Every finding on record at La Bella at Clifton

Based on interviews and record reviews the facility failed to protect one (R6) resident from verbal and physical abuse out of nine residents reviewed for abuse in a sample list of 12 residents. R6 was admitted to the facility on [DATE] and has the following medical diagnoses; Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Sepsis, Inflammatory Disorders of Scrotum, Abnormalities of Gait and Mobility, Unsteadiness on Feet, Cerebral Infarction, COPD, Muscle Wasting and Atrophy, Lack of Coordination, Type 2 Diabetes, GERD, Heart Failure, Major Depressive Disorder, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Tachycardia, HTN, Gout, Muscle Weakness, Malaise, Acquired Absence of Left Leg Above Knee and Nicotine Dependence. R6's Minimum Data Set (MDS) dated [DATE] documents R6's Brief Interview for Mental Status (BIMS) score 14, cognitively intact. R6's Health Note dated 6/7/25 at 8:37pm documents: Chief Complaint: General Notifications: Vitals: Temperature 97.8, Pulse 78, Blood Pressure 147/76, Respirations 18, Oxygen saturation 92% on room air. Summary: R6 reported to staff being choked by stepdaughter. No markings noted. R6 is stable. Local County Sheriff's Department Report #P2506-0012 dated 6/7/25 at 8:39pm documents on Saturday 6/7/25 at 4:59pm, V16 Deputy Sheriff's Department was dispatched to nursing home [NAME], Illinois, in regard to possible assault. V16 arrived on scene at 7:19pm and was met by V1 Administrator. V1 made V16 aware that R6 had complained about being grabbed and choked by V17 R6's Stepdaughter, during an earlier visit that day. V1 stated that shortly after their visit V6 pulled a staff member aside and explained to them what had happened. V1 said that R6 although elderly, was lucid and could speak for R6's self. V1 escorted R6 into an office where R6 could be interviewed. Upon first seeing R6, V16 noticed R6 to be an elderly man with some considerable physical disabilities. R6 left leg was amputated and R6 was wheelchair bound. R6 was able to give me R6's name and stated that R6 has been living here since December and that R6 was previously at a different nursing home for 6 months prior to that. R6 told V16 that V18 (R6's Wife) and V17 had been at the nursing home to visit R6 at around 4:00pm. R6 stated that during the visit V17 asked R6 for R6's bank card. R6 told V17 that R6 had given it to a friend to hold for safe keeping because R6 had recently lost R6's wallet. R6 said, at around 4:15pm is when V17 and V18 accompanied R6 to the parking lot to smoke a cigarette and say goodbye. R6 said, while in the parking lot, V17 again asked R6 for R6's bank card and claimed R6 owed R17 money. R6 stated that when R6 did not produce R6's bank card, V17 grabbed R6 by R6's shirt collar with one hand and grabbed R6 by the neck with the other. R6 said R6 had a hard time moving when V17 had ahold of him. V17 and V18 then exited the nursing home property in their vehicle. Facilities Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated March 2025 documents: Policy Statement: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain 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 facilitated or enabled through the use of technology. Policy Interrogation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, f. family members. On 6/24/25 at 12:13pm R6 stated, a couple of weeks ago V17 (R6 Stepdaughter) and V18 (R6's Wife) came to visit R6. R6 stated that during the visit V17 asked R6 for R6's bank card and R6 told V17 that R6 had given it to a friend to hold for safe keeping. R6 stated V17 and V18 went outside to smoke a cigarette and say goodbye. R6 stated, while outside V17 again asked R6 for R6's bank card and said that R6 owed R17 money. R6 stated that when R6 told V17 that R6 didn't have it V17 grabbed R6 by R6's shirt collar with one hand and grabbed R6 by the neck with the other. R6 stated R6 was unable to move and V17 let go and V17 and V18 left in V17's car. On 6/25/25 at 8:45am V20 (Licensed Practical Nurse) stated that on 6/7/25 at 5:50pm V19 (Activities) notified V20 that R6 informed V19 that V17 grabbed R6 by the neck. V20 stated that V20 spoke to R6 and R6 stated that V17 grabbed R6 by the collarbone and then put V17's other hand around R6's neck asking for R6's bank card. V20 stated that V20 assessed R6 for injuries and none were noted. On 6/25/24 at 9:21am V1 (Administrator) said, on 6/7/25 V1 was notified by V19 (Activities) that R6 reported to V19 that V17 R6's Stepdaughter had grabbed him by the neck and shoulder outside while they were smoking. V1 stated, V1 told V19 to inform V20 Licensed Practical Nurse about the incident so that V20 can assess R6. V1 stated that V1 was informed that V17 was no longer at the facility. V1 stated V1 immediately started an investigation. V1 stated that V1 notified the Local Sheriff's Department. V1 stated, V1 interviewed R6 who informed V1 that V17 had brought V18 to visit. V1 stated R6 further informed V1 that when V1 and V18 were leaving, V17 wanted R6's debit card, and R6 told V17 that it was safe, at which time V17 grabbed R6's shirt and necklace saying R6 owed V17 money. V1 stated that V17 let go of R6 and left the grounds by vehicle. On 6/25/25 at 10:30am V19 (Activities) stated on 6/7/25 at 5:50pm R6 told V19 that while V17 was visiting, that V17 wanted R6's bank card, and R6 told V17 that R6 didn't have it. V19 stated, R6 told V19 that while outside smoking V17 got mad and grabbed R6's shirt with one hand and grabbed R6's neck with the other wanting R6's bank card. V19 stated that R6 told V17 that R6 did not have the bank card and V17 let go of R6's neck.

Based on observation, interview, and record review the facility failed to ensure a severely cognitively impaired resident (R16) did not exit the facility unnoticed (elopement), failed to implement post fall interventions (R6), and failed to thoroughly investigate a fall/injury (R7). R1 is three of four residents reviewed for elopement, and R6 and R7 are two of three residents reviewed for falls in the sample list of eight. Findings include: 1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severe cognitive impairment, R1 has hallucinations/delusions, R1 does not use any mobility devices, and R1 transfers/walks with supervision or touch assistance from staff. R1's Admission Social Service assessment dated [DATE] documents the following: R1 has the physical ability to leave the facility. R1 is not sufficiently alert, oriented and coherent enabling him/her to be considered for independent outside pass privileges with a physician's order and appropriate compliance with any behavior management program/system/interventions. R1 has a history of unauthorized departure from a health care setting and/or verbalizing a serious intent to leave the facility. R1 has been hanging around facility exits and/or stairways or wandering between floors. R1 has been engaging in theme behavior such as a belief of specific responsibilities in another area such as going to work, returning home to take care of children, going to church, preparing dinner, etcetera. R1 is easily agitated, and or disoriented or shows poor judgement, for example would not be able to care for herself outside of the facility. R1 observes environmental or time of year cues, such as staff preparing to leave or putting on coats or approaching holidays, that may indicate a risk for elopement and specific triggers or warning signs to monitor that could suggest increased elopement risk. R1's Behavior Tracking dated 4/30/25-5/22/25 documents R1 was anxious, pacing and wandering on 5/2/25 and 5/3/25. R1's Care Plan with initiated date of 5/1/25 and revised date 5/8/25 documents the following: R1 admitted to the facility on [DATE] and is an elopement risk/wanderer with history of attempts to leave the facility unattended. R1 calls for her mom and asks to go visit her mom because R1 believes her mom is sick. While admitted in the hospital, R1 left to go visit her mom without anyone being aware. R1 sees people in the parking lot and believes they are R1's family or friends. On 5/7/25 R1 walked out of an emergency exit door and Social Services Director will help R1 find something on television that R1 enjoys watching. On 5/7/25 R1 exited through a fire exit during the night. Interventions dated 5/1/25 included monitor R1 for tailgating behaviors when visitors are in the facility, provide direct staff supervision when attending an out-of-facility activity, refer to social services as needed, use discreet identifier so staff are aware of R1's elopement risk, check functioning of the audible alarm system regularly and as needed, offer calling R1's family/friend for reassurance when exit seeking, and use audible monitoring system to alert staff of exit seeking behavior. R1's interventions dated 5/8/25 include one to one monitoring, room change closer to the nurse's station and away from fire exits, and talking with R1's family about sending referrals to memory care units. R1's Social Service Note dated 5/7/2025 at 11:16 AM documents R1's family was notified that R1 wandered out an exit door and R1's family was asked about R1's activity interests to help with R1's anxiety and expecting family. R1's Nursing Note dated 5/7/2025 at 6:45 PM documents the following: V22 Certified Nursing Assistant (CNA) stated V22 checked on R1 at 6:30 PM and R1 was in R1's room talking on the telephone. V19 CNA took an unidentified resident out for a smoking break between 6:30 PM and 7:00 PM. While V19 was sitting outside V19 noticed R1 was outside on the phone in the parking lot attempting to leave the facility. Staff assisted R1 back into the facility. R1 was assessed and had no signs of injury. R1's family was notified and enhanced supervision was initiated with 15-minute checks by staff. On 5/22/25 at 12:06 PM V16 CNA stated R1 is generally very confused and R1 wanders/exit seeks making it pretty rough to watch R1. V16 stated R1 got out of the facility around 6:30-7:00 PM about two weeks ago. V16 stated V16 did not observe R1 leave the facility that night. At 1:45 PM V16 stated the night R1 got out, V16 looked out a resident room window on B hall and saw R1 partway between the front parking lot and circle drive with staff. V19 stated V19 last saw R1 after dinner in R1's room around 6:00-6:30 PM. V19 stated R1 paces and wanders so it is hard telling which exit door R1 left from without having eyes on (R1) constantly. On 5/22/25 at 1:06 PM V22 CNA stated when R1 first admitted R1 did not try to leave the facility, but R1's family was here more during that time. V22 stated R1 then started looking for her family, mostly going to the front desk and front door. V22 stated there was only one time that R1 got out of the facility, V22 was working that day, and it was around 7-7:30 PM. V22 stated V22 did not see R1 leave the facility, V22 was R1's assigned CNA that night, V22 last saw R1 around 6:30 PM in R1's room and V22 thought R1's family had visited R1 earlier that day. V22 stated V22 was on B hall when V22 heard a door alarm sound. On 5/22/25 at 1:18 PM in regard to R1's elopement on 5/7/25, V19 CNA stated V19 went outside through the front door that evening, to take another resident outside for a smoke break. V19 stated there were no door alarms sounding at that time. V19 was outside for about 5-10 minutes and as V19 was returning to the facility, V19 saw R1 outside of the facility near the corner of the C Hall exit walking towards the front parking lot and road. V19 confirmed no staff was present with R1. V19 stated this incident occurred around 6:00-7:00 PM. V19 described R1 as being very confused that night and R1 did not want to go back into the facility. V19 stated V19 called V13 CNA to get help and notify the nurses. V19 stated at this time V2 Director of Nursing (DON) pulled into the parking lot, R1 was assisted back into the facility and placed on 15-minute checks. V19 stated prior to the incident V19 last saw R1 during dinner around 5:00 PM. On 5/22/25 at 2:24 PM V13 CNA stated V13 last saw R1 after dinner and received a phone call from V19 who found R1 outside of the facility. On 5/22/25 between 2:27 PM-2:34 PM V14 Social Services Director stated R1 was identified to be at risk for elopement and a departure alert device was initiated the day R1 admitted to the facility. V14 stated R1 wandered out of an exit door on 5/7/25 about 10:30-11:00 AM. V14 stated the C Hall door alarm sounded and either V2 DON or V5 Maintenance Director found R1 outside the facility. V14 stated this prompted V14 to notify R1's family to inquire about R1's activity interests, and R1's room was changed to closer to the nurse's station. V14 confirmed one to one monitoring was not implemented until after R1's elopement on the evening of 5/7/25. V14 stated R1's family had been visiting and taking R1 home which caused R1 increased confusion and anxiety. V14 stated R1 was always watching the parking lot and V14 knew then that R1 needed a memory care unit. On 5/22/25 at 2:06 PM V2 DON stated V14 is responsible for assessing elopement risk and R1's family reported R1 had a history of wandering. V2 stated I don't think we (the staff) were aware of how bad her (R1's) wandering actually was. V2 stated the departure alert bracelet was implemented initially and then we changed R1's room away from the exit doors, closer to the nurse's station to be within line of sight from the nurse's station. V2 stated we implemented a one to one sitter after R1's elopement incident on the evening of 5/7/25. V2 stated on 5/7/25 around 6:40 PM V2 pulled into the parking lot and the CNAs were already outside with R1 at that time. V2 stated V19 had been outside with another resident for a smoke break and V19 saw R1 as V19 was going to return back into the facility. V2 stated R1 was found in the vicinity of the outdoor benches located near the C Hall exit after the D Hall door alarm sounded, which alerted staff. V2 stated R1 was last observed at 6:30 PM in R1's room by V22, R1's assigned CNA that night. V2 stated that was the last time staff saw R1 prior to being found outside of the facility by V19. 2.) R6's Nursing Note dated 5/13/2025 at 6:30 PM documents R6 was observed standing at the desk and then fell to the floor hitting R6's head. R6's eyes rolled back and R6 had body twitching lasting approximately three seconds. R6 vomited twice. R6's pulse was 158 beats per minute and blood pressure was 102/74 millimeters of mercury. R6 was transferred to the local hospital. R6's Care Plan dated as revised on 5/14/25 documents the following: R6 is at high risk for falls. On 4/7/25 R6 was found on the floor near the nurse's station and the root cause was R6 became dizzy and lost balance. On 3/1/25 R6 fell at the nurse's station and the root cause was hypotension. On 1/6/25 R6 had a staff assisted fall and the root cause was hypotension, vomiting and diaphoresis (clammy/sweaty). On 12/7/24 R6 had an unwitnessed fall in the dining room and root cause was R6 became dizzy and lost balance. Neurology referral is listed as an intervention dated 5/13/25. As of 5/22/25 there was no documentation in R6's medical record that a neurology appointment had been scheduled for R6. On 5/22/25 at 5:26 PM V9 Licensed Practical Nurse stated V9 was talking with R6 who was standing at the desk prior to R6's fall. V9 stated R6 seemed just fine prior to the fall, R6 then fell suddenly to the floor and vomited. V9 stated R6 has a history of these spells that come on suddenly and without warning. V9 stated V2 DON said cardiology and neurology consults were ordered. On 5/22/25 at 4:57 PM V2 DON stated R6 has a history of these spells and has been sent to the hospital following each of these spells/falls. V2 confirmed the facility had not yet attempted to schedule a neurology consult appointment for R6. V2 confirmed cardiology and neurology consults were the post fall interventions for R6's 5/13/25 fall. 3.) R7's MDS dated [DATE] documents R7 has severe cognitive impairment, uses a walker for mobility, and uses partial/moderate assistance from staff for toileting, transfers, and walking over 150 feet, and requires supervision or touch assistance with walking up to 50 feet. R7's Nursing Note dated 5/12/2025 at 2:44 PM documents R7 had a skin tear to the left elbow and swelling. R7 reported to V30 Business Office Manager that R7 fell out of bed. An x-ray of the left elbow was ordered due to swelling. R7's Practitioner Note dated 5/12/25 at 2:17 PM documents R7 reported left elbow pain that started today. R7 stated R7 fell out of bed and landed on his elbow and R7 was unsure if R7 fell today or yesterday. R7 was unable to give additional information due to dementia with intermittent confusion. R7 reported severe pain with palpation and redness was noted to left elbow. R7's Practitioner Note dated 5/14/25 at 1:12 PM documents R7's left elbow x-ray was completed on 5/12/25 due to fall with new swelling and pain. R7's x-ray showed soft tissue swelling, but no fracture. R7's Care Plan dated as revised 5/15/25 documents R7 is at high risk for falls related to confusion and deconditioning. This care plan includes an intervention dated 4/27/25 for prompted toileting program and intervention dated 5/12/25 for a scoop mattress to help R7 identify safety boundaries of the bed. On 5/22/25 the facility's investigative file of R7's 5/12/25 fall, provided by V2 DON, was reviewed and the file did not include any staff interviews or statements regarding R7's fall/left elbow injury. On 5/22/25 at 4:27 PM R7 was lying in bed and R7 had redness and mild swelling of the left elbow. R7 stated R7 fell out of bed recently. R7 was unable to give any additional information regarding this fall. On 5/22/25 at 4:57 PM V2 stated swelling was noticed on R7's elbow, R7 was asked what happened and R7 stated R7 had fallen out of bed. V2 stated R7 walks independently with a four wheeled walker and it would be possible for R7 to self transfer off of the floor if he had fallen. V2 stated V2 spoke with staff regarding R7's fall/injury, but V2 does not have documentation of this. V2 stated the day prior R7 did not have any elbow swelling and V2 was unable to identify when or if R7 had actually fallen. V2 confirmed R7 had a prior post fall intervention for prompted toileting and there was no documentation of when R7 was toileted the day of R7's reported fall and left elbow injury. The facility's Fall Risk Assessment policy dated March 2018 documents staff will evaluate for functional and psychological factors that may increase a resident's fall risk, staff will identify environmental factors that may contribute to falling., and the staff and physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences.

Based on interview and record review the facility failed to ensure a Minimum Data Set (MDS) accurately assessed for wandering for one of three residents (R1) reviewed for elopement in the sample list of eight. Findings include: R1's MDS dated [DATE] documents R1 has severe cognitive impairment and did not wander during the look back period. R1's Behavior tracking dated 4/30/25-5/22/25 documents R1 exhibited wandering behavior on 5/2/25 and 5/3/25. R1's Nursing Note dated 5/1/2025 at 4:41 AM documents R1 went into another resident room, turned on the lights, and woke up the unidentified resident. On 5/22/25 at 3:25 PM V29 (MDS Coordinator) stated V14 (Social Services Director) completes the behavior section of the MDS. V29 confirmed V29 signs off on the MDS as being complete and accurate. V29 reviewed R1's MDS and behavior tracking and confirmed R1's MDS does not identify R1's wandering behavior that occurred during the seven day look back period. V29 stated V29 will have to review the number of days R1 wandered and submit a correction of R1's MDS. V29 stated when wandering is entered on the MDS, it prompts for additional questions to answer.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 74 residents residing in the facility. Findings include: On 5/5/25 and 5/6/25 V7 Dietary Manager was actively supervising dietary operations in the facility kitchen during resident meal preparations. On 5/6/25 at 8:46am V7 Dietary Manager stated that V7 is the full-time manager of the facility food service and not being a clinically qualified Certified Dietary Manager or having the equivalent training. On 5/6/25 at 9:00am V1 Administrator confirmed that V7 Dietary Manager is the full-time Dietary Manager, and is not Certified as a Dietary Manager or have the equivalent training The Resident Census and Conditions of Residents report dated 5/4/25 documents 74 residents reside in the facility. Facility Assessment Tool dated 4/2025 documents: Facility Resources Needed to Provide Competent Support and Care for our resident Population Every Day and During Emergencies. Position Dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Full Time Food Service Manager.

Based on observation, interview, and record review, the facility failed to develop and implement a person-centered comprehensive care plan to include residents smoking status. This failure affects one (R16) of seven residents reviewed for accidents in the sample list of 33. Findings include: The facility Care Plans, Comprehensive Person-Centered Policy (reviewed December 2024) documents the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. R16's Face Sheet dated 5/6/25 documents R16 was admitted to the facility on [DATE]. The facility Smoker List (undated) documents R16 is an independent smoker who requires supervision. R16's photo sheet that accompanies the Smoker List further documents R16 must wear a smoking apron. On 5/5/25 at 12:58pm, R16 observed out front of the facility smoking a cigarette and supervised by staff. On 5/6/25 at 1:15pm, R16 observed out front of the facility smoking a cigarette and supervised by staff. R16's Safe Smoking Evaluations dated 3/26/25 and 4/8/25 documents R16 is a safe smoker, requires no assistance to smoke, and develop care plan. R16's Care Plan dated 5/5/25 does not document R16 as being a smoker. On 5/6/25 at 11:18am, V1 Administrator stated R16 admitted to the facility as a non-smoker and began smoking a month later. V1 stated R16's Care Plan was updated today (5/6/25) to include smoking and interventions.

