Every finding on record at Inverness Rehab

Based on interview and record review, the facility failed to follow their change in condition policy by not notifying the provider about a resident's urinary retention and being unable to drain urine through catheterization. This failure has caused 1 of 3 residents (R1) in a sample of 3 reviewed for catheter care to be admitted to the intensive care unit (ICU) for aggressive treatment for sepsis secondary to urinary tract infection (UTI).The findings include:R1 is a [AGE] year-old female originally admitted on [DATE], having a slight cognitive impairment as per the Minimum Data Set (MDS) dated [DATE]. A further review of the MDS also documents that R1 was admitted with an admitting diagnosis including urinary retention and Urinary Tract Infection (UTI).A review of the admission progress note dated 12/26/25 documented that R1 was admitted with a Foley catheter in place.A review of the Physician Order Sheet (POS) and Medication Administration Record (MAR) documented a physician order in place dated 1/21/26 to start voiding trial after removing the Foley catheter and then do post void residual (PVR) every shift for five days. If PVR is greater than 300 milliliter (ml), straight catheter reinsertion, and third time reinsert foley catheter, and need to follow up with the Urologist.A review of R1's MAR documented that the bladder scan on 1/25/26: morning shift, 450; afternoon shift, 700; and night shift, 654. A review of the administration note dated 1/25/26 at 2:57 PM, V6 (Licensed Practical Nurse / LPN), documented a straight catheter (cath) draining approximately 500 ml of urine. A review of the general note dated 1/25/26 at 8:58 PM documented a bladder scan result of 716 ml urine, and V5 (LPN) straight cathed R1 and drained 650 ml urine out. A review of the administration note dated 1/26/26 at 4:54 AM documented that V6 (LPN) reinserted a 16 French Foley.On 2/5/26 at 6:15 AM, V6 (LPN) stated, I did the bladder scan for R1 on 1/25/26 night shift, and it was over 300. I reinserted foley, but it was not draining. Another nurse (V8) also tried and was still not draining. After the morning report, I removed the Foley as it was not draining. I know I should have reached out to the urologist or physician on call to let them know that R1 was retaining urine and was unable drain with a catheter.On 2/5/26 at 8:15 AM, V8 (LPN) stated, V6 was the nurse for R1 on 1/25/36 night shift, and she told me she tried twice to insert foley on R1 as the bladder scan was over 700. She asked for my help, and I inserted foley and it was not draining. V6 told me to leave the Foley in place and wait for a while to see if it drains. I believe the foley was not in place, and that's why it wasn't draining.On 2/5/26 at 8:25 AM, V7 (Morning Nurse/LPN on 1/26/26) stated, When I got the report from V6 on 1/26/26 morning shift, the foley was still there. I removed it as it wasn't draining, reinserted a new one, and the Foley still wasn't draining. I didn't notify the physician (MD) or nurse practitioner that the indwelling catheter was not draining.On 2/4/26 at 4:45 PM, V10 (hospital social worker) reported that R1 was sent from the urology appointment to the emergency room on 1/28/26 due to low blood pressure and lethargy, diagnosed with urinary retention and sepsis caused by a UTI, and was admitted to the ICU for intensive treatment.On 2/5/26 at 9:10 AM, V2 (Director of Nursing/DON) stated, If the foley is not draining, it may not have been in place. If multiple staff members couldn't reinsert the Foley in the right place to drain urine, my staff should notify the physician and follow their order.On 2/4/26 at 3:43 PM, V12 (Nurse Practitioner / NP) stated, I was on call, and nobody called me to report on R1's urinary retention or inability to drain urine through a Foley catheter. The voiding trial order clearly states to reinsert the Foley a third time if the post-void residual is greater than 300 ml and to follow up with a urologist. Urinary retention can cause discomfort and UTI to residents.The facility presented an acute change of condition policy (dated 1/5/25) statement document: It is the policy of this facility to promptly identify, evaluate, address, and report a resident's change in condition.Procedure:4. Phone calls to attending or on-call physicians should be made by the nurse who has collected pertinent information, including the resident's current symptoms and status, onset, duration, severity of the change in condition, and available strategies to manage the change of condition in the facility if appropriate.

Based on Observation, interview and record review, the facility failed to ensure food items in the walk-in refrigerator were labeled or dated. This practice has the potential to affect all 116 residents residing in the facility who receives food from the kitchen. The facility also failed to document personal refrigerator temperature logs and discard expired food from the refrigerators for seven residents R23, R28, R43, R30, R43, R65 and R72 reviewed for refrigerator logs in a sample of 24 residents.During an initial tour of the kitchen on 8/19/25 at 10:00am, surveyor and V17(Food service Director) observed in the walk-in freezer a sandwich condiment tray containing coleslaw salad, egg salad, lettuce, tomatoes, and sliced turkey with a use by date of 8/15/25. During an interview, at 10:15 am, V17 stated that the condiments tray should not be in the refrigerator. Facility policy dated 1/25/2025 title: Date Marking for Food Safety reads, The facility adheres to a date marking system to ensure the safety of ready- to -eat, time/ temperature control for safety food. Policy explanation and compliance guidelines for staffing: 2.The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 6. The head cook, or designee, shall be responsible for checking the refrigerator daily for food items that are expiring, and shall discard accordingly. On 8/19/25 at 11:10AM, observed R23's personal refrigerator temperature log sheet filled in up until the 12th of August and after that there is no entered temperature. On 8/19/24 at 11:40AM, observed and confirmed withV4 (ADON) that the temperature log sheet is not completed and that V4 confirmed that temperatures are checked daily. V4 is not aware who is the responsible person checking the personal refrigerators in residents' rooms. R30 is [AGE] year-old female who was admitted in the facility on 04/26/2025 with diagnoses of not limited to type 2 diabetes mellitus and morbid obesity. On 08/19/2025 at 10:24AM during unit rounds, R30's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 10:56AM during unit rounds with V14 (Registered Nurse), R30's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. R30's personal refrigerator had undated cut watermelon in a resealable bag. On 08/19/2025 at 10:56AM during interview with V14, V14 stated that R30's food items should be labeled and dated. V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. R65 is [AGE] year-old male who was admitted in the facility on 10/11/2022 with diagnoses of not limited to type 2 diabetes mellitus and chronic kidney disease stage 3. On 08/19/2025 at 11:04AM during unit rounds, R65's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 11:04AM during unit rounds with V14 (Registered Nurse), R65's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 11:04AM during interview with V14, V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. V2 stated that all food items in the resident's refrigerator should be discarded past the use by date. R72 is [AGE] year-old male who was admitted in the facility on 08/23/2022 with diagnoses of not limited to unspecified dementia and gastro-esophageal reflux disease. On 08/19/2025 at 10:11AM during unit rounds, R72's personal refrigerator temperature log for August 2025 indicated last entry of temperature on 08/12/2025. On 08/19/2025 at 10:55AM during unit rounds with V14 (Registered Nurse), R72's personal refrigerator temperature log for August 2025 again indicated last entry of temperature on 08/12/2025. R72's personal refrigerator had unlabeled and undated food items in the dessert cup and soup bowl. It also had 8 peach yogurts, one each with use by dates of 12/30/2024, 07/05/2025 and 07/31/2025 respectively, two with use by dates 05/15/2025, and three with use by date 05/22/2025. On 08/19/2025 at 10:55AM during interview with V14, V14 stated that R72's food items should be labeled and dated, and R72's yogurts should have been discarded before the use by date. V14 also stated that he is not sure how frequent the residents' refrigerators are cleaned and temperatures are checked. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that housekeeping staff checks the temperature of the residents' refrigerators daily and cleans it weekly. Review of R72's care plan revised 08/18/2025 indicated R72 has the tendency to store and keep items/food items in his room or refrigerator with interventions including check items that should be discarded, check expiration date of food, and offer to throw away as he allows. Review of R72's Progress Notes from May 2025 to present did not indicate any refusal of discarding food items from R72's refrigerator. Review of facility's policy entitled Resident Refrigerators implemented on 08/01/2025 indicated the following: Policy: This facility does not provide a refrigerator in a resident's room. However, it is the policy of this facility to ensure safe and sanitary any resident-owned refrigerators. Policy Explanation and Compliance Guidelines: 2. Staff shall record refrigerator temperatures weekly on a temperature log 3. Staff should clean the refrigerator weekly and discard any foods that are out of compliance. 4. Residents and staff shall comply with safe food handling and storage principles: b. Leftovers shall be dated upon receipt and discarded within three days. c. Foods with use-by dates shall be discarded accordingly. d. Any food with potential concerns (i.e. smell, packaging, appearance, frozen foods are not solid to touch) shall be discarded. 8. Noncompliance with safety and sanitation requirements of this policy will result in the removal of the refrigerator from the resident's room. On 8-19-25, surveyor observed R43's (at 10:27 AM) and R28's refrigerator logs with documented temperatures up to August 12,2025 with no further refrigerator temperatures documented. On 8-19-25 at 11:34 AM, V10 (Licensed Practical Nurse) said the refrigerator temperatures are checked and documented by the night shift nurse daily. On 8-22-25 at 11:01 AM, V2 (Director of Nursing) said the housekeeper is responsible for checking refrigerator temperatures and documenting on the log sheet. V2 said the refrigerator logs were overlooked when this task was not assigned when the housekeeper was not on duty.

Based on observation, interview, and record review, the facility failed to ensure infection control measures are implemented and prescribed oxygen inhalation was administered for 10 of 10 residents (R7, R14, R15, R23, R36, R45, R60, R63, R86, R98) reviewed for oxygen in a sample of 24. Findings include: R7 is a [AGE] year-old female admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, chronic kidney disease, heart failure, hypertension, anemia, atherosclerotic heart disease of native coronary artery without angina pectoris and peripheral vascular disease. On 8/19/2025 at 11:30 AM, R7 observed sleeping on the bed with oxygen concentrator @ 2LPM (liters per minute), humidification bottle not labeled, via nasal cannula (NC), oxygen tubing located on the floor with no date or labeling on the tubing. No oxygen sign located on doorway, nowhere visible. Oxygen via nasal cannula was not on R7. On 8/19/2025 at 1:00 PM V2 (Director of nurse), made aware of above findings and said it is expected for the nurses to ensure the nasal cannula is on R7 as ordered per physician's order and check R7s oxygen saturation level. Reviewed R7s medical records. R7 admitted on [DATE]. Active physician order shows 2L (2 LITERS) of oxygen O2 via NC continuously to keep SPO2 >92% every shift for oxygen, ordered on 6/23/2025. R7 admitted to Journey Care hospice diagnosis of congestive heart failure on 07/19/2025. Care plan revision date for 8/6/2025 with no respiratory/oxygen care plan. Weights and vitals summary report shows oxygen via nasal cannula was not administered daily per physician's order with no nurse's documentation of patient refusal to wear nasal cannula. Facility's policy on Oxygen Administration- Purpose: oxygen will be safely administered per physicians' orders. Place oxygen in use sign at the door of the residence room when is use smoking prohibited. Nasal cannula procedure place the nasal cannula into position by having one prong in each nostril adjust the strap for proper fit if hermeneutic humidification is used change humidifier bottle every seven days or as needed may label with date and initial. Policy medication administration- Observe resident consumption of medication. Administer medication(s) according to physician order. 1.R14 is an [AGE] year-old male with admission date of 11/24/2022 and diagnosis of not limited to chronic obstructive pulmonary disease. On 08/19/2025 at 10:51AM during unit rounds, R14 has an undated nasal cannula connected to oxygen concentrator. On R14's nightstand, there is an undated and uncovered nebulizer mask. On 08/19/2025 at 10:54AM during unit rounds with V14 (Registered Nurse), R14 was again observed with an undated nasal cannula connected to oxygen concentrator. At the same time, an undated and uncovered nebulizer mask was again observed on R14's nightstand. On 08/19/2025 at 10:54AM during interview with V14, V14 stated that R14's nasal cannula and nebulizer mask should be dated when changed. V14 also stated that the nebulizer mask should be stored in a bag at bedside after each use. Review of R14's Order Summary Report dated 08/20/2025 indicated an order for nebulization treatment with order date of 07/23/2025 2.R63 is a [AGE] year-old male with admission date of 12/28/2014 and diagnosis of not limited to chronic obstructive pulmonary disease. On 08/19/2025 at 10:50AM during unit rounds, R63 has an undated nasal cannula connected to oxygen concentrator. On R63's nightstand, there is an undated and uncovered nebulizer mask. On 08/19/2025 at 10:54AM during unit rounds with V14 (Registered Nurse), R63 was again observed with an undated nasal cannula connected to oxygen concentrator. At the same time, an undated and uncovered nebulizer mask was again observed on R63's nightstand. On 08/19/2025 at 10:54AM during interview with V14, V14 stated that R63's nasal cannula and nebulizer mask should be dated when changed. V14 also stated that the nebulizer mask should be stored in a bag at bedside after each use. Review of R63's Order Summary Report dated 08/21/2025 indicated an order to change nebulizer and tubing weekly and as needed with order date of 10/14/2023, an order for changing oxygen tubing and humidifier bottle as needed and every Wednesday night shift with order date of 03/19/2023, and an order for oxygen at 2-3 liters per minute via nasal cannula at bedtime and day time with order date of 09/28/2020. 3.R86 is an [AGE] year-old female with admission date of 04/18/2025 and diagnoses of not limited to chronic obstructive pulmonary disease, sarcoidosis and obstructive sleep apnea. On 08/19/2025 at 10:04AM during unit rounds, there was an uncovered BiPAP (Bilevel Positive Airway Pressure) mask on R86's nightstand. (BiPAP machine is used to treat sleep apnea.) On 08/19/2025 at 10:58AM during unit rounds with V14 (Registered Nurse), an uncovered BiPAP mask was observed again on R86's nightstand. On 08/19/2025 at 10:58AM during interview with V14, V14 stated that R86's BiPAP mask should be kept in a bag after each use. Review of R86's Order Summary Report dated 08/20/2025 indicated an order for BiPAP while sleeping every evening and night shift with order date of 06/04/2025. 4.R98 is a [AGE] year-old male with admission date of 07/09/2025 and diagnoses of not limited to unspecified asthma and obstructive sleep apnea. On 08/19/2025 at 10:31AM during unit rounds, there was an uncovered CPAP (Continuous Positive Airway Pressure) mask hanging on the side of the metal shelf at R98's bedside. (CPAP machine is most commonly used to treat sleep apnea.) On 08/19/2025 at 10:58AM during unit rounds with V14 (Registered Nurse), an uncovered CPAP mask was observed again on hanging on the side of the metal shelf at R98's bedside. On 08/19/2025 at 10:58AM during interview with V14, V14 stated that R98's CPAP mask should be kept in a bag after each use. Review of R98's Order Summary Report dated 08/20/2025 indicate an order for CPAP use with order date of 07/28/2025. Review of facility's policy entitled Oxygen and Respiratory Equipment- Changing/Cleaning revised on 09/19/2023 indicated the following: Guidelines Purpose: 2. To ensure the safety of residents by providing maintenance of all disposable respiratory supplies. 3. To minimize the risk of infection transmission. Procedure: 1. Handheld nebulizer and mask, if applicable. a. The handheld nebulizer should be changed weekly and PRN (as needed). b. A clean plastic bag will be provided with each new setup 2. Nasal cannula a. Nasal cannulas are to be changed once a week and PRN. c. A clean plastic bag will be provided to store the cannula when it is not in use. R15 is a [AGE] year-old male resident with diagnoses of but not limited to: hemiplegia and hemiparesis, dementia, type 2 diabetes mellitus, obstructive sleep apnea, and dependence on other enabling machine and devices. On 8/19/25 at 10:20AM, R15 observed to be in bed. Awake and alert. CPAP not in used. On top of side cabinet drawers. Not in plastic bag and left open to air. Next to it is a Nebulizer mask and with tubing not dated. And not stored in plastic bag and left open to air. On 8/19/25 at 11:04AM, V4 (ADON) stated that V4 will change the whole tubing for Nebulizer, since it is not dated and not stored in plastic. V4 stated that without the date, they don't know how long it's been being used. V4 stated that the Neb tubing and Mask is changed weekly, and that is why putting the date is important on the tubing. V4 also stated they store CPAP Mask/and Neb mask in plastic bag and do not leave it open to air. To keep it clean. And to follow their infection control practices. Physician order sheet reviewed. R15 has an order for Change nebulizer tubing and mask weekly and as needed dated 5/29/24. CPAP (Continuous Positive Airway Pressure) at bedtime dated 9/9/23. CPAP machine is a common treatment for sleep apnea, helping to keep airways open during sleep by delivering a continuous stream of air. R23 is a [AGE] year-old male resident, with diagnoses of but not limited to: paraplegia chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel. On 8/19/25 at 11:40AM. R23 is in bed, alert and awake. Observation and confirmed with V4 (ADON) that the Oxygen Tubing and humidifier not dated and not in storge and not stored in plastic bag and is hanging on Right side rail of R23. Per R23 it was just changed today, and V4 made a comment that V4 is glad that R23 is alert and oriented and able to tell that it was just changed. V4 also stated that the oxygen tubing is changed weekly, and the reason for dating the equipment so the staff would know when to change the tubing. Physician Order Sheet reviewed and R23 has an order for Change oxygen tubing weekly and as needed with an order date of 11/23/24. On 8-19-25 at 10:20 AM, surveyor observed R60's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag. At 10:32 AM, surveyor observed R36's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag. At 11:09 AM, surveyor observed R45's nebulizer mask on the bedside table, open to air, and not stored in a plastic bag and R45's nasal canula on the floor and not stored in plastic bag. On 8-19-25 at 11:34 AM, V10 (Licensed Practical Nurse) said she was not aware of the mask and nasal canula laying open to air on the bedside table and V10 said she will ensure the nebulizer mask will be stored in plastic bag. V10 said the nebulizer mask and nasal tubing should be stored in plastic bag for infection control. On 8-21-25 at 11:01, V1 (Director of Nursing) said nebulizers masks and nasal tubing are stored in plastic bags for infection control.

Based on observation, interview, and record review, the facility failed to accurately account for controlled medications for four of four residents (R42, R63, R87, R98) reviewed for controlled medications in a sample of 24. Findings include:1. R98 is a [AGE] year-old male with admission date of 07/09/2025 and diagnoses of not limited to unspecified asthma and obstructive sleep apnea. Review of R98's Order Summary Report dated 08/20/2025 indicated an order for Pregabalin 100mg (milligram) one time a day with order date of 07/09/2025. On 08/20/2025 at 10:25AM during medication administration observation with another surveyor, V11 (Licensed Practical Nurse) removed a pill from R98's Pregabalin 100mg blister pack. At 10:40AM after giving the medications to R98, V11 went back to the cart and did not sign R98's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg. 2. On 08/20/2025 at 11:38AM during review of controlled medications with another surveyor and V11, the following were noted:1. R42's medication blister pack of Lorazepam 1mg indicated there were 11 pills left and R42's Controlled Drug Receipt Record/Disposition Form of Lorazepam 1mg indicated there were 12 pills left on the blister pack2. R63's medication blister pack of Hydrocodone-Acetaminophen 5-325mg indicated there were 25 pills left and R63's Controlled Drug Receipt Record/Disposition Form of Hydrocodone-Acetaminophen 5-325mg indicated there were 27 pills left on the blister pack3. R63's medication blister pack of Pregabalin 100mg indicated there were 31 pills left and R63's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg indicated there were 32 pills left on the blister pack4. R87's medication blister pack of Alprazolam 1mg indicated there were 33 pills left and R87's Controlled Drug Receipt Record/Disposition Form of Alprazolam 1mg indicated there were 34 pills left on the blister pack5. R98's medication blister pack of Pregabalin 100mg indicated there were 9 pills left and R98's Controlled Drug Receipt Record/Disposition Form of Pregabalin 100mg indicated there were 10 pills left on the blister pack On 08/20/2025 at 11:38AM during interview with V11, V11 stated that she has not signed the Controlled Drug Receipt Record/Disposition Form yet of those residents that she gave the medications already. V11 stated that she should have signed the Controlled Drug Receipt Record/Disposition Form after each administration of the medications to the residents. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that nurses are expected to sign the Controlled Drug Receipt Record/Disposition Form after each administration of the medication to the residents. V2 stated that V11 signed R42's R63's, R87's and R98's Controlled Drug Receipt Record/Disposition Form before making copies. R42 is a [AGE] year-old female with admission date of 07/23/2025 and diagnoses of not limited to borderline personality disorder, major depressive disorder, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder. Review of R42's Order Summary Report dated 08/21/2025 indicated an order for Lorazepam 1mg three times a day with order date of 07/23/2025. R63 is a [AGE] year-old male with admission date of 12/28/2014 and diagnosis of not limited to hereditary motor and sensory neuropathy. Review of R63's Order Summary Report dated 08/21/2025 indicated an order for Hydrocodone-Acetaminophen 5-325mg every 4 hours with order date of 04/02/2024 and an order for Pregabalin 100mg two times a day with order date of 06/25/2025. R87 is a [AGE] year-old female with admission date of 02/27/2025 and diagnoses of not limited to anxiety disorder, panic disorder, major depressive disorder and depression. Review of R42's Order Summary Report dated 08/21/2025 indicated an order for Alprazolam 1mg two times a day with order date of 08/19/2025. Review of facility's policy entitled Medication Administration implemented on 01/01/2025 indicated the following:Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.Policy Explanation and Compliance Guidelines:21. If medication is a controlled substance, sign narcotic book.

Based on observation, interview, and record review, the facility failed to ensure medications are stored securely for two of two residents (R80, R122) reviewed for medication storage in a sample of 14. The facility also failed to label multidose medication with open date which has the potential to affect all 24 residents currently residing in Unit 3, and all potential new admissions in Unit 3. Findings include: R122 is a 73- year- old male admitted on [DATE] with medical diagnoses that include and are not limited to: diabetes mellitus type 2, adjustment disorder with depressed mood, hypertension heart disease without heart failure, atrial fibrillation and peripheral vascular disease. On [DATE] at 11:20 AM, observed a medication cup with multiple medications left at bedside in R122's room and no nurse in the room. On [DATE] at 11:00 AM R122 stated he did not know how long those medications have been sitting on the nightstand. R122 stated he had barely gotten out of his bed to sit in his wheelchair one hour ago. On [DATE] at 11:24 AM, V4 (assistant director of nurse, ADON) said medications should not be left on the nightstand by the nurse and medication administration should be administered by the nurse who prepared the medications. V4 (assistant director of nurse) went into R 122's room and removed the medications from his room. On [DATE] at 11:26 AM V7 (Registered nurse) had first stated she did administer R122 medications in the morning. After being told medications were just observed in R122s nightstand then V7 (registered nurse) said she left the medication at bedside and did not observe the patient take his medications. V7 (registered nurse) was made aware that V4 (ADON) had removed the medications from R122s room. On [DATE] at 1:00 PM V2 (Director of nurse) said V7 (Registered nurse) should have observed R122 take his medication and not leave the medications unsupervised at the bedside. Review of 122's order summary R122 does not have any medications scheduled for 6:00 am morning medications. The medication Admin Audit Report shows 14 medications were administered to the patient approximately 8:00 am. However, on [DATE] at 11:20 am medications were observed in R122's room on nightstand. Record Reviewed, there is no physicians order that states R122 may self-administer medication. Facility's Policy on Medication administration. Policy: Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice in a manner to prevent contamination or infection. 18. Observe resident consumption of medication. 19. Administer medication(s) according to physician order. 1. On [DATE] at 9:56AM during unit rounds, there was medication cup with round, white pill and half of an oval, orange pill at R80's bedside table. On [DATE] at 10:05AM during unit rounds with V4 (Assistant Director of Nursing), there was again a medication cup with round, white pill and half of an oval, orange pill at R80's bedside table. On [DATE] at 10:05AM during interview with V4, V4 stated that there shouldn't be any medications left at the resident's bedside. V4 stated that the pills on R80's bedside table looked like it was spit out. V4 also stated that nurses are expected to make sure that the resident completely swallowed their medications upon administration and before leaving the resident's room. 2. On [DATE] at 10:17AM during medication storage review with V15 (Licensed Practical Nurse), Unit 3 medication refrigerator had an open and undated vial of Tuberculin Purified Protein Derivative. The manufacturer container reads Once entered, vial should be discarded after 30 days. On [DATE] at 10:17AM during interview with V15, V15 stated that the open file of Tuberculin Purified Protein Derivative should be dated when it was opened and be discarded 30 days after it was opened. Review of facility's policy entitled Medication Storage implemented on [DATE] indicated the following: Policy: It it's the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Policy Explanation and Compliance Guidelines: 1. General Guidelines: c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. Review of facility's policy entitled Medication Administration implemented on [DATE] indicated the following: Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines: 13. Identify expiration date. If expired, notify nurse manager. 18. Observe resident consumption of medication.

Based on observation, interview, and record review, the facility failed to implement infection control measures during medication administration procedures for four of four residents (R3, R21, R30, R39) reviewed for medication administration in a sample of 24. Findings include:1. R21 is an [AGE] year-old male with admission date of 08/19/2025 and diagnosis of not limited to hyperlipidemia. On 08/20/2025 at 9:36AM during medication administration observation with another surveyor, V10 (Licensed Practical Nurse) disinfected a scissor with disinfectant wipes while wearing gloves then immediately proceeded to cutting the top of R21's Omega-3 fatty acids soft gel capsule without performing hand hygiene and changing gloves. On 08/20/2025 at 9:51AM during interview with V10, V10 stated that she should have performed hand hygiene and changed gloves before she cut R21's Omega-3 fatty acids soft gel capsule. Review of R21's Medication Administration Record for August 2025 indicated that V10 partially administered R21's crushed medications to R21 on 08/20/2025. Review of R21's Order Summary Report dated 08/21/2025 indicated R21 has orders for may crush medications and administer in food or liquids unless contraindicated with order date of 08/19/2025, and Omega-3 Fatty Acids Capsule 1000 mg (milligrams) one time a day with order date of 08/19/2025. 2. R3 is a [AGE] year-old male with admission date of 08/15/2025 and diagnosis of not limited to Klebsiella pneumonia as the cause of diseases classified elsewhere. On 08/20/2025 at 10:02AM during medication administration observation with another surveyor, V4 (Assistant Director of Nursing) while being observed by the facility's unit manager orientee, prepared the R3's intravenous (IV) antibiotic while wearing gown, gloves and mask. V4 was unable to remove air bubbles from the IV tubing so she asked the unit manager orientee to get her another bag of IV antibiotics. While waiting for the new bag of antibiotics, V4 patted R3 on R3's right arm apologizing for the delay. When the unit manager orientee came back and handed her the bag of IV antibiotics, V4 immediately proceeded with preparing the IV antibiotic without performing hand hygiene and changing gloves. On 08/20/2025 at 2:00PM during interview with V2 (Director of Nursing), V2 stated that V4 was expected to perform hand hygiene and change gloves after she touched R3 and before V4 prepared the new bag of IV antibiotics. Review of R3's Order Summary Report dated 08/21/2025 indicated R3 was admitted on [DATE] and has an order for Ertapenem sodium solution 1 gram intravenously in the morning with order date of 08/17/2025. Review of facility's policy entitled Hand Hygiene implemented on 01/05/2025 indicated the following:Policy: All staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Policy Explanation and Compliance Guidelines:2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand Hygiene Table conditions included after handling contaminated objects, before preparing or handling medications, and before and after handling clean or soiled dressings, linens, etc. 3. R30 is [AGE] year-old female who was admitted in the facility on 04/26/2025 with diagnoses of not limited to type 2 diabetes mellitus and morbid obesity. On 08/20/2025 at 11:32AM during medication administration observation with another surveyor, V11 (Licensed Practical Nurse) placed the blood glucose monitoring machine on R30's bedside table without placing a barrier before pricking R30. On 08/20/2025 at 11:37AM during interview with V11, V11 stated that she should have placed the blood glucose monitoring machine on the tray that she has instead of the bedside table. Review of R30's Medication Administration Record for August 2025 indicated that V11 performed blood glucose monitoring on R30 on 08/20/2025. 4. R39 is a [AGE] year-old female who was admitted in the facility on 06/19/2025 with diagnosis of not limited to type 2 diabetes mellitus. On 08/20/2025 at 11:51AM during medication administration observation with another surveyor, V12 (Licensed Practical Nurse) placed the blood glucose monitoring machine on R39's bedside table without placing a barrier before pricking R39. On 08/20/2025 at 11:37AM during interview with V12, V12 stated that she should have brought a tissue with her and placed it on the bedside table then she could have placed the blood glucose monitoring machine on that tissue. Review of R39's Medication Administration Record for August 2025 indicated that V12 performed blood glucose monitoring on R39 on 08/20/2025. Review of facility's undated document entitled Blood Glucose Testing Competency indicated the following:Competency/Skill:5. Places clean paper towel or clean barrier and places supplies on surface.

