Every finding on record at La Bella of Edwardsville

Based on interview and record review the facility failed to supervise and properly assessed 1 of 3 (R6) residents investigated for elopement in a sample of 11. This failure led to R6 eloping on 7/18/26 sometime between 6:00 PM and 6:30 PM from the facility and wandering through busy streets in the evening time and night, being gone for approximately an hour and half before staff realized he was missing, and being found almost a mile from the facility on 7/19/26 at 12.54 AM. This past non-compliance occurred from 07/18/26 to 07/19/26. An Immediate Jeopardy began on 7/18/26 at approximately 6:30 PM when R6 left the facility unsupervised out the front door. V1, Administrator, V2, Director of Nursing, and V15, [NAME] President of Clinical Operations were notified of the Immediate Jeopardy on 7/24/26 at 10:10 AM. The surveyor confirmed by record review and interview that the Immediate Jeopardy was removed on 7/19/26. The Immediate Jeopardy and deficiency practice that began on 7/18/26 was corrected/removed on 7/19/26 after the facility took the following actions to correct the noncompliance prior to the start of current survey: 100% resident reassessment completed. Environmental systems verified functional. Staff education completed. Enhanced monitoring implemented. QAPI oversight initiated. Resident-specific safeguards in place.Based on interview and record review the facility to properly secure a resident into the transportation van for 1 of 4 (R2) resident investigated for accidents in a sample of 8. This failure caused R2 to receive a head injury and a fractured left 4th finger. This past non-compliance occurred from 06/30/26 to 07/1/26. 1. Findings include:R6's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R6's EMR dated 12/27/23 documents a diagnosis of unspecified psychosis not due to a substance or known physiological condition and vascular dementia, unspecified severity with psychotic disturbances.R6's EMR dated 4/1/25 documents a diagnosis of unspecified dementia, unspecified severity, with psychotic disturbance.R6's Care Plan dated 12/28/23 documents The resident is an elopement risk/wanderer.R6's MDS (Minimum Data Set) dated 5/29/26 documents a BIMS (Brief Interview for Mental Status) score of 4 out of 15. The MDS documents that the resident has not any wandering behaviors. The MDS documents that the resident uses a walker as a mobility device. The MDS documents that the resident requires supervision or touching assistance to walk 150 feet. The MDS documents that the resident has Non-Alzheimer's Dementia and Psychotic disorder.All of R6's MDS document that the resident did not have any wandering behaviors.R6's Elopement Evaluation dated 5/26/26 at 2:26 PM documents Elopement Evaluation: History of elopement while at home: No. Wanders: No. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: No. Elopement Score: 0.0.On 7/23/26 at 9:32 AM, V14, CNA (Certified Nursing Aid) stated that (R6) definitely was a wanderer. She stated that staff have to redirect him to his room.On 7/23/26 at 9:35 AM, V16, CNA stated that (R6) wanders down other halls, but he did not check doors or try to follow people out the door.On 7/23/26 at 1:18 PM, V18, CNA stated that (R6) does wander down the halls of the facility.R6's Elopement Evaluation dated 7/19/26 at 10:09 AM documents Elopement Evaluation: The resident is independently mobile, with or without an assistive device (including wheelchair). The resident exhibits wandering behavior. Wandering behavior is goal-directed (i.e., follows a pattern, with a specific destination in mind, going home, etc.). Wandering behavior is not likely to affect the safety or well-being of self/others. Wandering behavior is not likely to affect the privacy of others. The resident has a cognitive impairment or diagnosis with impaired judgement or wayfinding (e.g., dementia, Alzheimer's disease, delirium, psychosis, severe mood disorder). No history of elopement at home. No history of / attempts to leave facility without informing staff. The family or responsible party has not expressed concern that the resident may attempt to leave the facility unsafely. Resident has not verbally expressed the desire to go home, packed belongings to go home, or stayed near an exit door. The resident has not been admitted or readmitted within the last 30 days. Elopement Score: 3.0.R6's only had 2 Elopement Evaluation noted in his EMR.R6's Event Note dated 7/18/26 at 11:19 PM documents CNA notified me that he did not know where the resident was. We immediately started searching the facility for the resident. We also went outside and searched on foot and others searched by car. Department heads were notified immediately. I was requested to all and notify the POA (Power of Attorney) and I called and left a message due to no answer. After the department heads arrived I was instructed to notify the MD (Medical Director). I notified him via telephone. I last saw the resident during dinner. I was shown who he was by the CNA due to not knowing who he was. Time is stamped when it was given.R6's Health Status Note dated 7/19/26 at 12:59 AM documents Police have notified facility that resident has been located, he is answering to his name. They have dispatched EMS (Emergency Medical Service) to perform a wellness check. Call to POA, no response leaving voicemail requesting return call to the facility.R6's Police Report dated 7/18/26 documents On 07/19/2026 at approximately 2120 hours, I, (V32), (V33), (V34), (V35), and (V36) were dispatched to (facility) for the report of a missing resident with dementia. (V36) and I responded to the scene while other officers began canvasing the area.Upon my arrival, I spoke with staff who advised the missing person was (R6). Staff advised (R6) suffers from dementia, is mostly non-verbal, has high blood pressure, COPD (Chronic Obstructive Pulmonary Disease), and a history of strokes. Staff advised they realized (R6) was missing when they located his walker near the front entrance to the building at approximately 1955 hours. They were unable to give an exact time (R6) left the building but estimated it to be sometime between 1800 and 1830 hours. (R6) ate dinner at the facility and was given his medication. Staff advised (R6) was last seen wearing a gray long sleeve shirt, blue pants, and black/white tennis shoes. Staff advised the front door alarm was not armed and that their cameras do not record. Staff advised (R6) shuffles without his walker and does not walk very far without the walker. Staff stated they checked the facility and they were actively looking for (R6) around the facility. Officers were eventually able to access camera footage at (local high school). This camera footage showed (R6) walking westbound through the parking lot of the school at approximately 1830 hours. I then responded to (local liquor store) and requested to see their exterior video footage. This footage showed (R6) traveling west across S State Route 157 and continue west near the end of Center Grove Rd at approximately 1923 hours. At approximately 0054 hours, (R6) was located asleep on the rear patio of (redacted).On 7/23/26 at 8:51 AM, V15, [NAME] President of Clinical Operations stated that the facility has not had an elopement in over a year. She stated that the receptionist had left early and forgot to set the alarm on the front door. She stated that shortly after (R6) left the building through the front door.On 7/23/26 at 11:14 AM, V7, Medical Director stated that in his professional opinion that any resident with dementia that elopes from the facility is at risk for serious injury or deathFacility's Elopement and Wandering Residents policy date 7/19/26 documents This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary.The Immediate Jeopardy that began on 7/18/26 was removed on 7/19/26 when the facility took the following actions to remove the immediacy:A. Identification of Residents Affected or Likely to be Affected: On 7/19/2026, 29 other residents were identified as wanderers and were added to the elopement list following the completion of the reassessment. All 29 residents were also added to the elopement binder. The Care plans were reviewed and updated accordingly for all 110 residents. There is a total of 29 residents on the elopement list/binder as of 7/19/2026. On 7/19/2026, the Administrator initiated an in-service/training on elopement protocol to staff. The trainings on elopement prevention mentioned are new and have been integrated in the facility's policies and procedures regarding elopement prevention. The facility DON/ADON (Assistant Director of Nursing)/Charge nurse will provide training on elopement prior to start of shift for all new hires and agency staff. 1. On 7/19/2026, the IDT (interdisciplinary team) which includes the DON (director of nursing) (V2), ADON (Assistant Director of Nursing) (V3), and Social Service Director V37) reviewed R6's care plans to ensure that wandering behavior and elopement risks are addressed. Resident placed on enhanced supervision 1:1 on 7/19/206. R6 - elopement reassessment was completed by nurse manager (V22) on 7/19/2026. 2. Resident head count of the whole facility was completed by the clinical managers (V22) and (V38) on 7/18/2026. There were no additional concerns identified. 3. Elopement/Wandering assessment have been completed for all residents. The assessments were completed by the ADON (V3), Administrator (V1), Nurse manager (V22), Business office Manager (V21) and Social Services Director (V37). This was completed on 7/19/2026. 4. Any resident who was identified with wandering behavior/ elopement risk will have care plans reviewed, revised, and updated. This will be completed by the IDT which includes the Administrator (V1), ADON (Assistant Director of Nursing) (V3), Nurse Manager (V22), Business Office Manager (V21) and Social Service Director (V37) on 7/19/2026. 5. The elopement binders were updated by the IDT which includes the ADM (V1), Nurse Manager (V22), ADON (Assistant Director of Nursing) (V3), Business Office Manager (V21) and Social Service Director (V37) on 7/19/2026 and will be located at all nursing stations, at the front desk, dietary, housekeeping, activities, and in facility transport vehicle.The elopement binder is not new, but it is updated when a new resident is added to the binder. A resident is added to the binder when the resident is identified with exit-seeking behavior/risk for elopement.6. The Maintenance Director (V39) has assessed all doors, exit alarms, of the facility to ensure proper working order on 7/19/2026.The Maintenance Director/MOD (manager on duty) will conduct rounds of all doors, exit alarms, daily to ensure exits are always secure. The QAPI (Quality Assurance and Performance Improvement) team conducted an Ad-Hoc QAPI meeting on 7/19/2026 discussing event and evaluating the current elopement program making addition of daily QI (Quality Improvements) of exits, routinely scheduled elopement drills, and change of shift alarm verification checklist.7. The Administrator (V1) will provide training to the DON (director of nursing) (V2), ADON (Assistant Director of Nursing) (V3), Nurse Manager (V22), Business Office Manager (V21) and Social Service (V37) on 7/19/2026 regarding development of care plans to address residents who are identified with exit-seeking /wandering behaviors and elopement risk.8. The DON/Administrator/Social Services Director/HR Director/Staffing Coordinator/Therapy Director/Dietary Manager/Activity Director will provide education to the staff on 7/19/2026. The education items include but not limited to:a) Code Pinkb) Use of the elopement bindersc) Exit-seeking behaviors and interventionsd) Elopement risk and wandering and interventionse) The use of stop and watch process for new or worsening elopement behaviorsf) Policy on missing residentg) Responding to alarms andh) Enhanced supervisioni) Reporting to the Administrator/Maintenance Director any concern related to exits The training will be completed on 7/19/2026 by Administrator (V1) will provide training to the DON (director of nursing) (V2), and ADON (Assistant Director of Nursing) (V3). Any staff who are not available, on vacation or leave of absence will have training completed at the start of their shift upon return to work. To be ongoing to include new hires and agency staff.To measure knowledge retention, post tests will also be started on 7/19/2026. The Administrator/Director of Nursing/Social Services Director/HR Director/Staffing Coordinator will conduct posttests of five (5) random staff to evaluate knowledge retention. Five (5) posttests per week for four (4) weeks will be completed, starting on 7/19/2026. The acceptable score of the post-test is 100%. Any staff who will not meet the acceptable score will receive additional training. The Administrator/Director of Nursing/Social Services Director will provide the staff with training on specific areas based on the results of the post tests.To ensure that all staff are trained prior to the start of their next shift if off duty, the DON/Administrator (V2)/(V1)/(V40) and or (V41) will notify the staff to meet with their supervisor/charge nurse/DON when they return to work. The supervisor/charge nurse/DON will ensure that the training is done before starting their work shift. The Administrator/DON/Social Services Director/HR Director/Staffing Coordinator will provide the training. If the DON/Social Services Director are not available, a trained nurse will provide the training.The facility will conduct the same training quarterly for four (4) quarters, and then annually thereafter. The training will also be included in the orientation of new employees.The DON (V2)/Social Services Director (V37)/Administrator (V1)/Human Resources Director (V40) and/or (V41), staffing coordinator will provide the same training to the agency staff.B. Actions to Prevent Occurrence/Recurrence:1. Ad-Hoc QAPI meeting was completed on 7/19/2026 by the leadership team which includes the Director of Nursing (DON), Social services Director (SSD), Maintenance Director, Business office Manager (BOM), Rehabilitation Manager, Human Resource Director and the Activities Director (AD). The Medical Director also participated via telephone. The QAPI team discussed the incident and the corrective actions to prevent similar events.2. Elopement drill will be completed on 7/19/2026 by the Maintenance Director (V39), DON (V2) and Administrator (V1). This will also be completed daily, for the seven (7) days, and will be done at different shifts. After seven (7) days, the elopement drills will be done weekly for three (3) months, then monthly thereafter.The elopement drills will be completed per policy, as indicated above.3. All exit doors in the facility will also be checked by the Maintenance Director (V39) on 7/19/2026 to ensure all doors were locked and secure and that delayed egress was functioning properly.Door checks will be completed daily, including weekends by the MOD-manager on duty/charge nurse. The door checks will be completed by Maintenance Director, or other members of the maintenance team. If there is any concern identified, the Administrator and/or the Maintenance Director will be notified immediately. If there is any concern with the door, a staff member will be assigned as door monitor until the door concern is addressed.4. Daily, the DON, clinical managers, and members of the IDT will hold clinical meetings and discuss new or worsening wandering/exit-seeking behaviors. Any new and/or worsening behaviors will be addressed by ensuring that appropriate clinical interventions are implemented to prevent an incident of elopement. The MOD (manager on duty)/charge nurse, DON will also conduct weekend clinical meetings to review new or worsening exit seeking/wandering behaviors and ensure interventions are in place to prevent elopement. 5. New admissions will be reviewed by the DON, ADON or MDS for elopement risk and any resident identified as being at risk will be updated into the facility elopement books.6. The QAPI team will hold a weekly Ad-Hoc QAPI meeting to discuss the elopement prevention program and review interventions to new/worsening wandering/exit-seeking behaviors. The QAPI team will determine if additional corrective actions are necessary based on concerns identified.The Administrator/Social Services Director/DON will conduct audits of the Elopement Binder daily for three (3) months to ensure that identified elopement risk are included in the binder. Additionally, the Administrator/Social Services Director/DON will also review five (5) residents weekly for three (3) months to ensure that residents who are identified with new and/or worsening exit-seeking behaviors and wandering are being addressed in the care plans. After three (3) months, the QAPI team will determine if additional monitoring or corrective actions are necessary.To evaluate the effectiveness of the removal plan, QAPI team will review results of the audits, posttests, door checks. The QAPI team will determine if additional monitoring or corrective actions are necessary based on the review of monitoring activities. 2. Findings include:R2's EMR (Electronic Medical Record) undated documents that the resident was admitted to the facility on [DATE].R2's EMR dated 5/13/26 documents a diagnosis of polyneuropathy, unspecified; dementia in other diseases classified elsewhere, moderate with mood disturbance; and acquired absence of left leg below knee.R2's EMR dated 5/14/26 documents a diagnosis of diabetes mellitus due to underlying condition with foot ulcer.R2's EMR dated 7/9/26 documents a diagnosis of multiple fractures of ribs unspecified side, subsequent encounter for fracture with routine healing and nontraumatic subarachnoid hemorrhage, unspecified.R2's MDS (Minimum Data Set) dated 6/30/26 documents a BIMS (Brief Interview for Mental Status) score of 15 out of 15. The MDS documents that the resident requires partial/moderate assistance for roll left and right. The MDS documents that the resident requires substantial/maximal assistance with sit to lying. The MDS documents that the resident is dependent on staff for lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, and toilet transfer.R2's Care Plan dated 6/10/26 documents Resident is at risk for falls. The resident has BALANCE OR WALKING IMPAIRMENTS., The resident has a HISTORY OF FALLS., The resident frequently FORGETS TO USE SAFETY/ADAPTIVE EQUIPMENT such as:(please SPECIFY), The resident EXPERIENCES WEAKNESS., The resident TAKES MEDICATIONS that may cause dizziness, loss of balance, or impair judgement. Resident uses wheelchair for mobility to support fall prevention and promote resident safety.Intervention added on 6/30/26: OTHER INTERVENTION ensure the resident is properly positioned and secured with the appropriate seat belt or wheelchair tie-down system before the vehicle moves.R2's Health Status Note dated 6/30/2026 at 12:37 PM documents Reported to this nurse by staff that guest fell out of w/ c (wheelchair) hitting the back of his head . Guest evaluated for injuries. sustained abrasion to back of head. Neuro checks initiated sent to ER (Emergency Room) for eval (evaluation). T (temperature) 97.7 P (pulse) 80 R (respirations) 20 B/P (blood pressure) 132/ 89 SPO2 (oxygen saturation) 95 % R/A (room air).R2's Care Plan Summary dated 7/1/2026 at 11:33 AM documents 0 1 Fall IDT (Interdisciplinary Team) reviewed fall and after further review. Resident was being transferred to an appointment via facility van. Transportation CNA (Certified Nursing Aid) reported that resident fell back in wheelchair when she went to drive the van. Resident wheelchair was not secured. Resident assessed immediately by DON (Director of Nursing). Neuro checks WNL (within normal limits). ROM (Range of Motion) WNL. Abrasion noted to back of head. Resident complained of pain to left 4th finger. Resident sent to ER (Emergency Room) for evaluation. Resident returned to facility and ER nurse reported resident's x-rays and CT (Computer Tomography) scans were negative. When requested all x-ray results. X-ray of left-hand revealed fracture to distal fourth digit. Splint in place. MD (Medical Director) notified and will follow at facility. RCA (Root Cause Analysis): wheelchair not secured in facility van before attempting to drive resident to his appointment. Intervention: ensure the resident is properly positioned and secured with the appropriate seat belt or wheelchair tie-down system before the vehicle moves IDT reviewed fall and after further review. Resident was being transferred to an appointment via facility van. Transportation CNA reported that resident fell back in wheelchair when she went to drive the van. Resident wheelchair was not secured. Resident assessed immediately by DON. Neuro checks WNL. ROM WNL. Abrasion noted to back of head. Resident complained of pain to left 4th finger. Resident sent to ER for evaluation. Resident returned to facility and ER nurse reported resident's x-rays and CT scans were negative. When requested all x-ray results. X-ray of left-hand revealed fracture to distal fourth digit. Splint in place. MD notified and will follow at facility. RCA: wheelchair not secured in facility van before attempting to drive resident to his appointment. Intervention: ensure the resident is properly positioned and secured with the appropriate seat belt or wheelchair tie-down system before the vehicle moves (V2), (V12) (V13) (V5)/(V10) self (V9). On 7/22/26 at 2:04 PM, V14, CNA stated that she was the person that secured (R2) into the van before his appointment. She stated that she was trained to be a driver. She stated that she thought that she had properly secured (R2) but thinks she forgot to clamp the front of his wheelchair. She stated that (V10) was going along as a helper and that (V5) was the driver. She stated that she locked the wheelchair and put on his seatbelt.On 7/22/26 at 2:12 PM, V5, Driver stated that she was the driver the day that (R2) fell. She stated that she went to the bathroom and another CNA decided to secure (R2) into the van. She stated that when they exited the parking lot to go to (R2's) appointment, she was turning and (R2) tipped backwards in his wheelchair. She stated that the front wheels on his wheelchair were not clamped. She stated that she always clamps all 4 wheels.Facility's policy Transporting a Resident (Facility Van) dated 6/30/26 documents It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary. 5. The van will be well-maintained and equipped with safety features. Each resident will be secured by a seatbelt. All wheelchairs will be secured with wheelchair tie-downs.

Based on interview and record review the facility failed to ensure newly identified pressure wounds were assessed and failed to follow physician orders for administration of treatments to pressure wounds for two (R3 and R7) of four residents reviewed for pressure wounds in the sample list of 10.1.R3's undated Care Plan documents R3's diagnoses include Severe Protein-Calorie Malnutrition, Pressure Ulcer to Right Heel, Open Wound to Right Foot, Muscle Weakness, and Parkinson's Disease. This Care Plan further documents an admission date of 03/15/2025. R3's Care plan dated 12/04/2025 documents a Focus to Document Pressure Ulcer with interventions to evaluate skin for areas of blanching or redness, evaluate ulcer characteristics, monitor bony prominences for redness, and provide wound care per treatment orders. R3's Care plan dated 5/20/2026 documents R3 has decreased mobility with functional limitation in range of motion to bilateral upper extremity (BUE)/ bilateral lower extremity (BLE) related to: Parkinson's Disease. R3's Care Plan dated 3/6/2026 documents R3 had actual skin impairment. Left buttock-pressure 7/7/25; Right heel-pressure 7/7/25; Left lateral buttock 2/4/26; Right pad of foot 2/16/26; Ball of right foot 3/6/2026. R3's Minimum Data Set, dated [DATE] documents R3 has moderate cognitive impairment. R3's Health Status Note dated 3/19/2026 documents nurse completed (R3's) treatment, upon assessment, Left foot edema was noted to be present, as well as Right back side pressure injury that was red and warm to touch, Right hip side red and warm to touch, and a blister noted to the Right knee. (R3) was repositioned to the Left side, with pillows under and in-between (R3's) knee(s) as well as a wedge to keep (R3) off of (R3's) buttock. (R3) is resting in bed, with call light in reach. No distress noted at this time and (V28) Nurse Practitioner (NP) has been notified. R3's Provider Note written by V28 dated 3/19/2026 documents (R3) is being seen acutely today as nursing staff report that (R3) continues to decline. Now with reports of worsening reddened areas on certain pressure points. Erythema noted to right hip, erythema and blistering noted to right knee, some erythema noted to bony prominences to left foot. (R3) appears to have several new reddened skin areas to several different pressure points, concerns with possible Kennedy terminal ulcer to the left heel monitor and notify provider of any further acute changes in condition. On 6/29/2026 at 1:23 p.m., V15 Licensed Practical Nurse (LPN) stated on 3/19/2026, V15 observed a new skin concern with R3. V15 stated R3 had non blanchable redness to left foot and right hip, and a blister to the right knee. V15 stated V15 notified V28 and was advised to refer to V5 Wound Nurse. V15 confirmed V15 reported the new skin concern to V5 and V5 stated V5 will take care of the new skin issues. V15 stated V15 was not aware of any interventions after V15 reported the new skin issues to V5. V15 stated any newly identified skin issues should have treatment orders as soon as they were identified and they should be recorded to be measured weekly. V15 confirmed there was no treatment or records of the new wounds after V15 reported the skin concerns to V5. On 6/29/2026 at 12:08 p.m., V12 LPN stated each wound should have their own treatment order on Treatment Administration Record (TAR) for nurses to refer for continuity of care. V12 stated if V12 gets the order directly from the provider, V12 puts the order in, otherwise V5 puts the treatment orders in. V12 stated newly observed wounds should be assessed and measured upon initial observation and then weekly thereafter. On 6/30/2026 at 12:25 p.m., V23 Registered Nurse stated treatment orders for any skin issues should be entered and implemented on the day the wounds were identified. V23 stated wound treatments should not be delayed. V23 stated skin issues including pressure ulcers should be assessed, measured and recorded upon identification. V23 stated wounds are being assessed weekly by V5 wound nurse. On 6/30/2026 at 3:10 p.m., V28 Nurse Practitioner (NP) stated R3 had existing pressure wound prior to the visit on 3/19/2026 and confirmed the new areas noted on V8's documentation on 3/19/2026 were newly identified pressures wounds. V28 confirmed the orders V28 provided for these newly identified pressures wounds for R3 was to monitor them and notify V28 if there were changes. V28 stated V28 expects separate wound treatments for each wound to be in place in R3's physician's orders for continuity of care. V28 stated wound treatments should be implemented as soon as the wounds were identified. On 6/30/2026 at 9:49 a.m., V5 Wound Nurse stated each wound should have their own separate treatment orders. V5 stated if there were new skin issues, it should be reported, recorded and the provider notified. V5 stated wounds should be measured and recorded upon initially identifying. V5 stated the treatment order should be entered in the resident's individual chart on the day the wound was initially observed. On 6/30/2026 at 12:38 p.m., V5 Wound Nurse stated there were no treatment orders to R3's new reddened areas and blister identified on 3/19/2026 because they do not do anything with an unopen pressure wounds except to monitor. V5 confirmed V28's recommendation to monitor the new skin issues on V28's provider notes dated 3/19/2026 was considered a physician order and should have been entered as physician's order under Treatment Administration Record (TAR). V5 confirmed nurses refer to the TAR for providing treatment and interventions for continuity of care. 2. R7 was admitted to the facility on [DATE] with documented medical diagnoses including Type 2 Diabetes Mellitus, Parkinson's disease, and Mild Protein-Calorie Malnutrition. The clinical admission referral packet dated 2/11/2026 documented an unstageable vascular wound to the left outer foot and a surgical wound to the left second toe following prior amputation. The first wound care orders entered into R7's electronic health record were dated 2/18/2026 with a start date of 2/19/2026 at 0700 for the left second toe. Additional wound care orders were entered on 2/19/2026 with a start date of 2/20/2026 at 0700 for the left fifth toe wound. A revision order entered on 2/18/2026 for the left fifth toe was discontinued on 2/19/2026 at 11:06 AM. Review of the February Treatment Administration Record showed these treatments were documented as completed daily beginning on their respective start dates. On 6/29/2026 at between 12:10PM and 12:54PM, V2 (Director of Nursing), V5 (Wound Nurse), and V29 (Licensed Practical Nurse) stated that the admitting nurse is responsible for entering wound care orders upon admission. V2, V5 and V29 reported that when discharge orders are unclear or incomplete, the admitting nurse contacts the facility's Medical Director for guidance. On 6/29/2025 at 12:54PM, V5 stated that if wound care instructions upon admission are incomplete, nursing staff are expected to obtain specific orders and enter them into the electronic health record at that time. V5 stated that V5 or the weekend wound nurse performs follow-up wound and skin assessments the day after admission or after a weekend admission. V5 confirmed that R7 was admitted with a Stage 3 pressure ulcer to the left outer foot and a surgical wound to the left second toe. She stated that R7's discharge paperwork from the hospital indicated continue wound care but did not specify treatments. On 6/29/2026 at 2:00 PM, V5, the Wound Nurse, provided a wound-care script dated 2/14/2026 signed by V35, Medical Doctor, instructing staff to cleanse the left second toe and left lateral foot daily with wound cleanser and apply a foam pad until assessed by wound care nurse. Review of R7's February 2026 Physician Orders Sheet (POS) and Treatment Administration Record (TAR) showed no wound care orders entered or in effect from 2/14/2026 through 2/18/2026. On 6/30/2026 at 2:15PM, V5 acknowledged that although the 2/14/2026 physician script clarifying wound care orders was uploaded into the chart under miscellaneous documents, no corresponding wound care orders were entered into the electronic health record, and therefore no wound treatments were in place from 2/14/2026 to 2/18/2026. V5 confirmed that the three wound care orders dated 2/18/2026 and 2/19/2026 were the only orders placed, and that the start dates were accurate. V5 acknowledged that R7 had no wound care orders implemented during the first five days following admission. The facilities Pressure Injury Prevention and Management policy revised on 12/28/2025 documents wound treatments will be provided in accordance with physician's orders and Licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Findings should include type of wound, wound measurements (measured upon discovery and at least weekly thereafter), other wound characteristics (color, exudate, odor, pain, tissue type in wound bed), and treatment and interventions implemented.

Based on observation, interview and record review the Facility failed to ensure steam table holding temperatures were in safe range, to prevent the growth of harmful pathogens for ensuring the safety and quality of the food served to residents for 8 of 13 residents (R2, R3, R7, R8, R10, R11, R12 and R13) reviewed for food temperatures in the sample of 15. Findings include: On 1/17/2026 at 12:02 PM, the steam table was cool to the touch as the food was being placed on the steam table. On 1/17/2026 at 12;05 PM, the chili, the alternate menu item was placed on the steam table by V5, Food Service Worker but no food temperature as taken. On 1/17/2026 at 12:30 PM, the chili did not have any steam coming from it. On 1/7/2026 at 12:42 PM, the Temperature Logbook was on the middle cabinet close to the stove. There were no temperatures documented for the lunch menu on 1/17/2026. On 1/17/2026 at 12:55 PM, during the lunch service after the last resident had been served food temperatures were taken with a calibrated metal thermometer and the pureed vegetables were 121.4 F (Fahrenheit), the gravy was 128.0F, and the mechanical chicken 100.5F and the chili was 118.0 F. These items were not being held at 135.0 F or higher on the steam table. On 1/17/2026 during the lunch service from 12:00 PM to 12:55 PM, R2, R3, R7 and R8 were all observed to be served chili during the lunch service. On 1/17/2026 at 1:00 PM, R7 stated she was served chili today and it could have been hotter. On 1/17/2026 at 1:04 PM, R2 stated her chili was lukewarm. Food is so so. Food is not always hot, like today, the chili was not hot. On 1/17/2026 t 1:54 PM, R3 stated he has been here in this facility for several years. He stated the food is hit and miss some days better than others. His food is cold and thinks the food could be warmer. Chili not so great today. On 1/22/2026 the Facility provided a list of residents on pureed diets and the following residents were documented as receiving a pureed diet R10, R11, R12 and R13. On 1/22/2025 at 1:38 PM, V24, Dietitian stated, I would expect staff to take temperatures on all items they place in the steam table and document those temperatures in the Food Temperature Logbook. I am not really sure what the food temperature should be on the steam table for holding, but I will find out. I come from the hospital and just started in June. Holding the food at the correct temperature is important to prevent illness, prevent bacteria from growing and causing food borne illness, to kill harmful pathogens and all sorts of things. This population can especially be vulnerable. On 1/22/2025 at 1:55 PM, V24 stated the policy for the Facility for holding food is 140.0 F. R14's Grievance Form dated 11/4/25 documents, Resident served cold cheeseburger for dinner. (It was so cold the cheese didn't melt).R2's Grievance Form dated 11/5/2025 documents, Last night cold grilled cheese, cold tomato soup. R15's Grievance Form dated 11/4/2025 documents, Resident was served cold cheeseburger and fries for dinner last night.The Food Policy with a revision date of 1/31/2024 documents, Check hot foods regularly to make sure they're held at or above 140 F. 6. Recordkeeping: Final Cooking and Reheating Log: (Facility) Food Cold Hot Holding Log: for all (Facility) foods being hot or cold held during internal and external catering (or other form of documentation as required by state or client contract.)