Based on observation, interview, and record review the facility failed to ensure the right to be free from physical abuse for three (R1, R2, &R3) of four residents reviewed for abuse from a sample list of four residents. Findings include: 1.) The facility provided incident report dated 4/19/25 documents that an altercation between R1 and R3 occurred in the dining room at approximately 6:00 AM. V14, Dietary Aid's, written statement dated 4/19/25 documents that V14, Dietary Aid, heard R1 and R3 screaming in the dining room at approximately 6:00 AM. R3 had blocked R1 in the dining room and was cursing at her. R1 complained that R3 kicked her. R1's Minimum Data Set, dated dated dated dated 3/26/25 documents that R1 is cognitively intact. On 4/21/25 at 11:45 AM, R1 stated that R3 bothers her and that R3 hit her left knee a few days ago and caused her pain. On 4/21/25 at 12:00 PM, V3, R1's Family Member, stated that the facility notified her on 4/19/25 that R3 had hit R1's leg and that R1 confirmed that R3 had kicked her in the knee. 2.) The facility provided incident report dated 4/19/25 documents that at approximately 6:30 PM, R2 and R3 approached the exit door on the B hall and R3 pushed R2, resulting in a right knee skin tear. V7, Certified Nursing Assistant (CNA), stated that he observed R3 raise both hands, place them on R2's back and pushed R2 to the ground. R2's minimum data set documents that R2 is severely cognitively impaired. R2's progress notes dated 4/19/25 documents that V7, CNA, observed R3 push R2 to the floor. On 4/23/25 at 11:01 AM, V12( Licensed Practical Nurse (LPN)) removed R2's right knee dressing where a quarter-sized skin tear was observed. R2 winced in pain as V12 (LPN) moved R2's over the wound and above the knee. On 4/23/25 at 11:05 AM, R2 stated as the bandage was removed, That's my knee that hurts. 3.) R3's care plan dated 2/7/25 documents that R3 has the potential to be physically aggressive toward other residents. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as severely cognitively impaired. R3's progress notes dated 2/9/25 documents that R3 has been very aggressive toward residents and staff with attempts at re-direction unsuccessful. R3's progress notes dated 4/19/25 documents that R3 was removed from the dining room at 6:30 AM while screaming. R3's progress notes dated 4/19/25 documents at 6:30PM that R3 was sitting in her wheel chair and that she and R2 were nearing the exit door on hall B when V4 (CNA) observed R3 push R2 with both hands causing R2 to fall. R3's 4/14/25 psychiatry note documents an increase in aggressive behavior. On 4/21/25 at 1:40 PM, V6 (Licensed Practical Nurse (LPN)) stated that R3 is aggressive toward both residents and staff. I was the evening nurse on 4/19/25 and after R3 pushed R2 onto the floor, we were instructed to send R3 to the emergency room because there had been two incidents with R3 in one day. On 4/21/25 at 1:57 PM, V9 (CNA) stated that when she came into work on 4/19/25, R1 and R3 were already arguing. R3 is hard to deal with. She uses a wheel chair and sometimes pushes it while walking. She curses at both residents and staff and she can also be physically aggressive. R3's local hospital notes dated 4/19/25 document that R3 was evaluated by the emergency room due to aggressive behavior with residents and staff. Out patient psychiatry was recommended. On 4/23/25 at 9:15 AM, V1 Administrator stated that R3 is transferring to a memory care unit to better meet her needs.

Based on interview and record review the facility failed to implement effective interventions to prevent abuse for three (R1, R2, R3) of four residents reviewed for abuse from a total sample list of four residents. Findings include: The facility provided Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating Policy dated September 2022 documents that upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions are needed for the protection of residents. 1.) The facility provided incident report dated 4/19/25 documents that an altercation between R1 and R3 occurred in the dining room at approximately 6:00 AM. V14 Dietary Aid's written statement dated 4/19/25 documents that V14 Dietary Aid heard R1 and R3 screaming in the dining room at approximately 6:00 AM. R3 had blocked R1 in the dining room and was cursing at her. R1 complained that R3 kicked her. On 4/21/25 at 11:45 AM, R1 stated that R3 bothers her and that R3 hit her left knee a few days ago and caused her pain. R1's Minimum Data Set, dated dated dated dated 3/26/25 documents that R1 is cognitively intact. On 4/21/25 at 12:00 PM, V3, R1's Family Member, stated that the facility notified her on 4/19/25 that R3 had hit R1's leg and that R1 confirmed that R3 had kicked her in the knee. 2.) The facility provided incident report dated 4/19/25 documents that at approximately 6:30 PM, R2 and R3 approached the exit door on the B hall and R3 pushed R2, resulting in a right knee skin tear. V7, Certified Nursing Assistant (CNA), stated that he observed R3 raise both hands, place them on R2's back and pushed R2 to the ground. R2's Minimum Data Set, dated dated dated [DATE] documents that R2 is severely cognitively impaired. R2's progress notes dated 4/19/25 documents that V7, CNA, observed R3 push R2 to the floor. On 4/21/25 at 1:40 PM, V6 (Licensed Practical Nurse (LPN)) stated that R3 is aggressive toward both residents and staff. I was the evening nurse on 4/19/25 and after R3 pushed R2 onto the floor, we were instructed to send R3 to the emergency room because there had been two incidents with R3 and other residents in one day. On 4/21/25 at 1:57 PM, V9 (CNA) stated that when she came into work on 4/19/25, R1 and R3 were already arguing. R3 is hard to deal with. She uses a wheel chair and sometimes pushes it while walking. She curses at both residents and staff and she can also be physically aggressive. 3.) R3's care plan dated 2/7/25 documents that R3 has the potential to be physically aggressive toward other residents with the documented plan for intervention to intervene as needed to protect the rights and safety of others. R3's Minimum Data Set, dated dated dated [DATE] documents R3 as severely cognitively impaired. R3's progress notes dated 2/9/25 documents that R3 has been very aggressive toward residents and staff with attempts at re-direction unsuccessful. R3's progress notes dated 4/19/25 documents that R3 was removed from the dining room at 6:30 AM while screaming. R3's local hospital notes dated 4/19/25 document that R3 was evaluated by the emergency room due to aggressive behavior with residents and staff. Out-patient psychiatry was recommended. R3's progress notes dated 4/19/25 documents at 6:30 PM that R3 was sitting in her wheel chair and that she and R2 were nearing the exit door on hall B when V4 (CNA) observed R3 push R2 with both hands causing R2 to fall. R3's behavior monitoring and interventions report dated 4/17/25, 4/19/25, 4/20/25, and 4/22/25 document physical and verbal abuse toward others with interventional success on only one date, 4/17/25. On 4/23/25 at 9:15 AM, V1 stated that interventions such as moving R3 to a different hall from R1 and 1:1 observations should have been attempted to decrease the incidences of resident altercations.

Based on observation, interview, and record review the facility failed to protect a resident's (R1) right to be free from physical abuse by another resident (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. This failure resulted in R2 abusing R1, causing R1 to experience psychosocial harm as evidenced by crying and fear of R2. Findings include: On 4/14/25 at 8:14 AM R1 was in a wheelchair and slowly propelled herself into her room. R1 stated R1 wishes another resident, R2, wasn't here in the facility. R1 stated a couple weeks ago around 5:00 PM, while in the main dining room, R2 hit R1 in the back of the neck. R1 demonstrated this with an open palm. R1 stated this caused R1 to have neck pain for a few days after the incident. R1 stated this incident was witnessed by V4 Certified Nursing Assistant (CNA). R1 stated R1 is afraid of R2 and every time R2 goes past R1, R1 gets all shaky and nervous. R1 stated R2 has Alzheimer's and R1's mother was the same way. R1 stated R1's mother used to spank R1, pinch R1, and pull R1's hair whenever R1 had an incontinence accident; and this incident brings back those memories. On 4/14/25 at 11:45 AM R2 was walking by herself, pushing a wheelchair out of the activity room. At 11:53 AM R2 was interviewed regarding the incident with R1. R2 did not recall the incident and was confused. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, requires substantial/maximal assistance from staff for transfers, and does not walk. R2's Admission MDS dated [DATE] documents R2 has severe cognitive impairment, physical/verbal/other behaviors noted one to three days during the review period, and these behaviors put others at risk for injury and significantly disrupts care or living environment. R2's Nursing Note dated 3/29/2025 at 5:30 PM documents R2 was near the nurse's station yelling shut the F**** (expletive) up, motherf****** (expletive) and banging on the walls. Attempts at redirection were unsuccessful. R2's Behavior Monitoring and Intervention Report dated 3/17/25-4/15/25 documents R2 had aggression towards others on 10 days. The facility's Daily Nursing Schedules dated 4/1/25 and 4/2/25 document V4 CNA worked the evening shift and was assigned to monitor the main dining room. On 4/14/25 at 9:14 AM V4 CNA stated on an unidentified date within the last month, around 4:30-5:00 PM, R1 and R2 were in the dining room. V4 stated R2 wheeled past R1 in her wheelchair, R2's wheelchair got stuck and couldn't get past R1. V4 stated R2 got upset with R1 and smacked R1 in the back of the neck with R2's hand. V4 stated V4 ran over there as fast as she could to get R1 out of the way. V4 confirmed V4 considered R2's actions as abuse. V4 stated R2 has hit staff during cares, has outburst and swats at people as they walk past her. V4 stated R1 cries now every time R1 sees R2 and tells the staff that R2 had hit R1. On 4/14/25 at 9:28 AM V18 Licensed Practical Nurse (LPN) stated it was reported to V18 that R1 does not like R2 around and freaks out. V18 stated V18 did not witness but was told that R2 had hit R1 on the back of the neck in the dining room, and this was reported by an unidentified CNA on an unidentified date. V18 stated when R1 has an experience, R1 doesn't forget it. On 4/14/25 at 9:50 AM V21 Activity Director stated on the morning of 4/4/25, R1 told V21 that R2 had smacked R1 in the back of the head. V21 stated V21 had been off work that week and returned on 4/4/25 and the incident happened sometime that week. V21 stated R1 said R1 did not want to be around R2, and inferred that R1 was afraid of R2. V21 described R1 as being sad when R1 reported this. V21 stated R1's mother had dementia and would spank R1 when R1 was incontinent and R1 is very fearful due to her history with her mother and not having the ability to run away from others. V21 stated R1 does not have any memory problems. On 4/14/25 at 12:44 PM V8 LPN stated there was a day within the last couple weeks that R1 would not go into the activity room because of R2. V8 stated R1 was crying but V8 could not understand R1 or why R1 was upset with R2. V8 stated V8 took R1 to her room to calm down. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated as revised March 2025, documents residents have the right to be free from abuse and abuse includes the willful infliction of injury with resulting physical harm, pain or mental anguish.

Based on observation, interview and record review the facility failed to identify triggers, develop a care plan and implement interventions and services to address a past history of abuse (R1). This failure affects three (R1, R2, R14) of seven residents reviewed for abuse in the sample list of 14. Findings include: The facility's Trauma-Informed and Culturally Competent Care policy dated August 2022 documents traumatic events which may affect residents during their lifetime includes physical and emotional abuse, and trauma survivors who transition to institutional living may experience triggers and re-traumatization. Triggers are individualized, but may include a lack of privacy or confinements in a crowded or small space, exposure to loud noises, exposure to bright or flashing lights, certain sights or objects, or sounds, smells and physical touch. This policy documents to use screening and assessment tools in collaboration with the Quality Assurance Performance Improvement Committee and use community organizations for services, referrals, training and information. Screen residents for exposure to traumatic events, including history of trauma type, severity, and duration; trauma-related or dissociative symptoms; behavioral concerns; protective factors; resources available. This policy documents this screening will identify the need for further assessment and care, assess for symptoms related to trauma, identify triggers, and utilize licensed and trained clinicians to conduct trauma assessments. This policy documents to develop individualized care plans that address past trauma in collaboration with the resident and their family, identify and decrease exposure to triggers that may re-traumatize the resident, develop a plan that embraces strengths and further learning rather than dictating a plan to change the behavior, and avoid a one-size-fits-all approach. On 4/14/25 at 8:14 AM R1 was in a wheelchair and slowly propelled herself into her room. R1 stated R1 wishes another resident, R2, wasn't here in the facility. R1 stated a couple weeks ago around 5:00 PM, while in the main dining room, R2 hit R1 in the back of the neck. R1 demonstrated this with an open palm. R1 stated this caused R1 to have neck pain for a few days after the incident. R1 stated this incident was witnessed by V4 Certified Nursing Assistant. (CNA) R1 stated R1 is afraid of R2 and every time R2 goes past R1, R1 gets all shaky and nervous. R1 stated R2 has Alzheimer's and R1's mother was the same way. R1 stated R1's mother used to spank R1, pinch R1, and pull R1's hair whenever R1 had an incontinence accident; and this incident brought back those memories. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, requires substantial/maximal assistance from staff for transfers, and does not walk. R1's active care plan documents R1 has episodes of anxiety, anger poor impulse control, crying, and child like tantrums. This care plan documents R1 is at high risk for abuse/ and or neglect due to ineffective coping skills related to cognitive deficit and decreased impulse control. Interventions include to assess for support systems and additional resources, discuss alternative coping strategies, provide a safe environment, provide emotional support, evaluate response to interventions, trauma informed support as needed, and refer for psychiatric evaluation. R1's care plan includes an intervention dated 9/5/24 to keep R1 away from other residents that seem to trigger R1's behaviors. R1's care plan does not include R1's history of abuse, associated triggers related to this past abuse, or interventions. R1's care plan documents R1's diagnoses include paraplegia, anxiety disorder, cerebral palsy, genetic related intellectual disability, and major depressive disorder with sever psychotic symptoms. R1's Social Service Comprehensive assessment dated [DATE] documents R1 has a history of abuse and or neglect, and exposure to trauma. This assessment does not document any additional details regarding this abuse/trauma. R1's Psychiatry Note dated 4/7/25, recorded by V23 Nurse Practitioner, documents R1 has a history of depression and anxiety, R1 reported her mood as good, and the staff reported no maladaptive behaviors. This note documents under family history, R1 did not know if there was any family history or psychiatric issues in her family, R1's chart did not indicate family history and there was no family at the bedside. R1's Nursing Note dated 4/9/2025 at 9:41 AM documents during breakfast R1 was getting agitated about another resident (R14) being in the wrong dining room. The nurse explained that R14 was not bothering anyone and was sitting quietly and R14 would be removed from the dining room later. The nurse left the dining room and later heard R1 yelling and screaming in the hallway about other residents. The nurse attempted to calm R1 and R1 began slapping and ripping the nurse's stethoscope off of her neck. The nurse calmly asked R1 to calm down and told R1 that R1 would have to go to her room until R1 was calm. R1 then began to cry and then calmed down. R1 was then taken to the dining room and explained that this behavior couldn't continue, R1 would need to remain calm if R1 wanted to be in the dining room. R1's Nursing Note dated 4/14/25 at 10:34 AM documents a psychosocial assessment for a resident to resident physical altercation and that R1 had new onset of increased behaviors including crying, tearfulness, fearfulness, anxiety, agitation, yelling and anger. This note documents R1 has a history of physical/emotional trauma and triggers include change in routine and living arrangement. Interventions include one to one with staff. On 4/14/25 at 9:14 AM V4 CNA confirmed R1's and R2's physical altercation as described by R1. V4 stated R1 cries now every time R1 sees R2 and tells the staff that R2 had hit R1. On 4/14/25 at 9:28 AM V18 Licensed Practical Nurse (LPN) stated when R1 has an experience, R1 doesn't forget it. V18 stated R2 is very loud/vocal and cusses, which makes R1 anxious. On 4/14/25 at 9:50 AM V21 Activity Director stated on the morning of 4/4/25, R1 told V21 that R2 had smacked R1 in the back of the head. V21 stated R1 said R1 did not want to be around R2, and V21 inferred that R1 was afraid of R2. V21 stated R1's mother had dementia and would spank R1 when R1 was incontinent and R1 is very fearful due to her history with her mother and not having the ability to run away from others. V21 stated V21 has told the CNAs that it's very important to be mindful of their approach with R1, especially with R1's incontinence, due to R1's history of abuse. On 4/14/25 at 11:04 AM V22 Social Services Director stated V22 started working in the facility in January 2025 and per unidentified coworkers, R1 likes to fixate on individual residents. V22 stated V22 thinks R1's mother treated R1 like a child, making R1 feel belittled, and R1 does not like when staff bring up her mother. V22 stated this would be care planned, as well as a history of abuse and included in the social services comprehensive assessment. V22 stated V3 Care Plan Coordinator is responsible for updating this on the care plan. V22 stated R1 would know about R1's history of abuse. On 4/14/25 at 11:33 AM V3 stated R1's mother was verbally abusive when R1 had accidents, and was unsure about physical abuse. V3 stated R1's family has discussed this during care plan meetings and V22 is responsible for obtaining this information. V3 confirmed this information should be care planned. V3 stated V3 did not see anything specific to R1's past history of abuse in R1's care plan. At 12:13 PM V3 stated R1's care plan includes an intervention to keep triggering residents away from R1, but no other new interventions have been implemented. V2 Director of Nursing stated we just try to keep the triggering residents away from R1. On 4/14/25 at 12:44 PM V8 LPN stated there was a day within the last couple weeks that R1 would not go into the activity room because of R2. V8 stated R1 was crying but V8 could not understand R1 or why R1 was upset with R2. V8 stated V8 took R1 to her room to calm down. V8 confirmed V8 documented R1's 4/9/25 nursing note. V8 stated R14 was the other resident mentioned in the note. V8 stated R1 has a history of being upset by other residents, just overall not happy with them. V8 stated R1 gets upset and cries and we take R1 to her room to calm down. On 4/14/25 at 2:08 PM V10, R1's Family, stated R1's/V10's mother spoke harshly to R1. V10 stated R1 later reported that their mother spanked R1 when R1 was incontinent and was rough with R1. V10 stated family started staying with R1 for three months until nursing home placement was found. V10 stated when R1 admitted to the facility several years ago, V10 spoke with the staff about R1's abuse and R1's fear of how staff would react when R1 had incontinence/accidents. On 4/15/25 at 10:33 AM V5 CNA stated R1 has a learning disability and the staff don't know how to care for R1. V5 stated V5 was unsure if R1 has a history of family abuse, R1 has never mentioned that to V5. On 4/15/25 at 11:08 AM V23 Nurse Practitioner stated R1 has been receiving psychiatry services through V23's company since at least 2022 and V23 has been seeing R1 since January 2025. V23 stated R1 has mild intellectual disability, V23 reviewed R1's chart and stated V23 did not see anything documented about a past history of abuse or trauma or a diagnosis of Post Traumatic Stress Disorder (PTSD). V23 stated PTSD would be past trauma or physical/verbal aggression that causes the resident to have anxiety and/or paranoia. PTSD could cause R1 to be reminded of her mother by other residents. V23 stated no one had reported that R1 had a history of abuse by her mother and V23 looks at the resident's medical record to determine past history and staff should also report this. V23 stated R1 had never brought up this history during V23's visits. V23 stated if V23 was made aware, V23 would have recommended Licensed Clinical Social Worker (LCSW) psychotherapy sessions, possible medication adjustments, and try to identify R1's triggers. V23 stated it would be helpful for the facility to identify R1's triggers related to R1's past history of abuse. V23 stated V23 will follow up and evaluate R1 for a diagnosis of PTSD. On 4/15/25 at 11:15 AM V2 stated R1 has not had psychotherapy sessions within the last six months. V2 stated the facility recently has a new LCSW providing these services, but R1 has not yet been seen.

Based on observation, interview and record review the facility failed to care plan, identify targeted behaviors and develop/implement personalized interventions to address dementia related behaviors (R2). This failure affects two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. Findings include: The facility's Dementia - Clinical Protocol dated November 2018 documents residents with dementia will have a resident-centered care plan to maximize remaining function and quality of life and the resident's needs will be communicated to direct care staff through care plan conferences, shift communication, and through written documentation such as nursing notes. This policy documents staff should report progressive or persistent worsening of symptoms and increased staff support to the Interdisciplinary Team (IDT), the physician will order appropriate interventions to address significant behavioral or psychiatric symptoms, and the IDT will adjust interventions on the care plan depending on the resident's response to the interventions. On 4/14/25 at 8:14 AM R1 stated a couple weeks ago around 5:00 PM, while in the main dining room, R2 hit R1 in the back of the neck. R1 demonstrated this with an open palm. R1 stated this incident was witnessed by V4 Certified Nursing Assistant (CNA). On 4/14/25 at 8:30 AM R1's and R2's rooms were located on the same hall of the facility. On 4/14/25 at 11:45 AM R2 was walking by herself, pushing a wheelchair out of the activity room. At 11:53 AM R2 was interviewed regarding an incident with R1. R2 did not recall the incident with R2 and was confused. R2's Admission Minimum Data Set, dated dated dated [DATE] documents R2 has severe cognitive impairment, physical/verbal/other behaviors noted one to three days during the review period, and these behaviors put others at risk for injury and significantly disrupts care or living environment. R2's active Care Plan documents R2 is or has the potential to be physically aggressive related to dementia (2/7/25) and interventions (2/7/25) include assess for resident's needs, monitor behaviors and attempt to determine the underlying cause, report signs of posing a danger to herself or others, provide a non-confrontational environment for care, intervene before agitation escalates, guide away from source of distress, staff to walk calmly away and approach later, explain care in terms the resident can understand, give choices about care and activities as appropriate, intervene as needed to protect the rights and safety of others, approach in a calm manner, divert attention, remove from the situation and take to another location as needed. R2's care plan documents R2 has impaired thought process and interventions include making eye contact when speaking to R2, reduce distractions, use simple/direct sentences, provide necessary cues, segment tasks into one step at a time, and stop and return if R2 is agitated. R2's care plan has not been updated to include R2's physical altercation with R1 or that R2 is resistive with cares. R2's Nursing Notes document the following: On 3/20/25 at 5:44 PM R2 refused wound care and medications, and R2 cursed at the nurse. On 3/29/2025 at 5:30 PM R2 was at the nurses station yelling at other residents, shut the f*** (expletive) up, motherf******! R2 was banging on the walls and staff attempts at redirection was unsuccessful. On 4/9/2025 at 6:36 PM R2 refused evening medications, refused care from staff, and cursed at staff. R2 was exit seeking and making statements as if R2 was working in a factory dictating to staff and other residents that they needed to get on the line and perform tasks. R2 appeared to calm down when allowed to walk around the facility on R2's own, away from staff and residents. R2's Behavior Monitoring and Intervention Report dated 3/17/25-4/15/25 is generic and lists a variety of behaviors and interventions, but does not identify which behaviors are specific to R2 and personalized nonpharmacological interventions or approaches for R2's behaviors. This report documents R2 has behaviors of wandering/exit seeking, refusing cares, and physical and verbal aggression towards others including kicking, hitting, grabbing, pushing, scratching, cursing, screaming, and threatening. R2's Fall Report dated 3/26/25 at 8:30 PM documents a CNA attempted to transfer R2 into a wheelchair to transport to the restroom in the hallway, R2 refused care, R2 hit the CNA, R2 lost her balance and fell hitting her head on the handrail. R2 did not have any injuries. On 4/14/25 at 9:14 AM V4 CNA stated on an unidentified date within the last month, around 4:30-5:00 PM, R1 and R2 were in the dining room. V4 stated R2 wheeled past R1 in her wheelchair, R2's wheelchair got stuck and R2 couldn't get past R1. V4 stated R2 got upset with R1 and smacked R1 in the back of the neck with R2's hand. V4 stated V4 ran over there as fast as she could to get R1 out of the way. V4 confirmed V4 considered R2's actions as abuse. V4 stated R2 has hit staff during cares, has outburst and swats at people as they walk past her. V4 stated staff try to engage R2 in activities or just let R2 roam, and staff try to monitor R2 so that R2 does not go into the dining room when R1 is in there. On 4/15/25 at 10:13 AM V4 confirmed V4 was the CNA assisting during R2's fall on 3/26/25. V4 stated V4 was pulling R2 in a wheelchair backwards down the hallway, R2 grabbed the handrail and flipped out of the chair. V4 stated V4 pulled R2's wheelchair backwards due to R2 resisting and planting her feet, but R2 had to be changed because it was the end of shift. V4 was asked about any alternative approaches or interventions used during this incident. V4 stated R2 is always combative and resistant to toileting. V4 confirmed no alternative approaches were used. V4 stated staff usually ask if R2 has to use the bathroom, but due to R2's dementia R2 has difficulty understanding words. V4 denied that any visual cues or aides have been trialed for R2. V4 stated R2 seems to do well for V25 CNA, but V4 did not ask for V25 to assist with R2's toileting cares that day. On 4/14/25 at 12:44 PM V8 LPN stated R2 yells/screams/cusses in common areas with other residents present and R2 thinks R2 is working in a factory and directs everyone. V8 stated this past Saturday R2 hit V8 in the face while attempting to change R2's incontinence brief. V8 stated R2 calmed down once R2 allowed the staff to change R2, and believes the incontinence is what triggered R2's behavior. On 4/14/25 at 11:33 AM V3 Care Plan Coordinator stated R2 cusses, is resistive to staff, and has dementia. At 12:13 PM V3 stated R2's care plan includes R2 has the potential to be aggressive. V3 confirmed this care plan has not been updated with R2's physical altercation or new interventions to address this behavior. On 4/15/25 at 9:37 AM V24 LPN stated R2 was in the hallway with V4 CNA when R2 fell on [DATE]. V24 stated V24 did not witness the fall and described R2 as being at her baseline, cursing and combative with staff when attempting to redirect or provide cares. V24 stated R2 just gets more agitated so we just try to reapproach R2 later. V24 stated staff had not mentioned if R2 was resistive or agitated prior to R2's fall. On 4/14/25 at 12:10 PM V2 Director of Nursing reviewed R2's behavior tracking report. V2 stated this is the behavior tracking that is used and is the same for all residents. V2 confirmed this behavior tracking does not identify R2's specific behaviors or personalized nonpharmacological interventions or approaches. V2 stated the nurses also document behaviors on the Medication Administration Record, but R2's specific targeted behaviors are not identified. On 4/15/25 at 10:40 AM V2 stated staff have been instructed when residents are resistive to cares they should try a different approach or try another staff person. V2 confirmed allowing time to vent and reapproach later would also be an appropriate intervention. V2 stated staff should honor the resident's right to refuse care and R2 does better for male staff. V2 confirmed V25 worked on 3/26/25 and confirmed staff should have implemented interventions or alternative approaches during R2's staff assisted fall. V2 confirmed pulling R2's wheelchair backwards would not be considered an acceptable approach. At 11:33 AM V2 confirmed R2's care plan has not been updated to include resistive to cares and nonpharmacological interventions/approaches to address this behavior.

Based on observation, interview, and record review the facility failed to follow physician's orders and manufacturer's instructions for two (R9, R11) of nine residents reviewed for medication administration in the sample list of 14. This failure resulted in three medication errors out of 26 opportunities, an 11.5% medication error rate. Findings include: 1.) R9's April 2025 Medication Administration Record (MAR) documents to administer Albuterol Sulfate Hydrofluoroalkane Inhalation Aerosol Solution 108 (90 Base) micrograms (mcg) per actuation give two puffs orally twice daily. On 4/14/25 at 3:27 PM V17 Licensed Practical Nurse administered two puffs of Albuterol 108 mcg inhaler to R9. The inhaler box had a label to shake, and V17 did not shake the inhaler prior to administration. At 3:50 PM V17 confirmed R9's Albuterol inhaler box contained a label to shake and confirmed she did not shake the inhaler prior to administration. V17 stated V17 was not aware V17 needed to shake the inhaler prior to administration. The Highlights of Prescribing Information for Albuterol Sulfate 108 mcg dated February 2019 documents to shake the inhaler well prior to each spray. 2.) R11's April 2025 MAR documents to administer Clonidine Hydrochloride 0.1 milligrams (mg) one tablet by mouth twice daily and hold if systolic blood pressure (SBP) less than 120. This MAR documents to give Insulin Lispro Injection Solution 100 UNIT per milliliter per sliding scale based on blood glucose four times daily at 7:00 AM, 11:00 AM, 3:00 PM, and 7:00 PM. R11's active vital sign report documents the last recorded blood pressure was 140/62 on 4/14/25 at 9:43 AM. On 4/14/25 between 3:38 PM and 3:48 PM V17 administered Clonidine 0.1 mg one tablet to R11. The medication card contained a label to hold the medication if R11's SBP was less than 120. V17 did not obtain R11's blood pressure prior to administering Clonidine. V17 checked R11's blood glucose level, which was 270 mg per deciliter. At 3:48 PM V17 administered Insulin Lispro 6 units, as ordered, into R11's right upper arm. There was no food at R11's bedside. On 4/14/25 at 3:42 PM R11 stated staff have not checked R11's blood pressure and R11 thought it was suppose to be checked twice daily. On 4/14/25 at 3:50 PM V17 confirmed R11's Clonidine physician order and medication card both document to hold for SBP less than 120. V17 stated R11's blood pressure was last checked that morning and V17 should have checked R11's blood pressure prior to administering Clonidine. At 4:48 PM V17 stated V17 thought short acting insulin could be given within 45 minutes of a meal. On 4/14/25 at 4:50 PM R11 was in R11's room. V26 Certified Nursing Assistant was pushing a cart of meal trays down R11's hallway. V26 stated hall trays, including R11's meal tray, had not been delivered yet. On 4/15/25 at 5:50 AM V2 Director of Nursing stated short acting insulin should be given within 15 minutes of a meal. The Highlights of Prescribing Information for Insulin Lispro dated September 2023 documents Lispro is a rapid acting insulin that should be administered within 15 minutes prior to a meal or immediately after a meal. The facility's Administering Medications policy dated April 2019 documents medications are administered according to physician orders.

Based on observation, interview, and record the facility failed to ensure a wheelchair was in safe operating condition for one (R3) of three residents reviewed for falls on the sample list of 14. Findings include: R3's Nursing Note dated 4/1/25 at 8:38 AM R3 had a witnessed fall. R3 was on the floor by his chair with his legs extended out in front of him and the Certified Nursing Assistant (CNA) stated R3 unclamped the sling from the lift and was then lowered to floor without hitting his head. At 12:20PM on 4/14/2025 V6 CNA stated when V6 lowered R3 into his reclining chair, the wheelchair was broken and tilted forward, causing R3 to slide out of the wheelchair. V6 stated R3's wheelchair had been broken for awhile prior to this fall. On 4/15/2025 at 1:30PM V9 CNA stated that she switched out R3's chair on 4/2/2025 due to the wheelchair being broken and tilted in an upright position. V9 stated she felt that R3 couldn't be comfortable sitting in the forward tilted position of the broken wheelchair. V9 stated R3's reclining wheelchair had been broken for awhile. On 4/15/2025 at 140PM, V11 (Maintenance Director) stated that the facility uses a logbook that he checks every 30 minutes to see if there are any repairs that need to be completed by the facility. V11 was observed going through the log and no date was given for R3's broken chair. V11 stated V11 was never notified that R3's reclining wheelchair was broken. Policy Dated April 2010 documents Maintenance work orders shall be completed in order to establish a priotrity of maintenance service which incudes work orers must be filled out and forwarded to the maintenance director. This documents also states that work orer requests should be placed in the Work Order Binder and are to picked up daily and emergency requests will be given priority in making necessary repairs.

Based on interview and record review the facility failed to timely report an allegation of resident to resident physical abuse to the administrator and to the state survey agency for two (R1, R2) of seven residents reviewed for abuse in the sample list of 14. Findings include: On 4/14/25 at 8:14 AM R1 stated a couple weeks ago around 5:00 PM, while in the main dining room, R2 hit R1 in the back of the neck. R1 demonstrated this with an open palm. R1 stated this caused R1 to have neck pain for a few days after the incident. R1 stated this incident was witnessed by V4 Certified Nursing Assistant (CNA). R1 stated R1 is afraid of R2 and every time R2 goes past R1, R1 gets all shaky and nervous. R1 stated R2 has Alzheimer's and R1's mother was the same way. R1 stated R1's mother used to spank R1, pinch R1, and pull R1's hair whenever R1 had an incontinence accident; and this incident brings back those memories. R1 stated R1 reported this incident to V1 Administrator and V7 Former Director of Nursing (DON) the next morning. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact, requires substantial/maximal assistance from staff for transfers, and does not walk. R2's Admission MDS dated [DATE] documents R2 has severe cognitive impairment, physical/verbal/other behaviors noted one to three days during the review period, and these behaviors put others at risk for injury and significantly disrupts care or living environment. R2's Nursing Note dated 3/29/2025 at 5:30 PM documents R2 was near the nurse's station yelling shut the F**** (expletive) up, motherf****** (expletive) and banging on the walls. Attempts at redirection were unsuccessful. R2's Behavior Monitoring and Intervention Report dated 3/17/25-4/15/25 documents R2 had aggression towards others on 10 days. V22 Social Service Director's handwritten note dated 4/7/25 documents R1 came to V22's office and reported that R1 did not like R2 because R2 hit R1's head. R1 reported that R1 and R2 were in the dining room eating and R2 reached across and their heads bumped each other. V1 Administrator's written statement dated 4/7/25 documents V22 reported that R1, who was tearful, wanted to speak with V1. R1 reported that the night prior, while in the dining room, R2 reached over R1 and bumped R1 on the front of her head, and R1 did not think R2's actions were done on purpose. R1 told V1 that R1 did not want R2 in the facility anymore. On 4/14/25 the facility's abuse investigative files between December 2024 and April 2025, provided by V1 Administrator, were reviewed. There was no abuse investigative file for any altercations between R1 and R2, and no documentation that the facility reported this altercation to the state survey agency. There is no documentation of this incident in R1's or R2's medical records. On 4/14/25 at 9:14 AM V4 CNA stated on an unidentified date within the last month, around 4:30-5:00 PM, R1 and R2 were in the dining room, R2 wheeled past R1 in her wheelchair, R2's wheelchair got stuck and R2 couldn't get past R1. V4 stated R2 got upset with R1 and smacked R1 in the back of the neck with R2's hand. V4 stated V4 ran over there as fast as she could to get R1 out of the way. V4 confirmed V4 considered R2's actions as abuse. V4 stated V4 reported this incident to V18 Licensed Practical Nurse (LPN) at an unidentified time on the date of the incident. V4 stated V1 Administrator is the facility's abuse coordinator but V4 did not report this incident to V1. V4 stated V4 followed the chain of command by reporting to the nurse, V18. On 4/14/25 at 9:28 AM V18 LPN stated staff have mentioned that R1 does not like R2 around and freaks out. V18 stated V18 did not witness but was told by an unidentified CNA on an unidentified date that R2 hit R1 on the back of the neck while in the dining room. V18 stated V18 did not report this to V1 since management staff/administration was already aware of the incident. On 4/14/25 at 9:50 AM V21 Activity Director stated on the morning of 4/4/25, R1 told V21 that R2 had smacked R1 in the back of the head. V21 had been off work that week and returned on 4/4/25, and the incident happened sometime that week. V21 stated R1 said R1 did not want to be around R2, and V21 inferred that R1 was afraid of R2. V21 stated administration/management was already aware of R1's allegation because that morning V11 Maintenance Director told V21 it was discussed in the morning meeting that R1 and R2 had to be kept separated. On 4/14/25 at 11:03 AM V11 Maintenance Director stated it was discussed in morning meeting within the last two weeks to keep R1 and R2 away from each other. V11 stated he didn't know any other details. On 4/14/25 at 12:54 PM V7 Former DON stated on an unidentified date an unidentified staff person reported that R2 had touched R1, but V7 was unable to recall any additional details. V7 stated it happened during the evening when management staff weren't at the facility and V7 was unsure if V1 Administrator was aware of the incident. On 4/14/25 at 2:08 PM V10 (R1's Family) stated on 4/11/25 R1 was in the hallway crying and V10 took R1 to her room. V10 stated R1 told V10 that another resident, R2, hit R1 in the back of the neck; and V10 reported this to V7 Former Director of Nursing. On 4/14/25 at 9:31 AM V1 Administrator stated about two weeks ago it was reported that R2 had touched R1, V1 spoke to R1 and determined it was an accidental bumping of heads as R2 leaned across the back of R1's wheelchair. V1 described R1 as being emotional when V1 spoke with her and was unsure that contact was even made. V1 stated it wasn't abuse since it wasn't intentional and V1 did not report this incident to the state survey agency. V1 stated staff are suppose to report abuse immediately to V1 and no staff had reported that R2 smacked R1 on the back of the neck. V1 stated that would have been reported as an abuse allegation. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated as revised March 2025, documents residents have the right to be free from abuse and abuse includes the willful infliction of injury with resulting physical harm, pain or mental anguish. This policy documents the facility will identify and investigate all possible incidents of abuse and report abuse allegations within the federally required time frames.

Based on Observation, Interview and Record Review the facility failed to properly perform a mechanical lift transfer resulting in a fall, failed to document falls in the medical record, investigate falls and develop/implement post fall interventions for two (R2,R3) of three residents reviewed for falls in a sample list of 14. Findings Include: Facility Policy dated August 2024 documents that two nursing assistants are needed to safely move a resident with a full mechanical lift. This policy also documents that the full mechanical lift may be used for tasks that require, transferring a resident from bed to the chair, and lateral transfers. 1.) R3 Minimum Data Set from 2/12/2025 documents R3 has severe cognitive impairment with substantial/maximum assistance. R3's Nursing Note dated 4/1/25 at 8:38 AM R3 had a witnessed fall. R3 was on the floor by his chair with his legs extended out in front of him and the Certified Nursing Assistant (CNA) stated R3 unclamped the sling from the lift and was then lowered to floor without hitting his head. On 4/14/2025 at 9:25AM, R3 was sitting in a laid-back wheelchair in his room with his eyes closed. At 12:20PM on 4/14/2025. V6 CNA stated that while transferring R3 to his lying back wheelchair by mechanical lift, R3 grabbed the sling that hooked on the mechanical lift and detached it from the mechanical lift. V6 stated that when she noticed R3 was unhooked she lowered R3 to his reclining chair which was leaning forward and R3 slid out of the wheelchair. V6 stated that V6 transferred R3 by herself. V6 stated , I should have asked for help, but everyone was too busy. On 4/15/2025 at 1:30PM V5 CNA and V9 CNA transferred R3 from the reclining wheelchair into bed using a full mechanical lift. R3 had no behaviors and wasn't reaching for the straps to unlock the sling from the mechanical lift. V9 stated V9 switched out R3's chair on 4/2/2025 due to the wheelchair being broken and it was leaning forward in an upright position, and would not recline. On 4/15/2025 at 3:25PM V2 (Director of Nursing) stated that all CNA's are required to complete transfer training upon hiring. V2 also stated that two-person assist is required with all mechanical lifts when transferring. 40385 2.) R2's Admission Minimum Data Set, dated dated dated [DATE] documents R2 has severe cognitive impairment, requires staff assistance with activities of daily living, has physical/verbal/other behaviors noted one to three days during the review period, and these behaviors put others at risk for injury and significantly disrupts care or living environment. R2's active Care Plan documents R2 is at risk for falls due to impaired cognition, safety awareness, and balance. This care plan does not document a post fall intervention for R2's fall on 3/26/25. R2's Fall Report dated 2/17/25 at 9:00 PM documents R2 was found on the floor next to her bed. This fall is not documented in R2's medical record. R2's Fall Report dated 3/26/25 at 8:30 PM documents a Certified Nursing Assistant (CNA) attempted to transfer R2 into a wheelchair to transport to the restroom in the hallway, R2 refused care, R2 hit the CNA, R2 lost her balance and fell hitting her head on the handrail. R2 did not have any injuries.This fall is not documented in R2's medical record. The investigative file for this fall, provided by V2 Director of Nursing (DON) does not document which CNA was involved in R2's fall, or that this fall was investigated to determine a root cause and implement a post fall intervention. On 4/15/25 at 6:15 AM V12 Licensed Practical Nurse (LPN) stated staff had just toileted and assisted R2 to bed prior to R2's fall on 2/17/25. V12 stated V12 notified R2's family and physician. V12 confirmed V12 did not document this fall in R2's medical record. On 4/15/25 at 9:37 AM V24 LPN stated R2 was in the hallway with V4 CNA when R2 fell on [DATE]. V24 stated V24 did not witness the fall and described R2 as being at her baseline, cursing and combative with staff when attempting to redirect or provide cares. V24 stated R2 just gets more agitated so we try to reapproach R2 later. V24 stated staff had not mentioned if R2 was resistive or agitated prior to R2's fall. On 4/15/25 at 10:13 AM V4 confirmed V4 was the CNA assisting R2 during the fall on 3/26/25. V4 stated V4 was pulling R2 in a wheelchair backwards down the hallway, R2 grabbed the handrail and flipped out of the chair. V4 stated V4 pulled R2's wheelchair backwards due to R2 resisting and planting her feet, but R2 had to be changed because it was the end of shift. V4 was asked about any alternative approaches or interventions used during this incident. V4 stated R2 is always combative and resistant to toileting. V4 stated staff usually ask if R2 has to use the bathroom, but due to R2's dementia R2 has difficulty understanding words. V4 denied that any visual cues or aides have been trialed for R2. V4 stated R2 seems to do well for V25 CNA, but V4 did not ask for V25 to assist with R2's toileting cares that day. V4 confirmed no alternative approaches were used. On 4/15/25 at 6:33 AM V2 DON stated R2 fell on [DATE] and a post fall intervention had not been developed/implemented. At 6:58 AM V2 stated the initial fall note should be entered in the risk management as a progress note that transfers into the resident's chart. V2 verified there is no initial note documenting the details of R2's fall on 3/26/25. V2 stated V2 was unsure which CNA was assisting R2 during the fall on 3/26/25. At 10:40 AM V2 confirmed R2's fall on 2/17/25 was not documented in R2's medical record and confirmed R2's 3/26/25 fall was not investigated. V2 stated V7 Former DON was responsible for the fall investigations at that time.

Based on observation, interview, and record review, the facility failed to implement a plan of care to reduce resident intrusion of privacy and resulting in aggression. This failure has the potential to affect two residents (R1 and R2) out of three reviewed for allegations of abuse on the sample list of three. Findings include: On 3/25/25 at 11:05 AM, V1, Administrator, stated there had been an incident between R1 and R2 on 3/21/25 when R2 wandered into R1's room, R1 had gotten out of bed to redirect R2 out of his room, and both residents ended up falling to the floor with R2 landing on top of R1. R2's Nursing Progress Note dated 3/20/25 documents R2 had exited his bathroom in the wrong direction on this date, entering the adjoining room of R1 and upsetting R1. This same note documents an interdisciplinary team review of this incident and formulated a plan of care to place a sign in the bathroom to indicate to R2 which bathroom door to exit to go into his own room. On 3/25/25 at 2:30 PM, there was not any sign in the adjoining bathroom between R1's and R2's room to indicate to R2 which bathroom door to exit to return to his own room rather than R1's room. On 3/26/25 at 1:45 PM, V2, Director of Nursing, stated she had participated in the interdisciplinary team review and the team did decide to place a sign in the bathroom between R1's and R2's rooms to indicate which direction R2's room was from the bathroom. V2 stated the sign did not get placed and then this other incident happened between R1 and R2 when R2 wandered into R1's room during the night. V2 continued to state the facility did install a locking doorknob cover on the bathroom door leading to R1's room so that bathroom door could not be opened from inside the bathroom. V2 stated when R1 uses the bathroom he has to leave the door open so he can return to his own room when he is finished. On 3/25/25 at 1:50 PM, V6, [NAME] President of Clinical Operations, was instructing V2 to resolve off R2's care plan for the doorknob cover and implement placement of the sign according to the interdisciplinary team decision. V2 then stated there wasn't any reason the facility couldn't do both the sign and the doorknob.

Based on interview and record review, the facility failed to develop their abuse prevention policy to include a definition of abuse to include abuse facilitated or enabled by the use of technology. This failure has the potential to affect all seventy residents residing in the facility. Findings include: The facility's policy Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated August 2024, does not include a prohibition of abuse facilitated or enabled by the use of technology. On 3/26/25 at 12:59 PM, V1, Administrator, acknowledged and confirmed the abuse prevention policy dated August 2024 was the most recent revision and did not include the prohibition of abuse utilizing technology such as video recording of residents in compromising situations. On 3/26/25 at 4:15 PM, V6, [NAME] President of Clinical Operations, stated she could put the prohibition against the use of technology into the facility policy right now. The facility's Resident Roster dated 3/25/25 documents 70 residents residing in the facility.

Based on observation, interview, and record review the facility failed to sufficiently staff Certified Nursing Assistants (CNAs). This failure affects five of seven residents (R1, R2, R3, R5, R7) reviewed for staffing in the sample list of seven. This failure has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 between 2:44 PM and 3:03 PM V18, V28, V29, V30, and V31 were the only CNAs working in the facility. 1.) On 1/22/25 at 7:55 AM R3 stated the facility doesn't have enough staff as the staff are constantly running. R3 stated if the CNAs are on their lunch break, then you must wait about 30 minutes for someone to answer your call light. R3 stated R3 is incontinent, uses the call light to be changed, and must wait for staff assistance. R3's Minimum Data Set (MDS) dated [DATE] documents R3 as cognitively intact and requires substantial/maximal staff assistance for toileting. 2.) On 1/22/25 at 8:06 AM R2 stated the facility is short staffed and it takes about 20-30 minutes for staff to answer R2's call light. R2's MDS dated [DATE] documents R2 as cognitively intact and requires partial/moderate staff assistance for most Activities of Daily Living. 3.) On 1/22/25 at 8:17 AM R1 stated the facility does not have enough CNAs they cut down to having one CNA per hall and a float for days and evenings. R1 stated R1 has waited for over an hour for R1's call light to be answered when R1 needed incontinence care. R1 stated R1 must wait when the CNAs are on their lunch break as well. R1's MDS dated [DATE] documents R1 as cognitively intact and R1 is dependent on staff for toileting assistance. 4.) On 1/22/25 at 9:38 AM R7 stated the facility doesn't have enough CNAs they are always running in and out and in a hurry when providing cares. R7 stated R7 waits up to an hour for R7's call light to be answered on day shift when R7 is waiting for incontinence care. R7's MDS dated [DATE] documents R7 is dependent on staff for toileting assistance. 5.) On 1/22/25 at 11:46 AM R5 stated there aren't enough staff, when R5 asks the CNAs to do things they tell R5 that they don't have time. R5 stated sometimes R5 waits an hour for R5's call light to be answered, and R5 pointed to the clock in R5's room and stated there's a clock right there for me to see. R5 stated sometimes R5 must wait for incontinence cares. R5's MDS dated [DATE] documents R5 requires substantial/maximal staff assistance for toileting. The facility's Facility assessment dated [DATE] documents the facility's staffing needs are six CNAs on day shift, five CNAs on evening shift, and three CNAs on night shift. The facility's Weekly Schedule dated 1/5/25-1/25/25 documents the following: there were five CNAs for evening shift on 1/11/25, 1/14/25, 1/19/25 and 1/20/25 and there were five CNAs for day shift on 1/19/25. The facility's Daily Census dated 1/9/25 documents a census of 77 residents. The facility's Daily Census dated 1/21/25 documents a census of 71 residents. On 1/22/25 at 5:03 AM V3 (CNA) stated there have been times where night shift had three CNAs within the last few weeks, which is a lot for 70 residents. On 1/22/25 at 8:40 AM V14 (CNA) stated we are supposed to have six CNAs on dayshift, but there are times we have worked with less than that and it's hard. V14 stated call light response times are affected which could affect timely toileting requests. On 1/22/25 at 10:07 AM V17 (CNA) stated V17 feels rushed and short cuts, such as not applying lotion after showers and quick morning care, are taken when there are five CNAs working. V17 stated call light response times are affected when there are only five CNAs working. On 1/22/25 between 2:44 PM and 3:03 PM the following interviews were conducted: V28 (CNA) stated there should be six CNAs working tonight, but we have worked with four and five CNAs within the last few weeks. V28 stated that isn't enough, showers don't get done and call lights are affected. V28 stated we don't even get to take our breaks, but we do the best that we can. V29 (CNA) sated we usually work with six CNAs, but there has been five or less recently. V29 stated we do the best we can but call lights might not be answered as quickly. V30 (CNA) stated we usually work with five or six CNAs, which is not enough based on the acuity of the residents not just the census. V30 stated care falls behind, showers don't get done, toileting and incontinence cares are delayed, and call lights are affected. V30 stated there was one weekend when only four CNAs worked, and the same care was affected. V30 confirmed there were only five CNAs working second shift tonight. V30 stated V30 is the B and D Hall float and will try to float to the other halls as well, but most of her time will be spent on B Hall since that is the heaviest hall. V31 (CNA) stated second shift is supposed to have six CNAs but V31 just found out there are five working tonight. V31 stated we have worked with five and V31 feels rushed and not enough time to give the residents that they deserve. V31 stated showers don't get done and it is difficult to keep up with the call lights. V31 stated some residents are incontinent because they had to wait too long for assistance. V31 stated our charting doesn't get done and we don't get our breaks. V31 stated there are a lot of residents that require two assist and mechanical lift transfers. On 1/22/25 at 3:11 PM V2 (Director of Nursing/DON) stated the facility likes to staff six CNAs on day and evening shifts, but sometimes evenings has five. V2 stated the facility staffs four CNAs on night shift. V2 stated V25 (Scheduler) determines the staffing and does the schedules. V26 (Assistant DON) stated staffing is based on the census and the census was up to 76 within the last two weeks. V2 and V26 confirmed five CNAs were currently working the evening shift today. V26 provided a copy of residents' transfer status and stated the facility requires two persons to operate the mechanical lifts. This list documents 28 of the 71 residents require two person assist for transfers. On 1/22/25 at 3:26 PM V25 stated V25 uses a staffing ladder to determine the number of CNA hours to provide based on acuity needs, which is not resident acuity needs but more so the activities that are scheduled for the CNAs each shift such as dayshift is responsible for getting residents up verses night shift is just doing rounding and a list of residents assigned for get ups. V25 stated the CNA staffing based on census of 71 residents is 126 hours of CNA coverage which is 16 CNAs per day. V25 stated a census of 75 residents is 133 CNA hours and 17 CNAs per day. V25 confirmed this staffing calculator is based on resident census and does not factor in the acuity needs of the residents. V25 stated the 16-17 CNAs needed per day is scheduled as six on days, six on evenings, and four on nights. V25 stated V15 (Restorative CNA) is pulled to work the floor any time there is less than six CNAs Monday through Friday. V25 stated 77 residents was the highest census on 1/8/25. V25 verified the weekly CNA staffing reports provided were accurate. On 1/22/25 at 4:48 PM V1 (Administrator) confirmed the Facility Assessment has not been updated since August 2024 and V1 stated it needed to be updated.

Based on observation, interview, and record review the facility failed to sufficiently staff dietary support personnel resulting in delayed timeliness of meals for four of seven residents (R1, R2, R3, R4) reviewed for dietary services in the sample list of seven. This failure has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 between 6:50 AM and 12:20 PM V32 (Dietary Manager) worked as the dayshift cook during the breakfast and noon meals. V22 and V23 (Dietary Aides) were the only other kitchen staff working in the morning. All resident meals were served to resident rooms due to the facility experiencing gastrointestinal illnesses. On 1/22/25 at 10:55 AM V32 (Dietary Manager) was setting up the steam table to begin serving the noon meal. At 12:00 PM the A, B, and C Hall meal trays were delivered. At this time staff began delivering the D Hall trays to resident rooms, including R1 and R2. 1.) On 1/22/25 at 7:46 AM R4 stated there was a day about a week ago that breakfast wasn't served until 9:00 AM due to something happening in the kitchen. R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. 2.) On 1/22/25 at 7:55 Am R3 stated there was one day that breakfast wasn't served until 9:00 AM. R3's MDS dated [DATE] documents R3 as cognitively intact. 3.) On 1/22/25 at 8:06 AM R2 was eating breakfast in R2's room. R2 stated breakfast was served late today and R2's meal tray was delivered at 7:50 AM. R2 stated there was one day that the noon meal wasn't served until 12:00 PM. R2's MDS dated [DATE] documents R2 as cognitively intact. The facility's Mealtimes dated 4/29/24 documents room trays are served at 7:00 AM for breakfast, 11:00 AM for lunch, and 4:45 PM for supper. V24's (Cook) Timecard dated 12/22/24-1/8/25 documents V24 clocked in at 5:14 AM on 12/22/24, 5:16 AM on 12/24/24, 6:09 AM on 12/26/24, 5:20 AM on 1/5/25, 5:31 AM on 1/6/25, 5:29 AM on 1/7/25, and 5:25 AM on 1/8/25. The facility's dietary schedules dated 12/22/24-2/1/25 document the following: The morning cook hours are 5:00 AM to 1:30 PM and V24 was scheduled as the facility's morning cook for the dates listed above on V24's timecard. On 1/22/25 at 9:58 AM V12 (Licensed Practical Nurse) stated there was one day about two weeks ago that breakfast wasn't served until 9:00 AM due to an issue in the kitchen. V12 stated blood glucose was checked for diabetic residents and nutritional shakes were given prior to breakfast being served that day. On 1/22/25 at 10:07 AM V17 (Certified Nursing Assistant) stated there was one day that the cook didn't show up on time, so breakfast wasn't served until close to 9:00 AM. On 1/22/25 at 12:57 PM V20 (Cook) stated we had a cook, V24, who would always show up late for work or sit in his car for an hour at a time, so breakfast and lunch were served 30 minutes and up to an hour late, which happened two or three times. V20 stated one time lunch was not served until 1:30PM-2:00PM due to breakfast being served late at 9:00 AM. V20 stated the dietary department has been short staffed recently and V20 is the only dayshift cook and only works part time. On 1/22/25 at 12:20 PM V32 (Dietary Manager) stated V24 (Cook) was hit and miss with reporting to work on time and V24 recently quit on 1/8/25. At 1:15 PM V32 stated 45 minutes past the scheduled mealtime is not considered timely. V32 stated today the D Hall meal trays did not leave the kitchen until 11:45 AM because staff kept coming back to ask for things. At 2:11 AM V32 stated V24's shift was 5:00 AM to 1:30 PM and verified V24's late clock ins on V24's timecard. At 4:56 AM V32 stated V32 works Monday-Friday from 8:30 AM until 4:30 PM, but V32 worked as the dayshift cook on 1/9/25, 1/10/25, 1/13-1/19/25. V32 stated V32 worked as the dishwasher on 1/6/26 and 1/7/25 since there was no one else scheduled. V32 stated V32 was off work from 12/25/24-12/28/24, 1/1/25, 1/3/25, 1/5/25 and 1/8/25. The facility's Daily Census dated 1/21/25 documents 71 residents reside in the facility.

Based on interview and record review the facility failed to maintain food ordering and supply to ensure the menus are followed and to log substitutes. This failure affects three of seven residents (R1, R2, R5) reviewed for dietary services in the sample list of seven and has the potential to affect all 71 residents in the facility. Findings include: On 1/22/25 at 8:06 AM R2 stated the facility runs out of food and doesn't always have substitutes available. On 1/22/25 at 8:17 AM R1 stated the facility has run out of milk, orange juice, and dinner rolls. On 1/22/25 at 11:46 Am R5 stated the facility has run out of certain foods and R5 is not always served yogurt with her meal. The facility's Week at A Glance Menu Week 2 documents cheeseburger on a bun as the main entree for the evening meal on Sunday (1/5/25) and sweet and sour pork as the main entree on Thursday (1/9/25) as sweet and sour pork. The facility's food order invoices dated 12/2/24, 12/23/24 and 12/30/24 document three boxes of 40 beef patties were ordered for each invoice. The facility's food order invoice dated 1/20/25 documents four boxes of 40 beef patties were ordered. There is no documentation that beef patties were ordered after 12/30/24 until 1/20/25. On 1/22/25 at 12:34 PM V21 (Cook) stated we run out of hamburgers, and we were without hamburgers for a month prior to this weeks' food order delivery. V21 stated we run out of meat because only half of the amount needed is ordered and therefore smaller portions are served rather than the correct serving size. On 1/22/25 at 12:57 PM V20 (Cook) stated the facility runs out of food a lot and often doesn't have the food listed on the menu to serve. V20 stated the facility has been without hamburger patties for a month, occasionally runs out of chicken breasts, and smaller portions/ounces of food and meat have been served due to not having enough supply to meet the serving requirement. V20 stated V20 must improvise and come up with something else to serve. V20 stated sometimes the kitchen staff doesn't have the food prepped or set out for thawing prior for the following morning. V20 stated V20 must get the food out to thaw first thing in the morning in hopes that it will be thawed to cook for the noon meal or V20 must find something else to serve. V20 stated for example V20 has had to serve fish sticks instead of fish and recently sweet and sour pork was served in smaller portions due to not having enough. V20 stated V20 asks V32 what foods to use in place of the foods that aren't available. V20 was unsure if the substitutions are logged anywhere and thought this was done by V32 (Dietary Manager). On 1/22/25 at 10:55 AM V32 stated the main entree was bratwurst burger patties with sauteed peppers and onions, and fajita chicken or hamburger on a bun were the main entree substitutes that were available for the noon meal. On 1/22/25 at 12:20 PM V32 and V20 (Cook) stated hamburgers is something that is offered as an always available substitute. At 1:15 PM V32 removed a binder from her door that contained a substitution log. The Menu Substitution Form indicates to log scheduled food item, substitution item, the reason for the substitution and the employee and dietitian's signature. This last recorded entry prior to 1/22/25 was 9/4/24, and this was confirmed with V32. V32 stated the staff should be logging substitutions on the log so that the dietitian can sign off and approve the changes. V32 stated chicken was used a substitute for the sweet and sour pork to have enough servings. V32 stated V32 uses the recipes as a guide to determine the quantity of food to be ordered and always rounds up. V32 stated hamburger patties were not ordered this month due to not being in the budget. V32 stated food orders are placed every Friday and delivered on Tuesdays. On 1/22/25 at 1:34 PM V27 (Registered Dietitian) stated V27 is in the facility one day per week and substitutions should be logged for V27 to review and approve. V27 stated V27 would have concerns if the staff weren't providing substitutes of equal amounts of an equivalent food to prevent weight loss. V27 stated V27 was not aware that the facility had been running out of foods or that smaller portions were being served. The facility's Daily Census dated 1/21/25 documents 71 residents reside in the facility. The facility's undated [NAME] and Kitchen Staff Orientation documents to use this guide to train the cooks, the menus/recipes must be followed, and any changes must be signed off by the dietitian and kept.

Based on observation, interview, and record review the facility failed to sufficiently staff housekeepers to maintain a clean and homelike environment for five of seven residents (R1, R2, R5, R6, R7) reviewed for housekeeping in the sample list of seven. Findings include: On 1/22/25 at 5:15 AM there was a white dusty substance on the floor outside of the B Hall Shower Room door. From 6:17 AM to 6:35 AM V8 (Housekeeper) cleaned the front entrance of the facility. V8 did not sweep prior to mopping the floor. At 6:41 AM V8 emptied the garbage cans at the nurses' station and mopped the floor. V8 did not sweep the floor prior to mopping. At 8:30 AM V8 cleaned and mopped resident rooms and bathrooms at the beginning of the C Hall. V8 used a broom to sweep up a pile of debris after V8 had finished mopping. V8 did not take a toilet brush into the bathroom to clean the toilet. At 8:43 AM V8 stated if there is only one housekeeper scheduled V8 only has time to clean V8's assigned two halls and then rotates and cleans the other remaining two halls the next day. V8 stated there has been days when only one housekeeper was scheduled, especially on the weekends. V8 stated V8 only uses a toilet brush to clean the inside of the toilets when they are visibly dirty and not every day. V8 stated V8 does not sweep prior to mopping to save time. On 1/22/25 between 9:08 AM and 9:19 AM V10 (Housekeeper) and V9 (Housekeeper orientee) were cleaning rooms at the end of A Hall. V9 and V10 did not sweep the entire room floor prior to mopping. At 9:28 AM V10 stated resident rooms, bathrooms, and toilets are supposed to be cleaned daily. V10 stated there should be two housekeepers divided up between the four halls, but on the weekends, there has only been one which makes it difficult so only two of the four halls are cleaned, and the other halls are cleaned the next day. V10 stated V10 only sweeps the floors prior to mopping if they are bad. 1.) On 1/22/25 at 8:06 AM R2 stated the housekeepers don't come into clean R2's room every day, it's usually every other day. R2 stated not all the housekeepers sweep prior to mopping or clean the toilets. On 8:17 AM R1, R2's roommate, stated housekeeping doesn't do a thorough job of sweeping and cleaning R1's room. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. R1's MDS dated [DATE] documents R1 as cognitively intact. R1's Concern/Compliment Form dated 1/15/25 documents R1 had concerns with housekeeping not cleaning the bathroom, not emptying the trashcan, and not thoroughly mopping and cleaning R1's room. 2.) On 1/22/25 at 9:38 AM R7 stated housekeeping does not clean R7's room daily and they only sweep/mop as one. R7 stated R7's room has not been cleaned today. There was a dried brown substance on R7's toilet. At 12:10PM there was debris on R7's room floor and R7's toilet remained dirty. R7 stated no housekeeping staff had been in to clean R7's room today. R7 stated the housekeepers should sweep prior to mopping, but they don't. R7 stated R7 records on a calendar when R7's room is cleaned. This calendar did not document R7's room was cleaned on 1/2/25-1/7/25, 1/9/25, 1/10/25, 1/12/25, 1/14/25, 1/15/25, 1/18/25, 1/19/25-1/22/25. R7's MDS is dated 12/12/24. R7's Concern/Compliment Form dated 12/17/24 documents R7's room was not being swept or mopped and the bathroom wasn't being cleaned. R7's Concern/Compliment Form dated 1/7/25 documents R7 had concerns that R7's room was not cleaned appropriately and there was debris on the floor. On 1/22/25 at 12:18 PM V10 stated they had not been down to clean B Hall (where R5 and R7 reside) yet today and was unsure if V10 would have time to clean that hall prior 2:00 PM when V10's shift ends. 3.) On 1/22/25 at 11:46 AM R5's toilet seat had a brown dried substance and there was a dark area on the inside bottom of the toilet bowl. 4.) On 1/22/25 at 7:46 AM the inside of R6's toilet bowl had rust colored stains. On 1/22/25 at 10:07 AM V17 (Certified Nursing Assistant) stated the housekeepers haven't been sweeping the floors prior to mopping and the toilets don't get cleaned every day unless you tell them there's a problem. On 1/22/25 at 10:37 AM V19 (Housekeeping/Maintenance Supervisor) stated daily cleaning schedule includes resident rooms, bathrooms, shower rooms, and dining rooms. V19 stated the housekeepers should be sweeping the floors prior to mopping and bathrooms should be cleaned daily from top to bottom, including the toilets. V19 confirmed there have been problems with this not getting done. V19 stated we had been short staffed in housekeeping and just recently hired V9 who started on 1/20/25. V19 stated every couple of days we only had one housekeeper scheduled so not all the resident rooms were getting cleaned daily and we had to alternate between the halls. V19 stated we are supposed to have two housekeepers scheduled each day. The facility's housekeeping schedule dated 1/5/25-2/1/25 document only one housekeeper was scheduled on 11 days between 1/5/25 and 1/19/25. The facility's undated Cleaning Process documents to disinfect or clean housekeeping surfaces such as floors on a regular basis and when visibly soiled and toilets should be cleaned at least daily. The facility's undated Detailed Cleaning Check Off List documents to clean/vacuum under all the beds and dressers and sanitize and disinfect the commodes thoroughly.

Based on interview and record review the facility failed to ensure a resident's opioid pain medication was administered as prescribed to avoid a potential lethal dosage for one of three residents (R1) reviewed for significant medication errors in the sample list of three. This failure resulted in R1 receiving a dose of Narcan (opioid reversal medication) and being transported by ambulance to the emergency room for evaluation. Findings include: The facility's Medication Administration Policy with a Revised date of [DATE] documents, Medications must be administered in accordance with a physician's order, e.g. (example), the right resident, right medication, right dosage, right route and right time. Do not administer a medication if you note a change in its color, consistency, and/or odor. If a medication and/or treatment error occurs, the licensed nurse will: a. Immediately notify the attending physician, b. Describe the error and the resident's response in the Nurse's notes, c. Complete an Incident Report, d. Identify the error on the 24-Hour Report, and e. Monitor the resident's status. The facility's Medication Errors and Adverse Drug Reaction policy with a Revised date of [DATE] documents, 1. All medication, treatment errors, and drug reactions must be reported promptly. 2. The charge nurse will be responsible for generating the Medication Error report, describing the action taken. 3. A detailed account of the incident must be recorded in the resident's medical record. Documentation should be factual. R1's Medication Administration Record dated [DATE] through [DATE] documents diagnoses including Chronic Obstructive Pulmonary Disease, Dyspnea, Anxiety Disorder, Anorexia, Delirium due to known Physiological Condition, Dysphagia Oropharyngeal Phase and Dependence on Supplemental Oxygen. R1's 60-day Physician Recertification of Terminal Illness report dated [DATE] documents R1 had terminal diagnoses of Chronic Obstructive Pulmonary Disease and Chronic Respiratory Failure. This report documents R1 had worsening Dyspnea and progressing decline. This report documents R1 was certified for another six months of hospice care valid until [DATE]. The facility's Medication Error Report dated [DATE] and completed by V4 (Licensed Practical Nurse/LPN) documents on [DATE] at 4:45 AM, R1 was given 4 ml (milliliters) of Hydromorphone (Narcotic pain medication) 10 mg (milligrams)/ml instead of the 0.4 ml Hydromorphone that was ordered. As a result, R1 received 40 mg of Hydromorphone instead of 4 mg as prescribed. R1's Medication Administration Record (MAR) dated [DATE] through [DATE] documents an order for Hydromorphone HCL (Hydrochloride) oral tablet 2 mg. Give 8 mg by mouth every 8 hours for pain/Dyspnea (shortness of breath) with a start date of [DATE] scheduled to be given at 12:00 AM, 8:00 AM and 4:00 PM. This MAR also documents an order for Hydromorphone HCL oral liquid 1 mg/ml, give 4 ml by mouth every four hours as needed for pain with a start date of [DATE]. R1's medical record contained a Physician's Order Form written by V12 (Hospice Registered Nurse/RN) dated [DATE] for Hydromorphone 10 mg/ml, 4 mg (0.4 ml) every four hours as needed for pain/Dyspnea. On [DATE] at 9:05 AM, V2 (Director of Nursing) confirmed there was a medication error on [DATE] for R1. V2 stated that R1 had been declining and had been receiving a large amount of Hydromorphone daily between the scheduled amount and the as needed amount. V2 stated that hospice increased the concentration of the Hydromorphone and that the night nurse was not aware that it had increased. V2 stated that they wanted to finish the previous bottle before starting the new bottle with new dose. V2 confirmed that the nurse did not look at the bottle and gave 4 mls of the 10 mg/ml Hydromorphone. V2 stated that she completed an investigation due to the medication error. V2 stated that R1 was in the hospital several days and was going to come back when he declined and passed away in the hospital. V2 stated that she completed several in-services with all of the nurses regarding the medication error and V4 received a one-day suspension. On [DATE] at 12:14 PM, V4 (LPN) stated that on [DATE] R1 had asked for a dose of his pain medication around 4:,d+[DATE]:45 AM. V4 stated that she had already given him the last dose from a bottle of Hydromorphone 1 mg/ml earlier that evening. V4 stated that she gave him 4 mls at that time and opened the new bottle this time and pulled the order up on the Electronic Medication Administration Record and it said to give 4 ml, so she automatically drew up 4 ml out of the new bottle of Hydromorphone and gave it to R1. V4 stated that when she administered it to R1 she noticed the color and mentioned that it was pink to R1 and V4 stated that R1 said that there was a change in the medication. V4 stated that V4 immediately went to look up the medication order and checked the medication bottle. V4 stated that the strength was not updated in the Electronic Medication Administration Record, but the bottle was 10 mg/ml. V4 stated she immediately notified hospice and the Physician (V5). V4 stated that hospice wanted her to monitor him. V4 stated that they started monitoring his vital signs. V4 stated that when she contacted V5 that he wanted her to give a dose of Narcan now and another in 30 minutes if needed and continue to monitor. V4 stated that V5 then decided he wanted R1 sent to the hospital to be evaluated. V4 stated that she gave R1 the Narcan and the ambulance was there before the next dose was due to be given. V4 stated that R1 remained conscious the entire time. V4 stated when the ambulance arrived R1's speech became slightly slurred but otherwise he was the same as he had been. V4 stated that she notified the Director of Nursing (V2) and then completed the Medication Error Report as directed. R1's Narcotic count sheet for the Hydromorphone 1 mg/ml is dated received on [DATE] and documents 120 mls received. The last dose documented as given was on [DATE] at 7:45 PM by V4 in the amount of 4 ml with zero doses left in the bottle. R1's Narcotic count sheet for the Hydromorphone 10 mg/ml is dated received on [DATE] and documents 30 mls was received. There is note written, New dose - give 0.4 mg (sic) to = (equal) 4 mg. The first and only dose given from this bottle is dated [DATE] at 4:45 AM with the amount given documented as 4 mls and 26 mls remaining in the bottle. This was signed by V4 (LPN). This resulted in R1 receiving 40 mg of Hydromorphone instead of 4 mg. On [DATE] at 10:22 AM, V13 (Hospice Director of Nursing) confirmed there was a change in the concentration of the Hydromorphone so that he did not have to take as much medication at one time. V13 stated that the hospice nurse wrote a new order for the Hydromorphone 10 mg/ml give 0.4 ml on [DATE] and stated that V12 (Hospice RN) gave the new order to the facility but did not document whom she gave the order to. V13 stated that R1 was alert and oriented at the hospital after the incident and the hospital had been working on getting him discharged back to the facility but then he declined. V13 confirmed that R1 was terminally ill, and death was an expected outcome. On [DATE] at 12:37 PM, V5 (On call Physician) on [DATE], stated that the facility nurse (V4) called hospice first and then called him. V5 stated he instructed the nurse to give R1 Narcan and to monitor his vital signs. V5 stated that he then decided they should send R1 to the emergency room for evaluation since it was such a high dose of Hydromorphone. V5 stated that R1 was stable when he spoke to the nurse the first time. V5 stated when he called the nurse back, he only told her to send R1 to the hospital, he did not get R1's condition report at that time. V5 stated that he did not have any immediate concerns with R1's condition but stated that could change rapidly. V5 stated that he could not say if the overdose of Hydromorphone contributed to R1's death. V5 stated that it was several days after the overdose before he passed away so he could not say that was the cause. On [DATE] at 2:03 PM, V10 (Hospice Pharmacist) stated that the concentration change was probably due to a condition change in the resident and with the increased concentration he would have to take less medication. V10 stated that he was probably closer to the end of life. V10 stated that as far as she could tell there was not alert placed on the bottle indicating the concentration change. V10 stated that it is up to the person preparing the medication and it is at their discretion to place an alert on the bottle. V10 stated that Hydromorphone has a fast half-life so if R1 would have died from the overdose it would have had to happen a lot sooner than it did. V10 stated that an overdose death is soon after the overdose. R1's hospital progress note dated [DATE] documents diagnosis of Acute on Chronic Hypoxic Hypercapnic Respiratory Failure Secondary to Severe Chronic Obstructive Pulmonary Disease (COPD) Exacerbation and documented R1 was currently on hospice. The hospital referral information documented possible discharge on [DATE]. R1's Death Certificate dated [DATE] documents the cause of death was Acute Hypoxic Respiratory Failure, COPD Exacerbation and Pneumonia.

Based on interview and record review, the facility failed to maintain and monitor adaptive devices to ensure proper functioning to prevent a fall for one of one resident (R53) reviewed for falls on the sample of 36. This failure resulted in R53's unsecured toilet seat riser sliding off the toilet when R53 was sitting and/or transferring onto the toilet, causing R53 to fall. R53 sustained a fractured finger and laceration requiring three sutures. Findings Include: R53's Fall Risk assessment dated [DATE] documents R53 is at risk for falls. R53's MDS (Minimum Data Set) dated 3/1/24 documents R53 has severe cognitive impairments. R53's Progress Notes document the following: 2/18/24 - CNA (Certified Nursing Assistant) heard R53 yelling. When CNA entered the room, R53 was sitting on the bathroom floor with dislodged toilet riser wedged between R53's torso and the toilet. R53 was bleeding from a laceration on the 5th finger. A hematoma was also noted on R53's left side of the forehead. R53 sent to the hospital. 2/18/24 - Hospital RN (Registered Nurse) called with report and states R53's pinky finger did show a fracture and the laceration required three sutures and glue for closure. 2/18/24 - returned to the facility with a splint to the left 5th finger and sutures. 2/22/24 - Laceration to the distal left 5th finger measuring 2.0 cm (centimeters) by 0.2 cm by 0.1 cm. Sutures intact. R53's Fall Investigation included a Falls Statement and Checklist dated 2/18/26 at by V12 (CNA) that documents it appears (R53) attempted to sit down and riser fell along with (R53). R53's Hospital ED (Emergency Department) Provider Note dated 2/18/24 documents R53 presented to the ED for evaluation after a fall. R53 is alert and oriented x 1 and does not follow commands. R53 has a partial avulsion to the skin and fat distal tuft of the left 5th finger {laceration} with exposure of muscle. Final Diagnoses: fall, initial encounter & open fracture of tuft of distal phalanx of finger. R53's X-ray dated 2/18/24 documents a displaced distal tuft fracture of the 5th digit with displacement measuring 2 mm (millimeters). On 5/21/24 at 9:07 AM, V2 (Director of Nursing) stated R53 self-transferred to the toilet which had a riser on it. The riser must not have been secured because R53 and riser both ended up on the floor. The riser was one that generally screwed onto the toilet. Our intervention was to remove those types of risers because that is how R53 got so banged up, due to being pinned between toilet and wall, and was trapped from the riser. On 5/21/24 at 9:24 AM, V11 (Maintenance Director) stated V11 never did checks on the facilities toilet seat risers to ensure they were secure. V11 explained R53's toilet seat riser was one with a front screw to secure it to the toilet itself and I (V11) just don't think it was screwed in all the way which allowed it to move and caused R53 to fall. The facility's Fall Prevention Program dated May 2022 documents 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. Malfunctioning equipment will be immediately reported to maintenance for repair or removed from service.