Based on observation, interview, record review, the facility failed to ensure low air loss mattress device was on the correct weight setting for a resident identified to be high risk in developing pressure ulcers. This deficient practice affects one (R23) of three residents reviewed for pressure injury prevention and treatment in a final sample of 24 residents. Findings Include: R23 is a [AGE] year-old male resident, with diagnoses of but not limited to: paraplegia chronic respiratory flare, heart failure, morbid obesity, anemia, and neurogenic bowel.On 8/19/25 at 11:10AM, observed R23 in bed, awake and alert on low air loss mattress set on 420 lbs. Per R23, he weighs 314 lbs the last time R23 was weighed.On 8/19/25 at 11:40AM, Observed and confirmed with V4 (ADON) that the low air loss mattress is set on 420 lbs. R23 commented that that is the setting R23 is comfortable with.On 8/21/25 at 8/21/25 at 10:30AM, V13 (Wound Nurse) stated that R23 is high risk for skin alteration such as pressure ulcer inuries. Stated that the resident has a pressure ulcer in the sacrum area, stage 4. Stated that the resident is noncompliance with the setting of the low air loss mattress and at times would instruct the staff to adjust the setting. Stated that the staff were also educated and R23 about the importance of staying in compliance with the low air loss mattress setting. V4 stated that the setting of low air loss mattress should be based on the resident's weight per manufacturers recommendation. Stated that R23 weighs 314 pounds currently. Stated that the resident is using this special mattress such as low air loss mattress for preventative measures for skin alteration and to relieve pressure. Requested for resident education form and staff education form from V13, and V13 failed to provide the resident education form for R23 and staff education. Physician Order Sheet reviewed and R2 has an order for specialty mattress such as low air loss mattress dated 11/22/24. Physician Orders also indicate that staff should change oxygen tubing weekly and as needed with an order date of 11/23/24. R23 has a care plan for at risk for skin impairment pressure ulcer due to paraplegia, CHF, edema, fragile skin, impaired/limited mobility, Incontinence/exposure to moisture, morbid obesity, impaired sensory perception, is chair fast, anticoagulant medication use, and presence of pressure ulcer. Sacrum - ulcer. Intervention reads to provide pressure relieving mattress (low air loss).Braden scale for predicting pressure sore risk dated 7/1/2025, scored 12. Scoring shows 10-12 is high risk.Wound Doctor progress note dated 8/8/2025 shows that R23 has a stage 4 pressure wound in sacrum full thickness with objective to prevent deterioration.R23 record reviewed. R23 has a current weight recorded as 314.4 lbs dated 8/6/25.Pressure injury Prevention and Management Policy with a review date of 6/17/2025, reads in part: This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/ injury, prevent infection and the development of additional pressure ulcer/injuries.Facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize; reduce or remove underlying risk factor; monitoring the impact of the intervention; And modifying the intervention as appropriate.Assessment of pressure injury risk. Licensed nurses will conduct a Braden scale tool form on all residents upon admission /re-admission, weekly times 4 weeks, then quarterly or whenever the residents condition changes significantly.The tool will be used in conjunction with other risk factors not captured by the risk assessment tool. Example of risk factors include but not limited to [NAME] impaired decreased mobility and decreased functional ability; Comorbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus, resident refusal of some aspect of care and treatment.Use of Support Surface Policy not dated, reads in part: Support surfaces will be used in accordance with evidence based practice for residents with or at risk for pressure injury. Support surfaces will be chosen by matching the potential therapeutic benefit with the resident specific situation. The goal and preferences of the resident and/ or authorized representative will be included in the plan of care and support surface selection. Support surfacess will be utilized in accordance with the manufacturer's recommendation including consideration for contraindication.

Based on interview and record review, the facility failed to provide services to maintain the highest level of mobility for one of six residents (R14) reviewed for mobility in a sample of 24. Findings include:R14 is an [AGE] year-old male with admission date of 11/24/2022 and diagnosis of not limited to chronic obstructive pulmonary disease and acquired absence of left leg above knee. During record review, R14 was not on any restorative nursing program. R14's Functional Abilities and Goals dated 06/03/2025 indicated R14 needs partial/moderate assistance with chair/bed-to-chair transfer and toilet transfer, and tub/shower transfer. Review of R14's Rehabilitation Screening Form dated 05/06/2025 indicated R14's current level of assistance with transfer was standby assist (SBA). Review of R14's Physical Therapy Discharge Summary on 01/23/2025 indicated R14's functional skills assessment revealed that R14 was independent with chair/bed-to-chair transfer and toilet transfer. On 08/20/2025 at 11:35AM during interview with V6 (Minimum Data Set Coordinator), V6 stated that the facility does not have a Restorative Nurse or Aides, and they currently do not have any residents on restorative nursing programs. On 08/21/2025 at 12:59PM during interview with V5 (Therapy Director), V5 stated that R14 was discharged from Physical Therapy on 01/23/2025 independent with chair/bed-to-chair transfer and toilet transfer. V5 also stated that she screens residents after 3-4 months from discharge to see if they had a decline or improvement with their functional abilities. V5 stated that when she screened R14 on 05/06/2025, R14 was on the same level of functional ability the reason why R14 was not picked up for therapy. V5 stated that she was not aware that R14 declined with transfer abilities, and if so, she could have screened R14 and determined if therapy is needed.

Based on observation, interview, and record review, the facility failed to implement interventions to reduce accident hazards and risks for one of two resident (R100) reviewed for accidents in a sample of 24. Findings include:R100 is an [AGE] year-old female who was admitted in the facility on 10/17/2024 with diagnoses of not limited to history of falling, anxiety disorder, Alzheimer's disease and unspecified dementia. On 08/19/2025 at 9:51AM during unit rounds, V8 (Hospice Certified Nursing Assistant/CNA) was performing incontinence care and assisting R100 with personal hygiene. V8 called for assistance from facility staff to transfer R100 via mechanical lift in which V9 (CNA) responded. V8 placed the reclined chair on the corner at the foot of the bed with the head part closer to the bed. V9 stood on the left side of the reclined chair which was the farther side from R100. V8 controlled the mechanical lift, and no staff was guiding R110's body midair while being transferred by V8. On 08/19/2025 at 9:55AM during interview with V8, V8 stated that V9 should be by R100's leg guiding it while R100 is midair and in the process of being transferred to the reclining chair. On 08/19/2025 at 12:55PM during interview with V9, V9 stated that she was supposed to hold R100's legs to guide and support while R100 is midair and in the process of being transferred to the reclining chair. On 08/21/2025 at 1:10PM during interview with V5 (Therapy Director), V5 stated that there should be two people assisting the resident when being transferred using a mechanical lift. V5 stated that one person is to control the mechanical lift and another person touching and guiding the resident, moving at the same time as the mechanical lift is moved, until the resident is completely transferred to where the resident is to be transferred. Review of R100's Care Plan revised 08/06/2025 indicated that R100 has ADL self-care performance and mobility deficits and interventions include to transfer with mechanical lift with 2-person assist. Review of R100's Minimum Data Set Section GG dated 08/01/2025 indicated that R100 is dependent with chair/bed-to-chair transfer, and Dependent is defined as helper does all of the effort, resident does none of the effort to complete the activity, or the assistance of 2 or more helpers is required for the resident to complete the activity.

Based on interview and record review the facility failed to provide medication as ordered by the prescriber to meet the needs of the resident, including acquiring medications. This failure affects one of three residents (R2), reviewed for medication administration.Findings include: On 8/7/2025 at 11:00am R2 said on Sunday 8/3/2025 and she think also Monday 8/4/2025 she did not have her 9am or her 1pm medication, it is for her anxiety and she was not informed until she counted her medication and it was short a pill, she then ask the nurses and they both said the medication had not been delivered, I then informed the social worker I wanted to file a grievance. On 8/7/2025 at 11:40am V3(Social Services Director-SSD) said that R2 ask to file a grievance because the nurse had not administered her medication, I did assist her with the grievance and then I informed the Assistant Director of Nursing-ADON. On 8/7/2025 at 12:00pm V4(Assistant Director of Nursing-ADON) said that V2 had already been informed about the medication not being administered, my expectation is that the nurses will retrieve the medication out of the emergency box as per policy and follow up with the pharmacy on the expected delivery. On 8/7/2025 at 12:45pm V5(Registered Nurse-RN) said on 8/3/2025, R2 did not have any Lorazepam (1.0 milligram-mg). I should have pulled the medication from the emergency box I informed my supervisor instead; I did not give the 9am or the 1 pm dosage. On 8/7/2025 at 1:30pm V6 (Licensed Practical Nurse-LPN) said on 8/4/2025, R2 did not have any Lorazepam (1.0 milligram-mg) dosage I called the pharmacy, and the delivery was due to come in, the protocol is to pull the medication from the emergency box she did not receive the 9am or 1pm dosage. On 8/7/2025 at 12:15pm V2 (Director of Nursing-DON) said, I expect the medication to been pulled from the emergency box, R2 did not receive medication the 9am and 1pm dose on 8/3/2025 and 8/4/2025. A resident information sheet dated 8/8/2025 indicates that R2 has a diagnosis of Bipolar, anxiety and schizophrenia. An order summary report dated August 2025 an order on7/23/2025 for Lorazepam 1.0 milligram three times a day for anxiety, and medication administration record dated August 2025 for Lorazepam 1.0 mg by mouth with at code of 10 for nurses note of medication not administered. A protocol for When medication is not available for residents Narcotics: pull from the emergency box. A care pan dated 3/6/2025 with a focus on psychotropic medication, an intervention to administer medications as ordered by the physician. Facility Policy:Medication Administration-1/1/2025 Medications are administered by licensed nurses or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy Explanation and Compliance Guidelines:23.Administer medications according to physician orders.

Based on interview and record review, the facility failed to follow their policy to ensure that blood glucose monitoring for three (R1, R3, R4) of three residents reviewed for blood sugar monitoring were checked before meals per the physician order. Findings include: On 6/17/2025 at 3:12 PM, V3 (RN) said that today is V3 first day work with R1. V3 said he first entered R1's room after 11:00 AM. V3 said that he was supposed to check R1's blood pressure and blood sugar. V3 said that the blood pressure and blood sugar was supposed to be done in the morning. V3 said that he had 29 residents, V3 said that he lost tract because the CNA was asking him for help with different residents. V3 said that he also lost internet between 9:30 AM and 10:00 AM check. V3 said that blood sugar checks were supposed to be done before breakfast. V3 said that by the time V3 lost internet connection, the residents had already eaten breakfast. V3 said that R1 refused for her blood sugar and blood pressure to be checked because she already ate breakfast. V3 said that blood sugar should be checked before the residents eat breakfast. On 06/18/2025 at 12:23 PM, V7 (RN) said that V7 have residents that have diabetes. V7 said that the residents blood sugar level was supposed to be checked before meals per doctors' order. V7 reviewed R4 blood sugar administration record with surveyor and observed that some blood sugars for R4 were not done on time per doctor's order. On 6/18/2025 at 4:12 PM V9 (LPN/Weekend Supervisor), said that V9 obtained R1's blood pressure reading on 5/23. V9 said that the blood sugar was not done because R1 has already eaten breakfast V9 said that the blood sugar check was to be done before breakfast. R1 is a [AGE] year-old female admitted on [DATE] with a brief interview of mental status (BIMS) score of 15/15. R1 admission diagnosis include type 2 diabetes and primary hypertension. R1's physician order indicate that blood sugar was ordered to be checked in the morning. R1s' electronic medication administration record indicate that R1 blood sugar should be checked at 8:00 AM. R1s' blood sugar summary sheet has blood sugar check recorded later than 8:00 AM per physician order. R3 is a [AGE] year-old-male admitted to the facility on [DATE]. R3 is alert and oriented with BIMS score of 15/15 and able to make her needs known. R3 physician order indicates that R3's blood sugar is to be checked in the morning. R3 electronic medication sheet indicates that R3 blood sugar is to be checked at 08:00 am; 12:00 pm; and 17:00 pm. R3 blood sugar record sheet indicates some R3's blood sugar check were not done per the physician's order. R4 is a [AGE] year-old-female admitted to the facility on [DATE] with a brief interview of mental status (BIMS) of 13/15. R4 physician order sheet indicates that blood sugar check is ordered to be done before meals and at bedtime. R4's electronic medication sheet has blood sugar check scheduled for 06:30 am, 11:30am, and 16:30 pm. R4's blood sugar record sheet indicates that some of R4's blood sugars were not checked per the physician order. Physician Orders Policy: A physician must personally approve, in writing, a recommendation that an individual be admitted to a facility. A physician assistant, nurse practitioner or clinical nurse specialist must provide written and/or verbal orders for the residents' immediate care and needs. Policy Explanation and Compliance Guidelines: 4. All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on resident's medical record during that shift. ACCUCHECK /BLOOD GLUCOSE MONITORING POLICY: It is the policy of this facility to perform accuchecks (BGM) as ordered by the resident's physician and to report alert levels to the attending physician as warranted. Standard parameters are as follows: Blood glucose level <60 or > 400 unless otherwise specified by the physician. PURPOSE: To assure that residents' blood sugar levels are appropriately monitored and to establish parameters for nursing interventions. PROCEDRE: 2. All accuceck orders will be implemented by nursing staff per physician order. All orders for insulin (sliding scale, etc,) will be implemented per physician order.

Based on interview and record review, the facility failed to investigate the allegation of sexual abuse for one of three residents (R1) reviewed for abuse. Findings include: On 04/11/2025 at 10:23AM, R1 was sitting quietly on her wheelchair by the nurse's station. R1 stated that an incident happened about a month ago around 7:00PM - 7:30PM when a male staff, unsure if he was a nurse or a CNA (Certified Nursing Assistant), tried to pick her up, took her clothes off, and touched her legs and arms inappropriately. R1 stated that she tried to pull away, but the male staff was grabbing R1's body. R1 stated that she has reported it to nurses and staff. On 04/11/2025 at 12:47PM during interview with V8 (Licensed Practical Nurse), V8 stated that he takes care of R1. V8 stated that on 03/06/2025, R1's sister visited R1 and mentioned to V8 that R1 could have been raped. V8 immediately reported the concern to V1 (Administrator). On 04/11/2025 at 12:50PM during interview with V1 (Administrator), V1 stated that on 03/06/2025, V8 told him that R1's sister has concerns with R1's comfortability of who's providing care to R1. V1 denied being told by V8 about R1's sister's concern that R1 could have been raped. V1 stated that together with R1's sister, he interviewed R1. V1 stated that R1 told him that while being transferred using a mechanical lift, R1 feels vulnerable & feels like the CNA has power over R1, and if the staff would want to, they could have raped R1. V1 stated that he asked R1 a couple of times if R1 was touched inappropriately before in which R1 answered no. V1 stated that no investigation was initiated at that time and no staff member were pulled out from schedule because there was no allegation of abuse made. V1 stated that no allegation of abuse has been made since then. On 04/11/2025 at 10:54AM during interview with V3 (Complainant/Hospice Social Worker), V3 stated that R1 reported to hospice staff that R1 was raped by male CNA/nurse on 03/07/2025. V3 said that since the allegation was made, R1 has been increasingly aggressive, and having crying spells. On 04/11/2025 at 11:00AM during interview with V4 (Hospice CNA), V4 stated that on 03/07/2025, she was having a conversation with R1 when R1 suddenly told her that R1 has something to tell her. V4 stated that she encouraged R1 to talk to her, then R1 told V4 that she was raped. V4 stated that she asked R1 to take a breath and asked R1 what happened. V4 stated that R1 told her that she was hanging on the mechanical lift, and was raped. V4 stated that R1 was able to describe to her the male nurse or CNA but unable to name him. V4 stated that she informed V9 (Registered Nurse/RN) of the allegation, and V5 (Hospice Nurse) per hospice protocol. V4 stated that she has been taking care of R1 for the past 6 months, and R1 has been quieter, sleeping more, and appears depressed ever since R1 reported she was raped. On 04/11/2025 at 1:56PM during interview with V9 (RN), V9 stated that she sees V4 when she comes in to take care of R1. V9 stated that V4 might have mentioned to her that R1 made a statement that R1 was raped but V9 did not report it to V1 because she already heard from a colleague that the same allegation was made. On 04/11/2025 at 2:00PM during interview with V1, V1 stated that if there were any allegation abuse, he would report it immediately to IDPH (Illinois Department of Public Health), and he would initiate an investigation. V1 stated that V9 should have informed him immediately when V4 told her about R1's rape allegation. On 04/16/2025 at 9:35AM, V1 stated that V13 (Psychiatric Nurse Practitioner) should have communicated with him about R1's statement to her when she visited R1 on 04/07/2025. V1 stated that if V13 communicated with him, he would have initiated an investigation and reported the allegation to IDPH. Review of R1's Order Summary Report dated 04/11/2025 indicated admitted [DATE] and diagnoses of not limited to Anxiety Disorder, Unspecified Dementia, and Major Depressive Disorder. Review of R1's Hospice Communication Log dated 03/07/2025 indicated CNA visited R1, R1 saying something happened, sat with R1, reported to the nurse and hospice. Review of R1's Hospice Communication Log dated 03/07/2025 indicated RN visited R1, R1 was being monitors for the alleged complaint. Review of R1's Psychiatric Nurse Practitioner Progress Notes dated 04/07/2025 indicated the following: R1 was seen today due to staff concerns about an incident that occurred approximately one month ago. R1 reported feeling that she was left undressed for too long and touched inappropriately during care, though she denied any penetration. R1 stated, I felt like I was placed in the [NAME] lifts for too long, possibly referring to feeling vulnerable or exposed. R1 experiences intrusive thoughts and sadness when seeing staff members who resemble the individual involved in the incident. Review of facility's policy entitled Abuse Prevention Policy revised 01/05/2024 indicated the following: This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. In order to do so, the facility 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 abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff, and mistreatment of residents. This will be done by: - Orienting and training employees on how to deal with stress and difficult situations, and how to recognize and report occurrences of abuse neglect, exploitation, and misappropriation of property; V. Internal Reporting Requirements and Identification of Allegations Employees are required to report any incident or allegation of neglect, exploitation, mistreatment or appropriation of resident property they observe or suspect to the administrator immediately, to an immediate supervisor who must then report it to the administrator or to compliance hotline or compliance officer. In the absence of the administrator, reporting can be made to an individual who has been designated to act in the administrator's absence.

Based on observation, interview, and record review, the facility failed to reorder scheduled medication to ensure availability for a resident and failed to pass medication timely, per physician orders. These failures applied to two (R1, R2) of three residents reviewed for medication administration. Findings include: R2 is a [AGE] year old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R2 has multiple diagnoses including but not limited to the following: type II DM, HTN, depression, and anxiety. Per R2's physician orders, R2 receives Insulin Lantus Subcutaneous Solution (100 unit/ml) 37 units two times a day scheduled at 8:00AM and 8:00PM. R2 also receives Insulin Lispro Solution (0.5 unit dial) of 17 units three times a day scheduled at 8:00AM, 12:00PM, and 5:00PM. On 1/29/2025 at 10:33AM, V3 (Licensed Practical Nurse) was observed administering medications. V3 said it is 10:33AM and I am still passing my 9:00AM medication. V3 said there are times when we struggle to pass medication in the allotted time which is one hour before and after the scheduled medication time. At 10:45AM, R2 had said there are times where I do not receive my medication till way after the scheduled time. R2 said I receive rapid and long-acting insulin and they are scheduled a certain way to ensure that my blood sugars remain controlled. On 1/18/25, 1/19/25, and 1/23/25, my diabetic medication was given extremely late. I am also concerned about my psych medication when my medication is given late. I can feel myself having increase agitation and becoming irritable when I do not take it timely. Facility Medication Admin Audit Report shows on 1/18/25, R2's Insulin Lispro was scheduled for 5PM and given at 6:41PM and Insulin Lantus was scheduled for 8:00PM and given at 9:45PM. On 1/23/24, R2's Insulin Lispro and Lantus were scheduled for 8:00AM and given at 9:16AM. R2's Insulin Lispro was also scheduled on 1/23/25 for 5:00PM and was given at 8:53PM. At 11:05AM, V4 (Registered Nurse) said it is protocol that we have an hour before and an hour after medication time to adequately pass medications. V4 said I currently have 29 residents and this is very difficult to do. We also use agency nursing staff and there is not way that they are passing medications in the allotted time. At 11:15AM, V2 (Director of Nursing) was interviewed. V2 said I would expect the nurses to pass the medications within an hour before and an hour after the scheduled time. Two residents, R1 and R2, expressed concern to me last week about their medications being late. V2 said if a resident that has a diagnosis of type II diabetes does not receive their insulin in a timely manner it may cause them to have uncontrolled blood glucose levels and become hyperglycemic. Facility policy titled Medication Administration states in part but not limited to the following: Medications are administered as ordered by the physician in accordance with professional standards of practice. 50519 R1 is a [AGE] year-old female admitted to facility on 11/22/2024 with medical diagnosis that includes and not limited to major depressive disorder, anxiety, insomnia, severe obesity, diabetes, hypertension, hyperlipidemia, and gastroesophageal reflux disease. On the (MDS) Minimal data Set assessment of 11/29/2024 section C the BIMS (Brief Interviewed mental status) score was 15/15. On 10/29/2025 at 10:45AM R1 said, I did not take my Pravastatin medication yesterday and I am not taking my medications as ordered per my physician. The PM shift nurse did not have my Pravastatin and had to order it from the pharmacy. On 01/29/2025 at 1:57PM V3 (Licensed Practical Nurse) said, R1 did not receive Pravastatin medication at bedtime. I reorder the Pravastatin medication that was missing. I entered code number 10 under the electronic medication administration record and I charted that medication was missing. On record review of the medication administration for the month of January 2025 the physician medication order reads: Pravastatin Sodium Oral Tablet 40 MG (Pravastatin Sodium) Give 1 tablet by mouth one time a day for hyperlipidemia. On 01/29/2025 at 2:05PM V2 (Director of Nursing) said, I spoke with V3 this morning and I am aware that R1 did not take Pravastatin medication yesterday and medication was reordered. Electronic medication administration record reviewed with V2. R1's medication records showed the Pravastatin medication for 01/27/2025 and 01/28/2025 had code 10. V2 said, R1 did not receive the medication as ordered per physician's orders for both days. V2 said, I expect the nurses to order medication when the stock is running low and when code 10 is used to chart the reason and notify the physician. V2 said, there are two ways that nurses know when to order medication, one is under the electronic medication administration record and the other is when the medication bingo card reaches the last doses. The Bingo medication card has blue or green marking on the last doses ranging from 5 or 8 doses before medication is completely used. There is an emergency box available to be used for emergencies but Pravastatin medication is not one of the medications in the box. On 01/29/2025 at 3:30 PM V2 presented Facility Policy undated, 1- Medication Administration. Which reads in part (but not limited to), 10. Ensure that the six rights of medication administration are followed: a. Right resident., b. Right drug, c. Right dosage, d. Right route, e. Right time f. Right documentation 2-Medication Reordering. Which reads in part (but not limited to), Policy: It is the policy of this facility to accurately and safely provide or obtain pharmaceutical services including the provision of routine and emergency medications and biologicals in a timely manner to meet the needs of each resident. 3. Each time a nurse is administering medications and observes medication doses are running low, that nurse will reorder the medication, time permitting.

Based on observation, interview and record review, the facility failed to follow physician order to check urine for presence of ketones for one (R1) of three residents reviewed for diabetic management. Findings include: R1's diagnoses include but not limited to Type 1 diabetes mellitus with ketoacidosis without coma. On 01/10/2025 at 10:09 AM, R1 was observed resting in her room. R1 voiced concerns about the facility not informing her of her blood sugar levels and not checking her urine for ketones. R1's Physician Order Sheet document an order dated 12/24/2025 as follows: Ketone Test In Vitro Strip (Acetone (Urine) Test) 1 unspecified in vitro as needed for DM related to TYPE 1 DIABETES MELLITUS WITH KETOACIDOSIS WITHOUT COMA (E10.10) To check when Accucheck is over 300 - notify MD if moderate or high. R1's January 2025 Medication Administration Record (MAR) documents the following blood sugar test results: 1/1/2025 07:30 341 miligrams per deciliter (mg/dL) 1/2/2025 07:30 314 mg/dL 1/5/2025 07:30 348 mg/dL 1/7/2025 07:30 349 mg/dL 1/8/2025 07:30 304 mg/dL 1/10/2025 07:30 350 mg/dL The January 2025 MAR excludes documentation that Ketostix test was completed. KetoStix is a ketone test that can warn you of a serious diabetes complication called diabetic ketoacidosis, or DKA. On 01/10/2025 at 10:43 AM, V5, Licensed Practical Nurse (LPN) ,stated that R1 has an order for Ketostix test to be done when blood sugar levels are above 300 mg/dl. V5 showed R1's unopened box of Ketostix Ketone strips taken from the Medication cart with a dispensed date of 12/29/2024. V5 confirmed that the box is still unopened and looked like nobody has used it yet. V5 stated that R1's blood sugar level was 350 mg/dL this morning but V5 did not use the Ketostix strip to check R1's urine for Ketones because R1 didn't want to check it at that time because R1 wanted to sleep some more. V5 also stated that Ketone test results should be documented in the Medication Administration Record (MAR). V5 confirmed that the January 2025 MAR excludes any Ketostix results. 01/10/2025 at 1:47 PM V2, Director of Nursing (DON) stated The facility policy is to make sure we follow the physician orders. I expect the nurses to follow the doctor's order. If it's not marked, if it's not documented, it wasn't done. If blood sugar levels are running that high, there is a danger for diabetic keto acidosis. KetoStix is used to find out if there's ketones in the urine, if there's high levels of ketone in the urine, it can be life threatening. 01/10/2025 at 3:00 PM V2, Director of Nursing (DON) stated that she has informed the doctor that the physician order for the Ketostix was not being performed as ordered and that the order for the Ketostix has been discontinued. Facility did not present a policy on following doctors' orders.