Based on interview and record review, the facility failed to assess and implement appropriate fall intervention for 1 of 3 (R3) residents reviewed for falls in a sample list of 28. This failure resulted in R3 experiencing an unwitnessed fall, sustaining a laceration to his forehead requiring 8 sutures by local hospital.Findings includeR3's Care Plan, dated 10/22/2025, documents that R3 at risk for falls. The resident has impaired cognition and impaired safety awareness. The resident has balance or walking impairments. The resident has a history of falls., The resident has FUNCTIONAL IMPAIRMENTS OF THE LOWER EXTREMITIES which causes safety issues with transfers and/or walking. Interventions anticipate and meet resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Fall RISK evaluation. Frequent monitoring of resident to ensure safe positioning and needs are met. Keep bed in lowest position acceptable by the resident when the resident is in bed. Turn and reposition. Visual and or verbal reminders to use call light. Family does not want resident to sit up for more than 30 minutes at a time. Discussed with family importance of sitting up for longer intervals to improve resident's strength.R3's Minimum Data Set, dated [DATE], documents that R3 is severely cognitively impaired and dependent on staff for mobility.R3's Fall Assessment, dated 10/15/2025, documents that R3 is high risk for falls.R3's admission Assessment, dated 10/16/2025, documents that R3's has unsteady gait requiring supervision, impaired balance, and has weakness.R3's Progress Note, dated 10/21/2025 at 4:47 PM, documents that Nursing staff request this NP evaluate the patient after a ground-level fall with injury. Nursing staff report patient was sitting in his wheelchair waiting the CNA to bring him to the shower. Staff report he was left alone no longer than 4 min. Patient stood up and attempted to walk and lost his balance and his head on the doorknob. He sustained a laceration to his forehead and a puncture wound to his upper lip just beneath his nose. Pressure was applied to his forehead laceration and bleeding had stopped prior to this NP's arrival at bedside.R3's Fall Report, dated 10/21/2025 at 1:15 PM, documents that Incident Description: Nursing Description: This nurse heard a boom and walked down hallway to find resident crawling on floor towards door. Resident Description: Resident Unable to give Description. Was this incident witnessed: N (no). Mental status: oriented to person and situation. Injury type/location: laceration/Face. Notes: resident noted to have a laceration in the middle of his forehead. Predisposing Physiological Factors: Confused and Impaired Memory. Predisposing Situation Factor: Ambulating without assist. Other Info: R3 was in bed after lunch, family requested that he be returned to bed following meal. Family left shortly before resident was returned to bed. Nurse heard noise in room -when she entered room, resident was seen crawling on the floor next to his bed. Resident had sustained a laceration to the middle of his forehead.On 10/23/2025 at 2:28 PM V6, R3's daughter, stated that she and her family visited R3 several days during his stay at the facility. V6 stated that on the day of his fall R3 was up in his wheelchair in the dining room. V6 stated that they were happy about this because R3 had been in the bed at the hospital for 5 weeks. V6 stated that they noticed that R3 was agitated, moving, yelling, and felt maybe the environment was overstimulating for R3. V6 stated that they asked if he could lay down after his meal and was told that this was possible. V6 stated that the family left. V6 stated that shortly after she received a call that R3 fell out of the bed and fell to the floor. V6 stated that she was informed that R3 was crawling on the floor with blood coming from head. V6 stated that she was informed that R3 would be sent to hospital due to having a cut on his head. V6 stated that she was informed that they knew R3 wouldn't stay in the bed and that is why they took his wheelchair out of the room.On 10/27/2025 at 12:50 PM V9, Licensed Practical Nurse, stated that she was R3 nurse on the day of his fall. V9 stated that the family was visiting and requested that R3 lay down after his meal. V9 stated that R3's family left and R3 stayed in the dining area until he started throwing cups and things. V9 stated that R3 was at that time removed from the dining area. V9 stated that she and V18, Certified Nurses' Assistant, assisted R3 into the bed. V9 stated that R3 was restless, not wanting to stay in the bed and not wanting to be in the chair. V9 stated V18 said that R3 needed a sitter. V9 stated that when admitted they didn't say he needed one. V9 stated that she informed V18 that she would have to talk with management. V9 stated that she informed V18 to go and take care of her other residents. V9 stated that she stayed and tried to calm R3 and keep him still and not trying to get out of the bed. V9 stated that she thought she had calmed and left the room. V9 stated that she made it to the nurses' station and heard a noise. V9 stated that she headed down the hall and saw R3 crawling on the floor with blood coming from head.On 10/28/2025 at 9:52 AM V15, CNA, took care of R3 the day before the fall. V15 stated that R3 was antsy and would move all over the bed. V15 stated that you had to check on R3 every 15 to 30 minutes because he would be all over the place. V15 stated that she never saw R3 stand up to transfer himself. V15 stated that she had came in the room and R3 was in a different position than she left him in.On10/29/2025 at 9:30 AM V9 stated that R3 would roll around in his bed. V9 stated that he would strip clothing and remove his gown and incontinent brief. V9 stated that R3 would pull at his catheter. V9 stated that he would roll around in the bed. V9 stated that she did not see him trying to get out of bed, but he did lay close to the edge with his feet hanging out at times. V9 stated on the day of the fall R3 had gotten up in his wheelchair. V9 stated that R3 didn't want to stay in the chair or in the bed. R3's family came to visit. V9 stated that R3 was throwing dishes and was brought to his room. V9 stated that R3 was assisted to bed. V9 stated that V18 took the wheelchair out of the room to keep R3 from trying to transfer himself. V9 stated that she can't make the decision for a 1 on 1. V9 stated that she must notify and wait for management before a 1 on 1 can be put in place.On 10/29/2025 at 10:56 AM V18, CNA, stated that she was assigned to R3 on the day of his fall. V18 stated that R3 was restless, trying to stand up, get out of bed, and once in the chair he would try to get out of the chair. V18 stated that R3 was making sudden abrupt movements. V18 stated that she knew R3 wasn't safe and stayed with him to keep R3 safe. V18 stated that she stayed with R3 until restorative came and got him up. V18 stated that R3 was taken to the dining area next to the nurses' station so he could be monitored. V18 stated that shortly after getting to the dining room R3's family came in. V18 stated that she was picking up hall trays and V9 brought R3 back to his room and V18 helped transfer R3 to the bed. V18 stated that they laid him down. V18 stated that R3 was making abrupt jerking movements, trying to get up and then trying to sit down repeatedly. V18 stated that he was not safe alone. V18 stated that she left the room once R3 was in the bed and V9 stayed with R3 to keep an eye on him. V18 stated that she knew he was unsteady, and they had removed the wheelchair to keep R3 from trying to transfer self into it. V18 sated that she sat with him earlier. V18 stated that once you lay him down you had to get him up. V18 stated that R3 would not stay in the bed, and he would not stay in the wheelchair. V18 stated that R3 was confused he was in a different time frame. V18 stated that R3 was saying that his car was stranded and that he needed to go get it. V18 stated that they stayed with R3. V18 stated that at no time was R3 left alone. V18 stated that R3 wasn't safe. R3 stated that the 1 on 1 was provided to keep R3 safe from falling and getting hurt.On 10/30/2025 at 8:50 AM V1, Administrator, stated that if a staff observes a situation that puts a resident at risk for fall and or injury the staff are to put interventions in place at that time and notify management. V1 stated that once they meet the intervention may change. V1 stated that she is confident in her charge nurses that they can implement and discontinue interventions. The facility's Fall Prevention policy, dated 8/15/2025, documents that Policy: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Policy Explanation and Compliance Guidelines: 2. Upon admission, the nurse will complete a fall risk assessment along with the admission assessment to determine the resident's level of fall risk. 4. Low/Moderate Risk Protocols: a. Implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to: i. A clear pathway to the bathroom and bedroom doors. ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. iii. Call light and frequently used items are within reach. Iv. Adequate lighting. v. Wheelchairs and assistive devices are in good repair. b. Monitor for changes in resident's cognition, gait, ability to rise/sit, and balance. c. Encourage residents to wear shoes or slippers with non-slip soles when ambulating. d. Ensure eyeglasses, if applicable, are clean and the resident wears them when ambulating. e. Monitor vital signs in accordance with facility policy. f. Complete a fall risk assessment every 90 days. and as indicated when the resident's condition changes. 5. High Risk Protocols: a. The resident will be placed on the facility's Fall Prevention Program. i. Indicate fall risk on care plan. b. Implement interventions from Low/Moderate Risk Protocols. c. Provide interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: I. Assistive devices ii. Increased frequency of rounds iii. Sitter, if indicated iv. Medication regimen review v. Lowbed vi. Alternate call system access VII. Scheduled ambulation or toileting assistance v111. Family/caregiver or resident education IX. Therapy services referral

Based on observation, interview, and record review the facility failed to ensure housekeeping services were provided to maintain a clean and sanitary environment for 9 of 14 (R3, R8, R16, R17, R18, R19, R20, R21, R22, R23) residents reviewed for housekeeping on the sample list of 23.Findings include:The Resident Council Meeting Minutes, dated 9/10/2025, documents that New News Housekeeping/Laundry: Resident have concerns about shower rooms not being mopped.The Resident Council Meeting Minutes, dated 10/15/2025, documents that New News Housekeeping/Laundry: Resident have concern about floors being dirty/sticky.On 10/27/2025 from 9:05 AM to 9:18 AM a tour was performed on 100 hall and 200 hall revealed:1. room [ROOM NUMBER], R16's and R22's room, had large torn pieces of incontinent briefs, food green beans and potatoes, and empty diet Coke bottle on floor. The floor was sticky when waking on it.2. room [ROOM NUMBER], R19's and R23's room, large torn pieces of incontinent briefs, soiled undergarments in trash can, strong urine odor in room and hallway. Flies observed in room on bed.3. room [ROOM NUMBER], R20's and R21's room, Strong urine odor immediately upon walking to doorway. Floor sticky and shoes sticking to floor when walking in room. Food on floor mat and floor of room. 2:26 PM Floor remains sticky with food on mat and floor.4. room [ROOM NUMBER], R17's and R18's room large torn pieces of incontinent briefs on floor, used gloves on floor.On 10/23/2025 at 2:28 PM V6, R3's daughter, stated that she visited her father for several days. V6 stated that on day 1 she came to the facility and her father was hanging out of the bed with his catheter tangled around his legs. V6 stated that there were a pair of urine-soaked pants hanging in the bathroom and R3 was laying in feces. V6 stated that on day 2 the pants remained wet and hand hanging in the bathroom. V6 stated that the floor was sticky with dirt and food on the floor. V6 stated that on Day 4 the floor remained sticky, and the same dirt and food remained on the floor. V6 stated that she asked the staff about the floor and did not get a response.On 10/23/2025 at 2:55 PM R1 stated that housekeeping does not clean her room every day. R1 stated that the floors are not mopped every day. R1 stated that they don't clean to her standards. R1 stated that she has her own hand dust mop and does some cleaning herself.R1's Minimum Data Set (MDS), dated [DATE], documents that R1 is moderately cognitively impaired.On 10/27/2025 at 9:00 AM V5, Housekeeper, stated that she is assigned a specific area to clean each day. V5 stated that she cleans and mops the residents' rooms that she is assigned daily. V5 stated that cleaning the rooms and mopping the floor daily is apart of her daily duties.On 10/27/2025 at 9:12 AM V7, Certified Nurse's Assistant (CNA), stated that housekeeping does come on the hall but not every room is cleaned.On 10/27/2025 at 1:10 PM R11 stated that the room are not cleaned every day. R11 stated that they have gotten better but it's not every day. R11 stated that her floor is sticky for days and sometimes it gets cleaned up and sometimes it doesn't.On 10/27/2025 at 2:24 PM R17 stated that her room is not cleaned every day. R17 stated that they do come from time to time and mop the floor and wipe stuff down but not daily.R17's sIDT IPOC (Care Plan/Care Conference), dated 10/2/2025, documents that R3 is alert and oriented x3 with little confusion.R11's 72 HR Occurrence F/U Charting, dated 10/6/2025, documents that R11 is alert and oriented.On 10/27/2025 at 1:16 PM R10 stated that he is the vice president of resident council. R10 stated that it is a concern of the cleanliness of the facility. R10 stated that housekeeping does not consistently clean the rooms as they should. R10 stated that the rooms are not cleaned daily.R10's MDS, dated [DATE], documents that R10 is cognitively intact.On 10/27/2025 at 3:10 PM V12, Housekeeping Supervisor/Assistant, stated that daily the residents' room are to be deep cleaned. V12 stated that the trash is pulled, the high and low touch areas are cleaned, and the floors are mopped. V12 stated that this includes the bathrooms. V12 stated that they clean the hallways and common areas daily. V12 stated that they have not been able to clean the resident rooms because they are short of staff. V12 stated that this is what happened today. V12 stated that they have had staff quit, not come to work, or don't work when at facility. V12 stated that they are actively hiring. V12 stated that they have job listings on websites.On 10/28/2025 at 9:47 AM V14, Social Service Director, stated that she was notified of V6's concerns 40 minutes after being posted on the internet. V6 stated that she was a little shocked because she had been in communication with V6 throughout R3's stay and this had not come up. V6 stated that R3 did have concerns of the cleanliness of the building, R3's bedroom floor being sticky and R3's catheter being tangled. V6 stated that she called up to the facility for them to address the concerns and informed V6 that she would have management give her a call on the following day.The facility's Daily Resident/Patient Room Cleaning Procedure, not dated, documents that Procedure: The room cleaning tasks should be performed in the following order: 1. Straighten up the resident's room; 2. Dust all flat surfaces with a cloth and disinfectant, clean the air vent covers, and spot clean all necessary areas; 3. Dust mop the floor and sweep all trash and debris to the door and pick it up with the dustpan. 4. Empty and clean the trashcans and put in a new liner if necessary. 5. Wet mop the room using disinfectant, ensuring a CAUTION floor sign is in use.The facility's Routine Cleaning and Disinfection policy, dated 1/2025, documents that It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. It also documents Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.The facility's Deep Clean Check Off List, not dated documents that This room must be sanitized, dusted and dirt-free when you are done. CHECK OFF THE FOLLOWING AREAS WHEN COMPLETED: 1. Pull out beds and sweep/vacuum under, wipe down bed frames and springs as well. 2. Pull out dressers and sweep/vacuum under, do not forget to wipe down sides as well. 3. Dust and wipe down TV and underneath 4. Clean and dust bed frame, pillows, and springs. 5. Clean ceilings, vents, and light fixtures. 6. Clean windowsills and inside of window. 7. Clean and wipe down heater/a.c. units, remove trash from inside of units. 8. Clean and wipe down pictures on walls. 9. Clean and wipe down [NAME].ge cans inside and out. 10. Clean and wipe down all walls (ESPECIALLY NEXT TO TRASH CANS AND SOAP DISPENSERS). 11. Check bed linens for rips or tears. 12. Check skid strips and alert management if they need to be replaced. 13. Clean and wipe down doors, door jams and door frames. 14. Clean and wipe down closets and shelves, inside and outside. 15. Clean and wipe down all table, nightstands and rolling tables. 16. Clean and wipe down all chairs - legs and backs included. 17. Clean and wipe down baseboards/edges (use scraper to remove dirt in corner). 18. Clean and disinfect floor. 19. Clean and disinfect toilet. 20. Clean and disinfect sink. 21. Disinfect and wipe down bathroom pull cords. 22. Clean and disinfect shower stall/tub. 23. Clean and wipe down vents. 24. Clean and wipe down ANY wheelchairs in the room. 25. Inspect curtains for spills or damage and alert management if they need replaced. 26. Clean and disinfect any refrigerators. 27. Clean and disinfect any phones, remotes, call lights and anything else in the room.

Based on interview and record review the facility failed to provide showers twice a week to 2 of 4 residents (R1 and R8) reviewed for bathing in the sample of 11. Findings include: 1. R1's Bath and Skin Report sheet dated April 2025 documents bath or shower preference to be done AM on Monday and Thursday. R1's bath and skin report does not document a shower being given from 4/14/2025- 4/23/2025. R1's Face Sheet dated 4/23/2025 documents in part a diagnosis of Quadriplegia, Dysphagia, Speech and Language Deficits following Cardiovascular Disease. R1's Care Plan dated 7/9/2022 documents R1 has an Activity Daily Living (ADL) self-care performance deficit related to Cerebrovascular Accident (CVA), Weakness. R1's care plan documents interventions R1 currently requires assistance for bathing total 2. R1's Care plan documents R1 has bowel incontinence related to immobility. R1's Minimum Data Set (MDS) dated [DATE] document unable to do Brief interview for Mental status due to R1's cognitive impairment. 2. R8's Bath and Skin Report sheet dated April 2025 documents shower preference AM. R8's sheet documents Tuesday and Friday as shower days. R8's Bath and Skin Report Sheet does document R8 had a shower on 4/4/2025, and next documented shower 4/15/2025. R8's Bath and Skin Report does not document R8 receiving a shower from 4/4/2025-4/15/2025. R8's Bath and skin report does not document R8 receiving a shower from 4/15/2025- 4/21/2025 with last documented shower on 4/22/2025. R8's Care Plan dated, 6/19/2024 documents R8 has a ADL self-care performance deficit needs and participation may vary. R8's Care Plan documents the following interventions; R8 currently requires assistance with ADL's , Bathing physical help of one staff On 4/22/2025 at 1:23PM V5, Maintenance stated a circualtion pump had been down at the facility. V5 stated there was no hot water on Friday. V5 stated he did repairs and was called back in on Saturday for no hot water. V5 stated he called (outside contractor) and they helped him trouble shoot. V5 stated parts were ordered and he got them on Monday and installed. V5 stated water temps were not high enough to gives showers at that time. V5 stated after parts installed took about 2 hours for holding tank to fill to get temps up. On 4/23/2025 at 10:25AM V2, Director of Nursing (DON) stated residents are expected to get showers twice a week or more if soiled or incontinent. The facility policy Bath/shower/tub dated revised February 2018 documents the purpose is to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy documents documentation; the date and time the shower/tub bath was performed, if the resident refused the shower/tub bath the reason why and intervention taken. the signature and title of the person recording the data.

Based on observation, interview and record review the facility failed to change dressing and provide skin care daily to Gastrostomy (G ) tube for 1 of 3 residents (R2) reviewed for enteral feeding tubes in the sample of 11. Findings include: 1. On 4/22/2025 at 9:03 AM R2's Gastrostomy (G) tube dressing in place with date of 4/18/2025 as verified by V3, Licensed Practical Nurse (LPN). R2's Care plan dated 3/21/2025 documents R2 requires tube feeding related to oropharyngial dysphagia after Cerebrovascular Accident (CVA). R2's care plan documents intervention; provide skin care to insertion site daily and as needed (PRN). R2's Physician Order (PO) dated 4/22/2025 documents G-tube site care - cleanse site and apply dry split gauze dressing every night after 12 AM. On 4/22/2025 at 9:03 AM V3, Licensed Practical Nurse (LPN) stated R2's gtube is to be cleaned and dressing changed daily. The facility policy Gastrostomy/Jejunostomy Site Care dated revised April 2025 documents the purpose of the procedure is to promote cleanliness and to protect the gastrostomy or Jejunostomy irritation, breakdown and infection. The policy documents to verify there is PO for the procedure, review the resident's care plan and provide for any special needs for the resident. The policy documents person performing the procedure should record the following information in the resident's medical record which would include date and time procedure was formed.

Based on interview and record review the facility failed to prevent verbal abuse for 1 of 3 residents (R6) reviewed for abuse in the sample of 9. Findings include: R6's (Electronic Medical Records (EMR) undated documents that resident was admitted to the facility on [DATE]. R6's EMR dated 4/4/25 documents R6 has diagnoses of spinal stenosis, lumbar region without neurogenic claudication; chronic obstructive pulmonary disease; major depressive disorder; anxiety disorder; chronic diastolic congestive heart failure; and chronic kidney disease, stage 3B. R6's medical record and Care Plan did not document a care plan for abuse. R6's Minimum Data Set (MDS) dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 14 out of 15. The MDS documents that the resident requires substantial/maximal assistance with sit to lying. The MDS documents that the resident requires partial/moderate assistance with lying to sitting on side of bed. On 4/9/25 at 1:13 PM, R5 stated that a staff member has been yelling at her roommate, (R6). Tell her to hurry up and I don't have time for this, I got places to go. On 4/9/25 at 2:09 PM, R6 stated that she does not know her name. She stated that she (V7) yelled and was very abrasive. She stated that she told her (V7) that she would feel better changing her clothes in the bathroom. (R6) stated that she was told that she was staying right here (by her bed) and changing her clothes. She stated that she told the staff that she wanted to eat breakfast in her room and was told you have to go to the dining room. On 4/9/25 at 2:40pm, V1, Administrator stated that this is the same staff member that alleged verbal abuse to (R2), V7. He stated that she was educated for abuse and customer service. It was V7 and she was suspended that day. On 4/9/25 at 3:08 PM, R6 stated that the staff yelled at her and that's verbal abuse. She stated that she is not scared or intimidated. She stated that she would not come back here. She stated that the staff member should not be doing this job if she does not know how to talk to people. On 4/10/25 at 8:33 AM, V10, LPN (Licensed Practical Nurse) stated that residents have complained about CNAs (Certified Nursing Assistant) and Therapy. She stated that they complain that they force them to do things or that they rush them to do things. She stated that the residents complain about the way staff talk to them. Facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 9/2024 documents Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in (R2) sustaining multiple bruises to her face requiring to be evaluated in the emergency room at the local hospital. This past non-compliance occurred on 10/31/2024 through 11/19/2024. R3's Face Sheet dated 11/4/2024, documents she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, schizophrenia, depression and dementia. R3's Minimum Data Set (MDS) dated [DATE], documents she is cognitively impaired with inattention and disorganized thinking. No indicators of psychosis. Behavioral symptoms not directed toward others. R3's Care Plan, dated 10/31/2024 documents focus: resident at risk for abuse, abusing others demonstrates behaviors that have potential to disturb others. 10/31/2024 altercation with another resident in which (R3) was the perpetrator. Goal: resident will be free from abuse and without abuse behavior. Interventions: 10/31/2024 enhanced supervision 1:1, address resident concerns as they arise, observe for changes in customary routines. Resident moved to sitting room, 1;1 with nurse until EMS (emergency medical services) and police responding to transport resident to local hospital for psych evaluation. R3's Progress Note, dated 10/31/2024 at 11:30 PM, documents there was screaming and yelling down the hall and the CNA (Certified Nurses Assistant) went down and noted it was coming out of res (resident) rm (room) and she was getting back in bed after attacking another res. Res stated that the other res was getting on her nerves. She stated that everything was building up so she got out of bed and started hitting res. R3's Progress Note, dated 10/31/2024 at 11:38 PM, documents res stated that the other res was getting on her nerves and also stated that it kept building up then she got out of bed and started hitting her then went back to get in bed. Res was asked to come out of her rm to go sit in the tv rm and res refuse until this nurse went down to res rm and told her to come up to the tv rm. Res sat in the tv rm until EMS arrived. MD (physician), DON (Director of Nurses) and res family notified of incident. R3's Petition for Involuntary/Judicial Admission, dated 10/31/2024 at 9:30 PM, documents res attacked another res. She has bruising on her hand and bruising to the other pt (patient) neck and face. (R3) stated she was getting on my nerves everything was building up and she got up and went over to the bed and started hitting the other res. R3's Hospital Progress Note, dated 11/1/2024 documents a [AGE] year-old female with history of major neurocognitive disorder admitted [DATE] through the local hospital emergency room after assaulting roommate at the nursing home. The patient has no memory of that. R3 was readmitted to the facility per facility progress note, dated 11/6/2024. On 11/20/2024 at 2:15 PM, R3 was observed laying in bed. (R3) smiled upon approach and when asked about the physical altercation between her and (R2) she stated she never hit anyone in her life and she would never ever do that because that's not the right thing to do. R2's Face Sheet, dated 11/4/2024 documents hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, facial weakness, cognitive communication deficit, dysphagia, expressive language disorder, frontal lobe and executive function deficit following other cerebrovascular disease, mixed receptive-expressive language disorder, pain and osteoarthritis. R2's MDS, dated [DATE], documents resident rarely/never understood, severely cognitively impaired with inattention and disorganized thinking, other behavioral symptoms not directed toward others occurred daily. Dependent with chair/bed-to-chair transfer, sit to lying, roll left and right, sit to stand. Incontinent of bowel and bladder. R2's Late Entry Progress Note, dated 10/31/2024 at 10:00 PM, documents resident is alert and disorientated per usual baseline. Resident denies/exhibits no mental anguish or emotional upset. No new injuries noted on assessment. No pain. Reddish-purple bruising noted. Physician notified of change in condition and responsible party notified. R2's Progress Note, dated 10/31/2024 at 11:54 PM, documents this res was assisted to bed and was not left in rm for about 15 to 20 min (minutes) before hearing screaming and yelling coming up the hall. CNA went down to see what was happening and she notice the other res was getting back in bed and she turned the light on and saw this res leg hanging to the side of the bed like she tried to get up and her face was scratched and bruised up then the CNA called for this nurse to come down to the rm. MD, DON and state representative for this res notified. Res was sent to local hospital to be assessed. R2's Alleged Abuse Report, dated 10/31/2024 at 9:37 PM, documents incident description: there were screaming and yelling coming down the hall and a CNA went down to see what was going on and she noted that this residents legs was hanging out the bed like she wanted to get up and the other res was getting back in bed. This res face was scratched up and a black area under l (left) eye. Resident has aphasia but can explain what's going on and she showed that she hitting her in the face. Immediate action taken: staff stayed in rm for awhile and then the other res was sent to the tv rm until EMS came to take her to psych for evaluation. Level of pain: 4/10, breathing: normal, negative vocalization: none, facial expression: facial grimacing, body language: tensed, consolability: distracted. Injuries observed at time of incident: bruise on face. R2's Hospital Paperwork, dated 10/31/2024, documents she was seen for injury due to physical assault: traumatic periorbital ecchymosis (bruising) of left eye and nose. R2's Progress Note, dated 11/1/2024 at 4:35 AM, documents resident returns to facility via EMS, MD notified. R2's New Identified Skin Condition Form, dated 11/4/2024, documents face - bruising to left eye, nose, left chin, right forehead and right bottom eyelid. On 11/20/2024 at 1:52 PM R2 sat up in a wheelchair in the dining room. Upon approach R2 smiled but didn't respond to IDPH (Illinois Department of Public Health) surveyor's questions regarding the physical altercation between her and R3. R2 had light purple/pink bruising under her left eye at the time of the interview. On 11/20/2024 at 3:07 PM V9, LPN (Licensed Practical Nurse) stated she worked the night of 10/31/2024 and responded to the physical altercation between R2 and R3. R2 doesn't communicate verbally due to post stroke. Prior to the incident R2 was up in the dining room. R3 communicates verbally and is ambulatory and was in bed when staff assisted R2 to bed. A few minutes later I heard screaming and told staff to go down the hall and see what was occurring. R3 was getting back into bed and noted R2's legs were off the side of the bed as if she was trying to get up. Staff turned the light on and saw R2's face was bruised up. Staff called for V9 to come to the room. She observed R2's face bruised and had a sad face and R2 is always happy so she knew R2 was affected by what occurred. R3 was asked why she hit R2 and R3 responded, She was getting on my nerves. R3 didn't respond to V9's additional questions. V9 assessed R2 at that time. Staff stayed in the resident's room. V10 (former DON) and V1 (administrator) were contacted. R3 was moved to the sitting area across the nurse's station and R2 was sent to the hospital for further evaluation and treatment due to the facial bruising. R3 was sent to the hospital for a psychiatric evaluation. On 11/21/2024 at 10:30 AM V11, CNA stated she worked 10/31/2024 2:00 PM - 6:00 AM but was not assigned to R2 and R3, she was assigned to another hall but she heard yelling so she went to the room and when she entered the room she turned the light on and noted R3 was getting back in bed and (R2) was in bed with her legs off the side of the bed which was odd because (R2) is a total lift, she doesn't get out of bed by herself or walk and she immediately noted bruising to (R2's) left eye. (R2) can't verbally communicate but V11 asked her if her roommate, (R3) hit her and (R2) pointed to (R3) yelled and shook her head yes. On 11/21/2024 at 10:50 AM V12, LPN stated she worked night shift on 10/31/2024 and arrived at the facility at around 10:00 PM. The resident to resident altercation occurred between (R2) and (R3) right before she got there. She assisted nursing staff and assessed (R2) when she got to the facility and assessed (R2). R2 was crying and when she asked her if she was in pain (R2) nodded her head, yes. (R2) Sustained bruising to her face from her roommate, (R3) hitting her. V12 also assessed (R3) who was in another room and assessed her to have red and swollen hands at that time. V12 asked (R3) why she hit (R2) and she stated, She deserved it. (R3) was also very agitated and called (R3) a w**** and stated she stole her stuff. On 11/21/2024 at 11:05 AM V13, CNA stated she worked day shift 2:00 PM - 10:00 PM on 10/31/2024. Toward the end of (V13) shift her and V11 were sitting at the nurse's station charting and they heard screaming from the 100 hall. They went to see what was going on and observed (R3) getting back into bed and saw (R2's) legs were off the side of the bed which is abnormal for her because she is a one staff assist lift to get out of bed and she doesn't communicate verbally. V11 asked (R2) if (R3) hit her and (R2) pointed at (R3) and shook her head yes. V13 stated she wasn't assigned to (R2) or (R3) and she didn't assist (R2) to bed that night. V13 stated the nurse came to assess both residents and she left the facility shortly after. On 11/21/2024 at 12:30 PM V14, CNA stated she was assigned to (R2) and (R3) on 10/31/2024 she worked evening shift from 2:00 PM - 10:00 PM. V14 stated (R3) ambulates throughout the facility and has no aggressive behaviors toward other residents, (R3) participated in Halloween activities that day and she was her usual chipper self. (R2) is a total care resident and a sit to stand lift to transfer from wheelchair to bed. V14 stated she worked with V15, CNA and they swapped residents to lay down so V15 assisted (R2) to bed that night. V14 observed the nurse running down 100 hall so she responded to (R2) and (R3's) room and noted (R2) had a bruised face and looked beat up. At that time (R3) was calling (R2) a w****. On 11/20/2024 at 1:45 PM V7, CNA stated roommate (R3) hit R2 on the face a few weeks ago and (R2's) face was all bruised up. R2 is total care resident and requires a sit to stand lift to transfer to and from bed. R2 can't defend herself because she is post stroke and she is unable to communicate verbally. V7 stated she wasn't here when the physical altercation took place but she observed R2 the next day and she looked all black and blue on her face like R3 must have jumped her or something. On 11/20/2024 at 2:00 PM A V8, Social Services Director (SSD) stated she received a call from facility staff on 10/31/2024 at 10:18 PM and staff reported that R3 hit R2 on the face and they were both being sent to the hospital. R3 for a psychiatric evaluation and R2 due to the extent of the injuries she sustained from R3 hitting her on the face multiple times. R3 was admitted to the facility 1/2024, she is pleasant and ambulates throughout the facility and had no behaviors at all until that day. V8 recalled observing R3 up in the dining room participating in Halloween activities that day and there were no signs of upcoming behaviors at that time. On 11/20/2024 at 2:30 PM V1, Administrator stated R3 has a psychiatric diagnosis and has had no bad behaviors since being admitted to the facility. V1 observed R3 participate in Halloween activities in the dining room the day of the incident and there were no signs that anything was off about her that day. V1 stated no other abuse allegation within the last 90 days. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 11/19/2024. Immediate Actions: 1-R1 was assessed, plan of care reviewed and updated. R2 was sent to the hospital for evaluation and treatment of acute psychotic state. 2-Admistrator, Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, Evening Receptionist and a unit manager in-serviced nursing and therapy staff regarding the facility's abuse policy with emphasis on how to prevent abuse. 3-Administrator immediately initiated ongoing audits of abuse immediately addressed upon identification and/or re-education conducted weekly for 4 weeks. After 4 weeks, the audits will be completed monthly for a minimum of 3 months. 4-Any concerns identified from the audits will be addressed immediately and will be reviewed by QAPI team monthly, to determine if current interventions are adequate or additional actions need to be completed to ensure compliance. Ongoing Actions: 1-Education will be provided to new employees prior to being allowed to work in the Facility and all employees at the monthly inservice. 2-Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.