Based on observation, interview, and record review the facility failed to maintain a mobility device within a resident's reach. This failure resulted R1 sustaining a fall, requiring hospitalization due to a Subdural Hemorrhage. The facility also failed to ensure a call light was within reach for R3, who has a history of falls. These failures affect two of three residents (R1 and R3) reviewed for falls on the sample list of three. Findings include: 1.) R1's Admission Diagnosis List dated 11/14/23 documents the following: Alzheimer's Disease with Late Onset, Unspecified Focal Traumatic Brain Injury With Loss of Consciousness of 30 minutes or less, Initial Encounter. R1's Admission Diagnosis List had a diagnosis added post-fall 12/03/23 as follows: Traumatic Subdural Hemorrhage Without Loss of Consciousness, Initial Encounter. R1's Minimum Data Set (MDS) dated [DATE] documents R1's admitted as 11/14/23. R1's MDS also documents R1's Brief Interview of Mental Status score as five out of a possible 15, indicating severe cognitive impairment. R1's Baseline (Admission) Care Plan documents R1 has a history of falls and that R1 requires partial/moderate assistance transitioning from a lying to sitting position and a sitting to standing position. R1's Nursing Note dated 12/3/2023 at 3:49 pm documents: V5 (Registered Nurse) called this nurse V6 (Licensed Practical Nurse) to resident's (R1) room at approximately 15:18 (3:18 pm) and reported that resident (R1) had a fall. Resident was found sitting upright and leaning against her bed, being attended to by CNA (V8 Certified Nursing Assistant). CNA (V8) reported that she was just in her (R1's) room about 10 minutes ago. Resident stood up and walked without her walker and fell on the floor. She acquired a laceration/hematoma to her left forehead. She remained alert and oriented x (times) 1-2 (knows who she is, and where she is) per baseline. Area (left forehead) was cleansed, applied with (sic) an ice pack, covered with protective dressing, and vital signs taken. POA, (V14 Power of Attorney) and NP (unidentified Nurse Practitioner) notified and received order to send to ER (emergency room ) for evaluation and treatment. Family requested to send her to (distant hospital-emergency room ) and they will meet her (R1) there. Order to send out, POLST (Physician Order for Life-Sustaining Treatment), Face sheet, Order Summary, Bed hold order, and E-transfers sent with her. CNA (unidentified) removed her (R1's) hearing aids for safekeeping. Incident occurred at 1515 (3:15 PM); ambulance left at 1545 (3:45 PM). Phone update reported to (Emergency Department) nurse. VS (vital signs): BP (blood pressure) 96/64, T (temperature) 97.0, R (respirations) 16, P (pulse) 65, SpO2 (blood oxygen level) 98% (percent) RA (room air). R1's Hospital report note dated 12/03/23 at 6:51 pm documents the following: Chief Complaint, Patient presents with Fall, Large hematoma to head HPI (history of present Illness), (advanced age and gender identified) past medical history of dementia presents emergency department from (company name) nursing facility for a fall that occurred apparently while patient was on the way to the bathroom. She fell face first and hit her head on the ground. They (unidentified) had stated that they (unidentified facility staff) did not think she lost consciousness. Upon arrival she is without her hearing aids and is very hard of hearing however does answer questions but given her history of dementia does not provide history. Family (unidentified) is at the bedside and states that she (R1) seems slightly tired and not as conversive as normal however, they (unidentified family) say it is difficult to have normal conversation with her (R1), given she is without her hearing aids at this time. Patient (R1) follows commands, moves all extremities and does complain of headache at this time. The same above report note documents: CT (Computed tomography) cervical spine without contrast. Head - Large left frontal scalp hematoma. No calvarial fracture. There is a small, slightly heterogeneous hyperdense, extra-axial collection lateral to the left cerebral hemisphere, primarily adjacent to the left temporal lobe, measuring up to 5 (five) mm (millimeters) in thickness, compatible with an acute Subdural hematoma. No significant midline shift. Moderate chronic small vessel ischemic changes in the white matter. Small chronic left cerebellar infarcts. Moderate to severe global volume loss. lntracranial vascular calcifications. There may be partial mastoid effusions. Cervical spine no acute fracture or dislocation. Diffuse osteopenia. Marked degenerative changes are seen, most severe at C5-C6, similar to prior. Mild multilevel spondylolisthesis is similar to prior exam. Prevertebral soft tissues are grossly unremarkable. The same note documents: ED Course and MDM (Medical Decision Making) Basic blood work was ordered as well as X-ray of chest and pelvis. CT noncontrast of head and neck were obtained. Discussed patient with neurosurgery I spoke to the (V15, Physician Assistant) who discussed patient with (V16, Physician Neurology Department). Blood pressure did become elevated 190/92 (measured) so Hydralazine 10 mg was given, patient will need systolic blood pressure goal less than 140 given Subdural hematoma. Chest X-Ray without acute disease. X-ray of pelvis and left hip without acute fracture dislocation of prosthesis. Discussed with hospitalist, they were agreeable to observation for Subdural hematoma (collections of blood leakage in the brain post- trauma). The same Hospital report documents Emergency Department to Hospital Admission on 12/3/2023. Repeat CT (Computed tomography) noncontrast of head was ordered for 4:00 am in the morning giving evidence of Subdural on her CT upon arrival. R1's facility Nursing Note dated 12/4/2023 at 09:16 am documents the following: Note Text: IDT (Interdisciplinary Team) reviewed: root cause found to be resident (R1) ambulating without walker. Resident also has severe Alzheimer's disease. Resident currently at (distant hospital) for observation. R1's Nursing Note dated 12/6/2023 at 11:07 am signed by V2 (Director of Nursing) documents: Note Text: IDT team reviewed root cause to be ambulation without walker. Resident gets frustrated when walker and wheelchair are not close to her proximity. Will ensure that resident has wheelchair close to bed when she is in her room. R1's Nursing Note dated 12/8/2023 at 12:21 pm, signed by V2 (Director of Nursing) documents: Care Plan Note, Note Text: Keep walker and wheelchair in locked position, near bedside. Bed rail for mobility to prevent falls. R1's fall Follow Up/Final Report Summary dated 12/08/23 documents R1 stated She (R1) walked without her walker. On 12/22/23 at 11:37 am V6 (Licensed Practical Nurse/LPN) stated I (V6) was passing medication on the C-hall. I was called by (V5 Registered Nurse) the other nurse. V6 stated When I got to (R1's) room, (R1) was leaning up against the bed, and (V8 CNA) was cleaning up blood. There was a lot of blood. I assessed (R1), she never lost consciousness. I got ice and had (V8) assist (R1), to hold it (ice pack) on her forehead. I went to get the treatment cart to do first aide. It had only been about 10 minutes since I had seen (R1). She was seated in her chair. The CNA (V8) who saw her on the floor thought (R1) got up without her walker to go to the bathroom. (V8) said (R1's) walker and wheelchair were across the room. I was focused on providing (R1's) care. I just took her word for it. I called the physician and family. Family wanted her to go out to the hospital. On 12/22/23 at 12:17 pm R1 was seated on the side of her bed. R1 had a one-inch scab on her left forehead. R1 also had one large bruise that extended over her left forehead, left side of her face, left side of her nose, left cheek and left neck. R1's bruise was reddish-purple, with fading yellow- green edges. R1 had no recall of falling. On 12/26/23 at 9:40 am V2 (Director of Nursing) stated (R1's) fall on 12/03/23 was deemed to be caused by (R1) getting up on her own without using her walker or her wheelchair for mobility. (R1's) walker or locked wheelchair should have been at (R1's) bedside within reach. On 12/22/23 at 2:45 pm V11 (Physician) stated he is not R1's Physician, V10 (R1's Physician) is out of town. V11 stated V11 can only speak in general. V11 stated the seriousness of a Subdural hematoma varies. The elderly person's vessel weakens over time. A fall that causes a Subdural hemorrhage can be minor or very serious. The fact (R1) was kept overnight in the hospital for observation certainly indicates there was a concern that required observation of the Subdural hemorrhage and likely repeat a CT. 2). R3's Diagnoses List, with multiple dates, includes the following diagnoses: Essential Hypertension, Pain, Unspecified, Other Symptoms and Signs Involving The Musculoskeletal System, Muscle Weakness Generalized, Myalgia, Unspecified Site, Dementia, Unspecified Severity, Anxiety, Alzheimer's Disease, Unspecified, History of Falling, and Repeated Falls. R3's Minimum Data Set (MDS) dated [DATE] documents R3 has a history of falls and R3 has had one fall since the last assessment with no injury. R3's Care Plan dated 8/16/23 documents the following: The resident (R3) is at risk for falls r/t (related to) Confusion, Deconditioning, Gait/balance problems, History of falls, (and) Incontinence. The same Care Plan documents: Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. R3's Fall Report dated 8/14/23 documents the following witness statement, written by V18 (Registered Nurse): One CNA (unidentified) was in the assisted dining and was feeding another resident (unidentified) at the time. Resident (R3) stood up on her own and fell . V18's witness statement also documents (R3) was restless as is her norm. On 12/22/23 at 9:08 am, R3 was in her room, seated in a reclined, geriatric wheeled chair that was approximately four feet away from R3's bed. R3 was reaching with her left hand, over the side of the left side of the chair and towards her call light cord. R3's call light cord was attached to the bed linen on the bed. R3's right buttock was off the seat of her reclined chair, as R3 shifted R3's weight to a left side lying position. As R3 leaned, surveyor entered the room and asked if I could get a staff member to help R3. R3 stopped leaning and sat back down in her geriatric wheeled chair. R3 shook her head yes confirming R3 would like surveyor to alert staff that R3 had a need for assistance. R3 pointed to her call light, four feet away from her geriatric recliner chair, and stated That is what I want. On 12/22/23 at 9:10 am V4 (Licensed Practical Nurse) confirmed R3's call light was out of R3's reach. V4 stated R3 has a history of falls, and her call light should be in her chair, so she does not have to reach for it. The facility Fall Prevention Policy dated as retrieved 12/2023 documents the following: 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. Quality Assurance Programs will monitor the program to assure ongoing effectiveness. The same policy included the following: Fall/safety interventions may include but are not limited to: Direct care staff will be oriented and trained in the Fall Prevention Program. At the time of admission and in accordance with the plan of care the resident will be oriented to use the nurse call device. The nurse call device will be placed within the resident's reach at all times. The location of the placement will be verbalized for those residents with visual deficits. The resident's personal possessions will be maintained within reach when possible. These items include tissues, water, drinking glass and phone. Assistive devices such as walkers and canes will be placed within reach of those residents who have physician's orders to ambulate independently.

Based on observation, interview, and record review, the facility failed to ensure a resident was properly secured during a vehicle transport while sitting in a wheelchair, failed to ensure a resident had a properly fitting wheelchair for safe positioning, failed to assess a resident with potential for injury after sliding off the wheelchair prior to moving them, and failed to immediately report the accident to facility administration for one of three residents (R14) reviewed for accident hazards on the sample list of 26. This failure resulted in R14 sliding forward, halfway falling out of the wheelchair and hitting R14's leg on the elevated van stoop/ledge and back of the driver's seat, resulting in a right sided fractured patella and femur, a suspected lateral clavicular fracture, and a suggested comminuted proximal fracture of the fibula. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/15/23 at 2:10 pm when R14 slid out of R14's wheelchair during transportation in the van due to not being properly secured with safety belts. V1 (Administrator) was notified of the Immediate Jeopardy situation on 4/6/23 at 2:25 pm. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 4/10/23, but noncompliance remains at Level 2 while the facility continues to educate all staff on the facility's Transportation for Resident Policy and Securement Process, obtain a return demonstration and knowledge quiz from all staff regarding the Transportation for Resident Policy and Securement Process, and complete audits to ensure a safety belt and the facility procedure for transportation accidents is followed. Findings Include: On 4/02/23 at 8:11 AM, R14 was lying in bed with a full leg cast on the right leg, and a wheelchair in the corner of R14's room with two four-inch cushions and one one-inch cushion on the wheelchair seat with a sign on the back of the wheelchair that read, Do not use this wheelchair or cushions. R14 stated R14 broke R14's kneecap and leg after having an accident in the facility van. R14 stated a vehicle in front of the facility van was backing up in front of them so V7 (Maintenance/Transportation) had to hit the brakes and swerve to avoid hitting the vehicle but in the process of that, R14 was thrown forward. R14 stated R14 never fully left/fell out of R14's wheelchair because R14 was secured in the wheelchair with the belt around R14's waist, but the force pushed R14 forward in the chair. R14 stated V7 and V5 (Certified Nursing Assistant/CNA), who was also in the van, immediately unlocked R14's breaks to scoot R14 back into the wheelchair. R14 stated that after arriving back to the facility, R14 was sent to the hospital and ended up being there a few days due to R14 having the fractures. The facility Report to IDPH (Illinois Department of Public Health) dated 3/22/23 documents an accident occurred on 3/15/23 at 2:10 pm where R14 was in a motor vehicle accident and slid forward in the wheelchair and sustained a questionable right leg injury. R14 was transported to the hospital for evaluation and treatment. While hospitalized , R14 was diagnosed with an acute traumatic mildly displaced distal right femoral metaphysis fracture, distracted avulsion fracture inferior right patella, and a suspected lateral right clavicular fracture. Based on the comprehensive investigation, the facility determined on 3/15/23, R14 was transported in the facility van from a medical appointment back to the facility when the van driver was forced to brake suddenly to avoid an accident. R14 complained of pain to the right leg when R14 returned to the facility. The facility's investigation into R14's 3/15/23 accident contained witness statements from V5 (CNA) and V7 (Maintenance/Transportation), both who were present and in the van with R14 at the time of the accident. V5's witness statement documents at approximately 2:10 pm V5, V7 and R14 were driving southbound when a black pickup truck pulled out in front of them and V7, the van driver, braked extremely hard and swerved left to avoid hitting the truck while V5 put V5's left hand back to try to pretty much hold R14 back. The statement documents V5 was able to touch R14's knees but was unable to hold R14 completely back {in R14's wheelchair}and R14 slid onto the floor of the van resting on R14's right side with R14's knees bent. The statement documents V5 and V7 pulled over right away, opened both doors, sat R14 up and assisted R14 back into the wheelchair and at that time, V5 looked R14 over and noticed R14 had a small abrasion and bruise on R14's right shin and R14 complained of pain to both knees, the right hip, and shoulders. The statement documents V5 and V7 came to facility and V5 notified V2 (Director of Nursing/DON) of the incident who then completed an assessment of R14 and sent R14 to the hospital. V7's witness statement documents at approximately 2:10 pm, V7 was headed southbound {in the van} when a black pickup truck pulled left into V7's lane and immediately stopped causing V7 to have to brake hard to avoid a collision, stopping approximately 2-3 inches from the pickup's bumper. The statement documents R14 was secured as usual, the floor anchors were secured, and the wheelchair was secured. The statement documents the seatbelt was across the lap of the resident and secured to the pin on the floor of the van. The statement documents the shoulder strap hooks to the lap seat belt but became unhooked from the lap seat belt. The statement documents V7 and V5 placed R14 back into the wheelchair, secured it, and returned to the facility and notified the DON immediately. This investigation also contained diagnostic imaging results dated 3/15/23 that document the following: 1.) suggested comminuted proximal diaphyseal fracture of the fibula. 2.) appears to be an acute fracture through the inferior 3rd patella with 6 mm (millimeter) distraction. There is additionally irregularity of the superior patellar margin possible avulsion injury. There is intra-articular fracture through the distal femoral metaphysis and epiphysis, possibly comminuted. Also, possibly chronic appearing deformity of the proximal shaft of the fibula. 3.) suspected lateral clavicular fracture with severe underlying shoulder internal derangement. R14's MDS (Minimum Data Set) dated 1/28/23 documents R14 is able to understand others and make R14's self-understood. R14's ongoing personal information documents R14 is 63 inches tall and weighs 104 pounds as of March 2023. R14's Fall Risk assessment dated [DATE] documents R14 is at risk for falls. R14's Progress Notes document the following: 3/15/23 - does not document R14's near vehicle accident and sliding forward partially out of the wheelchair but does document R14 was sent to the hospital with complaints of pain and new skin concerns: bruising/abrasion/scratch to the right knee, bruising to the right lower leg with a small abrasion, bruising to the left leg. 3/16/23 - called hospital to get an update on R14, the nurse reported R14 has a broken right femur, kneecap, and clavicle. 3/19/23 - Report from {hospital} nurse received and R14 is alert and oriented x 4, had a closed reduction of the leg, and is to use a Lidocaine patch to the fractured clavicle. R14 returned to facility via ambulance. On 4/02/23 at 2:57 PM, V1 (Administrator) stated when V5, V7, and R14 returned to the facility, V7 was so upset, V7 was in tears. V1 stated V1 had V7 re-enact the situation with V1 and come to find out, whenever R14 travels, R14 sits on three cushions so R14 can sit up tall and see, due to being so petite. When V7 hit the brakes, the shoulder strap came undone, R14 then went under the lap belt due to the three cushions sliding out from under R14. Therapy evaluated R14 for the cushions and type of wheelchair and R14 no longer uses those cushions or that wheelchair. V1 stated the root cause of R14 coming out of R14's wheelchair was the unsecured cushions. On 4/03/23 at 1:15 PM, R14 was lying in bed with V16 (CNA) and V8 (Licensed Practical Nurse/Wound Nurse) in the room. At this time, R14 stated, I (R14) have a good memory and I (R14) did not fall out of the wheelchair. I (R14) was sitting in the middle of the van, between the driver and CNA and when the truck pulled in front of us and we pulled over to the side of the road, I (R14) slid to the front of the wheelchair, but I (R14) was still buckled. That was part of the problem, my legs were up against the back of the seats, and I (R14) couldn't go anywhere because it {wheelchair} was tied down and my legs had nowhere to go other than up and that is how it broke. R14 again stated R14 was buckled around R14's waist only. R14 also confirmed the wheelchair in the corner with the do not use sign on it is the wheelchair R14 was in during the accident and that R14 was sitting on the three cushions in the wheelchair at the time of accident. R14 explained that R14's legs are so long, sitting on the three cushions is the only way R14 can sit comfortably in the wheelchair. R14 stated R14 use to have a different wheelchair but it kept breaking and needing repaired so after R173 passed away, the facility gave R14, R173's wheelchair to use. R14 stated the facility knew R14 needed a taller wheelchair but they didn't have any. R14 explained some of the CNAs check to make sure the cushions are all the way back in the wheelchair seat but R14 doesn't know if V5 did that day or not. R173's medical record documents R173 passed away on 1/3/23. On 4/03/23 at 2:54 PM, V2 (DON) stated R14 was coming home from a doctor's appointment and a car pulled out in front of them so V7 swerved and slammed on the breaks. V2 is not sure if R14 came out of the wheelchair or not but V2 knows there was talk of the wheelchair moving when V7 had to slam on brakes and swerve and wondering if during that process of the wheelchair moving forward and back again that the safety belt came unhooked but V2 don't really know. I know (R14) injured (R14's) knee, femur and shoulder due to the impact but again, don't know what the impact was on. V2 explained V2 was not aware that R14 used all 3 cushions when in the wheelchair until the incident. V2 does not know if R14 was evaluated for proper seating/positioning in the wheelchair when R14 was originally given it, sometime after 1/3/23, but stated since the accident, R14 was evaluated by OT (Occupational Therapy) and no longer uses that same wheelchair or cushions. On 4/03/23 at 3:13 PM, V5 (CNA) confirmed V5's written statement was accurate. V5 stated on the way back from R14's physician appointment, a black pickup pulled in front of the van R14, V5, and V7 were riding in. V7 braked and swerved to prevent from hitting the truck. V5 stated V5, who was in the passenger seat, immediately put V5's hand back {to where R14 was sitting in the wheelchair} to try and prevent R14 from moving forward and was able to touch R14's knees but V5 wasn't able to hold R14 back. V5 explained R14 had been secured in the wheelchair by the wheelchair brakes being locked, the wheelchair being secured to the van floor with the hooks and R14 being buckled in, with a lap belt only, but R14 still moved. V5 stated V5 had been instructed by V22 (Maintenance) that R14 was only to use the lap belt, and not the shoulder strap because it can choke R14. V5 stated the seat buckle, came loose somehow and R14 slid down out of the wheelchair explaining R14's buttocks was half on the wheelchair seat and half on the little step/ledge that the wheelchair pedals go over, slightly on R14's right side with R14's legs bent and facing to the left. V5 stated R14's right knee was touching the back of the driver's side seat and R14's upper body was behind the passenger seat. V5 stated the sheep skin cushion that R14 had been sitting on came out of the wheelchair and was on the ground and the two four-inch cushions stayed in the wheelchair but moved to behind R14 due to them not being secured or tied to the wheelchair. V5 stated V7 immediately pulled over and they got R14 up, back into the wheelchair, due to R14 complaining of R14's knee hurting. V5 explained, R14's knees don't normally bend the way they were so V5 thought the discomfort was just from the way they were bent so we wanted to get R14 up and situated. After getting R14 resecured in the wheelchair, we headed back to the facility, and a couple of miles down the road, R14 started to complain of R14's right knee hurting again and wanting to put R14's leg on the ground and off of the foot pedal. V5 stated V5 moved R14's leg for R14 and that relieved some of the pressure in the knee, so they continued to travel back to the facility, approximately 20 minutes away. V5 stated by the time R14 was almost back to the facility, R14 started saying that R14 couldn't move R14's right leg at all and wasn't able to feel R14's right leg. V5 stated when R14 returned to the facility, V2 (DON) was the nurse working the unit so V2 assessed R14 and sent R14 to the hospital. V5 stated V1 (Administrator) then in-serviced V5 and V7 to call 911 in a scenario like this, where a resident might be hurt, instead of moving the resident like V5 did. On 4/04/23 at 8:50 AM, the facility transport van was observed with V7 and V1 present. The van has a back ramp that the wheelchair rolls into with a 9-inch ledge/stoop that surrounds the wheelchair. Securement straps/hooks are in the van floor. V7 stated that after pushing R14's wheelchair into the van, V7 attached all 4 hooks to each corner of the wheelchair frame and then tightened them down so that the wheelchair could not move, then locked both wheelchair brakes, and then place the seat belt, which is also attached to the floor around R14. The seat belt consists of a lap belt with a shoulder strap that attaches to it with a hook and pin buckle (a piece of metal that goes into a hole in the other end of the buckle and slides into place). V7 stated the shoulder strap is always attached to the lap belt. V7 stated the day of R14's accident, R14 was secured in the wheelchair as described and V7 is pretty sure the shoulder strap was attached to the lap belt as V7 never undid it but that after V7 had to slam on the brakes and swerve, the shoulder strap was no longer on R14 and R14 buttocks were off of the wheelchair seat, knees resting on the 9 inch ledge and the 3 cushions R14 had been sitting on were up behind R14's back. R14 was complaining of knee pain at that time so V5 got R14 back into the wheelchair seat, and once R14 was secured again, we returned to the facility, which is approximately 12 miles away from the accident site. At this time, V1 stated R14 is alert and oriented and that with the differences in V5 and V7's details of the accident, R14 would be able to recall the accident. On 4/6/23 at 2:11 pm, V30 (Registered Nurse/RN) stated R14 does not have good hand dexterity. V30 stated R14 is not able to manipulate small objects and would not be able to unhook the transport seat belt. On 4/04/23 at 9:15 AM, R14 was lying in bed and again stated at the time of the accident the wheelchair was secured to the floor in the front and back of the wheelchair, the brakes were locked and that R14 had a belt around R14 but did not have a shoulder strap on. When asked if R14 knew what a shoulder strap was, R14 stated, I (R14) know what you are talking about because I (R14) remember seeing other people with a strap over their shoulder when in the van and I (R14) thought there must be something wrong with their upper body that they needed it because I (R14) had never used it. On 4/04/23 at 9:30 AM, V21 (Certified Occupational Therapy Assistant/COTA) with V11 (Therapy Director) present stated V21 has never evaluated R14 for a wheelchair, before or after R14's accident on 3/15/23. At this time, V11 stated that an actual evaluation was not completed, however after the accident R14 was given a different wheelchair to use, one with elevating leg rests and one cushion instead of three. V11 stated V11 then instructed the CNAs that if R14 was not positioned good in the new wheelchair to let therapy know and they would get an evaluation completed by the OTR (Occupational Therapist - Registered). V21 stated using three cushions is not good for positioning and safety. I (V21) would not recommend stacking the cushions but then again, (R14) isn't on my case load so I (V21) can't tell the nursing staff not to do that if that is what (R14) wanted. On 4/04/23 at 9:45 AM V22 (Maintenance) with V20 (Maintenance Director) present confirmed V22 provided education to V5 (CNA) a month or two ago on how to secure residents in the van for transportation and instructed V5 to push the resident into the van, lock the wheel brakes, hook all 4 corners of the wheelchair to the straps in the floor and secure the lap/shoulder strap, which is an all-in-one safety belt. V22 stated V22 doesn't remember ever telling V5 to not use the shoulder strap due to the risk of choking a resident but might have said make sure you aren't choking them but I (V22) never said not to use it. At this time, V20 stated V20 doesn't know how the shoulder belt could have come unhooked and confirmed when the inspector checked the van and securement devices out, they didn't find anything wrong/malfunctioning on the strap. On 4/04/23 at 11:49 AM, V25 (Van Inspector) stated V25 inspected all the straps and locking components in the van after the incident and did not see a problem with any of them. V25 also stated if the facility is claiming the chest strap came unsecured from the lap strap, it was probably because it was not hooked up correctly, because all the securement straps passed the pull test. On 4/04/23 at 12:01 PM, V27 (Nurse Practitioner) stated if R14 was complaining the wheelchair that the facility provided to R14 did not fit R14 correctly, and R14 was needing to sit on three pillows to be comfortable, R14 should have been evaluated for a different wheelchair. V27 reported that R14 told V27 that R14 was secured with a belt so V27 assumed it was like in a car, with a lap and shoulder belt and explained if it wasn't on, that would make more sense as to how R14 was able to move forward in the wheelchair. V27 explained, the safety belt would no longer be tight after the three pillows (measuring 9 inches tall) were no longer under R14, and that would have allowed enough space for R14 to slide out of the wheelchair, under the waist strap because R14 is so tiny, and the strap would no longer be tight then. V27 stated V5 and V7 should have never moved R14 with R14 complaining of pain, they should have called EMS (Emergency Medical Services) at that point instead of bringing R14 back to the facility. The undated User Instructions for securing a resident in the transportation van documents to first secure the wheelchair by placing the wheelchair facing forward, apply wheel locks, attach the tie downs to the floor anchors, attach the four tie down hooks to the solid frame of the wheelchair, and ensure all tie downs are locked and properly tensioned. After the wheelchair is secured, then you secure the passenger by attaching the lap belts between the seat back and bottom and/or armrest to ensure proper fit around the occupant then attach the shoulder belt by extending the shoulder belt over the passenger's shoulder and across the upper torso and fasten the pin connector onto the lap belt. Ensure belts are adjusted as firmly as possible, but consistent with user comfort. The facility Fall Prevention Program dated May 2022 documents this 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. The fall prevention program includes the following components: methods to identify risk factors, methods to identify residents at risk, educate resident and resident representative to fall prevention program at time of admission/throughout residents stay/and when changes occur, use and implementation of professional standards of practice, adherence to manufacturer's recommendation in use of alarm/medical devices/special care equipment. Safety interventions will be implemented for each resident identified at risk. The Director of Nursing or Designee is responsible for monitoring the Fall Prevention Program, including further staff education programs, purchase of additional equipment, or other appropriate environmental alterations. Each resident will be screened by a specialist therapist at the time of admission, quarterly, and after each fall, as appropriate, and with significant change in the resident's mental and functional abilities. The Immediate Jeopardy that began on 3/15/23 was removed on 4/10/23 when the facility took the following actions to remove the Immediacy. 1. R14 was evaluated by V24 (Occupational Therapist) on 4/5/23 for appropriate wheelchair placement. 2. V7 (Transportation), V17 (Activities Director), and V22 (Maintenance), all who are also transportation drivers, were all in-service on 3/16/23 by V20 (Maintenance Director) on appropriately loading and securing residents into the transportation van, including the use of all vehicle seatbelts and wheelchair belts. 3. On 4/6/23, the facility started educating all staff on the facility's Transportation for Residents Policy and Securement Process and having staff complete the securement process with a return demonstration and knowledge quiz. This education will continue until 100% of facility staff have been in-serviced. 4. Audits were initiated on 4/7/23 to ensure facility staff are using the appropriate safety belts on residents during transportation and the facility's procedure for transportation accidents is being followed. These audits will continue five times weekly for 12 weeks under the direction of QAPI (Quality Assurance Performance Improvement).

Based on observation, interview, and record review, the facility failed to follow the current standard of practice for one of three residents (R1) when the facility did not immediately assess a change in condition to R1's right knee that included: swelling and R1's knee no longer being contracted. This failure resulted in R1 going seven days without receiving diagnostic testing of R1's right knee. X-rays performed seven days after the change in R1's right knee appearance revealed an acute or subacute fracture of the distal femur with considerable impaction/shortening deformity for one of three residents (R1) reviewed for Injuries of Unknown Origin on the sample list of three. Findings Include: On 3/29/22 at 9:45 am, R1 was lying in bed with a brace to the right leg that went from mid-thigh to the lower calf. R1 was not able to say why R1's leg was in a brace. R1's MDS (Minimum Data Set) dated 3/7/22 documents R1 has severe cognitive impairment. R1's undated Final Abuse Investigation Report documents on 3/15/22 at approximately 1:50 pm, V1 (Administrator) was notified of an Injury with Unknown Origin. R1 was found to have swelling by R1's knee, an x-ray was conducted and revealed a distal femoral fracture. This Investigation contained witness statements from staff who had cared for R1 in the days prior to R1 being diagnosed with a fractured femur. Included in these witness statements were statements from V11 (Certified Nursing Assistant/CNA) and V7 CNA. V11's statement documents V11 noticed R1's knee to be red and swollen on 3/8/22. V7 CNA's statement documents V7 noticed R1's knee was swollen and no longer contracted and that V7 reported the findings to V20 (Agency Licensed Practical Nurse/LPN) as well as V6 LPN but does not document the day that V7 noticed the change. On 3/29/22 at 12:00 pm, V7 stated V7 doesn't recall what day it was that V7 noticed R1's leg to be swollen and no longer contracted. V7 explained it was between 5:00 am - 5:30 am when V7 went to put R1's pants on during morning cares that V7 noticed R1's right leg was no longer contracted, and the knee was swollen. V7 stated normally (R1) is very hard to get dressed due to contractures but (R1's) leg was actually really loose. V7 explained V7 reported the change to R1's nurse, an African American Agency Nurse, {later identified as V20 Agency LPN} but V20 refused to look at it. V20 said that (R1) was very discriminating and doesn't like black people, so V7 then asked V6 (LPN) to look at R1's leg. V7 stated V6 (LPN) was busy at the time but stated V6 would go assess R1. V7 explained that R1 is very contracted, and this was a big change. The facility Nursing Daily Schedule dated 3/7/22 - 3/15/22 was reviewed and the 3/9/22 Nursing Daily Schedule documents this is the only day that V6 (LPN) and V20 worked together, working 6:00 pm (3-9-22) - 6:00 am (3-10-22). Therefore, the day that V7 noticed R1's knee to be swollen and no longer contracted was the morning of 3/10/22. On 3/29/22 at 12:12 pm, V11 (CNA) stated V11 doesn't remember the exact day V11 noticed R1's right knee swollen and no longer contracted but it was one week prior to us finding out it was broke. At the time, there was no redness, but R1's leg was loose, not contracted anymore. V11 stated V11 reported it to the agency nurse, I (V11) don't know her name, but she was a petite African American. {later identified as V20 Agency LPN). V11 stated V20 did not check it out but did say V20 had already told another nurse about it. It was a crazy situation. (R1) is always very contracted and it {leg}wasn't. It was really loose. V11 stated it was a big change that needed reported because V11 didn't know what happened to cause it. R1's Progress Notes dated 3/14/22 documents R1 is noted to have a swollen right knee. V22 Physician notified and ordered received to order a mobile X-ray for tomorrow. This was the first documentation of R1's change in knee condition in R1's medical. R1's right knee X-ray dated 3/15/22 documents, there is an acute or subacute appearing fracture at the distal femur, with considerable impaction/shortening deformity. On 3/29/22 at 12:25 pm, V3 ADON (Assistant Director of Nursing) stated V3 doesn't remember the exact day V3 found out about R1's fractured leg but getting R1 an X-ray was on our honey do list that the DON (Director of Nursing) gives us due to R1 having issues with (R1's) leg, (R1's) knee was swollen. V3 explained R1's legs are generally always contracted and it wasn't. V3 stated V3 would expect staff to update the Physician and POA (Power of Attorney) with that kind of change. V3 also stated, with R1's change in condition being that extreme, it should have been reported to either the DON (Director of Nursing) or myself and Administrator at the time, not just the nurse. V3 ADON (Assistant Director of Nursing) stated V2 DON (Director of Nursing) completed most of the interviews regarding this investigation and those were centered around the staff that provided care to R1 around the time the injury was reported {3/15/22}, which was 7 days after the changes in R1's knee was noticed {3/8/22} by V11. On 3/30/22, V1 Administrator confirmed V1 did not find out about the changes to R1's knee until 3/15/22, 7 days after the change was first witnessed and reported to the nurses: V6 LPN and V20 Agency LPN. V1 also stated, the nurses should have assessed and documented R1's change in condition on the 3/8/22, and if they felt it was a big change they should have reported it to the Physician. The facility Abuse Prevention and Reporting Policy dated December 2021 documents An injury should be classified as an Injury of Unknown Source when both of the following conditions are met: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or location of the injury. If the injury is classified as an Injury of Unknown Source, the procedures and time frames for reporting and investigating abuse will be followed. This policy also documents, employees are required to report any incident, allegation or suspicion of potential abuse to the administrator immediately, and nursing staff are responsible for reporting the appearance of suspicious bruises, lacerations, or other abnormalities as they occur.

Based on interview and record review, the facility failed to provide adequate supervision to prevent one resident (R50) slipping from an assistive device, landing on the floor, and receiving several lacerations to R50's skull. R50 is one of four residents reviewed for accidents in a sample of 51. This failure resulted in R50 being sent to the emergency room and receiving 5 staples to repair the head lacerations. Findings include: R50's Physician's Order Sheet (POS) for March 2022 documents the following diagnoses for R50: Difficulty in walking, Lack of Coordination, Unsteadiness on Feet, Type 2 Diabetes Mellitus with Diabetic [CONDITION(S)], and Morbid (SEVERE) Obesity. R50's Nurses Notes dated 1/28/22 documents R50 weighed 233 pounds. R50's Minimum Data Set (MDS) for a Significant Change, a resident assessment and care screening tool, dated 2/25/22 documents R50 required extensive assistance (weight bearing assistance) with two staff members physical assistance to accomplish surface to surface transfers on no less than 3 occasions in the 7-day assessment period. This same MDS documents R50 required extensive assistance with two staff members physical assist for toilet use on no less than 3 occasions in the 7-day assessment period. This MDS also documents R50's balance during transitions for moving on and off the toilet and moving from seated to standing position documents R50 is not steady, only able to stabilize with staff assistance. On 3/11/22 at 3:14 pm, V20 (Minimum Data Set Coordinator) stated, If a resident has 3 or more occasions of needing a certain level of assistance in the 7-day assessment period, we code the MDS for that highest level. (R50) had (more than 3) occasions of needing 2-person assist for transfers during the 7-day assessment period. The facility's report titled Incident Report, Witnessed Fall dated 2/28/22 at 5:00 PM documents under Incident Description, (R50) in common shower/bathroom. (R50) lying on back right in front of toilet with left arm folded across chest and right arm lying against right side. Legs straight out. Active bleeding from back of head. Skin tear to left posterior arm. (R50) unable to give description of incident. R50's Nursing Note dated 2/28/22 at 5PM documents, At 4:40 pm, Aide reported resident was being toileted in shower room and hit (R50's) head upon falling. Resident was awake but not responding to staff initially when first approached. VS (vital signs) Taken, (blood pressure) 137/80, T (temperature) 98.1, POX (blood oxygen saturation) 94 % (percent) on 5L O2 (oxygen), RR (respiratory rate) 18, HR (heart rate) 74. Laceration to the back of head, with moderate amount of blood noted. Pressure applied to back of head to stop bleeding while maintaining resident still. + ROM (range of motion intact) in all extremities noted. Son notified and requested resident be taken to hospital to be evaluated. Resident sent to ER and awaiting further info at this time. On 3/10/22 at 2:14 PM, V16 (Certified Nursing Assistant/CNA) stated, I took (R50) to the bathroom, and I used the sit to stand mechanical lift. I was the only staff member working with (R50) at that time. We only use one person to take (R50) to the bathroom. (R50) completed her toileting and (R50) stood up and I was wiping her buttocks and (R50) slid out of the sling (stabilizing belt to be applied, adjusted, and tightened by staff) and fell to the floor. V16 further stated, I was never told (R50) was a two person assist, I always took (R50) to the bathroom by myself. R50's Care Plan, with the revision date of 2/21/2021, documents (R50's) ADL (activities of daily living) self-care performance deficit related to Heart disease, Impaired balance. Toilet Use: (R50) requires (limited assistance) by 1 staff for toileting. On 3/10/22 at 2:30 PM V2 (Director of Nurses/DON) confirmed (R50's) care plan was not updated and should reflect the correct information as the MDS did on 2/25/22. R50's Hospital report dated 2/28/22 documents (R50) was seen in the emergency department for a Scalp Laceration and Accidental Fall. Scalp lacerations required 5 staples to the head, do not get wet and have primary physician remove staples in 10 -14 days. The facility's Fall Prevention Program with revision date 11/21/17 documents: 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.

Based on record review and interview, the facility failed to supervise a resident (R2) with known sexual behaviors to ensure protection from non-consensual sexual abuse of another resident (R1), and failed to protect a vulnerable cognitively impaired resident (R1) without the mental capacity to consent to sexual activity. This failure affects two (R1 and R2) of five residents reviewed for sexual abuse in the sample of 17. Staff allowed R2 unrestricted access to R1, resulting in R1 being sexually abused by R2. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 11/16/21, the facility remains out of compliance at severity level two. The facility is in the process of conducting weekly staff interviews/audits to verify staff knowledge of the facility's abuse prevention policy. Findings include: R2's Census Detail documents R2 was admitted to the facility on [DATE]. The facility's Initial Report to the Illinois Department of Public Health dated 11/3/21 documents the facility received a report of possible sexual abuse between R2 and R1 related to resident to resident sexual contact without consent. R2's Nurse's Notes dated 10/29/21 at 7:30 am, documents, Resident (R2) was witnessed walking down hallway with penis exposed and hand on penis. Counseled regarding not to expose self and zipper zipped with no problem from resident. R2's Nurse's Note dated 11/2/21 at 1:42 pm, document, Resident (R2) was in hallway trying to pull down his pants, he had his hands down his pants, (Director of Nursing, V2) redirected him to his room and he tried to get me (V2) to go in first, redirected him to go first and he told me to go away. I (V2) prompted him to go to the bathroom to use the restroom and if he needed to masturbate to do this in his room with the door closed for his privacy and others. R2's Care Plan, dated as initiated 10/19/21 with revisions through 11/4/21, does not document any new targeted interventions related to R2's sexual behaviors or wandering as documented in R2's Nursing Notes on 10/29/21 and 11/2/21. R2's Nurse's Note dated 11/3/2021 at 8:40 pm, documents, I (V12, Licensed Practical Nurse) was notified by CNA (V6) that this resident (R2) was in another female resident's (R1) room. It was observed that he (R2) had his pants down and his penis was in female resident's (R1) mouth. Resident was immediately separated from female resident and placed on 1:1 (one to one) supervision with CNA. Resident stated that She (R1) asked for it. Skin assessment completed, no injury or bite marks noted. Administrator notified, resident (R2) sent to ER for evaluation. On 11/9/21 at 12:40 pm, V2, Director of Nursing, confirmed, No new targeted interventions had been initiated for R2's care plan regarding R2's sexual behaviors after the first 2 incidents on 10/29/21 and 11/2/21, and no new interventions were placed into R2's care plan until 11/4/21, after R2's discharge. R1's Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status as 00 out of a possible 15, rating R1 as severely cognitively impaired. R2's Minimum Data Set, dated dated dated [DATE] documents a Brief Interview for Mental Status as 12 out of a possible 15, rating R2 as borderline between cognitively intact and moderate cognitive impairment. On 11/5/21 at 9:57 am, V6, Certified Nursing Assistant stated, On 11/3/21 at 8:36 pm, as I was walking down the halls checking on residents, I witnessed (R2) with his pants unzipped and his penis was in her (R1's) mouth, his right hand was on her (R1's) head forcing her head on his penis. (R2) was in her (R1's) room, standing over (R1's) bed, one side of her depends (incontinence undergarment) was off and one of (R1's) legs was over the edge of the bed, I yelled and told him (R2) to get out of her room he cannot be doing that, his penis was still in her mouth and he didn't remove it until I physically moved him out of her room and took him back to his room. V6 further stated, After we got back to (R2's) room, I told him I would have to report his behavior and he started saying that he needed to get his shoes and coat on and get out of there before the police came, then he called his son on the cell phone to tell him to come get him out of there. V6 continued, (R1) in no way has any capacity to consent to such an act, but (R2) is alert, he had to walk right by the rooms of 5 female residents who are alert and oriented to get to (R1), the vulnerable resident. On 11/5/21 at 12:48 pm, V9, emergency room (ER) Nurse, stated, I was the ER nurse when (R1) came into theER on [DATE] and she was alert only to herself, she did not know why she was in the ER or why her kids would have sent her there, did not realize she was a resident in a nursing home, didn't remember anything about any incident even after I told her what had happened and why she was there. V9 continued, She did have redness on her left cheek and behind her left ear which I took pictures of. At her family's request I did do a gonorrhea and chlamydia swab test on her throat but I do not have the results of those yet. V9 further stated, I also did see (R2) when he came to the ER and he also had dementia among his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He (R2) knew he was in a hospital and that he wore glasses and didn't have his glasses with him, and that he had called his son on the cell phone before coming to the hospital. V9 further stated, He (R2) was unwilling to tell me why he was at the ER, but at one point he did say that the staff at the nursing home thought he had exposed himself to someone at the nursing home. V9 concluded by stating, There is no way possible (R1) could consent to a sexual act, she really couldn't make an informed consent to anything because of her cognitive status. On 11/5/21 at 2:45 pm, V11, Family Member of R1, stated, (R1) is a very compliant person, if someone says to her, Lets go do this, then she is going to go do this, but she in no way has any kind of capacity to consent to anything sexual. On 11/9/21 at 10:20 am, V2, Director of Nursing, confirmed, (R1) does not have the mental capacity to consent to sexual activity. The facility's Abuse Prevention and Reporting Policy dated 11/28/16 documents, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. It (abuse) includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled by the use of technology. Sexual abuse is non-consensual sexual contact of any type with a resident. Generally, sexual contact is non-consensual if the resident lacks the cognitive ability to consent. An Immediate Jeopardy was identified 11/16/21 and the facility Administrator (V1) was notified of an Immediate Jeopardy situation on 11/16/21 at 9:06 am. The Immediate Jeopardy was determined to have begun on 10/29/21 when the facility failed to provide interventions to address R2's inappropriate sexual behaviors, resulting in R2 having unrestricted access to a vulnerable resident and sexually abusing R1. The surveyor was able to confirm onsite through interview and record review that the facility took the following measures to remove the immediacy: 1. R1 was immediately examined head to toe and no noted physical injury to oral cavity or vaginal area, brief intact. No mental distress noted (11/3/21). 2. R2 was immediately placed on 1 on 1 observation (11/3/21). 3. R1 and R2 were both sent out to the hospital for evaluation (11/3/21). 4. R2 is no longer in facility (discharged [DATE]). 5. All residents reviewed - no residents with similar tendencies at this time. If any are identified in the future, they will be assessed immediately, interventions put in place and proper notifications made (11/3/21). 6. All Residents on Unit have been interviewed for any physical and/or psychological distress - 100% Completed (11/4/21). 7. Root Cause Analysis completed for sexual Abuse incident (11/5/21). 8. Plan to conduct weekly audit of 5 staff per week for 12 weeks verifying knowledge of abuse prevention policy (plan put in place on 11/5/21, to continue 12 weeks).

Based on observation, interview, record review, the facility failed to accurately assess, measure, and obtain a treatment order for a newly acquired pressure ulcer, complete pressure ulcer treatments as ordered, and reposition a dependent resident at least every two hours for two of three residents (R2, R3) reviewed for pressure ulcers on the sample list of three. These failures resulted in R2's two stage II pressure ulcers to the buttocks deteriorating to unstageable, and R2 developing a new unstageable pressure ulcer to the right foot. Findings Include: The facility Pressure Injury and Skin Condition Assessment Policy 1/17/18 documents: a wound assessment will be initiated and documented in the resident chart when a pressure and/or other ulcers are identified by a licensed nurse., Changes to the skin will be promptly reported to the charge nurse who will perform the detailed assessment. At the earliest sign of a pressure injury or other skin problem, the resident, legal representative, and attending physician will be notified. The initial observation of the ulcer or skin breakdown will also be described in the nursing progress notes., A wound assessment for each identified open area will be completed and will include: site location, size, stage of pressure ulcer, odor, drainage, description, date and initials of the individual performing the assessment., When there are weekly changes which require physician and responsible party notification, documentation of findings will be made in the clinical record. These changes include, but are not limited to: new onset of purulent drainage, new onset of odor, [MEDICAL CONDITION], increased pain related to wound, significant increase in wound measurements, onset of new wound., Physician ordered treatments shall be initiated by the staff on the electronic Treatment Administration Record after each administration. Other nursing measures not involving medications shall be documented in the weekly wound assessment or nurses notes. 1.) R2's MDS (Minimum Data Set) dated 11/26/20 documents R2 requires extensive assistance with bed mobility and only transferred once or twice with one assist. R2's Skin assessment dated [DATE] documents, R2 has an unstageable Pressure Ulcer (PU) to the left ankle measuring 0.2 cm (centimeters) by 0.3 cm, a stage II PU to the right buttock measuring 1.4 cm by 0.6 cm, and a stage II PU to the left buttock measuring 1.9 cm by 0.6 cm. This assessment also documents all wounds are healing and have granulation tissue. There is no documentation in R2's January 2021 TAR (Treatment Administration Record) or Progress Notes that R2's PU treatments were completed on 1/23/21 and 1/24/21. R2's Skin assessment dated [DATE] documents, R2 has an unstageable PU to the left ankle measuring 0.5 cm by 0.5 cm that is worsening and now covered in slough and granulation tissue. This Assessment also documents, a stage II PU measuring 2.5 cm by 0.5 cm, that is worsening and covered in slough, but does not document where this PU is located. R2's ongoing Weekly Wound Measurements dated 1/27/21 documents R2 has a stage II PU to the right buttock measuring 2.5 cm by 0.5 cm, and a stage II PU to the left buttock measuring 1.0 cm by 0.7 cm. {An increase in size of all wounds from the week prior.} R2's Skin Assessments dated 2/3/21 and 2/10/21 both continue to document R2's bilateral buttocks ulcers as stage II and R2's left ankle ulcer as an unstageable. R2's Physician order [REDACTED]. 1. Wound care for right and left buttocks wounds - clean with wound cleanser, apply Santyl {an enzyme used to loosen slough}, cover wound bed ONLY with calcium alginate, and cover with 8 in (inch) by 8 in bordered foam dressing daily and PRN {as needed}. 2. Wound care for left ankle wound - clean with wound cleanser, apply Santyl, covered with 2 in by 2 in bordered foam dressing daily and PRN. On 2/17/21 at 2:15 pm, V3 ADON (Assistant Director of Nursing)/Wound Treatment Nurse entered R2's room to complete the ordered dressing changes to R2's left ankle and bilateral buttocks. V3 removed a large foam dressing, with a moderate amount of serosanguineous {clear yellow} drainage dated 2/16/21 from R2's coccyx area, to reveal one wound to left and one wound to right buttocks, both covered in yellow slough. V3 measured R2's left buttock wound as 2 cm by 2.1 cm {more than doubled in size since 1/27/21}, and right buttock wound as 2.2 cm by 1.2 cm. V3 confirmed that R2's dressing that was removed did not have the ordered calcium alginate on the wounds, and stated the wounds are looking worse and are covered in slough. V3 then removed a dressing to the left ankle to reveal a wound measuring 1 cm by 0.6 cm, with a beefy red wound base. R2 had a foam dressing to right lateral foot dated 2/15/21. At this time, V3 stated, R2 doesn't have a wound or ordered treatment to the right foot, maybe it's there for prevention only. V3 removed the dressing to R2's right foot, which had a scant amount of Sanguineous {bloody} drainage, to reveal a wound that V3 measured and described as a 0.5 cm by 0.4 cm by 0.1 cm, full thickness, stage 3 pressure ulcer. V3 cleansed the wound with wound cleanser and applied a dry foam dressing to the wound and stated, I will have to call the doctor and get a treatment. V3 stated, when the nurse finds a wound, they are to notify the physician, POA (Power of Attorney) and RD (Registered Dietician) for orders after completing a full assessment of the wound, including measurements. V3 also stated that once a treatment is completed, it is signed out on the TAR. On 2/18/21 at 9:26 am, V13 LPN (Licensed Practical Nurse) stated, on 2/15/21, V13 noticed a scab, so an unstageable pressure area, on the outside of (R2's) right foot that measured 0.2 cm by 0.3 cm. V13 stated V13 observed the new wound when doing R2's other dressing changes, and that V13 measured the new pressure wound, and put the dry protective dressing on the wound but isn't sure if V13 charted the new wound. V13 stated, V13 forgot to fax the doctor to get a dressing {order} for it, but you can only do so much. On 2/18/21 at 10:13 am, V3 ADON/Wound Treatment Nurse stated with R2's buttocks wounds being covered with slough and not being able to see the wound bed, the wounds (right and left buttocks) are actually unstageable PU instead of stage II PU. At this time, V3 confirmed that they have been slough covered since the end of January, therefore the wound assessments dated 1/27/21, 2/3/21, and 2/10/21 are not accurate. R2's Progress Notes document R2 was seen by V12 RD on 2/8/21 and 2/15/21. V12's Progress Note on 2/8/21 document R2 has stage II PU that are deteriorating so V12 recommends adding zinc for wound healing. The Progress Notes on 2/15/21 documents R2 has triggered for a weight loss and with having compromised skin, weight loss is contraindicated so V12 recommends a nutritional drink twice a day. On 2/18/21 at 8:50 am, R2 was sitting up in a low to the floor rolling chair with R2's socked feet resting on the foot pedals. At 9:05 am, R2 was still in the chair but R2's right foot was resting on the floor. R2 remained in the same position at 9:24 am. At 9:52 am, R2 was in the same position but had heel protectors on bilateral feet. From 9:52 am - 11:35 am based on 15 minute checks, R2 remained in the same position. At 11:35 am, V14 CNA (Certified Nursing Assistant) stated R2 got up from bed into the low sitting rolling chair at 6:45 am. V14 stated R2 was lifted up with a mechanical lift and changed at 9:45 am {3 hours after being gotten up}, then placed back into the chair, and that is the only care provided to R2 since R2 has been up but R2 will be put back into bed after lunch. At 11:47 am, R2 remained sitting up in the chair, in the same position and V14 stated, we get to the residents when we can. It might not be every two hours or less but it's not like they go 7-8 hours without care. Maybe 2.5-3 hours. R2 remained in the same position at 12:00 pm, 12:12 pm, 12:25 pm, and then was placed in bed at 12:30 pm {2 hours and 45 minutes after last repositioned}. On 2/18/21 at 11:00 am, V12, RD stated V12 knew that R2's wounds were deteriorating based off of R2's skin assessments, but didn't realize R2's wounds were unstageable, and had been since January because the skin assessments documented the wounds to be stage II PU. V12 stated had V12 known that R2's buttocks wounds had deteriorated to unstageable's, back in January, or that R2 had developed a new Stage III PU, in addition to the zinc and nutritional drink that V12 recommended, V12 would have also ordered extra protein and calories to boost the wound healing. On 2/18/21 at 11:21 am, V11 Physician stated the facility notified V11 on 2/17/21 that R2's wounds are worsening and that R2 has a new stage III PU to the right foot. V11 stated, treatments should be done as ordered. V11 stated, the problem is R2 is getting weaker and weaker and can't move much on her own, and (R2's) nutrition isn't very good. (R2) needs to be repositioned at least every two hours and have the areas off loaded as much as possible. V11 also stated R2 is being seen by an RD and the recommendations are put into place to assist with wound healing. 2.) R1's Medical Record documents R1 was admitted to the facility on [DATE]. R1's Physician order [REDACTED]. R1's 72 Hour Admission Charting dated 1/29/21 documents R1 has two superficial areas to the left buttock, one area to the right buttock that is 2 cm (centimeter) and hard, and to the coccyx. R1's Progress Notes dated 1/29/21 by V4 LPN (Licensed Practical Nurse) documents, R1 has a superficial wound to left buttock and one to coccyx area and one to right buttock that has a 2 cm round hard area all wounds have no noted drainage and all area were cleaned and new dressings applied. There is no assessment of the wounds according to the facility policy and no measurements of these wounds. On 2/17/21 at 2:15 pm, V3 ADON (Assistant Director of Nursing)/Wound Treatment Nurse stated when a resident is admitted with a pressure ulcer, or develops one in the facility, the nurse is to do a complete wound assessment and document the measurements of the wound. On 2/18/21 at 12:31 pm, V4 LPN stated V4 was the nurse on duty when R1 was admitted to the facility. V4 stated upon R1's admission, R1 had three pressure areas, all in buttocks area. One was hard about 2 cm on the right buttock, then on the other side, R1 had two superficial areas that were blanchable, did not measure them.

Based on observation, record review and interview, the facility failed to ensure supervision and use of assistive devices to prevent injury for one of 14 residents (R2) reviewed for accidents on the sample of 14. This failure resulted in a large laceration on the leg requiring hospital treatment with sutures. Findings include: According to the current physician's orders [REDACTED]. This POS also lists an order for [REDACTED]. On 6/20/16 at 10:00am, R2 was identified by E3 (Assistant Director of Nursing) as interviewable. R2's careplan dated 4/6/16 states that R2 does not ambulate .transfer with mechanical lift for safety. The Resident Incident Report dated 5/1/16 states the following: CNA (Certified Nurse Aide) reported large laceration to resident's (R2) leg stated happened during transfer from wheelchair to bed. Laceration to right lower leg on outer aspect measuring 12 x 5.5 cm (centimeters) with unknown depth; noted fatty tissue attached to lacerated skin and muscle tissue visible. Site cleansed and covered with {non-stick} dressing .hospital transfer. Hospital discharge instructions dated 5/1/16 at 10:52pm note the repair of the laceration on the right lower leg. The POS documents continuing treatment with antibiotic ointment and dressing until suture removal on 5/14/16. The Final Report of the incident completed on 5/5/16 documents R2 returning from the hospital with 20 sutures. The dictated statement by Z2 (agency CNA) dated 5/1/16 states that Z2 had removed the footrests and heel boots prior to positioning R2's wheelchair next to the bed. I (Z2) asked {R2} to give me a hug. Then I (Z2) stood {R2} and pivoted to the left on to the bed. I noticed leg was bleeding. I cleaned the blood on the floor. I lifted {R2's} legs into the bed so {R2} was in a laying position. I applied pressure to {R2's} legs with tissue and my hand to stop the bleeding then I (Z2) reported to the nurse {R2's} injury. No mention is in the statement regarding use of gait belt, mechanical lift, or assistance from another staff person. Dictated statements by E16, E17, E18 and E19 (CNAs) all stated that Z2 did not ask for assistance with transfers from any of them throughout the evening. The written Witness Statement signed by E15 (CNA) on 5/3/16 states, I have worked with {Z2} before and I have told her multiple times how {R2} transferred. On 6/23/16 at 3:15pm, E15 confirmed the written statement, and stated E15 told Z2 that R2 was to be a sit-to-stand lift with two assist. E15 stated there are to be two assist with all mechanical lifts. The statement by E7 (Licensed Practical Nurse/LPN) dated 5/1/16 stated that Z2 entered the charting room on 5/1/16 about 7:55pm and reported a laceration to R2's leg. Along with E14 (LPN), E7 assessed the large laceration to the right lower leg, noting fatty tissue and white muscle tissue visible with no active bleeding present. E7 noted a blood smear on the floor. The statement documented that R2 stated at that time that the cut happened during the transfer but did not know what R2 cut her leg on. R2 also stated at that time that she had told Z2 to use a mechanical lift, but did not recall whether it was before or after the transfer and injury. E7's statement states that Z2 gave multiple versions of sequence of events, including when Z2 noticed the injury, cleaning up the blood, putting pressure on the wound, placement of bed rails, wheelchair, bedside table, etc. E7 also noted in the statement that the room had been re-arranged from the time of the transfer, including the wheelchair in the hallway, and the bedside table next to the bed. R2 complained of pain at that time. The wound was cleansed and covered, R2 was medicated for pain, and transferred per ambulance to the hospital as per physician's orders [REDACTED]. The written statement by E14 LPN concurred with the assessment of the laceration, and that R2 had said I told her (Z2) to use the machine, E14's statement also included that Z2 was told she should not have touched the wound or tried to clean up, to come and get the nurse directly. E14's statement noted that the bed and wheelchair were inspected with no sharp edges and no blood noted. {R2} does receive Coumadin. When entering room wound was not actively bleeding. On 6/21/16 at 9:45am, E12 and E13 (CNAs) transferred R2 for incontinence care, using a sit to stand lift. E12 and E13 stated at that time that R2 had always been either a mechanical or sit to stand lift for transfers. On 6/21/16 at 10:00am, E11 (Registered Nurse/Wound Nurse) cleansed and applied Skin Prep to the large, curved healing scar on R2's right lower leg. Upon completion of the treatment, R2 stated she didn't see anything in her (Z2's) hand, but somehow she sliced me and there was blood. The nurse came in and said she couldn't do anything for me, that I would have to go to the hospital and get stitches. R2 did not recall anything else regarding the incident, i.e. with the transfer, when the cut occurred, or if she told Z2 to get a lift. On 6/21/16 at 3:20pm, E7 LPN confirmed information in the written statement. E7 stated what caused E7 and E14 to be suspicious right away was, with the seriousness of the laceration, there was no active bleeding, and that Z2 had cleaned up, put pressure on the wound and rearranged the room prior to getting the nurse. E7 stated Z2 had to have been putting pressure on it for a while - {R2} is on Coumadin. E7 stated she saw a large blood smear on the floor where Z2 had apparently tried to clean it up, but did not see blood on anything else. E7 stated R2 said that R2 had told Z2 to get a lift and another person, but did not know when the cut occurred. E7 confirmed that Z2 transferred R2 by herself, without a lift or another person. E7 also stated that at that time the CNA worksheet had R2 down as a mechanical lift. E7 also confirmed that Z2 had worked at the facility multiple times. On 6/22/16 at 2:30pm, E14 LPN also confirmed information in the written statement. E14 stated Z2 was very sketchy as to how the laceration happened and versions of the reports didn't jive. E14 also stated that R2 said she had told Z2 that Z2 needed to use a lift. E14 stated that R2 was a mechanical or sit to stand lift at that time and the two people are used even with a lift. E14 stated agency staff are given sheets as what kind of transfer or lifts are to be used. E14 also stated that Z2 had worked at the facility and assumed had cared for R2 prior to the incident. On 6/22/16 at 11:15am, E2 (Director of Nursing) stated that agency staff read and sign the abuse policy, are paired up with facility staff, and given worksheets for the halls they are assigned to that gives resident information, including transfers and special instructions. E2 provided examples of same. E2 stated that Z2 had worked at the facility a lot prior to 5/1/16. E2 stated that Z2 will not be returning to the facility. On 6/23/16 at 11:40am, Z2 confirmed information in the written statement, that footrests were off, Z2 asked R2 to give her a hug and transferred R2. Z2 stated she noticed the blood after placing R2's legs on the bed. Z2 stated she did not use a gait belt because R2 didn't need it, and that Z2 had transferred R2 the same way that week prior to the incident. Z2 stated she did not know that R2 was to be a mechanical lift, nor did R2 say anything about using a lift. Z2 also stated she did not have a worksheet with instructions for residents. Z2 stated they do a walk-through on the halls at the beginning of the shift. Z2 stated she wanted to stop the bleeding and clean up the blood before getting the nurse, and Z2 couldn't reach the call light to get help. The facility policy for Safe Patient/Resident Handling and Movement dated 1/7/13 provides a process for all caregiver assisting inpatient movement to be protected for patient handling injuries while caring for patients/residents safely within an environment of dignity and respect. Staff should utilize the proper techniques, lifting devices, etc., to match the identified task. Avoid manual lifting unless identified as a qualifying manual lift in Section 3b.Use mechanical lifts, devices and other approved aids in accordance with instructions and training.

Based on observation, record review, and interview, the facility failed to supervise 2 of 7 residents (R6 and R8) on a sample of 12 for falls. The failure of not supervising R6 in the shower room resulted in R6 falling and sustaining fracture of ribs. The findings include: 1. According to the facility's 5-5-11 "Accident / Fall Report" completed by E12, Licensed Practical Nurse, R6 fell in the shower room at 7:10 P.M. R6 was found sitting in the floor between the shower chair and the shower wall. R6 stated to E12 that she was standing holding the bar after getting out of the shower chair. R6 stated her hands may have not been totally dry and they slipped. R6 fell and hit her head. A small hematoma was on the crown of the head. E12 stated on 6-21-11 at 4:20 P.M. that E14, Certified Nurse Assistant (CNA) was in the shower room with R6. E14 told E12 that she turned to get R6's wheelchair when R6 fell . E14 was not using a gait belt. R6 stated on 6-22-11 at 1:20 P.M., that E14 told her to stand up and hold on the shower grab bar while she got her wheelchair. R6 said she lost her balance, could hold on to the bar and fell . Fall Investigation report documented on 5-9-11 R6 complained of pain in her right shoulder and was sent for X-rays. The X-ray report lists "Multiple left lateral rib fractures either subacute or chronic in nature". According to R6's June 2011 Physician order [REDACTED]. R6 has a history falls. The 3-27-11 fall assessment listed her as a high risk for falls. The 3-28-11 Quarterly Resident Assessment Instrument listed R6 is totally dependant for bathing and requires the assist of one. R6's March 2011 Care Plan lists under problems as bathing and hygiene deficit related to deformed fingers do to Rheumatoid Arthritis. The intervention was total assistance with bathing and requires special handling. The Care Plan lists a problem with abnormal gait. The interventions were transfer with staff assistance and gait belt, not steady, only able to stabilize with human assistance related to moving from seating to standing position. R6 was observed on 6-20-11 11:30 A.M. and on 6-22-11 at 1:20 P.M. R6 hands and fingers are contracted and deformed that does not allow R6 to grasp the shower grab bars with a natural opposing grip to support her while standing. 2. The Accident/Fall Report of 12/24/10 found that R8 experienced a fall ont that day, acquiring a marble size bump to the back of her head. One [DIAGNOSES REDACTED]. The Fall Risk assessment dated [DATE] has R8 assessed at high fall risk. The"Transfer of Residents and Gait Belt" policy states that gait belts are to be used at all times with transfers and if assessed they are to use a Stand Up Lift which with interview with E2, Director on Nursing on 6/22/11 at 11:00am. found a Stand Up Lift should have been used with this transfer. The Accident/Fall Report dated 12/24/10 shows that R8 was being transferred from a wheelchair to the bed by E13, Certified Nurse Aide (CNA). The report says that R8 lost her footing and fell . Interview with E2, DON on 6/22/11 at 11:00am found that R8 should have been transferred with a Stand Up Lift if only one person is assisting and if 2 staff are doing the transfer then a gait belt is to be used. The report verifies that neither of the above was used during this transfer.