On 6/7/17 at 11:36 AM, R36's bed contained 2 oblong 1/4 side rails on both sides of the bed with 5 horizontal bars which created a 2-3 inch gap. R36's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of the side rails. R36's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 20. On 6/7/17 at 1:00 PM, R19's bed contained two oblong upper half side rails in the up position with five vertical bars creating gaps measuring approximately seven inches in width from bar to bar across the side rails. R19's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of R19's side rails. R19's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 21. On 6/7/17 at 11:30 AM, R27's low bed contained two upper bed mobility assist grab bar side rails in the up position that measure approximately six inches wide. R27's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of R27's side rails. R27's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 22. On 6/7/17 at 12:45 PM, R34's bed contained two oblong upper half side rails in the up position with five vertical bars creating gaps measuring approximately seven inches in width from bar to bar across the side rails. R34's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of R34's side rails. R34's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. 23. On 6/7/17 at 12:56 PM, R3 was lying in bed. R3's bed contained two rectangular upper half side rails in the up position with one horizontal bar creating two gaps measuring approximately four inches in width from bar to bar across the side rails. R3's current medical record does not include an informed consent, nor documentation of alternatives attempted prior to the initiation of R3's side rails. R3's Side Rail assessment dated [DATE] does not document an assessment for entrapment risk. On 6/7/17 at 12:10 PM, E2, Director of Nursing, stated that the facility does not obtain informed consents for any resident at the facility prior to the initiation of side rails. At this same time, E2 stated the facility does not document alternatives tried prior to the initiation of side rails for any resident at the facility. E2 stated, I know alternatives are a problem. It's a widespread problem. Our side rails are a little outdated. E2 then verified that the facility's current Side Rail Assessments do not assess for entrapment risk. C. Based on interview and record review, the facility failed to document, assess and investigate an incident and failed to implement new fall interventions after each fall for three of 13 residents (R10, R13 and R27) reviewed for falls in a sample of 29. These failures resulted in R13 falling and requiring transfer to a local hospital for,associated head injury, facial swelling and purple skin color changes. These failures also resulted in R27 falling and sustaining a forehead laceration and subsequently requiring transport to a local hospital for placement of sutures to repair the laceration. The facility's Event Management policy (revised 12/20/16) documents the following: An important component of a Quality Assurance and Assessment Plan is an effective Event Management system. Event Management includes a daily review of all events by the DON (Director of Nursing) or designee. Ideally, all events are reviewed at daily meetings for timely and effective follow-up. This same policy also documents, Procedure: The charge nurse shall initiate an Incident Report for required high-risk events. Determine if the care plan was followed as written. Based on initial assessment, immediate revision to the care plan to minimize the risk of repeat incident. 1. R13's most recent quarterly MDS (Minimum Data Set Assessment) dated 4/13/17 documents R13 has a BIMS (Brief Interview for Mental Status) of 7 of 15, is alert and confused. R13's Fall Risk Assessments dated 6/1/16 and 3/3/17 documents R13's has fall scores rated 7 and 9, indicating R13 is not a high fall risk. R13's fall tracking log dated 6/1/16- 6/2/17 indicates R13 fell at the facility 19 times during this time frame. On 6/8/17, E3, Restorative Nurse was unable to provide investigations of R13's falls on 6/2/16 and 10/12/16. R13's Investigation form dated 6/18/16 documents R13 was found on the floor with no alarms going off. The same form documents, Suggested Intervention: alarm when put to bed (battery). On 6/8/17 at 11:30 AM E3, Restorative Nurse, stated on 6/18/16, R13's alarm was not functioning properly and the intervention was to check the alarm batteries. R13's Investigation form documents on 6/24/16, R13 attempted to get self from wheelchair to toilet. The same form does not document an immediate intervention nor was an intervention care planned until 7/3/16. This form documents R13 sustained a skin tear to the right forearm from this fall. R13's Investigation form dated 6/25/16 documents R13 asked to go to bed at 4:55 PM and was advised by staff to wait a few minutes because the staff were passing out meals for supper and it takes 2 staff to help R13. R13 fell at 5:00 PM. This form documents the intervention was to take R13 to the main area for observation while staff was helping other residents with supper. R13's Event Report dated 10/11/16 at 6:50 PM, R13 was yelling out for help and was found on the bathroom floor in front of the wheelchair. This same form documented an intervention of a chair alarm. On 6/8/17 at 11:30 AM, E3, Restorative Nurse, stated E3 was not sure if a chair alarm was implemented because it was not documented in R13's care plan until 2/1/17. R13's fall tracking log documented R13 had a fall on 10/12/16. On 6/8/17 at 11:30 AM, E3, Restorative Nurse, stated there was no investigation available for R13's fall on 10/12/16. E3 stated according to the R13's care plan, E3 believes the intervention was frequent toileting. R13's Investigation form dated 10/18/16 documents R13 was found in R13's bathroom and was trying to get in the wheelchair from the toilet. R13's same investigation form is blank for the section titled, suggested interventions. On 6/8/17 at 11:30 AM, E3, Restorative Nurse, verified an intervention was not implemented for this fall. R13's Event Report dated 11/7/16 documents R13 was found on the floor in the bathroom. This same form documents the following immediate interventions: Chair alarm, use call light and CNA's (Certified Nursing Assistants) to attend to her quickly for bathroom requests. R13's fall intervention for a fall on 10/11/16 was also to implement a chair alarm. R13's Event Report dated 11/21/16 documents, (R13) asking to go to bed for 1 1/2 hours, fell in BR (bathroom). This same form documents the following fall interventions: Use call light, lock BR door (has alarm), has bed alarm, no body alarm on, body alarm. On 6/8/17 at 11:30 AM, E3, Restorative Nurse, stated the staff did not answer R13's call light timely on 11/21/16. R13's Event Report form dated 11/26/16 documents that R13, Was found on the floor out of her W/C (wheelchair), no alarm sounding. This same form documents the following immediate fall interventions: Make sure body alarm is on, obtain a UA (Urinalysis). On 6/8/17 at 11:30 AM, E3, Restorative Nurse, verified R13's, Alarm was not sounding. R13's Event Report dated 12/7/16 documents R13 was found sitting on buttocks in the bathroom. This same form did not document an immediate intervention. R13's Event Report dated 12/10/16 documented R13, Scooted self off low bed. The same form documents the immediate fall intervention was to implement a chair alarm. R13's Event Report dated 1/27/17 documents R13 was found on the floor in the bathroom and was trying to get off of the toilet. This same form documents R13, Has raised area to top of head, ice pack applied, area non open, bruised. This form documents R13 had been asking to go to bed and was told she had to wait. This same form documents the following immediate interventions: re-orient the need to ask for assist, re-orientate to call light use. R13's emergency room report dated 1/31/17 documents, presented to ED (Emergency Department) for a fall occurring 3 days ago with associated head injury, facial swelling and purple skin color changes. On 6/8/17 at 11:30 AM, E3, Restorative Nurse, stated this fall was due to, non-compliance with the bathroom door alarm. E3 verified that R13 received a Hematoma from this fall and was sent to the Emerg

Based on record review and interview the facility failed to maintain a safe mechanical lift transfer for one of three residents (R1) reviewed for falls in a sample of three. This failure contributed to a fall with a Right Supracondylar Femur Fracture, which required an Right Above the knee Amputee. Findings Include: The facility policy titled, Using A Portable Device dated 11/7/2014 documents, The primary purpose of using portable lifting machine is to help lift residents who may be too heavy to lift. The portable lift is also used to promote comfort and to maintain good body alignment while the resident is being moved. According to a History and Physical, dated 1/27/2017, R1 has a very complicated past medical history which includes an infected Right Total Knee Arthroplasty, which persisted, was taken out, but a spacer was left in.Coronary Artery Disease,Chronic Obstructive Pulmonary Disease, Right Distal Femur Fracture above the cement spacer, and Anxiety. R1's Careplan dated 1/19/2017 documents,Falls: The resident (R1) has had an actual fall where she (R1) slid from her(R1) mechanical lift while being lifted to the toilet on 12/27/2016 (While not a resident). Also, documents that resident (R1) fell out of the hoyer when being put to bed at bedtime. She (R1) has a Right AKA (Above the Knee Amputee.) Careplan also documents resident will transfer with 3:1 mechanical transfer, using a mechanical lift and an extra large full body sling. R1's Careplan documents, Mood:She (R1) is tired a lot and scared of falling again.Resident (R1) is depressed and only thinks of loss of her(R1) leg/unfairness of it. The MDS (Minimum Data Set) dated 2/14/2017, assesses R1 to be totally dependent on staff, requiring two persons physical assist for transfers.MDS also shows R1 requires two persons physical assist for toileting and bed mobility. R1's Nurses Notes dated 1/26/2017 at 8:30PM documents, CNA (Certified Nursing Assistant) called RN (Registered Nurse) to room 3101, stating that resident (R1) had fallen to the floor from a mechanical lift. Resident (R1) on floor laying on left side.Family (Granddaughter) was in room when incident occurred.Granddaughter states that CNA'S properly had resident (R1) in mechanical lift but, that resident (R1) jerked and sling slipped off mechanical lift,causing resident (R1) to fall. No visible injury noted. Resident complained of right lower extremity pain. Doctor notified.Ordered to send to emergency room to evaluate and treat. According to the emergency department Physicians Notes dated 1/26/2017. History of Present Illness. The patient (R1)presents with fall. Onset: 1/26/2017. Pt.(R1) is a resident of a local nursing home.Granddaughter states she (R1) was at bedside when she (R1) was dropped.Family reports she (R1) was being lifted with a mechanical lift by nursing staff when the strap of the mechanical lift came undone and patient (R1) fell straight to the floor.Family states her (R1) right leg hit the mechanical lift during the fall and then hit the floor.Patient (R1) is complaining of right leg pain. R1's Radiology results, dated 1/26/2017 at 1:29PM from the local emergency room documents Right leg emergency room interpretation: Spiral fracture of the distal Femur extending to the joint line. R1's Physician's Progress Notes dated 1/27/2017 from the local hospital documents Impression : 1. Right Periprosthetic Femur fracture with a history of recurrent infections,to the knee. Plan: I sat down with resident(R1) and family and discussed her clinical situation. Advised her(R1) that supracondylar femur fractures are most commonly treated with plate fixation or some medical device to restore stability.However, she (R1) would be at significant risk for reactivation of infection in the area of her knee and her fracture, which does extend down to her antibiotic spacer.I advised her that plate fixation of her fracture would be associated with significant risk of reactivation of infection .I discussed another option, which would be above-knee amputation.I feel that above the knee amputation is the most safe way of trying to control her pain and morbidity associated with this fracture given the chronic infection of knee .After a lengthy discussion with her(R1) and her(R1) family, she(R1) has elected to continue with the surgical plan of above-knee amputation. The facility witness statement written by E4/CNA (certified nursing assistant) dated 1/26/2017 at 8:30PM documents Resident anxious, shifted her weight in sling when this happened resident's front left side of sling came out causing resident to fall to floor. On 2/28/2017 at 10:10 AM, E6/CNA (certified nursing assistant) stated, Resident was being transferred from wheelchair to bed with a full sling mechanical lift. Resident (R1) was very anxious and tense.Because of another incident in another nursing home.Resident(R1) was uncomfortable and fidgety.Resident's(R1) body position was kinda shifting and leaning toward the left side. The other CNA and I attached the straps to the mechanical lift, we lifted resident(R1) out of wheelchair, not very far up, then placed resident(R1) back down, because resident(R1) was asking, Am I on correctly,Am I on correctly. So, we checked connections again to reassure the resident (R1). We lifted the resident (R1) back up again, then removed the wheelchair from underneath her (R1) and guided her towards the bed. As, I went around the bed with resident(R1) ,the left side loop just dropped from the left metal hook causing resident(R1) to fall out of the mechanical lift sheet and fall to the ground.The resident(R1) was leaning toward the left side, causing sling strap (loop) to snap out of the hook. I feel, that if the resident(R1) was not leaning toward the left side, and wasn't having so much anxiety and tension, that it wouldn't have caused a tip to the bar, that caused the loop to disengage from the hook. Causing resident(R1) to fall to floor. On 2/27/2017 at 3:15PM, E4/CNA(certified nursing assistant) stated, We were transferring resident(R1) from chair to bed.Resident became very nervous when using mechanical lift.Because prior to admission resident(R1) had a fall involving a mechanical lift in another nursing home. Resident(R1) becomes anxious anytime she(R1) uses a mechanical lift, everyone knows that.Another CNA and I attached the straps to metal hooks and checked them. Didn't see anything wrong. We started to lift the resident(R1) and she(R1) became very anxious and nervous. Resident(R1) kept asking us do you know what you are doing We put her(R1) back down into wheelchair. Gave her(R1) the reassurance and lifted her(R1) up again. Resident(R1) remained very nervous causing her(R1) to shift her(R1) weight to the left side, causing the strap (loop) on the sling to disengage from metal hook, causing the resident(R1) to fall out of mechanical lift onto the floor. I think, because resident(R1) was so anxious and nervous because of the transfer it caused her(R1) weight to shift around. On 3/1/2017 at 8:25AM, Z3/R1 Granddaughter stated, I was in the room when the staff was transferring my Grandmother(R1) from the chair to the bed. I've never seen the horizontal bar (above head) move so much. It moved from side to side to up and down. The staff had to hold the bar during transfer because it almost hit my grandmother(R1) across the face. My grandmother(R1) kept saying over and over again, something doesn't feel right, something doesn't feel right. I did notice that she(R1) was sitting back more then usual. All attachments looked right, from where I was standing. But, my Grandmother(R1) didn't feel comfortable.Staff knows that she(R1) gets very anxious everytime she(R1) gets moved. She(R1) fell straight down on the floor, hit the mechanical lift and broke her(R1) right leg. It looked like the hook and the sling came undone. On 3/1/2017 at 10:00AM, R1 stated, I am not real sure what happened, it all happened so fast.I do know I fell out of the mechanical lift and broke my leg and I had to have it cut off. I am not a suing a person but, someone should pay for this. I kept telling the CNA's (Certified Nursing Assistants) it didn't feel right, (transfer). On 3/1/2017 at 11:30AM, E2/DON (Director of Nursing) stated, Anxiousness,rigidity,anxiety,resident being on her left side, and the hook/clip are contributing factors that caused the resident(R1) to fall from the mechanical left and sustain a fracture of the right leg. Reapproaching resident(R1) does not work, she(R1) will still have anxiety. On 3/1/2017 at 9:40AM, E3/ Restorative Director stated, It is the responsibility of the CNA's (certified nursing assistant) to be inspecting the mechanical lift, including the metal hooks/with attached clip to ensure that the clip is close to the hook. There is a potential that the loop on the sling can go underneath the clip and detach from the hook causing the resident(R1) to fall.It is possible, that could have been the problem with the residents(R1) mechanical lift. On 3/1/2017 at 2:30PM, Z2/ Distributor for mechanical lift stated, There is a safety device on the metal hook(cradle) its function is to assist in keeping the sling on the cradle. With the patient(R1) in the sling,elevated off the surface, the weight of the patient(R1) will force the loops of the sling into the curve position on the cradle (hook.) If the sling is installed correctly on the cradle it will not come off the cradle,when the patient(R1) is on the sling and elevated.It is made so that the sling does not come out.The proper intended position is for the sling to be directly under the knees up to the shoulders, in a semi reclining position supported by the sling. If not positioned correctly, depending on the resident,they would be subject to a higher incident of injury. On 3/1/2017 at 8:00AM, Z1/Physician stated, The fall from the mechanical lift caused the resident(R1) to fracture the right leg.

Based on interview and record review, the facility failed to safely transport one of one resident (R1) reviewed for wheelchair safety in the sample of three. R1 was being transported without wheelchair pedals by E5 Transportation/(CNA) Certified Nursing Assistant when R1's left lower extremity prosthesis folded under R1's wheelchair and became trapped. R1 subsequently sustained a fracture of the left femur, was hospitalized and died . Findings Include: The Facility Classification Description for Transporter/CNA documents under Representative Duties: 3.) Responsible for transporting residents, supplies, equipment and staff in a safe and positive manner. R1's Admission Record dated, [DATE] documents the following Diagnosis: [REDACTED]. R1's Minimum Data Set (MDS) dated , [DATE] documents R1 requires extensive assistance/one person physical assist for locomotion on and off the nursing unit. R1's Careplan dated, [DATE] documents R1 is a below the knee amputee, R1 wears a prosthetic and is a two person transfer. E4 LPN (Licensed Practical Nurse) documents in R1's nurses notes on [DATE] at 9:20A.M., that R1 did not leave for dialysis and that R1's Left lower extremity was hurt. E4 sent E6 CNA (Certified Nursing Assistant) to get resident, due to E4 was taking care of another resident. R1's nursing note at 9:30 AM on [DATE]At 9:30A.M. indicated that E4 had brought R1 back to the nursing unit for assessment due to R1 refusing to come to unit with E6 due to pain. R1 stated to E4, I think my leg is broken, (E5/Transportation/Certified Nursing Assistant) wouldn't stop when I yelled, it was caught under the wheelchair twice. E4 documents that R1 was in tears when E4 touched left lower leg. R1 also stated to E4, I heard a pop when left leg was being bent backwards. The note stated R1 was sent to local emergency department for evaluation of the left leg. R1's History and Physical form from the local hospital dated [DATE] at 3:42P.M., documents by Z2 (Hospitalist/Physician) that R1 presents with left lower extremity pain, and R1 was being wheeled down in wheelchair for hemodialysis. It stated R1 had no pedals on R1's wheelchair, R1 could not hold up R1's left lower leg prosthetic, so it folded under R1's wheelchair, pulled on R1's left lower extremity and came off. The form also stated that the transporter that was pushing R1's wheelchair is deaf and could not hear screams of pain. R1's Imaging examination of left knee dated [DATE] indicated: Findings: There is some mildly angulated mildly displaced acute fracture identified in the distal metaphysis of the femur. (Femur Fracture.) R1's hospital Discharge Summary dated [DATE] indicates that R1 expired in the hospital. On [DATE] at 945A.M., E3 Receptionist/CNA (Certified Nursing Assistant) stated, On [DATE] around 8:30A.M., I was sitting at the reception desk and I could see( R1) and( E5) coming along the side of the reception desk towards the front door and I could hear( R1) telling( E5) My leg, please stop my leg. Just as I was getting ready to tell (E5) to stop ,( E5) had already stopped in front of the desk. Then I hear( R1) telling( E5) to fix( R1's) prosthetic leg. I go around the front of desk to see what I can do to help and( R1) is requesting that( R1's) prosthetic be removed, I start to remove the leg and( R1) says, Be real careful my leg hurts. I removed leg and noticed there was no pedals on wheelchair. On [DATE] at 1045A.M., E4 stated, On [DATE] at about 9A.M.( E6) received a phone call from the receptionist, that( R1) was down in the lobby area not feeling well and did not want to leave for dialysis. I sent (E6) to go get (R1), because I was busy with another resident. (E6) came back up to unit without (R1) and ( R1's) prosthetic in her hand. I went down to lobby area and was able to convince ( R1) to return to unit to be assessed. (R1) kept telling me that, I yelled for CNA (E5) to stop because I could not hold my left leg up, but ( E5) cannot hear well and did not hear me. (R1) said, my left leg was caught under the wheelchair, then I heard a pop. (R1) did not have any visual impairments, but I gently push on mid-thigh and ( R1) had severe pain. ( E4) then stated, I called ( R1's) daughter to inform her about ( R1's) left leg and to inform her that I felt ( R1's) condition was declining, 'just wasn't acting right. I also knew (R1) was due for ( R1's) dialysis. (R1) was sent out for evaluation to the emergency room , daughter agreed to meet (R1) there. ( E5) returned from transferring another resident and I stopped ( E5) to inform ( E5) that( R1) was sent out because I felt ( R1's) left leg was broken. and hurting very badly. ( E5) stated, It is a good possibility that ( R1's) left leg is broken, because leg got caught under wheelchair twice. First time, I literally had to grab ( R1) from falling out of the wheelchair, the force of the prosthetic leg caused( R1) to move forward.I told( E5) that( R1) continued to repeat over and over again, I just know my left leg is broken and (E5) would not stop wheelchair. On [DATE] at 1:54P.M., E6 CNA (Certified Nursing Assistant) stated, On [DATE] at 9:00A.M., the nurse received a phone call from the receptionist, that( R1) needed assistance.I was asked by( E4) to go and get( R1) because( E4) was busy with another resident. I went down to the reception desk and( R1 )asked me to remove the rubber sleeve from amputee site.I proceeded to remove sleeve very gently and( R1) says to me, when( E5) was pushing me( E5) hurt my leg. I knew that( R1) was in a lot of pain because( R1) would not let me touch the wheelchair to take( R1) to back to unit. I left( R1) near lobby and went to get( E4)(. R1) was not using foot pedals, and when( R1) goes to dialysis( R1) should be using the foot pedals. On [DATE] at 12:00P.M., E5/Transportation/CNA (Certified Nursing Assistant) stated, On [DATE] I was propelling ( R1) in wheelchair to the front lobby for dialysis, and all of the sudden ( R1's )wheelchair stopped and ( R1) went forward, I reached out to try and stop (R1) from falling out of wheelchair. I asked ( R1) if ( R1) was ok ( R1) answered, give me a few minutes to rest. ( R1's) prosthetic leg was bent and stuck underneath ( R1's) wheelchair, that is why the wheelchair stopped abruptly. I pulled wheelchair back and prosthetic realigned itself. There was no pedals on wheelchair so, I asked ( R1) if ( R1) was able to hold feet up to proceed and ( R1) said yes. ( R1) was able to keep both feet up, but not for long. So, I turned ( R1's) wheelchair around and pulled the wheelchair to front lobby. ( R1) did not complain of any pain. I made it to the front of the reception desk and asked ( E3) to come around and assist me to try and figure out what was wrong with ( R1). As I was kneeling down to zip ( R1's) coat, ( R1) complained of pain in left leg so, I asked ( E3) to call unit for nurse. I have never had any problems transferring ( R1), but I realize now that ( R1) was too weak to hold ( R1's) legs up. I should have used foot pedals. On [DATE] at 2:30P.M., E7 OT (Occupational Therapist) stated, We had ( R1) on and off for therapies, ( R1) was able to propel own wheelchair very short distances only. We put foot pedals on ( R1's) wheelchair, I don't know what happened to them.( R1) should have been using pedals on her wheelchair. On [DATE] at 10:30A.M., E2/ DON (Director of Nurses) stated, During my investigation I learned that( R1) was not feeling well and leaning toward the sides.( E5) should have used wheelchair pedals to transport (R1) in wheelchair. On [DATE] at 11:06A.M., E1/ Administrator stated, ( R1) was able to propel( R1's) wheelchair short distances only. ( R1) should have had the wheelchair pedals on, especially for long distances. On [DATE] at 11:07A.M., Z3/ R1's daughter stated, Back in (MONTH) of (YEAR) my mom started getting weak, and as I was propelling ( R1) in the wheelchair, (R1's) prosthetic leg dropped, and mom said, 'I can't hold my leg up anymore.' So, (R1) started to use the wheelchair pedals. On [DATE] at 9:00A.M. my mom called me crying out loud, 'I need help,please help me. They are trying to send me to dialysis, and I can't go. The lady was pushing me too fast and twisted my leg, I kept asking for help, but she couldn't hear me. Z3 also stated, My mom was weak and should have been using a foot pedal al least to the left prosthetic leg. On [DATE] at 12:20P.M., Z1/ Physician stated regarding the use of wheelchair redals for R1: Sure it makes sense, wheelchair pedals should have been used for ( R1. ) If staff would of used the wheelchair pedals to hold the prosthetic leg in place( R1) would have not sustained a fractured femur.

Based on observation, interview and record review the facility failed to recognize and investigate vaginal bruising of unknown origin as potential abuse for one resident (R1) and failed to report immediately and investigate a resident complaint of rough treatment during peri care as potential abuse for one resident (R2). The facility failed to protect R1 and R2. The facility failed to report to IDPH for R1 and R2. R1 was admitted to the hospital on [DATE]. At that time vaginal bruising was discovered and reported to the facility. The facility did not begin an investigation until the next day, 2/24/14. R2 complained of rough treatment during peri care by a CNA to the point of making R2 cry on 2/9/14. The facility failed to immediately notify the administrator of the alleged abuse of R1 and R2. There were two of eight residents reviewed for abuse in the sample of eight. This has the potential to affect all 223 residents in the facility. These failures resulted in an immediate jeopardy. While the Immediate Jeopardy was removed on 3/3/14 at 4:45 p.m., the facility remains out of compliance at a Severity Level Two. Additional time is needed to monitor the implementation of new policies and procedures and the effectiveness of the inservices conducted. Findings include: The Facility Data Sheet, dated 2/24/14, documents the facility had a census of 223 at the time of the survey. 1. R1's nursing notes document on 2/23/14 at 9:45 a.m. R1 was sent to the emergency room . R1's same nursing notes document at 2:00 p.m. Z1 (emergency room nurse) "called from ER (emergency room ) (R1) noted to have bruising to her inner vagina. Family aware." R1's ER notes document on 2/23/14 at 10:15 a.m. "Bleeding and bruising around urethra. Mild swelling and ecchymosis of external genitalia." ER notes dated 2/23/14 at 1:56 p.m. document Z1 notified facility of R1's admission. R1's ER record contained pictures taken of R1's vagina by hospital personnel. The pictures provided by the ER are dated 2/23/14 at 11:50 a.m. The first picture showed the external vagina and appeared to have a moderate amount of dried blood on the outside of the vagina. The other 3 pictures showed several small bruises, red in color in the inner labia and around the urethra of R1's vagina. On 2/24/14 at 11:30 a.m. R1 was in a hospital room lying in bed awake. R1's external vagina showed no abnormalities or dried blood. R1's inner labia and urethra had several small pinpoint sized red areas. On 2/24/14 at 10:45 a.m. Z1 (emergency room nurse) stated on 2/23/14 R1's vagina had "no obvious bruising externally. R1's inside labia and clitoris had moderate bruising." On 2/24/14 at 1:00 p.m. E1 (Administrator) stated the facility had not received or investigated any allegations of suspected abuse since December 2013. E1 stated on 2/23/14 approximately 3-3:30 p.m. E6 (Nursing Supervisor) reported to E1 that the hospital had reported to the facility that R1 had been admitted to the hospital with [REDACTED]." E1 stated E1 called E11(Case Manager) and asked E11 to go to the hospital the next morning (2/24/14) and check on R1. E1 stated at 8:30 a.m. on 2/24/14 E11 reported to E1 that the hospital reported the vaginal bruising to the elder abuse hotline. E1 stated around 8:30 a.m. 2/24/14 E1 called the police regarding the vaginal bruising to R1. E1 stated she did not see the vaginal bruising as potential abuse until 2/24/14 after finding out the hospital called the abuse hotline. On 2/27/14 at 12:10 p.m. E2 DON (Director of Nursing) stated E1 called on 2/23/14 at approximately 5-6:00 p.m. and reported to E2 that the emergency room had reported to the facility "potential abuse, bruising" to R1. E2 stated E2 began getting statements from staff on 2/24/14. On 2/27/14 at 12:30 p.m. E11 (Case Manager) stated E1 called E11 on 2/23/14 approximately 7:30 p.m. and asked E11 to go to the hospital on [DATE] to check on the status of R1's "bruising or redness to R1's peri area." On 2/27/14 at 2:13 p.m. E6 (Nursing Supervisor) stated on 2/23/14 approximately 2-2:30 p.m. E5 LPN (Licensed Practical Nurse) reported to E6 the hospital had called and reported bruising to R1's genitalia. E6 stated E6 immediately called E1 to report the bruising. E6 stated E6 was not asked by the facility until 2/27/14 to write a statement regarding R1's recent admission to the hospital and the bruising to R1's vaginal area. 2. R2's nursing notes dated 2/9/14 at 3:00 p.m. document R2 "complained of staff rushed her and too rough with cares this a.m. Rough with my legs when getting in chair and wiped my bottom too hard. She knows she was too rough because I cried at the time. You won't send her back to my room again?" This nursing note was signed by E5 LPN (Licensed Practical Nurse). R2's most recent MDS (Minimum Data Set) dated 2/13/14 documents R2's BIMS (brief interview for mental status) score was 15/15. The facility provided a list of interviewable residents, with R2 being indicated as interviewable. On 2/27/14 at 10:10 a.m. R2 stated "some CNA's (Certified Nursing Assistants) are rough, sometimes it causes bruising. One CNA was rough when cleaning me and I cried. I don't want her taking care of me. When CNA's are rough I have reported it to the nurse. R2 would not provide surveyor names of staff. On 2/27/14 at 1:45 p.m. E5 LPN stated E5 viewed the incident on 2/9/14 for R2 as potential abuse. E5 stated reporting it to E6 (Nursing Supervisor) on 2/9/14 and filling out an incident report. E5 stated the CNA in question for the alleged abuse was E12 CNA (Certified Nursing Assistant). On 2/27/14 at 2:13 p.m. E6 (Nursing Supervisor) stated "vaguely" recalling the incident on 2/9/14 for R2. E6 stated not being aware a CNA was too rough until 2/10/14. E6 reported interviewing R2 to find out who the CNA in question of being rough was. E6 said R2 stated "it was a black CNA on night shift?" E6 stated "there are 3 black CNA's on night shift so I did not know which one it was." I did not do any interviews or investigate any further. E6 stated the incident was not reported to E1 (Administrator). On 2/27/14 at 2:30 p.m. E1 stated the incident on 2/9/14 involving R2 was not reported to E1, E1 was unaware it occurred. On 3/3/14 at 12:40 p.m. E1 stated interviewing of staff had not begun but "they believe it was E12". E1 confirmed E12 has continued working since becoming aware of the the incident of 2/9/14 on 2/27/14 and has not been interviewed. On 3/3/14 at 1:10 p.m. E12 CNA stated E12 "floats to different floors a lot." E12 stated not being aware of any incidents and not being questioned regarding any incidents. E12 stated E12 has not been informed E12 can't work on any particular floor or with any particular resident. The Facilities Resident Abuse and Neglect Prevention Protocol, dated 2/21/11, states, "any suspected abuse or neglect shall be immediately reported to the abuse coordinators. The abuse coordinators shall be the administrator, Director of Nursing and Director of Social services. These coordinators shall be responsible to coordinate abuse and neglect investigations within the facility... Indications of abuse or neglect may include a pattern or trend of unexplained injuries such as cuts, bruises, scratches, fractures, bleeding and burns." On 2/24/14 E1 verified IDPH had been notified the of the potential abuse occurring on 2/23/14 on 2/24/14 at 11:13 a.m. On 3/3/14 E1 verified IDPH had been notified of the potential abuse that occurred on 2/9/14 on 2/27/14 at 3:50 p.m. On 3/3/14 E1 verified E6 (Nursing Supervisor) was suspended on 2/27/14 for not reporting the potential abuse that occurred on 2/9/14. E12 was suspended on 3/3/14 for the allegation of potential abuse that occurred on 2/9/14. On 3/3/14 at 12:40 p.m. an Immediate Jeopardy was identified to have begun on 2/9/14 when R2 complained of staff rushing her, being too rough with cares, and wiping R2's bottom too hard, causing R2 to cry; the allegation was not reported to E1 or IDPH; and no investigation was initiated. E1 was notified of the Immediate Jeopardy on 3/3/14 at 12:40 p.m. The surveyor confirmed through interview and record review that the following actions were taken to remove the Immediate Jeopardy: 1. The staff members involved with the alleged potential abuse that occurred on 2/9/14 were suspended. The staff member who did not report the incident was suspended on 2/27/14. The alleged abuser was suspended on 3/3/14. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 2. Residents in the facility with a BIMS score of 7 or above and considered interviewable were questioned regarding care being given by staff and the possibility of staff being rough or verbally rude. The results of the interviews will potentially lead to additional allegations and disciplines. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 3. All residents have been assessed for the potential to be abused or be abused upon admission and every 90 days. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 4. The facility's abuse policy and procedures have been revised to indicate the immediacy of reporting to IDPH. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 5. All management. licensed and supervisory staff inservicing was initiated on how and to whom to report abuse. As each shift reports for duty, they will be inserviced prior to reporting to their assigned unit. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-7-14. Responsible party: Administrator 6. All staff are being inserviced with training on abuse and neglect to encompass all staff, all shifts and all departments. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-7-14. Responsible party: Administrator 7. The facility is providing re-inservicing on mechanical lift transfers to all units and shifts. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-5-14. Responsible party: Administrator

Based on interview and record review the facility failed to recognize and report incidents of abuse, as defined by facility policy, for two of eight residents (R1, R2) reviewed for abuse in a sample of eight. R1 was admitted to the hospital on [DATE] where vaginal bruising was discovered and reported to the facility who did not begin an investigation until the next day, 2/24/14. R2 complained of rough treatment during peri care by a CNA to the point of making R2 cry on 2/9/14. This has the potential to affect all 223 residents in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 3/3/14 at 4:45 p.m. the facility remains out of compliance at a severity level two as additional time is needed to monitor the effectiveness of management and staff education on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Findings include: The Facility Data Sheet, dated 2/24/14, documents the facility had a census of 223 at the time of the survey. The Facility's Resident Abuse and Neglect Prevention Protocol Policy, dated 2/21/11, documents a staff member or anyone suspecting or experiencing abuse or neglect, shall immediately report the matter to one of the designated abuse coordinators and defines immediately as no later than the end of the shift or immediately following the incident. The abuse coordinators are the Administrator, Director of Nursing and Director of Social Services. The policy states, "Indication of abuse may include a pattern or trend of unexplained injuries such as cuts, scratches, fractures, bleeding or burns. Other indicators may include non verbal and verbal expressions of fear when a particular staff member or individual is near a resident." The "Reporting" section of the policy states, "If the reported incident indicates that a resident's life or safety is in imminent danger, the Abuse Coordinators shall initiate the investigation within 24 hours." The policy also states that if a staff member is the accused perpetrator it is "the expressed policy of the facility to bar any further contact with any resident until a formal investigation is completed. The employee shall be suspended without pay." 1. R1's nursing notes document on 2/23/14 at 9:45 a.m., R1 was sent to the emergency room . R1's same nursing notes document at 2:00 p.m. Z1 (emergency room Nurse) called from ER (emergency room ). R1 noted to have bruising to inner vagina. On 2/24/14 at 1:00 p.m. E1 (Administrator) stated the facility had not received or investigated any allegations of suspected abuse since December 2013. E1 stated E6 (Nursing Supervisor) reported to E1 on 2/23/14 at approximately 3-3:30 p.m. that the hospital had reported to the facility that R1 had been admitted to the hospital with [REDACTED]." E1 stated E1 called E11(Case Manager) and asked E11 to go to the hospital the next morning (2/24/14) and check on R1. E1 stated E11 reported to E1 at 8:30 a.m. on 2/24/14 that the hospital reported the vaginal bruising to the elder abuse hotline. E1 stated E1 called the police around 8:30 a.m. on 2/24/14 regarding the vaginal bruising to R1. On 2/27/14 at 12:10 p.m. E2 DON (Director of Nursing) stated E1 called E2 on 2/23/14 approximately 5-6:00 p.m. and reported to E2 that the emergency room had reported to the facility "potential abuse, bruising" to R1. E2 stated E2 began getting statements from staff on 2/24/14. On 2/27/14 at 12:30 p.m. E11 (Case Manager) stated E1 called E11 on 2/23/14 at approximately 7:30 p.m. and asked E11 to go to the hospital on [DATE] to check on the status of R1's "bruising or redness to R1's peri area." On 2/27/14 at 2:13 p.m. E6 (Nursing Supervisor) stated E5 LPN (Licensed Practical Nurse) reported to E6 on 2/23/14 at approximately 2-2:30 p.m. that the hospital had called and reported bruising to R1's genitalia. E6 stated E6 immediately called E1 to report the bruising. E6 stated E6 was not asked by the facility until 2/27/14 to write a statement regarding R1's recent admission to the hospital and the bruising to R1's vaginal area. 2. R2's nursing notes, dated 2/9/14 at 3:00 p.m., document R2 "complained of staff rushed her and too rough with cares this a.m. Rough with my legs when getting in chair and wiped my bottom too hard. She knows she was too rough because I cried at the time. You won't send her back to my room again?" This nursing note was signed by E5 LPN (Licensed Practical Nurse). R2's most recent MDS (Minimum Data Set), dated 2/13/14, documents R2's BIMS (brief interview for mental status) score was 15/15. The facility provided a list of interviewable residents, with R2 being indicated as interviewable. On 2/27/14 at 10:10 a.m. R2 stated, "some CNA's (Certified Nursing Assistants) are rough, sometimes it causes bruising. One CNA was rough when cleaning me and I cried. I don't want her taking care of me. When CNA's are rough I have reported it to the nurse." R2 would not give surveyor names of staff. On 2/27/14 at 1:45 p.m. E5 LPN stated E5 viewed the incident on 2/9/14 for R2 as potential abuse. E5 stated reporting it to E6 (Nursing Supervisor) on 2/9/14 and filling out an incident report. E5 stated the CNA in question for the alleged abuse was E12 CNA (Certified Nursing Assistant). On 2/27/14 at 2:13 p.m. E6 (Nursing Supervisor) stated "vaguely" recalling the incident on 2/9/14 for R2. E6 stated not being aware a CNA was too rough until 2/10/14. E6 stated interviewing R2 to find out who the CNA in question of being rough was. E6 said R2 stated "it was a black CNA on night shift?" E6 stated "there are 3 black CNA's on night shift so I did not know which one it was?" I did not do any interviews or investigate any further. E6 stated the incident was not reported to E1 (Administrator). On 2/27/14 at 2:30 p.m. E1 stated the incident on 2/9/14 involving R2 was not reported to E1 and E1 was unaware it occurred. On 3/3/14 at 12:40 p.m. an Immediate Jeopardy was identified to have begun on 2/9/14 when R2 complained of staff rushing her, being too rough with cares, and wiping R2's bottom too hard, causing R2 to cry; the allegation was not reported to E1 or IDPH; and no investigation was initiated. E1 was notified of the Immediate Jeopardy on 3/3/14 at 12:40 p.m. The surveyor confirmed through interview and record review that the following actions were taken to remove the Immediate Jeopardy. : 1. The staff members involved with the alleged potential abuse that occurred on 2/9/14 were suspended. The staff member who did not report the incident was suspended on 2/27/14. The alleged abuser was suspended on 3/3/14. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 2. Residents in the facility with a BIMS score of 7 or above and considered interviewable were questioned regarding care being given by staff and the possibility of staff being rough or verbally rude. The results of the interviews will potentially lead to additional allegations and disciplines. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 3. All residents have been assessed for the potential to be abused or be abused upon admission and every 90 days. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 4. The facility's abuse policy and procedures have been revised to indicate the immediacy of reporting to IDPH. Completed 3-3-14 at 4:45 PM. Responsible party: E1/Administrator 5. All management. licensed and supervisory staff inservicing was initiated on how and to whom to report abuse. As each shift reports for duty, they will be inserviced prior to reporting to their assigned unit. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-7-14. Responsible party: Administrator 6. All staff are being inserviced with training on abuse and neglect to encompass all staff, all shifts and all departments. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-7-14. Responsible party: Administrator 7. The facility is providing re-inservicing on mechanical lift transfers to all units and shifts. Initiated: 3-3-14 at 4:45 PM. To be completed with all staff by 3-5-14. Responsible party: Administrator

Based on interview and record review, the facility failed to attach all straps of the mechanical lift sling prior to transferring R2 and failed to have two staff present as specified in the care plan when transferring R1 with the mechanical lift. This involves two of four residents (R1, R2) transferred with the mechanical lift in the sample of twelve. R2 fell from the lift pad during the mechanical lift transfer sustaining a Right Clavicle and Right Orbital Fracture. R1 sustained a black eye. Findings Include: 1. R2's Quarterly Minimum (MDS) data set [DATE] documents that R2 is alert and oriented. This same Minimum Data Set identifies R2 as totally dependent on staff for transfers, locomotion on and off unit with wheelchair and for personal hygiene including bathing. The Care Plan dated 12/21/11 documents that R2 demonstrates decreased physical mobility and requires Mechanical Lift with 2:1 assist for transfers. The Goal is that R2 will transfer with mechanical lift safely with 2:1 staff. The Approaches are: explain task to resident, Monitor for safety when (R2) is transferring with mechanical lift, 2:1 for mechanical lift transfers and calm approach. The Event Report dated 9/8/11 3:55 PM, documents that R2 was observed on the floor on right side with head on the mechanical lift leg. R2 was bleeding from right side of head near right eye. The Investigation report of 9/8/11 documents that : Resident was being transferred with mechanical lift and two staff assist. Staff did not use the side straps of the sling because of not being used. Resident fell side ways out of the sling to the floor landing on the mechanical lift legs causing a laceration to right eye. The investigation report was faxed to IDPH on 9/9/11. The nurses notes dated 9/8/11 at 10:00 PM document that R2 was sent to hospital in Peoria and returned on 9/9/11 at 10:00 PM. The hospital History and Physical dated 9/8/11 under Assessment and Plan documents that R2 sustained right orbital fracture and facial fractures with exophthalmia and concern for entrapment of the Extra Ocular Movements. Imaging and physical examination revealed a distal clavicle fracture. R2's "clavicle fracture may require future surgical repair, but only after her facial/ophthalmologic injuries have healed. Follow up appointments: Future orthopedic consult for clavicle fracture and plastic surgery consult for facial repair after facial/orbital lesions significantly improve." On 2/1/12 at 3:05 PM, E14/Certified Nurse Aide stated that he was told not to use the middle strap because R2 complains that it is too tight. E14 stated that he did not know where to hook the middle straps. Most lift pads have four straps two at the top and two at the bottom. R2 had two straps in the middle, one on each side. E14 stated that CNA training only taught the basic mechanical lift transfers. "It did not train us on all types of lift pads." E14 stated that when E15/Certified Nurse Aide mechanically lifted R2 "in the air and pulled her out of bed, I was getting in position to help pull her over to the chair, (R2) fell out of the sling hitting her head on the bottom bar of the mechanical lift." On 2/1/12 at 3:30 PM, E15 stated that she and E14 were using the full body lift pad with the mechanical lift and "did not know where to hook the middle straps to the lift, so they left them off." E15 stated that when she lifted R2 up to put her in the chair, before E14 could get a hold of R2, R2 fell out of the lift pad and onto the floor hitting her head on the bottom of the lift. On 2/1/12 at 10:00 AM, E1/Administrator stated that E14 and E15 did not transfer R2 according to the plan of care and using the mechanical lift sling properly. 2. R1's quarterly Minimum (MDS) data set [DATE] documents that R1 is severely cognitively impaired. This Minimum Data Set notes that R1 requires extensive assist with bed mobility, transfers, locomotion on and off the unit with a wheelchair, dressing, eating and personal hygiene. R1's care plan dated 12/9/11 documents that R1 requires staff assist for his Activities of Daily Living, R1 can become combative with cares. The approach documents for staff to complete Activities of Daily Living. If combative leave and reapproach. The Problem: Behavior documents that R1 has severe Dementia. As a result he doesn't understand when staff in-forms of cares being performed. He then reacts to his reality. The Goal is to redirect from grabbing staff inappropriately. The Approach: Use two staff if able with cares, talk to R1 in a calm voice for redirection, identify behavioral triggers and 1 to 1 assist when needed. The problem Fall: documents that R1 requires 2:1 mechanical lift assist for transfers. He becomes anxious at times grabbing at staff, resident is propelled per staff or wife. R1 has a chair/bed alarm in place. One of the approaches is: 2 to 1 staff for mechanical lift transfer. The Event Report dated 1/23/12 2:30 PM documents that R1 was put to bed with mechanical lift. R1 has a black lift eye, puffy under eye and black and blue, slight abrasion on side of left eye. On the Investigation Report dated 1/24/12 at 10:00 AM, E21(Licensed Practical Nurse) documents that at lunch when E20 (Certified Nurse Aide) fed him, there was no red area or puffiness under left eye. E21 stated that E8 (Certified Nurse Aide) put R1 to bed about a half hour after lunch and reported to E21 that she thinks R1 is getting a black eye. On 1/24/12, E22(Licensed Practical Nurse) stated that on the morning of 1/23/12 R1 was not cooperating in the shower room. R1 grabbed E23's(Certified Nurse Assistant) left arm. E23 put light on and came to get E22. E22 stated that she went into shower room and told E23 to give a bed bath if R1 wouldn't cooperate. E22 stated that R1 did not have any injuries to his left eye at that time. On 1/25/12, E23 stated that R1 was combative and falling out of chair in shower room with her and agency CNA. E23 stated that she did not see him get any injury. E23 stated that when she left at 1:30, R1 was sitting in the recliner chair in the hallway and he had no injury to his face. E23 stated that she asked E8 (CNA) if she wanted help with R1 and E8 said no that she could get him. E23 stated that R1 had no injury from 5:00 AM to 1:30 PM when she left. On 2/1/12 at 10:30 AM, E8 (CNA) stated that on 1/23/12, she was in a meeting all morning. E8 stated that she got to the floor around 1:00 PM. R1 was seated outside another resident's room which was not normal. R1's wife always leaves R1 outside his room after lunch. E8 stated that she pushed recliner into R1's room and saw that he had a black eye. E8 stated that she tried to find E21(LPN) to report it to her, but couldn't. E8 stated that she couldn't find E22(CNA) to help, she left at 1:30PM. E8 stated that R1 is supposed to be 2:1 mechanical lift transfer, but E8 put him to bed by herself. At that time R1's eye was dark blue. E8 stated that she reported it to E21 shortly after putting R1 to bed. E8 stated as far as she knows she did not bump R1 with mechanical lift. E8 stated that she asked E9 (CNA) to say she was in the room during the transfer because she didn't want to get in trouble for transferring R1 with mechanical lift by herself. On 2/1/12 at 11:15 AM, E9 (CNA) stated that on 1/25/12, E8 called and asked E9 to say she was in the room during mechanical lift transfer of R1 because E8 didn't want the facility to know she transferred R1 alone. E9 stated that she told E8 that she was not even in the facility that day and she couldn't lie for her. On 2/1/12 at 3:30 PM, E1 stated that R1 is a 2:1 mechanical lift transfer. E1 stated that R1 did not have a black eye on 1/23/12 until 1:30 PM. E1 stated that E8 improperly transferred R1 by mechanical lift by herself. E1 stated that R1's eye would be in line with the mechanical lift arm with bar that swings if you don't have a second person to hold onto it. E1 stated that the care plan specifies to use 2:1 to transfer R1 with the mechanical lift.