Based on observation, interview and record review, the facility failed to provide timely and complete incontinence care for 1 of 3 (R4) residents reviewed for improper nursing care. This failure resulted in R4 feeling sad, and unsafe in the facility and experiencing pain to buttocks during incontinent care and obtaining open areas. Findings include: R4's Care Plan, dated 4/30/21, documents (R4) has bowel incontinence cognitive status. It continues, Provide pericare after each incontinent episode, Check resident Q (every) 2-3 hrs (hours) and PRN (as needed) for incontinent episodes. It also documents 4/27/24 (R4) has urinary incontinence. It continues, Provide incontinent/peri-care PRN, Check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed. R4's Minimum Data Set, dated dated [DATE], documents that R4 is cognitively intact, occasionally incontinent of urine and always incontinent of bowel. It also documents that R4 is dependent on staff for toileting. R4's Progress note, dated 7/2/2024 at 3:27 PM, documents Health Status Note, Note Text: Noted open sheared areas to right gluteal fold and to back of left thigh. incontinent care provided and skin protected cream applied. (V10) notified and guest requested to notify son because unable to contact daughter. On 7/20/2024 at approximately 11:24 AM, observed R4 lying in bed on her back, in her room. A strong foul-smelling odor in room. R4's top sheet was wet and soiled with a brown stain. Observed brown liquid dripping onto the floor. R4 stated that she needed to be changed and had been waiting since 7pm last night. R4 then pressed the call light button. V11, Certified Nurses Assistant (CNA), answered the call light. V11 pulled back the top sheet and covered R4 up and left the room. At 11:29 AM, V11 and V13, CNA, returned to R4's room with supplies. V11 pulled back the urine and stool-soaked top sheet revealing a heavily soiled and soaked incontinent brief. R4 was lying on top of a fitted sheet, a draw sheet and an incontinent pad. R4 was soaked through each layer of linen. R4's fitted sheet was soaked and had a large brown ring ranging from the back of R4's knees up to the back of R4's neck. V11 then opened R4's incontinent brief and a large amount of soft stool observed covering R4's peri area and lower abdominal fold. V11 then cleansed R4's peri area and abdominal fold. R4 had facial grimacing and yelled out it hurt when being cleaned. V11 and V13 then turned R4 onto her left side that revealed a heavily soaked and saturated incontinent brief stuck to R4's back and buttocks. The incontinent pad, draw sheet and fitted sheet were heavily soaked through with urine and stool. V11 removed the incontinent brief and revealed a large amount of soft foul-smelling stool ranging from R4's buttocks up to the middle of R4's back. V11 then cleansed the stool from R4's buttocks. R4 yelling in pain with each wipe. V11 attempted to calm R4 and paused between wipes. V11 cleansed R4's buttocks and revealed multiple deep red and brown creases in R4 skin that did not fade during incontinent care, and multiple open areas were observed to R4's buttocks and thighs. R4 stated that it was painful when being cleaned. On 7/2/2024 at 11:24 AM, R4 stated that she does not feel safe at the facility and would feel better at home. When asked why does she say that? R4 responded that they leave you alone here. R4 stated that They don't take care of me here. I have been dirty since 7pm last night. I have asked for help and no one helps. They say they will be back and don't come. R4 continued I am alone here, my son works and is not able to take care of me at home. They think its better here but its not. It makes me sad, no one wants to help me. On 7/2/2024 at 11:29 AM, V11 stated that this is unacceptable. V11 stated that (R4) should have been cleaned before now. V11 stated that she was not aware of (R4) having any open areas. V11 stated that (R4) is alert and able to verbalize her needs. V11 stated that she came in the room prior to this and (R4) was sleeping. V11 stated that they got (R4's) roommate up and then proceeded to the other residents. V11 stated that she was not aware that (R4) was in this condition. V11 stated that she prides herself on the care she gives and that this looks like (R4) had been like this for a long time. On 7/3/2024 at approximately 8:28 AM, V12, Licensed Practical Nurse (LPN) stated that she was made aware of (R4's) condition on yesterday. V12 stated that it was unacceptable the condition (R4) was in. V12 stated that she expects the staff to perform incontinent care after each episode of incontinence. V12 stated that the (R4) should have been checked on and if (R4) notified someone that she was incontinent then she expects them to change her. V12 stated that (R4) is alert and tells the staff when she has become incontinent. V12 stated that after the incontinent care was completed she assessed (R4's) skin and applied some cream to it. V12 stated that the areas to (R4's) body are new. V12 stated that the physician and family were notified. V12 stated that (R4) has been changed and repositioned and cream has been applied to (R4's) skin. The facility's Perineal/Incontinent Care Standards and Guidelines, dated 10/24/22, documents Standard: It will be the standard of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition and provide appropriate care and services required to maintain functional levels while providing perineal/incontinence care. It continues Guidelines: 4. Provide perineal/incontinence care In accordance with physician orders or resident's plan of care, while ensuring to maintain resident preferences as indicated and resident privacy/dignity.

Based on interview and record review the facility failed to initiate its abuse policy and report and investigate injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse. Findings include: R3's Care Plan, dated [DATE], documents that (R3) has an alteration in hematological status r/t (related to) Anticoagulant side effects, anemia, history of GI bleed. It continues, Report to the physician any S/S (signs/symptoms) abnormal bleeding or hemorrhage. If resident falls must be sent to emergency room due to anticoagulant use: Monitor for signs/symptoms of bleeding, bruising, active bleed, pain and swelling. It also documents [DATE] (R3) is at risk for abnormal bleeding r/t use of anticoagulant therapy for management of embolism and thrombosis of right popliteal vein. It continues, Monitor for and report to nurse any of the following s/s bleeding: Bleeding gums, Nose bleeds, unusual bruising, Tarry, black stools, Pink or discolored urine. Report to the physician any S/S abnormal bleeding or hemorrhage. R3's Minimum Data Set, dated dated [DATE], documents that R3 is moderately cognitively impaired. Verbal behavior symptoms directed towards others and other behavioral symptom not directed towards others. R3's Progress Note dated [DATE] at 4:30 PM, documents Health Status Note, Note Text:: Resident stating I don't care if I live or die. Resident with bruising on arms from self injurious behavior. R3's Progress Note, dated [DATE] at 1:54 PM, documents Social Services Progress Note, Note Text: SSD (Social Service Director) called behavioral health and spoke with SW (social worker). And they have admitted resident. They stated doctor has not transcribed the admitting DX (diagnosis) yet. She did ask what happened. SSD explained she was having self-harming behaviors. Yelling and screaming. Cussing staff and telling them she hates them. She told nursing she didn't care if she lived or died . R3's Weekly Skin Integrity Review, dated [DATE], documents new skin impairments identified: left antecubital 8.5 x 4cm bruise to left upper arm, left hand 1x1 cm middle finger bruise, 4th finger scab 1x5x0.3 and left lower wrist 1.5 x 3cm bruise. It continues Resident also told me she hits the wall often with her hands and arms. She also wheels herself around in her wheelchair causing bruising to her hands and arms. Resident stated that I hate my life and no one loves me, all you had to do was let me go smoke. Now I want to die and I am calling the abuse hotline. On [DATE] at 10:00 AM, R3's Incident Reports and Investigations were requested. As of [DATE] at 3:00 PM the facility had not provided R3's reports. On [DATE] at approximately 8:40 AM, V1, Administrator stated that the bruises to R3's arms and hands were not investigated only the documentation in the nurses note. On [DATE] at 10:11, V2, Director of Nursing (DON) stated that the nurse on duty was an agency nurse. V2 stated that because of this she handled the situation with (R3). V2 stated that (R3) was having behaviors of yelling, screaming, and cursing at staff. V2 stated that attempts to calm and redirect (R3) was not successful. V2 stated that (R3) stated that she didn't care of she died . When asked what was the self-harming behavior? V2 stated that (R3) stated that she was going to take a bottle of pills and didn't care if she died . When asked did (R3) hit, bite, or scratch herself? V2 stated No. V2 stated that the self-harming act was saying that she would take a bottle of pills and did not care if she lived or died . When asked how did the bruises to (R3's) hands and arms occur? V2 stated that it was from (R3) hitting her arms on the chair. When asked if there was an investigation related to the bruising performed? V2 stated No. V2 stated that they do not complete an investigation if they witness what happened. When asked if the bruising to (R3's) hands and arm were witnessed. V2 stated No. When asked which bruise was from hitting on the wheelchair? V2 did not know. When asked how did she know that the bruises occurred from hitting the wheelchair? V2 did not answer. On [DATE] at approximately 8:28 AM, V12, Licensed Practical Nurse (LPN) stated that (R3) has multiple behaviors. V12 stated that (R3) yells and curses at staff. V12 stated that she will swing at staff. V12 stated that she has not heard of (R3) connecting. V12 stated that (R3) will make up stories and try to get staff fired. V12 stated that she will like you one moment and then in a matter of minutes she is cursing at you and call you out of your name. V12 stated that she has not witness care with (R3). V12 stated that she has not witness any self-harm behavior from (R3). V12 stated that she was here when (R3) was sent out to the hospital. V12 stated that (R3) was yelling and cursing at the staff and was unable to be redirected. On [DATE] at approximately 1:30 PM, V3, Assistant Director of Nursing (ADON) stated that she completed the skin assessment. V3 stated that (R3) did have some bruising. V3 stated that the bruising appeared that they had been there for some time. When asked how did (R3) get the bruising, V3 stated that (R3) hits her hands on her chair but she could not say for certain that this is how (R3) obtained the bruising. V3 stated that she is not aware of (R3) having self-harm behavior. V3 stated that (R3) curses at the staff when she doesn't get what she wants. V3 stated that (R3's) behavior has gotten worse, the yelling and outburst have been more frequent. The facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated September2022, documents that All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The facility's Accident and Incidents -Investigating and Reporting policy, dated [DATE], documents Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The resident's representative; c. Adult protective services (where state law provides jurisdiction in long-term care); d. Law enforcement officials for serious injury e. The resident's attending physician; and f. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. 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 (if any) are needed for the protection of residents. Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated [DATE], documents Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on interview and record review the facility failed to initiate its abuse policy and report injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse. Findings include: R3's Care Plan, dated [DATE], documents that (R3) has an alteration in hematological status r/t (related to) Anticoagulant side effects, anemia, history of GI bleed It continues Report to the physician any S/S (signs/symptoms) abnormal bleeding or hemorrhage. If resident falls must be sent to emergency room due to anticoagulant use: Monitor for signs/symptoms of bleeding, bruising, active bleed, pain and swelling. It also documents [DATE] (R3) is at risk for abnormal bleeding r/t use of anticoagulant therapy for management of embolism and thrombosis of right popliteal vein. It continues Monitor for and report to nurse any of the following s/s bleeding: Bleeding gums, Nose bleeds, unusual bruising, Tarry, black stools, Pink or discolored urine. Report to the physician any S/S abnormal bleeding or hemorrhage. R3's Minimum Data Set, dated dated [DATE], documents that R3 is moderately cognitively impaired. Verbal behavior symptoms directed towards others and other behavioral symptom not directed towards others. R3's Progress Note dated [DATE] at 4:30 PM, documents Health Status Note, Note Text: Resident stating I don't care if I live or die. Resident with bruising on arms from self injurious behavior. R3's Progress Note, dated [DATE] at 1:54 PM, documents Social Services Progress Note, Note Text: SSD (Social Service Director) called behavioral health and spoke with SW (social worker). And they have admitted resident. They stated doctor has not transcribed the admitting DX (diagnosis) yet. She did ask what happened. SSD explained she was having self-harming behaviors. Yelling and screaming. Cussing staff and telling them she hates them. She told nursing she didn't care if she lived or died . R3's Weekly Skin Integrity Review, dated [DATE], documents new skin impairments identified: left antecubital 8.5x4cm bruise to left upper arm, left hand 1x1 cm middle finger bruise, 4th finger scab 1x5x0.3 and left lower wrist 1.5x3cm bruise. It continues Resident also told me she hits the wall often with her hands and arms. She also wheels herself around in her wheelchair causing bruising to her hands and arms. Resident stated that I hate my life and no one loves me, all you had to do was let me go smoke. Now I want to die and I am calling the abuse hotline. On [DATE] at 10:00 AM, R3's Incident Reports and Investigations were requested. As of [DATE] at 3:00 PM the facility had not provided R3's reports. On [DATE] at approximately 8:40 AM, V1, Administrator stated that the bruises to (R3's) arms and hands were not investigated only the documentation in the nurses note. On [DATE] at 10:11 V2, Director of Nursing (DON) stated that the nurse on duty was an agency nurse. V2 stated that because of this she handled the situation with (R3). V2 stated that (R3) was having behaviors of yelling, screaming, and cursing at staff. V2 stated that attempts to calm and redirect (R3) was not successful. V2 stated that (R3) stated that she didn't care of she died . When asked what was the self-harming behavior? V2 stated that (R3) stated that she was going to take a bottle of pills and didn't care if she died . When asked did (R3) hit, bite, scratch herself? V2 stated No. V2 stated that the self-harming act was saying that she would take a bottle of pills and did not care if she lived or died . When asked how did the bruises to (R3's) hands and arms occur? V2 stated that it was from (R3) hitting her arms on the chair. When asked if there was an investigation related to the bruising performed? V2 stated No. V2 stated that they do not complete an investigation if they witness what happened. When asked if the bruising to (R3's) hands and arm were witnessed. V2 stated No. When asked which bruise was from hitting on the wheelchair? V2 did not know. When asked how did she know that the bruises occurred from hitting the wheelchair? V2 did not answer. On [DATE] at approximately 8:28 AM, V12, Licensed Practical Nurse (LPN) stated that (R3) has multiple behaviors. V12 stated that (R3) yells and curses at staff. V12 stated that she will swing at staff. V12 stated that she has not heard of (R3) connecting. V12 stated that (R3) will make up stories and try to get staff fired. V12 stated that she will like you one moment and then in a matter of minutes she is cursing at you and call you out of your name. V12 stated that she has not witness care with (R3). V12 stated that she has not witness any self-harm behavior from (R3). V12 stated that she was here when (R3) was sent out to the hospital. V12 stated that (R3) was yelling and cursing at the staff and was unable to be redirected. On [DATE] at approximately 1:30 PM, V3, Assistant Director of Nursing (ADON) stated that she completed the skin assessment. V3 stated that (R3) did have some bruising. V3 stated that the bruising appeared that they had been there for some time. When asked how did (R3) get the bruising V3 stated that (R3) hits her hands on her chair but she could not say for certain that this is how (R3) obtained the bruising. V3 stated that she is not aware of (R3) having self-harm behavior. V3 stated that (R3) curses at the staff when she doesn't get what she wants. V3 stated that (R3's) behavior has gotten worse, the yelling and outburst have been more frequent. The facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated [DATE], documents that All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The facility's Accident and Incidents -Investigating and Reporting policy, dated [DATE], documents Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The resident's representative; c. Adult protective services (where state law provides jurisdiction in long-term care); d. Law enforcement officials for serious injury e. The resident's attending physician; and f. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. 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 (if any) are needed for the protection of residents. Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated [DATE], documents Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on interview and record review the facility failed to initiate its abuse policy and investigate injuries of unknown origin for 1 of 3 (R3) residents reviewed for abuse. Findings include: R3's Care Plan, dated [DATE], documents that (R3) has an alteration in hematological status r/t (related to) Anticoagulant side effects, anemia, history of GI bleed. It continues, Report to the physician any S/S (signs/symptoms) abnormal bleeding or hemorrhage. If resident falls must be sent to emergency room due to anticoagulant use: Monitor for signs/symptoms of bleeding, bruising, active bleed, pain and swelling. It also documents [DATE] (R3) is at risk for abnormal bleeding r/t use of anticoagulant therapy for management of embolism and thrombosis of right popliteal vein. It continues Monitor for and report to nurse any of the following s/s bleeding: Bleeding gums, Nose bleeds, unusual bruising, Tarry, black stools, Pink or discolored urine. Report to the physician any S/S abnormal bleeding or hemorrhage. R3's Minimum Data Set, dated dated [DATE], documents that R3 is moderately cognitively impaired. Verbal behavior symptoms directed towards others and other behavioral symptom not directed towards others. R3's Progress Note dated [DATE] at 4:30 PM, documents Health Status Note, Note Text: Resident stating I don't care if I live or die. Resident with bruising on arms from self injurious behavior. R3's Progress Note, dated [DATE] at 1:54 PM, documents Social Services Progress Note, Note Text: SSD (Social Service Director) called behavioral health and spoke with SW (social worker). And they have admitted resident. They stated doctor has not transcribed the admitting DX (diagnosis) yet. She did ask what happened. SSD explained she was having self-harming behaviors. Yelling and screaming. Cussing staff and telling them she hates them. She told nursing she didn't care if she lived or died . R3's Weekly Skin Integrity Review, dated [DATE], documents new skin impairments identified: left antecubital 8.5x4cm bruise to left upper arm, left hand 1x1 cm middle finger bruise, 4th finger scab 1x5x0.3 and left lower wrist 1.5x3cm bruise. It continues Resident also told me she hits the wall often with her hands and arms. She also wheels herself around in her wheelchair causing bruising to her hands and arms. Resident stated that I hate my life and no one loves me, all you had to do was let me go smoke. Now I want to die and I am calling the abuse hotline. On [DATE] at 10:00 AM, R3's Incident Reports and Investigations were requested. As of [DATE] at 3:00 PM the facility had not provided R3's reports. On [DATE] at approximately 8:40 AM, V1, Administrator stated that the bruises to (R3's) arms and hands were not investigated only the documentation in the nurses note. On [DATE] at 10:11, V2, Director of Nursing (DON) stated that the nurse on duty was an agency nurse. V2 stated that because of this she handled the situation with (R3). V2 stated that (R3) was having behaviors of yelling, screaming, and cursing at staff. V2 stated that attempts to calm and redirect (R3) was not successful. V2 stated that (R3) stated that she didn't care of she died . When asked what was the self-harming behavior? V2 stated that (R3) stated that she was going to take a bottle of pills and didn't care if she died . When asked did (R3) hit, bite, scratch herself? V2 stated No. V2 stated that the self-harming act was saying that she would take a bottle of pills and did not care if she lived or died . When asked how did the bruises to (R3's) hands and arms occur? V2 stated that it was from (R3) hitting her arms on the chair. When asked if there was an investigation related to the bruising performed? V2 stated No. V2 stated that they do not complete an investigation if they witness what happened. When asked if the bruising to (R3's) hands and arm were witnessed. V2 stated No. When asked which bruise was from hitting on the wheelchair? V2 did not know. When asked how did she know that the bruises occurred from hitting the wheelchair? V2 did not answer. On [DATE] at approximately 8:28 AM, V12, Licensed Practical Nurse (LPN) stated that (R3) has multiple behaviors. V12 stated that (R3) yells and curses at staff. V12 stated that she will swing at staff. V12 stated that she has not heard of (R3) connecting. V12 stated that (R3) will make up stories and try to get staff fired. V12 stated that she will like you one moment and then in a matter of minutes she is cursing at you and call you out of your name. V12 stated that she has not witness care with (R3). V12 stated that she has not witness any self-harm behavior from (R3). V12 stated that she was here when (R3) was sent out to the hospital. V12 stated that (R3) was yelling and cursing at the staff and was unable to be redirected. On [DATE] at approximately 1:30 PM, V3, Assistant Director of Nursing (ADON) stated that she completed the skin assessment. V3 stated that (R3) did have some bruising. V3 stated that the bruising appeared that they had been there for some time. When asked how did (R3) get the bruising, (V3) stated that R3 hits her hands on her chair but she could not say for certain that this is how (R3) obtained the bruising. V3 stated that she is not aware of (R3) having self-harm behavior. V3 stated that (R3) curses at the staff when she doesn't get what she wants. V3 stated that (R3's) behavior has gotten worse, the yelling and outburst have been more frequent. The facility's Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated [DATE], documents that All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The facility's Accident and Incidents -Investigating and Reporting policy, dated [DATE], documents Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities: If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The resident's representative; c. Adult protective services (where state law provides jurisdiction in long-term care); d. Law enforcement officials for serious injury e. The resident's attending physician; and f. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. 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 (if any) are needed for the protection of residents. Investigating Allegations: 1. All allegations are thoroughly investigated. The administrator initiates investigations. 3. The administrator provides supporting documents and evidence related to the alleged incident to the individual in charge of the investigation. The facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, dated [DATE], documents Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. Policy Interpretation and Implementation: 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.

Based on interview and Record Review the facility failed to perform cardiopulmonary resuscitation (CPR) for 1 of 1 resident (R7) reviewed for CPR in the sample of 48. This failure resulted in R7 not receiving life saving measures according to her Advanced Directives. The Immediate Jeopardy began on [DATE] when R7 did not received CPR. V1, Adminstrator and V2, Director of Nursing were notified of the Immediate Jeopardy on 05//,d+[DATE] at 3:14 PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed, and the deficient practice corrected on [DATE]. Findings Include: R7 's Minimum Data Set (MDS) dated [DATE] documents R7 has moderately impaired cognitive skills for daily decision making. R7s Care Plan dated [DATE] documents (R7) Advanced Directives on record Uniform POLST form (R7) goal is If R7 heart stops, or if they stop breathing, CPR WILL be initiated in honor with their FULL code wishes ongoing through next review date. R7's POLST (Uniform Practitioner Order for Life Sustaining Treatment Form) dated [DATE] documents CPR Attempt Cardiopulmonary Resuscitation, full treatment. R7's Physician Order Sheet dated [DATE] documents Advanced Directive: Full Code. R7's Nurses Note dated [DATE] at 22:42 documents nurse assessed guest (R7) at 3:30 PM, guest (R7) had just been laid back down. Nurse gave 4:00 PM med (medication) and pain pill given as well. Guest (R7) drank a cup of boost and stated thank you. At 6:40 PM staff came to nurse and said she believed guest (R7) had passed. Nurse checked and had 100 hall nurse confirm. Time of death 6:45 pm. R7's Nurses Note dated [DATE] at 11:58 AM Skilled Nursing Assessment completed. Vital signs obtained and reviewed. Cognitive assessment indicates resident has no delirium signs or symptoms present. Resident is alert/awake and responsive to verbal stimuli. Resident is able to recall nothing upon prompting. No neurological symptoms present at this time. PT (Physical Therapy) OT (Occupational Therapy), and/or ST (Speech Therapy) being provided. No cardiovascular symptoms noted. No respiratory symptoms noted. Even and unlabored Respirations are even and unlabored. No GI (Gastrointestinal) symptoms noted. Abdomen is soft/normal. No GU (Genitourinary) signs or symptoms noted. No endocrine symptoms noted. Nursing interventions provided throughout the day. Observed for changes in status. Encouraged activity as allowed. Encouraged resident to maintain correct positioning. Changed position for pressure offloading. On [DATE] at 1:45 PM, V11, Certified Nursing Assistant (CNA) stated, No I don't know anything about that she looked like she was going to die. She didn't want to eat. The other girl told me she had passed, They came in the shower room and told me. On [DATE] at 2:30 PM, V14, Registered Nurse (RN) stated, It was last night her nurse came and got me and asked me to be her second ear. I listened with the stethoscope. I don't know what her and the aide did (question if CPR was done). I was on the 100 halls. No, I didn't know her code status. I don't know the exact time. No, I didn't see the resident (V7) at all before. On [DATE] at 3:10 PM, V12, CNA stated, Right after dinner I went to check her. She had a broken hip, and she wasn't doing great. So, I entered the room, and took one look and knew she was gone. I thought she was hospice. So, I wasn't 100% sure. No ma'am we didn't start CPR. No, the nurse didn't do CPR. It's (code status) on the point click care on the chart. I don't know for sure where else it is. They don't have anything posted on the door. It's a HIPPA (Health Insurance Portability and Accountability Act) violation to post things on the door. The day before she threw up. She was declining. The nurse said before dinner. She spoke to the nurse. I didn't see her until after serving in the dining room, when I checked on her. On [DATE] at 3:40 PM, V13, Licensed Practical Nurse (LPN) stated, Well, I was the nurse on duty. I had been on vacation when she fell . I went in and gave medication and a pain pill at 4:00PM. She looked terrible when they laid her down. She drank a cup of boost, and she said thank you. I checked on her 45 minutes later. She look like she was sleeping, about 6:40 PM (V12) said she had passed. I grab my stethoscope. I couldn't find a pulse. I text the doctor and he said to call hospice and give his condolences to the family I really don't know where my head was. She wasn't on hospice. I talked to the son and he said she wasn't on hospice. He said I will be there in 30 minutes. She was completely cold. I didn't do CPR and yes, I'm CPR certified. On [DATE] at 8:10 AM, V15, CNA, stated in the event of an emergency she will notify the nurse or supervisor and find out what is going on with the resident. Stated she is CPR certified. On [DATE] at 8:13 AM, V16, RN, stated in the event of an emergency someone will stay with the resident while another checks code status. If they are a full code, they start CPR and the other person calls 911. Once EMS comes and takes the resident, they notify the doctor and family. If there is no POLST they are automatically a full code. Stated there is a binder that lists code status and you can also find it on the EMR. Stated she is CPR certified. On [DATE] at 8:16 AM, V17, CNA, stated in the event of an emergency she stays with the resident and yell out code to coworker. Nurses do CPR. I can start CPR if they tell me to but I'm agency and usually let the nurse find code status. +CPR certified. Stated she would never pronounce a resident dead. On [DATE] at 8:18 AM, V18, CNA, stated if there is an emergency she would tell her nurse. She is CPR certified and could check code status in the chart but depends on her nurse to tell her the code status. V21 LPN, stated she is CPR certified. V21 stated if she found a resident unresponsive she would call for help and not leave the room. V22 CNA, stated she is CPR certified. V22 stated if she found a resident unresponsive she would call code blue and call the nurse. V23 CNA, stated she is CPR certified and if she found a resident unresponsive she would call for help. V24 LPN, stated she is CPR certified and if she found a resident unresponsive she would start CPR, call for help, and check status. V25 CNA, states she is CPR certified and if she found a resident unresponsive I would check for a pulse and respirations and call for help. The facility's policy entitled Change in Condition dated [DATE] documents Observe resident during routine care and during monthly, quarterly or annual assessment periods to identify significant changes in physical and mental conditions, orientation, change in vital signs, weights. Any resident's condition is considered to life threatening, and the resident requires immediate medical care, notify the emergency medical system (911). Always make every attempt ot honor the resident's wishes regarding hospitalization and end of life issues. Maintain compliance with Advance Directives. The facility's policy entitled Cardiopulmonary Resuscitation dated ,d+[DATE] documents If an individual ( resident, visitor, or staff member) is found unresponsive and not breathing normally a licensed staff member who is certified in CPR shall initiate CPR unless: it is known that a Do Not Resuscitate order that specifically prohibits CPR and or external defibrillation exist for that individual. If The resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. The team completed the following from [DATE] through [DATE] to validate the facility's abatement plan: V22, V23, V24, V26, V31, V32, V33, and V34 were interviewed about the in-services they received regarding identification of code status in orders and POLST ( IDPH (Illinois Department of Public Health) Uniform Practitioner Order for Life -Sustaining Treatment POLST Form wishes, the need to perform CPR and contact 911 for Full Codes immediately, the need to continue CPR until EMS (Emergency Medical Services) arrives and provide documentation with POLST form to EMS. The facilities in-services, policies, and audits were reviewed. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice corrected on [DATE] when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. Polst Form, Resident orders, and Resident care plans audited on [DATE] by Social Services Director for accuracy. 2. All nurses in-serviced prior to next working shift by the Administrator (V1), LNHA, DON (V2), RN or ADON (V3), RN beginning on [DATE] and on-going via phone education by Administrator/DON/ADON on the facilities Code Status Policy and Procedures, where to find code status for each resident in the Medical Record in Point Click Care and in the Code Status Book in alphabetical order located on each RED crash cart. 3. All CNAs in-serviced prior to next working shift by the Administrator (V1), LNHA, DON (V2), RN or ADON (V3), RN beginning on [DATE] and on-going via phone education by Administrator/DON/ADON on the facilities Code Status Policy and Procedures, where to find code status for each resident in the medical record in Point Click Care and in the Code Status Book in alphabetical order located on each RED crash cart. 4. Audit all HR (Human Resources) employee files for staff who have provided current CPR cards [DATE] completed by HR Director (V35). 5. Identify on working schedule all current CPR card holders beginning [DATE] and on-going by (V2), DON or (V36), Staffing Coordinator. 6. Continue to collect CPR cards as they become available by HR Director (V35) and communicate with (V2), DON and (V36), Staffing Coordinator daily when new ones become available. 7. In-service Admissions Coordinator (V34) no one to be admitted to the facility without a confirmed code status beginning [DATE] and on-going. 8. Daily QA Audits on Code Status vs POLST vs Orders by Administrator (V1), LNHA or (V2), DON beginning [DATE] and on-going. 9. Next scheduled CPR classes are scheduled on [DATE]rd at 9am and 2pm with futures dates as they become available by (V37), LPN certified by (local ambulance company). 10. CPR Policy reviewed and revised [DATE] by Administrator and approved by Medical Director (V20), MD (completed [DATE]) 11. CPR Policy and Procedure laminated and attached to both RED Crash Carts located at each nurses station (completed by Administrator on [DATE]) Quality Assurance plans to monitor facility performance to make sure that corrections are achieved and permanent: The Administrator (V1) or (V2), DON will conduct a weekly audit/chart review of four residents per week times four weeks and then every two weeks for two months to ensure compliance. (V2), DON or (V3), ADON will conduct mock codes weekly per shift for 4 weeks, mode codes for each shift every other week for 2 weeks and monthly for 3 additional months to assure compliance and understanding of Policies and Procedures. Audits will be reviewed in the next QA/Risk management meeting.

