Every finding on record at Imboden Creek Senior Living

Based on observation, interview, and record review, the facility failed to implement fall interventions for four of five residents (R3, R1, R4, R5) reviewed for falls in the sample list of five. This failure resulted in R3 sustaining a laceration and requiring sutures. Findings include:1.) R3's Minimum Data Set (MDS) ,dated 7/31/26,documents R3 is cognitively intact.R3's Care Plan, dated 7/1/26, documents R3 is at risk for falls, with interventions including R3's call light needs to be within reach and R3 needs assist with ambulation, transfers, and locomotion on and off the unit. R3's Care Plan, dated 8/12/2026, documents a call don't fall sign is to be placed in R3's room as a reminder to call for help. On 8/25/2026 at 9:35 AM, there was no call don't fall sign in R3's room. On 8/25/2026 at 9:35 AM, R3 stated on 8/11/2026, R3 stood up from R3's wheelchair to reach the call light. R3 stated the call light was not in reach. R3 stated the call light was between the recliner and the bed. R3 stated R3 became dizzy and fell backwards. R3 hit R3's head on the floor and sustained a laceration that required suturing. R3 stated if the call light had been in reach, R3 would not have fallen. R3 stated R3 felt helpless when R3 could not ask for assistance. R3 stated R3 requires assistance getting into wheelchair, toileting and getting dressed.On 8/25/2026 at 11:30 AM, V8 (Power of Attorney, POA for R3) stated on 8/11/26, R3 reached for the call light, but it was out of reach. V8 stated R3 tripped on the wheelchair footrest trying to reach the call light and fell backwards.On 8/25/2026 at 12:00 PM, V9 (Nurse Practitioner, NP) stated R3 sustained a laceration from the fall that occurred on 8/11/2026.On 8/25/2026 at 12:10 PM, V6 (Licensed Practical Nurse, LPN) stated all residents should be able to reach their call light. V6 stated a fall could occur if a resident cannot reach their call light or be able to ask for assistance. V6 stated R3 had been complaining of lower extremity weakness and R3's legs giving out. V6 stated R3 is not safe to transfer independently and requires assist of one staff.On 8/25/2026 at 12:25, V11 (LPN) stated R3's inability to reach a call light would contribute to a fall.On 8/25/2026 at 1:00 PM, V14 (Director of Rehabilitation) stated R3's inability to reach the call light when needing assistance can result in a fall. V14 stated R3 is an assist of one with transfers and mobility.2.) R1's MDS, dated [DATE], documents R1 is cognitively intact. R1's Care Plan, dated 10/28/25, documents R1 is at risk for falls and requires assistance with transfers and ambulation. R1's Care Plan, dated 8/3/26, documents R1 is to have a call don't fall sign in the room as a reminder to ask for assistance before ambulating alone. On 8/25/2026 at 1:45 PM and at 3:00 PM, R1 did not have a call don't fall sign in R1's room On 8/26/2026 at 9:00 AM, R1 did not have a call don't fall sign in R1's room. At this time, V12 (Licensed Practical Nurse, LPN) confirmed the call don't fall sign was not in R1's room. On 8/27/2026 at 9:00 AM, R1 did not have a call don't fall sign in R1's room. 3.) R4's MDS, dated [DATE], documents R4 is cognitively intact. R4's MDS, dated [DATE], documents R4 is dependent on staff for transfers. R4's Care Plan, dated 2/7/26, documents R4 is at risk for falls related to deconditioning and gait/balance problems with an intervention to have the call light within reach and encourage to R4 to use the call light for assistance as needed. R4 needs prompt response to all requests for assistance. On 8/25/2026 at 9:45 AM, R4's call light is tied to the bed rail on the side next to the wall. The bed is pushed against the wall, and the call light is not in reach. R4 stated R4 is unable to reach the light. R4 stated not being able to reach the call light makes R4 feel ignored. R4 stated R4 has to yell for help, and this is unacceptable. 4.) R5's MDS, dated [DATE], documents R5 is severely cognitively impaired. R5's MDS, dated [DATE], documents R5 transfer assistance is partial to moderate assist. R5's Care Plan, dated 6/24/25, documents R5 is at risk for falls with an intervention to be sure R5's call light is within reach and encourage to use it for assistance as needed. On 8/25/2026 at 8:40 AM and at 10:30 AM, R5 was in a wheelchair in R5's room, the call light was between the wall and R5's bed, out of reach. On 8/25/2026 at 10:30 AM, V15 (Certified Nursing Assistant, CNA) stated R5 will yell when R5 needs assistance. On 8/25/20926 at 1:15 PM, V2 (Director of Nursing, DON) stated the expectation is for all residents to always have their call light within reach in case they need something. V2 stated falls are a consequence of residents not being able to communicate needs. The Facility Call Light Use/Response Policy, dated 3/20/24, documents the individual that assists a resident to their room or provides direct care, should ensure the call light is in comfortable reaching distance for the resident whether in bed or up in the chair.

Based on interview and record review, the facility failed to ensure residents were free from verbal abuse from facility staff members for one (R2) of five residents reviewed for abuse in the total sample list of six. This failure resulted in R2 being made to feel pressured, outnumbered, and extremely insignificant. Findings include:R2's Minimum Data Set (MDS), dated [DATE], documents R2 has diagnoses including Frontal Lobe and Executive Function Deficit Stroke, Atrial Fibrillation, Cerebrovascular accident (CVA), and Hemiparesis. R2's Electronic Medical Record (EMR) documents an admission date of 01/17/2025.R2's Minimum Date Set (MDS), dated [DATE], documents R2 is cognitively intact.R2's Progress Note written by V2, Director of Nursing, dated 6/18/2026, documents R2 was transferred to the Emergency Department for further evaluation and treatment related to possible infection. On 6/30/2026 at 10:30 AM, R2 stated R2 was sent to the hospital on 6/18/26 because R2 was not feeling well and the staff were informing R2 that R2 was not looking well. R2 stated R2 agreed to go to the hospital but not by ambulance. R2 stated R2 did not want to incur more charges with the ambulance company. R2 stated R2 was treated at the local hospital emergency department for low potassium and was to be returned to the facility. R2 stated R2 was told R2 would not be allowed back to the facility as there were no available beds. R2 stated V1, Administrator, and V2 came to the hospital on 6/25/26. R2 stated V15, Company Owner, and V17, Corporate Administrator, were on V1's phone on speaker. R2 stated V1 and V2 were verbally abusive. R2 stated V1 and V2 yelled at R2. R2 stated V1, V2, V15, and V17 stated R2 could not return to the facility. R2 stated V1 and V2 were rude. R2 stated V1, V2, V15, and V17 claimed R2 had behavioral issues, owed the facility a lot of money, and stated R2 was a bad person. R2 stated R2 felt pressured and outnumbered. R2 stated R2 felt terrible, awful, and two inches tall. R2 stated R2 never told the staff R2 did not want to come back until V1, V2, V15, and V17 told R2 they did not want R2 back. R2 had no difficulty hearing during this interview.On 6/30/2025 at 12:13 PM, V2 stated V2 sent R2 to the hospital on 6/18/26 because R2 had become weak, dizzy, and appeared pale.On 6/30/2026 at 10:40 AM, V8 (hospital Licensed Social Worker) stated R2 was transported to the hospital on 6/18/26 by private transportation. V8 stated R2 was initially evaluated for sepsis but was found to have a low potassium level. V8 stated the emergency department treated R2 and R2 was stable to return to the facility. V8 stated the facility refused to accept R2 back. V8 stated V2 came to the emergency room to have R2 sign a bed hold form. V8 stated V2 was rude, unpleasant, and harassed R2 in the waiting room of the emergency department. V8 stated the facility refused to take R2 back because R2 owed the facility a lot of money. V8 stated they informed the facility the hospital had no diagnosis to admit R2 to the hospital. V8 stated R2 stated R2 wanted to return to the facility until R2 was told R2 could not. V8 stated on 6/25/26, V1 and V2 came to the hospital to talk to R2. V8 stated they were told they were going to discuss R2's return to the facility. V8 stated V1 started telling R2 that R2 owes a lot of money to the facility and that is why R2 could not come back. V8 stated V1 asked if the conversation could be recorded and V8 stated no. V8 stated V1 put V15 and V17 on speaker phone. V8 stated V8 could not verify it was V15 and V17, but they identified themselves as V15 and V17. V8 stated V1 and V2 were aggressive and yelled at R2 about behaviors and were citing various incidences with R2. V8 stated they tried to redirect the conversation to a lower tone and back to the subject of R2 returning to the facility. V8 stated R2 stated feeling R2's rights were violated and R2 felt harassed. V8 stated V1 and V2 were harassing R2 and were trying to convince R2 not to want to come back. V8 stated the interaction was not therapeutic, V1 and V2 were listing off negative encounters with R2 and not discussing return to the facility. V8 stated the conversation was going nowhere so V8 terminated the visit and asked V1 and V2 to leave.On 6/30/2026 at 12:30 PM, V9 (hospital Licensed Social Worker) stated staff from the facility returned on 6/25/26 to deliver a letter to R2. V9 was on call on the night of 6/18/26 when R2 was brought to the emergency room for evaluation. V9 stated V2 was very rude and demanding to R2.On 6/30/2026 at 1:02 PM, V10 (hospital Case Manager) stated when R2 was ready to discharge and return to the facility, V2 stated the facility would not take back R2 and R2 knew why. V10 stated on 6/22/26, V1, V2, and V12, facility Social Services, came to the hospital to deliver a letter to R2 listing reasons why R2 cannot come back. V10 stated V1 and V2 returned to the hospital on 6/25/26 to discuss with R2 about R2's return to the facility. V10 stated V1 called V15 and V17. V10 stated V1 and V2 began to tell R2 all the problems R2 has caused for the facility. V10 stated R2 became very upset. V10 stated V1 and V2 stated R2 could return if R2 paid on R2's bill. V10 stated V1 and V2 were unpleasant to R2. V10 stated V8 asked them to leave.On 7/1/2026 at 12:35 PM, V1 stated V1 and V2 went to the hospital on 6/25/26 to talk to R2. V1 stated V15 and V17 were on the phone on speaker. V1 asked V8 if they could record the conversation and V8 stated it was against hospital policy. V1 stated V1 went through the letter that was written to R2. V1 stated V2 went through the bullet points of what got them to this point. V1 stated V1 asked R2 how R2 was going to change R2's behaviors. V1 stated they had to yell at R2 because R2 is heard of hearing. V1 stated V8 asked them to stop yelling and to calm down.R2's Progress Note, dated 6/18/2026 at 6:27 PM written by V2, documents V2 visited resident at a local hospital to provide the Bed Hold Policy and Bed Hold Notification form.R2's Progress Note, dated 6/22/2026 at 5:11 PM written by V1, documents V1 and V12 delivered a formal notification the facility will not accept R2 back to the facility.R2's Progress Noted, dated 6/25/2026 at 4:13 PM written by V1, documents V1 and V2 visited R2 at the hospital.The Facility's Abuse Prevention Policy and Procedure, dated 08/16/2025, documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This facility is committed to protecting our residents from abuse by anyone including, but no(t) limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. This facility will not knowingly employ individuals who have been convicted of abusing, neglecting, or mistreating individuals.

Based on interview and record review, the facility failed to provide a safe and planned discharge to an appropriate facility for one (R2) of three residents reviewed for inappropriate discharge in the sample list of six. Findings include:R2's Minimum Data Set (MDS), dated [DATE], documents R2 has diagnoses of Frontal Lobe and Executive Function Deficit Stroke, Atrial Fibrillation, Cerebrovascular accident (CVA), and Hemiparesis. R2's Electronic Medical Record (EMR) documents an admission date of 01/17/2025.R2's Minimum Date Set (MDS), dated [DATE], documents R2 is cognitively intact.R2's Progress Note written by V2, Director of Nursing, dated 6/18/2026, documents R2 was transferred to the Emergency Department for further evaluation and treatment related to possible infection. On 6/30/2026 at 10:30 AM, R2 stated R2 was sent to the hospital on 6/18/26 because R2 was not feeling well, and the staff told R2 that R2 did not look well. R2 stated R2 agreed to go to the hospital but not by ambulance. R2 stated R2 did not want to incur more charges. R2 stated R2 was treated at the local hospital emergency department for low potassium and was to be returned to the facility. R2 stated R2 was told R2 would not be allowed back to the facility as there were no available beds. R2 stated V1, Administrator, and V2, Director of Nursing, came to the hospital on 6/25/26. R2 stated V15, Facility Owner, and V17, Corporate Administrator, were on V1's phone on speaker. R2 stated V1 and V2 were verbally abusive. R2 stated V1 and V2 yelled at R2. R2 stated V1, V2, V15, and V17 stated R2 could not return to the facility. R2 stated V1 and V2 were rude, claimed R2 had behavioral issues, owed the facility a lot of money, and stated R2 was a bad person. R2 stated R2 felt coerced, pressured and outnumbered. R2 stated R2 felt terrible, awful, and two inches tall. R2 stated R2 never told the staff R2 did not want to come back until V1, V2, V15, and V17 told R2 they did not want R2 back. R2 stated R2 never notified the facility R2 was not planning to return.R2's facility bed was unoccupied on 6/30/26 and 7/1/26 and R2 had no issues with hearing during a telephone interview on 6/30/26.On 6/30/2026 at 1:43 PM, V1 (Administrator) confirmed all 95 beds in the facility are dually (Medicare/Medicaid) certified.On 6/30/2026 at 10:40 AM, V8 (hospital Licensed Social Worker) stated R2 was transported to the hospital on 6/18/26 by private transportation. V8 stated R2 was initially evaluated for sepsis but was found to have a low potassium level. V8 stated the emergency department treated R2 and was stable to return to the facility. V8 stated the facility refused to accept R2 back. V8 stated V2 came to the emergency room to have R2 sign a bed hold form. V8 stated V2 was rude and unpleasant and harassed R2 in the waiting room of the emergency department. V8 stated the facility refused to take R2 back because he owed a lot of money. V8 stated they informed the facility the hospital had no diagnosis to admit R2 to the hospital. V8 stated R2 stated R2 wanted to return to the facility until R2 was told R2 could not.On 7/1/2026 at 3:20 PM, V8 stated V15 had been on the phone with R2 on 6/25/25, and V15 sounded aggressive and was attacking R2 regarding R2's past behaviors. V8 stated the meeting was misrepresented; V8 was told this meeting was to discuss R2's return to the facility but instead it was more of a reprimand and the visit was terminated.V8 stated V1 and V2 came to the hospital to talk to R2 on 6/25/26. V8 stated they were told they were going to discuss R2's return to the facility. V8 stated V1 started telling R2 that R2 owes $123,000 to the facility and that is why R2 could not come back. V8 stated V1 asked if the conversation could be recorded and V8 stated no. V8 stated then V1 had V15 and V17 on speaker phone. V8 stated V8 could not verify that it was V15 and V17, but they identified themselves as V15 and V17. V8 stated V1 and V2 were harassing R2 and were trying to convince R2 to not want to come back. V8 stated the interaction was not therapeutic; V1 and V2 were listing off negative encounters with R2 and not discussing return to the facility. V8 stated the conversation was going nowhere so V8 terminated the visit and asked V1 and V2 to leave. V8 stated R2 was only admitted to the hospital because the facility refused to pick up or allow R2 back into the facility. On 6/30/2026 at 12:13 PM, V2 stated V2 sent R2 to the hospital because R2 had become weak, dizzy, and appeared pale. V2 stated R2 had an episode similar to this before and refused to be evaluated at the hospital, but on the 18th, R2 agreed to go because of a possible infection. V2 stated V2 went to the local hospital when R2 was in the emergency room to have R2 sign a bed hold agreement. V2 stated R2 refused to sign it. V2 stated when R2 refused to sign the form, V2 left. V2 stated V1 and V2 went to see R2 in the hospital on 6/25/26, V2's role was to have R2 sign the bed hold form. V2 stated R2 refused again. V2 stated the hospital called at 2:00 AM on 6/19/26 for R2 to return to the facility and V2 refused to let R2 return at that time.On 6/30/2026 at 12:30 PM, V9 (hospital Licensed Social Worker) stated V9 was on call on 6/18/26 when R2 was in the emergency room. V9 stated they were alerted to a situation when the emergency room nurse tried to return R2 to the facility around midnight. V9 stated R2 was brought to the emergency room for septic-like symptoms and was treated for low potassium. V9 stated R2 was treated and was stable to return to the facility. V9 stated when the emergency room called the facility, the hospital was told R2 was not welcomed back and R2 knew why. V9 stated V2 was rude. V9 stated V2 told V9 it was illegal to disclose why R2 could not come back and if the hospital sent R2 back to the facility, V2 will call the police. V9 stated R2 wanted to return to the facility. V9 stated staff from the facility returned on 6/25/26 to deliver a letter to R2. V9 stated the hospital made multiple calls to the facility and had a difficult time getting ahold of anyone.On 6/30/2026 at 1:02 PM, V10 (hospital Case Manager) stated when R2 was ready to discharge and return to the facility, V2 stated the facility would not take back R2 and R2 knew why. V10 stated V1, V2, and V12 came to the hospital on 6/22/26 to deliver a letter to R2 listing reasons why R2 could not go back. V10 stated V1 and V2 returned to the hospital on 6/25/26 to discuss with R2 about R2's return to the facility. V10 stated V1 and V2 began to tell R2 all the problems R2 has caused for the facility. V10 stated R2 became very upset. V10 stated V1 and V2 stated R2 could return if R2 paid on R2's bill. V10 stated V1 and V2 were unpleasant to R2. V10 stated V8 asked them to leave.On 7/1/2026 at 9:00 AM, V12, facility Social Services, stated V12 went to the hospital with V1 to deliver a letter and have the resident sign a bed hold form. V12 stated V12 did not fully understand what a bed hold form was. V12 was unable to explain what the bed hold policy was and what the form meant. V12 stated R2 refused to sign the form. V12 stated R2 had no difficulty hearing at normal volume. V12 stated R2 never stated R2 did not want to come back.On 7/1/2026 at 12:35 PM, V1 stated V1 and V2 went to the hospital on 6/25/26 to talk to the resident. V1 stated V15, facility owner, and V17, Corporate Administrator, were on the phone on speaker. V1 asked V8 if they could record the conversation and V8 stated it was against hospital policy. V1 stated V1 went through the letter that was written to R2. V1 stated V2 went through the bullet points of what got them to this point. V1 stated V1 asked R2 how R2 was going to change R2's behaviors. V1 stated they had to yell at R2 because R2 is heard of hearing. V1 stated V8 asked them to stop yelling and to calm down. V1 stated R2 was argumentative despite being offered financial assistance from V15. V1 stated V1 reiterated the bill that R2 has acquired during his stay at the facility. V1 stated V2 read the letter to the resident. V1 stated V1 told R2 that R2 had to make changes and pay towards the bill before R2 can return. V1 stated when residents leave the facility briefly for an outing, doctor's appointment, or a medical evaluation, a bed hold form is not typically necessary.On 7/2/2026 at 10:11 AM, V21, Corporate Nurse, stated R2 stated at the hospital R2 was not going to return to the facility. V21 stated based on R2's statement and request to not return, R2 was appropriately discharged from the facility. V21 stated a Quality Assurance and Performance Improvement was completed for R2's discharge. V21 stated when R2 decided not to return to the facility, V21 considered R2 self-discharged . V21 stated R2 was never offered to sign a Leave Against Medical Advice ([NAME]) form.R2's Progress Noted, dated 6/18/2026 at 3:48 PM written by V2, documents V1 and V12 met with R2 regarding concerns for possible infection. R2 was educated on the signs and symptoms of infection and the potential risks of untreated infection, including worsening illness and hospitalization. R2 was informed that nursing staff have a responsibility to advocate for R2's health and well-being and to recommend appropriate medical evaluation when clinically indicated. After discussion and education, R2 verbalized understanding of the risks associated with delaying treatment and agreed to be transferred to the Emergency Department for further evaluation and treatment.R2's Progress Note, dated 6/18/2026 at 3:57 PM written by V2, documents R2 was pale, had altered mental status, and was lethargic.R2's Progress Note, dated 6/18/2026 at 6:27 PM written by V2, documents V2 visited R2 at the hospital to provide the Bed Hold Policy and Bed Hold Notification form.R2's Progress Note, dated 6/22/2026 at 3:23 PM written by V12, documents a delivery of formal notification that R2 will not be accepted back to the facility.R2's Progress Note, dated 6/22/2026 at 5:11 PM written by V1, documents V1 and V12 delivered a formal notification that the facility will not accept R2 back to the facility upon discharge from the hospital.R2's Progress Note, dated 6/25/2026, documents R2 continued to refuse to sign a Bed Hold Agreement.R2's Care Plan, dated 2/4/2026, I (R2) wish to discharge to another facility or in the community at a future date of my (R2) choosing. This Care Plan documents an intervention of Referrals will be made to facilities of my (R2) choice. The facility will keep me (R2) updated with referral responses from facilities that I (R2) choose.R2's Progress Note, dated 6/30/2026 at 12:20 PM, documents R2's belongings were picked up by R2's pastor.The Facility Bed Hold Policy dated March 2017 documents Private Pay residents who decide not to sign the bed hold/ transfer letter, pay the bed hold per diem at 100% of the daily rate charge, or communicate to the facility they will not be returning to the facility will be discharged from the facility after being advised in writing of any action that must be taken to hold the bed while hospitalized or to seek a new episode stay.