Based on observation, interview and record review, the facility failed to implement effective fall interventions and adequate supervision for a dependent resident assessed as a high risk for falls with diagnoses of Parkinson's disease and Dementia. This failure affected one (R99) of three residents reviewed for falls in the sample of 44. This failure resulted in (R99) experiencing repeated falls that resulted in hospitalization s, sustaining lacerations on two occasions, with one laceration requiring three sutures. Findings include: R99 is a [AGE] year-old resident admitted to the facility on [DATE] with diagnoses including but not limited to: Parkinson's disease, dementia, depression, ataxic gait, cognitive communication deficit, urgency of urination and visual hallucinations. On 07/08/24 at 12:44 PM surveyor observed R99 dining in reclining chair with no concerns. R99 had an approximate quarter size yellowish purple bruise to right outer eye area. On 07/08/24 at 2:59 PM surveyor observed R99 sitting in TV (television) area with drink on table within reach. Surveyor requested to have staff bring resident to room for interview. Floor mat noted in room. Resident confused, does not want to talk with surveyor without staff present. When staff present resident stated, he is not the one I need to talk to. Surveyor observed an approximate quarter size yellowish purple bruise to right outer eye area. On 07/09/24 at 11:33 PM R99 is not in his room. R99 noted sleeping in reclining chair with seat cushion in place in front of nursing station by TV area. Surveyor observed an approximate quarter size yellowish purple bruise to right outer eye area. On 07/09/24 at 2:11 PM R99 is observed in reclining chair sleeping in TV area. R99 appeared comfortable. Surveyor observed an approximate quarter size yellowish purple bruise to right outer eye area. V16 (Registered Nurse - RN) stated, R99 has a laceration to back of the head, but due to resident sleeping surveyor unable to observe back of head. Surveyor observed large bruise to right hand area. V16 stated, he believes that was from a blood draw. MDS (Minimum Data Set) dated 05/07/2024 shows R99's BIMS (Brief Interview for Mental Status) score of 7 which means severe cognitive impairment. MDS dated [DATE] shows resident requires Substantial/maximal assistance for the following areas: toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, sit to stand position, chair to bed transfer, toilet transfer and tub/shower transfer. Resident requires partial/moderate assistance with oral hygiene, upper body dressing, personal hygiene, rolling left and right, sit to lying, lying to sitting on the side of bed, and walking 10 feet. Fall risk assessments dated 2/26/24, 5/23/24, 5/29/24, 6/8/24, 6/28/24 and 07/06/2024, R99 is categorized high risk for fall. Incident report/root cause analysis dated 2/25/24, R99 sustained 1-2 cm (centimeters) x less than 0.0 cm skin tear with minimal bleeding noted to lateral left parietal region behind left ear from unwitnessed fall. Predisposing environmental factors - wheelchair unlocked. Incident report/root cause analysis dated 5/22/24 R99 was noted on the floor in his room leaning up against wall. Writer noted bleeding on right side of his head. First aid immediately rendered and cold compress applied. CNA (certified nursing assistant) stayed with resident. Writer called 911 and resident was transferred to ER for evaluation. Predisposing factors: footwear and none. Predisposing physiological factors: cognitive factors - confusion/disorientation, cognitive factors- impaired memory, neuromuscular factors - gait imbalance, cognitive factors - impaired decision. Predisposing situation factors: ambulating without assist. Skin assessment dated [DATE] documents: 3 sutures noted to right lateral forehead. Denied pain or discomfort. With orders to apply dry dressing every 3 days and to remove sutures in 7 days per MD (medical doctor) & hospice order Hospital discharge instructions dated 5/23/24 document that reason for visit was fall and diagnosis was subarachnoid hemorrhage. This form also documents items done on this visit were laceration repair and wound/incision care. Imaging done on this visit were CT (computed tomography) brain without contrast and CT spine cervical without contrast. Progress note dated 05/23/2024 at 02:43 AM documents: Writer noted copious amounts of blood on the floor next to R99 and there was blood dripping from the right side of his head. Progress note dated 5/23/24 at 2:31 PM documents: Resident arrived back from ER, noted w/(with)skin impairment to right lateral forehead. Sutures intact. No bleeding noted. Denied pain or discomfort. MD made aware, Tx (treatment) and orders in place. Dry dressing applied. V19 (family member/power of attorney) and hospice updated. Hospital discharge paperwork dated 05/24/24 documents: This is a [AGE] year-old male with past medical history as below, who was seen in this ED 24 hours ago for fall diagnosed with small subarachnoid hemorrhage, ultimately discharged back to hospice who presents to ED again for another reported witnessed fall. This report also documents, discussed that there needs to be an improved plan of care for this patient. They understood the plan. CT Brain without contrast impression 1. No acute intracranial abnormality. 2. Chronic findings as above. Narrative findings: There is no hemorrhage, mass effect, midline shift or hydrocephalus. Incident report/root cause analysis dated 6/28/24 writer was notified by visitors that resident was on the floor at nurse's station. Writer observed resident sitting on the floor next to (geriatric) chair. Predisposing physiological factors: behavioral factors - agitation/combative, behavioral factors - restless/anxious, bowel/bladder elimination - incontinence, cognitive factors - confusion/disorientation and behavioral factors - resistive. No apparent injury. Incident report/root cause analysis dated 07/06/24 writer's attention was called by staff that resident is on the floor and immediately proceeded to the room and observed resident sitting on the side of the bed that is on low position, alert conscious and verbally responsive with not visible injury noted initially. Resident sustained laceration to back of head. Predisposing physiological factors: cognitive factors - confusion/disorientation, neuromuscular factors - gait imbalance. Progress note dated 07/06/24 at 07:39 AM documents: Resident had a fall and had a laceration on the back of the head about 3/4 of an inch with minimal bleeding. Placed a call to sister/POA unable to answer call left voicemail about the incident. Spoke to hospice and they stated they will have a nurse come to see the patient. MD notified. Care plan dated 08/01/23 documents: Focus: R99 is at risk for falls related to Parkinson's, dementia, impaired cognition, anxiety, depression, visual deficits, history of fall, impaired balance, and psychotropic medication use. Prefers his independence and does things on his own. With episodes of impulsivity, agitation, and restlessness. Will attempt to ambulate without an assistive device. Goal: Prevent serious fall related injury Interventions: Offer to assist R99 with getting snacks as he allows. Make frequent purposeful rounds when R99 is in room and offer toileting assistance as needed. Place R99 at nurse's station for closer supervision when unable to sleep during the night. Ensure proper positioning in reclining chair and adjust positioning as needed towards back of seat. High risk for falls - FALLING STAR ANTICIPATE and MEET R99's needs. Redirect him if he is agitated. Be sure his CALL LIGHT is within reach and encourage the resident to use it for assistance as needed. Check his ENVIRONMENT for clutter or trip hazards and area is well lit. Encourage NONSKID FOOTWEAR as needed. Fall RISK evaluation. Keep BED IN LOWEST POSITION acceptable by the resident when the resident is in bed. Remind to REQUEST ASSISTANCE when getting up if needed. REPORT to PHYSICIAN any untoward side effects associated with the resident's MEDICATION use. Refer to hospice for therapy evaluation. Remind R99 to lock his wheelchair brakes prior to attempting transfers out of his wheelchair and to request staff assistance as needed with ambulation from the dining room. Remind R99 to request staff assistance with toileting needs. On 07/09/24 at 2:07 PM Interview with V17 (Certified Nursing Assistant - CNA). V17 stated, I have worked with R99 before. He is a fall risk. We put the mattress when he is in bed but sometimes, he tries to jump it. I can't think of anything else we do to help prevent falls for R99. R99 can be aggressive and combative. I have not been here when he has fallen. Sometimes we have seen R99 on the mat. I think he falls because he is confused. He used to make is bed and walk around and now is confused. On 07/09/24 at 1:57 PM Interview with V18 (CNA). V18 stated, I have taken care of R99 before. He is a fall risk. We have a large floor mat to go on one side of the bed when he is in the bed. No other things I can think of. He has fallen when I was working. Dementia caused the fall that time. On 07/09/24 at 2:00 PM Interview with V16 (Registered Nurse - RN). V16 stated, R99 is a high fall risk. We change the bed to the lowest bed, frequent checks, bring to nurses' station/TV area. When he starts to get up, we try to bring him where we can see him. V19 (family member) doesn't want him in nurses' station. I think his cognitive issues are causing the falls. He wants to do the same things he used to be able to do like walking around. We discussed with V2, director of nursing 2 days ago to put him back to a 6am wake up depending on sleep the night before. He is combative at times and will hold the wrists of the staff and twist. He has a bruise on right eye and laceration to back of head. I was here for the laceration to back of head. I went in his room on July 6, 2024. He was sitting on the foot part of the bed. He fell and hit his head on the post. He was bleeding very minimal. This incident caused a laceration to back of head. The hospice nurse had wanted to change Seroquel dose, but sister did not want to agree to that. I believe the bruise was caused by him hitting himself accidentally as he was being combative with staff during care. On 07/09/24 at 3:03 PM Interview with V21 Licensed Practical Nurse (LPN). V21 stated, I have taken care of R99 before. On 6/28/24 day R99 was at nursing station in reclining chair. I had just went to 900 hall for a minute to pass medication. I was actually talking to another resident in the hallway when I was notified by visiting family member of another resident that R99 was on the floor next to his geriatric chair. He is not 1:1 We were keeping him at nursing station to keep a better eye on him. I had just checked on him probably 10-15 minutes prior and he was sitting calm in the chair. He is a high fall risk. We kept bed in low position and locked and fall mat in place. While in reclining chair we try to keep an eye on him as much as possible between myself and CNA's. If he is anxious, we try to see what is causing it. We offer snacks, fluids toileting. In my opinion I feel like he is sundowning more in evenings and that is causing him to have more falls. If we offer to take to bathroom, he will go but then gets aggressive, paranoid, combative very quickly. I try to encourage to have CNA check and change him 2x or more during the shift especially if he is getting restless. If we keep him clean and dry, he tends to be more calm but taking him for peri care is when we struggle. On 07/09/24 at 3:15 PM Interview with V22 (LPN). V22 stated, I have worked with R99 before. On 5/23/24 it was around the start of shift, so my CNA who I do not recall who it was, was doing rounds and immediately called me. R99 had floor mat in place but he crawls on that and is able to stand up. He has a reclining chair. He has a low bed and that was in place. He had his call light within reach. He has been instructed multiple times on call light use but appears unable to be able to use call light. He is always checked on frequently like every 15-20 minutes just to make sure he is safe. I think his increased confusion, restlessness, anxiousness, and incontinence is causing his falls. He is so unpredictable so it is very hard to put anything in place to decrease falls except to increase medications, but family will not agree to that. On 07/09/24 at 1:24 PM Interview with V2 Director of Nursing (DON). V2 stated, R99 he is under hospice care and very active. He really doesn't know his limitations. He attempts unsafe transfers, He has Parkinson's, history of hallucinations. This very last fall he rolled out of bed, and we decided to put in place to be put in his chair as soon as he is awake as he allows. And toileting and have his needs met. He is very active, and he bumps his hands and I think that is why he is having bruising. He is aggressive at times. He is also not aware of safety issues. Fall policy labeled: Fall Prevention Program AA Healthcare dated 2/12/2024 provided to surveyor by V2, DON on 07/09/2024 states: Policy: The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents. Procedure: 1. A Fall Prevention program will be implemented and maintained to assure the safety of all residents admitted to the facility. The program will be inclusive of measures which determine the individual needs of each resident by assessing the risk of falls, and implementation of appropriate staff interventions to assure adequate supervision is provided, and that assistive devices are utilized when necessary. Fall Incident Reports will be reviewed, and quality issues identified to assure the on-going effectiveness of the prevention program. 4. The DON or designee will be responsible for implementing and communicating resident-specific recommendations from the Fall Risk Committee to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. 7. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. Fall alarms may be utilized to alert staff to resident attempts to rise without assistance unless they prevent the resident from rising or pose an increased risk for falls.

Based on interview and record review, the facility failed to follow its policy on conducting background checks for four (R52, R103, R105 and R106, ) of 10 residents reviewed for admission screening. This failure has the potential to affect 117 residents currently residing in the facility. Findings include: Per census report, there are 117 residents currently residing in the facility. R52 is a [AGE] year old, female, admitted in the facility on 06/15/24 with diagnosis of Unspecified Fracture of Shaft of Humerus, left Arm, Subsequent Encounter for Fracture with Routine Healing. R52's Criminal History Information Response Process (CHIRP) was done on 06/17/2024, two days after admission. R103 is [AGE] year old, male, initially admitted in the facility on 01/05/24 with diagnosis of Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. R103's name was checked in the National Sex offender website on 03/30/2024, which was more than two months after admission. There was no documentation that R103's CHIRP was checked, nor his name checked under State Sex offender website and Department of Corrections. R105 is a [AGE] year old, female, admitted in the facility on 06/24/24 with diagnosis of Sepsis, Unspecified Organism. There was no record that her name was checked under Illinois Department of Corrections upon admission. R106 is a [AGE] year old, female, admitted in the facility on 03/01/24 with diagnoses of Anorexia; Adult Failure to Thrive and Major Depressive Disorder, Recurrent, Unspecified. Her CHIRP was done on 03/05/24, which was four days after admission. R106's name was checked in the Illinois Department of Corrections, State and National Sex offender websites on 07/09/24, which was four months after she was admitted . R106 is an identified offender for criminal offenses and had history of incarceration. On 07/09/24 at 3:05 PM, V1 (Administrator) was asked regarding background checks on residents. V1 stated, For new admissions regarding background checks, the team is notified that we have to check with National and State sex offender websites and the department of corrections. We have to do those prior to admission. CHIRP is done within 24 hours of admission. We want to make sure if there is a hit for sex offenders so we could provide a private room. V20 (Medical Director) was also asked on 07/10/24 at 4:27 PM regarding background checks. V20 verbalized, Regarding screening of new residents, they should be screened prior to admission to facility for background checks and at sex offender websites. We want to make sure they are not a danger to other residents and other staff. Facility's policy titled, Abuse Prevention Policy, dated 9/28/23 documented in part but not limited to the following: Procedures: II. Pre-Admission Screening of Potential Residents This facility shall check the criminal history background on any resident seeking admission to the facility in order to identify previous criminal convictions. This facility will: Request Criminal History Background Check within 24 hours after admission of a new resident Check for the resident's name on the Illinois Sex Offender Registration Website Check for the resident's name on the Illinois Department of Corrections sex registrant search page While the background or fingerprint checks, and/or Identified Offender Report and Recommendations are pending, the facility shall take all steps necessary to ensure the safety of residents. Facility's policy titled, Admission of Identified Offender, dated 5/3/22, stated in part but not limited to the following: Guidelines: 1. Screened on Sex offender website. 2. Criminal History record information requested. 4. Facility must review screenings and all supporting documentation to determine if the placement is appropriate.

Based on observation, interviews and record reviews, the facility failed to ensure call lights were answered in a timely manner for two (R44 and R87) of two residents in a sample of 44 reviewed for accommodation of needs. Findings include: R44 is a [AGE] year old, female, initially admitted in the facility on 08/21/2017 with diagnosis of Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side; and Cerebral Infarction, Unspecified. On 07/08/24 at 12:40 PM, R44 pushed the call light. At 12:50 PM, her call light was observed still on. R44 stated, I want my CNA (Certified Nursing Assistant). I want to get up now. At 12:55 PM, observed V14 (CNA) go to R44's room and respond to her call light. It took 15 minutes for V14 to respond to R44's call light. R87 is a [AGE] year old, female, initially admitted in the facility on 11/21/2023 with diagnosis of Nontraumatic Chronic Subdural Hemorrhage; Dementia in other Diseases Classified Elsewhere, Unspecified Severity, with Other Behavioral Disturbance; and Multiple Fracture Ribs, Left Side, Subsequent Encounter for Fracture with Routine Healing. On 07/08/24 at 12:25 PM, R87's call light was observed on. It was observed that there were no staff present in the hallway and by the nurses' station. At 12:40 PM, her call light was still on. Surveyor went to R87's room, observed lunch tray at bedside table. Bedside table was situated at the foot of the bed. R87 stated I tried to call to turn that table around so I can eat but I still have no assistance. V11 (Licensed Practical Nurse, LPN) was observed sitting at the nurses' station. At 12:59 PM, V15 (CNA) was collecting food trays in the hallway where R87's room can be found. Surveyor observed that V15 left and went to other unit. V15 did not go to R87's room. At 1:00 PM, R87's call light was still on. V13 (Housekeeping) was observed in R87's room. V13 was observed going to the nurses' station and talked to V11. V13 was asked if she told V11 about R87's call light. V13 stated, I told her (V11) and she said that one CNA is attending other residents. At 1:06 PM, R87's call light was still on, V11 was observed going to R87's room to provide assistance. It took 41 minutes for a staff to respond to R87's call light. R87's care plan documented: ADL (Activities of Daily Living) self-care performance deficit - Interventions - eating: one-person assist; encourage to use call light to call for assistance. On 07/09/24 at 1:19 PM, V2 (Director of Nursing, DON) was interviewed regarding call lights. V2 stated, We received complaints from residents regarding call lights. We do staff in-services regarding responding to call lights; department heads do rounds on a daily basis during morning shift ensuring call lights are responded. Staff on the floor do rounds at least every two hours and as frequent as needed. Reasonable time to respond to call light is not more than 5 minutes. Any staff in the facility should respond to call lights. I have talked to housekeeping and kitchen staff to not respond related to care but at least respond to call lights. If they responded to call lights and its related to care, they have to notify the nurse. 40920 On 07/8/24 at 11:00 AM to 11:30AM during observation in unit one of the facilities, observed several call lights going off in resident's rooms that were not answered promptly, some resident's beds were noted with no linens and stripped naked. On 07/9/24, between 9:46AM and 10:30AM, surveyor observed several call lights turned on in the 200 section of unit one with no staff observed answering responding to them. Surveyor responded to one of the lights and notified staff that resident needs to go to the bathroom. Several residents screened had concern with the call light not being answered in a timely manner, some residents said that it takes 30 mins to one hour for the call light to be answered. On 07/9/24 at 11:20 AM, V8 (Registered Nurse, RN) was presented with this observation, and she said that there are two CNA's that are assigned to the unit, one just went on break and the other one is probably in another room. Surveyor asked V8 why the call lights are not being answered in a timely manner and she said, The CNA's are usually pulled to help with lunch, right now one of them is on break and the other one is probably assisting another resident. On 07/9/24 at 1:15PM, V2 (DON), said call light response has been a concern and the expectation is that it should be answered in a timely manner, they provide in-service to staff and the department heads also do angel rounds during the day, the facility does not have managers in the evening so the floor nurses and CNA's will be responsible for monitoring the call light and ensuring that it is answered timely. V2 was asked to be a little more specific on what is considered timely, and she said within 5 minutes. The facility does not have any system in place to show how long a call light has been on before it was answered. She added that when a call light is on, any staff can answer it, even if they cannot provide the type of assistance that the resident needed, at least they can get the right person to assist the resident. Facility's policy titled, Call light Policy, dated 1-28-23 stated in part but not limited to the following: Purpose: To respond to the resident's requests and needs in a timely manner. Performed by: All Staff Procedure: 1. Answer call light promptly and turn the light off after entering the room. Knock on the door before entering.

Based on observations, interviews, and record review, the facility failed to ensure that nursing staff (including agency staff) have the necessary competencies, skill sets, and training required to prevent falls and assure resident safety. This failure applied to 3 (R1, R2, and R3) of 3 residents reviewed for staff competence and has the potential to affect all 117 residents currently in the facility. Findings include: On 2/20/24 at 9:45 AM, V2 (Director of Nursing/DON) presented the survey team with the total number of 117 residents currently residing in the facility. On 02/20/2024 at 10:48 AM V4 (Agency Registered Nurse) stated I work for an agency, and this is the first time I'm in this facility. The night shift nurse gave me verbal hand off report to familiarize me with the residents. I can also check resident specific needs in electronic medical record under (electronic note card). None of my residents have special needs. Surveyor clarified if V4 (agency RN) had any residents under fall risk. V4 responded: I have two residents who are at risk for falls, R4 and R5. On 02/20/2024 at 11:23 AM V5 (Certified Nursing Assistant/CNA) stated I've been working here for about three years. I'm pretty familiar with residents. For example, R3 is able to use a call light, uses urinal and needs assistance if needs to have a bowel movement or get dressed. R3 recently fell and hurt his hip. Before, we used gait belt to assist him, now he needs more assistance. R3 is not at risk for falls as far as I know. If we have a resident at risk for falls, we make sure bed is in the lowest position, there are fall mats at bed side, and we monitor those residents closer. We have fall risk resident list, we used to have a hard copy list in the binder, but now, we look it up in the electronic medical record under (electronic note card). V5 (CNA) unable to log in to electronic medical record. Unable to confirm fall risk resident list. On 02/20/2024 at 11:51 AM V7 (Registered Nurse/RN) stated there is no binder with residents' information, all information is available in electronic medical record under (electronic note card). V7 (RN) opened random electronic medical record, (electronic note card). (Electronic note card) was blank, no information available pertaining to resident's needs. On 2/21/24 at 11:18 AM V2 (Director of Nursing) stated we in-service on falls and the last time was right around first week of December 2023. Surveyor asked what the specifics were regarding this fall in-service training. V2 stated, It points out where to locate fall intervention which are located in the (electronic note card). It shows to our agency nurses how to access the (electronic note card). Surveyor asked if there are actual fall interventions provided to staff including agency nurses. V2 stated, No, it just directs them to the specific resident's (electronic note card) with that information. Surveyor asked if she maintained a list of residents at risk for falls. V2 stated, I maintain list of residents who fell , but I don't have a list of residents at risk for falls that I provide to staff. Surveyor asked how agency nursing staff are provided the information necessary for them to identify residents at risk for falls. V2 stated, When agency nurses start here, we have a new hire packet that they are supposed review and sign off when they receive the packet to confirm that they've read the packet. Surveyor asked about agency CNA staff. V2 stated, CNAs are also given binder to review, it is available in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board. V2 stated, They are just given a packet, but no one goes through it with them. We just trust they read it. Surveyor asked how V2 ensured agency nursing staff knew how to care for the residents in the facility they are unfamiliar with. V2 stated, I can't ensure that, they should know this. Surveyor asked if agency nurses are provided any information about the resident's fall risk status during shift-to-shift endorsements. V2 stated, We don't put this down on the 24-hour report because we got rid of it because it was not reliable unless for new admission. Surveyor clarified if the shift-to-shift reports were written anywhere or if it was a verbal endorsement. V2 stated, No, the nurses do write down the endorsements from shift to shift, but these 24-hour reports don't get maintained and are shredded at the end of the day, so I can't show you any past ones. On 2/21/24 at 10:30 AM V9 (Assistant Director of Nursing/ADON) was observed walking the units and was asked about falls. V9 stated, I don't know which residents are fall risk residents. I'd have to check their (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls. V9 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls. V9 stated, Well, all our residents are fall risk residents. Every one of us is considered a fall risk, including you (referring to the surveyor). Surveyor clarified her rationale to determine everyone including surveyors were at risk for falls, V9 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V9 that the surveyor was not a resident in the facility. V9 stated, Yes, but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy. V9 stated, No, it is not. On 2/21/24 at 12:35PM V20 (Staffing coordinator) stated we usually give a packet for agency staff to check off on it. The nurses are responsible for checking to see if the agency nurse signed off on the packet; however, there is no place on the packet to check off that the agency nurse went over it, and it is verified. The agency nurse gets the packet, and they work the same day. Surveyor asked if agency staff obtain any training. V20 stated, No, I don't think they're given actual in-service training, but what's in the packet. I just know we give them the packet before they work here, and they sign it. Surveyor clarified if there is a system to determine staffing needs. V20 stated, We use system that tells us how many staff members we need based on census; it does not include acuity though. We use about 50% of agency staff comparing to regular staff. We usually have more regular staff on the morning shift, evening is mostly agency, and night shift is mostly regular staff regarding CNAs. Regular nurses work mostly in the morning and afternoon, and two out of three nurses on night shift are form agency. New agency staff gets new hire packet that they need to review and sign off before the beginning of first shift. The nurse supposed to verify that agency staff went through the packet. On 2/21/24 at 12:50 PM Surveyor conducted a follow up interview with V9 (ADON) who stated, I was the fall nurse but V2 (DON) has kind of taken over, so we are all involved in fall program. We discuss our falls in our morning meeting. We discuss how residents' fell , how fall happened, what can we do to prevent it from happening again. Surveyor asked how this information gets conveyed to staff. V9 stated It is conveyed to front line staff by shift report. We transfer the intervention to (electronic note card) and to the nurse on the floor, to let them know there are new interventions. Every time we have agency staff, they go through orientation packet. We also talk about (electronic note card). The new hire packet is given to agency staff, but nobody verifies whether they read it and familiarize themselves with it. Surveyor asked V9 to go through packet with surveyor to show where fall prevention is discussed. V9 pointed out that the packet describes falls' identification but does not list preventative fall measures. It directs agency staff to go to (electronic note card). Surveyor asked about last fall in-services provided to staff. V9 (ADON) stated, Last time we had fall in-service was first week of December (2023), I think, but I can't be sure. Surveyor asked to see shift to shift report and/or 24-hour report. V9 (ADON) said, We got rid of 24-hour report because it was inaccurate. We maintain shift-to-shift report, but it gets shredded at the end of each shift. On 2/21/24 at 2:18 PM V21 (Registered Nurse) who related the following in summary: I think V9 (ADON) did the last in-service training for falls. They do this every week or every other week, I'm not sure, but they tell us this when we're on the floor as a one-on-one training. Surveyor asked who does this one-to-one training. V21 stated, V9 (ADON) does this. Surveyor asked when the last fall prevention in-service was conducted and by whom. V21 stated, January (2024) and monthly. I'm not sure but it was with V9. Surveyor asked who the designated fall prevention nurse was. V21 guessing, That would be V9? V21 (RN) does not appear to know. (V9 is not the fall nurse). Surveyor asked how V21 determines who is at risk for falls when he comes on his shift. I do my rounds first and endorsement with incoming nurses. It is written down on the list of 24 hours report. V21 asked to provide the record to surveyors, They took out the 24-hour report. We get endorsement from nights and then we shred it. On 2/22/24 at 2:30 PM in a follow-up interview, V2 (DON) stated to the survey team during interview that all residents in the facility are considered fall-risk residents. V2 added that everyone is at risk for falls. V2 stated, We are all at risk for falls. I can fall at any time, you can fall at any time just like residents can fall. According to record review, daily schedules from 12/01/2023 to 02/20/2024 show that facility uses about 50% of agency staff on daily basis. Education attendance record dated 12/05/2023 reads in part, Topic: Resident Care/(electronic note card). Summary of Education: Please check (electronic note card) before providing care to residents. Purpose: To have knowledge of resident needs and preferences. Goal: To provide the optimal safe care possible for residents. No mention of fall prevention interventions. Per record review, there is no in-service conducted by V9 (ADON) weekly or monthly as stated by V21 (RN). Facility Agency Orientation: Illinois Handbook (no date) reviewed. No fall prevention interventions listed; falls section pertains to post-fall interventions only.