Based on interview and record review, the Facility failed to use the services of a Registered Nurse (RN) for at least eight hours daily. This has the potential to affect all 102 residents living in the Facility. Findings Include: The Facility's Staffing List for RN (Registered Nurse), LPN (Licensed Practical Nurse), and CNA (Certified Nurse Aid) hours scheduled was provided from 4/30/24 through 5/13/24. These document the Facility did not have a RN for eight hours on 5/4/24, 5/7/24, 5/8/24, or 5/12/24. On 5/21/24 at 7:20 AM, V1, Administrator, stated she did not have RN coverage on all of those days. She stated the Facility does not have a policy regarding RN staffing, and they just follow the regulations. The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 5/14/24 documents there are 102 residents living in the Facility.

Based on observation, interview, and record review, the Facility failed to ensure food was stored, prepared, and served in a manner that prevents potential contamination. This has the potential to affect all 102 residents living in the Facility. Findings include: On 5/14/24 at 9:44 AM, there were plastic containers of dry corn cereal and dry rice cereal on the food preparation counter that were not dated or labeled. There was a plastic container of a brown granular substance that was not labeled or dated. On the same counter next to the microwave, there was a stack of plates with dried crusted food particles on top. On 5/14/24 at 9:46 AM, there was a large industrial sized food bin labeled flour under the food preparation counter across from the oven that was not dated. On 5/14/24 at 9:48 AM, in the walk in refrigerator there was a stainless steel container with slices of meat that was not covered, labeled or dated. V5, Dietary Manager, stated, That is pork, and it's going with me (to be thrown out). There was a box of dinner rolls that had been opened, and the plastic inside was not resealed, leaving the contents open to air. The package was not dated upon opening. There was a large plastic container with an orange liquid substance inside that was not dated or labeled. There were six trays full of cups with various colored liquids that were not individually wrapped and were covered with additional meal trays. These liquids were not labeled or dated. There was a pan with ground meat that was covered in plastic wrap. There was no legible date or label on the plastic wrap. V5 stated, That is sausage. We have had problems getting lids and labels from the company. On 5/14/24 at 9:56 AM, in the standing freezer there were six plastic bags of frozen French fries that were not opened, but were not dated upon delivery or removal from the original box. There was a box of sugar cookies, a box of dinner rolls, and a box of biscuit dough. All three boxes had been opened, and the plastic inside was not resealed, leaving the contents open to air. The boxes were not dated upon opening. On 5/14/24 at 10:00 AM, V6, Dishwasher, tested the sanitizer level with a test strip during the final rinse cycle. The strip turned orange which correlated with 0 ppm (parts per million) on the test strip container. V6 stated the test strip should be green which correlates with 100-150 ppm. He stated they are probably out of cleaner, and it probably just needs to be changed. On 5/13/24 at 10:02 AM, V7, Dietary Aid, went to the dish room to get cups. Several of the cups she was taking away had a dark tint inside. V7 stated, They're stained. Sometimes you have to run them through twice; otherwise they come out looking like this. V7 then took the cups out of the dish room to the kitchen. On 5/14/24 at 10:04 AM, V6, Dishwasher, loaded the dish machine with bowls and ran the machine without changing the cleaner. V6 then rinsed his hands with sanitizing solution from the sink. He did not dry his hands, then went to the bowls that had run through dish machine and put some of them back in the dirty stack. V6 stated, They are still dirty, so I will run them through again. V6 put the remaining bowls from that cycle in the clean stack. On 5/15/24 at 7:53 AM, V7, Dietary Aid, was plating breakfast on the tray line. She handed V5, Dietary Manager, a plate that appeared dirty. V5 took the plate back to dish room. On 5/15/24 at 7:58 AM, V9, Dietary Aid, handed a tray that appeared dirty to V5, Dietary Manager. V5 took the tray to the dish room. On 5/15/24 at 7:59 AM, V7, Dietary Aid, took a tray from the stack of trays being used, then put it back into another stack. She stated, Apparently they didn't wash them good last night. On 5/15/24 at 8:02 AM, V9, Dietary Aid, took a tray with yellow food debris from the stack and put it in the dish room. On 5/15/24 at 8:40 AM, V5, Dietary Manager, stated the repair company is coming in later today to service the dish machine and told him there is probably an issue with the chemicals. V5 stated he was unable to get the sanitizer levels where they needed to be this morning and had to run it three times. On 5/15/24 at 9:55 AM, V5, Dietary Manager, stated the dishwasher is actually a high temperature machine, so it does not use sanitizer, just a detergent. On 5/21/24 at 9:37 AM, V1, Administrator, stated she expects staff to follow all food service policies. The Facility's Food Storage: Cold Policy revised 10/2019 documents, It is the center policy to insure all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code. The Dining Services Director/Cook(s) insures that all food items are stored properly in covered containers, labeled and dated and arranged in a manner to prevent cross contamination. The Facility's Ware washing Policy revised 10/2019 documents, It is the center policy that all dishware and service ware will be cleaned and sanitized after each use. The Dining Services Director insures that the nutrition service staff is knowledgeable in proper technique for processing dirty dish ware to clean through the dish machine and proper handling of sanitized dish ware. The Facility's Long-Term Care Facility Application For Medicare And Medicaid dated 5/14/24 documents there are 102 residents living in the Facility.

Based on Interview and Record Review, the facility failed to respond to resident needs in a timely manner, by not responding to call lights, and call light not in working order for 2 of 2 residents (R41, R46) in the sample of 48. Findings Include: R41's Facesheet documents an admitted [DATE]. Diagnosis include Polyneuropathy, Chronic Respiratory Failure with hypoxia, Chronic Obstructive Respiratory Disease, Generalized Muscle Weakness. R41's Minimum Data Set, MDS, dated [DATE] documents R41 has no cognitive deficits. R41's MDS dated [DATE] documents R41 requires partial/moderate assist with showering. R41's Care Plan dated 12/19/2023 documents R41 is at risk for falls. Interventions include anticipate and meet R41's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Check the environment for clutter or trip hazards and area is well lit. Remind to request assistance when getting up if needed. Call Don't Fall sign placed in R41's room. On 5/17/2024 at 9:00AM R41 stated The call lights take a long time to answer. The worst time is the evening shift. The CNA's leave the premises, and we don't know where they go. My call light is broken, and I was given a bell to use. They can't hear the bell. I ask my room mate to push her call light if I need anything. On 5/17/2024 at 10:10AM, R41's call light pushed and not working. R41 had bell on bedside table. On 5/17/2024 at 10:10AM R93, (R41's roommate), stated Her (R41's) call light has not worked in a long time. If she needs anything I push my call light for her. On 5/17/2024 at 1:35PM, V30, Maintenance Worker stated I did not know anything about R41's call light not working. The system was recently down. R46's Facesheet documents an admitted [DATE]. Diagnosis include Sacrolitis, Muscle Weakness, Heart Failure, Polyosteoarthritis, Pain in hips and Knees, Orthostatic Hypotension. R46's MDS dated [DATE] documents R46 has no cognitive deficits. R46 is dependent with showering. R46's care plan dated 10/21/2023 documents R46 is at risk for falls. Interventions include be sure the R41's CALL LIGHT is within reach and encourage R41 to use it for assistance as needed. Check the environment for clutter or trip hazards and area is well lit. Remind to request assistance when getting up if needed. On 5/17/2024 at 9:00AM, R46 stated The call lights take a long time to answer. The worst time is evening shift. The CNA's leave and go to get fast food. If I tell the CNA's that someone's call light is ringing, they tell me not to worry about it. On 5/17/2024 at 2:00PM, V28, CNA, stated I answer a call light as soon as I see it on. I haven't been here very long, but I have heard evenings and nights are longer waits. Resident Council records dated 4/10/2024 document Resident had concerns about call light not being answered. On 5/21/2024 at 2:00PM V1, Administrator, stated that all call lights should be working and answered. We recently had a technician out and all call lights should've been working. If not I want my money back. Facility policy dated 9/1/2021 states The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Call lights will directly relay to a staff member or centralized location to ensure appropriate response.

Based on interview and record review the facility failed to offer Pneumonia vaccinations for 1 of 5 residents (R42) reviewed for Immunizations in the sample of 48 Findings Include: R42's Minimum Data Set (MDS) dated [DATE] documents R42 is severly impaired for cognitive skills for daily decision making. R42's Electronic Health Record (EHR) Influenza vaccine was given on 10/19/23 and COVID vaccine was given on 12/18/23. R42's EHR did not document a Pneumonia Vaccine. On 5/17/24 V4 Infection Control Preventionist (ICP) stated, They haven't had an IP in a while. I'm focusing on the TB (Tuberculosis) tests, But I will start on vaccinations, I have only been here a month. The facility policy Vaccination of Residents dated October 2019 documents all residents will be offered vaccines that aide in preventing infectious diseases. Unless the vaccine is medically contraindicated or the resident has already been vaccinated

Based on observation, interview and record review, the facility failed to obtain a treatment order and have treatments and interventions in place as ordered by the physician to treat pressure ulcers for 2 of 3 residents (R3 and R4) observed for pressure ulcers in the sample of 7. Findings include: 1. On 3/29/24 at 12:50 PM, R3 was lying in bed on a low air loss mattress. The mattress was not on and there were no lights lit up on controls and no alarm sounding. R3's mattress was still firm and inflated. R3 was lying on his back with the head of his bed up. His tube feeding was infusing per a pump. V7, Certified Nursing Assistant (CNA) came into R3's room to check on R3 and was asked about the mattress not being on . She checked the plug and stated it was unplugged and plugged it back in. V7 stated she was surprised it was not alarming since it was unplugged. She stated she was not sure when someone had last been in to see R3. V7 did roll R3 to his left side and a dressing was observed loosely covering his stage 4 sacral pressure ulcer on his coccyx. When V7 rolled him, the dressing partially came off and pressure ulcer was observed. The wound base of the pressure ulcer was observed to be mostly covered with yellow slough and there was a moderate amount of yellowish-green drainage on old dressing and some on his pad on his bed. R3's Face Sheet, printed 4/4/24, documents his diagnoses to include Non-traumatic Intracerebral Hemorrhage, Spastic Quadriplegic Cerebral Palsy, Type 2 Diabetes Mellitus, Anemia, and Unspecified Protein-Calorie Malnutrition. R3's Minimum Data Set (MDS) dated [DATE] documents R3 had no pressure ulcers at that time. R3's MDS dated [DATE] documents R3 had an unstageable pressure ulcer that was present on readmission. R3's current MDS dated [DATE] documents R3 is severely cognitively impaired, is dependent on staff for all Activities of Daily Living (ADLs), is always incontinent of bowel and bladder, and continues to have a Stage 4 pressure ulcer that was present on admission. R3's Care Plan dated 2/16/24 documents: Resident has area of skin impairment. admitted with pressure area from hospital. Goal: Resident will be free from complications related to skin impairment. Resident will not develop any new areas of skin breakdown. Resident's area of skin impairment will remain free from infection. Interventions: Administer/apply medications, ointments, creams as ordered- see MAR/physician orders. Assist with turning and positioning if resident is unable. Consult/make referral for therapy screen as needed. Consult/make referral for wound specialist as needed. Encourage good nutrition and hydration in order to promote healthy skin. Monitor extremity for color, warmth, sensation and/or swelling as needed. Monitor labs as ordered. Provide supplemental protein, amino acids, vitamins, minerals as ordered by physician to promote wound healing (see physician's orders). Report changes in skin status (i.e. s/s infection, non healing, new areas)to nurse/physician. Low air loss mattress applied to bed. Position with pillows to maintain proper body alignment as needed. Sees Wound Physicians R3's Readmission nursing assessment dated [DATE] documents R3 has a wound to coccyx measuring 10 centimeter (cm) x 10.5 cm x 1.5 cm. Under additional comments, this assessment documents, (V13, Wound Physician) to follow. R3 was readmitted to the hospital on 2/5/24 (the next day) and was hospitalized through 2/13/24. R3's Readmission nursing assessment dated [DATE] documents he had a skin condition to sacrum measuring 10cm x 10.5 cm x 1.5 cm. Under comments it documents, Hospital Acquired. (V13) to follow. R3's Physician Order dated 2/16/24 documents: Silver Sulfadiazine 1% mixed with collagen powder, covered with calcium alginate and border dressing QD (every day) and prn (as needed). No physician orders for pressure ulcer treatment to R3's Stage 4 pressure ulcer were documented from 2/13/24 to 2/16/24 on R3's Physician Order Summary and R3's Treatment Administration Record (TAR) dated February 2024 does not document any treatment being started until 2/17/24, 3 days after R3's readmission to the facility. On 3/29/24 at 1:30 PM V5, Wound Nurse, stated V7, CNA, told her about R3's mattress being unplugged and that is not alright. On 4/2/24 at 10:40 AM V13, Wound Physician, was here to see R3 today. V13 stated because R3 is on a continuous air flow mattress he should not need to be turned and repositioned as often because the bed should be taking care of redistributing his weight for him. V13 stated the down side of the alternating air flow mattresses is that sometimes residents are rolled out of bed by the mattress. He stated that if the bed was unplugged, the machine should have been alarming . On 4/4/24 at 10:15 AM V5, Wound Nurse stated she did not know why there was no order for a treatment to R3's pressure ulcer on his coccyx when he returned from the hospital on 2/13/24 and treatment not started until 2/17/24. She stated the nurse who admitted him on 2/13/24 should have notified the doctor for a treatment order if there was no orders for wound care on the hospital discharge orders. The facility's policy, Identification of Changes in Skin Condition, A Quick Reference Tool undated, documents, Assessment and Treatment of Pressure Ulcers: It is important that each existing pressure ulcer be identified, whether on admission or developed after admission, and that factors that influenced its development, the potential for development of additional ulcers or for the deterioration of the pressure ulcer (s) be recognized, assessed and addressed. Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers. The facility's policy, Standards and Guidelines: SG Wound Care, revised 3/27/21 documents, Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. 6. Wound care procedures and treatments should be performed according to physician orders. 49578 2. R4's Face Sheet printed 4/5/2024 lists her diagnosis to include: Pressure Ulcer of Sacral Region Stage 4; Chronic Non-pressure Ulcer to the right foot with unspecified severity; Unspecified Dementia with Mild Agitation; Type 2 Diabetes Mellitus with foot ulcer; Non Pressure Ulcer to the right foot with necrosis to the muscle; Venous Insufficiency Chronic Peripheral; Irritant Contact Dermatitis due to friction or contact with other specified body fluids. R4's MDS (Material Data Set) dated 1/9/2024 documents she requires extensive assist of 2 staff with bed mobility, transfers, dressing, eating, toilet use and hygiene. R4's Care Plan dated 5/12/2023 and revision of 11/6/2023 stated she was admitted with a pressure injury to the sacrum from the hospital. Interventions for this care plan documents to report any changes in skin status (infections, non-healing, new areas) to the physician/nurse. Wound care as ordered by the physician see TAR (Treatment Assessment Record). Position with pillows to maintain proper body alignments. Low air mattress to bed with bolsters. R4's Wound Physician Progress Note dated 2/27/2024, documents her stage 4 pressure ulcer to sacrum measured 1.8 cm length X 1.2 cm width x 0.2 cm in diameter. Surface area 2.16 cm Stage 4. Duration is greater than 282 days. Wound progress at goal. Exudate is moderate serous. Granulation tissue 100%. On 4/4/2024 at 8:35 AM V5, Wound Nurse, removed R4's adult brief to perform a pressure ulcer treatment to stage 4 pressure ulcer to sacrum. When R4's adult brief was removed there was no dressing in place to her pressure ulcer. R4's adult brief had stool on it. R4's wound bed observed to be about nickel sized red and moist with no foul odor detected. On 4/4/2024 at 8:55 AM V18 CNA, V19, CNA, and V20 were interviewed regarding R4's treatment not being done on her pressure ulcer. V18 stated that she has the resident R4 and checked her this morning and she was dry with no ADL care given at that time. V19 stated that she does not have the resident R4 and has not performed any care on her today. V20 stated that she does not have the resident R4 and works on another hall, and is just helping and denies doing any perineal care to R4 this morning. V5 stated that she was unaware of how long R4's dressing was off on her stage 4 ulcer to sacrum area. The facility's policy, Identification of Changes in Skin Condition, A Quick Reference Tool undated, documents, Assessment and Treatment of Pressure Ulcers: It is important that each existing pressure ulcer be identified, whether on admission or developed after admission, and that factors that influenced its development, the potential for developement of additional ulcers or for the deterioration of the pressure ulcer (s) be recognized, assessed and addressed. Any new pressure ulcer suggests a need to reevaluate the adequacy of the plan for preventing pressure ulcers. The facility's policy, Standards and Guidelines: SG Wound Care, revised 3/27/21 documents, Standard: It will be the standard of this facility to provide assessment and identification of residents at risk of developing pressure injuries, other wounds and the treatment of skin impairment. 6. Wound care procedures and treatments should be performed according to physician orders.

Based on observation, interview, and record review, the facility failed to ensure care plan interventions were appropriately in place for 2 out of 4 residents (R2, R7) reviewed for accidents in a sample of 18. Findings include: 1. R2's Admission Record, dated 3/5/24, documented that R2 was admitted on [DATE]. R2's admission record documented that R2's diagnoses are fracture of T11-T12 vertebra, type 2 diabetes mellitus with diabetic nephropathy, narcolepsy, hypertensive heart disease with heart failure, venous insufficiency, obstructive and reflux uropathy, depression, anemia, chronic kidney disease, obstructive sleep apnea, neuromuscular dysfunction of bladder, essential hypertension, hypothyroidism, mixed hyperlipidemia, benign prostatic hyperplasia and gastro-esophageal reflux disease. R2's MDS (Minimum Data Set), dated 2/1/24 documented that R2 is severely cognitively impaired and is dependent on staff for all ADLS (activities of daily living). R2's Care Plan, dated 11/9/23, documented that R2 requires a mechanical lift for all transfers. R2's Fall Risk Assessment, dated 12/19/23, documented that R2 is at high risk for falls. The facility's Incidents by Incident Type document, dated 3/4/24, documented that R2 had falls on 12/18/23, 1/24/23, and 2/2/24. R2's Care Plan, dated 11/9/23, documented that R2 is at risk for falls and is to have the following interventions in place: anticipate and meet resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, monitor/encourage appropriate footwear prn (as needed) it continues frequent monitoring of resident to ensure safe positioning and needs are met, keep bed in lowest position acceptable by the resident when the resident is in bed, remind to request assistance when getting up if needed, apply bolsters to bed, mat to right side of bed, it continues scoop mattress to bed. On 3/4/24 at 3:45 pm V10, CPC (Care Plan Coordinator) stated that (R2) is care planned to have a scoop mattress and a floor mat next to the bed. On 3/4/24 at 3:50 pm V10 and writer entered (R2's) room and (R2) was resting on an air mattress without a scoop, nor bolsters. (R2's) floor mat was folded up and leaning against the nightstand. At this time, V10 stated that she would expect (R2) to have a scoop mattress on his bed and that the mat should be on the floor next to the bed. 2. R7's admission record, dated 3/5/24, documented that R7 was admitted to the facility on [DATE] with diagnoses of acute on chronic congestive heart failure, chronic obstructive pulmonary disease, morbid (severe) obesity with alveolar hypoventilation, acute and chronic respiratory failure with hypoxia, fusion of spine, pulmonary hypertension, heart failure, muscle weakness, cardiomegaly, hypothyroidism, hyperlipidemia, major depressive disorder, peripheral vascular disease, gastro-esophageal reflux disease, hepatic fibrosis and hyperkalemia. R7's MDS, dated [DATE], documented that R7 is cognitively intact and requires partial/moderate assistance with toilet transfers. The facility's Incidents by Incident Type document, dated 3/4/24, documented that R7 had falls on 2/19/24 and 3/1/24. R7's Fall Risk Assessment, dated 3/4/24, documented that R7 is at high risk for falls. R7's Care Plan, dated 2/21/24, documented that R7 is at risk for falls and is to have the following interventions in place: anticipate and meet resident's needs, be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, check the environment for clutter or trip hazards and area is well lit, and remind to use walker during transfers. On 3/4/24 at 2:00 pm R7 stated that she has had a couple of falls but the one the other day was not her fault. Resident stated that she didn't have shoes on, the floor was wet, and the CNA (Certified Nurse Assistant) did not have a gait belt on her. R7 stated that she did not know the name of the CNA. R7's fall report, dated 3/1/24, documented resident observed on knees in bathroom on floor, resident alert and oriented X 3. Resident states to this nurse resident lost balance while attempting to transfer from toilet to wheelchair, resident denies any pain. R7's Health Status Note, dated 3/1/24 at 18:14, documented This evening 3:30 pm this nurse called to resident room per CNA while assisting resident to restroom resident assisted to floor per resident statement resident lost balance during toileting upon nurse assessment resident alert and oriented X3 resident denies any pain ROM (range of motion) Tol. (tolerated) well resident assisted back into WC (wheelchair) and assisted with needs resident VSS (vital signs stable) refer to flowsheet resident currently sitting up in WC in room call light within reach resident emergency contact made aware via phone call MD made aware. On 3/4/24 at 3:55 PM, writer observed V11 CNA in the restroom with R7. R7 was standing and holding onto the handrail. There was no gait belt on resident, nor was there a walker in the restroom. On 3/4/24 at 4:00 PM V10 CPC stated that she would expect R7 to have a walker in the restroom according to her Care Plan interventions. V10 stated that she would expect the CNAS to put a gait belt on R7 during transfers. On 3/4/24 at 2:20 pm, V8 CNA stated that she does not know where to find the fall intervention information for residents but she could ask the nurse. On 3/4/24 at 2:22 pm, V3 LPN (Licensed Practical Nurse) stated that she does not know where the fall intervention information is for the residents. On 3/4/24 at 2:24 pm, V4 LPN stated that she does not know where the fall intervention information is for the residents. On 3/4/24 at 2:26 pm, V9 LPN stated that she is an agency nurse and she does not know where to find what fall interventions the residents are supposed to have in place. On 3/5/24 at 1:25 pm, V2, DON (Director of Nursing) stated that R7 transferred herself to the toilet when she fell on [DATE]. V2 stated that R7 has periods of confusion. V2 stated that she does not have any witness statements from staff for R7's fall on 3/1/24. V2 stated that she did not know what CNAS were assigned to R7 at the time of the fall on 3/1/24 without looking at the schedules. V2 stated that she would expect the CNAS to use a gait belt when transferring residents and she would expect the fall interventions to be in place according to the Care Plan. The Facility's Fall Policy, dated 6/23/04, documented it will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent fall and injuries related to falls. Guidelines: 1. As part of the initial assessment, the facility will help identify individuals with a history of falls or risk factors for subsequent falling. It continues, 2. In addition, on admission, the nurse should assess and document/report items such as: vital signs, mental status, gait, pain, medications and active diagnoses. 3. The staff will discuss the resident's risk factors for falling and obtain orders from the physician for appropriate fall preventative devices as is needed. 4. The staff will evaluate, and document falls that occur while the resident is active in the facility census. It continues, 5. If a resident sustains a fall while a resident, staff should attempt to identify possible causes of the fall. It continues, if the cause of the fall is unclear, the IDT (Interdisciplinary Team) will attempt to establish reasonable interventions related to the current condition of the resident to attempt to prevent recurrence. 6. Based on evaluation of an existing fall(s) pertinent interventions will be implemented by staff such as, but not limited to: resident education if appropriate, staff re-education regarding transfer techniques and safety during ADL care, resident footwear, appropriate lightning, maintaining close proximity of frequently used items, mediation reviews, toileting programs, use of hip protectors, referral to therapy for strengthening/coordination/ balance. It continues, 8. Residents should be reviewed routinely or upon change of condition, if needed, to monitor for changes in fall risk factors.

Based on observation, interview and record review the facility failed to ensure safe transfers for 1 of 3 residents (R2) reviewed for transfers, in the sample of 12. This failure resulted in R2 being transferred incorrectly and resulted in severe bruising on her body covering her right shoulder from the back and underneath side and her entire chest which resulted in her being hospitalized . Findings include: R2's Physician Order Sheet (POS), dated January 2024, documented diagnoses of Atherosclerotic heart disease, hyperlipidemia, hypertension, abnormal finding of lung field, osteoarthritis, diverticulosis, disorder of thyroid, dysphagia, abnormal levels of serum enzymes, complete intestinal obstruction, acute kidney failure, and personal history of (healed) traumatic fracture. R2's POS also documented that she was taking 81 milligrams (mg) of aspirin once a day. R2's Minimum Data Set (MDS), dated [DATE], documented that R2 was severely impaired for cognition. It also documented that they needed assist for sit to stand, transfer chair to bed, toilet transfer, tub/shower transfer. It also documented, Dependent: Helper does all the effort, Resident does none of the effort to complete the activity or the assistance of two plus helpers (staff) are required for the resident to complete the activity. The MDS also documented that R2 uses a wheelchair and has no impairment on the upper or lower extremities. R2's Care Plan, dated 1/18/2024, documented, (R2) has an ADL self-care performance deficit related to confusion. (R2) is a minimum assist of 1 staff for bed mobility and assist of two staff with sit to stand. (R2) has an ADL (activities of daily living) self-care performance related confusion. R2's Progress Notes, dated 1/29/2024 at 7:53 AM, documented, hospitalized /bruising. R2's Initial Report, dated 1/27/2024 documented, (R2) has bruising of unknown origin in the abdominal region possibly caused by a gait belt. (R2) takes blood thinners. (R2) has not exhibited any loss of range of motion. MD (Medical Doctor) and family notified. Resident sent to hospital for further evaluation. Abuse not suspected at this time. Full evaluation and investigation to follow. On 1/30/2024 at 2:12 PM, R2's bruising started from over her right shoulder, approximately a foot wide, purple in color and extended underneath her arm (approximately five inches in width) on her right arm. The bruising was present from R2's right arm both behind and extended to the front of the shoulder, approximately 5 inches in width. From the front the area went from the top of the right shoulder area and extended to the entire chest area all the way across the chest to the left side. On the right side just above the breast area there was large baseball size swelling underneath the skin (hematoma). R2 grimaced when she was transferred and grabbed her left side and stated she did not know what she did, but the area hurt. Resident was asked what had happened and stated, How the he** would I know. There was no bleeding present. V6's, Certified Nursing Assistant (CNA), witness statement, dated 1/30/2024, documented, This writer (V2, Director of Nursing) spoke with (V6) on Saturday 1/27/2024. She stated that she transferred resident from bed to wheelchair after breakfast using gait belt. She then transferred resident again after lunch to toilet using a gait belt. Staff members commented that resident appears to be requiring more assistance, support with transfers as of recently. This writer asked CNA if she noted any grimacing or flinching when providing care or during transfers. (V6) stated that she feels the sit to stand would not be safe and feels that a mechanical lift would be more appropriate. On 1/30/2024 at 1:03 PM, V6, CNA, stated, Saturday morning I came in to work and when I came in (V10, Licensed Practical Nurse (LPN) and (V11, LPN) were working from the night shift and I asked them if they needed any help and they told me (R2) and her roommate (R6) still needed checked on. So, I went to help and change (R2) and (R6). I changed (R6) first because she is a (mechanical lift) and I got help with her. Then afterwards I went to change (R2). (R2) can roll and help out a little during a transfer. I put a gait belt on her and did a stand pivot with the gait belt. I did not have another staff member in the room with me. I did not use the sit to stand for the transfer. If you look on the computer (R2) it says (R2) is a sit to stand with 2 staff. (R2) is not able to hold on with her hands and I felt that it was safer to do the pivot with the gait belt versus the sit to stand. I do not believe it was me that gave her the bruises. I can only say I did not have assistance with (R2's) transfer and I do not feel that I gave her the bruises, but I did not transfer her with another staff member. On 2/1/2024 at 1:23 PM, V8, Registered Nurse (RN) stated, I was called into the room by a CNA (V6) and the CNA was changing (R2) and getting her ready for bed and she called me in because there was some bruising on her. I assessed her and she had extensive bruising, and I called the physician and had her sent out. I did not measure the bruising. The bruising was down her right side, on her ribs, a large hematoma above her chest. I am not aware of any falls prior or why she would have the bruising like she did, so I sent her out. On 2/1/2024 at 4:52 PM, V9, LPN, I was passing meds on 200 hall, (V8, RN) came and got me and said hey, I need you to witness something with me. I followed her to (R2's) room. (R2) was in the bed leaning on left side in bed and she had a lot of bruising from her mid shoulder area and the bruising went all the way across her entire chest. I did not see any visible bleeding, it was not dark in color and some small darker areas it was faint, it looked like a new bruise as there were no yellow or green colors in the bruise. It covered a very large area, and it surprised me because there was so much bruising from her shoulder to across her entire chest. I was not aware of her having any fall or injuries previously and (V8) sent her out. No measurements were taken but it was extensive bruising and covered her entire chest area. V7's, CNA, witness statement, undated, documented, I went to change (R2) into a gown and put her to bed at around 7:45 AM or 7:30 AM and I noticed she was all bruised up and when I took her shirt off while she was laying in the bed I told the nurse to come and look at her and asked if she knew she had bruises on her. On 1/30/2024 at 11:52 AM, V2, Director of Nursing stated, I reviewed (R2's) chart and (R2) was a sit to stand with two staff assist for transfers. I am not sure why (V6) was the only staff member that transferred (R2) and I am not sure why (V6) did not have another staff member assisting when transferring (R2). I would have expected (V6) to get another staff member when transferring (R2). I am not sure why she did not know (R2) required two staff members or why she transferred her by herself. R2's Hospital Records, dated 1/28/2024 at 12:43 PM, documented, Patient was brought from nursing home for evaluation of bruising noticed today. Nursing home facility is unable to give details about this bruising, it was between yesterday and today that she developed bruising on the anterior chest and the right upper extremity, denied fall or trauma, patient is not on blood thinner, does not have recurrent bruising in the past. She was evaluated in the ER (emergency room ) and there was no finding of fracture or dislocation, she has leukocytosis and urine sample has not been obtained in the ED (emergency department). Due to the findings of bruising with no explanation, patient is considered not safe to discharge back to same facility at this time and she will be admitted for observation. Hematoma present right anterior shoulder and bruising down left underarm. Exam: Chest wall: Bruising and ecchymosis on the entire anterior chest wall, hematoma on the right anterior chest, tender, no crepitus. Extremities: Bruising and ecchymosis on the right upper extremity involving the right axilla as well, lower extremity contacted. On 2/1/2024 at 4:48 PM, V1, Administrator stated we expect staff to follow the Care Plan for patient care. I do not have a policy for transfers. The Facility Fall Policy with a revision date of 3/27/2021 documents, It will be the standard of this facility to complete an initial assessment, on- going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls.