Based on observation, interview, and record review, the facility failed to perform incontinence care in a manner to prevent infection and potential skin irritation for three (R8, R19, R23) of three residents reviewed for incontinence care in a sample of 23 residents. Findings include: 1. On 6/9/26 at 1:25 PM, V18, Certified Nurse Aide (CNA), and V16, CNA, provided incontinence care to R8. V18 and V16 began the care by pulling down R8's urine saturated incontinence brief and pants. V18 then wiped R8's perineal area once with an incontinence wipe. V18 did not wipe in between R8's labia folds or clean R8's thighs. After they were finished providing the incontinence care to R8, they pulled up R8's urine saturated incontinence brief and then pulled up R8's pants. V18 and V16 then placed R8 back into R8's recliner. On 6/10/2026 at 2:00 PM, V18, Certified Nursing Assistant (CNA), stated the whole peri-area should be cleansed when doing incontinence care. 2. On 6/9/2026 at 1:55 PM, V18, CNA, removed R19's soiled adult incontinent brief. R19 was lying on R19's back. V18 CNA cleansed the front groin, inner thighs, penis and scrotum appropriately using moistened care wipes. V18 then turned R19 on to R19's right side and cleansed R19's rectal area and left buttock. V18 then applied a clean adult incontinent brief and rolled R19 onto R19's back and covered R19 up. V18 did not cleanse R19's right hip, thigh or buttock. R19's MDS, dated [DATE], documented R19's cognition was not intact. It also documented R19 was always incontinent of urine and feces. It also documented diagnoses of Spinal Stenosis and Dementia with Agitation. R19's Care plan, dated 6/18/2025, documented, Observe for incontinent episodes and provide care. 3. On 6/10/2026 at 11:36 AM, V22, CNA, removed R23's urine soiled adult incontinence brief. V22 then used a moistened care wipe and cleaned front to back, the center of R23's labia, once, without cleansing R23's bilateral groins or thighs. R23's MDS, dated [DATE], documented R23's cognition was intact. It also documented R23 was always incontinent of urine and feces. It also documented diagnoses of Parkinson's Disease and Dementia. R23's Care plan, dated 7/23/2024, documented, TOILET USE: The resident requires assistance adjust clothing, cleaning self, transfer onto toilet, transfer off toilet to use toilet. On 6/10/2026 at 11:25 AM, V23, CNA, stated when doing incontinence care, all areas are cleansed including the groin and inner thighs. On 6/10/2026 at 11:40 AM, V22, CNA, stated all areas are cleansed when performing incontinence care. The facility's policy, Perineal Care, undated, documented, The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. It continued, For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. B. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about three inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs, Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. (4) Gently dry perineum. It continues, m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly.

Based on interview and record review, the facility failed to implement their abuse policy related to misappropriation of funds for one (R2) of six residents reviewed for abuse in a sample of 23 residents.Findings include:The facility's policy, Abuse Prevention and Policy, dated 8/16/2026, documented, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents.R2's Minimum Data Set, dated [DATE], documents R2's cognition is intact.On 6/8/2026 at 10:30 AM, R2 stated R2 had kept R2's debit card in R2's drawer and no one had access to it. R2 stated R2 cancelled the card on 5/21 or 5/22/26. R2 said R2 gave R2's debit card to a V3, CNA (Certified Nurse Assistant), who works at the facility to buy R2 some orange slices at a local store. V3, CNA, got the candy for R2 around the beginning of May, and V3 brought the card back with the receipt. But there has been over $10,000 taken out of R2's account prior to V3 going to the store for R2. R2 stated R2 noticed on 5/22/2026 the money was missing when R2 called and ordered pizza from a local pizza restaurant and R2's card was declined. R2 called the bank and got R2's debit card shut off. R2 stated R2 does not do online shopping but will call for food to be delivered. R2 stated R2 would give his friend (V9) his debit card and V9 knows the pin but V9 is the only one who has R2's pin number. R2 stated V9 brought R2 in a new phone and V9 has R2's new debit card and pin number. R2 stated R2 had never given out R2's pin number to the staff and that the friend was the only one who had it. R2 stated when R2 had V3 go to a local store for R2, that was the only time R2 gave R2's card to a staff member.On 6/8/2026 at11:15 AM, V1, Chief Operations Officer, stated V1 has started the investigation into R2's allegation today (6/8/2026) and stated the current interim Administrator was made aware of it last Monday (6/1/26), but thought it was related to R2's billing, but R2 didn't pay anything, and no investigation was started.On 6/8/2026 at 11:40 AM, V3, Certified Nursing Assistant (CNA, stated V3 has been employed by the facility for three years. V3 stated V3 knew R2 from a different facility. V3 stated R2 asked V3 when V3 was going on break and asked if V3 wanted pizza because R2 was buying pizza for the staff that day. V3 stated V3 was going to go to a local restaurant to get V3's meal and R2 asked V3 if a local store was down the road and if V3 would pick R2 up some orange slices (candy). V3 stated V3 got R2 three bags of orange slices and then wrapped R2's receipt around R2's debit card and gave it back to R2. V3 stated V3 was not sure of the facility policy as to if they were allowed to go to a store if a resident asked and give them their debit card to get them something. V3 stated this was the only time V3 did this for R2 and all V3 did was run to the store and back.On 6/9/2026 at 10:40 AM, V8, Licensed Practical Nurse (LPN), stated R2 was upset and R2 told V8 that someone in the facility had been stealing money from R2's account. V8 stated V8 reported it to V10, Interim Administrator, and to V2, Director of Nurses. V8 also stated R2 has not asked V8 to get R2 anything from the store or give V8 R2's debit card.On 6/9/2026 at 11:20 AM, V2, Director of Nurses, stated V2 was made aware of R2 having money missing out of R2's account along with V10, Interim Administrator, last Monday (6/1/2026) when the nurses did morning rounds with them that day. V2 stated V2 assumed V10 started an investigation.On 6/9/2026 at12:22 PM, V10, Interim Administrator, via phone call, stated R2 told V10 the owner of the company stole R2's money out of R2's bank account, but V10 did not start an investigation because V10 wasn't aware of the money missing out of R2's bank account.R2's Progress note, dated 6/1/2026, documented R2 has been angry with staff all shift making accusation that R2 believed the facility stole money from R2's account. Management has already been notified of the behavior and the threats of calling state if R2's money hasn't been returned. No further complaints from the resident at this time was documented.R2's Local Police report, dated 6/8/2026, documented it was reported to them by V1, Chief Operations Officer, on 6/8/2026. There was no further documentation regarding statements by R2 or V3, CNA.R2's bank statement, dated 1/2026, 2/2026, 3/2026, 4/2026 and 5/2026, documented there were multiple online purchases, local restaurant purchases, and local grocery store purchases, totaling approximately $19,650. It also documented a purchase to a local store around 5/8/2026 totaling $15.05 for the candy R2 had V3, CNA, purchased for R2. There was no investigation documentation presented to the State Agency by the facility during this investigation.

Based on interview and record review, the facility failed to investigate misappropriation of property for one (R2) of six residents reviewed for abuse, in a sample of 23 residents.Findings include:On 6/8/2026 at 11:15 AM, V1, Chief Operations Officer, statedV1 has started the investigation into R2's allegation today (6/8/2026) and stated the current interim Administrator was made aware of the missing money last Monday (6/1/26) but thought it was related to R2's billing, but R2 didn't pay anything, and no investigation was started.On 6/8/2026 at 11:40 AM, V3, Certified Nursing Assistant/CNA stated V3 has been employed by the facility for three years. V3 stated V3 knew R2 from a different facility. V3 stated R2 asked V3 when V3 was going on break and R2 asked if V3 wanted pizza because R2 was buying pizza for the staff that day. V3 stated V3 was going to go to a local restaurant to get V3's meal and R2 asked V3 if a local store was down the road and if V3 would pick him up some orange slices (candy). V3 stated V3 got him three bags of orange slices and then wrapped R2's receipt around R2's debit card and gave it back to R2. V3 stated V3 was not sure of the facility policy as to if they were allowed to go to a store if a resident asks and give them their debit card to get them something. V3 stated this was the only time V3 did this for R2 and all V3 did was run to the store and back.On 6/9/2026 at 10:40 AM, V8, Licensed Practical Nurse (LPN), stated R2 was upset and R2 told V8 that someone at the facility had been stealing money from R2's account. V8 stated V8 reported it to V10, Interim Administrator, and to V2, Director of Nurses. V8 also stated R2 has not asked V8 to get R2 anything from the store or give V8 R2's debit card.On 6/9/2026 at 11:20 AM, V2, Director of Nurses, stated V2 was made aware of R2 having money missing out of R2's account along with V10, Interim Administrator, last Monday (6/1/2026) when the nurses did morning rounds with them that day. V2 stated that V2 assumed V10 started an investigation.On 6/9/2026 at 12:22 PM, V10, Interim Administrator, via a phone call, stated R2 told V10 that the owner of the company stole R2's money out of R2's bank account, but V10 did not start an investigation because V10 wasn't aware of the money missing out of R2's bank account.R2's Progress note, dated 6/1/2026, documented R2 has been angry with staff all shift making an accusation that R2 believed the facility stole money from R2's account. Management has already been notified of the behavior and the threats of calling state if R2's money hasn't been returned. No further complaints from the resident at this time.R2's Local Police report, dated 6/8/2026, documented it was reported to them by V1, Chief Operations Officer on 6/8/2026. There was no further documentation regarding statements by R2 or V3, CNA.R3's bank statements dated 1/2026, 2/2026, 3/2026, 4/2026 and 5/2026, documented there were multiple online purchases, local restaurant purchases and local grocery store purchases, totaling approximately $19,650. It also documented a purchase to a local store around 5/8/2026 with a total of $15.05 for the candy R2 had V3, CNA, purchase for R2. There was no investigation documentation presented to the State Agency by the facility during this investigation.The facility's policy, Abuse Prevention and Policy, dated 8/16/2026, documented, VI. Internal Investigation of Abuse, Neglect or Misappropriation Allegations and Response 1. All incidents will be documented, whether or not abuse occurred, was alleged or suspected. 2. Any incident or allegation involving abuse, neglect or misappropriation will result in an abuse investigation. 3. Following the Resident Protection Abuse Investigation Procedures. The appointed investigator will follow the Resident Protection Abuse Investigation Procedures, attached to this policy. The Procedures contain specific investigation paths depending on the nature of the allegation, and procedures for investigation, interview parameters, and reporting requirements.

Based on interview and record review, the facility failed to update the care plan with targeted interventions for one (R8) of three reviewed for care plan interventions following a fall on a sample list of 23 residents.Findings Include: R8's Electronic Health Record (EHR) documented R8 was admitted to the facility on [DATE] and continues to reside at the facility. According to the R8's EHR, R8 has several diagnoses including Chronic Systolic (Congestive) Heart Failure, Essential (Primary) Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery Without Angina Pectoris, Emphysema, Protein-Calorie Malnutrition, and Unilateral Primary Osteoarthritis, Right Hip, and repeated falls.On 6/9/2026 at 10:34AM, V8, Licensed Practical Nurse (LPN), stated the note V8 authored on 6/6/26 at 2:07PM was due to a conversation with R8's Power of Attorney (POA). V8 stated R8 sustained a fall on 6/1/26 or 6/2/26 at an unknown time as V8, LPN, was not at work but had read the Risk management in the medical record.On 6/9/2026 at 11:45AM, V11 (R8's) family member stated R8 fell on or about 6/2/26 and family has not seen any new fall interventions put in place for R8.On 6/9/2026 at 12:05PM, V2, Director of Nursing (DON), confirmed there is a fall investigation for 6/2/26 for R8. V2 confirmed the care plan did not contain any updates or targeted interventions following the documented fall of 6/2/26.R8's Care Plan, with an initiation date of 5/29/26, documented R8 is a fall risk. Interventions were put into place dated 6/1/26. The same document did not contain any other targeted interventions following the fall dated 6/2/26.Falls and Fall Risk, Managing policy, dated March 2018, documents under the resident centered approaches, Section 5, documents if falling occurs despite initial interventions, staff will implement additional or different interventions will be implemented.

Based on observation, interview, and record review, the facility failed to safely transfer and supervise three (R8, R19, R22) of four residents reviewed for accidents in a sample of 23 residents. Findings include: 1.R8's Electronic Health Record (EHR) documents R8 was admitted to the facility on [DATE] and continues to reside at the facility. According to R8's EHR, R8 has several diagnoses including Heart Failure, Heart Disease, Emphysema, Osteoarthritis, Hypertension, and Repeated Falls. R8's Care Plan, dated 5/29/26, documented R8 is a fall risk. R8's Minimum data Set (MDS), dated [DATE], documents R8 is not cognitively intact. On 6/9/2026 at 1:25PM, V15 and V11, R8's family members, stated R8 had to use the bedside commode. V18, Certified Nursing Assistant (CNA), and V16, Certified Nursing Assistant, came into the room to assist R8. V18 lifted R8 by R8's under arm only, and V16 lifted R8 under R8's arm while holding the gait belt. V18 and V16 transferred R8 from R8's recliner onto the bedside commode. V16 and V18 then exited the room, leaving R8 unattended. R8 made multiple attempts to stand unassisted. On 6/9/2026 at 1:28PM, V6, Licensed Practical Nurse (LPN), alerted V18, CNA, and V16, CNA, that R8 needed assistance. V18 and V16 entered R8's room. V18 then wiped R8 from front to back with a peri wipe and pulled up R8's incontinence brief, which had yellow stains in it, and pulled up R8's pants. V18 and V16 both lifted R8 under R8's arms with only V16 using the gait belt and placed R8 back into R8's recliner. On 6/9/2026 at 1:40PM, V6, LPN, stated, I would not expect (R8) to be left alone on the bedside commode the way (R8) is now. 2. On 6/9/2026 at 1:55 PM, V18, CNA, was preparing to lay R19 in bed from R19's bedside recliner. R19 was sitting on a full mechanical lift sling and leaning to the right. There was not a chair alarm present underneath the resident. V18 hooked up the full mechanical lift to the lift sling. V12, Activity Assistant, was present in the room and stated that V12 was there to assist V18. V18, CNA, operated the full mechanical lift but V12 did not support R19's body nor did V18. V12 stood off to the side of the room, by the bathroom door, during the full mechanical lift transfer. While R19 was being transferred by the full mechanical lift, the sling was swaying side to side, until R19 was lowered to the bed. R19's Minimum Data Set (MDS), dated [DATE], documented R19's cognition was not intact. It continues to document R19 required partial to moderate assistance from staff to transfer to and from a bed to a chair (or wheelchair). R19's Care Plan, dated 6/18/2025, documented, Observe for incontinent episodes and provide care. It also documented, Bed and Chair alarm for resident to alert staff of movement in room. It did not document an intervention for a full mechanical lift to be used. 3. On 6/10/2026 at 10:15 AM, V20, CNA, placed a gait belt on R22 who was sitting on the side of R22's bed. R22 was being transferred from R22's bed to the shower chair. V20 performed standby assistance, not touching or assisting R22 while R22 stood up from R22's bed. R22 was very shaky and moving very slowly. V20, CNA, stated R22 could actually transfer self with no assistance but R22 stated that R22 would not transfer by self without V20 or another CNA, to assist R22. R22's MDS, dated [DATE], documented R22's cognition was intact and that R22 required partial to maximal assistance to transfer to and from a bed to a chair (or wheelchair). R22's Care plan, dated 2/1/2026, documented, Staff to utilize the (partial full mechanical lift) machine for all transfers. On 6/10/2026 at 10:00 AM, V20, CNA, stated a gait belt should be used to transfer residents, and a full mechanical lift should be used with two CNAs with one CNA driving the lift and the other holding on to the resident in the sling. V20 also stated V20 was not aware that R22 needed a partial full mechanical lift when transferred. On 6/10/2026 at 11:25 AM, V23, CNA, stated there must be two staff members when using a full mechanical lift. One CNA working the controls on the lift and the other holding on to the resident in the sling. On 6/10/2026 at 11:40 AM, V22, CNA, stated that when using a full mechanical lift or a partial full mechanical lift, there must be two staff members when using it. One CNA is working the controls on the lift and the other holding on to the resident in the sling. On 6/10/2026 at 11:40 AM, V1, Chief Operations Officer, also stated two staff members are used when a full mechanical lift or a partial full mechanical lift is used. The facility's policy, Safe Lifting and Movement of Residents, dated 7/2017, documented, 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include Resident's preferences for assistance; Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability; Cognitive status; Whether the resident is usually cooperative with staff; and the resident's goals for rehabilitation, including restoring or maintaining functional abilities. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

Based on observation, interview, and record review, the facility failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop. These failures have the potential to affect all 61 residents residing in the facility. Findings include:1. on 5/20/2026 at 12:45PM, dishes were stacked beside and inside of the kitchen three-basin sink. V4 (Dietary Manager) was present and reported Dietary staff use the three-basin sink daily to wash, rinse, and sanitize dishes. V4 reported the drain valves on the wash and rinse basins leaked continuously and those basins will not hold water so staff must stuff towels into the drain openings and also continuously add water to effectively wash and rinse dishes. V4 reported previously sharing the sink concerns with facility managers but no repairs were pending for the sink. V4 denied the facility has any formal process to submit a work order for maintenance concerns.2. On 5/20/2026 at 12:30PM, the facility kitchen table-mounted can opener and receiver were excessively soiled with accumulations of food debris and grease that were black in coloration. Metal shavings were also present around the the cutting blade and gear of the opener. 3. On 5/20/2026 at 12:30PM, an ice scoop was stored in a plastic wall-mounted caddy located adjacent to the ice maker in the kitchen. [NAME] and green colored residue was located at the bottom of the caddy where the tip of the scoop was resting. On 5/20/2026 at 12:52PM, V4 (Dietary Manager) reported the above residue in the ice scoop caddy appeared to be like mold. The facility Room Directory (5/20/2026) documents 61 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 61 residents in the facility. Findings include:On 5/20/2026 at 12:05PM, V4 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V4 reported being the full-time manager of the facility food service (PIC) and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V4 also denied being a certified Food Protection Manager, as required, and denied any other dietary staff were certified Food Protection Managers. V4 reported the the facility Dietician does not work in the facility full-time.V4 denied:-being a Dietician;-being a Certified Dietary Manager;-having an associate's or higher degree in food service management or in hospitality;-having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting;-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager.On 5/21/2026 at 3:50PM, V4 (Dietary Manager) reported the food in the kitchen is available for all residents to eat.The Facility Assessment (2025) documents the facility's Staffing Plan includes a Certified Dietary Manager. On 5/20/2026 at 12:30-12:45PM, the facility failed to maintain functional sink basins and failed to maintain a sanitary can opener and ice scoop. The facility Room Directory (5/20/2026) documents 61 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to provide effective resident supervision to prevent repeat traumatic falls. These failures resulted in R7 experiencing 14 or more falls between November and December 2025 causing abrasions, skin tears, a hematoma, swelling, pain, and an eyebrow laceration requiring emergency transfer to the hospital for surgical repair. R7 is one of two residents reviewed for accidents on the sample list of 29.Findings include:R7's diagnosis list (1/7/2026) documents diagnoses including Metabolic Encephalopathy (brain dysfunction caused by metabolic imbalance), Convulsions, Muscle Wasting and Atrophy, Lack of Coordination, Unsteadiness on Feet, History of Falling, Neurocognitive Disorder, Dementia, Repeat Falls, Major Depressive Disorder, and Anxiety Disorder.R7's Resident Assessment (12/7/2025) documents R7 requires substantial/maximal assistance from staff for transfers, utilizes a wheelchair for mobility, and has bilateral upper extremity impairment in range of motion. R7's fall risk assessment (12/16/2025) documents R7 is at risk for falls.The facility fall log (November 2025 through January 2026) documents R7 had nine falls in the facility on the following dates: 11/14/25, 11/23/25, 12/2/25, 12/8/25, 12/12/25, 12/14/25, 12/16/25 (twice on this date), and 12/17/25. On 1/7/2026 at 2:40PM, V1 (Administrator) reported the above fall log documented all resident falls occurring during November 2025 through January 2026. On 1/9/2026 at 12:12PM, V2 (Director of Nursing) reported there were no more additional resident falls other than the ones documented on the above fall log. V2 stated, If that's what she's (V1) given you, that's all we have, we go through them every day.The facility SBAR Communication Tool to Physicians (12/28/2025) documents facility staff contacted R7's medical provider to report R7 had experienced six falls back to back in the facility over the weekend of 12/27/2025 to 12/28/2025. The same record documents R7 sustained abrasions to R7's forehead and nose, and a laceration resulting in sutures to R7's right eyebrow. Facility fall investigations (#578, #579, #580, #582) document R7 experienced five or more additional falls not reported on the above fall log. The investigations document R7 had falls on 12/23/25, twice on 12/26/25, and twice on 12/27/25.R7's Progress Notes (12/16/2025) document R7 was found by staff face down on the floor after an unwitnessed fall with a skin tear to the left arm and a goose egg to the back of the head. R7's Progress Notes (12/17/2025) document R7 complained to staff of head pain and body pain from R7's 12/16/2025 fall.R7's Progress Notes (12/23/2025) document R7 experienced a fall causing a skin tear to the right forearm. R7's Progress Notes (12/26/2025) document facility staff found R7 face down on the floor after an unwitnessed fall in front of R7's wheelchair with a bleeding laceration to the right side of the forehead and was sent by ambulance to the hospital emergency room for evaluation and treatment. R7's Fall investigation (12/27/2025) documents R7 returned to the facility from the hospital on [DATE] after R7's 12/26/2025 fall with sutures to R7's right eyebrow and orders for wound treatment.R7's Progress Notes (12/27/2025) document R7 was found by staff on the floor after having an unwitnessed fall resulting in a bleeding abrasion to R7's nose, a bleeding abrasion to R7's forehead, swelling to the right hand, and a skin tear with bleeding to the left arm.The facility Telephone Encounter (12/18/2025) documents an order from V24 (R7's Nurse Practitioner) for staff to ensure R7 is toileted frequently and R7 doesn't get up by R7's self.R7's Care Plan (November 2025 through January 2026) documents the focus area of R7 being at risk for falls and the goal of R7 to not experience any injuries related to falling. The same record documents a new intervention on 12/17/2025 as Resident (R7) to nurses station for 1:1 for resident's safety.R7's Physician Orders (1/8/2026) document the order Right Eye Lid: remove sutures after 6 days, if area is showing healed per hospital orders.On 1/8/2026 at 12:32PM, R7 was seated in a wheelchair at lunch and had sutures present on R7's right eyebrow. When asked if R7 experienced pain when R7 fell on [DATE] causing the eyebrow laceration and sutures, R7 replied, Oh yeah. V10 (R7's representative) was present and reported R7 had multiple falls in the facility over the weekend of 12/27/2025 to 12/28/2025. V10 reported believing the facility did not have enough staff to provide 1:1 supervision of R7 during that weekend. R7 denied ever receiving 1:1 supervision during the month of December 2025.The facility Falls policy (March 2018) documents the facility will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services and failed to employ a person-in-charge (PIC) with the required Food Protection Manager Certification. These failures have the potential to affect all 79 residents in the facility. Findings include:On 1/6/2026 at 12:42 PM, V5 (Dietary Manager) was actively supervising dietary operations in the facility kitchen. V5 reported being the full-time manager of the facility food service (person in charge) since September 2025 and reported not being a clinically qualified Certified Dietary Manager or having equivalent training. V5 denied meeting the State of Illinois standards to be a food service manager or dietary manager. V5 reported the facility Dietician does not work in the facility full-time. V5 also denied being a certified Food Protection Manager, as required, for every person in charge of a food service. V5 denied:-being a Dietician;-being a Certified Dietary Manager;-having an associate's or higher degree in food service management or in hospitality;-having 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting;-being a graduate of a dietetic and nutrition school or program authorized by the Accreditation Council for Education in Nutrition and Dietetics, the Academy of Nutrition and Dietetics, or the American Board of Nutrition; -being a graduate, prior to July 1, 1990, of a Department (Illinois Department of Public Health) approved course that provided 90 or more hours of classroom instruction in food service supervision and having experience as a supervisor in a health care institution which included consultation from a dietician; -or having completed an Association of Nutrition & Foodservice Professionals approved Certified Dietary Manager or Certified Food Protection Professional course. The Food and Drug Administration Food Code (2022) documents a dietary service Person in Charge (PIC) shall be a Certified Food Protection Manager.Throughout the duration of the survey from 1/6/2026 to 1/8/2026, the facility failed to maintain sanitary food storage areas, food service equipment, and food preparation areas.The Facility Assessment (2025) documents the facility's Staffing Plan includes a Certified Dietary Manager. On 1/6/2026 at 12:42PM, V5 reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (1/6/2026) documents 79 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure over the counter medications were not expired, failed to ensure a bottle of eyedrops was labeled, and failed to ensure insulin pens were dated when opened. This failure affects three of three (R2, R9, R74) residents reviewed for medication storage on the sample list of 29 and has the potential to affect all 79 residents residing in the facility.Finding include: The facility's Storage of Medications policy, dated April 2007, documents medications without a label will be returned to the pharmacy and expired medications will not be used and will be returned to the pharmacy or destroyed. On 1/7/25 at 9:45 AM, V21, Licensed Practical Nurse, opened the top drawer of a medication cart. Inside the drawer, a box labeled prednisone suspension 1% and with R74's name contained a white eyedrop bottle without a label. Also in the top drawer were opened bottles of zinc 50 milligrams with an expiration date of 12/2025, bisacodyl 5 milligrams with an expiration date of 12/2025, and multivitamin with minerals with an expiration date of 11/2025. At that time, V21 confirmed the eyedrop bottle did not have a label and stated she could not verify the contents of the bottle since it was not labeled. V21 confirmed that the bottles of zinc, bisacodyl, and multivitamin with minerals were expired. V21 stated the expired zinc, bisacodyl, and multivitamin with minerals could be used for any resident in the facility.On 1/7/26 at 10:07 AM, a medication cart contained an undated Lantus and an undated Lispro multidose insulin pen for R9. Both of these pens had been opened. This cart also contained an undated Degludec and an undated Lispro multidose insulin pen for R2. At that time, V2, Director of Nursing, who had opened the medication cart, stated the pens should be dated when opened and confirmed R2 and R9's multidose insulin pens were not dated and were opened. The Facility Long-Term Care Facility Application for Medicare and Medicaid, dated 1/6/25, documents there are 79 residents residing in the facility.

Based on observation, interview, and record review, the facility failed to maintain sanitary food storage areas, food service equipment, and food preparation areas. These failures have the potential to affect all 79 residents residing in the facility.Findings include:On 1/6/2026 at 9:48AM, the kitchen table mounted can opener and receiver were both soiled with heavy accumulations of dark and sticky food debris. The opener also had accumulations of metal shavings. On 1/6/2026 at 9:52AM, wire storage shelves present inside of the kitchen walk-in cooler were covered with white fuzzy biological growth resembling mold. Food was stored on all portions of the shelves. The cooler flooring surface was soiled with an unidentified puddle of brown liquid and another puddle of unidentified yellow liquid. Debris including plastic wrap, paper, and single serve condiment packets was scattered on the cooler floor which was also damp throughout.On 1/6/2026 at 9:54AM, the kitchen food preparation sink was heavily soiled and stained with brown deposits across all surfaces of the sink basins.On 1/7/2026 at 1:17PM, the can opener, walk-in cooler storage shelves and flooring, and two-basin sink remained as above.On 1/8/2026 at 11:24AM, the can opener, walk-in cooler shelves and flooring, and two-basin sink remained as above on 1/6/2025. V8 (Cook) was present and reported not being aware of when the can opener was last cleaned or if the kitchen staff cleans the can opener. On 1/8/2026 at 11:31AM, V8, Cook, reported the fuzzy substance covering the walk-in cooler shelves looked like mold.On 1/6/2026 at 12:42PM, V5, Dietary Manager, reported food from the kitchen is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (1/6/2026) documents 79 residents reside in the facility.

Based on interview and record review, the facility failed to develop and implement an antibiotic stewardship program that included protocols to ensure appropriate antibiotic use, systems to monitor antibiotic outcomes, resistance, and adverse events, and use of standardized tools and criteria to assess resident infections. This failure has the potential to affect all 79 residents in the facility.Findings include:On 1/8/2025 at 10:11AM, V1 (Administrator) provided the facility antibiotic use logs for infections for the previous calendar year. June through December 2025 logs were present and no other months were present. On 1/8/2025 at 3:12PM, V1 (Administrator) reported the facility does not have any additional information related to their antibiotic stewardship or infection control program than the above records document. The provided infections logs do not document what symptoms residents experienced signifying an infection, if any standardized criteria were used to justify and guide antibiotic use, when antibiotic therapies were first initiated, if response to treatment was monitored to determine if the antibiotic was effective and still indicated or adjustments should be made. The logs do not document the dose, schedule, or duration of antibiotic treatment for each infection. The logs do not document when an antibiotic therapy was changed when initially prescribed on an empirical basis by a medical provider. The facility Long-Term Care Facility Application for Medicare and Medicaid (1/6/2026) documents 79 residents reside in the facility.

Based on interview and record review, the facility failed to prevent unnecessary use of psychotropic medications, failed to complete psychotropic medication assessments, failed to track targeted behaviors necessitating use of psychotropic medications, and failed to implement non-pharmacological interventions prior to the use of psychotropic medications. These failures affect one resident (R6) of five reviewed for unnecessary medications on the sample list of 29.Findings include:R6's Physician Order Summary Report, dated 1/8/2026, documents the following orders: Citalopram (Antidepressant) 10 milligrams (mg) one tablet by mouth in morning; Lorazepam (Benzodiazepine) 0.5mg one tablet by mouth daily; Risperidone (Antipsychotic) 0.5mg one tablet by mouth at bedtime and Zolpidem (Sedative-Hypnotic) one tablet by mouth at bedtime.R6's Medical Record does not document any psychotropic medication assessments or behavior tracking.R6's Care Plan (current) documents R6 has Psychotic Disorder with delusions, Major Depressive Disorder, Delusional Disorder, and Anxiety Disorder. The Care Plan further documents R6 takes the following psychotropic medications: Citalopram, Lorazepam, Risperidone, and Zolpidem. R6's Care Plan does not document any specific behaviors or non-pharmacological interventions to manage behaviors.On 1/9/26 at 10:27 AM, V2, Director of Nursing, stated, I don't know about psych assessments. V2 confirmed R6 is not receiving psychiatric services. V2 confirmed R6 does not have any behaviors documented.On 1/9/26 at 10:36 AM, V7, Regional MDS Coordinator, confirmed there are no non-pharmacological interventions, behavior triggers, and/or targeted behaviors on R6's Care Plan.The facility's Psychotropic Medication Use Policy, dated February 2025, documents the following: When determining whether to initiate, modify, or discontinue medication therapy, the interdisciplinary team conducts and documents an evaluation of the resident. Behavioral and other non-pharmacological approaches are used to minimize or eradicate the need for medications. Residents receiving psychotropic medication are monitored and the response to treatment is documented.

Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan. This failure affects three (R3, R6, and R71) of 18 residents reviewed for care plans on the sample list of 29. Findings include: 1. R3's Physician Order Summary Report, dated 1/8/26, documents the following orders: Warfarin Sodium (Anticoagulant) 2 milligrams (mg), take one tablet by mouth at bedtime every Wednesday, Thursday, and Friday, and Warfarin Sodium 3mg, take one tablet by mouth at bedtime every Monday, Tuesday, Saturday, and Sunday. R3's Care Plan (current) documents R3 is on Anticoagulant therapy Eliquis. This same record does not include R3's Warfarin use and/or monitoring. On 1/8/26 at 10:08 AM, V7, Regional MDS Coordinator, confirmed R3's Warfarin is not on R3's current care plan. 2. R6's Physician Order Summary Report, dated 1/8/2026, documents the following orders: Citalopram (Antidepressant) 10 milligrams (mg) one tablet by mouth in morning; Lorazepam (Benzodiazepine) 0.5mg one tablet by mouth daily; Risperidone (Antipsychotic) 0.5mg one tablet by mouth at bedtime and Zolpidem (Sedative-Hypnotic) one tablet by mouth at bedtime. R6's Care Plan (current) documents R6 has Psychotic Disorder with delusions, Major Depressive Disorder, Delusional Disorder, and Anxiety Disorder. The Care Plan further documents R6 takes the following psychotropic medications: Citalopram, Lorazepam, Risperidone, and Zolpidem. R6's Care Plan does not document any specific behaviors or non-pharmacological interventions to manage behaviors. On 1/9/26 at 10:36 AM, V7, Regional MDS Coordinator, confirmed there are no non-pharmacological interventions, behavior triggers, and/or targeted behaviors on R6's Care Plan. 3. The EMR (electronic medical record) diagnoses sheet for R71, dated 1/14/2026, documents R71's medical diagnoses are Flaccid Hemiplegia Affecting Left Non-Dominant side and Frontal Lobe and Executive Function Deficit, Following Cerebral Infarction. The Minimum Data Set, dated [DATE], documents R71 is dependent on staff for all Activities of Daily Living, has an indwelling urinary catheter, and R71 has a BIMS (Brief Interview Mental Status Assessment) of 15, which indicates R71 is cognitively intact. Progress Notes, dated 12/18/25, document Referral Packets for transfer were sent to other facilities at R71's request. R71's care plan which was updated since R71 returned from the hospital on 1/5/26 does not address discharge planning for R71. On 1/9/26 at 2:30 PM, V1, Administrator, stated, We have been sending referrals to all the facilities (R71) has requested to be transferred to. I was not aware his care plan did not address (R71's) discharge planning. The facility's Care Plan, Comprehensive Person-Centered Policy, revised December 2016, documents the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan will: Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire.

Based on interview and record review, the facility failed to obtain resident diagnostics as ordered by a medical provider. This failure affects one resident (R7) of three reviewed for laboratory diagnostics on the sample list of 29.Findings include:R7's diagnosis list (1/7/2026) documents the diagnosis Convulsions. R7's Physician Orders (1/8/2026) document orders for Levetiracetam, Lamotrigine, and Divalproex sodium (all anti-convulsant medications).R7's neurology provider facsimile to the facility (12/9/2025) documents an order to obtain laboratory diagnostics for R7 including complete metabolic profile, complete blood count, ammonia level, Lamotrigine level, Levetiracetam level, and Divalproex sodium level. On 1/9/2026 at 12:09PM, V2 (Director of Nursing) reported R7's laboratory diagnostics ordered by R7's neurologist on 12/9/2025 were not obtained by the facility until 12/23/2025.R7's laboratory reports (12/23/2025, 12/24/2025) document the facility did not collect and submit R7's medical specimens to the laboratory until 12/23/2025.

Based on observation, interview, and record review, the facility failed to determine if a medication was appropriate and safe for self-administration. This failure affects one resident (R59) of 24 reviewed for supervised medication use on the sample list of 29. Findings include:R59's Resident Assessment (10/31/2025) documents R59 has intact cognition. R59's diagnosis list (1/13/2026) documents the diagnosis of Pain.R59's Physician Orders (1/8/2026) documents the medication order Tylenol Extra Strength Tablet, 500 MG, give two tablets by mouth every 8 hours as needed for pain.On 1/6/2026 at 2:05PM, R59 was seated in a chair in R59's room with a overbed table nearby. A medication cup was present on the table and contained two white oblong medication caplets resembling Tylenol. R59 reported the caplets were Tylenol and provided to him by the facility nurse the previous evening but were not taken. On 1/9/2026 at 12:19PM, V2 (Director of Nursing) reported staff should not leave medications in resident rooms for residents to take unsupervised. V2 reported the facility does not allow self-administration of resident medications and reported R59 had not been assessed for any self-administration medications. On 1/9/2026 at 2:11PM, R59's electronic medical record (undated) did not contain any assessment for medication self-administration. The facility Medication Administration policy (2/17/2024) documents staff will record in the resident's medication administration record each medication given to a resident and documents residents may self-administer their own medications only if their attending physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.

Based on observation, interview, and record review, the facility failed to provide privacy during a procedure by not pulling the curtain for R36. R36 is one of 29 residents reviewed for privacy in a total sample of 29.Findings include:The Physician's Order Sheet dated January 2026 documents R36's diagnoses as Cancer, Malignant Neoplasm of the Colon, and CVA (Cerebrovascular Accident) with right side impairment. R36 is on hospice for his cancer diagnosis. The Minimum Data Set, dated [DATE], documents R36 has a BIMS (Brief Mental Status Assessment) of 7, which indicates severe cognitive impairment, that R36 is dependent on staff for activities of daily living, and that R36 has an indwelling urinary catheter and is frequently incontinent of bowel.On 1/7/26 at 10:48 AM, V6, CNA (Certified Nurse Assistant) performed urinary catheter care for R36. V6 did not pull the curtain before performing the catheter care for R36. R36's bed is the first bed when you enter the room. There were two times staff knocked on the door and opened the door which exposed R36 to any person passing by the room.On 1/7/26 at 1:30 PM, V6 stated, Yes, I did forget to close the curtain around (R36). I should have closed the curtain for privacy.The facility policy titled Catheter Care, Urinary with revision date of September 2014 documents under Steps in the Procedure #12, Provide privacy. Cover the resident with a sheet, exposing only the perineal area.

Based on interview and record review, the facility failed to provide emergency response resuscitative efforts timely, resulting in a ten-minute delay in life saving services for one (R1) resident out of six residents reviewed for Death in a sample list of eleven residents. On [DATE], R1 was confirmed to be without signs of life ten minutes prior to the initiation of Cardiopulmonary Resuscitation (CPR). R1 subsequently expired at the facility on [DATE] at 9:45 am.Findings include:The Immediate Jeopardy began on [DATE] when facility staff noted R1 to be without signs of life and did not initiate CPR (Cardiopulmonary Resuscitation). V1, Administrator,was notified of the Immediate Jeopardy on [DATE]/25 at 4:27 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. R1's Electronic Medical Record (EMR) documents R1 admitted to the facility on [DATE], with medical diagnoses of Sepsis, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation, Acute on Chronic Diastolic Heart Failure, Chronic Respiratory Failure, Muscle Weakness, Unsteady on Feet, Hepatic Encephalopathy, Morbid Obesity, Cirrhosis of Liver, Diabetes Mellitus Type II, Depression, Gastroesophageal Reflux Disease (GERD), Chronic Fatigue, Lymphedema, Acute Kidney Failure, Hypertension and Acute Respiratory Failure with Hypoxia. This same EMR documents R1 chose to have full resuscitative efforts performed in case of emergency (Full Code) upon admission on [DATE]. R1's Brief Interview for Mental Status, dated [DATE], documents R1 as cognitively intact.R1's Minimum Data Set (MDS), dated [DATE], documents R1 requires maximum assistance from staff for personal hygiene, and R1 is dependent on staff for eating, oral hygiene, dressing, bathing, toileting, transfers, and bed mobility. R1's Care Plan, initiated [DATE], documents R1 chose to be resuscitated in case of emergency (Full Code). R1's Physician Order Sheet (POS), dated [DATE], documents a physician order starting [DATE], with no end date, for R1 to be a Full Code (be resuscitated in case of emergency). R1's POS, dated [DATE], documents an order, dated [DATE] with no end date, to obtain blood glucose levels before meals and at bedtime. R1's October Medication Administration Record (MAR) documents R1's blood glucose and sliding scale Insulin is scheduled at 7:00 AM, 11:00 AM, 4:00 PM and 9:00 PM. This same MAR documents R1's [DATE] 7:00 AM blood glucose result was '0'. R1's POS, dated [DATE], documents and order, dated [DATE] with no end date, to administer Humalog (Insulin) subcutaneously per sliding scale for blood glucose of 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 6 units; 300 - 349 = 8 units; 350 - 400 = 0 units Above 350 CALL PCP; 401 - 450 = 0 Above 400 call PCP, subcutaneously before meals and at bedtime for diabetes. R1's [DATE] MAR documents R1's [DATE] 7:00 AM sliding scale insulin administration was 'Not Applicable (NA).'R1's POS, dated [DATE], documents an order, dated [DATE] with no end date, to administer Tramadol 50 milligrams (mg) every six hours for pain. R1's [DATE] MAR documents R1's [DATE] 12:00 AM and 6:00 AM scheduled Tramadol was marked as refused.R1's Nurse Progress Notes, dated [DATE], documents at 9:05 AM, Upon entering (R1's) room to administer scheduled medications and check blood glucose, (R1) was found unresponsive. Staff (V8, V10, Certified Nursing Assistants (CNA)) were attempting to provide care on (R1). Immediate assessment revealed no pulse, no oxygen saturation, no blood sugar and no measurable blood pressure. According to (R1's) Electronic Health Record (EHR), (R1) is a full code. (V2) Director of Nurses (DON) and V4, Licensed Practical Nurse (LPN), were notified without delay. (V14) alerted Emergency Medical Service (EMS). CPR was initiated promptly by (V2) DON. EMS arrived and took over resuscitative efforts at approximately 9:20 AM. Despite continued efforts, EMS was unable to revive (R1). Time of death was confirmed by EMS at 9:45 AM.R1's Progress Note, dated [DATE] at 10:00 AM, documents Coroner's office notified of (R1's) death. V6, Coroner, stated V6 will call back or come out to the facility.R1's Progress Note, dated [DATE] at 10:29 AM, documents V6, Coroner, was at the facility and profile paperwork given to V6, Coroner.R1's Progress Note dated [DATE] at 12:23 PM, documents, (R1's) Funeral home here and (R1's) body was released to them.On [DATE] at 9:00 AM, V2, Director of Nurses (DON), stated R1 had not been 'feeling well' for two days prior to [DATE]. V2, DON, stated R1 was sent to the hospital on [DATE], and returned to the facility the same day with no new orders. R1 had previously chosen to be resuscitated in case of emergency. V2, DON, stated the evening of [DATE], R1 was asking staff to crawl on the floor to check on the kids. This was abnormal behavior for R1. The morning of [DATE], V5, Licensed Practical Nurse (LPN), asked V2, DON, to check on R1. V2, DON, stated she walked in R1's room at 9:10 AM to see that V8 and V9, Certified Nurse Aides (CNAs), were providing incontinence care for R1, who was laying in her bed. R1 was unresponsive with a limp body. V2, DON, stated she knew R1 was not on Hospice care or Palliative care, and was fairly certainR1 was a Full code, but asked the staff to verify R1's code status prior to initiating CPR. V2, DON, stated she performed a Sternal rub on R1 with no response. V2, DON, stated after verifying R1's code status as Full Code, V2, DON, V8, and V9, CNAs, used R1's fitted sheet to transfer R1 to the floor next to R1's bed and V2, DON, initiated CPR by doing chest compressions at 9:12 AM. V2, DON, stated V1, Administrator, had entered R1's room at this point and administered mouth to mouth rescue breaths for R1. V2, DON, stated she yelled out for V5, LPN, to call 911. V2, DON, stated V1, Administrator, and V2, DON, continued CPR at a 30:2 ratio until EMS arrived and took over R1's care at 9:21 AM. V2, DON, stated the facility did not use a backboard nor an Ambu bag to administer rescue breaths for R1. V2, DON, stated EMS placed an Intraosseous (IO) line in R1's left shoulder and continued CPR using a compression device until EMS called the time of R1's death as 9:45 AM. On [DATE] at 9:35 AM, V5, Licensed Practical Nurse (LPN), stated on [DATE] at 9:00 AM, V5, LPN, was standing at her medication cart outside R1's room. V5, LPN, stated she was preparing R1's glucometer to check R1's blood glucose. V5, LPN, knew V8 and V10, Certified Nurse Aides (CNAs), were inside R1's room providing morning incontinence cares. V5, LPN, stated she was not aware at that time that R1 was in distress. V5, LPN, stated no one told her R1 was in any distress, but V5 realized there was something wrong with R1 as V5, LPN, walked into R1's room. V5, LPN, stated she had not been in R1's room prior to 9 AM. V5 assessed R1, and R1 was found to have no pulse, no readable blood pressure, R1's blood glucose registered at 'low', and R1 had no signs of life. V5, LPN, stated she administered a sternal rub on R1 with no response. V5, LPN, stated her stethoscope has a digital read out of electrocardiogram (EKG). R1's EKG showed a flat line. You can't get any flatter. V5, LPN, stated, I knew (R1) was gone but I had to get another nurse to verify (R1's) death. V5, LPN, stated she left R1's room at the time to find another nurse to verify R1's death. V5, LPN, stated V8 and V10 remained in R1's room. V5, LPN, stated she found V4, LPN, on V4's hallway, so V4 and V5 then returned to R1's room. V5, LPN, stated to V4, LPN, I need help with (R1). I think (R1) coded. V5, LPN, stated V4, LPN, also assessed R1 and R1 was found to have no signs of life. V5 stated V4, V5, V8, and V10, were all present in R1's room, and no one provided any type of resuscitative efforts for R1. V5, LPN, stated she then left R1's room to find V2, Director of Nurses (DON). V5, LPN, stated when V2, DON, and V5, LPN, arrived back at R1's room, V2, DON, asked V5, LPN, to confirm R1's code status. V5, LPN, stated V5 went back out to the nurse's station to find that R1 was a Full Code. V5, LPN, stated she reported that to V2, DON, who then started chest compressions in R1's room. V5, LPN, stated R1 was sent to the emergency room on [DATE]. V5, LPN, stated, I knew (R1) hadn't been right since she got back from the emergency room (ER) on [DATE]. I should have checked on her when I first started my shift. I should have been in (R1's) room to see why she was still in bed and didn't feel good.On [DATE] at 10:00 AM, V8, Certified Nurse Aide (CNA), stated she was told in shift-to-shift report that R1 was not feeling well. V8, CNA, stated the facility night shift reported to the facility dayshift R1 should be left in bed for the morning, since R1 did not feel well. V8, CNA, stated she and V10, CNA, were working R1's hall that morning and did not make it into R1's room to provide cares until about 9:00 am. V8, CNA, stated V8 and V10 entered R1's room to provide incontinence care for R1 and ask R1 if she felt like getting out of bed for breakfast. V8, CNA, stated neither V8 nor V10 spoke with R1 directly because (R1) looked like she was sleeping. (R1) was very limp. We (V8, V10) had to move (R1) around because (R1) was not moving herself. I didn't see (R1) breathing, and she didn't make any sounds, and her eyes were closed. V8, CNA, stated V5, LPN, entered R1's room and assessed R1. V8, CNA, stated V5, LPN, stated R1 had no blood pressure, pulse or respirations. V8, CNA, stated V5, V8, and V10 did not provide any type of resuscitative efforts. On [DATE] at 10:15 AM, V4, Licensed Practical Nurse (LPN), stated V4, LPN, was asked by V5, LPN, to be the second nurse to verify R1's death. V4, LPN, stated V4 and V5 both went to R1's room to find V8 and V10, CNA's, standing by R1's bed. V4, LPN, stated V4 assessed R1 and found no signs of life. V4, LPN, stated R1 had no blood pressure, pulse, or respirations. V4, LPN, stated she sent V5, LPN, to get help due to R1 had passed away. V4, LPN, stated V8, V10, and V4, LPN, stayed in R1's room but did not provide any resuscitative efforts at that time. V4, LPN, stated V5, LPN, and V2, DON, returned to R1's room. V4, LPN, stated V2, DON, asked V5, LPN, to check R1's code status and V5, LPN, returned a few minutes later and stated R1 was a Full Code. V4, LPN, stated V4, LPN, V2 ,DON, V8 and V10, CNAs, assisted R1 to the floor. V4, LPN, stated V2, DON, initiated Cardiopulmonary Resuscitation (CPR) at that time. V4, LPN ,stated this was a couple of minutes after V5, LPN, left R1's room to check on R1's code status. On [DATE] at 12:50 PM, V11, Licensed Practical Nurse (LPN), stated V11 was R1's night shift nurse on the evening of [DATE] into the morning of [DATE]. V11, LPN, stated V11 held R1's scheduled Tramadol at 12:00 AM and 6:00 AM. V11 LPN stated, I couldn't get (R1) awake enough to take her pills. (R1) did not respond. (R1) was breathing and alive but she didn't act right. V11, LPN, stated she did not notify facility management, V19, Physician, or talk to other staff about R1's condition. V11, LPN, stated, I have only worked with (R1) one other time so I don't know what (R1's) normal is. V11, LPN, stated, I did not know (R1) well enough to determine if (R1) was ill or if that was (R1's) norm. I don't know what (R1's) norm is so how would I know if (R1) weren't acting herself? V11, LPN, stated she did not notify anyone (V1, Administrator, V2, Director of Nurses, V19, Physician) that R1 was too out of it' to take her scheduled Tramadol. V11, LPN, stated V11 reported to V5, LPN, during the shift-to-shift report R1 did not feel well, and R1's Tramadol had been held.On [DATE] at 1:00 PM, V10, Certified Nurse Aide (CNA), stated V8 and V10 entered R1's room for the first time at about 9:00 AM on [DATE]. V10, CNA, stated V5, LPN, V8 and V10, were all told in shift-to-shift report R1 wasn't feeling well. V10, CNA, stated she should have checked on R1 prior to 9:00 AM, but was busy taking care of the back half of the hall. V10 stated V8 and V10 did not talk directly to R1 prior to starting incontinence cares. V10, CNA, stated R1's body was very limp. V10, CNA, stated R1's hips and legs felt warm. V10 stated as V8 and V10 were providing incontinence care, both V8 and V10 noticed R1 was not acting right. V10, CNA, stated, I noticed that (R1) was not responding. (R1) was not talking, not moving and we (V8, V10) could not see a rise in (R1's) chest to show (R1) was breathing. V10, CNA, stated when V5, LPN, walked into R1's room, V10 stated to V5, LPN, I think (R1) is gone. V10, CNA, stated V5, LPN, assessed R1 and stated, (R1) is gone. I will go get another nurse to verify (R1's) death. V10, CNA, stated V4, LPN, stated at R1's bedside after V4 assessed R1, I don't think (R1) is with us anymore. V10, CNA, stated, I knew when I touched (R1's) face and her face and hands were cool to the touch, (R1) was gone. V10, CNA,stated V4, V5, V8, and V10 did not provide resuscitative efforts for R1. On [DATE] at 3:00 PM, V1, Administrator, stated R1 admitted to the facility on [DATE], as a long-term care resident. V1 stated R1 was alert and oriented upon admission but had had a clinical decline in the past week prior to R1's death on [DATE]. V1, Administrator, stated R1 was sent to the hospital for a change of condition on [DATE] and returned to the facility the same day. V1, Administrator, stated the staff should report changes in condition to the resident's physician and V1, Administrator, or V2, Director of Nurses, if there is a clinical change. V11, LPN, should have reported to V19, Physician, V1, Administrator, or V2, Director of Nurses (DON), the night of [DATE] into the morning of [DATE]. V1, Administrator, stated if a nurse is unsure if there is a clinical change, then the nurse should find those answers. R1 should have been provided cares prior to 9:00 AM. It is the expectation of the staff to offer/provide incontinence cares every two hours and as needed. If the staff knew R1 was not feeling well, then they (staff) should have assessed R1 first thing after their report in shift change. V1, Administrator, stated whoever noted R1 not having any signs of life should have started Cardiopulmonary Resuscitation (CPR) immediately. V1, Administrator, confirmed the facility policy documents if the staff are uncertain of a resident's Code Status, then CPR should begin immediately, 911 Emergency Services should have been called immediately, and staff should continue CPR until EMS arrives, or the resident Physician gives instruction on how to proceed. V1, Administrator, stated the facility delayed emergency service (CPR) for R1, which could mean the difference between life and death. On [DATE] at 11:15 AM, V41, Nurse Practitioner (NP), stated R1 had been ill prior to [DATE] when she passed away. V41, NP, stated she did not know if R1's death was caused by a delay in Cardiopulmonary Resuscitation (CPR) because there is no way to predict that. V41, NP, stated CPR should have been initiated by V8 and V10 CNAs without any delay. If V8 and V10 neither knew to start CPR, then V4, LPN, should have started as soon as she realized R9 was not showing any signs of life. V41, NP, stated CPR should be initiated if a resident is not breathing and has no response. A resident's Code status should be easily and quickly identified in case of an emergent situation. V41, NP, confirmed there was a delay in finding R1's Code Status and also delay in CPR for ten minutes. The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation (CPR) documents if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If an individual's Do Not Resuscitate (DNR) status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. If sudden cardiac arrest is likely, begin CPR. Instruct a staff member to activate the emergency response system (code) and call 911. Verify or instruct a staff member to verify the Do Not Resuscitate (DNR) or code status of the individual. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compression, airway, breathing). All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy:1. The facility implemented a revised Cardiopulmonary Resuscitation (CPR) policy. On [DATE] at 9:30 AM, V25, Chief Operating Officer (COO), stated the facility CPR policy was updated to instruct staff to call emergency services (911) earlier in the CPR process than what the original CPR policy instructed. On [DATE], V1, Administrator, stated the staff have been in-serviced on the updated CPR policy and procedures. V1, Administrator, stated the current staff have all been in-serviced as of [DATE]. V1, Administrator, stated any future staff that pick-up shifts or new hire staff will be educated prior to the start of their shift either through the onboarding employee hiring process or by V1, Administrator, or V2, Director of Nurses (DON). 2. All facility direct care personnel have been educated to ensure they are aware of the policy related to change of condition assessment and immediate initiation of CPR and identification of the location the resident's code status is documented. On [DATE], V28, Human Resources Director (HR), stated she provides the training for all new employees. V28 stated there is a new 'acknowledgement' form that all new employees will be signing which indicates that the employee has been trained on the facility CPR policy and where to find a resident's code status. V28, HR, stated if there are specific questions, then V2, Director of Nurses/Designee, will educate the newly hired staff further. On [DATE], V1, Administrator, stated training began on location and identification of code status on [DATE] and will continue with any new staff hired or staff categorized as 'As needed.'3. The facility provided education by V25, Chief Operating Officer (COO), to the facility management staff (V1, Administrator, V2, Director of Nurses, V22, Minimum Data Set/LPN) on the evening of [DATE]. On [DATE], V25, COO, stated he provided the training to the facility management staff on the evening of [DATE]. V25, COO, stated V1, Administrator, V23, Regional Clinical Nurse, and V25, COO, started training the facility direct care staff on the evening of [DATE] and have continued training with each new shift. V25 stated the trainings for direct care floor staff were completed on [DATE]. 4. The facility has incorporated effective CPR procedures for those residents who have chosen to be fully resuscitated in case of emergency. On [DATE], V25, COO, stated the facility has updated their CPR policy. On [DATE], V1, Administrator, stated every resident chart was reviewed and reconciled with the resident Physician Order Sheet (POS) and face sheet to ensure any resident who chooses to be a 'Full Code' has that information easily accessible to staff. 5. The facility held a Quality Assurance Performance Improvement (QAPI) meeting on [DATE] to discuss the facility change of condition assessment and initiation of CPR and to review policies and procedures. On [DATE], V1, Administrator, stated all required members of the QAPI team attended the facility QAPI meeting on [DATE]. V1, Administrator, stated facility staff have reviewed 100% of resident charts to ensure proper orders are in place and appropriate chart identification for advanced directives. V1 stated this was completed on [DATE] at 9:00 AM. V1, Administrator, stated the facility Interdisciplinary Team (IDT) team will continue with reeducation of change of condition assessment, reporting, and initiation of CPR. V1, Administrator, stated this education will be offered every 6 months for one year, annually, and upon hire.The facility presented an abatement plan to remove the immediacy on [DATE]. The facility revised the abatement plan four times between [DATE] initial version and three subsequent versions on [DATE]. The fourth version submitted on [DATE] was approved on [DATE].

Based on interview and record review, the facility failed to promptly notify a physician of a resident's change in condition and significant decline in mobility, which resulted in prolonged discomfort/pain for one cognitively impaired resident (R1). More than twenty-four hours after the initial change of condition was noted, an x-ray was obtained and R1 was sent to the Emergency Room, admitted , and had surgical repair of a left intertrochanteric hip fracture. R1 is one of three residents reviewed for falls in the sample of four. Findings Include: R1's Medical Diagnosis List, dated June 2025, documents R1 is diagnosed with Falls, Muscle Weakness, Difficulty Walking, Cognitive Communication Deficit, and Anxiety. R1's Minimum Data Set (MDS), dated [DATE], documents upon admission R1 was severely cognitively impaired and had Hallucinations, Delusions, Wandered Daily, had no impairment to her lower extremities, used a walker, and required supervision or touching assistance from staff for transfers and toileting. Upon discharge, R1 required substantial/maximal assistance for transfers and toileting. R1's Physical Therapy Treatment Encounter Note, dated 6/18/25, documents V14, Physical Therapy Assistant (PTA), completed R1's therapy session. R1 reported a new onset pain in her left lower extremity with movement. On 7/3/25 at 10:45 AM, V14, PTA, stated V28, Physical Therapist, completed R1's initial therapy evaluation on 6/17/25. Baseline R1 was assessed to require supervision and touching assist/contact guard with gait belt for transfers. V14 stated she completed therapy with R1 on 6/18/25, and R1 reported new onset left lower extremity (LLE) pain when lifting her LLE off of the foot pedal, however, R1 could still stand and bear weight. V14, PTA, stated on 6/19/25, V15, PTA, asked her to assist with R1, and at that time, R1 could hardly bear any weight on her LLE. R1 had declined to a maximal two assist with two PTAs. R1 was still complaining of LLE pain with movement. V14 stated she told V15 R1 had a significant change from the day before, and she should let the nurse know to notify the doctor and get an x-ray to make sure nothing was broken. R1's Physical Therapy Treatment Encounter Note, dated 6/19/25, documents V15, Physical Therapy Assistant, (PTA) completed R1's therapy session. R1 was noted to be voicing complaints of pain in her left lower extremity and hip area with movement and weight bearing. R1 kept stating she thinks her hip is broken. V15 notified R1's nurse (V22, Licensed Practical Nurse) and requested V22 follow up with a provider and get an x-ray of R1's left hip due to increased pain which was severely limiting R1's movement. At that point, R1 required maximal assistance of two therapist to transfer to the toilet. On 7/2/25 at 12:40 PM, V15, Physical Therapy Assistant (PTA), stated she completed R1's therapy on 6/19/25. R1 was having LLE pain with movement and weight bearing. R1 said she thought her hip is broken. V15 stated she notified V22, LPN, and requested she get an x-ray. R1 seemed to be in a lot of discomfort when V14 and V15 were toileting R1. V15 stated it was a significant change in condition from when she assisted with transferring R1 from her daughter's car to the wheelchair upon admission on [DATE], just three days prior. V15 stated she was concerned something was broken. R1's Physical Therapy Treatment Encounter Note, dated 6/20/25, documents V16, Physical Therapy Assistant, (PTA) completed R1's therapy session. R1 was noted to have left hip pain and could not bare weight. R1 did not use or move her left leg except to place it on the footrest for comfort. On 7/3/25 at 10:57 AM, V16, PTA, stated she worked with R1 for about a half hour on 6/20/25, and did not attempt to make R1 stand or transfer due to her left hip pain and subsequent inability to stand or bare weight. V16 PTA stated she was told an x-ray was just ordered for R1. The progress note, dated 6/20/25, documents V5, R1's Daughter, came up to the nurses' station very upset that something happened to R1's left hip and an x-ray had not been completed yet. A call was placed to V6, Medical Director, and a STAT x-ray was ordered to assess R1's left hip pain. R1's Radiology Patient Report, dated 6/20/25, documents R1 had a recent fall and new onset pain while weight bearing in therapy. R1's report documents R1 sustained an acute left intertrochanteric hip fracture. On 7/1/25 at 1:15 PM, V5, R1's Daughter, stated R1 arrived at the facility on 6/16/25 by car and could transfer with one assist and a walker. R1 was admitted to the facility for rehab after sustaining a fall at her assisted living facility. R1 was confused and impulsive, and required constant monitoring for safety. Later, on 6/16/25, V5 was notified R1 had fallen at the facility and was sent to the emergency room for evaluation. R1 returned to the facility with no acute injuries noted. V5 stated she came to visit R1 on 6/17/25, and R1 was walking around the facility pushing her own wheelchair and wandering unsupervised. V5 stated R1 was not complaining of any pain at that time. On 6/18/25, V5 stated she did not visit R1. On 6/19/25 when V5 came to visit R1, V5 stated she saw R1 sitting in her wheelchair and she was not trying to get up or move like she normally did. V5 stated V15, PTA, told her R1 was unable to move her left leg in therapy and she was complaining of a lot of pain. V15 told V5 she had told the nursing staff and requested they get a x-ray. V5 stated on 6/20/25 when she came to visit R1, she was being transferred to the commode by two unknown staff members, and R1 was screaming out in pain. V5 stated she was furious that her mom (R1) was still in pain and no x-ray had been completed. V5 stated she confronted V2, Director of Nurses, at the nurses station, who stated she was not aware that R1 had left hip pain or a change of condition. V2 called V6, Medical Director, and got an order for a x-ray. V5 stated later that evening, she got a call from the facility that her mom R1 was being sent to the hospital for a left hip fracture. On 7/2/25 at 1:55 PM, V2, Director of Nurses, stated on 6/20/25, R1's daughter (V5) came up to the nurses' station and was upset that an x-ray of R1's left hip had not yet been completed. V2 stated she was not aware anything was wrong with R1's left hip. V22, Licensed Practical Nurse, was also at the nurses' station and told V2 the day prior (6/19/25), V15, PTA, told V22 that R1 was complaining of left hip pain and could not bare weight anymore. V15 requested V22 notify the doctor and ask for an x-ray of R1's left hip to check for injuries. V2 stated she asked V22 if she had spoken with R1's doctor, and she stated she had not. V2 confirmed V22 had not documented any assessment or change of condition in R1's medical record, and confirmed V22 did not notify R1's physician or obtain an order for an x-ray. V2 confirmed staff should be documenting changes of condition, completing assessments, notifying physicians and families, and following up concerning the resident's change in condition in a timely manner. V2 confirmed V22, LPN, should have notified a provider on 6/19/25 when V15, PTA, informed her about her concerns with R1's change in physical condition/new onset - increased pain. On 7/3/25 at 2:15 PM, V9, Nurse Practitioner, stated the facility notified the provider group of R1's fall on 6/16/25 with no injuries, and asked to notify them if there were any changes in R1's condition. V9 denied the primary group was ever notified of R1's new onset left hip pain or decreased ability to bare weight. V9 confirmed the sooner they were notified, the sooner R1's hip fracture would have been identified, and the sooner she could have received treatment. The facility's Change in a Resident's Condition or Status policy, dated 5/28/24, documents the facility shall promptly notify the resident, his or her attending physician, and representative of any changes in the resident's medical/mental condition and/or status. The nurse should notify the resident's physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition.

Based on observation, interview, and record review, the facility failed to offer timely toileting assistance, implement fall interventions, and complete thorough fall investigations for three of three residents (R1, R2, R3) reviewed for falls in the sample list of three. Failing to provide R1 with timely toileting assistance resulted in R1 falling, after attempting to toilet independently, and suffering a hematoma to R1's head and a femur fracture requiring surgery and hospitalization . Findings include: 1. R1's undated Face Sheet documents Obstructive and Reflux Uropathy, Adult Failure to Thrive, Parkinson's Disease, Disorder of the Muscles, Lack of Coordination, Atrial Fibrillation, Dementia, Weakness, and History of Falling. R1's Minimum Data Set (MDS), dated [DATE], documents R1 as cognitively intact. This same MDS documents R1 as requiring moderate assistance with toileting, maximum assistance with transfers, and is dependent on staff for bathing and dressing. R1's Physician Order Sheet (POS), dated January 2025, documents a physician order for Warfarin Sodium (anticoagulant) 4 milligrams (MG) every Friday starting 12/20/24 and ending 1/19/25. R1's Fall Risk Evaluation, dated 12/12/24, documents R1 is at risk for falls. R1's fall investigation, dated 1/18/25, documents V6 and V7, Certified Nurse Aides (CNA), notified V8, Licensed Practical Nurse (LPN) of R1's fall. The fall investigation documents R1 had an unwitnessed fall that included hitting her head against the wall near the restroom. R1's Left side of Head had a small 2 centimeter (cm) length laceration that had moderate bleeding that had stopped on it's own before paramedics arrived. R1 was found laying on her back with legs out in front of her, complaining of pain. R1's wheelchair was near her as she appeared to have used it to get to the restroom and then tried to walk into bathroom trying to take herself to the restroom. This same fall investigation documents R1 was incontinent of urine at the time of fall, was ambulating without assistance, and was wearing improper footwear. This same fall investigation documents Interdisciplinary Team (IDT) met to discuss incident: R1 had breakfast at approximately 7:15 AM and was observed shortly after. R1 was observed on the floor near the bathroom/hallway. R1 stated to staff that she was trying to go the the bathroom. R1 reported to emergency room staff she had rolled out of bed and attempted to crawl to the door where she had been observed by facility staff. Intervention: offer/encourage R1 to toilet after breakfast and gripper socks when shoes are off. This same fall investigation documents R1 did not have on socks yet. R1 was trying to take herself to the restroom. V8, LPN, reminded R1 that she has incontinence briefs on so it is ok for R1 to urinate in her briefs with such urgency that she can't wait for assistance. R1's Final Report to the State Agency, dated 1/20/25, documents R1 had an unwitnessed fall on 1/18/25. This same report documents R1 is cognitively intact, has times of forgetfulness, and is impatient at times. This same investigation documents R1 ate breakfast at 7:15 AM and was found on the floor in her room at 9:45 AM. R1 was not wearing shoes or socks when found by staff. R1's Nurse Progress Note, dated 1/18/25 at 2:30 PM, documents, (R1) had an unwitnessed fall at 9:45 AM. Emergency services called and (R1) taken to the hospital by ambulance about 10:15 AM. Called hospital, (R1) has a Left Hip Fracture and is being admitted to the hospital. R1's Hospital Record, dated 1/20/25, documents R1 is an elderly frail patient, with a history of recurrent falls and Dementia, who presented to the emergency room from the facility after an unwitnessed fall. R1 stated to emergency room staff that she fell out of bed and was attempting to crawl to the door. R1's hospital record documents R1 has a past medical history significant for Atrial Fibrillation on Coumadin due to previous Deep Vein Thrombosis (DVT), Hypertension, Parkinson's Disease, Dementia, Stage IV Sacral Ulcer, as well as ulcers on both heels. This same report documents R1 presented to the emergency department status post fall at the facility. R1 was found to have Traumatic Hematoma of Forehead and Closed Intertrochanteric Fracture of Left Hip. R1's X-Ray report, dated 1/20/25, documents, Indications: Fall, pain. (R1) was found on floor, laceration and Hematoma to the Left side of her head, Altered Mental Status (AMS), Left Hip pain and Coumadin use. Impression: Comminuted Intertrochanteric Fracture of the Left Hip at its articulation of the Femoral Neck. R1's Computerized Tomography (CT) scan, dated 1/20/25, documents impression of Open Reduction Internal Fixation (ORIF) of Left Femur Fracture has been performed and Subcutaneous Hematoma on the Left side which measures 4.5 centimeters (cm) wide by 2.5 cm raised depth swelling by 10.5 cm long. On 1/28/25 at 12:05 PM, R1's Left Parietal area showed dark purple bruising, approximately 3 inches long by 4 inches wide. R1 stated her head hurt from where she fell and hit it. R1 stated she tells the staff when she needs to use the restroom. R1 stated, If the girls take too long, then I will try it myself. I don't want to wet myself. R1 stated she had to wait 'hours' that morning (1/18/25) to get any help to use the bathroom, and then after she fell , she yelled 'for a long time' to get anyone to come help her. R1 stated she broke her hip the day she fell because no one would help her use the bathroom. On 1/29/25 at 11:15 AM, R1 was laying in bed on her back. R1 stated, Oh! My hip hurts! I can't even move without it hurting. On 1/29/25 at 9:50 AM, V9, Certified Nurses Aide, stated V9 works on R1's hall regularly. V9 stated R1 is very good about asking for help. V9 stated R1 will attempt to take herself to the bathroom if no one helps her. On 1/28/25 at 12:00 PM, V3, Licensed Practical Nurse (LPN), stated R1 does complain of pain to her hip and head occasionally. V3, LPN, stated R1 is given as needed medication for her pain. 2. R2's undated Face Sheet documents medical diagnoses of Dementia, Syncope and Collapse, Overactive Bladder, Parkinson's Disease, Glaucoma, Unsteady on Feet, Abnormalities of Gait and Mobility, and Repeated Falls. R2's Minimum Data Set (MDS), dated [DATE], documents R2 as cognitively intact. This same MDS documents R2 as requiring moderate staff assistance with toileting and supervision with dressing and transfers. R2's Careplan intervention, dated 12/16/24, documents R2 is supposed to have a body pillow provided. R2's Fall Risk Evaluation, dated 12/13/24, documents R2 as a fall risk. R2's Nurse Progress Notes do not document R2's fall on 1/19/25. R2's Fall Investigation, dated 1/19/25, documents R1 had an unwitnessed fall in her room on 1/19/25 at 1:35 PM. This same fall investigation documents R2 obtained a skin tear to her Right Anterior Shin measuring 2.5 centimeters (cm) which produced scant bleeding which required three steri-strips. This same fall investigation documents (R2) must have fallen on her knees when sliding off of her bed. On 1/28/25 at 12:05 PM, R2 was laying in her bed. R2 had her head on the Right side of the bed with her torso pointed towards the left side of the bed and her feet were on the Left corner of the foot of the bed. R2 showed a large yellowing bruise approximately eight inches long and four inches wide just under her Right Knee. R2 had steri-strips just under her Right Knee at the top portion of the large bruise. R2 did not have a body pillow on her bed or within sight in R2's room. On 1/28/25 at 2:52 PM, R2 was laying in her bed with her head in the center of the bed, her knees were bent, and her feet were at the foot of the bed. R2 did not have a body pillow on her bed or within sight in R2's room. On 1/29/25 at 3:00 PM, R2 was laying in her bed, with her head in the center of the bed, with her torso positioned facing the Right side of her bed on the edge of her bed. R2's knees were bent with her feet hanging off the Left side of her bed. R2 did not have a body pillow on her bed or within sight in R2's room. On 1/28/25 at 1:50 PM, V3, Licensed Practical Nurse (LPN), stated R2 is able to answer simple questions, but is not oriented times four. V3, LPN, stated R2 is alert but not able to make complex decisions. 3. R3's undated Face Sheet documents medical diagnoses as Parkinson's Disease, Unsteady on Feet, Anxiety Disorder, and History of Falls. R3's Minimum Data Set (MDS), dated [DATE], documents R3 as moderately cognitively impaired. This same MDS documents R3 requires maximum assistance with bathing, dressing, personal hygiene, bed mobility and is dependent on staff for transfers. R3's Physician Order Sheet (POS), dated January 2025, documents a physician order starting 7/1/24 for Aspirin 325 milligrams (mg) daily with a medical history of Subarachnoid Hemorrhage. R3's Careplan intervention, dated 10/8/24, instructs staff to apply an overlay bolster to R3's bed. R3's careplan intervention, dated 1/20/25, instructs staff to exchange R3's overlay bolster. R3's Careplan intervention, dated 7/1/24, instructs staff R3 is supposed to wear slipper socks at all times. R3's Nurse Progress Note, dated 1/15/25 at 1:09 AM, documents, (R3) yelled 'HELP'. (R3) was found beside his bed, on the floor on his hands and knees. (R3) denied hitting his head. (R3) stated, I was trying to get something. (R3) could not tell what he was trying to get. On 1/29/25 at 9:45 AM, V12, Housekeeping and Laundry Supervisor, stated V12 removed R3's old overlay bolster after R3's fall on 1/15/25 and replaced it with a mattress with bolsters. V12 stated R3's old overlay bolsters were flat making them ineffective. V12 stated R3's overlay bolster should have been changed a long time ago. V13 stated he did not work during the night shift R3 fell , but that he changed the bolsters the next day. On 1/29/25 at 10:09 AM, V13, Licensed Practical Nurse (LPN), stated R3 fell out of his bed on the early morning of 1/15/25. V13 stated R3 has intermittent confusion and seemed to be confused that night. V13 stated she is aware of how to find R3's careplan, but did not look at R3's fall interventions. V13, LPN, stated R3 was not wearing any footwear, including slipper socks at the time of his fall. On 1/28/25 at 12:45 PM, V1, Administrator, stated residents should be offered toileting directly after each meal. V1, Administrator, stated prior to R1's fall on 1/18/25, R1 was able to propel herself in her wheelchair, and now she is not able to do that. V1, Administrator, stated R1 has had a general noticeable decline in her overall functioning since her fall on 1/18/25. On 1/29/25 at 11:30 AM, V2, Director of Nurses/DON, stated staff should offer complete toileting every two hours. V2, DON, stated complete toileting includes assisting the resident to the bathroom, making sure everything that is commonly used in within reach, making sure all of the fall interventions are in place, and ensuring the resident has the room set up to their preferences i.e. pulling the curtain, opening/closing the window, lights on/off, etc. V2, DON, stated R1's fall could have been prevented if staff would have offered toileting to R1 at least every two hours. V2, DON, stated it is the standard of care for residents to be assisted with morning cares including breakfast, and then offered to be toileted when the resident is done eating, not when the all the residents are finished eating. On 1/29/25 at 11:35 AM, V2, Director of Nurses (DON), stated the fall investigations for R1, R2, and R3 do not give enough information about the resident falls. V2, DON, stated there is no way to tell how exactly each resident (R1, R2, R3) fell , what interventions were in place or not. V2 stated R1, R2, and R3's fall interventions were not in place at the time of their falls. V2, DON, stated V2 will reeducate staff on fall interventions, accurate and complete charting, and how to prevent falls in general. The facility policy titled Routine Resident Checks, revised July 2013, documents the facility will provide scheduled toileting, offering repositioning and toileting every two hours, or other interventions to try to improve the individual's continence status.

Based on record review and interview, the facility failed to provide physician ordered wound care for a surgical incision. This failure affects one resident (R1) on a sample of three reviewed for wound care in the sample list of 37. This failure resulted in R1 experiencing a wound infection which required being sent to the hospital for a surgical debridement and multiple intravenous antibiotics. This past non-compliance occurred from 8/14/24 when the facility failure to monitor and treat R1's surgical incision through 8/22/24 when R1 was discharged from the facility. Findings include: R1's Face Sheet Admission Record documents R1 was admitted to the facility 8/8/24. This same record documents R1 was being admitted to the facility for medical diagnoses including Surgical Aftercare Following Surgery on the Nervous System (lumbar laminectomy, procedure to remove portions of vertebrae to relieve nerve pain), Post-Laminectomy Syndrome (pain following surgery), and Dislocation of Internal Left Hip Prosthesis. R1's Physician Order Sheet, dated 8/8/24 through 8/22/24, documents a physician order initiated 8/13/24 for facility nursing staff to complete wound care daily as lower lumbar surgical incision, cleanse with normal saline, pat dry, apply dry dressing, every day shift and as needed. This same Physician Order Sheet documents facility nursing staff were to monitor lower lumbar surgical incision for s/s (signs and symptoms) of infection or dehiscence every shift, notify MD (Medical Doctor) if complications. R1's Treatment Administration Record dated for August 2024 documents facility nursing staff did not provide R1's incision cleaning and dressing on 8/14/24, 8/17/24, and 8/20/24. This same record documents facility nursing staff did not complete monitoring of R1's surgical incision on these same dates during the day shift. R1's Nursing Progress Note, dated 8/22/24, documents, Resident had follow-up appointment this AM for back, doctor (V16, Surgeon) called and is sending resident straight to (local hospital emergency room ) for direct admit related to infection to back incision. On 8/27/24 at 10:03 AM, V12, Daughter of R1, stated, (R1) had to have a second surgery to remove E. coli (Eshericia coli, bacteria present in fecal material) from the incision. The nurses at the facility did not do the cleanings of her incisions like they were supposed to, the dressings they had would never stick in place, they left her on the bedpan for over an hour, she was left laying on her back almost all the time, now she has rashes under her breast and in her groin, and bed sores on her backside. V12 concluded by stating, (R1) is still in the hospital and has to stay here until the antibiotics are done. R1's partial Hospital Record, dated from 8/22/24 through 8/27/24, documents the hospital had obtained cultures from R1's dehisced (surgical incision split open) and draining back incision fluid and surrounding tissues, both of which resulted in heavy growth of E. coli. This same record documents R1 received preliminary doses of intravenous antibiotics including Vancomycin 1 gram every 12 hours requiring strict blood level monitoring and dosing by the hospital pharmacy, and Zosyn 3.375 grams every 8 hours, as a broad spectrum treatment until the susceptibility reports from R1's cultures could be processed to determine a more targeted antibiotic regimen. This record documents R1's laminectomy had been conducted on 8/3/24, with a subsequent discharge to (the facility name) on 8/8/24. This record documents V16's (R1's Neurosurgeon) comments during her evaluation of R1 in the hospital as, Multiple samples are growing E. coli as a result of fecal contamination and not from surgery, consistent with (R1's) statements of poor quality care at (the facility name) and V16 is in consultation with the Infectious Disease Department of the hospital. This record documents V16's further evaluation of R1 as, Rashes under both breasts and groin, and bed sores on the buttocks not present at discharge from the hospital on 8/8/24. This record documents V16 conducted a surgical debridement of R1's lumbar incision, removing staples, noting a large amount of brown purulent material and liquid, surgically trimming the edges of the incision, and noted the muscle layer was also separated which required a deep debridement through the muscle layers, sanitized the deep debridement with 2 rounds each of Betadine Iodine and Hydrogen Peroxide, placing 1 gram of Vancomycin below the muscle layer, and 1 gram of Vancomycin above the muscle layer before being able to re-close the incision. This record documents R1's intravenous antibiotic was changed on 8/26/24 to Ceftriaxone 2 grams daily. On 8/28/24 at 4:45 PM, V18, [NAME] President of Administrative Operations, and V19, [NAME] President of Clinical Operations, stated they had become aware of the issues with R1's wound care treatments on 8/22/24, when R1's daughter (V12) had called the facility. V18 and V19 stated they had implemented a plan of correction to address the issues with the nursing staff to ensure treatments were being completed according to physician orders, and being documented correctly. Prior to the survey date of 8/27/24 and 8/28/24, the facility had taken the following actions to the non-compliance: 1. Held a Quality Assurance and Performance Improvement meeting including V23, Medical Director, V1 Administrator, V2, Director of Nursing, V19, Regional Clinical Nurse (Vice President of Clinical Operations), and V17 Registered Nurse, to determine a plan of correction. 2. Formulated a plan of correction including: 3. Residents with identified wounds have been provided wound treatments according to physician orders; 4. Conducted a 100 percent audit of all residents residing in the facility to identify residents with wounds; 5. Provided inservice education to the licensed nursing staff regarding wound care, wound care policies, and documentation of treatments. 6. Implemented a wound monitoring tool to audit residents with wounds to ensure residents with wounds have an appropriate physician order for treatment, treatments completed timely and according to the physician order, wound monitoring documented timely, any changes in the wounds reported to the physician. These audits were completed for 6 residents on 8/22/24, 8/23/24, and 8/26/24, and for 4 residents on 8/25/24. These audits are scheduled in the plan of correction to be conducted for 5 residents weekly for 4 weeks.

Based on interview and record review, the facility failed to provide safe and effective supervision of R1 during incontinence care to prevent a traumatic fall. This failure resulted in R1 falling from R1's bed, striking R1's head on an adjacent nightstand, and landing on the floor resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list (3/22/2024) documents R1's diagnoses include: Muscle Weakness, Spinal Stenosis (narrowing), Cerebral Infarction (partial brain tissue death due to disruption in blood flow), Lumbago (low back pain), Osteoarthritis, Central Pain Syndrome, Presence of Artificial Hip Joint, Dementia, Depression, and Anxiety Disorder. R1's quarterly assessment (12/8/2023) documents R1 has both upper and lower extremity impairment limiting R1's range of motion, is frequently incontinent of bowel and bladder, and requires the assistance of two or more staff for toileting hygiene and to roll left and right while in bed. R1's Fall Risk assessment, dated 1/21/2024, documents R1 has a history of falls and is at high risk for experiencing falls. R1's 7 Day Look Back Charting (3/8/2024) documents R1 has moderately impaired cognition and requires the assistance of two or more staff for turning and repositioning in bed. The facility incident report (3/9/2024) documents V3 (Certified Nurse Aide) provided incontinence care to R1 on 3/9/2024 while R1 was in bed. The same report documents V3 had rolled R1 to R1's side to provide care, and when V3 turned to reach for an incontinence brief, R1 fell out of bed onto the floor and was sent to the hospital emergency department for evaluation and treatment. The report does not document any other staff were present during V3's care of R1 on 3/9/2024. The hospital emergency department report (3/9/2024) documents facility staff reported R1 hit R1's head on a nightstand during a fall from bed on 3/9/2024. The same record documents R1 sustained a clavicle (collarbone) fracture and scalp laceration requiring sutures as a result of the fall. The report documents R1 complained of head pain while in the emergency department and received intravenous narcotic pain medication. The facility incident investigation (3/9/2024-3/11/2024) documents a signed witness statement from V3 (Certified Nurse Aide) describing R1's fall on 3/9/2024. V3's statement documents R1 was in bed when V3 changed R1's clothing and removed R1's incontinence brief and positioned R1 on R1's right side to apply a new brief on R1, with V3 holding R1 in position with V3's right hand. The same record documents V3 noticed the new brief had fallen to the floor, and when V3 kneeled down to retrieve the brief, R1 rolled away from V3 (and fell out of bed onto the floor). The statement documents R1 complained of shoulder pain and an ambulance was called to transport R1 to the hospital. The investigation interview of V3 (3/9/2024) documents V3 reported providing incontinent care to R1 on 3/9/2024 and had placed R1 on R1's side while R1 used a bed side rail to hold R1's self in the side position while receiving care from V3. The interview documents V3 reported R1's new incontinence brief had fallen onto the floor, and when V3 bent down to retrieve the brief, R1 rolled away from V3 and fell to the floor. V2's (Director of Nursing) Staff Statement (3/9/2024) documents V2 observed R1 on the floor between R1's bed and wall after the fall, and when R1 was moved, blood was noted on the floor and an open area was found on the back of R1's head. The Statement documents R1 complained of head and left shoulder pain to V2. The facility In-Service attendance roster (3/9/2024) documents facility nursing staff received training to use two staff for bed mobility for R1. The facility In-Service Training Report (3/9/2024) documents V1 (Administrator) in-serviced V3 (Certified Nurse Aide) on 3/10/2024 about resident safety. The record documents: When supplies are/or have fallen to floor they are not to be reused on resident due to sanitary guidelines. Staff member retrained to make sure resident in safe position before getting supplies. On 3/22/2024 at 2:00PM, V3 reported providing incontinence care to R1 on 3/9/2024, and R1 rolled forward and fell out of bed when V3 went to place a new incontinence brief beneath R1. V3 did not report dropping R1's new brief to the ground and bending down to retrieve the brief when R1 fell from the bed as V3 had reported in V3's written statement in the facility investigation of R1's fall. V3 reported no other staff were present on 3/9/2024 when R1 fell from bed and stated, I'm pretty sure (R1's) head hit on (R1's) bedside table (when R1 fell to the floor). V3 reported R1 complained of shoulder pain after the fall. V3 denied being aware of R1 having any history of falling from bed and denied R1 has any behaviors, resists care from facility staff, or has any other issues increasing R3's risk of falls when staff provide incontinence care to R1. V3 reported R1 had a grab bar in place on R1's bed at the time of the fall. On 3/26/2024 at 11:15AM, V4 (Licensed Practical Nurse) reported all resident incontinence care is supposed to be completed by two staff members. On 3/26/2024 at 3:15PM, V7 (Certified Nurse Aide) reported frequently providing care to R1 since R1's admission to the facility. V7 denied R1 ever had any bed side rails or grab bars of any type during R1's stay in the facility. V7 reported R1 has never been able to grasp a grab bar or side rail and R1 is unable to roll herself in bed or independently complete bed mobility.

Based on observation, interview, and record review, the facility failed to ensure for the prevention of indwelling catheter associated urinary tract infections of residents by failing to provide supplies to ensure for hygienic perineal care, failing to securely maintain indwelling urinary catheter tubing, and failing to ensure use of residents catheter drainage bags in a dignified and sanitary manner. These failures affect three (R6, R4, R47) of seven residents reviewed for urinary catheter and urinary tract infections (UTIs) from a total sample list of 40. These failures resulted in R6 feeling humiliated by having to sit in feces for over an hour in the dining room, due to a lack of supplies, while being treated for a urinary tract infection. Findings include: Facility infection control logs dated by month, document urinary tract infections increased from five infections in April and May, four infections in June 2023, to eleven infections in July 2023. 1. R6's care plan, dated 8/19/23, documents ongoing urinary tract infections. R6's medication administration record documents Nifurantoin 100 milligrams twice daily for a urinary tract infection. R6's Minimum Data Set (MDS), dated [DATE], documents R6 was admitted to the facility on [DATE], is cognitively intact, is frequently incontinent of urine, always incontinent of stool, and totally dependent on two persons for toileting. R6's progress notes, dated 7/17/23, documents R6 weighs 430 pounds. On 8/20/23 at 10:01AM, R6 said she has a urinary tract infection (UTI). Yesterday I was wacky because of it! On 8/20/23 at 11:21AM, R6 stated, They are totally out of washcloths and towels, and now they don't have wipes for us. On 8/20/23 at 12:00PM, R6 was sitting in the dining room eating. On 8/20/23 at 12:54PM outside of the dining room, R6 stated, I just had to sit in the dining room all through lunch with poop in my pants because it takes two of them to change me and they didn't want to leave the dining room. They don't have any washcloths today, so they will use a dry diaper and it makes me feel like a nobody when they do that. I don't feel clean and they can't get me clean using the diapers, and now I have a UTI. This happens a lot here. On 8/20/23 at 12:55PM, R6 smelled strongly of feces, and staff entered R6's room stating they were going to provide perineal care for R6. On 8/20/23 at 11:30AM, V4, Licensed Practical Nurse, stated, They are out of washcloths and towels. The girls have to use toilet paper and wet it, or they buy their own wipes. On 8/20/23 at 1:00PM, V3, Infection Preventionist and Quality Nurse, said she noticed when the facility changed from wipes to washcloths, there was a spike in the number of urinary tract infections in the facility. On 8/20/23 at 11:45AM, V1, Administrator, said she knew that the facility was short on washcloths, and now we can't order wipes for the residents. It really is a problem. We stopped ordering them in June. On 8/20/23 at 1:00 PM, V51, Certified Nursing Assistant/CNA stated, I come early to get the towels and washcloths. Those who clock in after me just don't always get any. I know that someone cut some towels up once. On 8/20/23 at 1:02PM, V50, CNA, stated, I hid some towels yesterday. We never have any. On 8/22/23 at 11:25AM, V19, Medical Director, said, I expect linens to be clean and sanitized. Certainly sitting in feces can contribute to UTIs and resident discomfort. On 8/21/23 at 1:43PM, V19, Medical Director, stated, We discussed the issue and they should be cleaning the residents hygienically. The care has to be done and they have to have the equipment to do the job. It is the basics. We have to do better, the lack of hygienic pericare certainly can contribute to UTIs. 2. R4's Minimum Data Set, dated dated [DATE], documents admission to the facility on [DATE], with severely impaired cognition, and maximum assist for toileting hygiene. R4's care plan, dated 7/22/23, documents urinary tract infections. R4's infection report, dated 6/23/23, documents a facility acquired urinary tract infection being treated with Ciprofloxacin (antibiotic) 500 milligrams daily, started on 6/16/23. No culture or sensitivity performed prior to this antibiotic administration. R4's culture, dated 7/10/22, documents culture results were positive for Escherichia coli. No infection report was found in R4's medical record. R4's infection report, dated 7/21/23, documents a facility acquired urinary tract infection being treated with Cephalexin 500 milligrams daily on 7/19/23. On 7/22/23, R4's culture returned positive for Escherichia coli and Klebsiella. On 7/27/23, Meropenem 1 gram intravenous every 12 hours was ordered because of the sensitivity report. At this time, an indwelling urinary catheter was inserted for R4. R4's infection report, dated 8/16/23, documents a facility acquired urinary tract infection being treated with Nitrofurantoin Monohydrate/Macrocrystals, starting on 8/16/23. R4's culture and sensitivity report, dated 8/9/23, documents culture results were positive for Escherichia coli and sensitive for Nitrofurantoin. On 8/21/23 at 3:00PM, perineal care was performed on R4 by V23, Certified Nursing Assistant (CNA). R4's catheter was unsecured to the leg, and when V23, CNA, was performing perineal care, she wiped toward the umbilicus. V23, CNA, stated, I know what I did, I wiped up instead of down. On 8/21/23 at 3:10PM, V23, CNA, stated, They are short on washcloths and towels. When I have to, because there aren't any towels or wash clothes, I use a paper towel with soap and dry them. That's what you have to do. It doesn't get them clean like a good washcloth. 32853 3. R47's Physician Orders for the month of August 2023 documents a diagnosis of Retention of Urine and documents an order for an Indwelling Urinary Catheter 16 FR (french)/10 cc (cubic centimeters) inflate, change monthly and as needed with an order date of 7/24/23. On 8/21/23 at 10:31 AM, R47 was in R47's wheel chair being pushed in the activity room by V48, Certified Nursing Assistant, and the indwelling urinary catheter tubing and the drainage collection bag were dragging on the floor. The drainage bag was not inside a dignity bag. On 8/21/23 at 10:58 AM and 11:45 AM, R47's urinary catheter tubing and drainage bag were dragging on the floor. On 8/22/23 at 10:28 AM, R47 was in R47's wheelchair, and the indwelling urinary catheter tubing was laying on the floor. On 8/23/23 at 10:15 AM, R47's indwelling urinary catheter tubing was laying on the floor. On 8/23/23 at 1:00 PM, V17, Regional Nurse, confirmed the indwelling urinary catheter tubing and drainage bag should not be touching the floor. The facility Catheter Care, Urinary policy, dated 9/2014, documents, The purpose of this procedure is to prevent catheter-associated urinary tract infections. Ensure that the catheter remains secure with a leg strap to reduce friction and movement at the insertion site (catheter tubing should be strapped to the resident's inner thigh). For a female resident, use downward strokes to cleanse.

Based on interview and record review, the facility failed to provide and properly maintain essential lifesaving medical equipment during a respiratory medical emergency for R1. R1 did not receive effective rescue breathing for 12 minutes during CPR (Cardiopulmonary Resuscitation) due to the absence and/or availability of a mechanical ventilation device or mouth shield for staff use during a respiratory medical crisis. R1 subsequently died of Acute Cardiopulmonary Arrest. These failures have the potential to affect (13) additional residents (R4 - R11 and R15 -R19) who have chosen to be a Full Code. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified to have begun on [DATE] when the facility failed to provide lifesaving equipment and rescue breathing for R1 during a cardiopulmonary emergency. V16, Regional Director of Operations, was notified of the Immediate Jeopardy on [DATE] at 4:23 PM. The surveyor confirmed through interview, observation, and record review that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The facility is in the process of staff education on the Emergency cart location, completing daily checks on Emergency Cart inventory and accessibility of items, and education on life saving equipment during a life threating medical emergency to include bag valve mask use versus non-rebreather mask use. Findings include: R1's POLST (Physician Orders for Lift Sustaining Treatment), signed by R1, dated [DATE], documents R1 is a Full Code, meaning R1 has chosen to have full life sustaining measures attempted, including cardiopulmonary resuscitation, in the event of a medical emergency. R1's medical record documents on [DATE]: CNA (Certified Nursing Assistant) entered (patient) room and noted that (patient) had been incontinent of loose stool. She assisted (R1) to bed and (R1) began to have difficulty breathing. 9:35 AM (R1) was noted to have difficulty breathing, nurse notified. 9:36 AM, (V6 Licensed Practical Nurse) entered (R1) room. (R1) noted to be in respiratory distress, responded to nurse that he was trying to breathe, (R1) become unresponsive with no pulse. 9:37 AM CPR (Cardio Pulmonary Resuscitation) initiated, call for help, and (V12 LPN) called 911. 9:38 AM, (Nurse practitioner V4) reported to (R1) room. 9:40 AM, (R1) pulse 40, oxygen saturation 80% on 5 liters on oxygen. 9: 42 AM, (R1) again unresponsive, no pulse compression began again, oxygen increased to 15 liters per (V4). 9:44 AM no pulse. 9: 46 AM no pulse. 9:47 AM (local fire department on scene, take over CPR. 9:48 AM EMS (Emergency Medical Services) arrived. 10:02 AM, EMS departed building with (R1) transporting to (local hospital). Contacted (local hospital) update for (R1) condition. (R1) expired. Pronounced at 10:31 AM. On [DATE] at 11:20 AM V10 Certified Nursing Assistant/CNA, stated, (R1) was fine the morning of [DATE], (R1) had went down to breakfast meal, and came back to his room, (R1) needed to use the restroom and was a mechanical lift, I went and got the lift and someone to help me, we (V9 and I) had started getting (R1) up with the mechanical lift and (R1) (become incontinent) everywhere, I told (R1) we were just going to put him in bed and get him cleaned up. Once in bed (R1) started having trouble breathing, (V9) notified (V6), (V6) came to the room immediately, (V6) was explaining to (R1) to breathe through his nose, instead of his mouth. While (V6) was talking to (R1), (R1) became unresponsive, the nurses then started doing chest compressions, I went out of the room looking for an oxygen tank, I don't recall ever seeing the crash cart (emergency supply cart, E-cart) in (R1's) room, I remember hearing one of the EMS workers say something about no crash cart being in the room. On [DATE] at 11:30 AM V9 CNA stated, (V10) needed assist with (R1), (R1) had to use the bathroom after breakfast. (R1) was a (mechanical lift for transfers). As (V10) and I went to transfer (R1), (R1) said it is too late and had an (incontinent episode), so we placed (R1) in bed to be cleaned up, (R1) was talking about an upcoming doctors appointment, I had my back turned to (R1's) head, looking towards (R1's) feet, then when I turned around I noticed (R1's) face had turned blue, I ran out and got the nurse (V6), she came to (R1's) room and was doing patient teaching with (R1) on how to breath, (R1) was talking then and said I am trying, then all of the sudden (R1) went unresponsive. (V6) said get the crash cart, it was at the end of the hallway in the utility room, the cart was locked and the nurses (V12 LPN and V13 LPN) took over trying to find a key for it, I went back to R1's room, I do not remember seeing the crash cart being brought into (R1's) room. On [DATE] at 12:15 PM V4 Nurse Practitioner stated, I was working with another patient on the hallway, I heard (V6) in (R1's) room talking loudly so I knew something was going on, I finished wheeling the other resident down the hallway and I popped in the Directors room and I heard someone say we need the crash cart, I immediately went to (R1's) room, (V6) was in the room, (R1) was in his bed, (R1) was placed into a reclined position, (R1) had no pulse, (V6) started compressions, The crash cart was locked and unavailable, so we got a oxygen canister and non- rebreather mask to put (R1) on 15 liters of oxygen, we did pick a thready pulse back up around 40 to 60 beats per minute, but lost rhythm again, continued CPR until EMS arrived. On [DATE] at 12:21 PM, V5 (Registered Nurse, Former Director of Nursing) stated, I was told on [DATE] after putting (R1) to bed, (R1) was having trouble breathing, the nurse (V6) then did patient teaching with him on breathing through the nose, (R1) had his oxygen on, (R1) said back to her I am trying and then went unresponsive. Staff got assistance and started CPR. I went into the room and (V4 NP) was doing compressions at that time and had (R1's) oxygen concentrator up to 5 liters, at one point someone brought in an oxygen tank and (R1) was placed on 15 liters of oxygen on a non-rebreather mask. There was a crash cart, we could not find the keys to open the cart, I did not know where they were. I ended up finding them later that afternoon, in a drawer, not labeled. I started in January of 2023, I had never been orientated to where the keys to the (emergency cart) were at, I had not seen any forms or any type of check off lists being completed for the (emergency) cart. While (R1) was in (cardiac arrest) the crash cart was never able to be opened or brought into (R1's) room. There was a partial backboard (cardiac board) that was located at the nurses station and brought down to the room, but they were already doing compressions so they didn't use it. On [DATE] at 12:35 PM V6 LPN stated, (R1) was fine that morning, had went to the dining room for breakfast, blood sugar was stable, had taken medications and needed to go to the bathroom. I told (V10). Later (V9) alerted me that (R1) was short of breath, (R1) is a mouth breather, I went down to (R1's) room, (R1's) head of bed was elevated, (R1) was on 4 liters of oxygen per nasal cannula and was mouth breathing, I did patient teaching with (R1) to breathe through his nose, and (R1's) eyes rolled, pupils became fixed, I did a sternal rub and R1 groaned once, then had no pulse. (R1) was a full code, (V12) went to call 911, (V17 LPN) and I were taking turns doing chest compressions, (V4) came in room, (V5, V17) and myself were alternating doing chest compressions, someone brought in the back board, but we didn't need it or use it, we had already started doing compressions. (R1) had a regular bed mattress. We did not have the crash cart, someone had brought in an oxygen tank and we had a non-rebreather mask on (R1). We did not have an (bag valve mask) and rescue breathing was not done, we did get a pulse back briefly and lost it. We were doing 2 minute pulse checks. It took 12 minutes for EMS to arrive after they were called, EMS never got a pulse back. I think the key to the crash cart was found later, I don't know how or why the crash cart was locked, 3rd shift nursing responsibilities are to check the crash cart. Before the crash cart was like a tote, then back in December/[DATE] the prior DON changed it into this cart, no one knew where the key was kept for it. On [DATE] at 12:45 PM V12 LPN stated, (V9) came to the door and asked (V6) and I to come take a look at (R1). (R1) was in bed, (R1) looked really short of breath, (V6) was doing patient teaching with (R1) on breathing, I went to morning meeting. (V9 and V10) then reported that (R1) had coded, I notified 911 and was printing paperwork off, I got back down to (R1's) room they were switching off doing chest compressions. (V4) was in the room leading the code, staff continued to switch off doing compressions until EMS arrived, I did a round of chest compressions. I was not part of looking for the key to the crash cart key, I would have went to the DON and asked for it, I am not sure where to have looked if the DON wasn't here or where staff should have looked. R1's death certificate documents, date of death : [DATE]. Cause of death: Acute Cardiopulmonary Arrest. On [DATE] at 9:00 AM V15 Regional Nurse Consultant stated, they (facility) should be completing the (Emergency cart) checklist at night. When someone goes unresponsive in cardiac arrest nurses are to check code status, call for help, do not leave the patient, start chest compressions if by self. If with a team switch out, perform 30 chest compressions and then 2 rescue breaths, 911 should be notified. Use a backboard if available. The facility did not provide any documentation of the Emergency cart being checked or inventoried from [DATE] through [DATE]. The facility provided an undated list of all residents with Full Code Status, which included R4, R5, R6, R7, R8, R9, R10, R11, R15, R16, R17, R18 and R19. The facility's policy, with a revision date of [DATE], titled Policy for Emergency Care (E-cart) documents, purpose: to organize and maintain emergency cart (e-cart) to ensure adequate needed equipment for CPR procedures. Policy: All emergency equipment in the e-cart will be checked monthly by the DON. The e-cart should be locked. Once a month the e-cart should be opened and checked for outdated supplies. Internal and external equipment should be checked by ensuring proper function of equipment. E- carts will be maintained and supplied in accordance with the crash cart minimum requirements list which include respiratory equipment. All nurses should be familiar with e-cart contents and locations. New employees will be orientated to all emergency bags/kits and procedures and training programs will be provided to maintain competence in emergency response. E-cart location, supplies and emergency procedures shall be re-informed each time during the mandatory in-services. Equipment includes: Ambu bag with CPR mask. The facility policy, with a revision date of February 2018, titled Emergency Procedure- Cardio Pulmonary Resuscitation documents, 1- Sudden cardiac arrest is a loss of heart function due to abnormal heart rhythms. Cardiac arrest occurs soon after symptoms appear. I -If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: a- instruct staff member to active the emergency response system (911), d- initiate the basic life support (BLS) sequence of events: 2- The BLS sequence of events is referred to as C-A-B (chest compression, airway, breathing). 3- Chest Compressions, 4- Airway: tilt head back and lift chin to clear airway, 5- Breathing: After 30 chest compressions provide 2 breaths manually. 6- All rescuers, trained or not, should provide chest compressions to victims of cardiac arrest, Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30 to 2. https://cpr.heart.org/en/resources/what-is-cpr, documents, For healthcare providers and those trained: conventional CPR using chest compressions and mouth-to-mouth breathing at a ratio of 30:2 compressions-to-breaths. What to Know About Non-Rebreather Masks dated [DATE] documents: A non-rebreather mask is a special medical device that helps provide you with oxygen in emergencies. These masks help people who can still breathe on their own but need a lot of extra oxygen. The Facility provided documentation that V4, V5, and V6 had certifications and were trained in Cardiopulmonary Resuscitation. The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1) V16 Regional Director of Operations verified on [DATE] The Emergency Cart key was located and cart was unlocked and relocated to the clean utility room. Audits have been completed by the charge nurse from [DATE] through [DATE] and was verified by V3 Regional Director of Operations on [DATE]. 2) V16 RDOP verified that on [DATE] The Emergency Cart was inventoried and checklist was completed. The cart has been reviewed and checked daily (from [DATE] through [DATE]) by the charge nurse, and was verified by V3 Regional Director of Operations on [DATE]. 3) V16 RDOP verified that on [DATE] Inservice training for licensed nursing staff on the location of the Emergency cart began by V5 Former DON and then on [DATE] was amended to include education on Emergency Policy's and Cardiopulmonary Resuscitation, was started on [DATE] with education conducted by V24 Regional Nurse Consultant and V3 Regional Director of Operations. Inservice sign in sheet were reviewed. 4) V16 RDOP verified that on [DATE] all staff present in the facility were educated on life saving equipment, including bag valve mask use versus non-rebreather mask use by V24 Regional Nurse Consultant and V3 Regional Director of Operations. Inservice sign in sheets were reviewed. 5) V16 RDOP verified and provided a copy of the form to ensure the facility's New Employee Packet has been updated to include: Emergency Procedure - Cardiopulmonary Resuscitation policy, and the location of the Emergency Cart. 6) All items noted above will be reviewed and verified daily for 2 weeks, and then weekly for 2 months by the Director of Operations and Regional Nurse Consultants to ensure all items are in compliance and to provide re-education if deficiencies are recognized. All audits and verifications will be provided to QA team.

Based on interview and record review, the facility failed to notify a physician of a resident's laboratory results and change in a resident's condition. The facility also failed to administer antibiotics as ordered for one of three residents (R1) reviewed for urinary tract infections on the sample of 11. These failures caused R1 to have a delay in ordering antibiotic medication and miss antibiotic medication administration, causing R1 to have cognitive and physical decline and multiple hospital admissions for Urinary Tract Infections. Findings include: R1's Urinalysis Results, dated collected on 9/21/22 at 10:45am, document R1's urine was light brown in color and extremely turbid. This result documents the following additional results: Leukocyte Esterase 500! (reference range NEGATIVE) Nitrites 1+! (reference range NEGATIVE) Blood 1+! (reference range NEGATIVE) culture is indicated R1's Urine culture, dated 9/21/22, documents results of greater than 100,000 CFU (colony forming units)/mL (milliliter) of Escherichia coli (ESBL). This report documents Extended spectrum Beta-Lactamase (ESBL) producing organisms demonstrate decreased activity with penicillins, cephalosporins, and [MEDICATION(S)]. This report also documents R1's organism has been confirmed as an ESBL producer. R1's Progress Notes dated as follows document: 9/21/22 10:38am R1 started on [CONDITION(S)] surveillance due to increased confusion. 9/22/22 5:17am R1 continues on [CONDITION(S)] surveillance. Urinalysis (UA) result was faxed to V3, R1's Physician. There is no documentation the facility followed up with V3 to ensure V3 received R1's UA results. 9/23/22 1:22am, LATE ENTRY for 09/22/22 Second shift. R1 continues on [CONDITION(S)] surveillance. R1 UA was resulted on 09/21/22 with negative results. R1 is having increased confusion and agitation. R1 cut R1's oxygen tubing with scissors today and did not recognize any of the staff. Written notification was sent to V3 to notify of R1's condition change. There is no documentation of any follow-up with V3 to ensure V3 received the written notification of R1's change in condition. 9/23/22 1:41am, At this time R1 is only has confusion. 9/23/22 1:58pm, R1 seems sleepy today, blood pressure 80/60, still monitoring for [CONDITION(S)]. There is no documentation V3 was notified of R1's blood pressure or R1's sleepiness. 9/23/22 2:36pm, V3's office was called in regards to R1's confusion and increased behaviors. V3's office stated V16, V3's Nurse Practitioner is on vacation right now so the office would get the notifications to another provider who was taking over for V16. 9/23/22 4:13pm, Verbal orders from V3's office were received in regards to R1's UA results to start [MEDICATION(S)] Antibiotic medication by mouth and R1's Urine culture to be evaluated and sent to office and then on call doctor to be notified of results. 9/23/22 9:29pm, R1 continues to be lethargic, with low blood pressure and high blood sugar. R1 is having difficulty standing and doing daily activities of living. R1 was sent to the hospital. R1's urine culture and sensitivity results came back and were faxed to V3's office. There is no documentation the on-call physician was notified as per orders on 9/23/22 at 4:13pm as documented in R1's progress notes. 9/24/22 3:17am, R1 was admitted to the hospital. R1's Care Plans, dated 9/30/22, document R1 requires Antibiotic Therapy Intravenous to treat (blank) with interventions including: Administer medications as ordered, refer to physician if symptoms do not subside after course of treatment. These Care Plans document a care plan dated 9/29/22, Acute Urinary Tract Infection ([CONDITION(S)]) with interventions including: Administer antibiotics as ordered. R1's Physician Discharge Summary, dated 9/29/22, documents R1's Reason for admission including Acute [CONDITION(S)] due to urinary tract infection and Gram negative Bacteremia. This summary documents R1 presented to the hospital with altered mental status/confusion and leukocytosis. This summary documents R1's urine culture showed E. coli resistant except to [MEDICATION(S)] and [MEDICATION(S)]. R1's blood cultures resulted positive for Gram Negative Rods and Infectious Disease was consulted with recommendation to administer [MEDICATION(S)] (Antibiotic) for 10 more days. This summary also documents R1 had an Acute Kidney Injury most likely due to Urinary Tract Infection, Dehydration with a Creatinine of 1.51 with R1's baseline Creatinine normal. R1 also had Transaminitis with elevated AST ([MEDICATION(S)] transaminase) and ALT ([MEDICATION(S)] transaminase) liver enzymes, most likely due to acute infection/medication. This discharge summary documents R1's medication orders including [MEDICATION(S)] 1,000mg (milligrams) intravenously daily for seven days, maintain a peripheral IV site per protocol and discontinue once infusions are complete. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . These orders document this order was discontinued on 10/4/22 upon R1's transfer to the hospital. R1's Electronic Medical Administration Record (eMAR), dated September 2022, does not document R1 received R1's [MEDICATION(S)] intravenous antibiotic infusion as ordered on 9/30/22. R1's Electronic Medical Administration Record (eMAR), dated October 2022, does not document R1 received R1's intravenous antibiotic infusion as ordered on 10/3/22. R1's Progress Notes dated as follows document: 9/30/22 at 12:55am a late entry for second shift on 9/29/22. This note documents R1 readmitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This note documents R1 has a 20 gauge intravenous (IV) catheter in R1's left antecubital for IV therapy needs for the next seven days. 10/2/22 at 2:35am, R1 continues on IV antibiotic and has been having increased confusion, lethargy and needs assistance with feeding and requiring increase need of assistance with activities of daily living. There is no documentation V3, R1's Physician was notified of R1's changes in condition. 10/3/22 at 8:56pm, R1 on antibiotic therapy for a [CONDITION(S)]. 10/3/22 at 9:39pm Late Entry R1 has been on IV antibiotics and R1's IV became infiltrated and had to be removed. Staff attempted to place a new IV site without success. V17, Infectious Disease Physician's office was contacted and facility is awaiting new orders but did not receive a call back by the end of the day, will follow up in morning. There is no documentation there was follow-up with V17, R1's Infectious Disease Physician. 10/4/22 2:33am, R1 was seen by V16 and received new orders, see Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 10/4/22 at 7:04am, R1 very lethargic and does not respond when R1's name is called. 10/4/22 at 10:15am, R1 is unresponsive to painful stimuli . vitals are not within normal limits, elevated temp (temperature) and pulse. 10/4/22 at 10:47am, orders for R1 to be sent to the hospital for a new IV site and antibiotic therapy. 10/8/22 at 10:40am, R1 admitted to the hospital (on 10/4/22) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1 receiving oral antibiotic at the hospital and waiting for an infusion line to be placed for IV antibiotics. 10/11/22 at 9:28pm, R1 readmitted to the facility. On 10/27/22 at 2:30pm, V7, Director of Clinical Operations, stated the facility should be documenting details if the physician does not want called and prefers to only receive a fax of changes in resident condition. V7 stated the facility should follow up if a resident's physician does not return calls or the facility has not heard back from a physician regarding a resident's change in condition. On 10/27/22 at 3:33pm, V7 stated the facility should ensure the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V7 stated the facility should document details of what the facility notifies/contacts the physician about and responses. The facility's Urinary Tract Infections/Bacteriuria Clinical Protocol, dated with the year 2001, documents nurses should observe, document and report signs and symptoms of a urinary tract infection in detail. The physician will help nursing staff interpret any signs, symptoms and lab test results. The physician will order appropriate treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Generally, symptomatic [CONDITION(S)]'s should be treated. The physician and nursing staff will review the status of individuals who are being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, and record review, the facility failed to ensure a bed was in a low position, items on a bedside table were within reach, and a fall mat was in place, and failed to provide supervision while in the shower room for three (R60, R58, and R33) of four residents reviewed for falls on the sample list of 35. These failures resulted in R60 sustaining a subdural hematoma and hemorrhage after falling and hitting R60's head on the floor. Findings include: R60's hospital after visit summary dated 5/21/22 to 5/24/22 documents the reason for R60's admission was Fall, Subdural Hematoma, Subdural Hemorrhage and facial contusion. On 5/21/22 at 1:59 PM, There was a greenish blue donut shaped and sized bump on the center of R60's head and greenish blue bruising that extended down from the bump to the bottom of R60's cheeks. R60 stated she fell after trying to get up by herself. R60 stated she was needing something off of her bedside table but could not reach it and her call light was laying on the floor so she attempted to get up and fell on to the floor. R60's Nursing Note documents on 5/21/22 at approximately 6:49 am, R60 was observed lying on the floor in her room. R60 was observed lying on her left side with her legs under her bed and head under her bed side table. Bed was in mid position. Call light had not been activated. Upon review by the safety committee, it was determined that the root cause of this event was that R60's feet were unable to reach the floor, so when she sat up on the side of the bed, she fell forward and was unable to get back to a sitting position related to lack of core strength. Nurse reported an abrasion on her left knee and hematoma to her forehead. It is believed that she hit her head on the bottom of the bed side table. Pupils equal and reactive. Res alert and oriented x 3 with complaints of a headache. Range of motion to extremities completed without concern. Due to bruising and a baseball sized knot, R60 sent to hospital for evaluation. R60's fall care plan dated 3/1/22 documents R60 is at high risk for falls. This care plan includes an intervention to utilize universal fall precautions per facility protocol. On 6/2/22 at 9:04 AM, V2 Director of Nursing stated R60 is at risk for falls. V2 stated that they determined the root cause of her 5/21/22 fall was that her bed wasn't in the low position and her feet could not touch the floor and when she reached for cold cream on her bedside table she pitched forward and fell hitting her head on the base of the bedside table stand. V2 stated R60 is alert and oriented and can recall the past. V2 stated she would have expected her items on the bedside table to be in reach and the call light to be within reach. V2 stated R60 did sustain the hematoma and subdural hemorrhage as a result of the fall on 5/21/22. 2) R33's Nurse Note dated 3/10/22 documents, Resident (R33) fell out of shower chair in shower room. Resident was found on her knees, face down, with towel under face. Shower chair was on top of her. On 6/2/22 at 12:51 pm, V24, Regional Nurse Consultant, provided an Incident Investigation for a root cause of R33's fall on 3/10/22. This investigation documents, IDT (Interdisciplinary Team) determined that the root cause of the incident was the shower wheels on the shower chair were not locked. This same Incident Investigation documents, Safety committee has decided to provide education to staff to ensure the locks on the shower chair wheels are locked at all times. On 6/2/22 at 1:10 pm, V23, Licensed Practical Nurse, stated, No one was with (R33) in the shower room at the time when (R33) fell . A CNA (V28) left (R33) to go get an (incontinent brief). When (V28) came back, (R33) was on the floor. A resident should never be left alone in the shower room, (V28) had been educated on that. On 6/3/22 at 9:33 am, V28 stated, I had given (R33) a shower, I went to get an (incontinent brief) around the corner, and when I came back, (R33) had fallen out of the shower chair. R33's Minimum Data Set (MDS) dated [DATE] documents R33 could not complete a Brief Interview for Mental Status (BIMS) and was assessed by staff as having short-term and long-term memory problems, poor decision making, and requires cues and supervision. This same MDS documents R33 is not stable in transitions between sitting and standing, requires staff assistance for stability, and is dependent upon staff for transfers. 3) On 5/31/22 at 11:35 am, R58 was in R58's own room, supine in bed. There was a padded mat folded in the corner of the room approximately 7 feet away from R58's bed. There was not a mat on the floor beside R58's bed. R58's current Care Plan documents fall prevention interventions including, Fall mat placed on floor at bedside. This intervention is dated as initiated 4/13/22. On 5/31/22 at 12:27 pm, R58 remained in bed supine in R58's own room and the padded mat remained folded in the corner of the room. There was not a mat beside R58's bed. On 5/31/22 at 12:27 pm, V14, Registered Nurse, pointed to the mat in the corner and stated, The mat is supposed to be a current intervention for falls. R58's MDS dated [DATE] documents R58 received a BIMS score of 3 out of a possible 15, rating R58 as severely cognitively impaired. This same MDS documents R58 requires staff assistance for stability during transitions between sitting and standing.

Based on observation, interview, and record review, the facility failed to document complete and thorough investigations for falls, and failed to ensure a resident (R1), who is a high risk for falls with a history of multiple falls, received supervision to prevent additional falls from occurring. These failures affect three of three residents (R1, R3, R4) reviewed for falls in the sample of five. These failures resulted in R1 being left unsupervised, outdoors, where R1 stood and was walking without assistance, falling on a concrete patio, hitting R1's head. This fall resulted in R1 sustaining a right [CONDITION(S)] and posterior scalp hematoma. Findings include: 1. The facility's Resident Incident Report, dated 3/16/22, documents R1 fell sustaining a head injury on 3/16/22 at 4:10pm. This report documents V3, Activity Aide, came to notify V4, Licensed Practical Nurse (LPN), R1 was on the ground outside on the patio. This report documents R1 was outside when R1 fell ; R1 had stood up from R1's wheelchair and was walking, and fell to the ground. This report documents the facility implemented anti-rollbacks to R1's wheelchair. R1's Hospital History and Physical (H&P), dated 3/16/22, documents R1 presented to the local emergency department due to a fall leading to a right hip injury and right hip pain. This report documents the local emergency management system staff stated R1 was on the patio at the skilled nursing facility and fell backwards hitting the back of R1's head and injuring R1's right hip. This report documents R1's assessment revealed right hip pain/tenderness. This H&P documents R1 has an acute right femoral neck fracture caused by (R1's) fall and right hip pain caused by (R1's) right femoral neck fracture. R1 also has a head injury. R1's Computed Tomography (CT) exam results document R1 received a CT of the head due to pain after a fall on 3/16/22. This result documents R1 had a posterior scalp hematoma 1cm (centimeter) thick. On 4/14/22 at 2:25pm, V3, Activity Aide, stated V3 had R1 with V3 walking through the facility, and it was nice out so V3 and R1 went outside. V3 stated V3 had R1 go with V3 to keep R1 busy because R1 is always trying to stand up by R1's self and is not supposed to. V3 stated V3 left R1 outside with R2 and R5 in the enclosed patio area, and went into the closet inside the facility to put the checkers game away. V3 stated when V3 came out of the closet, which is 10 feet from door leading to outside patio, and walked toward the door, V3 saw R1 on the ground. V3 stated V3 notified V4, LPN, R1 was on the ground. On 4/14/22 at 2:55pm, R5 stated R1 got up on R1's own and was not supposed to while outside on the patio. R5 stated, There were no staff out there at the time (R1) fell . (R1) bumped (R1's) head really hard and had a nice sized bump. R5 stated, (R1) tries to get up without help and walk frequently, but is unable to. (R1) has fallen before. R1's Fall Investigations do not document a thorough investigation as follows: 3/3/22 7:30am- R1 was found on the floor next to R1's bed. There is no documentation of continuation of required neurological exams as per the facility's Neurological Assessment Flow Sheet documents they are to be completed. There is no documentation of a root cause of R1's fall. 3/3/22 11:24am- R1 was found sitting on the floor in the activity room. There is no documentation of Neurological exams being completed for this unwitnessed fall. There is no root cause of this fall documented. 4/9/22 3:57pm- Facility staff heard someone hollering help. R1 was observed laying in the middle of the hallway. R1 hit R1's head and had a light colored bruise to the right side of R1's head. This investigation does not document who completed the report, or who the staff member was who took R1 to toilet R1. This report documents an unidentified resident's family member asking the unidentified Certified Nursing Assistant (CNA) to assist with an unidentified resident, so the CNA left R1 in the doorway to transfer the other resident, prior to finishing assisting R1 with toileting. This report documents R1 was within the unidentified CNA's visual, however, does not document the CNA responded to R1 being on the floor in the hall. The post fall intervention documented is for Occupational Therapy to evaluate R1 for wheelchair positioning, and possibly place a foam lap device, although there is no root cause identified for the fall. On 4/13/22 at 3:20pm, R1 was sitting in a wheelchair in the lounge across from the nurses station. R1 was leaning forward removing R1's soft boots on R1's feet. One had been removed, and R1 sat on the end table to R1's left side. The sensor alarm box was hanging from R1's wheelchair, but the green light was not flashing/box not turned on. At 3:23pm, V9, Licensed Practical Nurse (LPN), turned the sensor alarm electrical box unit on, and came to the nurse's station and began to remind the nurse's of R1's need to have the sensor on/functioning. V4, LPN, stated therapy staff had brought R1 to the lounge area and notified the staff R1 was there, and R1's sensor alarms were on. On 4/14/22 at 9:00am, R1's wheelchair did not have anti-rollbacks in place. R1 was in a wheelchair completely different from the wheelchair R1 was observed in on 4/13/22 at 3:20pm. On 4/15/22 at 1:05pm, V2, Director of Nursing (DON), stated the investigations need to be thorough/complete and make sure the investigation is documented completely. V2 stated R1 is impulsive and stands and attempts to walk frequently without assistance. V2 stated R1 should have been supervised and not left by R1's self on the patio outside. 2. R3's Resident Incident Report, dated 4/3/22 at 7:15am, documents V12, Housekeeper, notified V11, Registered Nurse (RN), R3 fell . There is no witness statement from V12 as to if V12 observed R3 falling, or just found R3 on the floor. V11 found R3 lying on the floor next to the recliner complaining of pain to the head, and a small discolored hematoma was noted to R3's head. There is no documented root cause of this fall. On 4/15/22 at 1:05pm, V2, Director of Nursing (DON), stated the investigations need to be thorough/complete and make sure the investigation is documented completely. 3. R4's Fall Event investigations document as follows: 2/15/22 at 12:00am- R4 was found laying on the floor in R4's room on R4's right side. This investigation documents this fall was unwitnessed, and the floor was wet with urine. R4 sustained an abrasion to the the left eyebrow area with swelling and bruising, a skin tear to the left knee, and bruising to the left shoulder. Prior to the incident, R4 was sleeping in bed, and had been checked on at start of shift and was dry at that time. There is no documentation of an interview with who checked on R4 when R4 was dry. This report documents unidentified staff did not awaken R4 to offer toileting, in an attempt to allow restful sleep. Education was provided that R3 has a pattern of attempting to toilet self and should be offered toileting upon rounds to minimize R4's attempt to take R4's self. R4 is already on high fall risk protocol with frequent rounding. 2/24/22 7:58pm- R4 was found sitting on the floor in R4's room. This report documents R4 was unwitnessed, and bed was in low position with pillows to the right and left side of body. There is no root cause of this fall for R4. R4 had experienced increased agitation and restlessness, but there is no documentation of potential causes of the agitation and restlessness. The facility implemented a bed alarm to R4's bed as a post fall intervention after this fall. R4's Resident Incident Report, dated 3/7/22 at 10:31pm, documents R4 was found on the floor on R4's right side laying on right arm. This report documents multiple abrasions to R4's skin including R4's head. There is no root cause documented for R4's fall on 3/7/22, and the investigation does not document if the post fall interventions identified per R4's previous fall investigation were in place at the time of the fall on 3/7/22. This investigation documents the facility decided to utilize a low bed in the lowest position when in bed and body pillows when in bed, although these were interventions already supposed to be in place from R4's fall on 2/24/22. The narrative of investigation in this report documents an unidentified nurse assessed R4 and noted no injuries at the time of the fall, although the report completed by V7, Licensed Practical Nurse, documents R4 had the injuries as noted above. On 4/15/22 at 1:05pm, V2, Director of Nursing (DON), stated the investigations need to be thorough/complete and make sure the investigation is documented completely. The facility's undated guidance on what assessments to do when a fall occurs documents, All unwitnessed falls or witnessed falls where a resident hits their head, a fall risk assessment and neurological assessment must be completed in the computer. This sheet documents to make sure all information is filled out on the incident forms, including names. Without all applicable fields filled out, this is considered an incomplete report. The facility's Assessing Falls and Their Causes policy, dated March 2018, documents, The purpose of the procedure is to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. After a fall, clarify details of the fall including what the individual was trying to do. Refer to resident-specific evidence including medical history and evaluate the chain of events preceding a recent fall including time of last meal, what was resident doing, was the resident alone, were they trying to get to the toilet, whether any environmental factors were involved and if there is a pattern of falls for the resident. Continue to collect and evaluate information until the cause of falling is identified or it is determined it cannot be found.

Based on observation, interview, and record review, the facility failed to assess for, identify, and implement appropriate fall prevention interventions specific to the individual needs for R1 and R4, both with a known history of falls. Following a fall, R1 was admitted to a hospital for an acute intertrochanteric left femur fracture with severe varus angulation. Following a fall, R4 was admitted to a hospital for a laceration to right side of head and a Subarachnoid hemorrhage. R1 and R4 are two of four residents reviewed for falls in the sample list of four. Findings include: 1.) R1's undated Face Sheet documents R1's [DIAGNOSES REDACTED]. R1's Admission Observation, dated 12/31/2020 (admitted ), documents R1 having memory problems, fallen in the last month, balance problems, symptoms experienced with activity such as dizziness, unsteady gait, and weakness. The facility's Fall Risk Assessment Tool, dated 12/31/2020, documents a moderate fall risk for R1. A facility report titled Incident Follow-up Report, undated, includes the following documentation on R1: during R1's hospital stay, R1 had a decrease in [MEDICATION NAME] (antihypertensive) related to [MEDICAL CONDITION] episodes times 3, based on incident investigation it appears R1 fell (1/3/21) as a result of increased weakness related to Craniotomy and Orthostatic [MEDICAL CONDITION], and poor safety awareness. The report also documents R1 got up from bed to close R1's door and fell (1/3/21) and the nurse noted R1's left lower extremity (LLE) to be rotated inward and R1 stated R1 was having pain to the LLE and unable to bear weight; R1 was noted to be displaying signs of [MEDICAL CONDITION]; Power of Attorney was notified and stated R1 had been having episodes of Orthostatic [MEDICAL CONDITION]; R1 transported to a hospital and was admitted for a closed left [MEDICAL CONDITION]. R1's Adult Hospital Admission History and Physical notes, dated 1/3/2021 at 11:05 PM, documents [AGE] year old female just discharged to skilled nursing on 12/31/2020, had a fall overnight and sustained a femoral intertrochanter femur fracture, (R1's) daughter acts as main historian and states (R1) is very frail, during (R1's) last hospital course, (R1) had [MEDICAL CONDITION], [DIAGNOSES REDACTED], and [DIAGNOSES REDACTED]. These notes also document orthopedic surgery was consulted in the Emergency Department (ED), will be admitting patient (R1), patient (R1) cleared for surgery, however, due to comorbidities, she (R1) is a moderate to high risk for perioperative complications. R1's ED provider notes, dated 1/3/2021 at 11:14 AM, documents presenting to the ED for evaluation of a fall that occurred on 1/3/2021, resident (R1) states she was walking with her cane when she got out of balance and slipped on her side. R1's hospital records, dated 1/4/2021, Hip 2 views unilateral left x-ray documents findings which include: fall, left leg shortened and rotated, an acute intertrochanteric left femur fracture with severe varus angulation. R1's Adult Hematology Oncology Consult, dated 1/7/2021 at 8:48 AM, documents R1 admits to not eating on a regular basis and stated her legs have felt weak since her brain surgery on 12/22/20 and they buckle and that is why she fell and broke her hip. R1's Discharge Plan *Final Report*, hospital summary, dated 12/31/2020, documents, I also have these medical conditions: [MEDICAL CONDITIONS], High Blood Pressure, [MEDICAL CONDITION], [DIAGNOSES REDACTED], Squamous Cell [MEDICAL CONDITIONS] Fibrillation, [MEDICAL CONDITION], Orthostatic [MEDICAL CONDITION]. On 1/13/2021 at 11:36 AM, V2, Director of Nursing (DON), stated V2 was not aware of R1's Orthostatic [MEDICAL CONDITION] [DIAGNOSES REDACTED]. V2 stated Orthostatic [MEDICAL CONDITION] was not passed on in report that day. V2 stated from R1's care plan, we monitor for fall risk and apply interventions as needed. V2 stated, I do not have documentation of what was being done with resident (R1) due to increased fall risk status. V2 also stated, We knew to monitor her (R1) for fall risk, that just means keep an eye on her (R1) more frequently. V2 was asked if fall interventions were appropriate to prevent the resident (R1) from falling. V2 stated I (V2) don't know how to answer that because they (interventions) did not prevent a fall. On 1/14/2021 at 5:16 PM, V2, DON, stated V2 was aware R1 did not have the greatest safety awareness and R1 did have [MEDICAL CONDITION] episodes before coming to the facility and [MEDICAL CONDITION] could happen again. V2 also stated we address safety issues on a basic care plan such as: monitor if increased fall risk, help to assess risk for falls, and monitor skin. On 1/14/2021, at 3:03 PM, V1, Administrator, stated R1 had a baseline care plan initiated upon R1's admission that states that R1 is to have initial needs met; goal is to address/meet residents needs/wants until comprehensive care plan is established; approach is to monitor for fall risk; and apply interventions as needed to reduce resident's risk for falls. There is no documentation in R1's medical record regarding fall preventions specific to R1's [DIAGNOSES REDACTED]. 2.) R4's undated Face Sheet, documents [DIAGNOSES REDACTED]. region, Unspecified fracture of lower end of left femur, initial encounter for closed fracture, Presence of right artificial hip joint. R4's Care Plan, dated 6/27/2019, documents resident at risk for falls r/t (related to) history of falls, history of [MEDICAL CONDITION], vision deficits, mobility deficits, pain arthritis, status [REDACTED]. This same Care Plan documents approaches for R4 as: administer medications as ordered by physician and monitor for adverse effects which may effect gait, balance, endurance, cognitive status report changes to doctor as needed; Nursing Approach Start Date: 6/27/2019: assist with activities of daily living (ADL'S) to the extent required to promote safety; Certified Nursing Assistant (CNA), Direct Care Staff, Nursing Approach Start Date: 06/27/2019: be sure call light is within reach and encourage R4 to use call light for assistance as needed, R4 does not always use R4's call light related to occasional confusion, check R4's status at the appropriate intervals that will address R4's needs, keep bed in the lowest position that is safe for the resident while in it, provide activities that minimize the potential for falls while providing diversion and distraction, remain in shower/bathroom with R4. R4's Care Plan, dated 8/26/2020, documents potential for complications, injury related to anticoagulant or antiplatelet medications. R4's Minimum Data Set (MDS), dated [DATE], documents R4 requires extensive assistance for bed mobility and total dependence for transfers and locomotion on unit. R4's Care Plan does not document R4's highest fall risk areas nor what preventative measures to be implemented specific to R4 for falls. The facility's undated Incident Report Follow-up documents R4's 1/10/2021 incident as follows: [AGE] year-old female has a medical history that includes Dementia, Altered Mental Status, Visual Hallucinations due to [DIAGNOSES REDACTED], poor vision and hard of hearing. R4 is a mechanical lift due to history of bilateral lower extremity fractures. This document also states R4 fell as a result of a visual hallucination as R4 was trying to pick up a credit card that R4 saw, from the floor; nurse (V6) was alerted and found R4 face down on the floor with a large amount of blood on the floor; no credit cards or other items noted on the floor; nursing assessment performed identified hematoma to left forehead, skin tear on left forearm measuring 3 x 1 centimeters (cm), second skin tear to left forearm measuring 5 x 1cm, and laceration to right scalp. This report also documents post interview with nursing staff revealed that in the day leading up to R4's fall, R4 had been experiencing an increase in hallucinations. There is no documentation of these hallucinations pre-fall, documented in R4's medical record. Also documented in this report, R4 remains at a hospital for observation due to Subarachnoid Hemorrhage, six staples to scalp laceration and steri-strips to skin tears on left arm. R4's Hospital Encounter, dated 1/10/2021, documents 3-4 cm laceration to right side of head and large hematoma on front of forehead noting the clinical impression as a Subarachnoid hemorrhage. R4's Consult Note - Neurosurgery, dated 1/11/2021, documents Subarachnoid Hemorrhage extending along the posterior sylvian fissure, oral anticoagulant use, remain from anticoagulant for the next five days, if there is expansion of the hemorrhage, may need to remain off indefinitely. On 1/19/2021, at 11:38 AM, V6, Licensed Practical Nurse (LPN), stated I (V6) am the nurse that usually takes care of R4; R4 has visual issues, her (R4) vision is not good, R4 gets confused, and R4 sees things that aren't there. V6 also stated R4 stated R4 was seeing little girls in R4's room a few days before the fall. V6 stated R4 has gotten weaker since COVID-19 diagnosis, R4 gets tired sitting up in R4's wheelchair, R4's head falls down during meals and R4 is not eating a lot. V6 stated, R4 should not have been left alone in R4's wheelchair, we don't leave her (R4) sitting in her (R4) wheelchair, she's (R4) old and she's (R4) tired. V6 stated a nurse, a certified nurse assistant (CNA), activities, or therapy can transport R4 but not others because they are not familiar with her (R4) care plan. V6 stated V7, Restorative Aide, would not have had a matrix (care plan that CNA's use) that day because V7 was assisting with feeding and CNA's get the matrix when they come to work in the morning. V6 stated fall preventions should have been that R4 be transferred out of her (R4) wheelchair. On 1/19/2021, at 1:00 PM, V7, Restorative Aide, stated V7 fills in on the floor sometimes as a CNA. V7 stated V7 would not have left R4 alone in R4's room in R4's wheelchair if V7 knew R4 had been hallucinating. V7 stated V7 only picks up a matrix (care plan for CNA's) when V7 is working on the floor as a CNA. V7 also stated V7 was not aware of R4's decreased safety awareness. The facility's Safety and Fall Prevention Policy, dated reviewed December 2020, documents each resident will be assessed using the designated fall risk assessment tool upon admission to identify the resident's highest fall risk areas, and based on these areas, preventative measures will be implemented specific to resident individual needs.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review, the facility failed to safely transfer two residents (R5, R7) of 39 residents reviewed for accident hazards in a sample list of 39. This failure resulted in R5 sustaining a 12 centimeter skin tear, which required emergency services and 13 sutures to close. B. Based on observation, record review, and interview, the facility failed to ensure that hot water available to residents at handwashing sinks and bathing rooms was at a safe temperature to prevent potential burn hazards to residents. This has the potential to affect five residents (R35, R38, R45, R46, R60) reviewed for safety in the sample list of 39. Findings include: a.)1.) R5's physician's orders [REDACTED]. R5's Care Plan, with a revision date of 6/13/19, documents, (R5) transfers with one CNA/gait (Certified Nursing Assistants, belt) with a wheeled walker. Use two assist if needed related to weakness. R5's Care Plan also documents, (R5) is at risk for falls, related to poor safety awareness, mobility deficits, pain, Hypertension, [MEDICAL CONDITIONS]. Do not leave alone in recliner in room without supervision of staff/family. On 6/23/19 at 10:00 AM, V26 (R5's family member) stated, On (R5's) [MEDICAL TREATMENT] days (Monday, Wednesday, and Friday), (R5) is so weak that (R5) can barely stay awake. R5's Progress Note dated 3/14/2019 at 9:30 PM, documents, (V20) CNA reported to writer that (R5) had a skin tear to R (right) lower leg. Writer entered room and (R5) noted to be sitting on side of bed. Large skin tear actively bleeding noted to right lower leg. Measures 11 cm (centimeters) X 6 cm X 0.3 cm. Pressure applied. Area is too large for writer to approximate. CNA states thinks resident's leg may have got caught in recliner while transferring. MD (medical doctor) called, spoke with (Nurse Practitioner) and gave orders to sent to ED (Emergency Department). POA (Power of Attorney) called and coming to facility. R5's progress note, dated 3/15/2019 at 3:54 PM, documents, right lateral calf wound assessed. 13 sutures in place to cane shaped skin tear. No signs and symptoms of infection. Minimal serous exudate noted. No abnormal redness noted. Dark purple bruising noted on inner edge (more distal left lateral calf). Denies pain or discomfort. On 6/25/19 at 11:26 AM, V20 stated, I was getting (R5) out of the recliner in (R5's) room. I was the only staff present in the room. Before that (R5) was alone in room sitting in the recliner. R5 had feet outside the foot rest. I did not use a gait belt for (R5). I put (R5's) feet back on the foot rest and lowered the foot rest. I helped (R5) to stand. It was a Friday and (R5) had been to [MEDICAL TREATMENT]. (R5) gets weak and tired after [MEDICAL TREATMENT]. (R5) wasn't able to take a step or pivot, but I finally was able to get (R5) on the bed. As I was transferring (R5's) right leg twisted and got caught in either the recliner or the bed. I didn't even know (R5) was hurt until R5's roommate screamed for me after I had stepped into R5's bathroom. The roommate pointed out (R5) was bleeding quite a bit. I called another (CNA) to get the nurse. The nurse came in and we sent (R5) out to the hospital. On 6/25/19 at 3:30 PM, V31, Medical Doctor, stated I can definitively say that if the facility did not follow their policy or the care plan that it could have contributed to the injury to (R5). I would agree that the description of the transfer of (R5) would be consistent with the injury (R5) was seen at the emergency room for. a.)2.) R7's physician's orders [REDACTED]. On 6/23/19 at 9:30 AM, R7 was seated at the end of the hall in wheel chair with a bulky bandage covering R7's right hand, which was purple above the bandage. R7 stated, I got a skin tear this morning when they were taking me to the bathroom. I told the CNAs (Certified Nurse's Aides) to be careful, but I was holding on to the handles on the lift and they got too close to that metal plate on the door and my skin got torn. R7's progress note, dated 06/23/2019 on 6:20 AM, documents CNA came to get writer. Stated (R7) had skin tear to right hand being transferred to toilet on sit to stand. Cleaned area and applied steri strips (skin closure strips) with a non stick pad and wrapped with gauze. Passed information on to first shift to notify POA(Power of Attorney) and Continue to monitor area. On 6/26/19 at 4:00PM, R16, Licensed Practical Nurse (LPN)/Wound Nurse, stated, The skin tear to (R7's) right hand happened 6/23/19 on night shift. The CNA's were transferring (R7) to the bathroom with a sit to stand lift and bumped (R7's) hand on the door. The facility's policy Safe Resident Handling Policy, revised (MONTH) (YEAR), documents, Residents who require limited assistance (contact, guard/stand-by) will be transferred with a gait belt. This policy also states The specific method for transferring, repositioning, and mobilizing individual residents will be communicated to the nursing and care staff by ensuring this information is included in the residents care plan as well as on the (electronic) care tool that guides the resident care. b.)1.) On 06/25/19 at 12:18 PM, the hot water at the shampoo bowl in the beauty shop was measured. V14, Beautician, stated the hot water will burn your hand unless you adjust it. The hot water temperature measured 116 degrees F. V14 stated that she adjusts the water temperature when V14 washes resident hair. V14 stated, I've wondered about what if someone was in here working under my license and the water was too hot. On 06/25/19 at 12:24 PM, the hot water measured 117 degrees F. at the handwashing sink in the activity room. The hot water felt very hot to touch. On 06/25/19 at 1:03 PM, the hot water still measured 118 F at the activity room sink. On 06/25/19 at 12:26 PM, the hot water at the handwashing sink measured 117 degrees F. in the room shared by R60 and R38 . On 06/25/19 at 12:30 PM, the hot water at the bathroom sink measured 118 degrees F. in R46's room. On 6/25/19 at 12:35 PM, the hot water at the handwashing sink in R35's room measured 117 degrees F. On 06/25/19 at 12:38 PM, the hot water at the Aimee Way Bathing room handwashing sink and shower measured 116 degrees F. On 06/25/19 at 12:50 PM, the hot water at the handwashing sink in R45's bathroom measured 118 degrees F. R45 stated at that time, I can adjust the hot water at the sink in the bathroom. 06/25/19 at 12:58 PM, the Andrew Court bathing room handwashing sink measured 115 degrees F, and shower hot water measured 117 degrees F, when tested with Housekeeping Supervisor V12. On 6/25/19 at 1:00 PM, the hot water at the handwashing sinks measured 118 degrees F in the men's and women's public bathrooms. V1, Administrator, was notified at that time and was shown the digital temperature reading of the hot water of 118 degrees F. V1 stated at that time they have called a plumber to check the hot water system. On 06/25/19 at 01:13 PM, the surveyors digital thermometer was checked for accuracy using an ice point field calibration. The thermometer was accurate at 32 degrees F. The facility bathing schedules documents R35, R38, R45, R46, and R60 are bathed in the two shower rooms. The facility Water Supply Systems policy, dated (MONTH) 2012, states, The intent of this policy is to maintain a water supply system that is provided to residents at a safe temperature. The policy states Hot water available to residents at shower, bathing and handwashing facilities shall not exceed 110 degrees Fahrenheit (F). Facility hot water system is controlled using a thermostatically controlled mixing valve. Maintenance tests water temperature in varied locations with in the facility on a routine basis. Water temperatures noted to be below 100 degrees or above 110 degrees will alert maintenance to check mixing valve gauge, modify and contact plumber.

Based on interview and record review, the facility failed to track, trend and report weight increases to the [MEDICAL TREATMENT] center for a resident with End Stage [MEDICAL CONDITION]. The facility also failed to consult with the physician to request orders for compression hose. These failures affect one of three residents (R67) in the sample of 18. These failures resulted in the resident being readmitted to the hospital intensive care unit with a [DIAGNOSES REDACTED]. Findings include: R67's Resident Face Sheet dated 7/18/18 documents R67's [DIAGNOSES REDACTED]. R67's Care Plans dated 6/22/18 document R67 has a [DIAGNOSES REDACTED]. These care plans also document to assess, record and report weight gain. These care plans also document to monitor, record and report [MEDICAL TREATMENT] complications to the physician including fluid overload. R67's Weight list dated 7/18/18 documents R67's continued weight increases as follows: 6/14/18- 164.4 pounds (lbs) 6/15/18- 168.8 lbs (4.4 lbs weight gain since 6/14/18) 6/16/18- 172.8 lbs (4 lbs weight gain since 6/15/18) 6/17/18- 175.4 lbs (2.6 lbs weight gain since 6/16/18) There is no documentation in R67's medical record that the [MEDICAL TREATMENT] facility was notified of R67's continued weight gain from 6/14/18 through 6/17/18. R67's Progress Notes dated 6/19/18 at 2:30am document R67 was having increased weakness on 6/19/18 and R67 had [MEDICAL TREATMENT] on 6/18/18. This note documents R67's weight was trended and shows increase in weight. MD (medical doctor) faxed in regards. There is no documentation the MD responded to the concerns of the weight increases for R67. R67's Progress Notes dated 6/19/18 at 4:47am document R67 was looking worse than before according to staff and was short of breath at rest with respirations of 52 breaths per minute. R67's lung sounds were with wheezes on expiration and legs now noted to have four plus [MEDICAL CONDITION] and the MD was called. R67's Progress Notes dated 6/19/18 at 2:12pm document R67 was admitted to the Intensive Care Unit (ICU) with [DIAGNOSES REDACTED]. On 07/18/18 at 11:40 AM, V17, R67's Physician stated it is a possibility the compression stockings could cause fluid to be pushed back up to the heart and cause an exacerbation of [MEDICAL CONDITIONS] or fluid overload. V17 stated V17 did not recall giving an order for [REDACTED]. V17 stated the facility should be notifying [MEDICAL TREATMENT] related to fluid balance and weight increases. On 07/18/18 at 02:20 PM - V18, Nursing Director of [MEDICAL TREATMENT] unit stated R67 came to the facility after hospitalization on [DATE]. V18 stated R67 readmitted to the hospital from the facility on 6/19/18 with Acute Respiratory Distress and had to be placed on a ventilator for breathing support. V18 stated R67 had gained 3kg (Kilograms) from 6/16/18 to 6/18/18 per [MEDICAL TREATMENT] weight records and [MEDICAL TREATMENT] could not get all R67's extra fluid weight off when they dialyzed R67 on 6/18/18. V17 stated if the facility would have communicated the facility's assessment of weight increase values prior to the [MEDICAL TREATMENT] treatment on 6/18/18, the [MEDICAL TREATMENT] unit could have evaluated and changed treatment to take additional fluid off and potentially avoided R67's fluid overload that sent R67 to the hospital on [DATE]. V17 stated that due to R67's hospitalization and fluid balance concerns, post hospitalization on [DATE], the [MEDICAL TREATMENT] unit had to decrease R67's target weight and increase time R67 was on [MEDICAL TREATMENT] machine due to extra fluid so they could pull more fluid from R67. V17 stated some facilities send a communication form, but that the facility R67 resides in does not send communications with the [MEDICAL TREATMENT] unit. V17 stated communication sheets would help with updates related to the residents condition as well as changes in vitals, weights, orders or cares. V17 stated it is really important for specialized care and communication between the facility and [MEDICAL TREATMENT]. V17 also stated the [MEDICAL TREATMENT] facility does not give orders related to compression stockings and that they would defer those requests to the primary care physician. V17 stated R67 gaining 11 pounds from 6/14/18 to 6/17/18 is excessive and the [MEDICAL TREATMENT] facility should have been notified so they could evaluate the need for any changes in [MEDICAL TREATMENT] treatment to address additional fluid. V17 also stated when R67 was admitted to the hospital and intubated on 6/19/18, they removed a lot of fluid and R67 had lost 15 pounds of fluid.

Surveyor: Larsen, Kimberly Based on interview and record review the facility failed to implement the plan of care for safe resident transfer for one of three residents (R1) reviewed for falls and mechanical lift use in a sample of three. This failure resulted in R1 incurring a fracture to the left pelvis. Findings include: The Minimum Data Set, 6/30/14, documents R1 as requiring extensive assist of two plus staff members for transfers. The Care Tool, 9/3/14, documents R1 as requiring a mechanical lift with the assistance of three staff persons for transfers. The Care Plan, 1/3/14, documents R1 as requiring a mechanical lift for transfers. The Event Report, 8/30/14 completed by E3 (Nurse), documents at 3:45pm R1 slipped out of the mechanical lift sling during a transfer. The witnesses to the incident are E4 and E10 (Nursing Assistants). R1 was sent to the emergency room for evaluation of a possible injury to the left leg and head. The Progress Notes, 8/30/14, document R1 admitted with a [DIAGNOSES REDACTED]. The Progress Notes, 9/3/14, document R1 returning to the facility at 6pm with a [DIAGNOSES REDACTED]. On 9/4/14 at 2:30pm, E9 (Nursing Assistant), stated on 8/30/14, while E9 assisted another resident, E4 and E10 (Nursing Assistants) entered R1's room to provide care prior to dinner. E9 was to return to R1's room to assist E4 and E10 transfer R1 with the mechanical lift after assisting the other resident. R1 was observed on the floor when E9 entered the room. E4 reported R1 slipped out of the mechanical lift sling during transfer. R1 is a three person transfer. On 9/4/14 at 1:26pm, E4 stated R1 is a three person transfer. E4 stated while E4 and E10 completed the mechanical lift transfer of R1 one strap of the sling came off and R1 fell to the floor. E4 confirmed she was supposed to wait for E9 to return to the room so E9 could assist E4 and E10 with R1's transfer. On 9/4/14 at 2:20pm, E10 (Nursing Assistant) stated on 8/30/14 at approximately 3:40pm, E4 and E10 entered R1's room to prepare R1 for dinner. E4 placed the mechanical lift straps on one side of the lift and E10 placed the straps on the remaining side. E10 used the controls to lift R1 off of the bed and R1 was moved away from the bed. E4 turned away to move the wheelchair so R1 could be lowered into the wheelchair. As E4 turned away, the strap fell off and R1 fell to the floor. E10 stated E4 and E10 were the only staff performing the transfer. On 9/4/14 at 11:25am, E2 (Director of Nursing), stated R1 is a three staff mechanical lift transfer due to size. The Computerized Tomography Report of the Abdomen, Chest and Pelvis, 8/30/14, documents an impression of a Left Inferior Pubic Ramus Fracture. The facility policy, Safe Resident Handling Policy, documents procedures to reduce resident handling injuries include the specific method for transferring residents will be communicated to the nursing and care staff by ensuring this information is included in the Care Tool that guides staff with resident care.

Based on observation, intervention and record review the facility failed to provide services to prevent decline of foot [MEDICAL CONDITION] by failing to monitor,assess, treat, notify the physician or recognize the deterioration of foot [MEDICAL CONDITION] for one of one residents (R14) reviewed for wounds/[MEDICAL CONDITION] in a sample of 18. This failure resulted in R14's left foot becoming infected requiring antibiotic therapy. Findings include: The current electronic facility face sheet documents that R14 was admitted to the facility on [DATE] and hospitalized from [DATE] - 7/9/2014. R14 has a [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documents R14 is moderately cognitively impaired, incontinent of urine and require one staff assistance for bathing, dressing and grooming. On 7/15/2014 at 2:30PM, E8 (Registered Nurse), removed the sheet covering R14's feet revealing the following dark brown [MEDICAL CONDITION] to the right foot: the bottom, tip and side of the great toe, the second toenail bed, third toe tip and toenail bed and the left foot: the side of the great toe, the second toe top and toenail bed, the third toe tip, the fourth toe tip, and the fifth toe tip. A lesion to the side of the right foot was also present with the surrounding area appearing red. Four [MEDICAL CONDITION] were also present to the right outer ankle area. E8 stated "I haven't seen R14's feet for several days . . . I'm not sure what treatment he is currently receiving. On 7/15/2014 at 2:45PM, E2 (Director of Nursing) and E7 (Wound Care Nurse) both agreed they were not aware R14 had multiple [MEDICAL CONDITION] on his feet. E7 stated " No one notified me that R14 had these multiple open areas on return from the hospital 7/9/2014. I was only aware of the areas to the outer left heel and left great toe which were being treated with skin prep. R14 also had several callous areas on his feet that we also applied skin prep to." R14's Physicians Order Sheet (POS) dated 7/1/2014 documents orders for daily skin assessments and the following treatment orders skin prep to left great toe and left heel. No treatments were ordered for any other areas of the feet. On 7/15/2014 at 12:50 PM, E11 (Licensed Practical Nurse) stated "I have skin prep ordered to the left great toe and left heel areas. These are the only treatments ordered for him (R14) and the only areas I treat." The Resident Admission assessment dated [DATE] at 9:00PM document these areas to the feet and ankles: left great toe outside discolored, callous back of right great toe, second - fourth toe of the right foot discolored areas, left heel 2 centimeter (cm) x 1.5 cm open area, left little toe scabbed, first and second toes scabbed areas , left outer great toe area scabbed and scabbed areas to the right ankle area. These areas are also marked on the anatomical body figure on the Assessment form. The progress note dated 7/9/2014 at 10:44 PM, documents "9 PM resident (R14) readmitted to the facility from the local hospital. Resident has several bruises over both arms and tops of hands. Resident has a large reddened area inside the left arm. Dark small spots noted on left foot and toes. Callous noted on back of right great toe. Resident continues in isolation for VRE in the urine." On 7/17/2014 at 11:00AM, E7 stated "daily skin checks are signed off by the nurses on the Electronic Medication Administration Record [REDACTED]." The progress notes dated 7/10/2014 through 7/15/2014 at 3:07 PM document no skin issues to the feet or ankle area for R14. The E-MAR dated 7/1/2014 for R14 document that a skin assessment was completed on the 5:00AM-5:00PM shift daily from 7/9/2014 - 7/14/2014. On 7/16/2014 at 11:00AM, Z4 (Nurse Practitioner) stated " He (R14) was hospitalized recently from 6/29/2014 - 7/9/2014. He had a very difficult time while hospitalized and was very combative. I was aware that he had [MEDICAL CONDITION] on his feet from kicking the foot board at the hospital due to a elevated International Normalized Ratio (INR) of 8. No one informed me the areas were red and swollen in appearance. I saw him yesterday but did not look at his feet. . . . His left foot is red on the heel, the great toe, second toe third toe and the lateral wound is swollen with red lines horizontally on the top of the foot to the wound. I ordered Keflex for the infected foot and skin prep to all [MEDICAL CONDITION]. I will reassess the areas on Friday (7/18/2014) and consider adding [MEDICATION NAME] ointment to the infected [MEDICAL CONDITION]. It is possible that he contaminated his feet with urine as he is incontinent and urinates on himself, therefore I can't rule out the possibility of VRE infection in the wounds." The Physical Exam Form completed 7/16/2014 by Z4 states "Multiple [MEDICAL CONDITION] to bilateral feet and ankles, left lateral wound with streaking redness, redness to left great toe, second toe, third toe and fifth toe of left foot and left outer ankle, with multiple dried [MEDICAL CONDITION]. Start Keflex and skin prep daily to [MEDICAL CONDITION]." On 7/16/2014 at 11:15AM, E2 confirmed that R14's left foot had more redness and swelling than on 7/15/2014. E2 stated "there was only slight redness around the lesion on the side of his (R14's) foot. There was no redness to any of the toes and there was no redness streaking from the side of the foot to the top of the foot. Nurses are to report any new open areas to the doctor, the wound nurse and myself. I was not notified of these [MEDICAL CONDITION] on his (R14's) feet." The undated facility policy "Skin Care Protocol" documents "If assessment reveals abnormal findings, notify Resident Quality Care Nurse, implement any facility protocols for wounds, and notify the physician."

Based on interview and record review the facility failed to transfer R1 following the plan of care to prevent injury for one out of three residents reviewed in a sample of three. R1 sustained a left tibia/fibia fracture. Findings include: R1 has a Brief Intermittent Medical score of 14 out of 15. Minimum Data Sheet dated 1/13/14 and coded an annual assessment states R1 requires extensive assistance of two staff for bed mobility, transfer, ambulation and toileting. Functional assessment dated [DATE] states R1 is assistance of two staff for bed mobility, transfer, toileting and ambulation. On 6/10/14, at 11:30 am, R1 stated that R1 was being transferred by E4 (Certified Nursing Assistant/CNA) from the commode to wheelchair on 4/2/14 at approximately 5:00 pm. R1 stated that E4 and E6 (Certified Nursing Assistant/CNA) transferred R1 to the commode but E6 left the bathroom after the transfer of R1 to assist answering other call lights and E6 stated would return to assist with the transfer off of the commode when E4 or R1 activated the call light. On 6/10/14, at 11:30 am, R1 stated that R1 had completed using the bathroom and E4 (CNA) was in a hurry and wanted R1 to "get going to eat dinner". R1 stated that R1 felt too slow for E4. R1 stated that E4 assisted R1 from commode to standing position and R1 was holding onto grab bar attempting to transfer to wheelchair. R1 stated R1 lost balance and E4 fell into R1 and landed on R1's left leg. E4 then immediately sat R1 back on to the commode. R1 stated that E4 performed the transfer without assist of another staff member or a gait belt. On 6/10/14, at 2:15 pm, E6 (CNA) stated that when E6 arrived to the bathroom approximately ten minutes later to assist with transfer from commode back to wheelchair, R1 already had trousers up. E6 questioned why R1 was sitting on the commode with trousers up. E6 stated that E4 (CNA) told E6 that E4 tried to transfer by self. E6 stated that R1 complained of left ankle pain at that time. E4 and E6 completed the transfer from commode to wheelchair at that time. Nursing note dated 4/2/14, at 5:00 pm, states that R1 was being transferred from toilet to wheelchair and twisted left ankle. X-ray report dated 4/2/14 documents findings as oblique fracture involving distal fibula and a fracture of the distal tibia. Hospital History & Physical dated 4/7/14 documents R1 was transferred and admitted to hospital on [DATE] with left tibia/fibia fracture requiring surgery. On 6/10/14, at 12:00 pm, Z2 (Physical Therapist) stated the R1 was not on therapy but was in a restorative program and that Z2 stated that R1 required assist of two staff due to inconsistency on functional abilities. On 6/10/14, at 1:50 pm, E3 (Director of Nursing/DON) stated that R1 did not experience a fall but R1's injury occurred during the transfer with E4. E3 stated that E3's recommendation would have been a two person transfer because of inconsistencies from day-to-day. E3 stated R1 is "not always the same" and assessment has been verified to always require two staff during transfers. Safe Resident Handling Policy effective July 2010 states, "The method for transferring, repositioning and mobilizing individual residents will be communicated to the nursing and care staff by ensuring this information is included in the residents care plan as well as on the care tool (Matrix) that guides the staff with resident care." The Policy also states, "Gait belts are to be used on anyone that is not independent."