Based on observation, interview and record review, the facility failed to implement their fall prevention care plans and have an effective process in place to ensure direct care staff are aware of and educated about care plan interventions for 4 (R1, R3, R4, R6) of 5 residents reviewed for care plans in the sample. Findings include: Facility policy dated [DATE] titled Fall Prevention Program reads in part, Purpose: To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A care plan for fall prevention will be implemented and maintained to assure the safety of residents who are at risk. The IDT will meet to review all resident falls that have occurred. Fall incident reports will be studied to determine any significant factors that may have caused the fall and to identify additional fall prevention strategies. The DON and nurse mangers and/or designee will be responsible for implementing and communicating resident-specific recommendations from the IDT to the nursing staff assigned to the resident. The nursing staff will be responsible for assuring the recommendations are followed through. Fall prevention strategies will be utilized for all residents at risk for falls including individualized interventions in accordance with the assessed needs of each resident. 1. R1 is a [AGE] year-old with diagnoses of respiratory failure with hypoxia, type 2 diabetes, congestive heart failure, gait abnormality, and cardiomyopathy. Care plan dated [DATE] reads in part, R1 is at risk for falls. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions: Fall risk evaluation; Refer to therapy for screen/evaluation and treatment as indicated. Assist and encourage the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position acceptable by the resident when the resident is in bed. Remind to request assistance when getting up if need. Remind resident to sit away from edge of mattress when sitting on the bed. Remind resident to request staff assistance with transfers out of bed. On [DATE] at 02:41 AM, V27 (Agency nurse) wrote in part, [DATE] at 02:41 AM Event Note: Resident was observed on the floor in left side lying position & rubbing her right hip/leg area. Resident stated she fell & when writer asked how it happened, she said she can't remember. Also asked if she hit her head, she did, pointing on her forehead. Resident unable to move her right leg, also said she has pain on the right hip/leg ,d+[DATE]. Noted a bump with mild bruising to her forehead. Notified doctor and called 911. Applied ice pack to bump on forehead & stayed with resident till paramedics came. On [DATE] at 07:55 AM, V31 (LPN Nurse Manager) wrote in part, Health Status Note: Nurse spoke with hospital nurse. Resident is being transferred to alternate hospital for orthopedic surgery. Resident has a pelvic fracture. On [DATE] at 12:09 PM, V26 (agency RN) stated, Yes I remember R1. She was alert but forgetful and ambulates with some assistance and she spoke a little English. I would say her gait was very unsteady and she was tall skinny and weak and was supposed to use a cane. I think she was a fall risk, but I don't remember anyone telling me this. I'm agency here if you didn't know that so I have to figure things out on our own here. Surveyors asked if she received any training or orientation from the facility about fall risk interventions in the care plan or if the facility identified any residents who were at risk for falls before the start of her shifts. V6 stated, No. I've never received any training like that. On [DATE] at 11:15 AM, V30 (family member) stated, I was called that my mom was found on the floor, and they sent her to the hospital because she was in a lot of pain and the hospital told me she had a hip fracture. Surveyor asked if this was the first time her mother fell . V30 stated, No, she had just fallen several days prior to this one and no one told me until she fell the second time when she was sent to the hospital. If they were doing what they said they were going to do for my mom, this would not have happened. Hospital records dated [DATE] at 10:02 AM written by V29 (emergency room Doctor) reads in part, Patient arrived via emergency medical services from facility following being found on floor. Unwitnessed fall. Does not recall how got to floor. Positive for hematoma to mid forehead. Positive for pain and deformity to right hip with decreased range of motion. reports increased pain. Problem list: Atrial fibrillation, Blunt head injury, right Hip fracture. 2. R3 is a [AGE] year-old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus; Chronic Diastolic Heart Failure; Chronic Kidney Disease; Hyperlipidemia; Spinal Stenosis; Essential Hypertension; Cognitive Communication Deficit; and Dizziness and Giddiness. R3's Fall care plan dated [DATE] reads in part, Anticipate and meet (R3's); Be sure (R3's) call light is within reach and encourage (R3). No intervention pertaining to monitoring noticed. On [DATE] at 11:31 AM Surveyor observed R3 sitting up in the bed. Surveyor noticed bilateral bruising around R3's eyes, R3 stated, I got up to the bathroom, tripped and fell down. I think it was last week. I went to the hospital, and they said I broke my hip. When I came back to the facility, they told me I can walk, but only with assistance, and put 20% of weight on my left leg. Surveyor noticed R3's demeanor to be quiet and sad, surveyor clarified how is R3 feeling. R3 stated, I'm depressed and looked away. Surveyor observed bed in the lowest position; no fall mats; reaching device laying on recliner, out of R3's reach; call light in the nightstand's drawer, out of R3's reach; room cluttered and dark. On [DATE] at 3:53 PM Surveyor observed R3 in his room, sitting in the wheelchair, in the bathroom. R3 said, I think I need to go to the bathroom; I'm going to sh*t myself. Surveyor observed call light in R3's nightstand ' s drawer. Call light not initiated upon surveyor entrance to R3's room. On ,d+[DATE] 2024 between 9:00 AM and 4:00 PM, in 3 separate attempts, surveyor called V28 (Licensed Practical Nurse/LPN); however, V28 did not answer, voicemail was left. On [DATE] at 12:21 PM V2 (Director of Nursing/Fall coordinator) who related the following in summary: R3 is pretty impulsive, likes to get up on his own and do things for himself. R3 usually transfers with 1 person assistance. R3 is able to use a call light. At the time of the incident (on [DATE]), R3 got dizzy, lost his balance, and fell . R3 was transferred out to the hospital due to head and left side pain. Hospital records showed left femur fracture. Prior to the fall on [DATE], R3 was not a fall risk resident. Surveyor clarified if R3 has history of falls that would place him at risk for falls, V2 (DON/Falls coordinator) responded, R3 had another fall on [DATE] and on [DATE]. That would put him at a risk for falls. I think R3 ' s care plan interventions are appropriate to prevent him from falling. According to record review, progress note written by V28 (Licensed Practical Nurse) dated [DATE] at 00:51 AM reads in part, During shift report, heard loud noise from R3's room and R3 screamed for help. Immediately, writer (V28 LPN) and certified nursing assistant in the room. R3 lying on the floor on his left side. R3 with raised area to left side of forehead. Left knee abrasion and right-hand abrasion in between fingers. R3 stated, I started walking toward bathroom to take a dump, I felt dizzy and fell down. Upon full body assessment ROM (range of motion) WNL (within normal limits), R3 assisted back to level of comfort. First aid to areas of injury given. Ice pack placed on forehead r/t (related to) raised area. Left knee cleansed with NSS (normal saline solution) and (antibiotic ointment) applied. Right hand cleansed with NSS, (antibiotic ointment) applied. Neurological checks initiated. Peri care and toileting provided. 911 called, R3 taken to (local) hospital for further f/u (follow up). Final Facility Reported Incident report dated [DATE] at 12:33 PM reads in part, Investigation/Conclusion: R3 experienced change in condition which resulted in sudden change in plane. R3 was admitted to the (local) hospital. Hospital record dated [DATE] authored by V32 (ER doctor) reads in part, (R3) was apparently trying to transfer from chair to the toilet and did not have any help. He felt dizzy and hit forehead on the ground; also, c/o (complaining of) right knee pain with a bruise to the right knee; some left knee abrasion; soreness to the left shoulder. He had severe pain in the left hip after the fall. X-ray Pelvis 1 or 2 views: Left femoral greater trochanter avulsion fracture. 3. R4 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Unspecified Dementia; Essential Hypertension; Hyperlipidemia; Muscle Weakness; Cardiomegaly; Alzheimer's Disease; and Personal History of Transient Ischemic Attack. R4's Fall care plan dated [DATE] reads in part, Be sure (R4's) call light is within reach and encourage (R4) to use it for assistance as needed. Place floor mats on the floor beside the bed. R4's Fall risk assessment dated [DATE] reads in part, (R4) is at high risk for falls. On [DATE] at 11:20 AM R4 not in the room at this time. Fall mats and wheelchair stored in R4's bathroom. On [DATE] at 3:52 PM R4 was in bed asleep at this time. Bed in the lowest position, but no fall mats were on the floor and fall mats remained stored in the bathroom. Call light was placed on the nightstand, out of R4's reach. 4. R6 is an [AGE] year-old with diagnosis of Parkinson's disease, dementia, delusional disorder, and anxiety disorder. A facility reported fall incident on [DATE] by V2 (DON) reads in part, Upon making rounds when arrived at 11:00 PM, CNA informed that resident (R6) had blood on the floor of the room and was scooting around on the floor. I went to assess the resident's condition and noticed some specks of dried blood on the floor. Noticed dried blood on the back right side of resident's head. Resident was alert and oriented times 1. Resident is very confused and very fidgety. Resident mumbling incoherent words and moved all extremities without any signs of pain. Once stabilized, left the room and proceeded to call 911. V2's root cause analysis reads, (R6) has tendencies to attempt self-transfers and will at times attempt to transfer herself out of bed or from her wheelchair. Staff will place the resident in areas of high staff visibility for closer supervision when awake. Fall care plan dated [DATE] reads in part, (R6) is at risk for falls. The resident has Impaired cognition and impaired safety awareness due to dementia and Parkinson's. The resident has balance impairments. The resident has a history of falls. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement (psychotropic). The resident has vision impairments. She can be impulsive and does things on her own. Has tendency to reach for things on the floor, at nurses' station, or at the table in the dining room. With periods of restlessness due to Parkinson's and dementia. Goal: Prevent a serious fall related injury. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall risk evaluation. Assist the resident in wearing non-skid footwear when out of bed. Keep bed in lowest position when the resident is in bed. Place floor mattress on the floor beside the bed while resident is in bed. Ensure proper positioning when seated in wheelchair and remind resident not to lean forward when in wheelchair. Keep resident in areas of high staff visibility for closer supervision when awake. High back wheelchair for positioning. Offer group activities for resident to attend as she allows. On [DATE] at 10:15 AM, R6 was in her room with the door fully closed. R6 was observed lying in bed awake and flailing her arms and appeared agitated. The room was dark with no lights on and with drapes that were closed. A heater was blowing air directly toward the resident who was immediately adjacent to the heater. Per care plan, R6 should have been placed in a high visibility area when the resident was awake. V10 (agency nurse) was at the other wing of the unit and was asked about R6. V10 stated, This is only my second day here. I have 2 CNAs today, I think. I don't know who they are. Surveyor asked if the residents she took care of today were considered at risk for falls. V10 stated, I don't know which residents are fall risk, sorry. Surveyor asked if she was told by anyone from the facility before she started her shift anything about her residents. V10 stated, No I wasn't told anything special, why? Surveyor asked if she received any in-service training before taking on a shift at the facility. V10 stated, No, I didn't get any in-services, it's only my second day here. On [DATE] at 10:30 AM the doors to R6 were once again closed and resident was observed awake in a bed. V10 was again observed on the same wing and asked if she obtained any endorsement from the outgoing nurse, V10 stated, No the nurse didn't tell me anything this morning because she was gone when I got here. On [DATE] at. 11:18 am: V2 (DON) said I am in charge of falls. When we have a fall I determine the root cause, update the plan of care with appropriate interventions. I type up the summary of any fall and meet with my IDT (interdisciplinary team) which consist of all the dept heads, but clinical team are my ADON (Assistant Director of Nurses) and nurse managers. They know who fell and generally speaking, they know what the interventions are. Surveyor asked if she maintained a list of residents at risk for falls. V2 stated, I maintain list of residents who fell , but I don't have a list of residents at risk for falls that I provide to staff. Surveyor asked how agency nursing staff are provided the information necessary for them to identify residents at risk for falls. V2 stated, When agency nurses start here, we have a packet that they are supposed review and usually they sign off when they receive the packet that they've read the packet. Surveyor asked about agency CNA staff. V2 stated, CNAs are also given in a binder to review and it is in the employee lounge. Surveyor asked if the orientation packets provided to agency staff are reviewed by her or any of her nurse managers prior to agency staff coming on board. V2 stated, They are just given a packet, but no one goes through it with them. We just trust they did it. Surveyor asked how she ensured agency nursing staff knew how to care for the residents in the facility they are unfamiliar with. V2 stated, I can't ensure that, they should know this. On [DATE] at 10:30 AM, V9 (ADON) was observed walking the units and was asked about falls. V9 stated, I don't know which residents are fall risk residents. I'd have to check their (electronic note card). Surveyor asked if she had to look up every resident's record every time a nurse cares for a resident to determine if they were at risk for falls. V9 stated, Yes. Surveyor asked how that would be considered preventative fall interventions if her nurses cannot identify which residents were at risk or high risk for falls. V9 stated, Well, all our residents our fall risk residents. Every one of us is considered a fall risk including you (referring to the surveyor). Surveyor clarified her rationale to determine everyone including surveyors were at risk for falls. V9 stated, Yes, you (referring to the surveyor) can fall at any time, just like I can fall. Surveyor reminded V9 that the surveyor was not a resident in the facility. V9 stated, Yes but we are all still at risk to fall. Surveyor asked if this rationale was in their fall risk policy, V9 stated, No it is not. [DATE] 12:50 PM, follow up interview with V9 (ADON) stated, I was the fall nurse but (V2 DON) has kind of taken over so we are all involved in fall program. In our morning meeting we discuss our falls and discuss how the resident fell , how fall happened, and what can we do to prevent from happening again. Surveyor asked how this information gets conveyed to staff. V9 stated, It is conveyed to front line staff by a shift report. We transfer the fall intervention to the (electronic note card). Surveyor asked how this information is given to agency staff. V9 stated, Every time we have agency, they go through an orientation pack. It talks about the (electronic note card) and we talk about falls, change of condition and this packet is given to agency staff. Surveyor asked V9 to go through the orientation packet provided to agency staff to show where this information is. V9 stated, It says Falls identification but no it doesn't have preventative fall measures, it just directs agency staff to go to the (electronic note card).

Based on interview and record review, the facility failed to provide freedom from inappropriate physical restraint for 1 (R2) of 1 resident reviewed for restraints in the sample of 7. Findings include: According to face sheet, R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to anxiety disorder; Depression; Unspecified Dementia; Essential Hypertension; Hypothyroidism; and Unspecified Abnormalities of Gait and Mobility. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 00 indicating severely impaired cognition. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section E, shows that R2 did not display wandering behaviors. Per record review, no elopement/wandering care plan developed related to R2 care needs. On 02/21/2024 at 2:18 PM V21 (Registered Nurse/RN) who related the following in summary: I was told that staff tucked in R2 with the sheets really tight to prevent her from getting out of bed. I think it was the V22 (Licensed Practical Nurse/LPN) because they were fired after that. On 02/21/2024 at 2:47 PM V1 (Administrator) who related the following in summary: It was reported to me, by R2's Power of Attorney, that R2 was secured to the bed with sheets on the morning of 12/11/2023. R2's Power of Attorney came in early in the morning, around 8:00 AM and, reported to me later that day, what she witnessed in the morning. R2's pain and skin assessment were completed. I immediately suspended two employees, V22 (Licensed Practical Nurse) and V23 (Certified Nursing Assistant/CNA), who worked that night and were assigned to R2, and I started the investigation. We interviewed staff directly involved in R2's care and other staff who worked on the same unit. We also interviewed other residents on that unit. Finally, I reported it to the state agency. R2 was a poor historian, she wasn't able to provide any details in regard to the incident due to her cognitive impairment and language barrier. Shortly after, we initiated audits in regard to restraints. As a result of the investigation, restraint allegation was not substantiated because there were no witnesses that R2 was restrained. V22 (LPN) was terminated around the end of January 2024 due to unrelated incident. V23 (CNA) is still works here. On 02/21/2024 at 3:43 PM V23 (CNA) who related the following in summary: I worked the night of 12/11/2023 with V22 (LPN). I was only CNA on the unit that night. I was monitoring residents assigned to me, but I was also asked by a supervisor, to help monitor V22's (LPN) residents as well. R2 was among residents assigned to V22 (LPN). When I checked on R2, upon the beginning on my shift (11:00 PM), she was sleeping. Later that night (between 00:30 AM and 3:00 AM), V22 (LPN) asked me to bring him an extra sheet. Then V22 (LPN) placed the sheet across R2's legs and tucked it underneath the mattress. V22 (LPN) then said, I hope she's going to stay in bed now. I didn't check on R2 after that. V1 (Administrator) called me and talked to me about the incident the following day, and then I was suspended for about a week and a half. Per record review, V22 (Licensed Practical Nurse) interview (no date and time included) reads in part, At 12:30 AM, Tucked (it) pretty tight. Why tucked it tight? Didn't want (R2) to get up and fall. At 1:30 AM, Sheets still secured. At 5:00 AM (R2) was still tucked in as left it. At 7:00 AM, The sheets were still tucked in as left. Facility Abuse Prevention Program policy dated 7/28/2022 reads in part, The facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish to a resident. The term willful in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on interview and record review the facility neglected to ensure that one resident (R1) of 4 residents reviewed for neglect and abuse, was cleaned thoroughly and free from being intimidated by a member of their staff. This failure resulted in R1 crying and feeling intimidated, so much so that she was afraid to ask again for help and allowed stool to sit on her person for hours until the next shift came so that she would not be confronted by a staff member who refused to clean her thoroughly. Findings include: Review of R1's medical records document the following diagnosis: Morbid obesity, need for assistance with personal care and abnormalities of gait and mobility. R1's Minimum Data Set (MDS) dated [DATE] section G documents R1 requires extensive 2 + persons physical assist for bed mobility (including turning side to side) and section C documents her cognition to be intact as evidenced by a Brief Interview for Mental Status (BIMS) Score of 14 out of 15. The facility's incident final report dated 4/25/2023 documents the following in summary: R1 stated that around 2 AM on Saturday, she put her call light on to receive incontinence care. The light was answered by V3 (Certified Nurse Assistant/CNA). R1 reported that the CNA entered the room very loudly, causing the door to bang, and talking loudly on her phone. Per R1, V3 changed her too quickly and did not finish wiping all the excrement from her behind before installing a new brief. R1 asked V3 if she cleaned her and V3 said, Yes, I did clean your butt, do you need anything else. R1's roommate, R2, report of the incident was similar to R1's. V4 (CNA) was the one who saw R1 later that morning and answered R1's call light. R1 told V4, that V3 was in a rush when V3 changed her and did not change her all the way. A staff member told the administrator that V3 was hard to work with and V3 was consistently arguing with other staff members and was not a team player. On 5/18/2023 at 10:05 AM R1 lying in bed, alert and oriented, polite, and soft spoken. R1 states regarding the incident that she woke up about 2 AM in the morning and she had a bowel movement. R1 stated that V3 (CNA) must have been close to her room because she heard only her voice talking loudly and laughing. R1 states she put on her call light to get help to change. R1 states her door was closed and V3 must have been right outside the door because she came in right away and swung the door open so hard that it hit the wall loudly. R1 states V3 was still loudly talking on the phone and asked her what she wanted. R1 states she told V3 she needed to be changed. R1 states V3 pushed her over to the side and pulled the diaper from underneath her like she was in a hurry. R1 states V3 cleaned her buttocks cheeks but did not get the stool in the between her buttocks. R1 states V3 then put a diaper on her. R1 states she could still feel the stool there and was trying to figure out in her own head why V3 did not clean the stool. R1 states she then told V3 that she still had stool and she needed to be cleaned thoroughly. R1 states she told V3 there was still stool on her and V3 responded there isn't any poop on you, I cleaned you. R1 states she said I can feel the stool. R1 states V3 said angrily I wiped you, did you s*** again and kept saying she wiped her. R1 states V3 then left loudly talking on the phone and slammed the door loudly using her outside voice. It was 2 AM in the morning and people were trying to sleep. R1 states when V3 left she asked R2, her roommate, if she heard that and R2 said yes. R1 states, R2 said she refused to clean you. R1 states she does not like confrontations. R1 states She [V3] made me feel like she [V3] didn't care, like I was the last thing she wanted to do. She was mean like she had a chip on her shoulder. I felt intimidated. The look she gave me and when she said, Did you S*** again. made me afraid to ask to get cleaned up until the next shift. R1 states, when the next shift came in, V4 (CNA) was assigned to her, and she told V4 what had happened. R1 states V4 was cleaning her up and said that this should not have happened. R1 states V4 told V10 (Licensed Practical Nurse/LPN). On 5/18/2023 at 10:23 AM R2 states R1 needed to be cleaned up and V4 came into the room to clean R1 up. R1 states she still felt the stool on her. R2 states V3 said I wiped you that's impossible. Did you s*** again! Did you s*** again! R2 states V3 said it with a snooty, abrasive attitude. R2 states R1 said no I didn't. R2 states, poor [R2] had to sit in there with stool on her all night till the next shift. The morning aid came and said this should never have happened. R2 states V10 (LPN) came into their room and said R1 should not be afraid of anyone here. R1 states V3 was rude and was antagonizing, R2 states V3 was trying to intimidate R1 when she was saying Did you s*** again! with an attitude. R2 states, R1, can't walk she is at their mercy, I'd say it was cruel, unpleasant and uncalled for. On 5/18/2023 at 1:08 PM V6 (Staffing Coordinator) states the V3 worked a lot and wanted to be on her usual unit. V6 states unit was V3's regular hallway and she liked to go there, but we started getting complaints from residents. The residents would say she [V3] is too rough. V3 would say she would come back and then not come back, she [V3] would just make them wait, residents would say V3 was gossiping to residents about other CNAs. Staff didn't like working with her. V3 would change her own assignment. She would argue with other staff. Staff said, we would rather work short than work with someone with that attitude, they would say. She is not a team player. R4 for sure would complain about V3. She would wheel herself to our office and tell us or the CNAs about V3 and CNAs would tell us also. V6 states she remembers V11 (LPN) reporting that to the ADON also that R4 would say V3 puts me on the toilet and leaves me there and will not come back to help me. V6 states, After that we started floating her [V3]. For the night shifts for sure we did not put her on the unit. V6 states ADON told V6 to float V3 to another unit. On 5/18/2023 at 1:31 PM R4 states she doesn't remember V3 that much just that V3 would not help her into bed and would leave her in the bathroom. R4 states she had no problem letting staff know she didn't want V3 again. On 5/19/2023 at 10:59 AM V4 (CNA) states she came in that morning R1 was crying and R1 said she was not being cleaned properly. V4 states R1 was crying and V4 states that R1 told her V3 didn't get the poop out of her butt and refused to clean it. V4 states R1's diaper was clean when she went between her cheeks to clean the stool (bowel movement) from in between her buttocks. V4 states R1 is a two-person assist and because of her size you have to spread her buttocks apart to get in there to clean. Normally, if we clean R1 we have two people. I told V10 (LPN) about it. V4 states, if a resident asks to be cleaned again, so she can feel better, she will just clean them. V4 states R1 was crying when I saw her that morning and R1 told her that V3 had refused to clean her. V4 states she tried to comfort R1 and told R1 it was ok, don't worry, I will clean you. R1 had on a new diaper but V3 didn't clean in between R1 buttocks. . Review of R1's witness statement taken by V2 on 4/24/2022 documents the following: R1 stated that during the early morning hours on Saturday 4/22/2023 at approximately 2:00 AM, R1 was awakened by loud laughter and loud talking coming from the hallway outside her door, which was closed at the time. [R1] explained that she'd had a bowel movement and needed to be changed, so she activated her call light to alert staff. [R1] stated, At about 2 o'clock in the morning, V3 came into the room like gang busters by banging the door into the wall. V3 was loudly talking on her cell phone with an ear bud and continued to talk on the cell phone while cleaning me up. V3 was so loud that I thought to myself, 'Why is she being so loud while people are trying to sleep?' [R1] told [V3] I needed to be changed because I had pooped. V3 pulled my diaper off quickly and you could see there was poop there. [V3] quickly started to wipe me off and finished. I told her [V3] I can still feel something there like I'm not completely clean. I asked her [V3], did you clean me?' she kind of got in my face and said, yes, I did clean your butt! . When the next CNA came on day shift, I asked her if she could change me. I still had poop left on me from during the night when [V3] would not clean me. Review of R2's witness statement taken by V2 (DON) on 4/24/2022 documents the following: V3 came into the room loudly in response to R1 putting the call light on. R1 told V3 she still felt soiled and was not completely clean and the CNA told R1 I already did it, ok? She [V3] was so intimidating, and I know [R1] just wanted her out of the room. She [R1] said she would rather just wait until the next shift comes in to help her. On 5/18/2023 at 3:00 PM V2 states she expect[s] staff to speak respectfully to residents, make sure their needs are met before they leave the room. I expect staff not to use personal electronic device while providing care, they should not use phones while on the unit, only at break time. I expect that incontinence care is thoroughly done, especially for someone alert and oriented like [V3], if she says I'm not clean, I expect the CNA to ask what needs to be done and then do it. On 5/18/2023 at 3:41 PM V12 (CNA) states if a resident says they are not clean she would clean them again to make them feel adequately clean and feel better. On 5/18/2023 at 3:45 PM V13 (CNA) states she is familiar with V3. V13 states R1 requires total care. V13 states R1 is alert and oriented. V13 states, if a resident felt like they needed to be cleaned more thoroughly she would clean them because it is the right thing to do. On 5/18/2023 at 11:17 AM V1 (Administrator) stated that V3 was terminated over the phone. The facility's final incident report documents V3 was removed from the schedule and will not return permanently based on poor customer service. It was determined that the CNA did not provide incontinence care to the resident's satisfaction. Review of V3's termination report (Counseling report) dated 5/1/23 document the reason for termination being Per scheduler and executive director inability to work respectfully with others on several occasions and reports. Reviewed V3's counseling report of 3/13/23 that documents unsatisfactory work performance for spending the majority of her day charting. The facility's policy Standards and Guidelines (SG) dated 9/8/22 documents the following: it will be the standard of this facility to honor resident's rights and to address with employees the seven (7) components regarding mistreatment, abuse, neglect, sexual misconduct, injuries of unknown source, involuntary seclusion, corporal punishment, misappropriation of resent property or funds or use of physical or chemical restraint not required to treat the resident's symptoms in accordance with Federal Law. The facility's SG Resident Rights, Dignity, and Visitation Rights policy dated 9/8/22 documents the following: It will be the standard of this facility that employees shall treat residents with kindness, respect, and dignity.

Based on observation, interview, and record review the facility failed to prevent a resident from being verbally abused by a CNA (Certified Nursing Assistant) for one of two residents (R337) reviewed for abuse in the sample of 45. This failure resulted in R337's psychosocial harm as witnessed by R337's increased anxiety and agitation. Findings include: R337 was admitted to the facility on [DATE] with diagnosis including but not limited to Malignant Neoplasm of Endometrium, Polyneuropathy, Osteoarthritis of knee, Essential Hypertension, and Acquired Absence of both Cervix and Uterus. On 04/10/2023 at 01:42 PM Surveyor observed R337 laying the bed, with eyes closed. V16 (R337's husband) sitting at the bedside, indicated R337 is not able to be interviewed at this time. On 04/10/2023 at 1:45 PM V16 (R337's husband) stated, On Thursday, 04/06/2023, one of the staff said to R337, I'm not going to turn you. I don't want to hurt my back. You're going to die anyways. R337 could still talk at that time, and she thought it was a Certified Nursing Assistant but I'm not sure. Later in the day, the same staff came into the room and R337 pointed at her to confirm that this was a person who said that to her. The incident might have happened after lunch time. On 4/10/2023 at 3:38 PM V2 (Director of Nursing/Abuse Coordinator) stated, I am not aware of any issues pertaining to R337. No one has reported any abuse allegations to me. On 04/10/2023 at 3:56 PM V1 (Administrator) stated, We don't know anything about the incident involving R337. We will start the abuse investigation right away. On 04/10/2023 at 4:03 PM V3 (Assistant Director of Nursing) stated, I was in my office on Saturday (04/08/2023), and I saw V16 passing by. I spoke to him about R337. I asked if everything is ok, V16 said that when Certified Nursing Assistants turn and reposition R337, should be more careful, but he said, not to worry about it. I didn't ask if there was a particular Certified Nursing Assistant who is not being careful during patient care. V16 stopped me from questioning him further. I told the assigned Certified Nursing Assistant to be careful with repositioning R337. If abuse was reported to me, I would report it to Abuse Coordinator right away but V16 said there was an issue with R337's repositioning, but V16 told me not worry about it. Per record review, Abuse Education Attendance Record reads in part, Abuse Coordinator, When to Report Abuse, and Types of Abuse and confirms V3 (ADON) attendance. On 04/10/2023 at 4:18 PM Surveyor interviewed V16 in presence of another surveyor about the abuse incident that occurred on 4/6/2023. V16 confirmed the incident and R337 nodded her head and said, Yes. V16 is expressed concerns about staff retaliation and apprehensive about initiated abuse investigation. R377 showed signs of anxiety, agitation, and fear during V16's interview. R337 grabbed V16's hand and said expressed Take me home, I want to die at home. On 4/11/23 at 10:43 AM V1 (Administrator) stated, We were able to determine it is V23 (agency Certified Nursing Assistant) and we were trying to reach out to her, she is yet to respond. We talked to the V16, but he is not willing to talk about the incident anymore. We established that V16 reported to V3 (ADON) on Saturday 04/08/2023, V3 denied that there was an abuse allegation that was reported. We assessed R337 and interviewed residents who were assigned to the alleged abuser. On 4/11/2023 at 11:37 AM V24 (Registered Nurse) stated, R337 was assigned to me few times. R337 experienced big drop in cognition over the last few days. Even couple of days ago R337 was coherent and today R337 is incoherent and unable to speak. Last week R337 was able to answer some questions, trying to eat, even asked me for a can of ginger ale. I was also able to assess her pain. R337 was alert x1-2. Right now, R337 is not alert, gasping for air; hospice nurse assessed R337 yesterday and placed additional orders for end-of-life care. Surveyor further clarified if V24 was aware of abuse allegations that occurred on 04/06/2023. V24 stated, I worked last Thursday (04/06/2023), but I was not aware of any incidents involving R337. There is a lot of agency staff that cause problems. On 4/12/2023 at 9:41 AM and 4/12/2023 at 1:40 PM Surveyor called V23 (agency Certified Nursing Assistant), no answer, voicemail left. On 04/12/2023 at 12:07 PM Surveyor requested V23's employee file, not provided. Per record review, Agency Staff Orientation Checklist signed by V23 (agency CNA) on 03/25/2023, reads in part, V23 oriented to Preventing Abuse, Neglect, Exploitation; Reporting and Investigation. On 04/13/2023 at 2:26 PM Surveyor interviewed V10 (Attending Physician). V10 indicated that statement such as I'm not going to turn you. I don't want to hurt my back. You're going to die anyways expressed to a resident who is under hospice care could worsen depression or anxiety, furthermore V10 stated, I don't know how people who say things like that to residents could work in the healthcare industry. Per record review, SG ANE and Investigations policy dated 11/01/2004 reads in part, Abuse is the willful intimidation with resulting in pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. IDENTIFICATION: When any allegation or confirmed abuse, neglect, mistreatment, or exploitation of a resident occurs including suspicion, the appropriate state agencies will be notified immediately including Federal Reporting using the Immediate and 5-day Federal reports and the local police or Ombudsman if indicated. The supervisor, Administrator and/or Director of Nursing will be notified immediately. Staff members involved will be removed from the schedule pending investigation.

Based on interview and record review, the facility failed to provide necessary care and radiological services in a timely manner, failed to follow the physician order for a STAT/immediate x-ray; failed to follow their diagnostic/labs notification policy and caused a delay in treatment for 1 (R187) of 3 residents reviewed for quality of care from the sample of 45 residents. This failure resulted in R187 waiting over 48 hours to obtain an x-ray that revealed a transverse fracture of the arm causing delayed treatment of the fracture. Findings include: R187 is blind and cognitively impaired resident admitted to the facility on [DATE] for a 5-day hospice/respite stay and with diagnoses of Alzheimer's Disease, atrial fibrillation, obstructive sleep apnea, seizures, anxiety disorder, and cardiac pacemaker. A facility federal report notification dated 2/27/23, authored by V6 (previous Director of Nursing) reads in part (but not limited to): Per staff interview, on 2/22/2023, (CNA/Certified Nurse Assistant) dressed resident and reports skin intact and no skin alterations during morning care. Then 2 staff reports assisting resident to transfer using mechanical lift without any issues. Resident was sitting at nurse's station when staff assisted resident with her meals and then transferred to bed for incontinent care by 2 CNAs during AM shift. Resident was assisted with dinner while at nurse's station. Resident noted flailing arms and legs around during meals. No pain indicators noted at that time. Resident redirected with verbal stimuli, and she completed her dinner. At approximately 7:30 PM, 2 CNAs using mechanical lift transferred resident to bed without any issues. As CNA was removing resident's clothing, she noted a skin tear on left forearm and immediately alerted the nurse. Based on staff interview no fall noted or reported as resident was being supervised at nurse's station from change of shift until after mealtime. Resident was then transferred to bed by 2 CNAs for the night. On 2/23/23, the hospice nurse came in to evaluate the resident and x-ray ordered with results as follows: There are transverse fractures involving the distal radius and ulna; with mild callus and minimal displacement. Left forearm fracture. Hospice and physician collaborated and determined to apply left arm splint, immobilize extremity, pain medication regimen revised, and referral made for orthopedic specialist. Resident admitted to our facility for 5-day respite stay and discharged to home on 2/24/23 with hospice care. Efforts to contact V6 (previous Director of Nursing) during the survey were left unanswered. V2 (current Director of Nursing) indicated V6's agency did not want to provide her contact information and was currently assigned to work in an alternate nursing rehabilitation facility. Interview with V2 on 4/10/23 at 11:00 AM stated, I've only been here a month and that incident report was just laying on my desk. I don't know anything about it. Surveyor asked if she reviewed the incident report in anticipation of any investigations from the public health department. V2 stated, No. I didn't get the chance to do that. Asked later which x-ray company the facility used, V2 indicated she was not certain but would obtain the information for the survey team. A review of R187's progress notes show the following the timeline of events in the delay of care: 1. On 2/22/2023 22:01, V8 (Registered Nurse/RN) wrote, CNA reported to nurse that she noted a skin tear on patient's left arm while changing her long-sleeved shirt in bed. Skin tear was noted to be 6 centimeters long ,1.25 centimeters wide on left arm. Scant amount of blood, no swelling, no bruising to surrounding area. Area was cleaned with normal saline, bacitracin applied, covered with dry dressing. Left message with doctor, husband was updated. 2. On 2/23/2023 21:15, V40 (agency RN) wrote, Note Text: (x-ray/imaging company), they have no one to take, to come and do x-ray tonight, a tech will be out in the morning to perform the x-ray. 3. On 2/24/2023 at 06:35, V37 (agency RN) wrote, Note Text: Results of x-ray came in this am, resident noted with a left forearm transverse fracture of the distal radius and ulna with mild callus and minimal displacement. MD on-call number was called and a message for MD was left. R187's radiology results report showed: Findings: There are transverse fractures involving the distal radius and ulna with mild callus and minimal displacement. Conclusion: Left forearm fractures as described. Addendum: Acute fractures. Electronically signed by M.D. 2/24/23, 3:32 PM. Efforts to reach V40 (agency RN) and V37 (agency RN) for interview could not be obtained and with no return calls. On 4/13/23 at 2:15 PM V3 (Assistant Director of Nursing) stated, I recall (R187), she was sitting by nurses' station a couple of days. She came in respite stay and wasn't here very long. I remember the V6 (previous DON) mentioned in our morning meeting about R187 getting a skin tear. The husband communicated with the staff that he wanted to know about the skin tear, so we followed up an x-ray for a skin tear. Surveyor asked if obtaining x-rays for a skin tear was regular practice. V3 stated, No, I found it odd that he requested an x-ray, but I think he wanted to rule out a fracture because he thought that maybe R187 may have fallen. Surveyor asked if R187 had a fall during her short time she was in the facility. V3 stated, Not that I am aware of. Surveyor asked if that was a possibility given the number of falls that had occurred within the facility. V3 stated, It could have but I nothing was reported to us. Surveyor asked what the x-ray results revealed. V3 stated, R187 had fracture transverse on the arm. Asked about x-ray company used at facility. V3 stated, The only concerns I have is that they (x-ray company) don't come in immediately. Surveyor asked if there was an issue with the x-ray company if she communicated this to administration. V3 stated, No but I should have and will do so now. Surveyor asked the procedures of her nurses when an x-ray cannot be taken when ordered by the physician. V3 stated, The nurses should call doctor again and inform the doctor that the x-ray company will not come until the next day. A stat order means right away and not tomorrow, so we should be following the doctor's order if he ordered it stat. Surveyor asked what the implications of not carrying out the doctor's order as given. V3 stated, A delay in treatment can be harmful to the resident I guess because we should find out what's going on with the resident. In this case we found out she got a fracture. Interview with V10 (Physician) at on 4/13/23 at 2:45 PM stated, I remember that resident was on hospice or respite care, and she was not in the facility very long. Surveyor asked if he was informed of the fracture. V10 stated, Yes, I recall the facility informing me. Surveyor asked about transverse fractures. V10 stated, Transverse fractures are painful. All fractures are painful. Surveyor asked if R187 should have been provided pain medications if she had a fracture. V10 stated, The resident should be treated for pain medications if she exhibits any pain symptoms and if she had a fracture which we now know she did, she would definitely be in some pain. Someone who is nonverbal would probably show signs of pain like agitation. Surveyor asked the meaning of STAT orders. V10 stated, A STAT x-ray means immediately. If the x-ray company cannot come immediately, I should have been called and I would have ordered that patient to be sent out to the hospital for evaluation, and x-ray, and treatment. I was not informed that the x-ray company could not do the x-ray, but I should have been because as I said, I would have sent that patient out. Surveyor asked if this delay would have caused R187 to endure any pain while waiting for an x-ray. V10 stated, Well in hindsight, we know she had a fracture so the sooner we knew that the sooner it would have been treated. On 4/13/23 at 2:06 PM, V24 (RN) stated, We've had a lot of problems with this x-ray company and management is well aware of it. They (x-ray company) will not come when we order x-rays. They will usually come when there are multiple orders or batches of x-rays they have to do, but if it's only one x-ray they won't come until several days sometimes. Surveyor asked the meaning of a STAT x-ray. V24 stated, STAT means within 4 hours, that's the usual guidelines for STAT. On 4/13/23 at 3:30 PM, V35 (Unit Manager/Licensed Practice Nurse/LPN) stated, From what I can remember the husband had brought up concern that (R187) expressing pain or wincing at the slightest touch and so normally he was wondering what could have happened. I can recall the husband asking if she (R187) had fallen or anything had happened. I didn't observe anything on my shift so the husband asked on the morning shift and asked the nurses if she fell and that would explain why she would be in pain. No one reported it to me, so I think they did an x-ray, and it showed a fracture. That is why the husband was prompted as to how did she get this fracture. So, I was in touch with hospice to see what we could do with her, and the doctor ordered an orthopedic consult. Hospice was to hold off the orthopedic consult to manage her pain first and we would send orders scheduled pain medication. She was discharged to home then. Surveyor asked what a STAT order meant to her. V35 stated, Stat is a 4-hour turnaround and we are supposed to reach out to the doctor if the x-ray company can't do that within that time. Surveyor asked if there were any concerns with the timeliness of the current x-ray company the facility used. V35 stated Yes, sometimes they do not come. Surveyor asked if this problem was communicated to administration. V35 stated, I don't know. Facility policy revised 3/27/21 titled Standards and Guidelines: Diagnostic Labs Radiology Notification reads in part, Standard: It will be the standard of this facility to provide or obtain timely laboratory, radiology and diagnostic services when ordered by a physician; physician assistant, nurse practitioner; or clinical nurse specialist in accordance with State law, including scope and practice laws. The facility shall promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. The facility staff shall further ensure communication with the physician regarding other diagnostics such as vital sign measurements, readings, and EKG's. If the facility is unable to provide the necessary laboratory, radiological or diagnostic services in the facility, the facility shall assist the resident in making transportation arrangements to and from the source of service and file in the resident's clinical record signed and dated reports of laboratory, radiological and other diagnostic services.

Based on observation, interview, and record review, the facility failed to follow the plan of care and procedures for wound care to prevent and heal avoidable facility-acquired pressure ulcers for 2 (R3, R64) of 3 residents reviewed for pressure ulcers in the sample of 45 residents. This failure resulted in R3 and R64 to sustain facility-acquired, clinical stage 4 pressure ulcers that required surgical removal of necrotic tissue. Findings include: On 4/10/23 at 10:00 AM the facility presented survey team with a list of the facility's pressure ulcer list which showed R3 and R64 with facility-acquired stage IV pressure wounds. 1. R3 is cognitively impaired with diagnoses listed in part with hypertension, anxiety state, congestive heart failure, atrial fibrillation, and diabetes. MDS (minimum data set) assessment dated [DATE] showed R3 with no pressure ulcers upon assessment but was considered at-risk for the development of pressure ulcers. This same assessment showed R3's listed skin and ulcer/injury treatments to have: Pressure reducing device for chair, pressure reducing device for bed, turning and repositioning program, and nutrition or hydration interventions to manage skin problems. A proceeding MDS assessment dated [DATE] showed R3 now with a stage 4 pressure ulcer and with listed skin and ulcer/injury treatments as: Pressure reducing device for chair, pressure reducing device for bed, turning and repositioning program, and nutrition or hydration interventions to manage skin problems, Pressure ulcer/injury care, and application of dressings to feet. This same MDS assessment showed R3 with no behavioral symptoms that interfered with her care. Lastly, this MDS showed R3 required extensive assistance in bed mobility (turning and repositioning) and required a minimum 1 staff person to perform this task. R3's Care plan dated 12/14/22 reads in part, (R3) is at risk for skin impairment/developing a pressure ulcer due to Braden Scale score, diabetes, incontinence, limited mobility, history of healed pressure ulcer, fragile thin skin. Goal: (R3) will have intact skin, free of redness, blisters, or discoloration over a bony prominence through next review. Interventions: Assist with turning and repositioning if resident is unable; Minimize pressure over bony prominences, Offload pressure to heals, Preventative skin care per house protocols, lotion to dry skin, barrier creams to areas affected by moisture as needed; Provide chair cushion; Provide incontinence care after incontinence episodes, apply barrier cream as needed; Provide pressure relieving mattress. A proceeding care plan dated 2/27/23 reads in part, (R3) has a pressure ulcer on her right lateral foot. Interventions: Assist PRN (as needed) to reposition/shift weight to relieve pressure; Right lateral foot-wound care as ordered by physician until resolved; Minimize pressure over bony prominences; off-load heels; Provide incontinence care after incontinence episodes, apply barrier cream as needed; Provide pressure relieving or reduction device, pressure reduction specialty mattress chair cushion, heel protectors. On 4/10/23 at 11:10 AM, R3 was observed awake in bed, with her back propped up and watching television. Her bed was made with several sheets and blankets under her body and her feet were exposed and not covered by the blankets. The resident's bed had an air mattress overlay and with the electronic pump laying on the left side of the bed on the floor. Surveyor asked how R3 was doing, R3 stated, I'm fine, are you a doctor? Surveyor identified self and asked how her stay was going. R3 stated, It's fine I just want to get a shower today and I can't seem to get anyone to even come in here. I know who my nurse is it's (V5 Licensed Practical Nurse/LPN). She was in here earlier, but she doesn't do much just gives me my pills and goes. She told me that my CNA (Certified Nurse Assistant) is V15, but they keep changing CNAs around here and you never get the same one. This one today (V15) came in when I used the call light, said he'd be back and never did. What time is it, almost noon and he still hasn't come back. He's one of those agency CNAs they keep using and they're just horrible. They come in and when I think they are going to help me or get me what I need, they just turn off my light and then say they'll be back, but they won't return. This nurse (V15) I have isn't any better, she always says she'll get the CNA, she'll get the CNA. I mean why can't she do anything for me? Surveyor asked if anyone comes in to turn her or to help her reposition in her bed. R3 smiled and said, You've got to be kidding. I can't get them to even answer my call light. On 4/11/23 at 11:46 AM, R3 was observed lying on her bed in the same position with her back upright and with similar number of bed linens layered under her body and with her feet atop the air mattress with no pillows or other devices to off-load her feet. The electronic air pump to keep the air mattress inflated remained on the floor and the bed had no foot board. Surveyor asked how she was doing today. R3 stated, Oh I'm just a bit tired today. Surveyor asked who her nurse and aide were today. R3 stated, Oh it's V5 (LPN) but it's a different CNA again so don't ask me who that is because it always changes. Surveyor asked when she last saw her aide. R3 stated, It was around 7 or 8 because he came around the same time I was watching my show but it definitely wasn't V15 (CNA). On 4/11/23 at 12:00 PM, V5 (LPN) was asked about R3. V3 stated, I don't normally work this unit, but I know her. She's always in bed and I give her medications on time in the morning, and she takes it all. Surveyor asked if there was anything special, she did for R3. V5 stated, No, not really. What do you mean? Surveyor asked since she had a specialty air mattress if staff did anything different for R3. V5 stated, Well, I know the wound nurses sees her, but I don't know what else you're asking. Surveyor asked whether R3's number of linens under her body were appropriate to maintain the functioning of the air mattress. V5 stated, No that shouldn't be that way. There shouldn't be that much under her. Surveyor asked what happened to the foot board on the bed and whether the air pump should be sitting on the floor. V5 stated, That's been like that awhile but I'm not sure about the pump. Surveyor asked how often R3 needed to be seen during the shift. V5 stated, Well we try to see everyone frequently. After several questions, V5 failed to mention any turning, repositioning, or offloading of R3's wounds. On 4/11/23 at 1:40 PM, surveyor observed wound care being conducted by V19 (LPN/Wound Nurse). Surveyor asked V19 to describe the procedure and wound to surveyor. V19 stated, R3 has a right lateral pressure ulcer, and it was discovered on 2/20/23 and is facility-acquired. She had boots to elevate the feet, but her family said it made her feet too hot, so we just prop the feet up with pillows. As you can see her legs are twisted outward, so the right lateral foot is always resting against the bed and creates pressure. We do frequent rounds to ensure that her feet are off loaded, and the staff do this when they do incontinence care and whenever they come in the room. Surveyor asked whether the wound was preventable. V19 paused and stated, Yes sir I think it was but sometimes R3 refuses to she won't ask for help to reposition. Surveyor asked R3 in V19's presence whether what the nurse said was true. R3 responded, When I call someone for help no one comes. They don't come in at all sometimes. The CNA today hasn't come in since this morning. No one checks on me that is not true. On 4/13/23 Surveyor asked about R3, V38 (Wound doctor) stated, R3 has had several foot wounds, one was on her dorsal foot which healed and the other was on her lateral foot which I staged at a stage 4. She lays in bed most of the time and does not like to reposition herself. I debrided the eschar (dead skin) to the foot bone. R3 is rigid and bed bound. She was placed on boots to off-load the foot, but I was told she tends to take those off and so the staff use pillows to off-load the pillows. Surveyor asked if R3 had these tendencies to remove the boot and pillows, whether staff should be responsible to ensure these were in place. V38 stated, Well yes they should but as I said, she is resistive to staff doing this, so I'm told by the nurses. Surveyor asked if he had any input on the way bed linens should be made atop a specialty air mattress. V38 stated, There should be minimal linens in order for the air mattress to operate properly. If there are too many linens, it creates pressure points and defeats the purpose of a specialty air mattress. There should be a flat sheet, a draw sheet and blanket and really no more than that. On 4/13/23 at 2:45 PM, V36 (Medical Director) stated, I am the medical director here. I attended the quality assurance meeting last month. We discussed mainly treatment of Covid patients and readmissions to hospital, statistics, and generally what's happening in the facility. We discuss fall risk who is fall risk and that has always been a concern, but the numbers were much better recently. We had specific supervisor that really helped for more staff to improve situation in the fall risk. We recommended to do hours visits to the patient to put fall risk to station. They have alarms in place on high fall risk people. There are other devices more frequent visits, padding on the floor, etc. Surveyor asked about R3's wounds and wounds in general. V36 stated, We do have a wound care team attending to the wounds and we screen the patients; we do air mattresses; we do wound care consult; we have infectious disease consults to make sure the wound is not infected; and we check all the wounds. Surveyor asked about R3's wound, V36 stated, I know that my patient is being seen by the wound doctor, but I would have to pull up her records to tell you more. Surveyor asked about R3's air mattress and other residents placed on air mattresses. V36 stated, Most of the time air mattress have feature that can have and rotation every two hours. Some of them have limited abilities but staff still need to physically come in and reposition the patient and not rely totally on the air mattress. We also have paddings on chair if the patient is transferred out of bed. When patients are in chair, it is harder to do, but it is the responsibility of staff to offload on chair. They should shift position and help them to rest in the bed unless patient family is resistant and even still, they should try. 2. R64 is a severely cognitive impaired resident with diagnoses listed in part with aphasia, dysphagia, vascular dementia, hemiplegia and hemiparesis, anxiety disorder and pressure ulcer stage 4. MDS (minimum data set) annual assessment dated [DATE], and quarterly MDS assessment dated [DATE] both showed R64 with no pressure ulcers but considered at-risk for the development of pressure ulcers. These same assessments showed R64's with listed skin and ulcer/injury treatments to have: Pressure reducing device for chair and pressure reducing device for bed however R64 did not require a turning and repositioning program, nutrition, or hydration intervention to manage skin problems although R64 was considered at-risk for the development of pressure ulcers. A proceeding MDS significant change assessment dated [DATE] could not be provided as the assessment was in the process of completion. Care plan dated 3/14/23 reads in part, (R64) is at risk for skin impairment/developing a pressure ulcer related to incontinence, impaired mobility due to history of CVA, fragile skin, decreased intake with recent weight loss, presence of right ischium wound. Interventions: Minimize pressure over bony prominences; Provide chair cushion; Provide incontinence care after incontinence episodes, apply barrier cream as needed; Provide pressure relieving mattress. A proceeding care plan dated 3/14/23 and revised 4/11/23 (the second day of the facility's survey) reads in part, (R64) has a pressure ulcer on her right ischium. Goal: Pressure ulcer will exhibit sign of healing. Intervention: Assist with turning and positioning if resident is unable. Turn & Reposition every 1-2 hours and as needed (date initiated: 7/15/2020 Revision on 4/11/2023). On 4/10/23 at 11:00 AM, R64 was observed sitting in her wheelchair asleep in the common area along with several other residents. There were no staff in the immediate area conducting activities or any observed prompting of R64 to off load her buttock while on the chair. On 4/11/23 at 11:20, R64 was again observed in the common area sitting in her wheelchair with her eyes open staring at the ceiling. R64 did not appear to be engaged in any form of activity or movement that off-loaded pressure from her buttocks area. Staff were observed walking past R64 and did not engage with R64 in any manner. On 4/11/23 after R3's wound care, V19 (Wound Nurse) went over to R64's room to initiate the wound care. Surveyor asked V19 to wait until the surveyor came to the room to start the wound care. Upon entering the room at 2:15 PM, R64 was already taken off her chair and transferred on to the bed where bedside care was already in progress. R64's incontinence pad had already been removed and was in the process of being provided incontinence care. Surveyor asked why the wound care started and did not wait as requested by surveyor. V19 stated, Oh, I'm sorry. I wanted V12 (CNA) to change her diaper first. Surveyor asked V12 to retrieve the incontinence brief out of the garbage bin to show the surveyor. The incontinence brief was soaked with urine that it was dripping wet when V12 was taking it out of the garbage can. V12 showed surveyor the sweatpants R64 was wearing while seated in her wheelchair. The sweatpants were also saturated with urine all through the buttock area of the pant. Surveyor asked V12 (CNA) if R63 was his resident to take care of today. V12 stated, No, she's not mine, I'm just here to help V19 (wound nurse) out for wound care. I usually help out during wounds. Surveyor asked V19 to proceed with the wound care. V19 stated, R64 has a pressure sore on her right ischium, and it is facility-acquired on 3/13/23. I was informed by the nurse and when I came in on Monday morning, the doctor rounded with me and staged it at a stage 4 pressure ulcer. Surveyor asked to describe the wound. V19 stated, It is a stage 4 and it's about 2.5 inches deep. It is the size of a golf ball. I can see bone and fascia, some redness, and there is no drainage, undermining or tunneling of the wound. Surveyor asked if the wound was preventable. V19 stated, I think so, it's avoidable. Surveyor asked what measures the facility had in place to prevent the wound, and now heal the wound. V19 stated, Well she is on an air mattress when she is in bed, and we upgraded her wheelchair cushion to a gel cushion. V12 (CNA) interjected without being asked, Staff still have to reposition her even if she is in the mattress because it can't do it for her. Surveyor turned to V19 (Wound Nurse) and stated, Yes that's true but she is resistant sometimes. Surveyor asked if the resident shows resistance to care, as she says, what staff should do. V19 stated, Well they should still keep trying. Surveyor asked how staff would reposition someone when they are in the chair. V19 stated, I don't know, that's more difficult. Surveyor asked if staff should be prompting the resident to shift her weight if she is unable to do this herself. V19 stated, Yes you're right. We should be doing that too. After the wound observation, V19 informed surveyor of the exact measurements of R64's wound. V19 stated, The wound measures 3.9 centimeters long by 2.1 centimeters wide by 3.4 centimeters deep. You were right, it appeared deeper than 2 inches. On 4/13/23 at 11:46 am, V38 (Wound doctor) stated upon interview, I was informed about R64's wound. It started out as an unstageable wound at the time, and I debrided the necrotic area and so it was staged to 4. Looking at the records, it appears that I was initially informed of the wound on 3/13/23. R64 tends to sit on her chair most of the day. Staff need to off-load the pressure and I know she has a chair cushion and we upgraded it to a gel cushion. It was a challenge to get her out of her chair all day and to get her back to bed but I then I was informed by the nurses that when she was in bed she tends to climb out of bed, so again R64 has presented challenges for staff. We provided her a special air mattress for that. Surveyor asked if staff should be repositioning R64 while in bed. V38 stated, Yes, we can't just rely on the special mattress or gel cushion, she needs to be off-loaded by staff. I can tell you she is very resistant however. Surveyor asked whether he considered the wound to be an avoidable wound. V38 paused a moment and stated, I believe it is unavoidable due to her behaviors from what staff has indicated to me. A review of R64's MDS (Minimum Data Set) annual assessment of 11/19/22, MDS quarterly assessment dated [DATE], and MDS significant change assessment on 4/12/23 show no behaviors exhibited by R64 that impacted her care, contradicting the information provided to V38 by facility staff. A review of R64's annual MDS assessment dated [DATE], showed no behaviors exhibited by R3 that impacted her care. R3's quarterly MDS assessment dated [DATE] showed no behaviors exhibited by R3 that interfered or impacted her care contradicting the information provided to V38 by facility staff. Facility policy issued 3/1/2008, revised 3/27/21 titled Wound Care reads in part, It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. A pressure injury risk/skin assessment evaluation will be completed upon admission, with each additional assessment, quarterly, annually and with significant changes in condition. Skin will be assessed evaluated for the presence of developing pressure injuries or other changes in skin condition on a weekly basis at least once each week or as needed by a licensed nurse. Wound care procedures and treatments should be performed according to physician orders. Preventative measure, such as barrier creams, can be employed to help maintain skin integrity as well as utilization of pressure relieving surfaces, floating heels, protective boots and use of positioning devices.

Based on observation, interview and record review, the facility failed to provide effective pain management for a hospice resident with severe cognitive impairment, failed to identify signs and symptoms of pain for 1 (R187) of 5 residents reviewed for pain in the sample of 45 residents. It can be determined that the reasonable person in the resident's position would have experienced pain from the left forearm fracture. Findings include: R187 was admitted to the facility on [DATE] for a 5-day respite stay under hospice care with diagnoses of Alzheimer's Disease, atrial Fibrillation, obstructive sleep apnea, seizures, anxiety disorder, cardiac pacemaker. Per facility medical records, R187 is blind, cannot communicate her needs and totally dependent on staff. A facility federal report notification dated 2/27/23, authored by V6 (previous Director of Nursing) reads in part (but not limited to): Per staff interview, on 2/22/2023, (CNA/Certified Nurse Assistant) dressed resident and reports skin intact and no skin alterations during morning care. Then 2 staff reports assisting resident to transfer using mechanical lift without any issues. Resident was sitting at nurse's station when staff assisted resident with her meals and then transferred to bed for incontinent care by 2 CNAs during AM shift. Resident was assisted with dinner while at nurse's station. Resident noted flailing arms and legs around during meals. No pain indicators noted at that time. Resident redirected with verbal stimuli, and she completed her dinner. At approximately 7:30 PM. 2 CNAs using mechanical lift transferred resident to bed without any issues. As CNA was removing resident's clothing, she noted a skin tear on left forearm and immediately alerted the nurse. Based on staff interview no fall noted or reported as resident was being supervised at nurse's station from change of shift until after mealtime. Resident was then transferred to bed by 2 CNAs for the night. On 2/23/23, the hospice nurse came in to evaluate the resident and x-ray ordered with results as follows: There are transverse fractures involving the distal radius and ulna; with mild callus and minimal displacement. Left forearm fracture. Hospice and physician collaborated and determined to apply left arm splint, immobilize extremity, pain medication regimen revised, and referral made for orthopedic specialist. Resident admitted to our facility for 5-day respite stay and discharged to home on 2/24/23 with hospice care. Efforts to contact V6 (previous Director of Nursing) during the survey were left unanswered. V2 (current Director of Nursing) indicated V6's agency did not want to provide her contact information and was currently assigned to work in an alternate nursing rehabilitation facility. On 4/10/23 at 11:00 AM, V2 (current Director of Nursing) stated when asked about R187's incident report, I've only been here a month and that incident report was just laying on my desk. I don't know anything about it. Surveyor asked if she reviewed the incident report in anticipation of any investigations from the public health department. V2 stated, No. I didn't get the chance to do that. On 4/13/23 at 2:15 PM, V3 (ADON/Assistant Director of Nursing) stated, I recall her (R187). I was passing by the unit and (R187) was by nurses' station a couple of days. She came in respite care, so she wasn't here very long. I don't recall seeing family. I remember the previous DON (V6) that she mentioned in the meeting about a skin tear. The husband communicated to the staff that he wanted to know about the skin tear. I did not look at the skin tear itself but If I recall correctly the nurse working that day was V8 (Registered Nurse/RN) so she must have done the assessment. I know that we followed up an x-ray for a skin tear and I found it odd that the family requested an x-ray to rule out injury fracture because I think he suspected that there may have been a fall. The x-ray came back and there was a transverse fracture of her arm. Surveyor asked whether she a transverse fracture would be a painful fracture. V3 stated, I don't have much experience with fractures, but I would think they would be. Surveyor asked whether R187 would be able to communicate whether she had any pain or not. V3 stated, I think we talked about that in our meeting, and I think the DON assessed her for no pain, but I will check and see if she got anything for it. On 4/13/23 at 4:15 PM V3 (ADON) presented surveyor with the medication administration record and pain assessment. V3 stated, it was the previous DON (V6) who did this pain assessment, and she wrote that the resident wasn't in any pain, but I see that the resident was given Lorazepam for agitation which is a sign of pain. I see there was PRN (as needed) pain medication, which should have been given instead. Surveyor asked how the facility treats any resident in pain. V3 stated, Nurses should treat pain as whatever the resident is saying. If the resident is non-verbal, they should look for cues for pain like grimacing, moaning, increased agitation. Surveyor asked if, based on R187's medication record, whether her pain could have been caused by the fracture. V3 stated, That's what it looks like and we should have identified it and given her pain medication, or at least informed the doctor. On 4/13/23 at 3:15 PM, V7 (CNA) stated, I took care of (R187) for a little bit because she wasn't here long. I recall she was in a lot of pain, and she would want to be boosted up a lot and she'd complain when we'd boost her up in bed. Her husband came here too and would ask for us to help the resident. Surveyor asked how many staff it took to boost R187 up and/or transfer her from her bed to chair. V7 stated, It would take two persons, but I never saw her fall or anything like that. Surveyor asked why she mentioned falling as the question wasn't asked. V7 stated, Sorry, I just thought you were going to ask me if she fell or not, but I never did see her fall or anything like that. I do remember her always agitated when we tried to move her even a little bit. Surveyor asked when she first noticed R187 in pain and whether she mentioned it to the nurse. V7 stated, She was always in pain, and I did tell my nurse. I just assumed they gave her something for it. On 4/13/23 at 2:45 PM, V10 (Physician) stated, I remember that resident was on hospice or respite care, and she was not in the facility very long. Surveyor asked if he was informed of the fracture. V10 stated, Yes, I recall the facility informing me. Surveyor asked about transverse fractures. V10 stated, Transverse fractures are painful. All fractures are painful. Surveyor asked if R187 should have been provided pain medications if she had a fracture. V10 stated, The resident should be treated for pain medications if she exhibits any pain symptoms and if she had a fracture which we now know she did, she would definitely be in some pain. Someone who is nonverbal would probably show signs of pain like agitation. Surveyor asked the meaning of STAT orders. V10 stated, A STAT x-ray means immediately. If the x-ray company cannot come immediately, I should have been called and I would have ordered that patient to be sent out to the hospital for evaluation, and x-ray, and treatment. I was not informed that the x-ray company could not do the x-ray, but I should have been because as I said, I would have sent that patient out. Surveyor asked if this delay would have caused R187 to endure any pain while waiting for an x-ray. V10 stated, Well in hindsight, we know she had a fracture so the sooner we knew that the sooner it would have been treated. On 4/13/23 at 2:45 PM, V36 (Medical Director) stated, I am the medical director here. I attended the quality assurance meeting last month, 1 and half months ago. We discussed mainly treatment of Covid patients and readmission to hospital and statistics what's happening in general in the facility. Surveyor asked how the facility staff manage pain for their residents. V36 stated, Patients have to have their pain controlled. Having minimal pain is the best approach to pain management. Occasionally patients cannot be pain-free but scheduled pain medications should be administered as ordered. Chronic pain should be assessed every two to 3 hours. If the patient is not alert, or if patient has signs for tachycardia (rapid heart rate), that would warrant taking pulse, that will warrant looking further into possible pain. Patients with dementia or with dysphagia then we know the non-verbal signs of pain. Surveyor asked whether fractures were painful. V36 stated, Fractures are generally painful. Surveyor asked specifically about transverse fractures. V36 stated, Transverse fractures do not normally occur spontaneously. They could happen possibly during a transfer or fall. A review of R187's physician order sheet does not provide any pain medications ordered or administered during R187's respite stay until being discharged to home on 2/24/23. A review of R187's MAR (Medication Administration Record) showed that an order for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) was ordered on 2/24/23 and administered by V35 (Licensed Practical Nurse/LPN) only once upon discharge of the resident. There were no other pain medications prescribed or administered during R187's hospice/respite stay that began on 2/20/24. Facility policy issued 3/1/2008, revised 3/26/2021 titled Pain Screening and Management reads in part, It will be the standard of this facility to screen residents and attempt to provide effective pain and comfort management. Guidelines: Residents will be screened for potential pain on admission. This may be achieved by asking the resident if they have or are experiencing pain, observing for signs and symptoms of pain or by reviewing physician's orders and history and physical. Residents may additionally be screened for pain quarterly, annually, upon change of condition or upon resident report of new pain or newly observed non-verbal signs and symptoms of potential pain. Attempt to obtain physician's orders for pain management, if needed. Administer pain medications according to physician's orders and resident request for PRN medications. On-going monitoring of residents receiving interventions should be completed in the clinical record as indicated. Resident's goals and preferences should be considered when developing the pain management regime and administration of medication. Implement/update a person-centered plan of care related to pain manage, as is appropriate. Facility policy issued 2/1/2008, revised 3/27/2021 titled Hospice/Palliative/End of Life Care reads in part, It will be the standard of this facility to provide, participate in or collaborate with the provision of dignified palliative, Hospice or End of life care. The physician will order appropriate interventions to help relieve pain and make the resident as comfortable as possible. The facility staff will provide care and services per physician orders and the resident's person-centered plan of care related to palliative, hospice or end of life care. According to Cleveland Clinic medical journal article dated 5/5/2022 titled Transverse Fracture reads in part: Transverse fractures are almost always caused by traumas like falls or car accidents. Transverse fractures and transverse process fractures are different types of bone fractures. Even though they have similar names, they're very different injuries. Transverse fractures occur when your bone is broken perpendicular to its length. The fracture pattern is a straight line that runs in the opposite direction of your bone. They can happen to any bone in your body, but usually affect longer bones after a trauma like a fall or accident. Transverse fractures can affect anyone. This is especially true because they're caused by accidents and traumas. Symptoms of a transverse fracture include Pain. Swelling. Tenderness. Inability to move a part of your body like you usually can, Bruising or discoloration. A deformity or bump that's not usually on your body. Any impact on your bones can cause a transverse fracture. Some of the most common causes include Falls, car accidents or sports injuries.

Based on interview and record review the facility failed to protect 3 female residents from being sexually abused by a male resident. This failure resulted in R4 inappropriately touching R1 on 9/22/22, R2 on 9/17/22 and R3 on 9/21/22. This applies to 3 of 3 residents (R1, R2 and R3) reviewed for sexual abuse in a sample of 4. As a result, R1, R2, and R3 cognitive impaired residents would have suffered psychosocial harm by the reasonable person concept. The findings include: 1. The Incident Report dated 9/22/22 states, On 9/22/222 at around 10:20 AM, the Administrator was alerted to an allegation of Abuse. (R4) was noted attempting to fondle another resident (R1) . A written statement dated 9/22/22 by V3 (Certified Nurse Assistant/CNA) states, As I was picking up room trays, I saw (R4) in the TV room with his hands in (R1's) pants. I quickly told him to stop. He ignored me and I removed him from the TV room. I then fixed (R1's ) clothing because he had her shirt pulled up . On 10/14/22 V2 (Interim Director of Nursing) stated, (R4) had no prior incidents, in fact the family was shocked when we called them and told them what had happened. (R4) is confused and has a BIMS (Basic Interview for Mental Status) score of about 5 or 6 (cognitively impaired). When the CNA found him, he had his hands in the (R1's) pants. They were both out in the day room, very visible to everyone. They were separated immediately. On 10/14/22 at 1:10PM V8 (R4's Psychiatrist) stated, Since that one episode I don't believe he has had any other issues. I would say it is just his Dementia with behaviors. The [MEDICATION(S)] seems to be working really well for him. R4's Admission Record shows that R4 is a male resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Minimum Data Set assessment dated [DATE] shows that R4 has Severe Cognitive Impairment. R1's Admission Record shows that R1 is a female resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Minimum Data Set assessment dated [DATE] shows that R1 has Severe Cognitive Impairment. The facility Incident Audit Report dated 9/23/22 states, Male resident was observed inappropriately touching resident in the TV room. Contributing Factors: Both residents confused with Dementia. BIMS for both residents is coded as severely impaired . The facility policy entitled SG ANE and Investigations _ MW last revised on 3/27/21 states, Sexual abuse is non-consensual sexual conduct of any type with a resident. 2. On 10/14/22 at 11:47 AM, V1 (Administrator) stated, I am going to be perfectly honest with you. When we interviewed the other CNAs about this incident (with R1) , we found out that (R4) had been sexually inappropriate with (R2 and R3) also. An undated written statement by V4 (CNA) states, On September 17, 2022, I saw (R4) touching (R2) inappropriately. I removed him and notified the nurse. As I went back to check on (R2), (R4) was back trying to talk to her. I asked him to please go somewhere else and leave her. He kept trying to find his way back to her multiple times and I kept blocking him. The nurse was notified the whole time. In a different handwriting this same form shows a statement of, DON re-interviewed (V4-CNA) to clarify the above statement. (V4) stated (R4) touched (R2) on the breast over her clothing. On 10/14/22 at 2:00PM V4 stated, From what I think I saw, (R4) was in the TV area and he was next to (R2). From far away it looked like he was touching her breast. I called his name and he looked at me but then it looked like he was reaching toward her breast. I told the nurse (V5 Registered Nurse/RN). I have never seen him touch anyone else before. Most of the time he is in the TV area. He goes to the little book corner, and he sits and reads. His speech is not very easy to understand, and I have never heard him say anything about wanting to have sex. A written statement by V5 (RN) dated 9/22/22 states, On 9/17/22 V4 reported to me that (R4) kept trying to touch (R2). I was not notified that (R4) touched any body part of (R2). I was made aware that he was trying to get close to (R2). I also noted myself that (R4) was trying to touch (R2) by reaching out and approaching her. I did not see (R4) touch any body part of (R2). On 10/14/22 at 1:45 PM V5 stated, I was told (R4) was trying to touch (R2), not that he had actually touched her. He is Aphasic and confused. (V4) reported to me that (R4) was trying to touch (R2). She didn't say anything about (R4) physically touching (R2). The CNA didn't say where he was trying to touch. I assessed the situation in the TV area. I didn't remove him from the area. I have never seen him do anything. I had no issues with him. I did an assessment on (R2) just to be sure, but she is confused. I don't think she was even aware that anything happened. R2's Admission Record shows that R2 is a female resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Minimum Data Set assessment dated [DATE] shows that R2 has Severe Cognitive Impairment 3. A written statement by V6 (CNA) dated 9/22/22 states, On September 21st, V7(RN) asked me to take (R4) away from a (R3) because he was touching her inappropriately. I saw him touching her breast. On 10/14/22 at 12:55 PM V6 stated, I was far away and when the nurse asked me to separate them, and I went toward (R4), he kind of pulled back away from (R3). I know I said (R4) was touching her beast but now I am not sure if that is what I saw. I moved (R4) away from (R3) and I moved him to his room. He likes to read, and he likes puzzles so when he went to his room. He grabbed his book and started reading. I have never seen him touch anyone else. Nothing like this before that. An undated written statement by V7 (RN) states, On September 21st I noted (R4) touch (R3's) hands, they were sitting in the TV room, and I had (V6) remove (R4) and take him to his room. I have never witnessed inappropriate behavior, but I didn't want him to continue to touch her, so I separated them. On 10/14/22 at 12:35 PM V7 stated, (R4) was touching (R3's) hands. They were both in wheelchairs in the TV room. His room used to be (XXX). I was on the phone, so I asked (V6) to please separate them. I think she put (R4) at the nurse's station. I didn't do anything after that. He wasn't just touching her hand; he was more like holding her hand and I didn't like the way it looked. (R3's) daughter is very involved with her care and is here almost every day and I knew she would not like that if she saw it. (R3) is non-verbal and she really didn't react to what (R4) was doing. R3's Admission Record shows that R3 is a female resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Minimum Data Set assessment dated [DATE] shows that R3 has severe Cognitive Impairment.

Based on observation, interview, and record review, the facility failed to assess and monitor residents for potential side effects of [CONDITION(S)] medications and document adverse effects of [CONDITION(S)] medications; and plan alternative interventions for these medications. This failure resulted in R4 having extended periods of non-responsiveness and inability to consume meals and participate in ADL (Activities of Daily Living). This applies to 1 of 3 residents (R4) reviewed for [CONDITION(S)] medications. The findings include: The Face sheet shows that R4 was admitted to the facility on [DATE]. The Face Sheet shows R4's diagnoses that included dementia with behavioral disorder, [CONDITION(S)] (cerebral vascular disease), depressive disorder, dysphagia, muscle wasting, weakness and lack of coordination, delusional disorder, and history of Covid -19. On 4/1/2022 at 10:15 A.M., together with V3 (Registered Nurse) reviewed R4's [CONDITION(S)] medications. V3 stated that R4 were taking the following [CONDITION(S)] and other medications that would affect R4's alertness: -[MEDICATION(S)] 0.5 mg. (antianxiety) scheduled to be administered daily at 9:00 A.M. -[MEDICATION(S)] 250 mg. (use as mood stabilizer) twice a day to be administered daily at 9:00 A.M. and 5:00 P.M. -[MEDICATION(S)] 25 mg. twice a day to be administered daily at 9:00 A.M. and 5:00 P.M. -[MEDICATION(S)] (neurological pain) 100 mg. to be given 3 times a day daily at 9:00 A.M.; 1:00 P.M. and 5:00 P.M. -[MEDICATION(S)] 10 mg. to be given twice a day daily at 9:00 A.M. and 5:00 P.M. -[MEDICATION(S)] 40 mg. every 9:00 P.M. -[MEDICATION(S)] 4.6 mg. every 24 hours to be given daily at 10 P.M. -[MEDICATION(S)] 0.5 mg. every 8 hours as needed During this time of medication review with V3, R4 was at the lounge area next to the nurse's station. R4 was lying in R4's reclining wheelchair. R4 was not responding to command, and to tactile stimuli. R4 was heavily sedated. R4's eyes were closed. V3 attempted to wake, arouse R4 for approximately 30 minutes but no avail. R4 remained in deep sleep and was not moving at all nor had open R4's eyes. V3 did a chest rub stimulation for at least 5 minutes, manipulate by touching and stimulating face, throat, and extremities but R4 remained unresponsive. V3 added that (R4) is usually like that very sedated after scheduled morning medications were given to (R4). This is not something new. She might wake up later. When surveyor asked V3 how she will document R4's current observation: V3 replied 0 for no behavior (since R4 was asleep)/ NA (Not Applicable) for SE (Side Effects). Continued observation was made for R4 from 10:15 A.M. through 2:30 P.M. Then an intermittent observation with R4 (every 20-30 minutes) was done from 2:30 P.M. to 4:30 P.M. R4 was propelled by a staff to the main dining room at 12:00 noon, R4 remained unresponsive. R4 was placed in the last table. Staff started serving lunch. R4's tray was placed on a table in front of R4. R4 eyes remained closed and was not responding. V11 (CNA/ Certified Nurse Assistant) tried to wake up R4 by tactile stimuli, and calling R4's name, shook R4's body/wheelchair but R4 did not move a muscle and no response at all. V12 (Assistant Director of Nursing) came over to try to wake up R4 by calling R4's name, touching most part of R4's body including face, throat, ears, hands, chest rub but R4 remained non-responsive and not a single moan /verbal response nor had R4 open her eyes. V12 attempted to have R4 drink an apple juice from a glass by placing the rim of the glass in R4's mouth. There were few drops of the juice that was placed in R4's mouth, but there was no swallowing reflex noted. Not even a mouth /oral stimulation had made R4 response. V12, then placed an approximate 1/2 teaspoon of the apple juice inside R4's mouth. Surveyor informed V12 that R4 was not responding at all and R4 might aspirate with the juice. V12 then manipulate R4's throat/neck area to induce swallowing reflex. R4 again had no response. V12 said, I am just trying to moisten (R4's) mouth. During lunch observation, up to 1:20 P.M., R4 remained unresponsive and heavily sedated. V13 (Resident Assistant) propelled R4 back to R4's room. R4 had missed lunch due to being heavily sedated. V6 (CNA, been at the facility for 20 some years) who happened to be at the same dining room with R4 had stated that (R4) is usually like that, in deep sleep. V11 and V14 (CNAs) transferred R4 back to bed by lifting R4 manually. V11 proceeded to turned R4 to sides while in bed and incontinence check was done. R4 was bone dry. V11 said the last time R4 had urine noted in R4's incontinence brief was at 7:30 A.M. There was no liquid/lunch that R4 had consumed during all these times. Observation was continued on an intermittent interval of 20-30 minutes from 2:30 P.M. to 4:30 P.M., V9, V10, V18 (CNAs) used the total lift transfer device to transfer R4 from bed to wheelchair at 4:30 P.M. V9 and V10 applied the sling under R4's back by turning R4 side to side while in bed, then hoisted R4 via the lift device for transfer to the reclining wheelchair. All this time, R4 remained with eyes closed, no response at all from all the verbal and tactile stimuli. V9, V10 and V18 have all said that (R4) is usually like this, not responding, deep sleep and this is not something new. We cannot wake (R4) up. (R4) may wake up later. R4 was then propelled to the hallway by V10. V2 (Director of Nursing), then came over and touched, shook, did chest rub to R4. However, R4 remained unresponsive. V3 was asked at this time and stated that R4 had remained sedated all this time since in the morning as observed. The observation that R4 was heavily sedated was a total of 6 hours. R4 was left being still heavily sedated at 4:30 P.M. However, the progress notes dated 4/1/2022 at 9:00 P.M. shows that R4 was sleeping until dinner time. V2 confirmed on 4/3/2022 at 12:10 P.M. that dinner time for residents is 6:00 P.M. So, this is a total of around 8 hours that R1 was heavily sedated from the time R4 was seen in the morning. On 4/1/2022 at 4:45 P.M., together with V2, the behavior monitoring form for the month of February and March 2022 was reviewed and discussed. There was no documentation that R4's excessive sedation was documented at all including the day of observation of 4/1/2022 for the morning shift. The behavior monitoring shows that there was no behavior observed and no side effects. There was no specific targeted behavior to justify the continued use of the [CONDITION(S)] medications. V2 explained because that was how the computer was set up, so it was all generalized behavior and symptoms. The Behavior Monitoring Form also shows some blank spaces that indicate behavior was not address and monitored. V2 has no explanation why R4's multiple occurrences of excessive sedation were not documented as side effects on the Behavior Monitoring Form nor on R4's EMR. The POS (Physician Order Sheet) was also reviewed with V2 and shows current [CONDITION(S)] and other medications that can affect R4's alertness and sedation: - [MEDICATION(S)] 0.5 mg. 1 tablet every 8 hours as needed ordered on 1/28/2021. - [MEDICATION(S)] 25 mg. originally ordered 1/28/2021. -[MEDICATION(S)] Sprinkles 500 mg. BID with some changes in dosage but was initially ordered on 9/7/2021. V2 said [MEDICATION(S)] is use as mood stabilizer. - [MEDICATION(S)] 0.5 mg. with different dosages but originally ordered on 12/12/2021. - [MEDICATION(S)] 100 mg. 3 times a day for nerve pain ordered on 1/28/2021 -[MEDICATION(S)] 10 mg. 2 times a day ordered on 1/28/2021 -[MEDICATION(S)] 40 mg every night ordered on 1/28/2021 -[MEDICATION(S)] 4.6 mg. every 24 hours ordered on 5/25/2021 V2 confirmed. that R4 is currently on 8 medications that can affect alertness and cause sedation. V2 said that R4 showed excessive sedation and is very confused and insight when awake. V2 also said that she does not know why the progress notes entered by V15 (Psychiatric Nurse Practitioner) showed that V15 had discussed all the treatment plan including side effects of [CONDITION(S)] medication with R4 and that R4 was agreeable. V15 has conflicting assessment to reflect the actual condition of R4. V2 said that she had talked to V15 about the accuracy of his progress notes but V15 remained documenting the same conflicting assessment and does not reflect the actual condition of R4. When asked why the staff showed no intervention during the prolonged time that R4 was heavily sedated as observed on 4/1/2022, V2 had responded with no answer. The progress notes dated 3/27/2022 documented by V15 (Psychiatric Nurse Practitioner) shows (R4), was evaluated at (facility) for a follow up .Nursing reports patient has been more sleepy the past couple days. Patient seen in room and appears calm. Patient with limited participation to interview. The patient has been medication compliant without side effects. MENTAL STATUS EXAM: Appearance; The patient appears stated age. Disoriented and confused .Thought process; unable to assess .Cognitive is poor, memory is poor. PLAN: Will continue with current treatment plan and monitor' Will monitor closely for efficacy, side effects or any possible interactions; Pt will report and changes in mood, affect, behavior; DISCUSSED WITH PATIENT THE RISK AND BENEFITS OF CONTINUED USE OF PSHOTROPIC MEDICATION USE AND THE PATIENT EXPRESSED CLEAR UNDERSTANDING OF THE INFORMATION DISCUSSED. Psycho-education provided about medication and worsening of depression or emergence of suicidal behavior, as well as psychotic s/s or [CONDITION(S)] and was told to stop meds and call 911, or go to closest ER if this occurs. Total time spent in the care on this date was 25 minutes. Over 50% of that time was spent in counseling regarding treatment compliance, pros and cons of various treatment options . The 3/13/2022 notes from V15 basically were the same assessment: SOURCE OF INFORMATION: Patient interview RELIABILITY: Good. The patient has been medication compliant without side effects. MENTAL STATUS EXAM .Disoriented and confused Insight and judgment is good. Cognitive is poor, memory is poor. PLAN: Will continue with current treatment plan and monitor; Will monitor closely for efficacy, side effects or any possible interactions; Pt will report and changes in mood, affect, behavior; Discussed with the patient the risks and benefits of continued [CONDITION(S)] medication use and the patient expressed clear understanding of the information discussed; Psycho-education provided about medication and worsening of depression or emergence of suicidal behavior, as well as psychotic s/s or [CONDITION(S)] and was told to stop meds and call 911, or go to closest ER if this occurs; Total time spent in the care on this date was 25 minutes. Over 50% of that time was spent in counseling regarding treatment compliance, pros and cons of various treatment options . The EMR shows no documentation from V16 (Nurse Practitioner for V17 R4's Attending Physician) regarding R4's multiple episodes of excessive sedation. The progress notes entered by V16 dated 3/22/2022 shows that R4 resident seen today for continuing care and follow up on gen weakness, dementia. Pt is alert, nonverbal, make sound. seen pt is room, sitting in WC. No agitation noted or reported today. She is a poor historian due to advanced dementia. R4's MDS (Minimum Data Set) assessment dated [DATE] codes R4 as being unable to assessed for cognition and could not be interviewed. R4's MDS also documents R4 as having no behaviors. The MDS documents that gradual dose reduction was not attempted for R4. R4's POA (Power of Attorney) did agree to the psychoactive medications, however most were signed in January of 2021. R4's Plan of Care dated February 15, 2021 documents the resident has behaviors, and use of [CONDITION(S)] medications. Care plan interventions for behaviors and [CONDITION(S)] medications lists interventions such as, monitor for effectiveness of drug(s), Monitor/record occurrence of target behaviors and monitor and report adverse reactions. The Behavior Monitoring Form and the EMR shows no documentation that monitor the responses to or effects of the change in R4's ADL's participation, and whether the change of condition was related to the [CONDITION(S)] medications. On 4/1/2022 at 3:00 P.M. V17 (R4's Attending Physician) stated that R4's excessive sedation was most likely due to R4's [CONDITION(S)] medications and he will come the next day to evaluate R4. The facility's policy for [CONDITION(S)] medications with a revision date of 3/21/2021 shows: It will be the standard of the facility that [CONDITION(S)] medication therapy shall be used only when it is necessary to treat a specific condition.4. Nursing staff will document in the medical record and individual's target symptom/s.7. The staff will observe and report to the attending physician or psychological services information regarding effectiveness of any interventions, behavioral changes, or other pertinent data to assist with needed medication adjustments/recommendations .13. Nursing staff shall monitor and report any ill side effects to the attending physician.

Based on record review and interview, the facility failed to ensure a resident was free from abuse. A staff member (V7) intimidated a resident and created a hostile environment. The facility also failed to have a staff member (V8) recognize a resident was being abused and failed to intervene immediately to stop the abuse and protect the resident. This applies to 1 of 4 residents (R1) reviewed for abuse. As a result, R1 was subjected to the abusive behavior of V7 (certified nurse aide) who mentally abused R1 by making R1 afraid. The facility's investigation did not include all employees' accounts of the abuse incident leaving V7 on duty to intimidate residents. This was identified as an immediate jeopardy situation which began on 1/27/2022. On 2/15/2022 the administrator was notified of the immediate jeopardy. The immediate jeopardy was removed on 2/17/2022. However, the deficiency remains at the second level of harm until the facility determine the effectiveness of the implementation of the removal plan. Findings include: The state agency received an abuse incident report from the facility on 1/27/2022. The information included the following: Patient (R1) is a [AGE] year-old, short term resident of this facility who is alert, oriented x 3. (R1) has DX of Femur Fracture, Spinal Stenosis, polyneuropathy, Polyarthritis, Anxiety, hypertension. On 01/27/22, resident reported to DNS (Nurse) that CNA from last night was very mean to (R1), refused to help (R1) and hit (R1) on the face while telling (R1) to go to the bathroom even after (R1) told her (R1) didn't have to go. Upon learning about the allegation, the facility initiated an investigation. CNA was placed on suspension pending result of investigation. Immediate corrective / protection actions documented in the report: MD (Medical Doctor) and POA (Power of Attorney) notified 2) Full body assessment done on resident 3) CNA was placed on suspension pending result of investigation. 4) Staff and resident interviews initiated 5) Body checks on all residents in the unit with BIMS>10 6) n abundance of caution, Abuse in service initiated. In conclusion the facility reported R1 on 1/31/22 reported during the provision of care, specifically, helping the resident in the bathroom with toileting, the CNA bumped (R1's) face with her elbow. The resident reports that (R1) did not think this was intentional. The accused CNA (V7) was interviewed. She denied ever elbowing the resident and reported that she did not recall her elbow touching the resident ' s face. After a complete and thorough investigation, the facility could not find evidence to support abuse. According to R1 ' s MDS (minimum data set) assessment dated [DATE], R1 had a BIMS (brief interview for mental status) score of 14 showing R1 to be cognitively intact with no confusion and no behaviors indicating any resistance to care. R1's functional ability showed R1 to require maximum assistance in all R1's activities of daily living due to a history of a femur fracture and spinal stenosis. The following interviews were conducted during the investigation: 1. On 2/7/22 at 11:00 AM R1 stated, I'm not feeling too well today. The surveyor asked about what happened on 1/26/2022 (3-11 shift) to R1 with one of the aides who took care of R1. R1 reported, That CNA (certified nurse aide) was shouting at me and told me to take off my gown off and she made me get in the chair and took me and put me on the toilet, then left me there for over an hour. I told her I didn't need to go to the bathroom, and she was angry with me and kept shouting at me to take my gown off and then she ripped it off of me, and in the process, elbowed my face. She didn't even say she was sorry. She threw my gown in the toilet and I asked her why she did that and she said because it had sh** on it so I took it out of the toilet because it was my own personal gown that I liked, and I put it on the floor because it was soaking wet. I don't know why this girl hated me so much, but she frightened me at the time. Everything went so fast, and I was a little shocked this was happening. She was in such a rush to get me on the toilet even though I kept telling her I didn't need to go, and so I shouted out to the hall to get someone's attention, but she even told me to quiet down. I told her (V7) I was going to report her to the nurse, and she said to me go ahead and wouldn't go anywhere because she would tell the nurse first. That's when I saw the nurse (V8-registered nurse/RN) finally come in, but she didn't do nothing either when I tried to tell her what happened. She asked CNA to come outside the room and then the CNA came back and then put me back in the bed and actually said to me see nothing's going to happen to me. I didn't see the nurse (V8) again until she gave me medications, but the CNA (V7) came back again in my room later on and I pretended to be asleep. The next day (1/27/2022) I complained to another nurse (V9) on what happened to me and then some other nurse (V2-Director of Nursing) and some boss man came and asked how I was doing. The gal (V2) kept trying to justify that the CNA didn't mean to hit my face. How did she know this? V2 kept trying to convince me it was not intentional. So, I just told her (V2) okay so I guess it wasn't intentional, but I also told her that CNA shouldn't be working here if she is that angry. I'm a tough cookie but she should not have treated me like that. Surveyor asked if the CNA. (V7) ever took care of (R1) again after that. R1 stated, No, but next time I will call the police. 2. On 2/11/22 at 12:09 PM, interview with V2 (Director of Nursing) stated, I am the abuse prohibition designee, not the administrator. That's just how it's been with our company that I am the abuse person in charge of investigating abuse, but the administrator (V1) helps too. I conducted the investigation when V9 (RN) reported to me on 1/27/2022, R1 reported to her (R1) was hit in the face by the CNA (V7) on the previous night (3-11 PM). I called V7 at home and interviewed her and told her she was suspended pending the results of the investigation. V7 told me that the resident wanted to be changed while she was passing dinner trays, so she went and assisted the resident to the restroom. V7 said R1's night gown was soiled and R1 didn't want to be changed, but V7 insisted on changing (R1) and told (R1) there was BM (bowel movement) on (R1's) gown. V7 also said that the nurse (V8) was present during all of this. Surveyor asked if R1 was considered a confused resident. V2 stated, No (R1) is very alert and oriented x 3. Surveyor asked if she interviewed the other nurse on duty as a potential witness to the incident. V2 stated, No I didn't do that, but I guess I should have. Surveyor asked what the conclusion was to her investigation. V2 stated, We don't know what actually happened whether the CNA hit (R1) or not because she denied this. When the administrator talked to R1, (R1) said it wasn't intentional but V7 should have asked for assistance to help her if R1 was telling her (R1) didn't need to go to the bathroom because that is (R1's) right. We concluded this was just a customer service issue and we brought V7 back to work after the final investigation. 3. On 2/11/22 at 2:00 PM, V1 (Administrator) presented surveyor with type-written statement by V7 which read: Attention (V2-Director of Nursing), On January 27, 2021, (R1) had put on (R1) call button because (R1) wanted me to change (R1's) disposable brief because it became soiled. I canceled the light and informed (R1) that I couldn't help because I was passing dinner trays and when I'm done, I could assist. The nurse (V8) was aware of the situation the whole time because she was standing there outside the patient room due to her medication passing for patients on her assignment. The roommate of (R1) had come out the room and walking with her wheelchair screaming that she had a cup of tea had soiled her bed and she needed help. I told her the same thing that I will help after dinner was over. Don't really know what time it was and didn't think it was a big issue. I came and assisted to transfer (R1) to (R1's) wheelchair to restroom to toilet (R1) and (V8) put her in bed. (R1) was still angry from earlier because I didn't stop what I was doing to help (R1) put on dry underwear. I then stepped out to show privacy and I came back in to provide perineal care and (R1) had soiled (R1's) own personal night gown with feces. I insisted that it had to be removed and (R1) should change it right away and (R1) refused, and I asked (V8) to come in and help and the nurse did. (R1) helped us remove the pajama top and (R1) threw the top in my face and I threw the top on the toilet seat because of the item being with fecal matter on it. I immediately left the room and (V8) tucked in the patient and I left the room. At 8:52 PM, the nurse asked me to change (R1) but at the time I was charting on the people I care for that shift and 20 minutes later I provided clean sheets and the roommate stated be careful going home tonight. I never said anything to (R1) while in the room the whole time. Thanks, (V7). The typewritten report was unsigned and not dated as to when the report was written by V7. On 2/11/22 at 2:10 PM V1 (Administrator) brought in V7 to speak with surveyor and stated, I think you were looking for her. She's been working today all along. The surveyor interviewed V7. V7 stated, That particular day we kind of needed help and we were short-staffed. (R1) said (R1) needed help to be changed so I didn't neglect (R1). I was passing trays and they don't have hot plates to keep the trays warm, so I had to do too many things at once. They wanted me to pass trays and change R1's diapers and take care of my other residents, and so I went right away to change (R1's) diapers first. (R1) became very agitated and became mad at me for some reason. After the nurse passed the medications, it seemed (R1) calmed down, so it was probably (R1's) medications (R1) just needed. Surveyor asked whether she knew the medications R1 took. V7 stated, No I just know (R1) calms down once (R1) gets them. V7 continued, So I dropped the dinner trays off to both R1 and R1's roommate. The roommate was screaming about something, but she didn't want my help when I asked her, so I left. After I picked up the trays after they were done eating, I gently took R1 to the bathroom because (R1) had stool in the back of (R1's) gown. (R1) didn't want me to take the gown off, so (R1) took the gown off (R1's) self and threw the gown with poop on it at me. Surveyor asked if the poop R1 threw at her hit her. V7 stated, No. I took it and placed it on the floor. Surveyor asked to clarify who took R1's gown off, V7 stated, R1 took off (R1's) gown (R1's) self and then (R1) threw it at me. V8 (RN) was right there when R1 did this so she can tell you exactly what happened. Surveyor asked why R1 would have thrown a night gown at her. V7 stated, I don't know. Like I said (R1) was already angry at me because (R1) wanted to be changed right away. After (R1) threw the gown at me, I just left the room and told the nurse that I refused to help (R1) anymore so V8 ended up putting (R1) back in the bed because R1 was out of control. I got a call the next day from the Director of Nursing (V2) and she said I had to be suspended because R1 said I elbowed (R1's) face, and I was yelling at (R1). Surveyor asked if this was true. V7 stated, No I never touched (R1). (R1) threw a gown at me and I left the room. Surveyor asked if she never touched the resident how R1 got on to the toilet. V7 stated, Yes, so I put (R1) there because (R1) had poop on (R1's) gown. Surveyor asked whether she assisted R1 in removing R1's gown. V7 stated, No (R1) took it off (R1's) self and then (R1) threw it at me with the poop on it because like I said (R1) was angry with me. Surveyor asked if she knew why R1 was angry with her. V7 stated, Because like I said (R1) needed (R1's) medications and once (R1) got them, (R1) was calm. 4. On 2/11/22 at 2:40 PM interview with V8 (RN) stated, I was the nurse that night when this (incident) happened. It was a very busy night. I was passing medications and I heard arguing and yelling going on with the CNA and the resident, so I approached the room. Surveyor asked if she was able to hear anything that was loudly spoken. V8 stated, No at first I thought it was the two residents shouting at each other but when I entered the room it was V7 and the resident. I saw (V7) with R1 in the bathroom. I saw the resident's clothes thrown on the ground and V7 shouldn't have been yelling at the resident and I remember telling that to V7 when she left the room. I didn't want to say that to V7 in front of the resident, so I told her outside the room and told her No more fighting. Surveyor asked whether staff should be fighting with residents as she mentioned. V8 (RN) stated, No they shouldn't be, but I didn't want to get in their personal business. Surveyor asked whether it was her responsibility to report this immediately to administration. V8 (RN) stated, I didn't want to get involved. Surveyor asked again whether what she heard and observed between a CNA and a resident warranted reporting immediately to her supervisors. V8 stated, I've been working in the hospital many years and we run in to this many times, and if I report everything to my supervisor, nobody would be working anymore. Surveyor asked if the hospital setting was the same as a nursing home setting. V8 stated, I guess you are right, the residents lives here. Surveyor asked if she assisted the CNA in removing R1's night gown as V7 (CNA) explained. V8 stated, No I wasn't there to do that because (R1's) gown was already on the floor. Surveyor clarified and asked whether at any time she assisted R1 to the bathroom and help R1 remove R1's gown. V8 stated, No not at all. Surveyor asked if she assisted R1 back to bed as V7 (CNA) mentioned. V8 stated, No I already left the room, it must have been V7 (CNA) who put (R1) back to bed. Facility abuse prohibition policy revised 3/27/2021 contains the following: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation goby an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Training: Training of employees will be through the following: Orientation program; ongoing in-service training, annually and more often if needed, one to one counseling when identified, indicators to identify staff burnout. Training will focus on the following topics: Recognizing abuse, neglect, and misappropriation of resident property. Steps on how to report including to whom and when. How to protect residents, staff, and others from immediate danger. Signs of and intervention techniques to be used with residents having aggressive behavior or catastrophic reaction. How to recognize the signs of burnout, frustration, and stress in self and co-workers. Employees' responsibility upon witnessing abuse, neglect or misappropriation of property. Federal standards on resident protection, reporting and investigation Prevention: Staff, residents, and resident representatives will be instructed of how to identify and report concerns, events, and grievances. They will also be given the name of the facility's designated abuse contact person as well as numbers for state agencies. This will be done through: Resident council, family council, in-service training, 1:1 if indicated. Based on observation, record review and interview the surveyor confirmed the following removal plan interventions were implemented: - On 2/14/2022 Nurse (V8) was suspended pending further investigation and was provided with 1:1 education on the process of timeliness regarding the reporting of abuse and neglect prior to being allowed to return to work - On 02/15/2022, V7 (CNA) was terminated and reported to the CNA registry. -On 2/14/2022-2/16/2022 On Site education to address nursing staff not adequately trained to recognize abusive behavior and implement immediate action to stop the abuse. The training conducted by Facility Administrator, Reg. Dir. Clinical Operations, Reg. Dir. Operations, and Nurse managers- provided education regarding Abuse, Neglect, Exploitation & Investigation Policy and Procedure, including completion of an Abuse Post-Test Competency to staff on duty in the facility at the time of the IJ notification and education and testing continues all shifts. Education and completion of post-test to establish understanding and competency will be completed with staff prior to their first shift worked post IJ notification. It is the expectation that staff will complete the test and score 100% with/without remediation. Education and testing will continue until all staff have been educated and have verified their understanding of these expectations by signing an acknowledgment of the training and completed the Abuse Post-Test Competency. - On 2/17/2022 the facility revised educational information to be onsite, after region noted the education would be done via the US mail on 2/25/2022. Facility Administrator, Reg. Dir. Clinical Operations, Reg. Dir. Operations, and Nurse managers- initiated re-education with Staff of all departments and agency staff while on site at the facility on Abuse, Neglect, Exploitation & Investigation Policy and Procedure with the emphasis on identification of verbal abuse, expectation of immediate reporting to the Abuse Coordinator and Action steps to ensure resident safety. Education and competency testing was completed on-site on 2/15/22-2/17/2022.

Based on observation, interview, and record review, the facility failed to have individualized care plans to meet resident specific needs for falls and failed to implement the interventions set place per the resident's plan of care for three of three (R1, R2, and R3) residents reviewed for care plans. This failure resulted in (R1) sustaining fractures to the tibia and fibula (2 long bones of lower leg) as a result of a fall. Findings include: R1 R1 is cognitively impaired who primarily speaks the Urdu language and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/7/21 at 10:50am, V2 (Director of Nursing/DON) stated, on 11/26/21 during the morning shift, V5 (certified nurse aide/CNA) assisted R1 from the bed to go to the bathroom but did not get any assistance from fell ow staff to transfer R1 as required by the resident's transfer assessment. R1 fell to the ground and the incident was never reported to the nurse on duty (V6). The following day on 11/27/21, R1 refused to get out of bed. R1 complained of pain and swelling. R1 was transferred to the hospital late afternoon. R1 was admitted with fracture of the knee, [CONDITION(S)] and fractures of the tibia and fibula (two long bones located on the lower leg). MDS (minimum data set) dated 11/6/21 shows R1 requiring extensive assistance in transfer with minimum two-person physical assist. R1's care plan dated 8/18/21 states in part (but not limited to): (R1) is at risk for falls. The resident has impaired cognition and impaired safety awareness. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Goal: Prevent a serious fall related injury. Interventions: Be sure all light and other personal items are in reach. Keep bed in lowest position; refer to physical or occupational therapy as needed for treatment; remind to request assistance when getting up if needed; Educate, remind and reinforce safety awareness for call for assistance with transfers if resident is cognitively able to understand and retain the information; Report falls to physician and responsible party. R1's care plans do not have any other interventions that focused on R1's strengths nor addressed R1's inability to understand the directions provided as R1 was not English speaking nor able to retain any of the information provided to the resident. On 12/7/21 at 1:25 PM, R1 was observed in bed with the call light that was above R1's head and not easily reached by the resident. There were no fall mats or any other fall preventative devices or measures in place to prevent future falls or from re-injuring the current fracture. Interview with R1's nurse on duty, V3 on 12/7/21 at 1:30 PM stated, I don't speak R1's language. I normally communicate with R1 through motions, but I don't understand R1. Surveyor asked how R1 was able to communicate R1's needs to the staff. V3 stated, There is someone here later this afternoon I think that speaks R1's language but I'm not sure who that person is. Surveyor asked if there were any other means of communication provided to the resident. V3 stated, No. Surveyor asked V3 whether R1 was a fall risk. V3 stated, I'm not sure. I don't know R1 very well and I haven't heard anything about R1 except I think R1 fell recently. Surveyor asked if R1 had a recent fall and what measures would be in place to prevent further falls. V3 stated, I know that R1 should have R1's call light within reach but I don't know what else. Surveyor asked if fall mats were utilized in the facility. V3 stated, I think so and R1 probably needs one, so I'll make sure R1 has them when R1 is in bed. On 12/7/21 at 1:40 PM, surveyor asked V4 (CNA) to ask R1 what R1 was saying. V4 stated, I have no clue. Surveyor asked how she was able to know what R1 needed. V4 stated, I guess R1 just points but I don't know what R1 is saying. Surveyor asked if V4 was given any information such as fall risk regarding R1. V4 stated, I wasn't told anything. I'm just agency. On 12/7/21 at 1:50 PM, V7 (unit manager) was asked if there were fall risk residents on the unit she managed. V7 stated, I'm the unit manager for all 3 units and there are fall risk residents in all of them. Surveyor asked if the nurses and aides working with each resident should know what to do for fall risk residents. V7 stated, Yes they should. R2 R2 is cognitively impaired with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan dated 11/2020 reads: (R2) is at risk for falls related to fall history, incontinence, medication use, risk score per fall screen, weakness. Goal: (R2) will not sustain a fall related injury by utilizing fall precautions through the review date. Interventions: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Report falls to physician and responsible party. Report to physician any untoward side effects associated with the resident's medication use. Use Fall Risk screen to identify risk factors. On 12/7/21 at 1:45 PM, R2 was observed in bed that was elevated up waist high and did not have any fall mats on either side of the elevated bed to sustain any potential fall. The resident was asked if R2 was able to use R2's call light for assistance but appeared moderately confused and disoriented. On 12/8/21 at 2:40 PM R2 was in bed that was lifted to the highest level. There were no fall mats in place and R2's call light was under the sheets and above the left side of R2's head. On 12/8/21 at 2:45 PM R2's nurse V13 (Licensed Practical Nurse/LPN) did not identify R2 as at risk for falls. V13 stated, I don't think R2's at risk. I only have two people on this wing that are fall risk and R2 is not one of them. Surveyor asked who the aide that was assigned to R2 during her shift. V13 stated, I don't know who that is. It's some agency aide and I haven't seen her. R3 R3 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's care plan dated 10/6/21 reads: (R3) is at risk for falls related to fall history, gait/balance problems, limited mobility, risk score per fall screen, weakness. Goal: The resident will not sustain a fall related injury by utilizing fall precautions through the review date. Interventions: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Bed in low position while in bed. Provide clutter free environment with adequate lighting. PT/OT evaluate and treat as ordered or as needed. Remind resident and reinforce safety awareness for locking wheelchair, reporting when a fall occurs, calling for assist with transfers. Report falls to physician and responsible party. Report to physician any untoward side effects associated with the resident's medication use. Use Fall Risk screen to identify risk factors. On 12/7/21 at 1:45 PM, R3 was observed in bed on an air mattress. The bed was elevated waist high and there were no fall mats or other fall preventative measures to keep R3 safe from falling out of bed. Surveyor asked V3 (LPN) about R3. V3 stated, I don't know R3 well but looking at R3 I think R3 is a fall risk and R3's bed should be lowered and R3 should have mats on each side in case R3 falls. I don't know where the mats are, but I will get some for R3. Surveyor asked if there were any other fall prevention interventions for R3. V3 stated, I'm sorry I don't know. Surveyor asked if she received any fall training for residents at risk for falls. V3 stated, Not really. I just finished orientation of this floor and I wasn't given any training on that. On 12/8/21 at 2:50 PM, R3 was again in bed with a bed at the highest level. There were no fall mats or other fall prevention interventions in place to keep R3 from falling out of bed. R3's assigned nurse V13 (LPN) stated, R3 is not a fall risk. I wasn't told R3 was at risk for falls but R3's bed should be lowered as it is pretty high up. Surveyor asked if she was provided any fall interventions for R3. V13 stated, No because I didn't even know R3 was a fall risk resident. V9 (Registered Nurse/RN) was also asked about R3. V9 stated, No R3 is not one of the residents that are high risk ( for falls). Policy dated 3/27/2004 titled Standards and Guidelines: Falls states in part (but not limited to): It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. The staff will evaluate and document falls that occur while the resident is active in the facility. If a resident sustains a fall while a resident, staff should attempt to identify possible causes of the fall. Causes refer to factors that are associated with or that directly result in a fall. Often multiple factors in varying degrees contribute to a falling problem. After a fall the interdisciplinary team should review the circumstances surrounding the fall and develop an appropriate intervention(s) and plan of care. Based on evaluation of an existing fall(s) pertinent interventions will be implemented by staff such as resident education if appropriate, staff re-education regarding transfer techniques and safety during activities of daily living care, resident footwear, appropriate lighting, maintaining close proximity of frequently used items, medication reviews, toileting programs, use of hip protects, referral to therapy for strengthening/coordination/balance, addressing medical issues such as [CONDITION(S)] and dizziness, use of fall prevention programs that provide more frequent supervision.

Based on observation, interview, and record review, the facility failed to respond in a timely manner to address a resident's complaints of pain and waited several hours to notify the physician that a STAT (urgent/immediate) order for an x-ray was delayed. This failure applied to one (R1) of three residents reviewed for nursing care services and resulted in R1 being in pain for over nine hours before being sent to local hospital for evaluation and x-ray, where it was then determined that R1 had sustained a fracture of the right tibia and fibula (two long bones of lower leg). Findings include: R1 is cognitively impaired who primarily speaks the Urdu language and with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 12/7/21 at 10:50am, V2 (Director of Nursing/DON) stated, On the morning shift (7am-3pm) of 11/26/21, V5 (certified nurse aide/CNA) assisted R1 from the bed to go to the bathroom. R1 fell to the ground and was assisted back up and placed back in bed. The nurse (V6) during the PM shift of the fall was unaware of the incident as there was no communication with her aides including V5 during the shift. The following day in the morning of 11/27/21, R1 refused to get out of bed. R1 complained of pain and swelling. R1 was transferred to the hospital later in the afternoon. R1 was admitted with fractures of the tibia and fibula (two long bones located on the lower leg). R1 came back with a fracture and R1 is wearing a leg immobilizer. The C.N.A. (certified nurse aide V5) didn't report the fall to us and she didn't get help to do the transfer. We only found out the next day when (R1) complained of pain to a nurse that spoke R1's language. We tried to get an x-ray, but the x-ray company couldn't give us a quicker response, so we called the physician assistant to get R1 transferred to the hospital. Surveyor asked what caused the delay in transfer. V2 stated, I know that the morning nurse once the resident complained she called the PA (Physician assistant). We normally call the PA who's assigned to (R1). When we reached the PA, she ordered for stat x-ray, but the x-ray company couldn't give us a time they'd come so the PA was called back for orders to send (R1) out to the hospital. Surveyor asked why R1 was transferred late in the day almost 9 and a half hours later and not immediately. V2 stated, I don't know why I cannot answer that. R1's progress note reads: V10 (LPN) wrote: 11/27/2021 07:00 AM Health Status Note Text: patient refused to get up and stated, It's hurt. Noted swelling on right knee and patient unable to move leg. Called Physician Assistant and received order for stat X-ray of right hip, right knee, and right tibula-fibula. V9 (RN) wrote: 11/27/2021 11:02 AM Health Status Note Text: Followed up with X-ray company what time X-ray is coming, unable to give ETA, per staff to call us back once he knows ETA. V10 (LPN) wrote: 11/27/2021 16:50 (4:30 PM) Health Status Note Text: patient is taken to ER for pain to right leg via ambulance. On 12/9/21 at 3:00 PM, V14 (Physician assistant) stated upon interview, They (the facility) contacted me very early in the morning and said R1 had some pain in the leg so they asked me for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . I then got a second call around 3:30 in the afternoon and they asked me for orders for stronger pain medications because the resident was in more pain, so I told them to send R1 out to the ER. I contacted the daughter, and it shows on my texts around 8 am that Saturday (11/27) that the resident was having pain in R1's hip and knee. The nurse said R1 had a possible fall last night and I recall the nurse called me early that morning and daughter tried to figure out how R1 fell but she wasn't told of any fall the night she visited her mom. So again, R1 got Tylenol at 3:30pm and the facility called me again because the nurse told me that the x-rays were not even here yet and that the resident was in more pain. So, I said to just send R1 out to the hospital. R1 spent the entire day I guess waiting for the x-ray but later in the afternoon R1 was in more pain. I don't recall the nurse telling me a pain scale or how much pain but like I said just to send R1 out. The usual protocol for an incident like this would be to give pain medications and give x-rays but I was not told until later in the day that the x-rays didn't come. I know weekends take longer for x-ray company to come out, but I followed the normal protocol. Perhaps I could have been called sooner that the x-ray people were not providing stat service.

Based on observation, interview, and record review, the facility failed to monitor and prevent a fall with serious injury for a cognitively impaired resident, failed to educate staff on fall prevention measures, and failed to ensure that staff implemented these measures to mitigate resident fall risk. This affected one (R1) of three residents reviewed for accidents and supervision and resulted in R1 sustaining a fracture of the tibia and fibula (long bones of lower leg). Findings include: R1 is cognitively impaired who primarily speaks the Urdu language and with diagnoses listed in part (but not limited to): diabetes, hypertension, muscle weakness, and [CONDITION(S)]. MDS (minimum data set) dated 11/6/21 shows R1 requiring extensive assistance in transfer with minimum two-person physical assist. R1's care plan dated 8/18/21 states in part (but not limited to): (R1) is at risk for falls. The resident has impaired cognition and impaired safety awareness. The resident has balance or walking impairments. The resident experiences weakness. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. Goal: Prevent a serious fall related injury. Interventions: Be sure all light and other personal items are in reach. Keep bed in lowest position; refer to physical or occupational therapy as needed for treatment; remind to request assistance when getting up if needed; Educate, remind and reinforce safety awareness for call for assistance with transfers if resident is cognitively able to understand and retain the information; Report falls to physician and responsible party. R1's care plans do not have any other interventions that focused on R1's strengths nor addressed R1's inability to understand the directions provided as R1 was not English speaking nor able to retain any of the information provided to the resident. On 12/7/21 at 10:50am, V2 (Director of Nursing/DON) stated, on the morning shift (7 am-3 pm) of 11/26/21, V5 (certified nurse aide/CNA) assisted R1 from the bed to go to the bathroom. R1 fell to the ground and was assisted back up and placed back in bed. The nurse (V6) during the PM shift of the fall was unaware of the incident as there was no communication with her aides including V5 during the shift. The following day in the morning of 11/27/21, R1 refused to get out of bed. R1 complained of pain and swelling. R1 was transferred to the hospital later in the afternoon. R1 was admitted with fractures of the tibia and fibula (two long bones located on the lower leg). Interview with V2 (director of nurses/DON) on 12/7/21 at 10:50 AM stated, R1 is the resident that was hospitalized for a fall. R1 came back with a fracture and R1 is wearing a leg immobilizer. The C.N.A. (certified nurse aide V5) didn't report the fall to us and she didn't get help to do the transfer. We only found out the next day when (R1) complained of pain to a nurse that spoke R1's language. We tried to get an x-ray, but the x-ray company couldn't give us a quicker response, so we called the physician assistant to get R1 transferred to the hospital. We found out later R1 got a fracture of the knee I think, or I know it was the right lower leg. Surveyor asked what caused the delay in transfer. V2 stated, I know that the morning nurse once the resident complained she called the PA (Physician assistant). We normally call the PA who's assigned to (R1). When we reached the PA, she ordered for stat x-ray, but the x-ray company couldn't give us a time they'd come so the PA was called back for orders to send (R1) out to the hospital. Surveyor asked why R1 was transferred late in the day almost 9 and a half hours later and not immediately. V2 stated, I don't know why I cannot answer that. R1's progress note reads: V10 (LPN) wrote: 11/27/2021 07:00 AM Health Status Note Text: patient refused to get up and stated, It's hurt. Noted swelling on right knee and patient unable to move leg. Called Physician Assistant and received order for stat X-ray of right hip, right knee, and right tibula-fibula. V9 (RN) wrote: 11/27/2021 11:02 AM Health Status Note Text: Followed up with X-ray company what time X-ray is coming, unable to give ETA, per staff to call us back once he knows ETA. V10 (LPN) wrote: 11/27/2021 16:50 (4:30 PM) Health Status Note Text: patient is taken to ER for pain to right leg via ambulance. On 12/9/21 at 3:00 PM, V14 (Physician assistant) stated upon interview, They (the facility) contacted me very early in the morning and said R1 had some pain in the leg so they asked me for an order for Tylenol and x-rays and so I said give R1 Tylenol and ordered stat x-rays. I then got a second call around 3:30 in the afternoon and they asked me for orders for stronger pain medications because the resident was in more pain, so I told them to send R1 out to the ER. I contacted the daughter, and it shows on my texts around 8 am that Saturday (11/27) that the resident was having pain in R1's hip and knee. The nurse said R1 had a possible fall last night and I recall the nurse called me early that morning and daughter tried to figure out how R1 fell but she wasn't told of any fall the night she visited her mom. So again, R1 got Tylenol at 3:30pm and the facility called me again because the nurse told me that the x-rays were not even here yet and that the resident was in more pain. So, I said to just send R1 out to the hospital. R1 spent the entire day I guess waiting for the x-ray but later in the afternoon R1 was in more pain. I don't recall the nurse telling me a pain scale or how much pain but like I said just to send R1 out. The usual protocol for an incident like this would be to give pain medications and give x-rays but I was not told until later in the day that the x-rays didn't come. I know weekends take longer for x-ray company to come out, but I followed the normal protocol. Perhaps I could have been called sooner that the x-ray people were not providing stat service. On 12/7/21 at 1:25 PM, R1 was observed in bed with the call light that was above R1's head and not easily reached by the resident. There were no fall mats or any other fall preventative devices or measures in place to prevent future falls or from re-injuring her current fracture. Interview with R1's nurse on duty, V3 on 12/7/21 at 1:30 PM stated, I don't speak R1's language. I normally communicate with R1 through motions, but I don't understand R1. Surveyor asked how R1 was able to communicate R1's needs to the staff. V3 stated, There is someone here later this afternoon I think that speaks R1's language but I'm not sure who that person is. Surveyor asked if there were any other means of communication provided to the resident. V3 stated, No. Surveyor asked V3 whether R1 was a fall risk. V3 stated, I'm not sure. I don't know R1 very well and I haven't heard anything about R1 except I think R1 fell recently. Surveyor asked if R1 had a recent fall and what measures would be in place to prevent further falls. V3 stated, I know that R1 should have R1's call light within reach but I don't know what else. Surveyor asked if fall mats were utilized in the facility. V3 stated, I think so and R1 probably needs one, so I'll make sure R1 has them when R1 is in bed. On 12/7/21 at 1:40 PM, surveyor asked V4 (CNA) to ask R1 what R1 was saying. V4 stated, I have no clue. Surveyor asked how she was able to know what R1 needed. V4 stated, I guess R1 just points but I don't know what R1 is saying. Surveyor asked if V4 was given any information such as fall risk regarding R1. V4 stated, I wasn't told anything. I'm just agency. On 12/7/21 at 1:50 PM, V7 (unit manager) was asked if there were fall risk residents on the unit she managed. V7 stated, I'm the unit manager for all 3 units and there are fall risk residents in all of them. Surveyor asked if the nurses and aides working with each resident should know what to do for fall risk residents. V7 stated, Yes they should.

Based on observation, interviews and recored reviews the facility failed to follow the resident transer policy procedure, for R12 one of residents reviewed for accidents and incidents in a same of 21. The improper transfer using a mechanical lift resulted in R12 sustaining right and left ankle fractures. R12 was immediately sent out to the hospital for treatment. Findings include: On 2/26/19 at 2:30pm visited R12 in her romm. R12 was sitting in bed watching television. R12 talked about attending activities, food and activities of daily living (ADL) care. Resident stated she gets help from certified nursing assistants (CNA) when she need it. Resident talked about a fall she experienced. R12 said I broke both of my ankles when I slid out of the wheel chair. R12 denied being in pain at this time but she could not recollect when the incident happened. R12 noted to be wearing heel protector boots on both feet. A review of facility's fall investigation for R12 with incident date of 10/21/2018, documents R12 stated she slid off the wheelchair. V12 CNA transferred R12 from bed to wheelchair using the mechanical lift without any staff assistance. A review of R12's resident care card shows weight bearing restriction bilateral lower extremity, bed mobility assist of 2, transfer total lift, non-ambulatory. R12's facility face sheet dated 2/27/19 shows R12 is a [AGE] year old person with [DIAGNOSES REDACTED]. R12's minimal data set ((MDS) dated [DATE] section G documents: R12 is totally dependent, requires two or more person assist with transfer between surfaces including from bed to wheelchair. A review of R12's plan of care dated 8/28/2018 and 12/3/2018 documents that R12 has care deficits and needs extensive assistance with bathing, hygiene, dressing, grooming, toileting, bed mobility and total assistance with transfer due to [DIAGNOSES REDACTED]. Mechanical lift for transfers. R12's hospital records and radiology exam dated 10/22/2018 documents x-ray of right ankle, history of fall, 2 views are obtain showing fractures of distal tibia fibula. Impression: distal tibia and fibular fractures, left ankly x-ray history of fall, 2 views obtained, the bones are osteopenic, there are diffuse vascular calcification, faint luency ankle mortise appears intact, no other further evidence for fracture. Impression: faint luency over the medial malleolus could be a fracture and needs clinical correlation. R12's hospital records consultation report dated 10/23/18 shows reason for consultation; bilateral ankle fracture clinical impression and recommendation right distal tibia fractured with angulation, left non displaced extra articular medial malleolar fracture. On 2/27/19 at 9:42am V2 (DON-Director of Nursing) said, R12 sustained an ankle fracture after sliding from wheelchair when V12 (CNA providing care for R12) inappropriately transferred R12 to wheelchair using a mechanical lift. It should have been two persons or more using a mechanical lift to do this transfer. There is a risk for an accident. No staff should transfer a resident with a mechanical lift along. During the survey of 2/26/19-2/28/19, V12 CNA was not available for interview. ON 2/28/29 at 12:21pm V13 Registered Nurse stated on the day of incident in (MONTH) (YEAR), another staff memeber came to her and told her that R12 was on the floor and needed help V13 stated when she went to R12's room, R12 was sitting on the floor and V12 was there with the mechanical lift. V12 stated V12 told her that he attempted to transfer R12 to the wheelchair using the mechanical lift. He stated he was able to halfway place her in the chair but could not reposition her when she slid to the floor. V13 stated V12 told her that he left the room to get help to reposition R12 in wheel chair safely. V13 said she does not remember any more details of the incident. At this time V13 did not comment that she completed a nursing assessment or assess for pain. V13 said CNAs V16, V15 and V12 were present at the time. V16 and V12 were not available for interviews. However V15 was available for an interview. On 2/28/19 at 2:40pm V15 stated that he does not remember any details from the incident related to R12. A review of V12's statement dated 10/22/18 documents V12 transferred R12 from bed to her wheelchair using mechanical left. When the resident was on the wheelchair, she was slouching. V12 told the resident he will be right back then left to find another staff to help him reposition the resideent. As soon as he walked out the resident slid out of her chiar, another CNA called the nurse. A review of facility incident investigation completed by V2 DON dated 10/22/18 documents type of incident fall, R12 is alert and oriented 2-3, R12 started complaining of pain to both (B) ankles 10/22/18. R12 was sent to the hospital, investigation type: fall. V2 identified (B) to mean both. investigation conclusion; etiology of incidenet determined as R12 slid off wheelchair after V12 transferred R12. V12 left resident's room to get someone to help him reposition R12. A review of the facility preliminary incident investigation for R12 dated 10/21/18 documents on 10/21/18 at 11:00 am R12 was observed on the floor on side lying position. Stated that she slid off the wheelchair. Denied any pain at that time. No obvious injury. On 10/22/2018 at 9:00 am R12 started complaining of pain in bilateral ankles. Nurse gave pain medicine. When nurse reassessed, resident was stil aving pain, unable to do Range of Motion (ROM) with internal rotation of both feet. MD (Medical Doctor) notified. R12 sent to local hospital for evaluation. Power or Attorney notified. At around 5:00 pm received call from local hospital. R12 being admitted with didtal tibia and fibular fracture. A review of facility's Resident Abuse investigation report for R12 dated 10/30/2018, shows date of incident 10/21/18 at 11:00am, resident injured box is checked for yes, desciption shows distal tibia and fibual fracture, resident sent to local hospital for evaluation and treatment, based on interviews conducted the facility determined that the CNA transferred R12 from bed to wheelchair using mechanical lift by himsef which resulted to resident falling. R12 did not show any signs of injury nor complain of pain until the following day, R12 was then sent to hospital as soon as injury was observed. One CNA was terminated for not following facility protocol on mechanical lift transfer. A review of V15(Nurse) written statement dated 10/22/18 documents in part: he(V15) heard V16 CNA say R12 was on the floor, upon entering R12's room, R12 was in a side lying position with arm's underneath her head. R12 was smiling. We asked V12 what happened, and he said he transferred R12 with mechanical lift into wheelchair and R12 was slouched position. Client R12 noted to be boosted in chair. He V12 came out looking for help and by that brief period of time, R12 was on the floor. When asked resident R12 simply stated slid off the chair On 2/28/19 at 10:22am V14 (Physical Therapy Manager) said R12 was evaluated for physical and occupation therapy on 9/30/18 due to decrease in strength, decrease in transfer, reduced dynamic and static balance and increased need for assistance from others. V14 said R12 had poor truck control and was unable to shift her weight. V14 said R12 must be positioned well in her wheelchair she would not be able to stop herself from a fall, due to her weakness, but she must be positioned in chair sitting back, and with leg rest with feet supported by leg rest. A review of R12's physical therapy evaluation dated 10/1/2018 documents sitting balance during ADL's poor (max (A), V14 said max A meants R12 required maximum assistance and upper extremity support to maintain balance and reach ipsilateral, unable to shift weight, kyphotic posture, head forward, R12 requires a great deal of assistance in all care including sitting at w/c (wheelchair per V14) level secondary to decrease BUE Bilateral upper exteremity strength, decrease strength in core, decrease sitting balance for feeding, of hard of hearing, and Left upper extrenity care decrease in confidence in herself. On 2/28/19 at 1:40pm V11 (restorative nurse) said she does the training for staff on the use of the mechanical lift. V11 said there should be at minimum two people when transferrign a resident with mechanical lift. V11 said you need two people to allow for one to guide the sling with the resident in it and one person operate the machine. V11 said the risk for accident is high when using mechanical lift alone. V11 said a resident should never be left alone during a transfer, or left sitting half way in a wheelchair, it is unsafe. V11 said R12 has poor trunk control, R12 can slide out the chair and would not be able to brace herself due to weakness. A review of facility policy titled Resident Transfer dated 1/13/2006 documents the facility will assess the resident to determine the safest method of physical transfer as a component of activities of daily living, if the resident has a sitting balance deficit a second care giver should be present to aid in balancing the resident while the second care giver applies the sling, the care giver should never reduce the level of device used unless directed by a nursing or therapy department, non-weight bearing residents must be designated as a total mechanical lift transfer. A review of V12 transfer/lift competency worksheet dated 9/18/18 shows documents V12 signature with te date showing to check equipment before use, two people minimum, guest in middle of sling, at same color loops fully on hooks, be sure legs of mechnicl lift are fully apart and locked, support guest head as needed, and guide guest to surface, support their legs.

Based on interview and record review, the facility failed to monitor the dining room and failed to ensure the self -releasing seat belt and wheelchair alarm were in place to prevent or reduce the risk of falling for one of nine residents (R1) reviewed for falls prevention and supervision. This failure resulted in R1 being left unsupervised in the dining room and fell from the wheel chair sustaining a (C2) cervical neck fracture and right superior pubic rami fracture. Findings include: R1 has the following medical Diagnoses: [REDACTED]. Progress noted dated 03/2/2018 documents that V6 (Licensed Practical Nurse) was notified that R1 fell in the dining room. R1 was noted on the floor with a laceration to her forehead with bleeding. R1 stated that I was trying to clean my shoes, and my neck hurts. 911 was called and arrived to transport R1. V7 (Medical Doctor) and R1's family were notified. At 6:00PM, the facility called the local hospital. The local hospital stated that R1 was being admitted for a cervical (C2) fracture. Death certificate dated 03/09/2018 documents that R1's immediate cause of death is [MEDICATION NAME] force injuries of neck and pelvis from a fall. On 1/25/2019 at 11:06AM, V6 stated, I do not remember who called me. Someone told me that R1 fell . R1 was bleeding from her head. All the nurses went to the dining room. One of the nurses called 911; one nurse did a pressure dressing; another nurse took vitals. The ambulance came within 2-3 minutes. R1 said she was trying to reach something in her shoe. Staff is supposed to be in dining room. CNA'S (Certified Nursing Assistants) should be with the residents. Progress note dated 1/06/2018 documents that per V7 notes that self- release belt should be applied if R1 attempts to get up from her wheelchair. Also, to use wheelchair pad alarm. Physicians Order Statement dated 1/6/2018 notes that chair pad alarm should be used for fall prevention. Fall Risk assessment dated [DATE] documents that R1 has the following risk factors: unsteady gait; confusion with disorientation; poor balance; weakness and poor judgment and decision making. R1 is also at significant risk for falls related to dementia, [MEDICAL CONDITION], antidepressant, and diuretic medication usage. The Fall Risk Assessment also documents fall prevention measures. The fall prevention measures are to monitor R1 frequently and apply self- release belt. On 1/25/2019 at 12:49PM, V8 (Dietary Cook) stated, R1 was falling forward out of her wheelchair to the ground. No staff were present at the time of her fall. On 1/25/2019 at 3:00PM, V5 (Restorative Nurse) stated, During meal times everyone is responsible for monitoring residents. R1 needed to be monitored due to her history of falls with injury. On 1/29/2019 at 10:07AM, V2 (Director of Nursing) stated, The dining room should be monitored to prevent accidents. Staff were attending to other residents during lunch. They were not available at that time to monitor this resident. R1 did not have her self-release belt on. The wheelchair alarm was not in place during the time of fall. On 1/25/2019 at 11:22PM, V7 stated, I specifically told nursing staff to continue to use the belt. R1's family was very aggressive and wanted to have R1 to wear the belt; I approved it. I was notified went resident fell out of the wheelchair. R1 had advanced dementia. R1 did not know about things she should or should not do. On 1/29/2019 at 10:00AM, V3 (Nurse Consultant) stated, There were no nursing staff in the dining room when R1 fell . I do not know why there were no nursing staff available at the time. Care plan dated 1/30/2018 documents to apply self-release belt with alarm on wheelchair; ensure seat belt alarms are working properly; follow specific fall prevention protocols listed on fall assessment; provide supervision; use self-release alarm belt when R1 is not under supervision. Facility policy titled Fall Risk Assessment and Care Planning Policy and Procedure, dated 10/18, notes the facility will evaluate the resident's potential for falls and to help ensure resident safety. The staff will develop a plan to prevent falls based on known and identified risk factors. Facility Policy titled Incidents and Accidents Policy and Procedure, dated 10/18, documents the facility will take every precaution to prevent the occurrence of accidents. Facility Policy titled Fall Risk Assessments, dated 09/03, notes when significant potential for falls is noted via the assessments, appropriate fall prevention measures will be implemented.

Based on interview and record review, the facility failed to prevent an injury of unknown origin for one resident (R1) of four residents reviewed for abuse in a total sample of four residents. This failure resulted in R1 sustaining a fractured wrist requiring medical attention. Findings Include; According to the facesheet, R1 is an [AGE] year old resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Interview on 6/22/18 at 1:30 PM V4 MD (Medical Doctor) stated R1 had an impacted [MEDICAL CONDITION]. This type of fracture is almost always from arms stretched out to break a fall. I have no idea how the fracture happened, R1 is bed bound. R1's hands are not contracted, he/she just holds them that way. I would have never ordered an x-ray, if I thought there was a fracture, I would have sent R1 directly to the hospital. I was very surprised about the fracture. On 6/22/18 at 11:00 AM V5 V5 CNA (Certified Nursing Assistant) stated R1 is always a two person assist, and a mechanical lift, total dependence. R1 doesn't move her hands, not combative. I noticed swollen and purple left arm first thing in the morning around 7:00 AM on 5/23/18 . I called for the nurse before I did anything. I wasn't here the day before (5/22/18 ), so I didn't know if something had happened on my day off. It ( bruise) wasn't there the last day I worked 5/21/18. The MDS (Minimum Data Set) dated 3/21/18 documents in section C Brief Interview for Mental Status (BIMS) , R1 has severely impaired cognation. Section G Activities of Daily Living Assistance documents R1 is total dependence two person physical assist for bed mobility, how a person moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture, also total dependence with a two person assist for transfer, how a resident moves between surfaces including to or from bed, chair, wheelchair, standing position. Section F documents R1 is always incontinent for bowel and bladder. The facility Report of Injury for R1, incident date 5/24/18 documents; On 5/23/18 CNA reported to nurse that resident's left arm has some bruising and appears swollen. When nurse assessed resident, noted left hand with bruise and swelling with pain noted when touched. Resident with limited range of motion on both upper extremities and with contractures to both hands prior to incident, MD was notified with order to apply cold compress and to do left hand x-ray. POA (Power of Attorney) notified. Final Investigation: Nurses and CNAs that took care of resident the last 3 days were interviewed. Resident requires extensive assistance with ADLs (Activities of Daily Living). He/she and swelling on has contractures/stiffness on both upper extremities. Staff stated that they did not notice any bruising and swelling, resident slept well and CNA did not notice pain. Then, on 5/23/18 when CNA was going to get up resident, noted bruising and swelling on resident's left arm. CNA reported this to nurse immediately, did not proceed with getting R1 up until resident was seen by nurse. Resident seen by Orth (Orthopedic) MD on 5/25/18. Findings was left closed radius fracture. Resident was unable to say what happened. Per staff, resident tries to grab or hold on to something when they give care or when they are transferring with the mechanical lift. Based on investigation and interviews conducted, it is possible that resident may have accidentally bumped her wrist on the side rail when being turned to sides during incontinence care or in the arm of the geri chair when they got R1 up. The X-ray report dated 5/24/18 for R1 documents; Impression: Acute impacted [MEDICAL CONDITION] end of the radius and avulsion [MEDICAL CONDITION] side process. Positive ulnar variance. On 6/26/18 at 10:00 AM V2 DON stated that we do not know what happened to R1, how he/she got the injury. R1 cannot say. R1 is a extensive total dependence assist with two staff and a mechanical lift for transfers. I did this incident investigation and wrote the report. I interviewed all staff who cared for R1 and was unable to find out what happened. Review of R1's Treatment Record documents on 5/18 resident's skin is warm, dry to touch, no skin breakdown noted, no injury noted, fair skin integrity.

Based on observation, interview and record review, the facility failed to provide a resident with two person assistance during turning/repositioning to prevent a resident injury for one resident (R1). The facility also failed to follow their Transfer Policy in not locking wheelchair brakes for one resident (R4). These failures affect 2 of 4 residents (R1, R4 reviewed for accidents and incidents in a total sample of four residents. As a result, R1 sustaining a [MEDICAL CONDITION] which required a hospital visit and head sutures. Findings Include: According to the facesheet, R1 is an [AGE] year old resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set) dated 3/21/18 documents in section C Brief Interview for Mental Status (BIMS) , R1 has severely impaired cognition. Section G Activities of Daily Living Assistance documents R1 as an extensive two person physical assist for bed mobility, how a person moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture. Section F documents R1 is always incontinent for bowel and bladder. The Incident Report dated 6/2/18 for R1 documents at 1:10 AM CNA (Certified Nurse's Assistant) called this writer's attention to come to resident's room. Noted resident (R1) was bleeding on the forehead/face. When examined, resident sustained [REDACTED]. CNA said he/she hit his/her head against the side rail while CNA was turning/repositioning the resident. The written statement from V3 CNA in the incident report documents; on my first round I was going to change R1. When I was rolling him/her inwards to straighten the diaper, his/her legs fell off the bed, I pushed her legs back on the bed when moving pt (patient) his/her arm moved too far when rolling back which caused her head to slam into the rail. The statement is signed by V3. The Report of Injury, Date of Incident 6/2/18 written by V2 DON (Director of Nursing) documents, R1 is an [AGE] year old long term resident of this facility. R1 is alert but confused and disoriented. R1 requires extensive assistance with her ADL's. (Activities of Daily Living). On 6/2/18 at around 1:10 AM when CNA (V3) turned resident to the side to provide incontinence care, resident's weight shifted, and R1 accidentally bumped his/her head on the side rail, causing a laceration on the forehead with minimal bleeding. No alteration in level of consciousness. Pressure dressing applied, bleeding controlled. No manifestation of pain or discomfort. MD (Medical Doctor) notified with order to send resident to local hospital for evaluation and treatment. POA (Power of Attorney) notified. Resident returned from hospital with 7 sutures intact. Interview on 6/22/18 at 10:15 AM V2 DON stated, The CNA (V3) works 11-7 shift. V3 was fired because of this incident (R1). V3 did the incontinence care himself. It is a two person assist for R1, that's why V3 was fired. On 6/22/18 at 11:00 AM V5 CNA stated that R1 is always a two person assist, total dependence. He/she doesn't move her hands, not combative. V3's personal recorded documents, V3 was terminated on 6/4 18 for not following protocol resulting in resident injury. The resident (R1) supposed to have a two person assist with transfer. R1's Care Plan dated 6/8/18, goal date 7/10/18 documents; R1 has self-care deficits and requires assistance in turning/repositioning in bed, toileting needs, dressing, eating, personal hygiene, locomotion on and off unit and bathing. He/she is totally dependent on staff in transfer due to Dementia, Contractures of right and left hands. Goals; R1 will be turned/repositioned with the assistance of 2 people. R4 is a [AGE] year old resident admitted to the facility on [DATE] with an admitting [DIAGNOSES REDACTED]. R4's MDS dated [DATE] documents in section C Brief Interview for Mental Status (BIMS) 13 out of 15. Section G documents R4 requires an extensive two person assist with transfers. On 6/27/18 at 11:30 AM V6 CNA and V7 RN (Registered Nurse) transferred R4 from a wheelchair to a weight chair. V7 applied a gait belt around R4's upper waist area. V6 locked the left wheelchair brake but did not lock the right wheelchair brake during transfer for R4 from the wheelchair to the weight chair. V6 and V7 transferred R4 holding his/her arms and the gait belt. During the transfer the wheelchair was moving. V6 and V7 sat R4 in the weight chair, and weighed the resident. V6 locked the right wheelchair brake before transferring R4 back to the wheelchair. V6 and V7 both stated that the right wheelchair brake was not locked. V7 stated the wheelchair should be locked, if not, the resident could fall. R4 stated, The move back to the wheelchair went much more smoothly than the first move. On 6/27/18 at 12:20 V8 Nurse Consultant stated, The wheelchair should always be locked during transfer. The facility policy titled, Moving a patient from bed to a wheelchair , documents 3. Put the brakes on and move the foot rest out of the way.