Based on observation, interview and record review, the facility failed to identify, develop and implement effective fall precaution interventions to prevent falls for 2 of 3 residents (R1, R2) reviewed for fall precautions in the sample of 6. This failure resulted in R1 with a un-witnessed fall, with injury's to the face, receiving 7 stitches to the chin, an maxillary sinus, (front of face), fracture, bruising to face and right radius, (thumb side), fracture and R2 Physician Order was for the use of a Full Mechanical Lift for transfers. Findings include: 1. R1's Admission Record, documented, vascular dementia, psychotic disturbance, mood disturbance and anxiety, other abnormalities of gait and mobility, frontal lobe and executive function deficit, signs of cognitive functions and awareness, anxiety, repeated falls and major depressive disorder, recurrent. R1's, Initial Report, dated 11/8/22, documents, had fall at facility on 11/8/22. Sent to ER, (emergency room ), for further evaluation. admitted for abnormal imaging. R1's, Hospital Records, dated 11/8/22, history and physical emergency room report, documented, right radius, (hand), fracture and left maxillary, (face), fracture. Treatment of 7 stitches to chin, and a Velcro wrist splint for immobilize, continue fracture precautions is expected for healing for the next 5-6 weeks and documented, discharge instructions, as, Please Don't Leave Patient Unattended. R1's, typed letter, undated, signed by a Registered Nurse, documents, resident was remitted from (hospital) to facility on 11/9/22 fall with injuries as follows: facial fracture, right wrist fracture, and sutures to chin. R1's, entitled, #816, Fall, dated 11/24/22, documented, fell to floor in her room, no witnesses found. R1's, entitled, #887, Fall, dated 2/3/23, documented, resident in sitting position next to bed, R1 states, I got up and took a fall and tumbled out for bed headfirst into the door. Further documented, injury of abrasion, to right hip. Mental status as confused, impaired memory. Fall un-witnessed. R1's, Care Plan Intervention, dates, 2/3/23 Keep BED IN LOWEST POSITION acceptable by the resident when the resident is in bed. R1's, entitled, #902, Fall, dated 02/16/23, documented, on floor, between bed and wall, discoloration observed to the right shoulder and right hand, sent out to hospital for evaluation and treatment, documented, no witnesses' found. R1's, Care Plan Intervention, does not document a new fall intervention for fall incident of 2/16/23. R1's, entitled, #915, Fall, dated 2/24/23, documented, found laying on her right side with her back against the bed, sent to hospital for evaluation and treatment, injury of bruise to face at time of incident. R1's mental status as confused, orientated to person and impaired memory. R1's, Care Plan Intervention, dates, 02/24/23 SCOOP or PERIMETER MATTRESS to bed. R1's, entitled, #916, Fall, dated 2/25/23, documents, CNA, (Certified Nurse Aide), walked in and found the resident ambulating without assist. CNA stated, she told the resident that she needs to press her call light when she needs help. Mental status documented oriented to person, impaired memory, confused. R1's, Care Plan Intervention, dates, 02/25/23 Refer to THERAPY for screen/evaluation and treatment as indicated. Not an individualized effective intervention for fall. R1's, entitled, #946, Fall, dated 3/24/23, documented, observed sitting on buttocks on floor, between bed and wheelchair. R1's mental status, impaired memory. On 3/24/23, a second fall, same day, documented, CNA found R1 sitting on the floor beside her bed. R1's, Care Plan Intervention, dates, 03/24/23 Anti-roll backs to wheelchair. R1's, entitled, Maintenance Work Order, dated 3/27/23, documents, Work to be done: Install anti-Roll back on guest wheelchair. R1's, entitled, #967, Fall, dated 4/7/23, documented the CNA approaches floor nurse and states resident is on floor laying on left side lying next to bed and between rollator, (a walker with a seat). R1's mental status documented as confused. R1's, Physical Therapy discharge Summary, dated 12/30/22 through 2/10/23, 3/16/23 through 4/14/23 and 4/13/23 through 4/27/23, documented progress as baseline as requiring; supervision or touch assistance with gait and stand pivot transfers and transfers. On 5/2/23 at 1:00PM, R1 was in her room, sitting in a wheelchair that was identified to not have anti-roll backs to the wheelchair she was sitting in. On 5/2/23 at 1:14PM, V5, Licensed Practical Nurse, stated, R1 should have Anti-roll backs on her wheelchair, and she struggles day to day with memory. On 5/2/23 at 1:30PM, V4 titled as a Corporate Regional Nurse and V1, Administrator both stated, that R1 is to have anti-rollbacks to her wheelchair as that a work order was submitted to have them placed on her wheelchair. V1 stated, she went to R1's room and states, R1 is currently sitting in someone else's wheelchair, must have been taken from the hall by staff, by mistake and R1 was given her correct wheelchair. On 5/3/23 at 9:19AM, V9, Director of Therapy, states, R1 had Covid, as this changed her mobility instability which resulted in R1 having a medical decline. R1 currently is undergoing Therapy, which she is only able to walk 3-4 steps, she has a lot of progressive fatigue and can only sustain 30 seconds with ambulation as V9, had reviewed back to therapy records from 8/2022 through 4/13/23. On 5/3/23 at 10:50AM, V10, CNA stated, R1 is able to activate her call light, but will not, will get up when she wants too, cannot tell you the day of week or month, she only is aware of herself and surroundings. On 5/3/23 at 11:20AM, V1 and V4 both stated, that R1's falls are reviewed with the Interdisciplinary team, (IDT), with each fall, interventions are discussed, evaluated, documented in the Care Plan and implemented. 2. R2's, Admission Record, dated 5/1/23, documented, admitted [DATE] and medical diagnosis; hemiplegia and hemiparesis affecting left side of body, muscle weakness, lack of coordination. R2's, Order Summary Report, dated 5/1/23, documented Hoyer (Full Mechanical Transfer Lift of two assist), ordered recommendation from V8 (Physical Therapist) R2's, Nurse Risk Screen, dated 4/5/23, documents, In progress, no Fall Risk Screen Documented. R2's, Nurse Risk Screen, dated 4/14/23, documented, at High Risk for Falls. On 5/2/23 at 1:28PM, surveyor entered R2's, room, V6 and V7 both CNA's, placed a gait belt around R2's waist, transferred R2 from his high back chair into the bed. R2's high back Chair was observed to have a Full Mechanical Lift sling in the chair that R2 was sitting on. R2's, entitled #976 Fall, dated 4/13/23, documented, R2 found lying on floor by fall mat, was lifted back to bed using a Mechanical lift. Notes: Alert to person, place and time, non-ambulatory, transfer dependent with Mechanical lift. On 5/4/23 at 9:15AM, V1 stated, R2 is ordered for a Full Mechanical Lift, and will assure this is addressed with V6 and V7. The facility's policy and procedure, entitled, Falls, dated 3/27/21, documents, It will be the standard of this facility to complete an on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. After a fall, the interdisciplinary team should review the circumstances surrounding the fall and develop an appropriate intervention (s) and plan of care.

Based on observation, interview and record review the facility failed to ensure a resident was treated with dignity, and had needs met timely for 4 of 4 residents (R35, R51, R54, R77) observed for dignity in a sample of 43. This failure resulted in R77 feeling dirty, nasty and embarrassed. Findings include: 1. R77's Minimum Data Set (MDS), dated [DATE], documents that R77 is cognitively intact. On 2/22/2023 at 9:10 AM, R77's wheelchair was heavily soiled with visible caked on food on the foot pedals, cushion, and both sides of the wheelchair. On 2/22/2023 at 8:59 AM, R77 stated that his wheelchair is dirty. R77 stated that he has not had his wheelchair cleaned since being here. R77 stated that he was pissed off and felt embarrassed. R77 stated that he doesn't have any legs and his wheelchair is how he moves round. R77 stated that he feels dirty and nasty. This is what you see when you see me. They don't do nothing. Who wants to be seen like this? This is embarrassing. On 2/22/23 at 9:05 AM, V13, Certified Nurse Assistant (CNA), stated that the day shift does not clean the wheelchairs. V13 stated that the wheelchairs are supposed to be cleaned on the midnight shift. V13 stated that caked on food looks like has been there for some time and does not look like the wheelchair has been cleaned. On 2/22/23 at 9:30 AM, V7, CNA, stated that the day shift does not clean the wheelchairs. V7 stated midnight shift does the wheelchairs. V7 stated that she is not sure about a cleaning schedule because this is not something that she does. On 2/23/2023 at 2:15 PM, V1, Administrator, provided the wheelchair cleaning schedule, date 12/15/22, that documents R77's wheelchair is scheduled to be cleaned on Tuesday. As of 2/24/2023 at 3:00 PM the facility had not provided any documentation of R77's wheelchair being cleaned. 2. R35's MDS, dated [DATE] documents that R35 has moderately impaired cognitively. On 02/22/23 at 03:12 PM, R35 stated the agency staff act as if they don't care, and they are not always respectful. 3. R51's MDS, dated [DATE], documents that R51 is cognitively intact. On 02/22/23 at 03:12 PM, R51 stated the agency staff act as if they don't care, and they are not always respectful. 4. R54's MDS, dated [DATE], documents that R54 is cognitively intact. On 02/22/23 at 03:12 PM, R54, stated the agency staff act as if they don't care, and they are not always respectful. The Residents' Rights for People in Long-Term Care Facilities, not dated, documents Your rights to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interview and record review, the facility failed to notify the physician of critical lab results for one of 14 residents (R7) reviewed for quality of care in the sample of 14. This failure resulted in R7 continuing to receive the same treatment for his diabetes despite multiple episodes of hypoglycemia, and R7 being admitted to the intensive care unit of local hospital with diagnosis of hypoglycemia. Findings include: R7's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses of Rhabdomyolysis, Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Unspecified Vertebral Artery, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Depression, Gastro-Esophageal Reflux Disease Without Esophagitis, Primary Hypertension, Metabolic Encephalopathy, Acute Kidney Failure, Dysphagia Following Cerebral Infarction, and Cognitive, Social, or Emotional Deficit Following Cerebral Infarction. R7's Physician Order Summary includes an order dated 12/16/22 for lab testing including a CMP (Complete Metabolic Profile) and HgbA1C (a test that measures your average blood sugar levels over the past 3 months). Another order dated 12/21/22 documents an order for another CMP to be done. An order dated 12/16/22 documents, Perform accucheck one time a day related to Diabetes Mellitus with Hyperglycemia. R7's medication orders dated 12/15/22 document orders for Glimepermide 2 milligrams (mg) once a day and Metformin 500 mg twice a day for diabetes mellitus. R7's results of his CMP dated 12/19/22 document his blood glucose level as 33 (normal limits are 65-99). There is a stop sign symbol on the lab indicating this is a critical level. R7's results of his CMP dated 12/22/22 document his blood glucose level as < 31 (less than 31). There is a stop sign symbol on the lab indicating this is a critical level. Review of R7's Progress Notes from 12/15/22 when he was admitted to the facility, through 12/23/22 when he was discharged to the hospital, do not include any documentation of R7's medical doctor being notified of R7's critical lab results. On 1/6/23 at 10:58 AM, V9, staff with the facility's contracted lab, stated the lab staff call any critical labs to the facility, and if there is no answer, they continue to call the facility until someone confirms they received the critical lab results. V9 stated R7's critical glucose level of <31 was called to V2, Director of Nursing on 12/22/22 at 4:24 PM, and R7's critical glucose level of 33 was called to V17, Licensed Practical Nurse (LPN) on 12/19/22 at 5:32 PM. On 1/10/23 at 9:55 AM, V2, Director of Nursing (DON) stated she does not know why there is no documentation of R7's critical lab values being called to the doctor. She stated she took one of the calls from the lab about his low glucose level but by then the nurse had already taken action and corrected his blood sugar after his accucheck was low that morning. V2 stated the critical lab results should still have been called to the medical doctor. She stated on the day that R7 was sent to the hospital, V15, Nurse Practitioner, was on the phone with the nurse and was aware of R7's accucheck of 21 and V15 ordered Glucagon to be given and 911 to be called when R7's blood sugar was still 21 after Glucagon was administered. V2 stated again that all critical lab results should be called to the Medical Doctor (MD). V2 stated she thinks the MD also has access to the electronic medical record but should still be notified by the nurse to be sure it is not missed. V2 stated she was not aware until it was brought to her attention during the survey that R7 had two different critically low blood glucose results. On 1/10/23 at 11:15 AM, V15, Nurse Practitioner (NP), stated she saw R7 once while he was a resident in the facility. She stated she was not notified of R7 having any critical labs, and stated she would definitely have remembered a blood glucose of 33 or less than 31 being reported to her. V15 stated there was no documentation of V16, Medical Doctor (MD), being notified of the critical lab results in their file on R7, which she stated is where V16 would have documented any communication with the facility regarding critical labs. V15 stated V16 did say the facility did report that R7 had a low accucheck result in the morning on the day V16 made rounds (Wednesday, 12/21/22) and that they had taken action to bring it back up, but they did not report R7's critical low glucose of 33 on 12/19/22 on his CMP to V16 or herself. V15 stated she was also not aware of R7's glucose of less than 31 on his CMP lab report on 12/22/22 when she was talking to the nurse about R7's accucheck result of 21 on 12/23/22 that ended up with him being sent to the hospital. V15 stated if she was aware of R7's critical lab results of low glucose levels, she would have held or discontinued his diabetic medications. V15 stated when R7's accuchecks were low on those other mornings, his diabetic medication should not have been given. V15 stated she would have held R7's Glimepermide (diabetic medication) after his first critically low blood glucose on 12/19/22, but because he continued to receive the same medications, he continued to have low blood glucose and ended up in the hospital with hypoglycemia (low blood glucose). On 1/11/23 at 3:55 PM, V1, Administrator, stated the facility does not have a policy regarding reporting critical labs. The facility's policy, Standards and Guidelines: SG Change in Condition revised 3/27/21 documents, Standard: It will be the standard of this facility to notify the physician, family, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. It continues, Guidelines: 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The facility's undated policy, When to Call/Notify the Doctor documents, 2. Change in Resident Condition: h. results of labs/xrays/diagnostic tests.

Based on interview and record review, the facility failed to provide adequate diabetic management for one of 14 residents (R7) reviewed for quality of care in the sample of 14. This failure resulted in R7 continuing to receive the same treatment for his diabetes despite multiple episodes of hypoglycemia, and R7 being admitted to the intensive care unit of local hospital with diagnosis of hypoglycemia. Findings include: R7's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses of Rhabdomyolysis, Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Unspecified Vertebral Artery, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Depression, Gastro-Esophageal Reflux Disease Without Esophagitis, Primary Hypertension, Metabolic Encephalopathy, Acute Kidney Failure, Dysphagia Following Cerebral Infarction, and Cognitive, Social, or Emotional Deficit Following Cerebral Infarction. R7's Physician Order Summary includes an order dated 12/16/22 for lab testing including a CMP (Complete Metabolic Profile) and HgbA1C (a test that measures your average blood sugar levels over the past 3 months). Another order dated 12/21/22 documents an order for another CMP to be done. An order dated 12/16/22 documents, Perform accucheck one time a day related to Diabetes Mellitus with Hyperglycemia. R7's medication orders dated 12/15/22 document orders for Glimepermide 2 milligrams (mg) once a day and Metformin 500 mg twice a day for diabetes mellitus. R7's Minimum Data Set (MDS) dated [DATE] documents he is severely cognitively impaired, and requires limited assist with bed mobility, transfers, walking in his room, dressing, toileting and eating. The MDS documents he is occasionally incontinent of urine and always incontinent of bowel. R7's Care Plan dated 12/15/22 documents the focus of: Resident has Diabetes and is at risk for high or low blood sugar. The goal for this care plan is: Resident will not experience serious complications related to high or low blood sugar. Interventions for this care plan include: Monitor for and report as needed signs or symptoms of low blood sugar (hyperglycemia) such as irregular heart beat, shakiness, anxiety, sweating, confusion, change in level of consciousnessm or low fingerstick readings. Report consistent unstable blood sugars to physician as needed. (This care plan incorrectly identifies low blood sugar which is hypoglycemia). R7's Medication Administration Record (MAR) dated 12/2022 documents he received his diabetic medications, Glimeperide 2 mg once a day and Metformin 500 mg twice a day despite his accucheck results being below normal on 12/22/22 and his lab reports documenting a critically low glucose level on 12/19/22 and 12/22/22. R7's results of his CMP dated 12/19/22 document his blood glucose level as 33 (normal limits are 65-99). There is a stop sign symbol on the lab indicating this is a critical level. R7's results of his CMP dated 12/22/22 document his blood glucose level as < 31 (less than 31). There is a stop sign symbol on the lab indicating this is a critical level. Review of R7's Progress Notes from 12/15/22 when he was admitted to the facility, through 12/23/22 when he was discharged to the hospital, do not include any documentation of R7's medical doctor being notified of R7's critical lab results. R7's Progress Note dated 12/22/22 at 6:44 AM documents, Perform accucheck one time a day related to Type 2 Diabetes Mellitus with hyperglycemia. Resident BS (blood sugar) was 44 at 5:45 AM. Boost given, he was alert and talking to me saying he did not know if he has had hypoglycemia episodes. Resident consumed the the whole container of Boost and rechecked BS 56 at 6:45 AM. Resident was also given an oatmeal cream cookie. Reported to day nurse. R7's Progress Note dated 12/23/22 at 1:27 PM documents, Resident daughter informed this nurse her dad facial has changed, went to resident room, resident was lying in bed, left hand to his mouth, called resident name, he looked but did not respond . Resident left hand was twitching. Took resident V/S (vital signs) BP (blood pressure) WNL (within normal limits) but HR (heart rate) is irregular. around 9:30 AM, when administer resident medication, resident seem A&O (alert and oriented) 1-2. Now resident is 1-2, AM (morning) medication was administered, but resident medication should crushed due to swallowing precaution, due to alter mental changes. EMS (Emergency Medical Services) was called. Around 1:03 PM BS (blood sugar) was checked, result 21. Glucagon 1 ml (milliliter) given, in the left thigh at 1:11 PM, 1:12 PM EMS was here, gave to EMS. EMS retook BS, BS result 21. IV (intravenous access) was started by EMS, around 1:28 PM resident was on stretcher. Daughter is here. PCP (Primary Care Physician) was called. R7's Hospital Records dated 12/24/22 documented his admitting diagnosis as: Hypoglycemia, likely secondary to oral hypoglycemic adn poor p.o. (by mouth) intake. The hospital summary documents, Patient is a [AGE] year old gentleman came in with hypoglycemia. Likely related to poor p.o. intake and also patient on soft oral diabetic medication. Stopping this medication resolved his blood sugar issues. The hospital History and Physical dated 12/23/22 at 5:45 PM documents, Despite receiving several amps of dextrose and food in the ED (Emergency Department) he remains hypoglycemic and he is being admitted to the ICU (Intensive Care Unit) in this setting on a D10 (dextrose) drip. On 1/6/23 at 10:58 AM, V9, staff with the facility's contracted lab, stated the lab staff call any critical labs to the facility, and if there is no answer, they continue to call the facility until someone confirms they received the critical lab results. V9 stated R7's critical glucose level of <31 was called to V2 on 12/22/22 at 4:24 PM , and R7's critical glucose level of 33 was called to V17, Licensed Practical Nurse (LPN) on 12/19/22 at 5:32 PM. On 1/10/23 at 9:55 AM, V2, Director of Nursing (DON) stated she does not know why there is no documentation of R7's critical lab values being called to the doctor. She stated she took one of the calls from the lab about his low glucose level but by then the nurse had already taken action and corrected his blood sugar after his accucheck was low that morning. V2 stated the critical lab results should still have been called to the medical doctor. She stated on the day that R7 was sent to the hospital, V15, Nurse Practitioner, was on the phone with the nurse and was aware of R7's accucheck of 21 and V15 ordered Glucagon to be given and 911 to be called when R7's blood sugar was still 21 after Glucagon was administered. V2 stated again that all critical lab results should be called to the Medical Doctor (MD). V2 stated she thinks the MD also has access to the electronic medical record but should still be notified by the nurse to be sure it is not missed. V2 stated she was not aware until it was brought to her attention during the survey that R7 had two different critically low blood glucose results. V2 stated she did rounds on 12/23/22 and saw R7 and his roommate and they both stated they were doing alright. She stated about an hour later, R7's daughter notified the nurse that R7 didn't look right and that is when his blood sugar was checked and found to be 21. She stated he was fine just an hour before. V2 stated she told the nurse on duty to check his BS because he had been running low in the mornings. On 1/10/23 at 11:15 AM, V15, Nurse Practitioner (NP) stated she saw R7 once while he was a resident in the facility. She stated she was not notified of R7 having any critical labs, and stated she would definitely have remembered a blood glucose of 33 or less than 31 being reported to her. V15 stated there was no documentation of V16, Medical Doctor (MD) being notified of the critical lab results in their file on R7, which she stated is where V16 would have documented any communication with the facility regarding critical labs. V15 stated V16 did say the facility did report that R7 had a low accucheck result in the morning on the day V16 made rounds ( Wednesday, 12/21/22) and that they had taken action to bring it back up, but they did not report R7's critical low glucose of 33 on 12/19/22 on his CMP to V16 or herself. V15 stated she was also not aware of R7's glucose of less than 31 on his CMP lab report on 12/22/22 when she was talking to the nurse about R7's accucheck result of 21 on 12/23/22 that ended up with him being sent to the hospital. V15 stated if she was aware of R7's critical lab results of low glucose levels, she would have held or discontinued his diabetic medications. V15 stated when R7's accuchecks were low on those other mornings, his diabetic medication should not have been given. V15 stated she would have held R7's Glimepermide (diabetic medication) after his first critically low blood glucose on 12/19/22, but because he continued to receive the same medications, he continued to have low blood glucose and ended up in the hospital with hypoglycemia (low blood glucose). The facility's policy, Standards and Guidelines: SG Diabetes Hypo/Hyperglycemia revised 3/27/21 documents, Standard: It will be the standard of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. It continues, Guidelines: 4. The physician will order appropriate lab tests (for example, periodic fingersticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. It further documents, 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in clinical record. The facility's policy, Standards and Guidelines: SG Change in Condition revised 3/27/21 documents, Standard: It will be the standard of this facility to notify the physician, family, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. It continues, Guidelines: 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The facility's undated policy, When to Call/Notify the Doctor documents, 2. Change in Resident Condition: h. results of labs/xrays/diagnostic tests.

Based on interview and record review, the facility failed to provide treatment in accordance with professional standards of care for a fall resulting in injury for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3. This failure resulted in a delay in treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognitive skills for daily decision making. R2's MDS dated [DATE] documents R2 requires limited assist for transfers, bed mobility and is occasionally incontinent of urine. R2's face sheet documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan, dated 8/23/22, documents R2 is at risk for abnormal bleeding related to use of anticoagulant. Interventions include report to the physician any signs/symptoms abnormal bleeding or hemorrhage. R2's 10/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Chart Note dated 10/19/2022 02:44 AM, documents: guest fell , no injury noted, daughter called waiting for call back, message left for gen med (general medicine) in folder. R2's Chart Note, dated 10/19/2022 10:07 AM, documents: Resident continues to complain of pain Tylenol not effective. Dr. notified. Vital sign monitoring continues from being observed on the floor. Neuro checks continue and remain WNL (within normal limits). Afebrile Resident has loss of appetite due to increased pain. Small hematoma noted behind right ear. Unable to move without yelling out. New order received to send to the hospital for evaluation and treatment. POA (Power of Attorney) notified and gave verbal consent to send to hospital. (local) EMS (emergency medical services) notified of order for Resident pick up. R2's Chart Note dated 10/19/2022 3:00 PM, documents: EMS arrived for Resident pick up and transport to (local hospital) ED (emergency department). EMS arrived to facility. Resident left facility accompanied by x2 EMTs (emergency medical technicians) via stretcher. POA in NH (nursing home) sitting with Resident prior to arrival of EMS transport. On 10/27/2022 at 12:00 PM, V4, Licensed Practical Nurse (LPN), stated he received report from night shift nurse on 10/19/22 that R2 had a fall around 2-3am with no injuries and that the doctor and POA were aware. V4 stated he did walking rounds at the beginning of his shift and R2 was in bed. V4 stated around breakfast time the CNA (Certified Nursing Assistant) staff asked him to go to R2's room because they tried to raise the head of R2's bed to eat and she was in pain. V4 stated he entered R2's room and asked R2 what was going on. V4 stated R2 said she had fallen last night and she hurt all over. That her knee, head and shoulder hurt. V4 stated he gave R2 some acetaminophen for her pain and asked her to try and eat. V4 stated he did not do a physical assessment on her at that time. V4 stated around 10:00 am, he called V5, Nurse Practitioner (NP). V4 stated he told V5 that R2 had fallen last night and that she hit her head and was on blood thinners, that R2 was in pain unrelieved by acetaminophen and that her leg was turned outwards. V4 stated he received orders from V5 to send R2 to the hospital. V4 stated he called (local ambulance) transportation and they stated they were running behind. V4 said (local ambulance) transport asked him if this was an emergency and he stated no. V4 stated the (local ambulance) transport stated that they would be at the facility at 12:30-1:00pm for transport. V4 stated R2 did not transport to hospital until 3pm. V4 stated he did not make any additional calls to get R2 to the hospital earlier. V4 stated he felt as if R2 should have been transported to ER (emergency room ) on night shift. V4 stated he did not notify NP of delay in transfer and he did not request any additional pain medication for R2 due to the acetaminophen not controlling the pain. On 10/27/2022 at 1:00 PM, V5, NP, stated she would expect the facility to transfer R2 immediately to the hospital due to her being on blood thinner and hitting her head during the fall. V5 stated she would have ordered something more for pain if she was aware of R2 not being transferred to ER until 3pm due to her pain not being relieved with acetaminophen. V5 stated she was not a made aware that R2 wasn't transferred to ER until 3pm. R2's hospital records for emergency room visit note dated 10/19/2022 documents per EMS that R2 received 4 milligram (mg) of [MEDICATION(S)] for pain and that R2's right lower extremity noted to be externally rotated and shortened. This document also documents R2 as having a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control. The Facility standards and guidelines document includes the following: contact the primary physician to update him/her to the change of condition, if the residents condition is considered to be life threatening and the resident requires immediate medical care notify the emergency medical system (911).

Based on interview and record review, the facility failed to ensure that pain management was provided for one of three residents (R2) reviewed for pain in the sample of three. This failure resulted in R2 lying in pain for an excess of 5 hours crying out in pain with any movement without transfer to the hospital or receiving pain medication. R2 sustained a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control. Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognitive skills for daily decision making. R2's MDS dated [DATE] documents R2 requires limited assist for transfers, bed mobility and is occasionally incontinent of urine. R2's face sheet documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's care plan dated 8/23/22 documents R2 has the potential for pain, interventions include notify the resident's physician if they do not state/demonstrate relief or reduction of pain with current pain management regimen. R2's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen tab 650mg (milligram) by mouth every 6 hours as needed for pain. R2's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Chart Note dated 10/19/2022 2:44 AM, documents: guest fell , no injury noted, daughter called waiting for call back, message left for gen med (general medicine) in folder. R2's Chart Note dated 10/19/2022 10:07AM documents: Resident continues to complain of pain Tylenol not effective. Dr. notified. Vital sign monitoring continues from being observed on the floor. Neuro checks continue and remain WNL (within normal limits). Afebrile Resident has loss of appetite due to increased pain. Small hematoma noted behind right ear. Unable to move without yelling out. New order received to send to the hospital for evaluation and treatment. POA (Power of attorney) notified and gave verbal consent to send to hospital. (local) EMS (emergency medical services) notified of order for Resident pick up. R2's Chart Note dated 10/19/2022 3:00 PM, documents: EMS arrived for Resident pick up and transport to (local hospital) ED (emergency department). EMS arrived to facility. Resident left facility accompanied by x2 EMTs via stretcher. POA in NH (nursing home) sitting with Resident prior to arrival of EMS transport. On 10/27/2022 at 12:00 PM, V4, Licensed Practical Nurse (LPN), stated he received report from night shift nurse on 10/19/22 that R2 had a fall around 2-3am with no injuries and that the doctor and POA were aware. V4 stated he did walking rounds at the beginning of his shift and R2 was in bed. V4 stated around breakfast time the CNA (Certified Nursing Assistant) staff asked him to go to R2s room because they tried to raise the head of R2's bed to eat and she was in pain. V4 stated he entered R2's room and asked R2 what was going on. V4 stated R2 said she had fallen last night and she hurt all over. That her knee, head and shoulder hurt. V4 stated he gave R2 some acetaminophen for her pain and asked her to try and eat. V4 stated he did not do a physical assessment on her at that time. V4 stated around 10:00 am, he called V5, Nurse Practitioner (NP). V4 stated he told V5 that R2 had fallen last night and that she hit her head and was on blood thinners, that R2 was in pain unrelieved by acetaminophen and that her leg was turned outwards. V4 stated he received orders from V5 to send R2 to the hospital. V4 stated he called (local ambulance) transportation and they stated they were running behind. V4 said (local ambulance) transport asked him if this was an emergency and he stated no. V4 stated the (local ambulance) transport stated that they would be at the facility at 12:30-1:00pm for transport. V4 stated R2 did not transport to hospital until 3pm. V4 stated he did not make any additional calls to get R2 to the hospital earlier. V4 stated he felt as if R2 should have been transported to ER (emergency room ) on night shift. V4 stated he did not notify NP of delay in transfer and he did not request any additional pain medication for R2 due to the acetaminophen not controlling the pain. On 10/27/2022 at 1:00 PM, V5, NP, stated she would expect the facility to transfer R2 immediately to the hospital due to her being on blood thinner and hitting her head during the fall. V5 stated she would have ordered something more for pain if she was aware of R2 not being transferred to ER until 3pm due to her pain not being relieved with acetaminophen. V5 stated she was not a made aware that R2 wasn't transferred to ER until 3pm. R2's hospital records for emergency room visit note dated 10/19/2022 documents per EMS that R2 received 4mg of [MEDICATION(S)] for pain and that R2's right lower extremity noted to be externally rotated and shortened. This document also documents R2 as having a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control.

Based on interview and record review the facility failed to monitor a change of condition and respond timely for 2 of 3 residents (R1, R2) reviewed for change of condition in the sample of 5. This failure caused a delay in treatment which resulted in R1's fall sustaining a left [CONDITION(S)] requiring hospitalization and R2 having multiple episodes of [CONDITION(S)] before being sent to the hospital. Findings include: 1. R2's Admission Record, not dated, lists Acute Respiratory Failure with [CONDITION(S)] as R2's Primary diagnosis. It also lists [CONDITION(S)] with Exacerbation and Chronic Pulmonary [CONDITION(S)] as diagnosis. R2's Care Plan, dated 3/29/2022, documents (R2) has actual/potential altered respiratory status. It also documents Interventions Administer oxygen as ordered VIA O2 (oxygen) CONCENTRATOR: (Specify frequency below) PRN (as needed) At 2-5LPM (liters per minute) via Nasal cannula Humidification Needed, Monitor for changes in / development of signs & symptoms of breathing difficulty and report to nurse if noted: SOB (shortness of breath), Cough (productive or non-productive), Fever, Chills, Difficulty speaking, Bluish skin color, Changes in cognition. Notify nurse for any observed or reported breathing difficulty, excess secretions, or persistent coughing. 4-8-22 Resident will remove 02 at times, Encourage resident to leave 02 on. Provide resident / responsible party education PRN to include: Coughing / deep breathing, Fluid needs, Pursed-lip breathing, Need for rest, Compensatory strategies, Remind resident to breathe slowly and deeply when short of breath PRN, Report changes in respiratory status to physician. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is moderately impaired cognitively. R2's Monthly Summary, dated 4/17/2022, documents R2 is alert with confusion. R2's Progress Notes, dated 4/30/2022 at 8:15 AM, document, Health Status Note, Note Text: Resident hypoxic when staff got her sat up for breakfast with SpO2 (oxygen saturation) in 40-50%. Resident was refusing to go to hospital and code status is DNR (Do Not Resuscitate). Called MD (physician) and received orders to increase O2 flow to 4-5L (liters) via non rebreather and contact emergency contact for further info R/T (related to) transferring to acute care ED (emergency department) for further treatment. This RN (Registered Nurse) spoke with (V7, R2's family) and he was agreeable to increasing O2 via mask and re evaluation before sending (R2) to hospital. Resident immediately had improved SpO2 after increasing flow and application of non rebreather. current SpO2 @ 90%. R2's Progress Notes, dated 4/30/2022 at 7:30 PM, document, Health Status Note, Note Text: Call placed to 911 by this RN to transport Resident to hospital due to [CONDITION(S)], after speaking with her son to verify his agreement with decision. VS (vital signs) 99HR (heart rate) Resp (respirations) 16 on 5L O2 via mask SpO2 71% 97.5 145/71 Decision to transfer made after multiple episodes of [CONDITION(S)] and s/s (signs/symptoms) of abnormal lung sounds. EMS (emergency medical services) transported Resident to (local hospital) ED. On 5/12/2022 at 8:40 AM, V7, R2's Emergency Contact, stated that he was called at 7 PM on the day of her discharge to the hospital. V7 stated at that time he was notified that his mother was having shortness of breath and that she was delirious and she needed to go to the emergency room and be placed on a [CONDITION(S)] to help her breathing. V7 stated at 7 PM was the first time he was told that she was having problems. V7 stated that he was not aware of his mother having problems with her breathing and that her SPO2 level was 40% at all and that he was not notified until 7 PM at night. V7 stated that if he would have known that, he would have had her sent to the hospital. V7 stated that his mother was a DNR but she still would go to the hospital if something was wrong. V7 stated that his mother went to the hospital in March and this was the first time he was made aware of how serious it was to have a low SPO2. V7 stated prior to that he was not aware of how serious it was. V7 stated that because of this he would have sent her to the hospital. V7 stated within the last 30 days of her life R2 was having increased confusion and erratic conversations. V7 stated that they were not aware if this was because of dementia, the [CONDITION(S)] (urinary tract infection) she had or the low SPO2 levels. V7 stated that his mother would not have been able to make that decision and if he was aware, he would have sent her to the hospital. V7 stated that he was not notified throughout the day of any problems with his mother's condition or breathing problems. V7 again stated that he was not made aware of his mother's breathing problems until 7pm when she was being sent to the hospital. On 5/12/2022 at 9:15 AM, V9, RN, stated that she was notified of R2's oxygen level being 40 by V10, Licensed Practical Nurse (LPN). V9 stated that she was going to send R2 out to the hospital. V9 stated that she called the Nurse Practitioner and told her that the resident oxygen level was ranging from 40% to 50%. V9 stated that R2 stated that she did not want to go to the hospital. V9 stated that she was informed by the NP that with R2's Oxygen levels being this low and her being hypoxic she would not be able to make the decision and to contact the family. V9 stated that she requested a nonrebreather mask. V9 stated that she called the son and told him about his mother's condition and orders received from the doctor and V7 agreed to monitor but stated that he wanted to be kept informed of her condition. V9 stated that she then applied the mask and R2's oxygen levels came up to high 80's, low 90's. V9 stated that for a good part of the day R2's oxygen levels stayed in the high 80's and R2 kept the mask on. V9 stated that as the day went on R2's oxygen level dropped to low 70's. V9 stated that she then sent R2 to the hospital. V9 stated that upon EMTs (emergency medical technician's) arrival she was notified by the Technician that R2 appeared to be dying. V9 stated she told the technician that R2 required a higher level of care than what was being provided at this facility. On 5/12/2022 at 9:30 AM, V8, R2's Physician, stated that he was not notified of R2's change of condition. V8 stated that he came to visit residents and was told that by V9 that she had sent R2 to the hospital. V8 was not sure if it was later that day or the following day. On 5/12/2022 at 9:35 AM, V10, LPN, stated that she was not assigned to R2. V10 stated that she was aware that R2 takes off her mask so she went in her room. V10 stated that when she entered the room, R2 was gray and pale and her Oxygen level was super low. V10 stated that she notified the nurse and stayed with R2 until able to get Oxygen level up. V10 stated that then she left and V9 took over. V10 stated that R2 has a history of taking off her oxygen and her oxygen levels drop. On 5/12/2022 at 10:00 AM, V11, LPN, stated that she was the manager on duty on 4/30/2022 and in the building. V11 stated that she was notified by the agency nurse that R2 was sating low. V11 stated that she was unsure of the time but it was after breakfast but before lunch. V11 stated that she walked to the resident's room and the Resident was sitting up in the bed with head of bed elevated and oxygen on with a nasal cannula. V11 stated that the saturation level came up a little. V11 stated that she then left the room. V11 stated shortly after the nurse asked her help to find a mask. V11 stated that she helped the nurse find the mask. V11 stated that she was called by the nurse and told she was sending the resident out. V11 stated that this was prior to 12:30 PM. V11 stated that she did not see the resident go to the hospital but assumed she did. On 5/12/2022 at 12:50 AM, V2, Director of Nursing (DON), stated that she reviewed R2's progress notes and spoke with the nurse. V2 stated that V9 notified the physician and family and the decision was made for R2 to remain in the building. V2 stated that she was not in the building and did not speak with the son so she is not sure of what V7's understanding was. V2 stated that some families don't understand that if a resident has an acute situation that they can be sent out. V2 stated that 90% oxygen level after dropping to 40% to 50% was stable. V2 stated that per the documentation and conversation with the nurse later that day the nurse called the physician and the son. V2 stated that at that time, the son was ok with sending R2 to the hospital. V2 stated that she would expect the nurse to continue to monitor R2 and document. V2 stated that if they did it it would be documented. V2 stated that if there was any further episodes of [CONDITION(S)], dropping of O2 sat she would not consider R2 to be stable and would expect the nurse to notify the physician and get directions and update the family with each episode. V2 stated that V9 has (V8) documented as the doctor she spoke to but it would have been his nurse practitioner (V14). On 5/12/2022 at 11:05 AM, V14, Nurse Practitioner, stated that she was previously notified of R2 being confused and having episodes of removing oxygen tubing the weekend prior to hospitalization . V14 stated that she was made aware at that time that R2 removes her oxygen tubing and her sat drop and the facility reapplies and they come up. V14 stated that she was not notified of R2's change in condition. V14 stated that with R2 having an Oxygen level ranging from of 40% to 50% she would have sent R2 out to the hospital. V14 stated that she would have expected the nurse to notify her or the physician if R2 continued to have hypoxic episodes. On 5/12/2022 at 12:50 AM, V2 stated that as a result in V9 not notifying the physician of the additional hypoxic episode during the day, this caused a delay in treatment. 2. On 5/10/22 at 12:15PM, R1 was observed in her bed. R1 was tearful and stated she fell on [DATE] around 11AM. R1 stated she was sitting on the toilet, felt herself going forward and she fell forward. R1 stated she was weak the day of the fall due to having diarrhea. R1 stated she had been having diarrhea for about 2 weeks prior to the fall and they (R1 and V6, R1's family) had been telling V4, LPN, and V4 was telling her it wasn't diarrhea, just loose stools. V6 confirmed she had told V4 that R1 had been complaining of diarrhea for the past two weeks (unsure of dates) and stated R1 was diagnosed with [CONDITION(S)] while in the hospital. R1's Progress Note, dated 4/27/22 at 9:00AM, documents, Patient in wheelchair without pants on. Stated she didn't want to put them on due to frequent urges to use the bathroom for loose bowels. Informed nurse of patient's wishes. R1's Fall Report, dated 4/27/22 at 10:59AM, documents while being toileted by staff, R1 was sitting on toilet, leaned forward attempting to get up, slipped in feces and fell on to the floor. Resident complaining of pain to the left hip and leg. Unable to fully evaluate resident for injury. Resident non-compliant. Staff was present when this occurred. Resident states she leaned forward on the toilet and fell . Injury to top of scalp, complaining of pain level of 6/10. Resident is alert, oriented to person, situation, place and time. R1's Hospital History and Physical, dated 4/27/22, documents patient complained of left hip pain. Patient states she was sitting on the toilet and fell forward. Patient states she has been having multiple episodes of diarrhea for the past couple of days, felt weak and when she leaned forward, she fell on to her left side. R1's Hospital Laboratory Report, dated 4/28/22, documents R1 was positive for [CONDITION(S)]. R1's Hospitalist Progress Note, dated 5/6/22, documents R1 had a displaced intertrochanteric fracture of the left femur with surgical repair on 4/29/22 and entercolitis due to [CONDITION(S)]. R1's MDS, dated [DATE], documents R1 is cognitively intact and requires an extensive assistance of 1 staff with toileting. R1's Care Plan, dated 5/18/21, documents R1 has the potential for loose stools with an intervention to monitor bowel movement status and to report changes in bowel status to resident's physician. On 5/10/22 at 12:50PM, V4, LPN, stated she was called to R1's room by V5, CNA, R1 was on the floor in the bathroom. V4 stated R1 is on [MEDICATION(S)] and was having loose stools and there was feces all over the floor in front of the toilet. V4 stated R1 was complaining of loose stools one time on the day she fell , they weren't liquid but loose. V4 stated, R1 takes [MEDICATION(S)] and she (R1) gets upset, always saying she has diarrhea, I try to explain to her (R1) that it's not diarrhea, just loose stools. V4 stated V8, R1's Physician, was here one day, unsure of date, and explained to R1 that if it's not liquid stool, just loose, he (V8) wasn't worried about it. On 5/10/22 at 1:05PM, V5, CNA, stated when R1 fell , she had a bowel movement on the floor. V5 stated it could have been she (R1) was weak and fell forward or was trying to get up. V5 stated she (R1) would normally use her call light but she didn't ask that day, I think it was because she was having watery diarrhea. V5 stated this was the first day she had watery diarrhea that she was aware of. V5 stated R1's stool wasn't hard normally but it was the consistency of pudding. V5 stated R1 wanted to go out to the hospital that morning before she fell because of the diarrhea, and she (V5) reported it to V4, LPN. On 5/10/22 at 1:15PM, V2, Director of Nurses (DON), stated R1 was having loose stools on the day she fell . V2 stated if a resident is alert, oriented and requested to go to the hospital, she would call the physician and let them know but she wouldn't argue with them, it's their right. On 5/10/22 at 10AM, V2, DON, stated if a resident has a change in condition, the nurses are to notify the physician, get orders for labs or anything that could help them pin point what's going on, make a note and let the family know. On 5/12/22 at 9:40AM, V8, R1's Physician, stated any infection can cause weakness which can contribute to falls and he was not notified of R1 complaining of diarrhea for two weeks prior to the fall. The Mayo Clinic defines [CONDITION(S)] as a bacteria that causes an infection in the large intestine, symptoms can range from diarrhea to life-threatening damage to the colon and it most commonly affects older adults in long term care facilities. The Change in Condition policy, dated 3/27/21, documents Standard: It will be the standard of this facility to notify the physician, family, resident and/or responsible party/resident representative (as is applicable) of significant changes in condition and provide treatments according to the resident's wishes and physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . When a change is noted, gather pertinent data such as vital signs, weights and other clinical observations; 7. Contact the primary physician to update him/her to the change in condition; 11. Notify the family or responsible party/resident representative regarding the resident condition and change.

Based on interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents (R1) reviewed for falls in the sample of 5. This failure resulted in R1 falling, sustaining a [CONDITION(S)] requiring hospitalization and surgical repair. Findings include: R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact and requires and extensive assistance of 1 staff with toileting. R1's Care Plan, dated 5/18/21, documents R1 is at risk for falls. R1's Nursing Risk Screen, dated 4/14/22, documents R1 is at risk for falls. On 5/10/22 at 12:15PM, R1 was in her bed. R1 was tearful and stated she fell on [DATE] around 11AM. R1 states she was sitting on the toilet, felt herself going forward and she fell forward. R1 states she, later identified as V5, Certified Nurses Assistant (CNA), wasn't in the bathroom with her when she fell . R1 stated she told V4, Licensed Practical Nurse (LPN), that her hip was broken and she wanted to go to the hospital. R1 states V4 told her her hip wasn't broken and refused to send her to the hospital, but she was eventually sent. R1 stated V4 and V5 told her to get off the floor, but she couldn't so they got her up into the wheelchair and then put her in bed. R1 stated V5 did not evaluate her before getting her off of the floor and into her wheelchair after the fall. R1 stated she did break her left hip and had to have surgery to repair it. R1 stated she fell around 11AM, her family was notified around 11:30AM and her family told the nurse to send her to the emergency room . R1 stated she is supposed to have help going to the bathroom, but staff tell her you can do it. R1 stated she was weak the day of the fall due to having diarrhea. R1 stated she had been having diarrhea for about 2 weeks prior to the fall and was telling V4 and V4 was telling her it wasn't diarrhea, just loose stools. V6, R1's family, stated R1 was diagnosed with [CONDITION(S)] while she was in the hospital. R1's Progress Note, dated 4/27/22 at 11:33AM, documents R1 attempted to transfer self to wheelchair, slid in feces and fell . Complains of pain to the left hip and leg, requesting to go to the emergency room . Unable to fully evaluate for injury. Resident non-compliant. R1's Progress Note, dated 4/27/22 at 2:58PM, documents R1 was admitted to the hospital with a left hip fracture. R1's Fall Report, dated 4/27/22 at 10:59AM, documents while being toileted by staff, R1 was sitting on toilet, leaned forward attempting to get up, slipped in feces and fell on to the floor. Resident complaining of pain to the left hip and leg. Unable to fully evaluate resident for injury. Resident non-compliant. Staff was present when this occurred. Resident states she leaned forward on the toilet and fell . Injury to top of scalp, complaining of pain level of 6/10. Resident is alert, oriented to person, situation, place and time. R1's Emergency Medical Services (EMS) Report, dated 4/27/22, documents EMS received the call at 11:57AM, they were dispatched at 12:05PM and was at the scene at 12:27PM. The report documents the nurse (unidentified in report) stated patient fell off of the toilet with staff present and fell on to the left side. Found patient in bed, patient complained of left hip pain at 10/10. Left leg shortening and left leg rotated externally. R1's Hospital History and Physical, dated 4/27/22, documents patient complained of left hip pain. Patient states she was sitting on the toilet and fell forward. Patient states she has been having multiple episodes of diarrhea for the past couple of days, felt weak and when she leaned forward, she fell on to her left side. R1 was diagnosed with an intertrochanteric fracture of the left femur. R1's Hospitalist Progress Note, dated 5/6/22, documents R1 had a displaced intertrochanteric fracture of the left femur with surgical repair on 4/29/22 and entercolitis due to [CONDITION(S)]. On 5/10/22 at 12:50PM, V4, LPN, stated she was called to R1's room by V5, CNA, R1 was on the floor in the bathroom. V4 stated R1 is on [MEDICATION(S)] and was having loose stools and there was feces all over the floor in front of the toilet. V4 stated R1's left leg was caught between the riser and the toilet, I told her to calm down cause she was upset, she (R1) kept saying get me up, so we (V4 and V5) got her up in the wheelchair and then into bed, she (R1) was screaming, not calming down. I did not assess her while she was on the floor. I tried to assess her after she was in the bed and she started complaining of her left hip and leg hurting, saying I want to go to the hospital so I sent her to the hospital. V4 stated R1 was complaining of loose stools one time on the day she fell , they weren't liquid but they were loose. V4 stated she was not aware of R1 complaining of being weak due to having diarrhea. V4 stated R1 is stand by assist or a 1 assist with toileting and therapy wanted us to have her do what she could for herself, so we would encourage her. V4 stated V5, CNA, was in the bathroom with R1 when she fell . On 5/10/22 at 1:05PM, V5, CNA, stated when R1 fell , she had a bowel movement on the floor, the wheelchair wasn't in the bathroom and R1 was trying to get off of the toilet. V5 stated she was in R1's room and not the bathroom, putting stuff down, V5 stated, I told her (R1) to sit down on the toilet, I wasn't in the bathroom when she fell , my back was turned and it could have been she was weak and fell forward or was trying to get up. V5 stated R1 was moving around on the floor and she (V5) and V4, LPN, got R1 off of the floor and after they got R1 into the bed, R1 was requesting to go to the hospital. V5 stated R1 told her, she leaned forward and fell . V5 stated R1 was doing her regular grunting after the fall, but didn't complain of pain until she was in bed. V5 stated R1 required supervision with toileting. On 5/10/22 at 1:15PM, V2, Director of Nurses (DON), stated when R1 fell , V5, CNA, was getting wipes out of the sink outside of R1's bathroom but in R1's room, R1 got up off the toilet and fell . V2 stated R1 got her foot caught on the toilet riser because she was impatient and didn't want to wait for the CNA. V2 stated R1 was a 1 assist with toileting and was at low risk for falls. V2 stated if a resident is a 1 assist, we wouldn't leave them in the bathroom alone but the girl just walked away to grab the wipes. V2 stated V5, CNA, helped R1 to the bathroom and R1 was having loose stools on the day she fell . V2 stated after a fall, she would expect the nurse to assess the resident, get vital signs and if signs of injury, they aren't to move them and they are to call the ambulance. V2 stated the assessment should include assessing for bruising, swelling, pain and range of motion, if able. On 5/12/22 at 9:40AM, V8, R1's Physician, stated any infection can cause weakness which can contribute to falls. The Fall Prevention policy, dated 3/27/21, documents Standard: It will be the standard of this facility to complete and initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. Guidelines: As part of the initial assessment, the facility will help identify individuals with a history of falls or risk factors for subsequent falling.

Based on interview, observation and record review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R11) reviewed for falls in the sample of 49. This failure resulted in R11 falling and sustaining a subdural hematoma requiring hospitalization . Findings include: R11's Face Sheet, undated, documents R11 has a diagnosis of Muscle Weakness and a History of Falls. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has moderate cognitive impairment, requires an extensive assist of one staff with transfers and has impaired balance. R11's Care Plan, dated 5/18/21, documents R11 is at risk for falls due to impaired cognition and impaired safety awareness with the following interventions implemented on the following dates: 6/30/21, Will provide with sitter while awake; and 7/21/21, self-releasing seat belt. On 3/22/22 at 1:43PM, V8, R11's Family, stated R11 had a fall about 3 to 4 weeks ago, went to the emergency room , had a brain bleed and urinary tract infection. V8 stated R11 is supposed to have a sitter at bedside and alarms. V8 stated when R11 has to go to the bathroom, she will get up and go and doesn't know to ask for help. On 3/22/22 at 1:55PM and 3/23/22 at 9:35AM, R11 was observed sitting up in the wheelchair in hallway. R11 had no seat belt in place and staff not providing one on one care. R11's Fall Report, dated 2/14/22, documents R11 was observed on the floor in her room on her left side. R11 leaned too far over to the left and fell out of the wheelchair. R11 was assessed, a hematoma to R11's face was noted, and she was sent to the emergency room for further evaluation. R11's Hospital History & Physical, dated 2/14/22 documents R11 had an unwitnessed fall and was diagnosed with a Subdural Hemorrhage and Traumatic Cephalohematoma. R11's CT scan, dated 2/14/22, documents a posterior cephalohematoma and suggestion of a small underlying acute subdural hematoma. R11's Therapy Post Fall Assessment, dated 2/18/22, documents Patient had an unwitnessed fall from the wheelchair. Patient has a self-releasing wheelchair belt, however, was not in place at the time of fall. The facility Initial Federal Report, dated 2/21/22, documents R11 had a fall on 2/14/22, which resulted in a subdural hemorrhage. Description of events: R11 was observed on her left side on the floor of her room. Corrective actions: Resident placed on one on one when up in wheelchair. On 3/24/22 at 9:55AM V2, Director of Nurses, stated she would expect fall interventions to be in place but she thinks they stopped providing one on one care for R11 about a week ago. On 3/23/22 at 2:15PM V35, Regional Director of Clinical Operations, acknowledged that R11's care plan was reviewed on 3/23/22 and the intervention initiated on 6/30/21 of providing R11 with a sitter while awake was removed on 3/23/22. The Falls policy, dated 3/27/21, documents pertinent interventions will be implemented by staff.

Based on observation, interview and record review the facility failed to provide incontinent and catheter care in a manner to prevent Urinary Tract Infections ([CONDITION(S)]) and discomfort for 5 of 6 residents (R18, R25, R29, R41 and R71) reviewed for Urinary Tract Infections in the sample of 49. This failure resulted in R18, R25, and R71 requiring hospitalization s for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: 1. On 3/22/22 at 9:36 AM, V7 Certified Nursing Assistant (CNA) came in to provide incontinent care after R18 was incontinent of stool. R18 has an indwelling urinary catheter and when V7 pulled R18's jeans off she pulled on R18's catheter which was not secured with a leg strap. R18 cried out when V7 pulled on her catheter when removing jeans. The urine in R18's catheter bag was murky brown. V7 donned gloves without performing hand hygiene, and using disposable wipes, wiped visible fecal material from R18's buttocks and rectum. V7's gloves were visibly soiled, and she changed gloves without performing hand hygiene. V7 then turned R18 onto her back and wiped fecal material from R18's thighs and groin but did not spread R18's labia to cleanse her meatus or the catheter tubing. V7 then wiped R18's catheter from about an inch from insertion site out, still wearing the same gloves that were soiled with fecal material. V7 stated, I wash my hands out there and she left R18's room without washing her hands and walked to the soiled utility room and pressed several buttons to unlock the door, dumped her trash in a container, then walked to the nurse's station to wash her hands. On 3/23/22 at 10:38 AM, V27 and V28, CNAs, were providing incontinent care for R18 who had been incontinent of bowel movement (BM). R18 was placed on her side. R18's catheter was pulled from her front, stretched between her legs and sitting between her buttocks, soiled with BM. There was a bottle of body shampoo sitting on R18's bedside table, but no basin of water. V28 turned around and wet a washcloth under the faucet, then turned back to wipe the fecal material from R18's buttocks, still with the catheter tubing between her buttocks. When V28 was wiping the fecal material from R18's buttocks, he was pulling on R18's catheter tubing and she yelled out ouch two different times, but he continued to leave the catheter between her buttocks. R18 did not have a leg strap to secure her catheter to her leg. After wiping the feces from R18's buttocks, the CNAs put a clean diaper on R18, and were getting ready to tape it closed, and writer asked to see the catheter. V27 and V28 opened the clean diaper and R18's catheter was still soiled with feces. V28 wet a washcloth with just water from the sink, no soap, and wiped R18's catheter with one swipe then fastened her diaper. V28 did not spread R18's labia to cleanse around the catheter or her meatus. After V27 and V28 left the room, R18 stated, They did not clean me in front, they just wiped the poop off my butt. There was a package of disposable cleansing wipes under R18's bed. On 3/23/22 at 12:04 PM, V28 approached the surveyor and asked why he had been asked questions while he was providing care to R18, and the survey process was explained to him. V28 asked, So how did we do? Explained to him there were concerns with care, including a concern with catheter tubing positioned between her legs and laying between her buttocks in feces, and he stated, Where should it have been? R18's Face Sheet documents she was admitted to the facility on [DATE] and documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] R18's Lab Results Report dated 10/18/21 documents she had a [CONDITION(S)] and identified the causative agent as [CONDITION(S)] Pneumoniae. R18's Lab Results Report dated 12/3/21 documents she had a [CONDITION(S)] and identified the causative organism as Pseudomonas Aeruginosa. R18's Progress Notes dated 12/15/21 document R18 was readmitted from the hospital on IV antibiotics to treat her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized from 12/9/21 to 12/15/ 21 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Progress Notes dated 1/6/22 document she was readmitted from the hospital after being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She was hospitalized from 12/24/21 to 1/6/22 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Lab Results Report dated 3/12/22 documents she had a [CONDITION(S)] and identified the causative organism as Escherichia Coli. R18's Progress Notes dated 3/24/22 at 5:47 AM documents she is currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . R18's Minimum Data Set (MDS) dated [DATE] documents she has moderate cognitive impairment, requires extensive assist with toileting, has an indwelling catheter and is always incontinent of bowel. R18's Care Plan dated 9/3/21 documents, (R18) has indwelling catheter. Interventions for this care plan include: Retention strap in place to assist in maintaining catheter alignment as tolerated. Another Care Plan focus for R18 dated 3/15/22 documents, (R18) has a urinary tract infection. Interventions for this care plan include, Provide education as needed to resident in good clean hygiene techniques to avoid cross contamination, wash hands frequently and especially after bowel movements. 2. On 3/23/22 at 9:54 AM R25 stated they do not clean him up timely and do not always clean around his catheter. He stated he has had UTIs the last couple of times he went to the hospital. On 3/24/22 at 12:25 PM V5, CNA and V37, CNA positioned R25 onto his back to perform catheter care. R25's indwelling urinary catheter was not secured to his leg with a leg strap and the catheter was pulled taut several times during care when R25 was rolled back and forth for care. R25 stated sometimes the catheter rubs his skin and irritates it. V37 filled a wash basin with water and squirted some body wash into the water. V37 stated she had just finished providing R25 incontinent care to clean him after he was incontinent of bowel just before writer entered the room. V37 stated the nurse had told her to clean him up before she changed his dressing. V37 soaked a washcloth in soapy water and dabbed the sides of R25's penile shaft, then removed gloves and applied new gloves with no hand hygiene and dabbed around the insertion site of R25's catheter. V37 did not retract R25's foreskin from the head of his penis to thoroughly wash the area, or to completely cleanse his catheter tubing. Several of the washcloths V37 used to clean R25's scrotum were soiled with fecal material after she swiped his scrotum. V37 removed her soiled gloves but did not perform hand hygiene before donning a new pair of gloves. When cleansing the underside of R25's scrotum, there was a moderate amount of fecal material noted on the washcloth but V37 did not go back and wipe R25's scrotum a second time to ensure he was completely clean. V37 did not rinse any of the soap from R25's skin, but just patted him dry. V37 put a new diaper under R25, and applied barrier cream to his groin and scrotum, and pulled him up in bed with the same gloves she had used to wipe fecal material from his scrotum. V37 presented the bottle of soap she used to clean R25. The label on the bottle of soap documented the directions: Skin and Hair Cleanser. Pour a small amount onto a wet washcloth or directly onto hands. Rinse thoroughly. R25's MDS dated [DATE] documents he is alert and oriented and has an indwelling catheter. The MDS also documents R25 is always incontinent of bowel, and he has a Stage 4 pressure ulcer. It documents he is dependent on staff for toileting. R25's Care Plan dated 2/12/22 documents the focus, (R25) has a potential for recurrent urinary tract infections related to: history of UTIs. The interventions include, Provide education as needed to resident in good clean hygiene techniques to avoid cross contamination, wash hands frequently and especially after bowel movements. Another focus in R25's care plan, dated 1/22/22, documents, (R25) has an ADL (Activities of Daily Living) self-care performance deficit related to limited mobility, shortness of breath, weakness. The interventions for this care plan include, Toileting, Maximum assist. Another focus of R25's Care Plan dated 1/22/22 documents, (R25) has Indwelling Catheter related to [CONDITION(S)] ([CONDITION(S)]). Interventions for this care plan include, Retention strap in place to assist in maintaining catheter tubing alignment as tolerated. R25's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R25's Lab Result Report dated 1/3/22 documents his urinalysis results as amber colored cloudy urine with greater than 50 red blood cells (normal is less than 6) and greater than 50 white blood cells (normal is less than 6). The report documented that a culture was indicated and completed but did not identify the causative organism. R25's Hospital Discharge Note dated 1/12/22 documents he was admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Discharge instructions included, Routine Foley care-remove foley with patient able to get to a bedside commode. Monitor for urine retention and check bladder scanner if patient has poor urine output. R25's Hospital Discharge Note dated 2/19/22 documents he was admitted to the hospital on 2/13/22 with CHF (Congestive Heart Failure), Chronic urinary infection-catheter related. His discharge medications included an antibiotic ([MEDICATION(S)]) to treat his [CONDITION(S)]. 3. On 03/22/22 at 10:06 AM R41 was lying in bed and her catheter is hanging under her wheelchair, not on her bed close to R41. The tubing of R41's urinary drainage bag was stretched between the wheelchair and R41 in bed. On 3/24/22 at 11:20 AM V5 and V7 CNAs provided catheter care for R41. V7 filled a wash basin with water and squirted some body shampoo into the basin. Before V5 and V7 removed R41's pants, her catheter was under her left leg. While they were removing her pants, R41 cried out when her catheter got caught on her pants and was pulled on. R41 did not have a leg strap to secure her catheter to her leg to keep it from getting pulled on during care. V7 washed her hands, then left the room to get a new diaper for R41. Upon returning to R41's room, V7 did not perform hand hygiene again before donning gloves. R41's groin was slightly red, and she verbalized discomfort when V7 cleansed that area. V7 did not rinse the soap from R41's skin after cleansing her. V7 cleansed R41's catheter starting about an inch out from the insertion site. V7 did not spread R41's labia and cleanse around the catheter or urethra. V5 and V7 turned R41 onto her left side and V7 used disposable wipes to remove dried fecal material from R41's buttocks, then resumed using wash cloths to cleanse her buttocks with soapy water but did not rinse the soap off R41's skin. V7 then placed the new diaper under R41 and fastened it, pulled her up in bed, fixed her pillow and covered her with a blanket without changing her gloves or performing hand hygiene. R41's Electronic Medical Record (EMR) documents her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Lab Results Report of Urinalysis and Culture and Sensitivity dated 2/28/22 documents she had a [CONDITION(S)] with the causative organisms being Escherichia Coli and Enterococcus Faecalis. R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Attach leg strap to secure catheter tubing. R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. On 3/23/22 at 9:00 AM, R29 stated she gets urinary infections all the time. On 3/23/22 at 9:20 AM, V16, CNA and V17, CNA performed incontinent/catheter care on R29. V17 opened the front of R29's incontinence brief and R29 had a bowel movement. V17 took a washcloth, wiped upwards towards R29's urethra, feces was noted on the washcloth, then took the washcloth and threw it on the floor. V16 then took a package of wipes, getting feces on the outside of the package and turned R29 onto her left side, then changed gloves with no hand hygiene performed. V16 then wiped feces off of R29's right buttock and around a dressing in place to R29's left buttock. The dressing was loose and soiled with feces. V16 and V17 turned R29 onto her back and wiped down the catheter. With dirty gloves on V16 and V17 proceeded to place a clean incontinence brief and clean sheet under R29. V16 removed her gloves, picked up the package of wipes with feces still on the outside of the package and placed them in the hallway. V17, with dirty gloves on, then picked up a clean dry towel, wiped R29's left front perineal crease and closed R29's incontinence brief. V17 then picked up the dirty washcloth, turn sheet and towel up off of the floor, proceeded to the door, touched the doorknob and disposed of the dirty linen. R29's Face Sheet, undated, documents R29 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R29's MDS, dated [DATE], documents R29 is cognitively intact, requires an extensive assistance of 2 staff with toileting, has an indwelling urinary catheter and is incontinent of bowel R29's Care Plan, dated 1/28/21, documents R29 has a [CONDITION(S)] related to use of a urinary catheter with an intervention to provide catheter care as ordered. R29's Urine Culture, dated 3/7/22, documents R29 has Escherichia Coli, Enterococcus Faecalis, [MEDICATION(S)] Resistant Enterococcus (VRE) and Group D Enterococcus. R29's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 4. On 3/22/22, R71 was observed in bed with the indwelling urinary catheter bag touching the floor. On 3/24/22 at 2:05 PM, incontinent care/catheter care was observed with V16, CNA and V17 CNA. V16 pulled back R71's incontinence brief and R71 had a bowel movement. V17 wiped down the right inner thigh area removing a large amount of feces. V16 and V17 then rolled R71 onto her right side, cleaned R71's right buttocks, then rolled R71 onto the left side but neither V16 nor V17 cleaned R71's left buttock. V16 and V17, with dirty gloves on, then placed a clean incontinence brief and clean bed pad under R71. V16 and V17 then rolled R71 onto her back and still with dirty gloves cleaned R71's anterior perineal area and down the catheter tubing leaving feces on the upper pubic area and right inner thigh area. V16 and V17 then, still with dirty gloves on pulled the clean incontinent brief up and covered the resident up with a blanket. R71's Face Sheet, undated, documents R71 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R71's MDS, dated [DATE], documents R71 is dependent with toileting, has an indwelling urinary catheter and is always incontinent of bowel. R71's Care Plan, dated 11/5/21, documents R71 has a Urinary Tract Infection related to the use of an indwelling urinary catheter and to provide catheter care as ordered. R71's Urine Culture, dated 1/11/22, document R71 has Escherichia Coli in the urine. R71's Urine Culture dated 1/24/22, documents R71 has Proteus Mirabilis in the urine. R71's Urine Culture, dated 2/28/22, documents R71 has Proteus Mirabilis with Extended Spectrum Beta Lactamases (ESBL) and Enterococcus Faecalis in the urine. R71's Treatment Administration Records for January 2022, document catheter care was not completed 8 times during that month. R71's Hospital History & Physical, dated 1/28/22, document R71 was admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 3/23/22 at 9:55AM V2, Director of Nurses stated she would expect the CNAs to perform catheter/incontinent care completely and appropriately and to change gloves and perform hand hygiene when going from a clean area to a dirty area. The Standards and Guidelines: SG Indwelling Catheters policy, dated 3/27/21 documents, Standards: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines it further documents, 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site.

Based on observation, interview and record review, the facility failed to administer medications as ordered by the physician for 1 (R4) of 3 residents reviewed for medication administration in the sample of 9. This failure resulted in R4 receiving three extra doses of [CONDITION(S)] medication, and subsequently being sent to the Emergency Department (ED) for evaluation of redness and facial swelling. Findings include: 1. R4's Minimum Data Set (MDS) dated [DATE] documents he is moderately cognitively impaired and requires limited assistance with Activities of daily living (ADL). R4's Electronic medical record documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Oncology Report dated, 04/02/21 documents V15 (Oncologist) ordered Regorafenib, also known as [MEDICATION(S)] (A [CONDITION(S)] drug) 80 (milligrams) mg daily, days 1-21 every 28 days. R4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . 05/15/21: Regorafenib was given twice on that date when it should have only been given once. 05/16/21: Regorafenib was given twice on that date when it should have only been given once. R4 received three extra doses of Regorafenib from 05/14/21 through 05/16/21. On 5/20/21 at 2:01 PM, V6 (Licensed Practical Nurse/LPN), stated, (R4) had a medication error with his [CONDITION(S)] medication. The medication was started on Friday and (V9), Registered Nurse (RN), found the error on Monday (5/17/21). The computer said to give it 2 times a day but that was incorrect. (R4) had swelling to the left side of his face and was sent to the ER (emergency room ) and they put him on antibiotics. On 5/24/21 at 11:30 AM, V2 (Director of Nursing/DON) stated, (R4) was sent to the hospital on 5/17/21 because of a medication error that occurred and (R4) had some facial swelling to the left side of his face. V15 recommended that (R4) go to the hospital for evaluation and treatment. On 05/24/21 at 12:05 PM, V9 (Registered Nurse/RN) stated that when she arrived to 600 hallway on the morning of 05/17/21, the Certified Nursing Assistant (CNA) came to her and reported that R4 stated that his face felt weird. V9 stated that she went and completed a physical assessment of R4. V9 stated that the left side of R4's face was swollen and red and that R4's left eye was almost swollen shut. V9 stated that R4 denied any pain. V9 stated that she checked to see if R4 had started on any new medications and found that Regorafenib ([MEDICATION(S)]) was recently started. V9 stated that she held R4's Regorafenib that morning. V9 stated that V12 (Nurse Practitioner/NP) was at the facility and examined R4. V9 stated that she called V15's office and explained what was going on with R4. V15 asked V9 what dose did the facility have ordered for the Regorafenib. V9 stated that the order the facility has documented was that R4 was to get Regorafenib 80 mg twice daily. V15 stated that the order the facility has in the computer was incorrect, and that R4 was receiving too many doses. V15 stated that the order was for Regorafenib 40 mg two tabs daily and not twice a day. V9 stated that V15's office said to hold the AM dose of Regorafenib. V9 stated that after she had talked with V15, she went to report the medication error to V2. V9 stated that V2 was not in her office, so V9 left a note on V2's desk to please come and talk with her when she got the message. V9 stated that V2 finally came to talk with her and V2 told her that she had talked to V15 and that they wanted R4 sent to the hospital for evaluation and treatment. V9 stated that V2 told her not to worry about charting on the incident. V9 stated that V2 said she would document it under risk management. R4's emergency room Visit Note dated 5/17/21 documents, Patient presents to the emergency department from ECF (Extended Care Facility) for a medication administration error. The patient is currently on [MEDICATION(S)] for colon cancer and is followed by (V15). Per the ECF, the patient is supposed to be receiving 80 mg daily but for the past 3 days has been given 160 mg daily. It continues, Clinical Impression: Impetigo, Medication administered in error. It further documents, Prescriptions: New: [MEDICATION(S)] HCL 300 mg Q (Every) 6 hours times 7 days. R4's Medication Incident Report, dated 5/17/21 documents, Incident Description: Nursing Description: Regorafenib 40 mg 2 tabs PO (By mouth) daily for 21 days off 7 days and follow up with oncologist. The entered order in computer was incorrect. It was entered at twice daily rather than once daily. Resident received 3 days of med. incorrectly, was started on Friday given sat, and sun. Noticed facial swelling, med held Monday and reported, order was verified as daily. Oncologist was notified of error. Resident was sent to hospital for evaluation. Resident Description: Resident stated his face felt swollen. Immediate action taken: Description: Med was held. Order was corrected in eMAR (Electronic medication administration record). Reported to oncologist. His recommendation was to send resident to hospital for evaluation. NP present and agreed to send for evaluation. Resident taken to hospital? Y (Yes). On 5/25/21 at 1:48 PM, V15 stated, There have been 3 incidents of medication errors of two different cancer medications prescribed to (R4) in the past 4-5 months. I would expect the orders to be followed. The Stavarga was ordered to take 2 tablets once daily for 3 weeks. The nursing home contacted our facility and said the patient developed facial swelling and redness. They also said that he was getting the 2 tablets of the medication twice a day, instead of once a day. I do believe that lead to the development of the symptoms and therefore I sent him to the ER, to be sure the swelling didn't get worse. I do think it was a significant medication error and caused harm to the resident. The concerning thing is also that it has happened now with two different medications. I start that medication out as a low dose because the potential for the side effect of swelling. Standards and Guidelines: Medication Errors revised date, 03/27/21 states: Standard: It will be standard of this facility that the staff and practitioner shall try to prevent medication errors and adverse medication consequences, and shall strive to identify and manage them appropriately when they occur. Guidelines: 1. The staff and practitioner shall strive to minimize adverse consequences by: A. Following relevant clinical guidelines and manufactures specifications for use, dose, administration, duration, and monitoring of the medication.

Based on interview and record review, the facility failed to perform ongoing assessments for potential bleeding related to anticoagulant use, monitor for change in condition and notify the physician of all pertinent information regarding a fall with head injury for 1 of 6 residents (R128) reviewed for falls and/or incidents with related anticoagulant use in the sample of 37. This failure resulted in an immediate jeopardy as the facility delayed treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . R128 was sent to the hospital two days later, and diagnosed with traumatic large left frontal lobe intraparenchymal hematoma with intraventricular extension and overlying subarachnoid hemorrhage with midline shift of the brain, and expired. The Immediate Jeopardy began on [DATE] when R128 had an unwitnessed fall at the facility and staff did not initiate or complete an assessment that included a physical or neurological assessment, monitor for signs and symptoms of a change in condition and did not notify the physician of the fall or any other pertinent information including R128's anticoagulant use. V1, Administrator, V2, Director of Nursing (DON) were notified of Immediate Jeopardy on [DATE] at 10:11 AM. The surveyors confirmed by observation, interview and record review, that the Immediate Jeopardy was removed on [DATE] but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: R128's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R128's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R128's Nurse's Note dated [DATE] at 2:31 AM, documented R128 was found sitting on the floor in her room by the door. Abrasion to the left side of face by eye. When this nurse asked this resident, what happened the resident stated, 'I went to the line and almost to the door and went down again and now in the middle of the ice.' This nurse asked her if she was hurt or cold this resident stated, 'I'm being disciplined being in the ice in this place.' This nurse called the resident's husband at her request. Vitals--temp 98.2, O2 (Oxygen) 95% on room air, pulse 78, resp (respirations) 8, BP (blood pressure) ,d+[DATE]. This nurse helped this resident back into bed. Call light within reach. Will continue to monitor. There were no documented ongoing assessments, neurological assessments or nursing notes in R128's medical record after the fall that occurred on [DATE] that would describe her status until a Nurse's Note, dated [DATE]. There was no documentation in R128's medical record that the V15, Physician, V26, Advanced Practice Nurse, V1, Administrator, or V2, Director of Nurse's (DON) was notified of R128's fall that occurred on [DATE]. R128's neurological evaluation document, dated [DATE], was blank. There was no documentation in R128's medical record from any facility nursing staff of R128's condition, any care that was given, meal intake records or activities in R128's medical record from [DATE] at 2:31 AM until [DATE] at 8:48 AM. R128's Nurse's Note, dated [DATE] at 8:48 AM, documented, Received resident laying in bed with eyes closed, lethargic and verbally nonresponsive. Facial pallor noted. Skin is warm and dry to touch. Resp even and nonlabored @ (at) 20/min (minutes). SpO2 (oxygen saturation level) of 94% on room air. Blood sugar of 132 mg (milligrams) /dL (deciliter). Lung sounds clear per auscultation. No facial drooping was noted on assessment. Abdomen is soft and nondistended with normoactive bowel sounds noted. Called 911. Two licensed staff stayed @ bedside for closed monitoring while awaiting for the ambulance to arrive. Necessary papers were copied. EMS (Emergency Medical Service) arrived @ approximately 0758, report was given. Patient in route to Hospital ED (Emergency Department) for eval and tx (treatment) @ approximately 0810. APN, (Nurse practitioner) was made aware of the above @ 815, patient's spouse was informed @ 0820. Report was called in to ED nurse @ 0840. Will follow-up. On [DATE] at 2:05 PM, a Situation Background Assessment Recommendation (SBAR) documented a change in condition due to Altered Mental Status Functional decline (worsening function and/or mobility) Unresponsiveness. The SBAR documented R128's Neurological Status Evaluation as Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse). The SBAR documented nursing observations, evaluation, and recommendations were Patient is lethargic, verbally nonresponsive with facial pallor. Due to recent fall, patient needs to be transferred to an acute facility for further eval and Tx. The SBAR documented Primary Care Provider responded with the following feedback: Transfer patient to the nearest Hosp ED due to an acute change in mental status. This SBAR/fall investigation report regarding R128 was not initiated until [DATE] after R128 was sent to the hospital. R128's Nurse's Note, dated [DATE] at 11:04 PM, documented, Patient was admitted with Intraventricular Hemorrhage. R128's Hospital Computerized Tomography (CT) Scan Report, dated [DATE] documented Large left frontal lobe intraparenchymal hematoma with intraventricular extension and overlying subarachnoid hemorrhage. Mild midline shift. R128's Hospital Record History of Present Illness, dated [DATE], documents This is an [AGE] year-old female that presents to the emergency department for altered mental status. Reportedly patient was admitted to a nursing facility 3 days ago. She was able to walk and talk at that time, although does have history of dementia and [CONDITION(S)]. On Saturday reportedly she had a fall with head injury. Also was reports of some bruising to the hip. Patient was not evaluated after this. Yesterday patient was not wanting to eat anything. Today patient is lying in bed and will only follow a few commands. R128's Hospital Record documented R128 was unresponsive to verbal stimuli with a Glasgow Coma Scale score of 10, indicating moderate traumatic brain injury. R128's Hospital Discharge Finding documented Traumatic Intraparenchymal Hemorrhage. R128's Hospital Record documented R128 was sent for higher level of care to another receiving hospital, then placed on hospice services and later expired on [DATE]. R128's Death Certificate, dated [DATE], documented R128's cause of death as Left Frontal Temporal Intraparenchymal Hemorrhage. On [DATE] at 10:00 AM, V2 stated she was not aware that R128 had fallen on [DATE] until R128 was sent to the hospital on [DATE] with suspected head injury. She stated she was made aware that R128 had a fall on [DATE] and then realized there had been no fall investigation initiated. V2 stated she had called V28, Licensed Practical Nurse (LPN) who was the nurse working when R128 had fallen and interviewed her as to why she had not followed through with reporting and notifying the appropriate parties of the fall. V2 stated V28 did not report the fall as per facility policy and did not notify the physician or administration of the incident. V2 stated V28 informed her that she did not report the fall because she felt like R128 was acting fine and showing no signs or symptoms of injuries. V2 further stated V28 told her that R128 did not hit her head but had contradicted what she had documented with an abrasion to the face. V2 stated she gave a verbal warning via telephone and gave a verbal in-service on reporting and assessments. V2 stated after discussion with administration, V28 was terminated due to this incident coupled with other negative incidents that occurred with V28. V2 stated that many of the staff that worked on [DATE] and [DATE] were agency staff. V2 stated R128 was admitted to the facility with an extensive fall history of over three years with a history of brain hemorrhages. V2 stated she spoke with R128's husband on [DATE] regarding her fall and current condition. She stated he told her that R128 was on hospice services. V2 stated she would have expected V28 to have notified the physician and administration of the incident and to follow facility policy regarding fall protocol. On [DATE] at 10:50 AM, V11, Registered Nurse (RN) stated she was the admitting nurse for R128 on [DATE]. She stated R128 was confused upon arrival and was admitted to the facility for therapy services after falling at home. She stated R128 needed assist of one staff for transfers and ambulation and used a walker as an assistive device. V11 stated R128 was admitted with bruising to her face. She stated that when she saw R128 on [DATE], the abrasion to the left side of her eye was new and was not there on admission. V11 stated she entered into R128's room on [DATE] to give her morning medications and found her unresponsive. V11 stated she would not open her eyes or follow commands. V11 stated she completed an assessment and notified the physician and called 911. V11 stated she later notified the POA and DON. On [DATE] at 12:30 PM, V26, Advanced Practice Nurse (APN) stated she was not notified of R128 falling on [DATE] and was not aware that R128 was on an anticoagulant. V26 stated she would have anticipated to be notified of an incident that occurred and that she would have expected R128 to be sent out right away anytime an unwitnessed fall occurred where the resident was on an anticoagulant and struck their head. V26 stated she was supposed to see R128 on [DATE] for the initial visit but was informed she went to the hospital. V26 denied having any knowledge of R128's condition upon transfer to the hospital or current status. On [DATE] at 2:30 PM, V27, Certified Nurse Assistant (CNA), stated she was the person who found R128 on the floor on [DATE]. She stated she was doing rounds for the CNA assigned to the 500-hall where R128 resided. V27 stated she does rounds or visual checks of every resident on her assigned hall every two hours. V27 stated she found R128 on the floor near the door around 2:30 AM and was not aware how long she had been on the floor or the last time someone had seen R128. V27 stated she got the nurse and they assisted R128 by holding onto her on either side and walking with her back to bed. The Facility's Fall Policy, revised [DATE], documented 4. The staff will evaluate, and document falls that occur while the resident is active in the facility census. The Policy documents In the event of major injury or suspected major injury, the resident should be sent to a higher level of care, such as the hospital, as ordered by the physician. If the nurse is unable to reach the physician, it is permissible for the nurse to initiate the resident transfer to the hospital if there is concern for the resident's safety, well-being, potential for injury or voice expressed desire. The policy documented following a fall, post event monitoring should occur to monitor vital signs, change in function, change in condition, increased pain or changes in skin condition, etc. The policy and procedure titled, Standards and Guidelines: SG Anticoagulant Therapy, revised [DATE] was reviewed. It documented under Guidelines: 7. Nursing staff will monitor residents receiving anticoagulant therapy for abnormal signs of bleeding and report as indicated to nurse or physician. 8. A plan of care will be developed related to the use of anticoagulant therapy. The plan should address the use of the anticoagulant medication as well as interventions related to assessment and monitoring of the resident's condition while on the anticoagulant medication. The Immediate Jeopardy which began on [DATE] was removed on [DATE] when the facility took the following actions: 1. On [DATE] and [DATE], the Regional Director of Clinical Operations and Director of Nursing Services conducted a facility wide quality review to determine that falls sustained within the last 30 days have the following components in place at it related to fall care management and events that cause significant injury with bleeding and anticoagulant/aspirin use. This will include: Fall placed in electronic tracking platform, and post fall investigation includes a root cause analysis and suitable preventative measure implemented (review completed [DATE]); Nurse's note reflects MD (medical doctor)/Responsible Party notification (review completed [DATE]); Order (if required) for current intervention (review completed [DATE]); Intervention is placed on Care plan/CNA patient care summary document (review completed [DATE]); Interventions is validated in place by visual observation (review completed [DATE]); Use of anticoagulant/aspirin is identified and present on care Plan/patient care summary document (review completed [DATE]); Current in-house residents were reviewed to determine their fall risk and anticoagulant/aspirin use (completed [DATE]). 2. On [DATE], License Nursing, therapy and agency licensed nursing staff were re-educated by the Regional Director of Clinical Operations and Director of Nursing Services on the components of this regulation with an emphasis on fall prevention and events that cause significant injury with bleeding and concurrent use of anticoagulants/aspirin and management that includes the following: Fall Risk evaluation to be completed Admission, Quarterly, Significant Change and Post fall event; Resident evaluation to include suitable supervision; Notification to Physician, Notification to responsible party, Prevention intervention (includes immediate), Importance of carrying out intervention post fall including obtaining and transcription of MD order; Neurological evaluation (unwitnessed event or witnessed head impact); Resident status review 3 days or 72 hours post event; Care plan update to identify fall risk and concurrent use of anticoagulant/aspirin therapy; CNA patient care summary document update to identify fall risk and concurrent use of anti-coagulant /aspirin therapy; Resident who sustain a fall that are currently receiving anticoagulant/aspirin therapy shall have the physician notified an resident sent to the Emergency Department for evaluation. 3. On [DATE], facility and agency CNAs were re-educated by the Director of Nursing on: CNA patient care summary document to identify residents at fall risk with use of anticoagulants/aspirin; Communicating resident change in condition; Resident who sustain a fall that are currently receiving anticoagulant/aspirin therapy shall have the physician notified and resident sent to the Emergency Department for evaluation. 4. On [DATE], facility licensed nursing, agency licensed nursing facility CNAs, agency CNAs and therapy staff were re-educated by the Director Nursing on: Process to be carried out when a resident sustains a fall to included do not move resident, call for assistance, Notify the licensed nurse who evaluate the need to be sent to a higher level of care based on anticoagulant/aspirin therapy; and Revise Standard and Guideline (policy), Anticoagulant Therapy. Director of Nursing will obtain information utilizing administrative morning meeting and 24-hour report to identify resident who have fall events and ensure responsible measure have been executed. As of [DATE], nursing therapy or agency staff will not work without receiving this education. As of [DATE], Newly hired nursing, therapy and agency staff will receive education on above in orientation. 5. On [DATE], the facility revised its Standard and Guideline (policy) Anticoagulant Therapy and additions included: The plan of care will reflect monitoring residents at risk for falls who are receiving anticoagulant/aspirin therapy; Physician notification and transfer to a higher level of call will be carried out for residents who are a risk for falls who are receiving anticoagulant/aspirin therapy who sustain an unwitnessed fall or witnessed head injury unless otherwise directed by the attending physician and/or advance care planning wishes post fall. 6. On [DATE], residents considered moderate to high risk for falls or that sustain and event that causes significant injury with bleeding that concurrently receive anticoagulant/aspirin therapy will have this identified in the residents' plan of care, CNA patient care summary document and noted in the Special Instructions that the resident is at risk for falls and receiving anticoagulant/aspirin therapy; in the event of a fall notify the physician and send resident to Emergency Department for evaluation. 7. On [DATE], the facility initiated that the facility Director of Nursing Services will conduct a weekly quality review of at least 5 resident records to include fall record if available on each unit weekly x 4 weeks, and then every 2weeks x 2 months to ensure fall care management practice, with emphasis on residents receiving anticoagulants/aspirin, has been properly followed that includes notification of physician for orders, transfer to hospital and ordered by the physician or per medical necessity, resident care plan and CNA patient care summary document identify resident as fall risk with concurrent use of anticoagulants/aspirin and visual validation of fall interventions. 8. On [DATE], an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was convened to review the above plan and the Medical Director reviewed and approved the plan.

Based on interview, observation, and record review, the facility failed to provide services for range of motion (ROM) to maintain and/or improve functions including degrees of limitations for 6 of 6 (R3, R14, R19, R33, R44, R68) residents reviewed for range of motion in the sample of 37. This failure resulted in R19 experiencing a decline in range of motion from no limitations of upper or lower extremities to limitations to both upper and lower extremities on one side, and decline in bed mobility, transfers, dressing and ambulation. Findings include: 1. On 4/07/21 at 12:03 PM, R19 stated he was going to the dining room for lunch. As R19 propelled himself in his wheelchair (w/c) to the dining room, his two middle fingers on his left hand were bent towards the palm of his hand while his other two fingers were straight. He stated he used to get physical therapy but doesn't get anything anymore since his insurance ran out. He stated the problem with his fingers is that when he goes to the bathroom, he is unable to grasp the help bars with all his fingers when he tries to help pull himself up to transfer from his w/c to the toilet. On 4/13/21 at 1:24 PM, R19 stated he did walk before with a walker his son brought him. He stated therapy stated he could walk with his walker if a CNA (Certified Nursing Assistant) stood by him and helped him a little to get up, and then stand by him while he walked. R19 stated he hasn't walked in over two weeks since therapy finished with him. He stated he is not sure if he can still walk but might be able to if a CNA would help him, but there is usually only one CNA working on his hall. R19 stated his fingers on his left hand curl up worse at night, and his toes do the same thing. He stated he would like to walk sometimes but there is nobody to help him. R19's Face Sheet documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R19's Order Summary Report, dated 4/13/21, documents the order dated 2/1/20, May participate in restorative program as needed and as tolerated. R19's Minimum Data Set (MDS)) dated 7/19/20, documents he is alert and oriented, and he is independent with bed mobility, but requires limited assist from staff for transfers, walking, and dressing. This MDS documents R19 did not have any functional limitation in range of motion to his upper or lower extremities. R19's MDS dated [DATE] documents he has a decline of functional limitation in range of motion as he now requires assist with bed mobility and has impairment in range of motion to one side of upper and lower extremities. R19's MDS dated [DATE] documents further decline in his ADLs in that he requires limited assist from staff for bed mobility, transfers, dressing, and walking in his room or in the corridors did not occur. The MDS documents he continues to have limited ROM on one side to his upper and lower extremities. R19's Care Plan dated 1/15/21 documents the focus, (R19) has an ADL (Activities of Daily Living) self-care performance deficit related to limited mobility. The goal for this care plan is, (R19) will maintain current level of ADL function through the review date of 5/10/21. Interventions for this focused care plan include, (R19) currently requires assistance with ADLs: Transfer: 1 assist, Walking: SBA (Stand by Assist). R19's Care Plan Focus, dated 2/10/21, documents, (R19) has a goal to improve physical functioning and will be receiving Physical, Occupational, and/or Speech therapy. R19's Occupational Therapy Discharge Summary dated 3/19/21 documents he received therapy from 1/14/21 to 3/19/21 and was discharged from therapy for the reason, Maximized Functional Potential. The discharge summary documents #3-Met on 3/19/21: Pt (patient) will demonstrate improved functional grip strength as evidenced by ability to grasp and maintain grip on grab bar during toilet transfers to increase safety and I (independence) with ADLs. According to the discharge summary, as of 3/19/21, R19 was able to demonstrate this with consistent stand-by assist and rare minimum assist. R19's Discharge Summary documents his prognosis to maintain current level of functioning = excellent with consistent staff support. It documents the RNP (Restorative Nursing Program) : To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following RNPs has been completed with the IDT (Interdisciplinary Team): transfers, dressing and grooming. R19's Physical Therapy Discharge Summary dated 3/18/21 documents he received physical therapy from 1/12/21 to 3/18/21. This discharge summary documents R19 met his goals for ambulation, transfers and balance, and included the recommendation for Restorative Nursing Program: To facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following Restorative Nursing Programs has been completed with the IDT: ambulation. R19's Care Plan was not updated with person-centered interventions for restorative services to maintain his level of functioning after R19 was discharged from Physical and Occupational Therapy. R19's Care Plan focus, dated 4/8/21, documents, (R19) has Musculoskeletal Disorders related to contractures of his arm. The goal of this care plan is, Resident will verbalize relief of pain. The interventions for this care plan include, Report symptoms to physician: Pain extreme or increasing pain on passive movement of extremity, development of muscle tension or tenderness with [CONDITION(S)], but does not include an intervention to provide passive range of motion exercises to R19's joints to prevent further contractures or decline. R19's PT/OT Screen Form dated 4/14/21 documents his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This report further documents, under comments, Pt (patient) reports hands have not declined since therapy discharge and continues to require assistance with ADLs due to decreased ROM and pain. On 4/13/21 at 4:06 PM V23, Occupational Therapist /Director of Therapy, stated after residents are done with therapy, the therapists try to communicate with the CNAs to let them know what therapy has worked on and what the resident needs as far as assistance to maintain their current functional ability. V23 stated therapy does quarterly assessments on all residents to assess their abilities and needs and treats accordingly. She stated R19 just got done with therapy a few weeks ago, and at that time he was up walking with his walker. V23 stated R19 does have limited movement in his shoulders, but she was not aware of any problems with his hand. She stated he does need some assist to stand up and may need some stand-by assist, but he was doing well with walking. She stated she would hope staff will help him to walk because, If you don't use it, you will lose it. V23 stated there has not been any Restorative Programs going on in the facility for quite some time. 2. On 04/06/21 at 10:00 AM, R44 stated he was on therapy services a while ago and used to walk up and down the halls with the CNAs, but since COVID had recently been in the building they quit walking with him. He stated he had not been walking since January 2021. R44 stated he cannot walk at all now and feels like he could go to home or to an assisted living facility if he could walk better. R44 stated he does not get any type of therapy now. R44 stated he had a stroke and that he had weakness to the left hand and both legs. R44 stated he would like to have therapy or someone to help him walk so that he could be more independent and possibly go home. The POS, dated 04/01/21, documented R44 was admitted to the facility with the following [CONDITION(S)] (CVA) with [CONDITION(S)] and [CONDITION(S)], unsteadiness on feet, visuospatial deficit and special neglect following CVA, muscle wasting and atrophy and difficulty walking. The Physical Therapy Discharge Summary, dated 09/17/20, documented recommendations for Restorative Nursing Program to facilitate patient maintaining current level of performance and in order to prevent decline, development of and instruction in the following: ambulation with staff instruction for 'walk to dine' type program using wheeled walker up to two times daily. An Individualized Exercise Program Referral sheet, dated 09/17/20, written from physical therapy to restorative therapy staff documented R44 was recommended by therapy for ambulation with minimal assist of caregiver up to 75 feet with wheeled walker. It documented Patient to be ambulated with staff two times daily on a Walk to dine program. On 04/06/21 at 10:20 AM, V43, CNA stated the facility did not have restorative CNAs now and that they were told to not walk the residents due to the COVID restrictions. She stated this had been going on since January 2021. V43 stated R44 was not being walked and had not been walked since at least January 2021. On 04/14/21 at 12:35 PM, V23, Director of Rehab Services, stated V44 was on therapy services last year and was then recommended for restorative services for walking and seemed to do well. She stated then with the change in restrictions during COVID, change in CNAs and the resident moving to different halls, she was not sure why he was not getting the assistance with walking anymore. She stated he would be a candidate for restorative ambulation. 3. R14's Face Sheet, undated, documents R14 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 4/6/21 at 12:56 PM, R14 was observed with limited Range of Motion (ROM) in both her upper and lower extremities and contractures to both hands, hips, knees, ankles, and feet. R14's Minimum Data Sheet (MDS), dated [DATE], documents limitations in ROM in one of the upper extremities and both lower extremities. R14's MDS, dated [DATE], documents limitations in ROM in both upper and lower extremities. R14's Care Plan, dated 1/27/21, documents R14 has musculoskeletal disorders related to contractures in her arms and legs with a goal to avoid decline. R14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] There is no documentation in R14's medical record R14 is receiving restorative service to address her contractures and limited range of motion. 4. R68's Face Sheet, undated, documents R68 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/21 at 10:36 AM, R68 was observed with limited ROM in both her upper and lower extremities. R68's MDS, dated [DATE], documents limitations in ROM in both lower extremities. R68's MDS, dated [DATE], documents limitations in ROM in both upper and lower extremities. R68's Care Plan, dated 3/8/20, has no documentation addressing limitations in ROM. R68's POS, dated 2/2/21, documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] There is no documentation in R68's medical record R68 is receiving services to address her limited range of motion. 5. R3's Face Sheet, undated, documents R3 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/7/21 at 10:21 AM, R3 had a contracture to her left hand and limitations in range of motion of both upper and lower extremities. R3's MDS, dated [DATE], documents impairment on one side of the upper and lower extremities. R3's Care Plan, dated 3/7/20, has no documentation of R3's limited ROM. R3's POS, dated 2/1/20, documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation in R3's medical record, R3 was receiving services for her limited range of motion. On 4/8/21 at 8:03 AM, R3 states she would participate in an exercise program. 6. R33's Face Sheet, undated, documents R33 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 4/8/21 at 8:06 AM, R33 was observed with limited range of motion (ROM) to both upper and lower extremities. R33's MDS, dated [DATE], documents no limitations with ROM. R33's Care Plan, dated 3/7/20, has no documentation of R33's limited ROM. R33's POS, dated 2/19/21, documents an order for [MEDICAL RECORD OR PHYSICIAN ORDER] There was no documentation in R33's medical record R33 was receiving any service to address limited range of motion. On 4/8/21 at 10:44 AM, V2, Director of Nurses (DON), stated the facility does not have a Restorative Nurse or Restorative Certified Nurse Assistant (CNA) so they do not have any formal restorative programs or assessments because they don't have a nurse to follow the programs. The facility Contracture Management Policy with a revision date of 3/1/21, documents the facility must ensure that a resident with a limited ROM receives appropriate treatment to increase ROM and/or prevent further decrease in ROM. The facility Restorative Nursing Programs Policy with a revision date of 12/1/16, documents the facility will provide restorative nursing services to residents that require them to attempt to maintain or improve function or as ordered by the physician.

Based on observation, interview and record review, the facility failed to administer medications as ordered for one of 4 resident (R52) reviewed for significant medication errors in the sample of 37. This failure resulted in R52 receiving 16 extra doses of [CONDITION(S)] medication and experiencing weakness, falls, and a blister to his right finger. Finding includes: R52's Electronic Medical Record documents his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's Minimum Data Set (MDS) dated [DATE] documents he is moderately cognitively impaired and requires limited assist with Activities of Daily Living. On 4/07/21 at 11:30 AM, R52 was propelling himself in his wheelchair (w/c) out of his room to nurses desk. R52 stated he could not find his wallet. His appearance was unkempt. He stated he was weak and can't walk, but does okay in his w/c. He stated he takes too much medication. R52's Incident by Incident Type documents he has had multiple falls on 2/4/21, 2/11/21,2/23/21, 3/7/21, 3/11/21, 3/21/21, 3/23/21, 4/3/21,4/3/21 and 4/7/21. The report also documents he had a medication error on 3/10/21. R52's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The PO documents [MEDICATION(S)] 500 milligrams (mg) (4 pills, 2000 mg) BID (twice daily) po (by mouth) x 7 days on then 7 days off repeated sequence. R2's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R52's Medication Administration Records (MAR) documents the following medication errors: 1/29/21: [MEDICATION(S)] was given twice on that date when it should have been on hold. 1/30/21: [MEDICATION(S)] was given in the PM on that date when it should have been on hold. 1/31/21: [MEDICATION(S)] was given in the PM on that date when it should have been on hold. 2/1/21: [MEDICATION(S)] was given in error when it should have been on hold for the 7 days per physician order. 2/4/21: [MEDICATION(S)] was given once in the morning. PM dose was not given. 2/5/21: [MEDICATION(S)] was not given on that day. 2/6/21: [MEDICATION(S)] was given one time in the PM. AM dose was not given. 2/7/21-2/11/21: [MEDICATION(S)] was not given on 2/7/21 which would have been the 7th day it was to be given. Then, per physician orders, it should have been held 7 days, but was only held five days. 2/12/21-3/7/21: [MEDICATION(S)] was given twice a day for 23 days continuously, without the ordered 7 days on/7 days off schedule as ordered by V32, Oncologist. R52 was ordered to receive 28 doses (14 days) of [MEDICATION(S)] in January 2021, but instead received 32 doses (16 days). R52 was ordered to receive 28 doses (14 days) of [MEDICATION(S)] in February 2021, but instead he received 36 doses (18 days). R52 should have received 10 doses (5 days) of [MEDICATION(S)] in March 2021 before it was discontinued on 3/8/21, but instead received 14 doses (7days). R52's Medication Incident Report dated 3/10/21 at 10:18 AM documents, Medication [MEDICATION(S)] ([MEDICATION(S)]) chemo drug was accidentally ordered wrong; was ordered continuously instead of 7 days on 7 days off. The report documented when incident was caught, order was changed, cancer doctor and family were notified, and medication was immediately held. There was no assessment of resident's response to the medication error documented on the report. R52's Oncologist Progress Report dated 4/2/21 documents, On 2 separate occasions over the past two months, patient did receive this [MEDICATION(S)] for two weeks on and 1 week off. On 4/14/21 at 2:25 PM V30, Pharmacist, stated R52's [CONDITION(S)] medication, [MEDICATION(S)], would have been ordered to be given for 7 days and then not given for 7 days on a cycle, in order to give R52's body a rest in between cycles of the medication. He stated with most [CONDITION(S)] drugs, the risk of them having been given daily, without the 7-day rest, would be bone marrow suppression. He stated the most common side effects of this medication are nausea and diarrhea. He stated dizziness could be a side effect also. On 4/14/21 at 2:35 PM V31, Registered Nurse (RN) from R52's Oncology Clinic stated there have been two medication errors with R52's [MEDICATION(S)], chemo drug, reported to their office. V31 stated one error was reported on 2/4/21 stating R52 had received extra doses of his [MEDICATION(S)], and then again on 3/8/21 when the facility's nursing supervisor called and stated R52 had received an additional 13 doses of the medication. V31 stated on 3/12/21 R52's wife had called the office with concerns of his increased weakness and falls, and V32, Oncologist, recommended R52 be sent to the Emergency Department for evaluation due to having received excess doses of the medication. V31 stated R52's oncologist stopped R52's medication because it is risky to not get the [CONDITION(S)] correctly. She stated the oncologist would need to answer questions about side effects of R52 receiving the extra doses of his [CONDITION(S)]. On 4/15/21 at 8:00 AM V33, Registered Nurse (RN) stated she found both medication errors regarding R52 receiving too much of his [CONDITION(S)] medication, [MEDICATION(S)]. V33 stated she corrected the order in the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . V33 stated the first time a medication occurred with R52's [CONDITION(S)] in February, he had received about 11 or 12 extra doses. She stated she reported it to whoever was here as Director of Nursing (DON) or the Administrator, she was not sure because there have been a few different people in those positions in the last few months. V33 stated she did not do a Medication Error Report because she did not know how in the new EMR system. She stated she found the same error the second time on 3/8/21, and that time R52 had received 13 extra doses of the [MEDICATION(S)]. V33 stated she again notified his oncologist and R52's wife. V33 stated she noticed R52 was more lethargic, having more falls, and he had more confusion during the time the errors were occurring. She stated she has not seen any improvement in these symptoms since the medication was stopped. On 4/15/21 at 8:31 AM V32, R52's oncologist, per phone interview, stated R52's [MEDICATION(S)] was stopped due to it not being effective treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . V32 stated he saw R52 in his office this month (April) and he had labs done. V32 stated R52's liver enzymes were normal, indicating he had no toxicity from the medication error. V32 stated there are two primary side effects that may occur with the use of [MEDICATION(S)]: Hand-Foot Syndrome, where a patient gets blisters and/or burning sensation on his hands and feet. V32 stated R52 did have a blister on one of his fingers during his clinic visit, which would have been a minimal consequence of R52 receiving extra doses of the [MEDICATION(S)]. V32 stated the other common side effect of [MEDICATION(S)] would be nausea and diarrhea and R52 did not have this symptom. V32 stated despite the concentrated chemo drug being administered, it did not phase R52's cancer. V32 stated this medication ([MEDICATION(S)]) does not cross the blood/brain barrier and would not have caused confusion or [CONDITION(S)]. V32 stated he would expect staff to administer medications as ordered to avoid side effects and possible toxicity to the medications. On 4/16/21 at 8:45 AM R52 was sitting in the dining room eating breakfast. He has a healing blister on his right middle finger which he stated does not hurt. He stated he has calluses on his feet, but they do not hurt. He stated he would like to go to a different facility and his wife is working on it. He stated, I'm not falling anymore.

Based on observation, record review and interview, the facility failed to provide supervision to prevent falls for 1 of 3 residents (R2) reviewed for falls in the sample of 9. This failure resulted in R2 falling and sustaining a left-sided intraparenchymal hemorrhage, bilateral small subdural hematomas, traumatic subarachnoid hemorrhage, left parietal lobe contusion and left eye contusion that required emergency treatment and hospitalization . In addition, R2 had surgical placement of a gastrostomy tube and surgical revision of the ventriculoparetoneal shunt in R2's head after R2 deteriorated from ventricular enlargement. As a result of this latest fall, R2 can have nothing by mouth, no longer participates in restorative ambulation program and is restricted when seated in a wheelchair, with a full lap tray. Findings include: R2's physician's orders [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documents R2's Brief Interview of Mental Status (BIMS) Score was 9, indicating moderately impaired with cognition. The MDS documents she requires extensive assistance of two staff persons for transfers and ambulation, and has unsteady sitting and standing balance. The Incident/Accident Report for R2, dated 12/15/2016, at 7:30 PM, documents, in part, Lost balance while ambulating with one assist. Resident (R2) has a history of self transfer attempts. Resident is 2 assist and employee (E12, Certified Nurses Aide, CNA) was one assisting resident (R2). Post Investigation Actions-staff discipline. E12's, CNA Incident/Accident Witness Statement, dated 12/15/2016 at 7:25 PM, documents, in part, Was using walker to transport (R2) to the toilet. (R2) lost her footing and tried to grab her by the gait belt to pull her back up, and she fell hard and fast. The Report documents R2 sustained redness to the left back area. R2's Care Plan, updated 12/15/2016, documents R2 received a pureed diet, with nectar thickened liquids and was on a restorative ambulation program with the assistance of 2 staff. R2's Care Plan of 12/15/2016 documents R2 was at risk for falls related to attempts to ambulate and transfer without assistance, with poor safety awareness. The Incident/Accident Report for R2, dated 1/08/2017, at 7:55 PM, completed by E4, Licensed Practical Nursed (LPN) documents, in part, This nurse heard a noise, looked out in the hallway and saw (R2) laying on her face in a pool of blood. The Fall Investigation, dated 1/08/2017, documents Resident is impulsive and yelling out this evening. Resident has [DIAGNOSES REDACTED]. Resident (R2) sent to the hospital and admitted . Nurse was one on one care starting at 6:15 PM due to impulsive behavior. Nurse uncomfortable leaving resident in room due to resident history and current behavior. Stood up from wheelchair due to impulsive behavior. Nurse (E4) placed resident, wheels locked along the wall next to room 208, while she cared for that resident (in room 208). This is when resident (R2) stood up and fell . The Incident/Accident Report for R2 on 1/08/2017 does not document if R2 had a safety alarm on her wheelchair, or if it was sounding. A Incident/Witness Statement,dated 1/08/2017 at 8:00 PM, from E11, Certified Nurses Aide (CNA) documents, in part, that E11 did not witness the fall, but the resident was in the hallway near the nurse by her cart, when E11 was asked where she last observed R2. E11 documented, I had the alarm on her wheelchair, but it must have fallen off, or she took it off because she (R2) was acting crazy. On 1/24/2017 at 2:55 PM, E4 stated, Previously, the CNA asked me if I would watch her, and I said yes. Can't remember her name. She (R2) had been trying to get up out of the wheelchair. I brought her with me everywhere I went. I was in hallway 200, in front of another resident's room passing medication. (R2) was sitting in a wheelchair. I went into the room of another resident and talked to him and when I came back out (R2) was sitting in the wheelchair. I went back into his room to show him the MAR (Medication Administration Record) and thats when I heard a boom. I leaned over, and I could see the wheelchair, partially. She was laying there. I moved her. Her eyes started to roll, but she never did lose consciousness. She was yelling, 'My head, my head!' She injured the left side of her forehead. The alarm was sounding on the wheelchair. (R2) was not on official one to one observation. I just agreed to watch her. Another CNA gave me a towel. I applied pressure. Staff dialed 911. E4 stated, The first time I ever took care of her. I got no report about her when I got there. She had a caregiver or family member sitting with her. She could stand and bear weight, but did not have a steady gait. E4 reported R2 had no gastrostomy tube at that time. E4 reported R2 had been out of her sight when she was giving medication to the other resident. E4 reported she is an agency nurse. On 1/24/2017 at 4:00 PM, E2, Director of Nursing (DON) reported E4 had no specific orders for 1 on 1 observation for R2. E2 stated, It is a nursing decision. I expect them to be in someone's sight at all times. We don't have a policy or procedure for 1 to 1 observation. R2's hospital record, dated 1/09/2017 at 6:59 AM, documents R2 was air lifted to a more critical care hospital after being taken to a local hospital on [DATE], due to her altered mental status with a slow response time. R2's Post-Acute Care Transfer Report, dated 1/09/2017 documents R2's head CT (computed tomography) scan done on 1/08/2017 at 8:30 PM documents multiple intracranial injuries, including a left temporal contusion, small subdural hematomas and traumatic subarachnoid hemorrhage. On admission, her (R2) CT scan demonstrated ventricles that were stable in size, with a prior CT performed when she was at her baseline. Later on during her admission, she underwent a routine followup head CT scan for evaluation of her traumatic injuries, which demonstrated ventricular enlargement. She would open eyes. She would not follow commands, and she would groan, this was off her baseline, which is where she is oriented to name, and at times can tell where she was located. Based on these findings, we proceeded to the operating room after obtaining informed consent for revision of her right ventriculoatrial shunt. R2's Physician Discharge Summary/Orders from the hospital, dated 1/16/2017, documents, in part, (R2) was evaluated by speech therapy who recommended a modified barium swallow which demonstrated that her swallowing mechanism is abnormal. Speech therapy recommended NPO (nothing by mouth). On 1/13/2017, the patient was taken to the OR (operating room) and had a PEG (percutaneous endoscopic gastrostomy) placement. The Nurse's Note for R2 dated 1/16/2017 at 2:30 PM, documents, in part, Resident readmitted to (resident room). 22 sutures noted to right scalp. Approximately 8 sutures noted to left scalp with scabbed area direct on top. Fading bruise noted to right neck, multiple bruises noted to bilateral upper extremities at various stages. [DEVICE] (gastrostomy tube) site new, intact. Uses low bed with mat on floor, sensor alarm to recliner, (mechanical lift) to transfer, NPO (nothing by mouth) at this time. On 1/20/2017 at 4:07 PM, R2 was in bed asleep. A fall mat was next to the bed. The head of R2's bed was raised 30 degree. R2's hair had been shaved. A healing and scabbed, large laceration was on R2's forehead. R2 had dark bruising to the left upper cheek and left orbit area. A large surgical scar was on the right side of R2's head above the right ear. There were no siderails on R2's bed. A bagged enteral feeding solution was connected to a gastrostomy tube in R2's abdomen and was draining by gravity. On 1/24/2017 at 8:25 AM and 9:17 AM, R2 was up in a wheelchair with a full lap tray. R2 kept her head down and her eyes closed, unless she was spoken to. Then, R2 would only answer with a few words or not at all. At 9:25 AM, R2 was transferred to bed from the wheelchair by E7 and E8, CNA's using a mechanical lift. R2's body was flaccid and required the total assistance of E7 and E8 to position and turn R2 in bed. R2 was positioned on her back with her heels floated on a pillow. On 1/24/2017 at 1:12 PM, R2 remained asleep and in the same position. On 1/25/2017 at 8:10 AM, 8:25 AM and 8:47 AM, R2 was up in the wheelchair with her eyes closed. A full lap tray was on the wheelchair preventing R2 from rising from the chair. When attempting to talk with R2 at 8:47 AM, R2 opened her eyes, but did not verbally respond, then closed her eyes. R2 was sitting on a mechanical lift pad. R2's current Care Plan, updated 1/17/2017, documents, in part, Interventions-Utilize full lap tray related to unsafe attempts to transfer self, and (mechanical) lift transfer. R2's restorative nursing program for ambulation has been discontinued. On 1/25/2017 at 9:30 AM, E1, Administrator was discussing R2's fall of 1/08/2017 and stated, She (R2) was out of sight. She was declining prior to this. She has a history of manic episodes and cycles through them. On 1/25 and 1/26/2017, multiple attempts to contact Z3, Physician were unsuccessful. The facility's policy and procedure, dated 9/2003 and entitled, Fall Risk Assessments documents, in part, When significant potential for falls is noted via the assessments, appropriate fall prevention measures will be implemented. The facility's policy and procedure, dated 2/2003 and entitled, Incident/Accidents documents, in part, (Facility's name) will take every precaution to prevent the occurrence of accidents.

Based on interview, observation and record review, the facility failed to follow facility policy/procedure for safe transfer of residents using a full mechanical lift with the assistance of two staff and failed to provide adequate supervision/safety devices during shower time for 2 of 3 residents (R3, R1) reviewed for falls in the sample of three. This failure resulted in R3 falling out of the full body mechanical lift sling during a transfer sustaining a bilateral subdural hematoma which resulted in death. Findings include: 1. The Minimum Data Set (MDS), dated [DATE], documents R3 to have severe cognitive impairment and be dependent on two staff for transfers. The MDS also identifies her to be aphasic. A Fall Risk assessment, dated [DATE], documents R3 to be at significant risk of falls. The Care Plan, dated [DATE], documents R3 has a [DIAGNOSES REDACTED]. There is no fall prevention plan in the Care Plan. The [DATE] physician's orders [REDACTED]. The POS also documents [REDACTED]. An Incident/Accident Report completed by E4, Licensed Practical Nurse (LPN), dated [DATE] at 8:30 PM, documents CNA (Certified Nurse Aide) reported to nurse that resident fell . CNA put resident back in bed before reporting fall to nurse. The report identifies the CNA as E3. The report documents R3's injuries as a 6 centimeter (cm) circular hematoma to the head. The physician was notified and orders were received to send to the emergency room for evaluation. Nurses Notes, dated [DATE] written by E4, documents R3 was transported at 9 PM and on [DATE], R3 returned to the facility at 12 AM with orders for an ice pack and neurochecks every 6 hours. Nurses Notes document R3 was seen on [DATE] at 11:30 AM by Z1, Medical Director, following the fall with new orders noted, but no change in condition documented by either Z1 or the nurses. On [DATE] at 3:30 PM, the Nurses Notes document the CNAs notified the nurse that R3 was off and wasn't responding to touch as usual. Z1 was notified and orders were received to send to the hospital. The Nurses Notes, dated [DATE] at 9:30 PM, document a hospital representative stated resident had brain bleed in multiple spots and family had admitted resident into Hospice. A Death Certificate documents R3 expired on [DATE] with cause of death documented as Bilateral Subdural Hematoma due to fall. On [DATE] at 10:45 AM, E1, Administrator, identified E3 as the CNA involved in R3's fall. E1 stated it was explained to her that E3 chose to transfer R3 by herself with no assistance and when E3 started to raise R3 up from the wheelchair with the lift, the top strap of the sling came undone causing R3 to lean sideways and fall to the floor. E1 stated E3 said she lowered her to the floor then used the lift to transfer her to bed before notifying the nurse of the fall which she shouldn't have done either. E1 stated she should have left R3 on the floor and notified the nurse. E1 stated the facility has had no other incidents with falls from the mechanical lifts and E3 had been inserviced on proper use of the lifts, including requiring two staff members, prior to the fall incident occurring with R3. E1 stated staffing was fine on the hallway that night adding that there were two other CNAs on 100 hall at the time. E1 also stated E3 has been disciplined for not following facility policy. At 11:18 AM, E1 stated E3 offered no explanation as to why she didn't have another staff member help her and that staffing that evening was adequate. On [DATE] at 2:36 PM, Z1, Medical Director, stated it was his understanding that E3 did not follow facility protocol to use two staff members in transferring and that the sling was not properly attached to the lift. Z1 stated he thought R3 sustained a slow bleed during the fall which resulted in the subdural hematoma. Z1 acknowledged he saw R3 several days after the fall and did not notice any change in consciousness at that time nor was he informed of any change until [DATE] when she became unresponsive. E3's employee file includes a disciplinary action for following policy/procedure when using full body mechanical lifts. The file also contained a safety policy for using mechanical lifts signed by E3, dated [DATE]. The Procedure documents, in part, Total mechanical lifts require a minimum of 2 trained staff members to complete a resident transfer. The Facility policy entitled total resident transfers using Mechanical lifts, dated [DATE], documents staff members will ensure residents safety during total transfers of residents. Under procedure, it documents only trained employees will use the lift and total mechanical lifts require a minimum of 2 trained staff members to complete the transfer. The procedure also directs employees to follow the manufacturer's directions when using the lifts. The Manufacturers directions document the lift has the option of both a 6 point sling or a 4 point positioning cradle sling with both systems using a different attachment method and sling. The guide assumes the straps will be properly attached to the lift arm and secured prior to lifting the resident. 2. The MDS, dated [DATE], documents R1 to have severe cognitive impairment and short/long term memory deficits. The MDS documents R1 requires extensive assist of two staff for mobility and is unable to move from one point to another without the assistance of staff. The Care Plan, dated [DATE], documents R1 has had several falls from bed and two falls during shower/bath time with interventions for fall preventions to include a lap top cushion to prevent unsafe transfers - unable to remove during mealtime due to anxiety, non-slick footwear that fits, and raised edged low bed with mattress on the floor in part. An Incident/Accident Report, dated [DATE], documents at 9:45 PM that resident slid out of w/c (wheelchair). She was wet coming from a shower. Injuries identified as skin tear to left buttocks. E6, CNA, witness statement documents R1 was in her chair and slid out of her chair, (mechanical lift) pad was wet under her and her feet were wet. The investigation does not include an analysis of the fall for causative factors and no interventions were added to the fall prevention plan to ensure safe transfer during and to/from showers. An Incident/Accident Report, dated [DATE] at 4:30 PM, documents another fall during shower time for R1. The Witness Statement with the report written by E7, LPN, documents CNA was giving resident shower. I saw CNA looking for help at the shower room door. Before I enter the room I heard something fall, walked in and saw resident laying on the floor. E7 documented R1 had one slipper sock on and had been in the shower chair prior to the fall. The CNA identified as being at the door of the shower looking for assistance was E5, CNA. Her witness statement documents resident tried to get out of shower chair and fell . Again, there is no causative factor identified in the report. However, there is an Inservice Education/Meeting Attendance sheet, dated [DATE], attached to the investigation which documents All residents whom are (full body mechanical lifts) MUST be showered on the shower bed. The facility failed to identify E5 turning her back on R1 as she sat in the shower chair without her lap top cushion as a causative factor as well. E5 was not one of the participants of the in-service education regarding the shower bed use for all full body mechanical lifts residents. R1's Care Plan, as of [DATE], does not include any interventions toward safe transfers during shower time. On [DATE] at 2:30 PM, when was asked about R1's falls prevention plan not including any interventions or directions to staff regarding safety during shower time and transfers, E9, Care Plan Coordinator/LPN, stated she's not sure how those falls occurred, she just lists the falls on the Care Plan. On [DATE] at 2:36 PM, Z1 stated R1 has repeated falls and the facility is responsible to ensure adequate supervision is provided and shouldn't be left alone in the shower. Z1 was unsure how the fall during the transport down the hall occurred and could not comment. On [DATE] at 11:30 AM, E1, Administrator, stated it is a facility policy for all residents transferred via a full body mechanical lift to have a shower bed used for shower and transport. E1 stated R1 should have been in a shower bed both times her falls occurred. E1 stated she didn't think there was a written policy on it, but that it is known by all staff that a shower bed is to be used by residents requiring the full body lift. When asked why using the shower chair wasn't an intervention within R1's falls prevention plan, E1 stated all staff were aware, even though both R1's falls involved 2 separate CNAs. E1 was unaware as to why the CNAs did not use a shower bed or if they were unaware they needed to. On [DATE] at 12:30 PM, E2, Director of Nurses, also stated she was unaware of whether the CNAs involved in R1's falls were not aware of the facility policy to use a shower bed or if they chose not to at the time. E2 stated both CNAs are no longer employed at the facility.

Based on interview, observation and record review, the facility failed to ensure that residents are free from abuse for one of two residents (R19) reviewed for staff abuse, in the supplemental sample. This abuse resulted in (R19) being kicked and sustaining a leg wound and being frightened. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE] documents R19's cognition to be intact. The MDS documents R19 requires extensive assist of two staff for toileting and transfers. An Incident/Accident Report, dated 1/14/16 at 9:00 PM, completed by E16 Registered Nurse (RN), documented Heard resident yelling, entered her room and resident alleged CNA (Certified Nurses Aide, E15) kicked her on her legs. Observed hematomas on bilateral lower extremities and skin tear on L (lower) shin. The report documented E15 was sent home immediately and the physician and family member (Power of Attorney over healthcare) were notified. The Final Incident Report, dated 1/20/15, documents R19 as a [AGE] year old female who is alert/oriented and able to make her needs known. The Report narrative documents R19 stated she was sitting on the toilet and the CNA told her to get up off the toilet and R19 told the CNA she needed help. The report documents R19 stated the CNA was putting her hands up in her face and that she turned her head to avoid being hit. The Report documented R19 told E16 that E15 kicked both of her legs and that E15 put her roughly in the wheelchair. The report documents R19 then started screaming and the nurse came into her room. The Report documented E16 told E1, Administrator, that she heard R19 screaming for help and entered her room to find her in her wheelchair by the bed crying and that R19 told her E15 kicked her legs. The Report documented E16 stated R19 had hematomas to both legs and a skin tear to the left lower leg. The Narrative Report documents that E1 spoke with E18, RN/ Night Nurse and E18 reported that R19 provided the same information as she did earlier. E18 stated R19 reported to her that the CNA kicked her legs hard and E18 confirmed bruising to bilateral legs with a small skin tear on the left lower leg. On 4/22/16 at 11:20 AM, R19 recalled the 1/14/16 incident and shaking her head stated I screamed bloody murder as she stood in the doorway with her hands on her hips. R19 stated the CNA made a real ugly face and made fists stating I thought (E15) was going to hit me so I turned my head. R19 stated E15 was hateful and she was very afraid after that. R19 stated she still had a hole in her leg from being kicked and now sees the wound clinic for it. R19 was sitting in her wheelchair at bedside and had a dressing on her left lower leg. Wound documentation dated 4/19/16 describes R19's leg wound as full thickness wound to the left lateral lower leg s/p (status [REDACTED]. The wound measures 4.2 centimeters (cm) x 3.1 cm with a circumferential area of undermining measuring 0.5 cm. On 4/22/16 at 3:15 PM, E1 Administrator stated R19 was really really shook up after the incident, wouldn't come out of her room, wouldn't eat, wouldn't talk to anyone, put herself into this shell, and still to this day, talks about it. E1 confirmed E15 was terminated due to resident's injury being consistent with the residents claim of abuse after being kicked. On 4/26/16 at 9:45 AM, Z2, Medical Doctor/Facility Medical Director, stated R19 was irritated when he saw her after the incident. Z2 stated R19's lower leg had a large hematoma which was soft to touch when he first saw it but later opened up, got infected and is still being treated thru the wound clinic at this time. Z2 confirmed that he'd been notified and that the facility terminated the employee upon completing their investigation. The facility's policy entitled Abuse Prevention Policy dated 3/2011 documents This facility believes that each resident has the right to be free from abuse, neglect, corporal punishment, misappropriation of their property, and involuntary seclusion. The policy documents the definition of Abuse as Physical Abuse - the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment.