Every finding on record at La Bella of Mascoutah

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan in 3 of 4 residents (R3, R4, R12), reviewed for development of the comprehensive care plan in the sample of 12.Findings Include:Findings include: 1. On 2/26/26 at 10:35 AM, R3 was observed in her room in a reclining wheelchair, with the television on. Contractures were observed to the left hand with the fingers completely contracted to the palm of the left hand. There were not any splints/washcloths in place to aid in contracture management. R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified Skin Changes, Pulmonary Hypertension, Age Related Debility, Urinary Retention, Protein Calorie Malnutrition, HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), Anorexia, and Pain. R3's MDS (Minimum Data Set), dated 1/1/26, documents R3 has severe cognitive impairment, has impairment in ROM (Range of Motion) in one upper and one lower extremity, is dependent with ADLS (Activities of Daily Living), and is not receiving any ROM programs. R3's Activity Assessment, dated 4/4/25, documents R3 enjoys listening to music, sitting outside, watching TV and movies, prefers to stay in room, and prefers activity programs in small groups or in room. R3's Care Plan, dated 9/30/24, failed to document a ROM/Contracture Management or Activities Care Plan. 2. R4's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE]. R4's EMR dated 9/3/25 documents a diagnosis of legal blindness, as defined in USA. R4's EMR dated 9/3/25 documents a diagnosis of anxiety disorder, unspecified. R4's EMR dated 10/3/25 documents a diagnosis of other psychotic disorders not due to a substance or known physiological condition. R4's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents that the resident requires setup or clean-up assistance for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident requires supervision or touching assistance for chair/bed to chair transfer and toilet transfer. R4's Care plan dated 10/24/25 documents I prefer (Specify: to participate, little participation or no participation) in activity involvement. Care Plan is not done. R4's Activity Assessment (Quarterly or Annually) dated 12/3/25 documents Unedited the form is blank. 3. R12's EMR undated documents that the resident was admitted to the facility on [DATE]. R12's EMR dated 7/13/25 documents a diagnosis of paralytic syndrome, unspecified. R12's EMR dated 10/20/25 documents a diagnosis of acute respiratory failure with hypoxia. R12's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer. R12's Activities Assessment (Quarterly or Annually) dated 8/29/25 documents Unedited. Assessment is not done. R12 did not have a care plan for the resident's preference for activities. On 2/27/26 at 12:17 PM, V8, Activity Director/Social Service Designee stated that activity assessment and social service assessments should be done on admission and quarterly. She stated that care plans for activity and social service should be updated every 3 months. On 2/27/26 at 12:23 PM, V20, MDS/Care Plan Coordinator stated that care plans should be updated quarterly. On 3/3/26 at 11:38 AM, V1, Administrator, stated she is aware the care plans need to be updated and they are currently in the process of doing this. The Care Plan Policy, with a revision date of 11/6/19, documents the facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The care plan is based on the resident's comprehensive assessment.

Based on observation, interview, and record review, the facility failed to provide positioning assistance to 2 of 3 residents (R3, R11), when reviewed for ADL (Activities of Daily Living) care provided to dependent residents in the sample of 12.Findings Include:1.On 2/26/26 at 8:40 AM, R3 was observed in the dining room, up in her reclining wheelchair being assisted with the breakfast meal.On 2/26/26 at 10:35 AM, R3 was observed in her room in her reclining wheelchair.On 2/26/26 from 8:40 AM to 1:00PM, R3 was observed in 15-30-minute increments, R3 was not repositioned during that time.On 2/26/26 at 1:30 PM, R3 was observed being assisted to bed by staff.On 2/26/26 at 1:30 PM, V4, CNA (Certified Nursing Assistant) stated she laid R3 down after breakfast, incontinent care was provided and was repositioned. V4 stated she was unsure of the exact time and did not lay R3 down or reposition her again until 1:30 PM.R3's Face Sheet, undated, documents R3 has the following diagnoses: Intracerebral Hemorrhage, Hyperosmolality, Hypernatremia, Plasma Protein Metabolism Disorder, Unspecified Skin Changes, Pulmonary Hypertension, Age Related Debility, Urinary Retention, Protein Calorie Malnutrition, HTN (Hypertension), COPD (Chronic Obstructive Pulmonary Disease), Anorexia, and Pain.R3's MDS (Minimum Data Set), dated 1/1/26, documents R3 is dependent with ADLs.R3's Care Plan, dated 9/30/24, documents R3 has an ADL self-care performance deficit and requires staff assistance with care needs. 2. On 2/26/26 at 8:15 AM, R11 was observed in her reclining wheelchair in the dining room. On 2/26/26, from 8:15 AM to 12:45PM, R11 observed in 15-30-minute increments and was in the dining room in her wheelchair and had not been repositioned.On 2/26/26 at 1:50 PM, R11 was observed being assisted to bed with staff.On 2/26/26 at 2:00 PM, V5, CNA, stated she laid R11 down after breakfast, unsure of time, provided incontinent care and got her back up in her reclining wheelchair.On 3/3/26 at 11:38 AM, V1, Administrator, stated the residents that are unable to reposition themselves should be assisted by staff every two hours.The Activities of Daily Living Policy, with a revision date of 3/17/25, documents residents will be provided with care, treatment and services as appropriate to maintain or improve their quality of life. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with their plan of care, including appropriate support and assistance with (in part): mobility.

Based on interview and record review the facility failed to provide a comprehensive assessment and preference for 3 of 3 (R4, R5, R12) residents investigated for activities in a sample of 12.1. R4's EMR (Electronic Medical Records) undated documents that the resident was admitted to the facility on [DATE].R4's EMR dated 9/3/25 documents a diagnosis of legal blindness, as defined in USA.R4's EMR dated 9/3/25 documents a diagnosis of anxiety disorder, unspecified.R4's EMR dated 10/3/25 documents a diagnosis of other psychotic disorders not due to a substance or known physiological condition.R4's MDS dated [DATE] documents a BIMS score of 14 out of 15. The MDS documents that the resident requires setup or clean-up assistance for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident requires supervision or touching assistance for chair/bed to chair transfer and toilet transfer.R4's Care plan dated 10/24/25 documents, I prefer (Specify: to participate, little participation or no participation) in activity involvement.Care Plan is not done.R4's Activity Assessment (Quarterly or Annually) dated 12/3/25 documents Unedited the form is blank.2. R5's EMR undated documents the resident was admitted to the facility on [DATE].R5's EMR dated 7/24/20 documents a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.R5's EMR dated 10/18/21 documents a diagnosis of morbid (severe) obesity due to excess calories.R5's EMR dated 7/29/20 documents a diagnosis of major depressive disorder, single episode, unspecified.R5's MDS dated [DATE] documents a BIMS score of 15 out of 15. The MDS documents that the resident that the resident requires supervision or touching for roll left and right, sit to lying, lying to sitting on side of bed, and sit to stand. The MDS documents that the resident partial/moderate assistance for chair/bed to chair transfer and toilet transfer.R5's Activities Assessment (Quarterly or Annually) dated 7/26/25 documents Unedited the form is blank.3. R12's EMR undated documents that the resident was admitted to the facility on [DATE].R12's EMR dated 7/13/25 documents a diagnosis of paralytic syndrome, unspecified.R12's EMR dated 10/20/25 documents a diagnosis of acute respiratory failure with hypoxia.R12's MDS dated [DATE] documents a BIMS score of 11 out of 15. The MDS documents that the resident is dependent for roll left and right, sit to lying, lying to sitting on side of bed, and tub/shower transfer.R12's Activities Assessment (Quarterly or Annually) dated 8/29/25 documents Unedited. Assessment is not done.During this investigation, no observations of R4 and R12 engaging in any activities nor did any activity staff engage with R4 and R12 for 1 on 1 activities. R5 was observed playing bingo one day.On 2/26/26 at 8:20 AM, R4 stated that there are no activities for him except bingo and he only plays bingo to get snacks.On 2/27/26 at 12:17 PM, V8, Activity Director/Social Service Designee stated that activity assessment and social service assessments should be done on admission and quarterly. She stated that care plans for activity and social service should be updated every 3 months.On 2/27/26 at 12:23 PM, V20, MDS/Care Plan Coordinator stated that care plans should be updated quarterly.Facility's Activity Programs policy and procedure dated 11/5/19 documents An ongoing program of activities is designed to meet the needs of each resident.

Based on observation, interview, and record review, the facility failed to implement safety measures to prevent falls in 1 of 5 residents (R11) when reviewed for freedom of accidents in the sample of 12.Findings Include: On 2/27/26 at 9:48 AM, R11 was observed in the dining room in her wheelchair with a clear plastic lap tray in place. The tray is attached to the wheelchair with Velcro straps going from the tray to the wheelchair arm rests. The tray is easily moved and slides up/down very easily. R11's Progress Note, dated 12/19/25 at 10:07 PM: 9:25 PM, documents the following: Resident observed lying on her back/right side in dining room next to her wheelchair. No apparent physical injury; AROM (Active Range of Motion) and PROM (Passive Range of Motion) WNL (Within Normal Limits) for resident. Neuro checks initiated and WNL for resident. VSS (Vital Signs Stable) 120/78, 63, 16, 97.4, 99% RA (Room Air). 9:35 PM, DON (Director of Nurses), Administrator, POA (Power of Attorney), and MD (Medical Doctor) notified. POA would like resident to be sent to the local hospital. 9:50 AM, Transferred from floor to stretcher by 2 EMT's (Emergency Medical Technician), transported via ambulance.R11's Progress Note, dated 12/20/25 at 5:30 AM, documents the following: The nurse at the local hospital called to give report said CT of the head was normal, also did UA (Urinalysis) with reflex to C&S (Culture & Sensitivity). UA was positive sent for C&S, Rocephin 1gm (gram) given at hospital, script for Vantin (Cefpodoxime) sent to pharmacy. Resident returned to facility at 5:15AM, resident transferred from stretcher to bed, no signs or symptoms of pain or discomfort at this time, call light within reach.R11's Face Sheet, undated, documents R11 has the following diagnoses: CP (Cerebral Palsy), Seizures, Dependence on Wheelchair, Disorders of the Muscle, and Intellectual Disability.R11's MDS (Minimum Data Set), dated12/12/25, documents R11 has severe cognitive impairment and is dependent with ADLs (Activities of Daily Living). R11's Care Plan, dated 3/31/25, documents R11 has the potential for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication/comprehension, and is unaware of safety needs with an intervention for a lap tray to be used while R11 is up in her chair to prevent falls and ensure resident safety. There were no new interventions implemented for R11's fall on 12/19/26. The Facility Repair Requisition, dated 12/19/26, included in R11's investigation of the fall, documents the following: Specialized chair check and problems apparent. Placed apparent. Placed arm back on chair. Transfer belt to assure resident's safety. There was no name on the requisition.On 2/27/26 at 9:17 AM, V9, CNA (Certified Nursing Assistant) stated she was working on 12/19/26 when R11 fell. V9 stated she was on break and came back and found R11 lying on the floor in the dining room. V9 stated R11 did have her lap tray on but it wasn't secure and the family and facility knew that. V9 stated when R11 moves around in her wheelchair, the tray loosens, lifts and slides off and R11 will slide out of her wheelchair. V9 stated she did not witness R11 fall but is sure that is what caused her to fall.On 3/3/26 at 11:38 AM, V1, Administrator, stated, she understands R11's tray is easily moved/loose and will have maintenance address this. The Fall Reduction Policy, with a revision date of 10/30/24, documents the purpose of the policy is to provide an environment that remains as free of accident hazards as possible and to identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries.

Based on observation, interview, and record review, the facility failed to have a sufficient number of CNAs (Certified Nursing Assistants) to care for their residents when reviewed for Nursing Services. This failure has the potential to affect all 33 residents residing in the facility. Findings Include: On 12/17/25 at 9:06 AM, there were 2 CNAs observed working. On 12/16/25 at 11:10 AM, R33 stated they don't have enough aides, it takes a long time for him to get his call light answered and to get help. On 12/17/25 at 10:55 AM, 10:59 AM, 11:15 AM, and 11:30 AM - R20's call light was on. Staff in hallway were passing by, not answering call light. On 12/17/25 at 11:41AM R20 stated she has had her call light on since 10:30 AM and no one has come into her room to help her. R20 stated, I understand that now they are getting ready for lunch, feeding the residents, but I'm tired of it, tired of waiting, they think oh it's just (R20), she'll understand, but I'm tired of waiting. I want a shower and want to get up for the day. They don't have any aides here today, I haven't even seen any. On 12/17/25 at 11:54 AM - R20's call light remained on. R20 verified no one has come into her room yet. On 12/17/25 12:22 PM R20's call light remained on. R20 verified no one has come into her room to help her.On 12/16/25 at 11:55 AM V5, R31's Family stated this past Sunday 12/14/25, at approximately 1:30 PM, he came into the facility and R31 was still in bed with no brief, she was incontinent of urine. She hadn't been dressed for the day and looked like she hadn't even gotten out of bed. V5 stated they were short staffed on aides and there is a problem with continuity of care with the CNAs. On 12/18/25 at 11:46 AM V19, R14's Family, stated the food is horrible. Over the weekend, they served a cheese sandwich on 2 pieces of dry bread and 1 piece of cheese, with tater tots that were barely warm. V19 stated almost daily he goes out to get R14 food because it's that bad. V19 stated the facility is very short staffed on aides. V19 stated the Administrator and DON (Director of Nurses) come in often to help out but then there isn't anyone to do their jobs. V19 stated they will hire aides and then 2 days later they're gone, they've been fired. V19 stated the ones that are here try but they don't have enough of them. On 12/18/25 at 1:00 PM, during the Resident Council Meeting, R1 and R30 stated they do not have enough CNAs to provide care, they are overworked and tired.12/17/2025 9:30 AM V7, LPN, stated they have enough CNAs most of the time, there are times they are short, but she helps out on the floor. The Resident Council Minutes, dated 4/1/25, documented concerns with being short staffed and the CNAs working too hard. The Resident Council Minutes, dated 7/31/25, documented concerns that more CNAs were needed. The Nursing Staffing Assignments document the following: 12/14/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. 12/17/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. 12/18/25, 3 CNAs scheduled for day shift, 3 CNAs scheduled for evening shift, and 2 CNAs scheduled for night shift. The Employee Timecards for the CNAs document the following: On 12/14/25, there was 1 CNA working day shift, 2 CNAs working evening shift, and 2 CNAs working night shift. On 12/17/25, there were 2 CNAs working day shift, 2 CNAs working evening shift, and 3 CNAs working night shift. On 12/18/25, there were 4 CNAs working day shift, 2 CNAs working evening shift, and 3 CNAs working night shift. On 12/16/25 at 10:40 AM, V1, Administrator, stated the CNAs think they need 4 CNAs per shift, but with a census of 33, they only need 3 CNAs on day shift, 3 CNAs on evening shift and 2 CNAs on night shift. V1 stated they have had turnover with the CNA staff recently and are actively hiring and recruiting. The Facility Assessment, dated 11/1/25, documents they require 15 full time employees to provide competent resident support and daily care. The Staffing Policy, with a revision date of 2/20/25, documents the following: The facility will provide sufficient staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment. The Centers for Medicare and Medicaid Services, Form 671, dated 12/16/25, documents there are 33 residents residing in the facility.

Based on observation, interview, and record review, the facility to serve palatable food and food cooked at the appropriate temperature when reviewed for Food and Nutrition Services. This failure has the potential to affect all 33 residents residing in the facility.Findings Include: 1. On 12/16/25 at 3:00 PM, R20 was observed and appears thin. R20 stated the food needs perked up, she couldn't eat the meals on Saturday (12/13/25), they were horrible. Sunday (12/14/25) they were a little better, so she ate. R20 stated she has lost weight and needs to gain it back but the food tastes so bad she can't eat it. R20's MDS (Minimum Data Set), dated 10/10/25, documents R20 has a BIMS (Brief Interview for Mental Status) score of 14, indicating R20 is cognitively intact. 2. On 12/16/25 at 11:20 AM, R27 stated the food tastes horrible. She is hungry but can't eat it. R27 stated they offer substitutes, but they aren't any better. R27 stated she is never offered snacks and doesn't know if they even have any. R27's MDS, dated [DATE], documents R27 has a BIMS of 15, indicating she is cognitively intact. 3. On 12/16/25 at 11:10 AM, R33 stated he isn't getting enough to eat, they tell him he is getting double portions at meals, but he isn't. When he asks for more, he is told they don't have any food left. R33 stated when he asks for snacks, he is told they don't have any. R33's MDS, dated [DATE], documents R33 has a BIMS of 14, indicating he is cognitively intact. 4. On 12/18/25 at 11:46 AM, V19, R14's Family, stated the food is horrible. Over the weekend, they served a cheese sandwich on 2 pieces of dry bread and 1 piece of cheese with tater tots that were barely warm. V19 stated almost daily he goes out to get R14 food because it's that bad. R14's MDS, dated [DATE], documents R14 has a BIMS of 9, indicating she has moderate cognitive impairment. 5. On 12/16/25 at 2:32 PM, R1 stated the food is always cold and there is real a temperature abuse problem going on. R1 stated the food in the facility is not impressive at all. R1 stated the facility doesn't give a crap on what they serve the residents. R1's Undated Face Sheet documents R1 was admitted to the facility on [DATE]. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is cognitively intact. R1's Physician Order dated 9/30/2025 at 3:07 AM documents R2 is on a Regular Diet. 6. On 12/16/25 at 11:39 AM, R16 stated the food in the facility is terrible and cold. R16's Undated Face Sheet documents R16 was admitted to the facility on [DATE]. R16's MDS dated [DATE] documents R16 is cognitively intact. R16's Physician Order dated 11/30/2025 at 1:57 PM documents R16 is on a Low Concentrated Sweets Diet. 7. On 12/16/25 at 11:06 AM, R29 stated the food in the facility is horrible and herself and other residents practically go hungry because the food is awful, cold, and there is not enough at times. R29's Undated Face Sheet documents R29 was admitted to the facility on [DATE]. R29's MDS dated [DATE] documents R29 is cognitively intact. R29's Physician Order dated 11/12/2024 at 10:42 AM documents R29 is on a Regular Diet. 8. On 12/17/25 at 11:46 AM, V6, Dietary Cook, removed an industrial sized pan of scalloped potatoes out of the oven and placed them on top of the stove underneath the hood vent. On 12/17/25 at 12:20 PM, V6 placed the industrial sized pan of scalloped potatoes on the steam table and served the residents without taking the temperature before serving. 9. On 12/17/25 at 12:30 PM, after the last resident had been served, food temperatures were taken with a calibrated thermometer on the steam table, and the following food temperature was not within the safety food code guidelines of 135 degrees Fahrenheit (F) or higher: pork loin 123.0 F. 11. On 12/18/25 at 1:00 PM, during the resident council meeting, the following concerns with the food were voiced: R20 stated the food is gross, over the weekend they had some sort of fettucine, the noodles weren't cooked, and it wasn't fit to eat. R20 stated another time she got to the dining room late for lunch because there wasn't enough staff. She asked for a grilled cheese and the cook, told her no they didn't have time. R20 stated she is hungry a lot because the food isn't edible. R1 stated the food [NAME] are small, not even child size portions. R1 stated they started using smaller glasses too. R20 stated he has snacks in his room he can eat but not everyone does. R1 stated it's all due to budget. R30 stated on the weekends they are screwed, the food is bad, they have an alternate menu but it is just as bad. R30 stated he was going to go out and buy some canned sardines and smoked ham so he will have something to eat. On 12/17/2025 at 3:20 PM V17, Dietary Manager, stated all hot food temperatures should be between 170-190 degrees Fahrenheit and temperatures are taken before food is served to prevent food borne illness. On 12/18/25 at 3:00 PM, V1, Administrator, stated they do not have a policy on food palatability/taste. The Facility's Food Temperatures Policy Revised 12/30/2024 documents Food stored hot will be kept at 135 degrees F or above. Food will be cooked to the appropriate internal temperature per regulations. The Facility's Food Storage Areas Policy Revised 12/30/2024 documents Hot foods or potentially hazardous food will leave the kitchen or steam table at 135 degrees F or above. The Centers for Medicare and Medicaid Services, Form 671, dated 12/16/25, documents there are 33 residents residing in the facility.

Based on observation and interview, the Facility failed to store foods in a manner that prevents foodborne illness and potential contamination. This has the potential to affect all 33 residents living in the Facility.Findings Include:On 12/16/2025 at 10:35 AM in the standing refrigerator there was a clear plastic container covered with plastic wrap labeled sloppy joe and a clear plastic container covered with plastic wrap labeled cheesy broccoli rice, neither container was dated. In the dry good storage area, there was an uncovered, clear plastic container with a plastic bag full of a white powdery substance that appears to be flour with label or date.On 12/17/2025 at 12:30 PM a large plastic container of dry cereal was on the bottom of a three-tier metal rolling cart uncovered with no date. On 12/17/2025 at 3:20 PM V17, Dietary Manager, stated all food stored in the refrigerator should be stored in a covered container and labeled with the date it was cooked. V17 stated food is only good for 3 days once cooked and placed in the refrigerator. V17 stated all dry good including cereal should be in a sealed labeled and dated container. V17 stated when flour is opened, it is placed in a plastic bag and then placed in a closed container and labeled with what it is and dated. The Facility's Food Storage Areas Policy Revised 12/30/2024 documents Prepared food stored in the refrigerator until service shall be dated. Such food will tightly sealed with plastic wrap, foil, or a lid. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 12/16/25 documents there are 33 residents living in the Facility.

Based on interview and record review, the facility failed to develop a comprehensive care plan on 2 of 18 residents, (R20 and R26), reviewed for Comprehensive Resident Centered Care Plan in the sample of 25.Findings Include:1.R20's Face Sheet, undated, documents R20 has a diagnosis, in part, of Severe Calorie Protein Malnutrition. R20's Care Plan, dated 10/30/24, fails to document a care plan related to her nutritional status/needs. 2.R26's Face Sheet, undated, documents R26, has a diagnosis, in part, of (ESRD) End Stage Renal Disease. On 12/17/25 at 8:33 AM, R26 stated he receives dialysis. R26's Care Plan, dated 11/11/25, fails to document a care plan related to his diagnosis of ESRD, which requires hemodialysis. On 12/19/25 at 8:15 AM, V1 Administrator, stated care plans should be developed for each resident's specific needs and she is working on them. The Comprehensive Care Plan Policy, with a revision date of 6/25/25, documents the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS).

Based on interview, observation, and record review, the facility failed to give resident showers to 3 of 5 residents (R2, R3, R5) reviewed for ADL (Activities of Daily Living) care provided for dependent residents in the sample of 5.Findings Include:1. R2's Face Sheet, undated, documents R2 has a diagnosis, in part, of Quadriplegia.R2's MDS (Minimum Data Set), dated 10/12/25, documents R2 is cognitively intact and is dependent upon staff for showers.R2's Care Plan, dated 6/3/25, documents R2 has an ADL self-care deficit and requires 1-2 assist with showers.R2's Shower Sheets, fails to show any documentation of a shower given/offered from 9/9/25 until 9/22/25 and none documented in 11/2025On 12/2/25 at 10:35 AM, R3 stated they don't have enough CNAs (Certified Nursing Assistant), and when you don't have enough CNAs, you don't get your showers.2. R3's Face Sheet, undated, documents R3 has a diagnosis, in part, of Cerebral Infarction with Hemiparesis/Hemiplegia.R3's MDS, dated [DATE], documents R3 is cognitively intact and requires partial/moderate assist with showers.R3's Care Plan, dated 10/20/21, documents R1 has an ADL self-care performance deficit, requires one staff participation with bathing, and to shower Monday/Thursday on day shift and as needed.R3's Shower Sheets, fails to show any documentation of a shower given/offered from 11/1/25 until 11/12/25 and none documented after 11/19/25.On 12/2/25 at 10:30 AM, R5 stated she is not getting her showers.3. R5's Face Sheet, undated, documents R5 has a diagnosis, in part, of Fibromyalgia and Congestive Heart Failure.R5's MDS, dated [DATE], documents R5 has moderate cognitive impairment and requires set up / clean up assistance with showers.R5's Shower Sheets, fails to show any documentation of a shower given/offered from 10/16/25 until 11/5/25.On 12/4/25 at 8:50 AM, V1, Administrator, stated showers are being given. Some of the residents will be offered a shower on their shower day, refuse and then want it at a different time and they do their best to accommodate. V1 stated she assists with showers. V1 stated V2, DON, interviewed the residents on their preferred date, shift, for showers and made a new shower schedule based on their preferences and it's been working out, it's that some refuse and then want it at a different time, so they might have to wait, but they do get their showers. The Shower Care Policy, dated 11/24/20, documents it is the policy of the facility to assist residents with bathing to maintain proper hygiene and help prevent skin issues.

Based on interview and record review the facility failed to ensure quality/safe transportation for 1 (R2) of 4 residents reviewed for unsafe transportation in the sample of 7. This failure resulted in R2's fractured right leg coming off R2's foot pedals and R2 dragging fractured right leg on ground. Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan updated currently has an alteration in her mobility and needs assistance due to limited range of motion due to non-weight bearing to right lower to right lower extremity status post-surgery. R2 requires mechanical lift for transfers. Interventions include: Cueing, reorientation as needed. Monitor/document ability to perform ADLs. Encourage/provide gentle range of motion as tolerated with daily care. Report any decline in abilities to Physician. Weight bearing restriction to right lower extremity. R2 uses a wheelchair and requires total dependence of 1 staff for locomotion. Physical/Occupational therapy evaluation and treatment per orders.On 10/23/2025 at 3:30PM V15 stated, On 10/21/2025 the staff got (R2) up right before we were to leave for her appointment. She (R2) was in a lot of pain in the transport van. She was screaming and I couldn't do anything to help her. The van driver and I tried to pull her up, but we couldn't do much. No staff member came with us. When we got to the Doctor's office her leg, the one with the immobilizer on, was dragging the ground because she had slid down that far in the wheelchair. Therapy had put a small mat to connect her foot pedals since the boot she is wearing is so big. The mat had started to come off and that caused her right foot to drag. Her right foot was dragging while I was pushing her. The staff at the Doctor's office pulled her up and then she was better. She had been crying so much the Doctor wanted an Xray. The Doctor's office called an ambulance to take R2 over to the hospital to get an Xray. Then the ambulance took us back over to the Doctor's office and then transferred R2 back to her wheelchair and the transport van took us back to the facility. On 10/23/2025 at 3:30PM R2 stated I was in such pain. I was screaming. I had been looking so forward to getting out of here too. I was afraid to move because I thought I would fall. My leg was dragging and that hurt.On 10/23/2025 at 9:00AM V21, Complainant, stated (V15) was pushing (R2) to the appointment and her broken leg was dragging the ground, and she was crying in pain. It took 5 of us to pull her up. They are very dissatisfied with the facility.On 10/24/2025 at 2:00PM V2 stated, (V15) would have assumed responsibility if he was going to the appointment with (R2). The mat on the foot pedal was probably coming off because (V15) had backed her wheelchair up. He probably needs more education. On 10/23/2025 at 3:30PM V1 stated, The Doctor's office wanted to get (R2) an Xray at the local hospital and we offered to do the Xray here. I knew (R2) would be a difficult transfer so I thought it would be easier to do here. We outsource our transportation right now. We do not have our own van.Facility policy states, It is the policy of this facility to safely transport residents to/from necessary appointments when needed. If the interdisciplinary team (IDT) determines a resident requires assistance, then arrangements must be made to send an appropriate escort to meet that particular need. Examples of residents requiring assistance are residents who need assistance with AOL's, have impaired decision making, are elopement risk or otherwise deemed unsafe to be out alone.

Based on observation, interview, and record review the facility failed to monitor and document pressure ulcer development for 1 (R2) of 3 residents reviewed for pressure ulcers in the sample of 7.Findings include:R2's face sheet documents an admission date of 9/11/2025. Diagnosis include Encounter for other Orthopedic Aftercare, Infection Following a Procedure, Superficial Incisional Surgical Site, Fracture of Lower End of Right Femur, Dementia, Morbid Obesity. R2's Minimum Data Set, MDS, dated [DATE] documents R2 is moderately cognitively impaired. R2 is dependent for transfers and mobility. R2's care plan dated 10/23/2025 documents R2 currently has an alteration to R2's Integumentary System due to Surgical Incision Right Leg. Non-Blanchable area to right/left buttocks and coccyx. Blister to Left Buttock. On 9/25/25: R2 has a stage 1 to her buttocks/coccyx. Educate R2, Power of Attorney, POA or caregiver as to causes of skin break down, skin tear, or pressure ulcer: transfer/positioning or during ambulating. Encourage resident to do what she /he can do for self. Place nonslip pad in her wheelchair to prevent R2 from sliding down in her wheelchair.On 10/23/2025 at 9:55AM V4, Licensed Practical Nurse, LPN, V5, LPN and V6, Certified Nursing Assistant, CNA, assisted R2 back to bed via mechanical lift. Coccyx/lower buttocks area dressing changed. Coccyx/lower buttocks area has 2 open wounds. One on right side quarter size and one on left side dime size. V4 changed dressing according to orders. R2's Electronic Health Record had no documentation of wound measurements or wound monitoring. R2's Skilled Nursing assessment dated [DATE], Section G Skin/Wound, documents no new changes in skin integrity. Type of wound present - surgical. Other skin issues - none. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - skin shear on buttocks. Notable changes to wound present - skin shear on buttocks.R2's Braden Scale for Predicting Pressure Sore Risk dated 9/13/2025 documents R2 is at risk for pressure sore development. R2's order sheet dated 9/25/2025 documents Cleanse open area to left upper buttocks with normal saline. Apply foam bordered dressing. Change daily and as needed every evening shift for skin management.R2's order sheet dated 10/23/2025 at 4:56PM Cleanse open area to buttocks with NS. apply skin prep. Apply barrier protectant cream. Apply foam bordered dressing. Change daily & PRN.R2's order sheet dated 10/23/2025 at 4:23PM Cleanse open area to left upper buttocks with NS. Apply barrier protectant cream. Apply foam bordered dressing. Change daily and as needed.R2's shower sheets dated 9/29/2025 documents 2 spots with arrow pointing to lower buttocks. and blister burst when peri care was given. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents shear and red 8.3, 8.0, blister 0.1 x 0.4, R 4.0 x 3.0.R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented.R2's shower sheets dated 10/2/2025 documents red with arrow pointing to coccyx area. R2's Skilled Nursing assessment dated [DATE] Section G Skin/Wound type of wound present - surgical. Other skin issues - none documented. On 10/23/2025 at 10:20AM V11, Physician, stated, When I visit, I usually see most of the residents out of their bed and in the dining room area. I saw (R2) about two weeks ago and she had a Stage-1 sore on her coccyx that was just red at the time. (R2) always wanted to stay in bed most of the day, so I put in orders, after seeing her wound, for her to get out of bed to wheelchair for all meals and then out of bed for two hours between meals. I was off last week, and I have not seen her wound since then. If her wound has gotten worse than a stage-1 wound, then no one notified me about it. On 10/23/2025 at 3:16PM and 3:30PM Surveyor asked V1 for wound notes and measurements for R2's wounds. Surveyor asked V1 on 10/24/2025 at 8:20AM for R2's wound notes and measurements. V1 stated, The areas on R2's bottom are shearing from her sliding down. We have new orders now and I will send the measurements. On 10/24/2025 at 10:00AM V4, LPN, stated R2 has 2 areas but they aren't really pressure they are kind of connected and are from friction. I measured the area yesterday, but I don't think we had been measuring. On 10/24/2025 at 11:55AM V2, Director of Nursing, DON, stated I saw R2's wounds yesterday. The area that is quarter size did not appear open. It could be called a stage 2. I would expect a wound to be measured, and the resident referred to the wound company that comes in. From what I understand of R2's wound situation is that R2 was referred to the wound company when admitted . The wound company found R2 did not need services at that time. The facility did treatments here. Going forward our nurse manager V18 is going to do measurements and treatments. Facility policy updated 5/2/2022 states, To identify factors that place the residents at risk for the development of pressure ulcers. To implement appropriate interventions to prevent the development of clinically avoidable wounds. To promote a systematic approach and monitoring process for the care of residents with existing wounds and for those who are at risk for skin breakdown. To promote healing of existing pressure ulcers.

Based on interview and record review, the Facility failed to assess, monitor, and provide treatments as ordered and notify a provider of maggots for 2 of 3 residents (R1, R2) reviewed for quality of care in the sample of 3. This failure resulted in maggots in R1's foot wound. that R1 described as giving her the heeby jeebies. Using a reasonable person concept, maggots in a wound would cause a person to feel shame, embarrassment, anxiety, and uncleanliness for this profound, disturbing experience of parasites in a wound.1-R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including paraplegia, acquired absence of right leg above the knee, and pressure ulcer of left heel.R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, ambulated via wheelchair, and had three stage 3 pressure ulcers that were present on admission.R1's Care Plan initiated 6/30/24 documents R1 has a wound.R1's Specialized Wound Management Note dated 7/14/25 documents R1 has left dorsal foot pressure ulcer (no stage listed) measuring 3.0 cm (centimeters) x 5.5 cm x 0.3 cm.R1's Progress Note by V5, Licensed Practical Nurse (LPN) on 7/19/25 at 2:05 AM documents, this nurse was completing wound dressing change, when maggots were noticed. maggots removed with normal saline and hydrogen peroxide was applied to wounds. wound were dried and wound dressings applied. (V6), PA (Physician Assistant) was notified and NNO (no new orders) were received.On 8/29/25 at 2:15 PM and 9/3/25 at 11:55 AM, V5 was unavailable by phone.On 8/29/25 at 2:05 PM, V6 was unavailable by phone.On 9/3/25 at 10:55 AM, R1 stated, I've had maggots in my wounds twice here. That (V5) didn't know how to do a dressing (correctly). I told her to cover up my toes good, but she didn't, and that's what happened. They were all over my foot and moving around. I told her to get them out of there. It gave me the heeby jeebies. R1 stated V5 removed the maggots, but did not send her to the hospital. On 9/3/25 at 9:35 AM, V7, Wound Nurse Practitioner (NP), stated she was not aware of R1 having maggots in her wound and would have expected the Facility to notify her, if that were the case. She stated R1 goes out to smoke frequently, and dressing changes can prevent maggots. The general procedure is to remove the maggots and send the resident to the hospital.2-R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including quadriplegia, contracture of upper arm muscle, and acquired absence of right and left legs above the knee.R2's MDS dated [DATE] documented R2 was cognitively intact, ambulated by wheelchair, and had one stage two pressure ulcer and one stage three pressure ulcer that were present on admission.R2's Care Plan initiated 6/3/25 documents R2 was admitted with pressure ulcers. The interventions included treatments as ordered by physician.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 2 left buttock pressure ulcer measuring 2.0 cm x 2.0 cm wide x 0.2 cm deep.R2's Physician Order dated 6/17/25 documents cleanse left buttock with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate, and cover with bordered foam dressing every day shift. R2's Treatment Administration Record (TAR) does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, or 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 left posterior thigh pressure ulcer measuring 12.0 cm x 12.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse left posterior thigh with normal saline or wound cleanser, apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-6/26/25, 8/1/25, 8/2/25, 8/6/25.R2's Wound Assessment Report dated 8/25/25 documents R2 has a stage 3 right posterior thigh pressure ulcer measuring 12.0 cm x 15.0 cm x 0.3 cm.R2's Physician Order dated 6/17/25 documents cleanse right posterior thigh with normal saline or wound cleanser apply Dakin's Solution 0.5%, then Hydrocortisone cream, then collagen, then calcium alginate. Cover with bordered foam dressing every day shift. R2's TAR does not document this treatment was completed on 6/26/25, 6/27/25, 7/2/25, 7/23/25-7/26/25, 8/1/25, 8/2/25, 8/6/25.On 9/3/25 at 9:46 AM, V2, Director of Nursing (DON), stated wound treatments should be given as ordered and documented in the TAR, when given. The Facility's Wound Care Policy and Procedure revised 11/9/19 documents, Document treatment.

Based on observation, interview and record review, the facility failed to order a abdominal ultrasound, urinalysis/culture and sensitivity in a timely manner for 1 (R4) of 3 residents reviewed for timeliness of care in the sample of 3. This failure resulted in a nonverbal resident (R4) being transferred to the emergency room and diagnosed with a impacted stool in the intestine that was digitally removed from her rectum, enema, IV hydration and intramuscular shot for the urinary tract infection and put on oral antibiotics. Using the reasonable person approach, this failure caused pain, discomfort and invasive interventions during a hospital visit. Findings include: R4's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnoses including cerebral palsy, constipation and GERD.R4's Care Plan, dated 3/31/2025 documents focus bowel and bladder incontinence. Interventions: record bowel movements, frequency, and consistency. Assess any signs of discomfort, burning or itching around anus, loss of appetite, etc. No documentation of R4's diagnosis of constipation was addressed/documented on her care plan. Another focus: R4 has a communication problem, she is nonverbal. Goal: R4 will feel heard and understood, as reflected in her body language and facial expressions. Interventions: encourage resident to continue stating thoughts even if resident is having difficulty. Focus on a word or phrase that makes sense or respond to the feeling resident is trying to express. Monitor/document for physical/nonverbal indicators of discomfort or distress and follow-up as needed. R4's Annual Minimum Data Set, dated [DATE] documents she is severely cognitively impaired, no constipation present, both sides functional impairment in range of motion, wheelchair for mobility device, doesn't ambulate, dependent on staff for toileting, incontinent of bowel and bladder. R4's Physician's Order Sheet (POS), dated 12/2/2021 MiraLAX 17 grams by mouth every day for constipation. 12/2/2021 Senokot S 8.6 milligrams/50 mg two times a day for constipation and 1/27/2025 Bisacodyl 1 suppository rectally at bedtime every other night for constipation. R4's Medication Administration Record (MAR) dated 8/2025 staff documented physician prescribed medications to treat constipation were administered as ordered. R4's POS, dated 8/4/2025, documents a urinalysis and reflex culture (no reason for order) and an ultrasound abdomen and pelvis indication: mass in lower left quadrant.R4's Bowel and Bladder document, dated 8/3/2025 through 8/14/2025 staff documented R4 had a small bowel movement on 8/3/2025, large bowel movement on 8/9/2025 and 8/11/2025 and a small bowel movement on 8/12/2025. R4's Nursing Progress dated 8/4/2025 through 8/7/2025 no documentation as to why a urinalysis and reflex culture was ordered and no documentation if either test was collected/completed. R4's Nursing Progress Note, dated 8/7/2025 at 1:33 AM, documents attempted to get urine per sterile technique without success. No documentation if the ultrasound abdomen and pelvis was completed. R4's Physician's Progress Note, dated 8/8/2025 at 7:00 AM documents urinalysis and reflex culture sent. R4's Medical Record dated 8/8/2025 through 8/11/2025 showed no urinalysis and reflex culture, or ultrasound abdomen and pelvis results were not uploaded in R4's Medical Record. R4's Physician's Progress Note, dated 8/11/2025 at 7:00 AM, documents the patient is a poor historian due to cerebral palsy and aphasia. The patient history is taken from her family and nursing staff. The patient has been restless and agitation for the past week. There was possible grimacing and complaint of pain witness by her family. Anxiety versus GI/GU (genitourinary/gastrointestinal) symptoms, continuing to await US (ultrasound) and UA (urinalysis)/UC (urine culture.) R4's Medical Record was reviewed for the UA/UC and abdominal/pelvic ultrasound on 8/12/2025 at 12:00 PM. The results were not uploaded in R4's electronic medical record at that time. On 8/12/2025 at 12:10 PM V1, Administrator and V2, Interim Director of Nursing stated he noted a day or so ago that R4's UA/UC was not collected yet and the abdominal/pelvic ultrasound was not completed yet and he had been on the phone with the ultrasound company all morning trying to figure out why it wasn't done yet. V2 stated the ultrasound company informed him that the physician's order verbiage was not correct, and it needed the word limited to be added to it so the ultrasound would be covered by insurance. V2 stated he didn't know why the physician ordered a UA/UC other than to rule out a UTI and the ultrasound abdomen/pelvis was ordered because R4's physician felt a mass in her abdomen. V2 wasn't aware the laboratory and ultrasound tests were not completed until the surveyor requested the test results, that's when he started making calls to see why the tests were not completed. V1 stated when a physician orders a lab test and/or an ultrasound she expects the UA to be collected and sent off to the lab the next day and if it was attempted to be collected and unsuccessful, the nurse should report that to the oncoming nurse and that nurse should attempt to collect the specimen. If there are any issues getting a specimen i.e. urine collected and/or issues with getting an ultrasound completed nurses should notify the resident's physician within 24 hours and update them on why the tests were not done. V1 stated it was a breakdown of communication between nurses as to why these tests were not completed in a timely manner. R4's Nursing Progress Note, dated 8/12/2025 at 2:16 PM staff documented company here to do abd (abdominal) x ray for a mass to left quad. At 2:50 PM, staff documented, attempted to obtain UA sample via straight cath per sterile technique. Attempt was unsuccessful. Evening shift nurse notified that sample is needing to be collected, verbally understood. At 9:21 PM, staff documented x ray results received and faxed to MD (physician.) At 9:34 PM staff documented, urine obtained & in fridge in med room. Lab req filled out & faxed to lab. Lab to p/u (pick up) urine in the AM (morning.)R4's Laboratory Report, dated 8/12/2025 documents urine specimen collected on 8/12/2025. UA results: pending. UC results: Escherichila Coli (E-Coli.) R4's Ultrasound Patient Report, dated 8/14/2025 documents pelvis ultrasound findings: images of the bladder are unremarkable. Left lower quadrant images are unremarkable as well. There is no evidence of mass, cyst or fluid collection. Impression: unremarkable examination. R4's Ultrasound Patient Report, dated 8/14/2025 documents abdomen ultrasound findings: trace amount of ascites is noted in the left lower abdomen/pelvis. Peristalsing bowel loops are noted in the left lower abdomen early in the exam, measuring up to 2.3 centimeters in diameter. No discrete mass is identified. Impression: slightly dilated peristalsing bowel loops in the lower left abdomen. Correlate for enteritis versus small bowel obstruction. R4's After Visit emergency room Summary, dated 8/15/2025 documents, reason for visit: abdominal pain. Diagnoses: impacted stool in intestine, UTI and constipation. Instructions: Evaluated in the emergency department today with primary concern of possible constipation. Your workup was concerning for UTI as well. Fecal disimpactation at bedside. Medications administered: Rocephin 1 gram injection (treatment of UTI), saline enema, sodium chloride 0.9% (intravenous fluid for hydration) and Iodamide. R4's POS, dated 8/15/2025, documents a new physician's order Cephalexin 500 mg twice a day for 7 days to treat UTI. On 8/19/2025 at 10:00 AM V1, Administrator and V2, DON stated R4 is a total care, she is incontinent of bowel and bladder and is dependent with all care and is nonverbal. V2 stated staff are expected to document when a resident has a bowel movement in the electronic medical record so they can ensure residents are not constipated. Staff documented R4 had a small bowel movement on 8/12/2025. R4 was transferred to the emergency room after R4's physician reviewed the abdominal ultrasound results on 8/15/2025 as she wanted to rule out a small bowel obstruction. The emergency room discharge paperwork documents she was impacted, and emergency room staff digitally removed the impaction at bedside. After an enema was administrated R4 had a large bowel movement, and she had another large bowel movement when she was readmitted to the facility. V2 stated R4 was also diagnosed a UTI and was administered an intramuscular shot of antibiotics in the emergency room and is continuing by mouth antibiotics at the facility to treat the UTI. V2 stated R4 didn't have a bowel obstruction and the constipation was resolved immediately after the enema was administered in the emergency room. On 8/19/2025 at 10:40 AM V19, R4's physician stated she ordered the abdominal ultrasound on 8/42025 due to feeling a mass in her abdomen but she was more concerned with her having a UTI at that time. R4 is nonverbal and therefore she can't voice pain but when she assessed her on 8/42025 V19 felt R4 was either in pain or experiencing anxiety so she ordered a UA/C&S and an abdominal ultrasound for the mass felt in her abdomen that day. V19 stated the tests were not done in a timely fashion and stated she comes to the facility on Mondays and Fridays and she expected to have both test results back that Friday, 8/8/2025 but she spoke to the floor nurses who were agency staff and they told her the tests were completed but the results weren't in R4's electronic medical record and the medical records employee was on vacation at that time so she had issues getting the test results. After the abdominal ultrasound was completed, she reviewed the results the next day and stated she sent R4 to the emergency room to rule out a small bowel obstruction and stated she reviewed the emergency room records and it was determined R4 had impacted stool near the rectum which was digitally removed at bedside in the emergency room and R4 received an enema in the emergency room where she had 2 large stools right after. V19 stated it was determined that R4 has a UTI and she received an intramuscular shot of antibiotics in the emergency room and she is on a by mouth antibiotic at the facility to treat that. V19 stated she expected the facility to follow the policies and procedures to ensure physician ordered tests are completed in a timely fashion. On 8/19/2025 at 3:00 PM, V2 stated the facility doesn't have a policy or procedure that documents when a lab or ultrasound timeframe should be done.

Based on interview and record review the facility failed to prevent resident-to-resident abuse for 1 of 3 residents (R7) reviewed for abuse in the sample of 11.Findings Include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8's Quarterly MDS, dated [DATE], documents R8 is severely cognitively impaired, wanders daily, has disorganized thinking, inattention, altered level of consciousness, physical and verbal behaviors towards others occurred 4-6 days, other behaviors not directed towards others occurred 4-6 days and rejects care 1-3 days.R8's Nursing Progress Note, dated 7/29/2025 at 9:42 PM documented, res noted in another res room. Res confused and disoriented. When res asked him to leave out of room, he grabbed her left arm and held on to it causing a skin tear. Res requested assistance from staff to have him assisted out of room. Res taken to room & placed in bed. All parties have been notified.On 8/12/2025 at 1:35 PM, R7 sat up in her wheelchair in her room and stated a few weeks ago at around 9:30 PM R8 was in her room, when she told R8 to get out of her room he walked up to her grabbed both her forearms, and he squeezed them to death, and it hurt bad. R7 stated she had a large bruise to her left forearm and a skin tear. R7 stated the skin tear bled down her arm. Resident pulled left sleeve up and noted steri- strips on her left forearm, no bruising noted. R7 stated it scared the h*** out of her, but she didn't cry. R7 stated when she sees R8 down her hall now, she has staff redirect him because she doesn't want to get hurt again. R7 stated she knows R8 has Alzheimer's disease but that she wishes staff would redirect him more often because he really scared her that day.On 8/19/2025 at 12:30 R8 was observed sitting in the dining room at the facility. R8 didn't respond to any of the IDPH surveyor's question, R8 just starred straight ahead. On 8/19/2025 at 1:00 PM V20, LPN stated R8 is not alert and has Alzheimer's disease. Staff try to keep an eye on R8 because he often goes in other residents' rooms and lays in empty beds. R7 reported to her one night that while attempting to redirect R8 out of her room, R8 grabbed R7's left forearm which caused a skin tear. On 8/12/2025 at 2:15 PM V1 Administrator, V8 Regional Administrator and V2 Interim DON stated they were not aware of any resident-to-resident altercations on 7/29/2025. V1 stated she would have expected staff to report what occurred so she can start an investigation as soon as possible and put an intervention in place to prevent it from occurring again. V8 stated he didn't view the incident as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. The Facility's Resident Right to Freedom of Abuse, Neglect and Exploitation policy, initiated 10/16/2023, documents the facility's residents have the right to be free from abuse, neglect, misappropriation of their property and exploitation as defined in this policy. The facility shall review altercations from resident to resident as a potential situation of abuse. Staff shall monitor for any behaviors that may provoke a reaction by residents or others, which include physically aggressive behavior, such as grabbing and verbally aggressive behavior such as intimidating.

Based on interview and record review the facility failed to investigate a resident-to-resident abuse for 1 (R7) of 3 residents reviewed for abuse in the sample of 11. Findings include: 1. R7's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including major depression disorder, anxiety disorder, chronic pain syndrome, paraplegia, anemia, heart failure, high blood pressure, osteoarthritis and neuropathy. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents BIMS 14 and no behaviors. R7's Nursing Progress Note, dated 7/29/2025 at 10:08 PM documented, res sustained skin tear to left forearm by another res holding her arm. Skin tear measures 0.4 centimeters (cm) x 0.3 cm. Area cleansed with NS (normal saline), steri strips applied. All parties notified. No documentation of a bruise on R7's left forearm. 2. R8's Undated Face Sheet, documents she was initially admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and mood disorder. R8's Quarterly MDS, dated [DATE], documents R8 is severely cognitively impaired, wanders daily, has disorganized thinking, inattention, altered level of consciousness, physical and verbal behaviors towards others occurred 4-6 days, other behaviors not directed towards others occurred 4-6 days and rejects care 1-3 days.R8's Nursing Progress Note, dated 7/29/2025 at 9:42 PM documented, res noted in another res room. Res confused and disoriented. When res asked him to leave out of room, he grabbed her left arm and held on to it causing a skin tear. Res requested assistance from staff to have him assisted out of room. Res taken to room & placed in bed. All parties have been notified.On 8/12/2025 at 1:35 PM, R7 sat up in her wheelchair in her room and stated a few weeks ago at around 9:30 PM R8 was in her room, when she told R8 to get out of her room he walked up to her grabbed both her forearms, and he squeezed them to death, and it hurt bad. R7 stated she had a large bruise to her left forearm and a skin tear. R7 stated the skin tear bled down her arm. Resident pulled left sleeve up and noted steri- strips on her left forearm, no bruising noted. R7 stated it scared the h*** out of her, but she didn't cry. R7 stated when she sees R8 down her hall now, she has staff redirect him because she doesn't want to get hurt again. R7 stated she knows R8 has Alzheimer's disease but that she wishes staff would redirect him more often because he really scared her that day.On 8/19/2025 at 12:30 R8 was observed sitting in the dining room at the facility. R8 didn't respond to any of the IDPH surveyor's question, R8 just starred straight ahead. On 8/19/2025 at 1:00 PM V20, LPN stated R8 is not alert and has Alzheimer's disease. Staff try to keep an eye on R8 because he often goes in other residents' rooms and lays in empty beds. R7 reported to her one night that while attempting to redirect R8 out of her room, R8 grabbed R7's left forearm which caused a skin tear. V20 stated she reported the incident to V8, Regional Administrator but that she didn't think it was a resident-to-resident altercation, V20 thought it was just a skin incident. V20 didn't ask R7 if she was scared of R8 and didn't note her left forearm was bruised. On 8/12/2025 at 2:15 PM V1 Administrator, V8 Regional Administrator and V2 Interim DON stated they were not aware of any resident-to-resident altercations on 7/29/2025. V1 stated she would have expected staff to report what occurred so she can start an investigation as soon as possible and put an intervention in place to prevent it from occurring again. V8 stated he didn't view the incident as a resident-to-resident altercation, he viewed it more as an incidental contact between R7 and R8. V1, V2 and V8 stated they started a resident to resident abuse investigation when it was brought to their attention on 8/12/2025. The Facility's Elder Justice Act and Reporting Suspected Crimes Against Residents Policy & Procedure, initiated 10/1/2023, documents it is the policy of the facility to empower and enable all owners, operators, employees, agents or contractors of the facility to make reports to the relevant authorities pursuant to the provision of the Elder Justice Act (EJA) and CMS regulations. Within five working days of the incident, the facility will provide in a follow-up investigation report. This report will contain information from the resident's record, summary of other documents obtained, sufficient information to describe the results of the investigation, and indicate any corrective actions taken, if the allegation was verified, who investigated the incident, and who is submitting the report.

Based on interview and record review the facility failed to perform safe mechanical lift transfer for 1 of 3 residents (R3) reviewed for accidents in the sample of 6. Findings include: R3's Care Plan, dated 6/13/2025, documents that the resident has potential for falls confusion, deconditioning, Gait/balance problems, incontinence, and poor communication/comprehension, unaware of safety needs. The Care Plan documented Resident had actual falls -6/11/25: Witnessed fall in room out of (full body lift), no injury -1/30/25: Unwitnessed fall in room, no injury. Intervention 6/16/2025 sling with straps for transfers. R3's Incident Report, dated 6/11/2025 at 7:44 PM, documents that Resident transferring per usual from chair to bed by 2 CNAs (Certified Nurse's Aides) using mechanical full lift. During transfer, CNA moved chair out from under resident to position to place in bed. During chair move, resident self-changed position resulting in her rolling through lift straps and onto floor lying on her right side. Resident assessed for injuries; none noted at this time. ROM (Range of Motion) WNL (Within Normal Limits) for resident; baseline contractures to all extremities. Resident shook her head no when assessing for pain. Neuro checks initiated; mental status and movements at baseline and WNL (with in normal limits) for resident. Resident assisted to bed. It also documents that R3 is oriented to person and place, incontinent with no predisposing environmental and situation factors. R3's Nursing Progress Note, dated 6/11/2025 at 10:23 PM, documents Resident transferring per usual from chair to bed by 2 CNAs using mechanical full lift. During transfer, CNA moved chair out from under resident to position to place in bed. During chair move, resident self-changed position resulting in her rolling through lift straps and onto floor lying on her right side. Resident assessed for injuries; none noted at this time. ROM WNL for resident; baseline contractures to all extremities. Resident shook her head no when assessing for pain. Neuro checks initiated; mental status and movements at baseline and WNL for resident. Resident assisted to bed. Resident assessed by nurse; neuro checks initiated. Admin (Administrator), DON (Director of Nursing), and POA (Power of Attorney) notified. MD (Medical Doctor) notified, requested Xray of right shoulder and right hip. POA requested monitoring and notify of any changes as he does not want her to be sent out at this time. Resident to have 3 staff present for all transfers; PT (Physical Therapy) to assess for positioning with transfers. R3's Progress Notes, dated 6/11/2025 at 11:12 PM, documents Orders -Administration Note. Note Text: Tylenol Tablet 325MG (milligrams) Give 2 tablet by mouth every 6 hours as needed for pain. On 7/2/2025 at 10:00 AM requested transfer and sling assessment. As of 7/8/2025 at 3:00 PM the facility did not provide any assessments. On 6/30/2025 at 9:10 AM V13, R3's Brother, stated that he is R3's guardian. V13 stated that he has concerns about his sister's care at the facility. V13 stated that R3 flipped out of the chair. V13 stated that his sister has been at the facility for 30 to 40 years. V13 stated that he has put a camera in the room because he can't trust the care being given to his sister. V13 stated that on June 11th his sister fell out of the fully body mechanical lift hitting her head on the floor. V13 stated that he has the fall on video. V13 stated that his sister was slouched and side laying in the wheelchair. V13 stated that they lifted R3 out of the chair that way. V13 stated that they didn't bother to fix her before lifting her out of the chair. V13 stated that when they lifted R3 she fell out of the sling. V13 stated that you can hear the staff yell and R3 yell. V13 stated that R3 does not verbalize yes or no. V13 stated that R3 moans, groans, grunts and moves about. On 6/30/2025 at 10:00 AM V13 provided a video to view. V13 verified that the person in the video was R3. The video dated 6/11/2025 at 7:31 PM. During video at 7:35 PM R3 is transported in room by wheelchair by V4, Certified Nurse's Aide (CNA). R3 was observed lying on right side in wheelchair. At 7:36 PM V6, CNA, pushes the full body lift into the room. V6 and V4 assisted with the transfer. V4 placed the wheelchair sideways, with R3's right side facing the lift. V4 and V6 attached the sling hooks to the lift. R3 remained on her right side while in the sling. R3 was not in the center of sling. V6, standing behind the lift and operating the controls, lifts R3 in the air. R3 remained in right side lying position. V4 then removes the wheelchair from beneath R3 allowing R3 to hang in sling without support. V4 then moves the wheelchair away from R3. V4 was not in reach of R3. V6 then pulled the lift back causing the sling to jerk forward and back. R3 then falls face forward out the sling. R3 was heard letting out a yell. R3 feet remained in sling. Then feet fell to floor. On 6/30/2025 at 1:31 PM V4 stated that she was present during the fall with R3 on 6/11/2025. V4 stated that she noticed that R3 was leaning and lying back in chair. V4 stated that R3 was moving in wheelchair and groaning and grunting. V4 stated that this (grunting and groaning) means that R3 is in pain. V4 stated that R3 was uncomfortable and need to lie down. V4 stated that she and V6 assisted R3 with the transfer using the (full body lift). V4 stated that they applied the sling and lifted R3 into the air. V4 stated that once in the air she removed the chair from beneath R3. V4 stated that she did not have a hold of R3 at that time. V4 stated that she was maneuvering the chair and did not see the fall initially. V4 stated that she heard V6 yell and looked up and saw R3 hanging from the lift. V4 stated that she then went to help and R3's body fell to the floor. V4 stated that R3 did hit her head on the legs of the lift. V4 stated that R3 was grimacing, moaning, grunting, and grinding her teeth on the floor. V4 stated that R3 looked in pain. V4 stated that she went and got the nurse, and the nurse took over from there. V4 stated that R3 came out the side hole of the sling. V4 stated that she did not reposition R3 in the chair or sling because she thought R3 was positioned appropriately. V4 stated that she felt the sling was appropriate size. V4 stated that the sling that was used was the one that R3 had under her, not sure of size. V4 stated that she is not sure what determines the size of the lift sling. On 6/30/2025 at 12:15 PM R4 stated that she was in the room when R3 fell. R4 stated that R3 was slouched down in the chair. R4 stated that the girls attached R3 to the lift. R4 stated that V4 moved the wheelchair back over by R4's bed. R4 stated that V4 was away from R3 and not touching her. R4 stated that she was watching V4 with the wheelchair and then heard a yell and turned. R4 stated then R3 was hanging out the lift with head on legs of lift. R4 stated that the CNAs yelled and V4 was trying to get to R3 and then R3 body fell from lift. On 6/30/2025 at 2:22 PM V6 stated that she and V4 assisted with R3's transfer on 6/11/2025. V6 stated that she was at the controls and V4 had R3. V6 stated that she and V4 applied the straps. V6 stated that R3 was on her back sitting up right in the lift. V6 stated that she lifted R3 out of the chair. V6 stated that V4 removed the chair from under R3. V6 stated that R3 flipped out the side of the sling, face first, hitting head on the legs of the lift. V6 stated that R3 let out a yell. V6 stated that initially R3's legs were still in the sling and then they came out and her body fell to the floor. V6 stated that she felt R3 was in the right sling and positioned correctly. V6 stated that she assumed V4 had a hold of R3 but not sure if she did. On 6/30/2025 at 3:16 PM V12, Registered Nurse, RN, stated that she was the nurse on duty at the time of R3's fall on 6/11/2025. V12 stated that when she entered the room R3 was on the floor. V12 stated that she assessed R3. V12 stated that she did not see any bruising or swelling at that time. V12 stated that R3 was in pain on the floor as she should after hitting her head on the legs of the lift from the air. V12 stated that she notified V1, Administrator and V2, Director of Nursing. V12 stated that she also notified the physician, and a zoom call was performed, and it was determined that R3 didn't require hospitalization at that time. V12 stated that she notified V13 as well and notified him of the fall. V12 stated that V13 did not want R3 to go to the emergency room. V12 stated that they monitored R3 and performed neuro checks. V12 stated that she was informed that while in the lift R3 made a jerking movement and fell out of the sling onto the floor hitting her head and body on the legs of the lift and floor. On 7/2/2025 at 9:20 AM V14, CNA/Shower Aide, stated that she is familiar with R3 and have positioned her. V14 stated that R3 does make jerking movements in her chair and in the lift. V14 stated that you must always have a hold of her during the transfer because she can fall out. V14 stated that at times you need 3 people to help with the transfer. V14 stated that R3 requires the lift sling that crosses between the legs. V14 stated that this is the appropriate lift for her. V14 stated that the brother doesn't like the sling. V14 stated that she uses the sling anyway because it's the safest for her. V14 stated that the resident needs to be sitting up right as much as possible while in the lift. V14 stated that if the resident is not then they are lowered in the chair, repositioned, and then transferred. V14 stated that the slings are determined by size and weight. On 7/2/2025 at 9:33 AM V16, CNA, stated that she has transferred R3 multiple times. V16 stated that R3 makes these movements. V16 stated that R3 will be stretched out then she will randomly draw her feet up in a jerking movement. V16 stated that R3 will be in the fetal position and then will stretch out. V16 stated that none of these movements are slow. V16 stated that it is scary at times lifting R3. V16 stated that when R3 is moving in the bed or in the chair, V16 stated that she gets a 3rd and sometimes 4th person. V16 stated that its safer because she will have these movements, and it will cause the sling to move, and I am afraid of her falling out of the sling. On 7/2/2025 at 10:00 AM V1, Administrator, stated that the conclusion of the fall from what was told to him is that R3 was agitated in the wheelchair and during the transfer. V1 stated that the staff lifted the R3 in the air, using the lift. R3 move in the lift and R3 fell to the floor, hitting her head on the legs of the lift. V1 stated that he and V2, Director of Nursing, were notified and performed a zoom call while R3 was on the floor and had the staff describe what happened. V1 stated that he did not ask if the staff was in contact with the resident during the transfer. He assumes that they were. On 7/2/2025 at 10:15 AM V3, Assistant Director of Nursing (ADON (Assistant Director of Nursing)) stated that R3 is challenging at times in the lift. V3 stated that R3 makes jerking movements and moves in the lift. V3 stated that R3 makes these movements in her chair as well as causing her to slide down in her chair. V3 stated that when R3 is like this it is challenging to transfer R3. V3 stated that the transfer is scary because R3 could fall out of the chair. V3 stated that when R3 is like that they will use a 3rd person. V3 stated that she has transferred R3 and due to her movements, she had to be repositioned in the chair and in the sling prior to transfer. V3 stated that this is to assure R3's safety. V3 stated that is R3 was in a lying position he would expect the staff to reposition R3 in her wheelchair prior to attaching the lift. V3 stated that once in the air of R3 was not positioned appropriate in the sling she would expect the staff to reposition R3. V3 stated that if that was not possible, she would expect the staff to get a 3rd person to assist in the transfer. V3 stated that the staff are aware of these movements with R3 and that they can always add people with the lift and always maintain contact with the resident during the transfer. On 7/8/2025 at 11:50 AM V19, Therapy Director, stated that R3 was seen after fall. V19 stated that an evaluation was completed, and they work on transfer safety. V19 stated that the staff were in serviced. V19 stated that R3 is to have 3 staff for transfers. The (Brand name of mechanical lift) PATIENT SLING REFERENCE GUIDE, not dated, documents Patient Sling Guide It is very important to use the correct sized sling and make sure it is fitted properly prior to lifting. This ensures the safety of both the person being lifted and the caregiver. The goal of this guide is to assist those responsible for selecting the correct sling on a patient by patient basis and outlines a few factors that need to be addressed in the selection of the appropriate type of sling for a patient. (Brand name of mechanical lift company) wishes to ensure that the task of moving patients is done in an effective and safe manner. Size & Weight Range Guide (approximately). Please note the following sling guide is a recommendation only. A full risk assessment must be done prior to any sling being selected. This will ensure safety for the patient and caregiver. Small (S) 75- 150. 59 - 64. (The Brand name of mechanical lift company) Owner's Manual, not dated, documents that Transfer From Wheelchair - Grasp the sling at each corner of the U shape of the commode aperture. - The sling should be fitted with the handle on the back section facing outward. - Help the user lean forward slightly, then slide the sling down between the chair and the user's back. - Position the commode aperture where the buttocks meets the seat. - Position the sling equally around both sides of the body. - Draw the leg sections to the front along the length of the user's thigh. - Check the sling's central positioning by comparing the lengths of the leg sections when they are drawn forward. - Reposition the sling if the leg sections are not equal in length. - Feed the leg sections under the thighs. o From between the legs, gently pull the leg section up the inner thigh. - Feed as much material as possible under and between the thighs. - Ensure the leg sections are positioned midway under the thighs to provide good support and greater comfort. - Move the lift slowly towards the user and position the spreader bar over the user's chest. - Attach Loop a of sling to Hook A on Spreader Bar; attach Loop b to Hook B; attach Loop c to Hook C; attach Loop d to Hook D. - Lift patient above the wheelchair by using the hand control. - Pull lift away from wheelchair. Position patient over bed and lower patient onto it. SAFETY INSTRUCTIONS: Please pay careful attention to the following important information regarding the care, maintenance, and operation of the (Brand name of full body mechanical lift). Carefully read these instructions before assembling the lifter or attempting to lift any user with the device. PLEASE NOTE THE FOLLOWING: - Special care must be taken with users/patients who cannot themselves provide assistance while being lifted. (i.e. patients who are comatose, spastic, agitated, or otherwise severely handicapped.) - While being lifted in a sling, always keep the user/patient centered over the base and facing the caregiver operating the lifter.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices, including not wearing a beard net to protect hair from getting into the food, and not covering food items during transportation. This failure has the potential to affect all 38 residents in the facility. Findings include: On 6/12/25 at 8:10 AM, V4, Cook, was seen working in the kitchen, preparing residents breakfast meal with no beard net on while having a full beard and mustache. On 6/12/25 at 9:25 AM, V5, Cook, was seen in the kitchen with a hat on, has a full beard with no beard net on. After V5 was interviewed, he went and got a hairnet and a beard net and put them on. On 6/12/25 at 9:30 AM, R5 stated she mainly eats in the dining room, the food always has a lid on the plate only, but in her room, there is no lid on her drinks or side dishes. R5 stated she does not see the male cooks wearing anything over their beards. On 6/12/25 at 9:35 AM, R2 stated he eats both in his room and in dining room and the main plate of food has a lid on it when delivered to his room, but nothing else is covered. R2 stated he doesn't remember seeing anyone with a beard net or something covering their beard. On 6/12/25 at 10:10 AM, R3 stated that he eats in his room for dinners and in the dining room for breakfast and lunch. R3 stated that the food delivered to his room is always covered, but not the side dishes or drinks. R3 stated that he does occasionally see the men in the kitchen with beards wear a beard net and usually a hat, but he estimates only about 60% of the time. R3 stated he was an inspector for the United States Department of Agriculture (USDA), and he is well aware of what kitchen requirements are and the expectations of the kitchen staff and he watches for things like that, and this facility needs some improvements. On 6/12/25 at 10:35 AM, R1 stated he is the President of the Resident Council. R1 stated whether he eats in his room or the dining room, the main food always come covered, but the side dishes and drinks are not. R1 stated the kitchen staff don't wear hairnets at all unless the State walks in. R1 stated the guys with the beards (V4, V5) never wear a beard net like they are supposed to. On 6/12/25 at 11:20 AM, V6, Certified Nursing Assistant (CNA)/Shower Aide, stated that she sees the kitchen staff wear hair nets, but not beard nets. V6 stated only the main plate of food has a lid on it, the sides and drinks never do. On 6/12/25 at 11:22 AM, V7, CNA, stated she has not seen the guys in the kitchen with beards wear a beard net. V7 stated the plates delivered to resident rooms are always covered, but the side dishes and cups are not covered. On 6/12/25 at 11:30 AM, lunch trays were being delivered to those residents eating in their rooms. A small two shelf cart that is open to air, has resident meal trays on it, with the main plate of food having a hard cover, while the side dishes and drinks were uncovered. On 6/12/25 at 12:00 PM, R4 was seen in his room after his lunch tray delivered. There was no lid seen on his bowl of corn or any drink. There was a lid covering the main plate only. R4 stated he always eats in his room and there is never a cover over the side dishes or his drinks. On 6/12/25 at 12:05 PM, R1 received his lunch tray in his room with a lid over his main plate only. There was no cover on his bowl of corn or drinks. R1 stated there is never a lid on his side dishes or his drinks. On 6/12/25 at 12:15 PM, V9, CNA, stated they deliver the meal trays to those eating in their rooms on a small cart. V9 stated that only the plate is covered and that the drinks and side dishes are never covered. On 6/12/25 at 12:20 PM, V10, R5's Daughter, stated she visits R5 several times a week and R5 usually eats in the dining room, but sometimes will eat in her room. V10 stated the main plate of food is usually covered but the side dishes and drinks are never covered. V10 stated she does see the kitchen staff with a hairnet on, just not sure of the beard nets. On 6/12/25 at 1:30 PM, V1, Administrator, stated I know we have some kitchen problems, and we are hiring and trying to fix the problems. When advised of food being delivered and transported across the building with no lids or covers, V1 stated I will have them ordered and will take care of it. When advised of the kitchen staff not wearing beard nets, V1 stated I know we ordered them, and they have them in there. I will make sure that they always have one going forward. I would expect the kitchen staff to maintain proper sanitation and food handling practices at all times. The Facility's Transportation of Food Policy, dated 11/5/19, documents Food being transported from the kitchen to other parts of the building must be done in a safe and sanitary manner. 1. All food must be covered during transportation. The Facility's Dress Code Policy, dated 11/5/19, documents Staff members will dress appropriately, according to their job description. 4. Hair restrains to be worn in the kitchen. 5. [NAME] Guards if facial hair is present. The Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 6/12/2025, documents that the facility has 38 residents living in the facility.

Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This IJ began on 3/30/2025 when R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. R2 described a decrease in her quality of life, along with expressions of feeling forgotten and wanting to die. Additionally, R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body. This failure resulted in Immediate Jeopardy on 3/30/2024 when R2 was transferred to the emergency room for pain treatment due to not receiving scheduled pain management and experiencing ongoing excruciating pain. R1 experiencing ongoing unrelieved pain. On 5/19/2025 at 8:51 AM V1, Administrator was notified of the Immediate Jeopardy. The surveyor confirmed by interview and record review, the Immediate Jeopardy was removed on 5/20/2025, after abatement reviews dated 5/19/2025 at 11:43 AM, 2:17 PM, 3:56 PM, 4:09 PM, 5/20 11/59 AM, 12:07 PM but remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-servicing training. Findings include: R1's Admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome as diagnosis. R1's Care Plan dated, 1/28/2025, documents that the resident has pain. Interventions include Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R1's Minimum Data Set, (MDS), dated [DATE], documents that R1 is cognitively intact, dependent on staff for ADLs (activity of daily living). It also documents that R1 experience pain almost constantly that frequently interferes with day-to-day activities. It also documents that R1 receives pain medication routinely and as needed and has experienced pain at level of 7. R1's Progress Note, dated 4/9/2025 to 4/24/2025, documents that Orders -Administration Note, Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain not in stock. R1's Controlled Substances Proof of Use, dated 3/25/2025, documents last dose of Xtampza ER 18mg was administered 4/8/2025 at 4 PM. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents the first dose of Xtampza ER 18mg administered 4/26/2025 at 10 AM. R1's Progress Note, dated 4/21/2025, 4/22/2025, documents that Orders -Administration Note, Note Text: oxycodone HCl Oral Tablet 15 MG Give 15 mg by mouth six times a day for pain give 15mg PO q 4 hours routine for pain med out of stock(OOS). R1's Controlled Substances Proof of Use, dispense date 4/22/2025, documents that the first dose of Oxycodone HCL 15mg tab was administered on 4/23/2025 at 12 AM. R1's Progress Note, dated 4/28/2025 at 7:27 PM, documents that Orders -Administration Note, Note Text: Lyrica Oral Capsule 100 MG Give 100 mg by mouth every 12 hours for pain take 100 mg PO q12 hours med out of stock. R1's Medication Administration Record, dated April 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank 4/1 at 4 PM, 4/8 at 12 PM, 4/18 at 8AM, 12PM, and 4 PM. 4/19 at 12 PM and 4 PM, 4/20 at 8AM, 12 PM and 4 PM. R1's Progress Note, dated 5/6/2025, 5/8/2025, 5/9/2025 documents that Orders -Administration Note Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain OOS. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents that the last dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/5/2025 at 4PM. R1's Controlled Substances Proof of Use, dispense date 5/6/2025, documents that the first dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/7/2025 at 4AM and last dose administered 5/7/2025 at 4 PM. R1's Medication Administration Record, dated May 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank on 5/3 and 5/4 at 8AM, and 12PM. On 5/13/2025 at 11:50 AM R1 stated that when he doesn't have his pain medication his pain is ongoing, uncontrolled, and severe. R1 stated that his pain, is rated 9 on pain scale (1 to 10) to left side of his body. R1 stated that the pain gets so high that when he finally gets his medication it takes a while for the pain to lower. R1 stated that they don't do anything different for him he just waits till the medication comes in. R1 stated that he goes out of the facility but that can be difficult because of the pain. 2. R2's Admission Record, print date 4/14/2025, documents that R2 was admitted [DATE]. It lists R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy as diagnosis. R2's Care Plan, dated 4/10/2024, documents (R2) has potential impairment to skin integrity. It also documents Administer Morphine and Hydrocodone as per orders. R2's MDS, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 experience pain almost constantly that rates a 10 (1-10) on pain scale and receives routine and as needed pain medication. R2's Progress Note, dated 3/27/2025 and 3/28/2025, documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain HOLD IF PATIENT IS NODDING OR SHOWING S/S of BEING OVER-MEDICATED med out of stock, insurance issue, pharmacy notified. R2's Progress Note, dated 3/29/2025, documents that new order for liquid morphine given. Morphine Sulfate ER Oral Tablet Extended Release 60 MG discontinued. Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 4 hours for pain med out of stock, pharmacy notified. R2's Progress Note, dated 3/30/2025 at 3:15 AM, documents that Health Status, Note Note Text: Resident c/o uncontrollable pain requesting to be sent to ER (emergency room ). Call placed to 911 at this time. 0330 Resident leaving facility with (local) Ambulance service at this time. Report giving to (local hospital). At 1:07 PM Health Status Note Note Text: Resident returned to facility via ambulance at 11:15am after being sent out r/t back pain. Hospital treated pain with medications this morning. No new dx or medication orders at this time. Resident is currently in her room sitting up. R2's Progress Note, dated 4/7/202508:50 Orders -Administration Note, Note Text: Gabapentin Oral Tablet 800MG Give 1 tablet by mouth four times a day for neuropathy MEDICATION CURRENTLY UNAVAILABLE R2's progress Note, dated 4/12/2025 12:25 PM, documents that Health Status Note, Note Text: Resident was able to find local pharmacy that had previous Morphine script in stock wanted to know if it would be possible to change Morphine script back to Morphine 60mg: 1 tablet by mouth every 12 hours for pain scheduled at 8AM & 8PM. Spoke with (V19's) office asked if she could notify the provider of this and asked if they did approve change if they could send over Morphine ER 60mg to (local pharmacy). (V19's) Morphine 60mg 1 tab every 12 hours was approved and sent to (Local pharmacy) Will update prescription changes in EMR (electronic medical record). R2's Progress Note, dated 5/11/2025, 5/12/2025, 5/13/2025, and 5/14/2025 documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain med unavailable. R2's Resident Controlled Substance Record, not dated, documents the last dose of Morphine ER 60mg was administered 5/11/2025 at 8AM. R2's MAR, dated April 2025, documents blank for Baclofen 10mg on 4/1, 4/14, 4/18, 4/19, 4/20 Baclofen 20mg 4/6 at 6AM, 4/19 at 2Pm and 8 PM, 4/20 at 6AM and 8 pm. Gabapentin 800mg 4/1 at 4pm and 8 pm, 4/14 at 4 8 pm 4/18, 4/19, 4/20 at 4PM and 8 PM. R2's MAR, dated May 2025, documents Baclofen 10mg at bedtime and 20mg 5/10 blank. Gabapentin 800mg 5/3 and 5/4 at 8AM and 12 PM. 5/10 at 8PM blank. On 5/12/2025 at 2:30 PM V3, LPN, stated that they have had some issues with medication. V3 stated that more on the other halls. V3 stated that they had a recent change in pharmacy and causes some delays with the change. V3 stated that when there is a blank in a routine medication the system highlights that and it alerts her to verify if the medication was given because at that time it would look as it was not. On 5/12/2025 at 3:00 PM V2, Director of Nursing, stated that the facility is chaotic. V2 stated that she has been at the facility for about 3 months. V2 stated that prior to the changeover it was difficult to get medications from the pharmacy. Communication was horrible. V2 stated that the medication would be ordered and not delivered. V2 stated that they would have to call the pharmacy and then they were told it was an issue with the script or insurance. V2 stated that the previous pharmacy had emergency boxes in the medication room, but it was no good if you can't access it. V2 stated that it was difficult to care for the residents. V2 stated that then the changeover happened and again there were some challenges with getting medication. V2 stated that there were delays with getting medication. V2 stated that she feels its getting better. V2 stated that she is aware of medications not being delivered. V2 stated that when the medications are administered, they are signed off. V2 stated that the medication being blank would indicate that it wasn't given. V2 stated that she expects the staff to administer medication as ordered. V2 stated that she was aware of R1's medication being out and difficulty with getting the medications. V2 stated that R1 has a lot of pain and withdrawals from not receiving his pain. V2 stated that R1 goes out of the facility and when this happened the medication are to have documentation there shouldn't be an empty space on the MAR. The system is set up to make you document. V2 stated that if it's not documented it's not given. V2 stated that R2 medication is out currently, and they are trying to get it. V2 stated that R2 takes a lot of medication for pain and needs her medication. V2 stated that she likes to stay in her room, but she is different and lays in the bed more. V2 stated that due to R2's pain and the amount of pain medication she takes to manage it when the medication is not administered her pain is horrible and she has withdrawals depending on the length of time she is without. V2 stated r1 and R2 did not received their medication as ordered and did not receive medication from emergency kit or pixis. On 5/12/2025 at approximately 3:30 PM R2 stated that the pain scale did not cover her pain, the pain is excruciating and continuous. R2 stated that she went to the emergency room for pain relief. R2 stated that she stays in bed due to the pain, it hurts to breathe. R2 stated that due to her diagnosis of spinal muscular atrophy her muscles in her head and face are continuously being pulled downward. The pain is already horrible but without the pain medication it is horrid. R2 stated that she smokes cigarettes but not as much. R2 stated that smoking cigarettes helps with her anxiety which is elevated due to pain, and she doesn't go out to smoke as much because of it. R2 stated that she feels forgotten and the pain gets so bad she wants to die. R2 stated that this is not the first time. R2 stated that she has experienced withdrawal symptoms as well. R2 stated that she is always nauseated and has anxiety but it is more its extreme and she can't stand it. On 5/14/2025 at 2:16 PM, V17, Pharmacist, stated that the pharmacy took over April 1st. V17 stated that R2's Xtampza is a medication that is not in the pyxis and not available in the facility. V17 stated that 2 doses were sent on 5/6/2025 and then 5/9/2025 a 2 week dosage was sent. V17 stated as soon as they received the request and script the medication was sent out. V17 stated that the were notified of refill needed for R2's Morphine on 5/8/2025. V17 stated that the script was written by a physician that was not Medicaid eligible. V17 stated that the facility was notified about this. V17 stated that they were awaiting a script from another physician. V17 stated that at this time the medication has not been filled. V17 stated that the medications are scheduled medications and would be a significant medication error. V17 stated that R2's medication was not taken from Pixis. On 5/14/2025 at 2:45 PM V1, Administrator, stated that she was made aware by the pharmacy that there was an issue with script from V20. V1 stated that V19 was notified and requested a script from him for the medication. V1 stated that the medication is now being filled at a local pharmacy and awaiting call from pharmacy for pick up. On 5/14/2025 at 3:47 PM, V16, CNA, stated that R2 is having pain. Appetite has decreased. V16 stated that R2 usually sits up in her chair and has not been doing that as much. On 5/13/2025 at 4:00 PM V18, LPN, stated that she gave R2 the last dose. V18 stated that she ordered the morphine at that time. V18 stated that she has been off and today was her first day back. On 5/15/2025 at 9:40 AM V20, Nurse Practitioner, stated that she was aware that the facility recently went through and change and new pharmacy. V20 stated that there were some problems with getting medication when that transition occurred. V20 stated that she was made aware when a resident is getting low on the medication, and she will get the medication. V20 stated that R1 and R2 not receiving their schedule meds this is a significant medication error. V20 stated that obviously R1 and R2 would experience some discomfort related to not receiving the pain medication. V20 stated that it's obvious if they don't get the medication. V20 stated that she would expect the patients to get there medications as prescribed. V20 stated that she would expect the staff to address the pain with alternate interventions. V20 stated that she has ordered pain management in the past. On 5/15/2025 at 10:43 AM, V15, Medical Director, stated that he is usually notified of need for refills. V15 stated that he expects medication to be administered as prescribed. V15 stated that it is unfortunate that the medications were not available and administered to the patient as ordered. As of 5/15/2025 at 4:00 PM observed R2 outside leaning against wall crying. R2 stated that she is in so much pain that she didn't want to live like this and wanted to die. R2 stated that it hurts to sit and hurts to stand. R2 stated that it was miserable. R2 stated that her pain medication has not been delivered and she has not received her medication. The facility Pain management policy, dated November 22, 2021, documents Policy Statement: To provide a broad spectrum of treatment for pain management as they apply specifically to older people and with specific recommendations to aid in decision making about pain management of acute or chronic pain. The Administering Medication policy dated October 15, 2023, documents 3. Medications shall be administered according to physician written/verbal orders upon verification the right medication, dose, route, time and positive verification of resident identity when no contraindications are identified, and the medication is labeled according to accepted standards. 8. The individual administering the medication shall sign of the electronic Medication Administration Record date for the specific day before administering the medication. The Facility Abatement Plan documents as follows: This plan of correction constitutes my written allegation of compliance for the deficiencies cited. However, submission of this plan of correction is not an admission that a deficiency exists or that one was cited correctly. This plan of correction is submitted to meet requirements established by state and federal law. 1.x The corrective action for the alleged deficient practice has been achieved by the following: a. Medical Director consulted regarding the availability of pain medication for R1 and R2 on 5/14/25. b. Medication for R1 and R2 were ordered, received, and administered as prescribed. c. All medication orders received by pharmacy on 5/14/25, from the physician, for R1 and R2 and delivered STAT to the facility. d. An audit for all resident medications for pain was completed by the ADON on 5/14/25. e. Medical Director provided pain medication orders to pharmacy on 5/14/2025. f. Education provided to nursing staff initiated on 5/15/25 and completed on 5/20/25, by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain. The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift. 2. Residents with active orders of pain medication have the potential to be affected by the alleged deficient practice. 3. The following systematic measures have been implemented to ensure the alleged deficient practice does not recur: a. Education provided to nursing staff initiated on 5/15/25 and completed on 5/20/25, by the Administrator to ensure appropriate identification, documentation, and timely treatment for pain, as well as processes and procedures that assure the accurate acquiring, receiving, dispensing, and administering of medication for pain. The Director of Nursing or Designee will provide on-going education to any new or agency nursing staff, not in-serviced, prior to the start of their next shift. b. Pain assessment on the MAR/TAR to be completed by nurse every shift and addressed if pain noted. c. Director of Nursing or designee will conduct audit of pain medication administration 3x a week x 4 weeks, to ensure appropriate knowledge and understanding of narcotics delivery, documentation, and administration practices. d. The Director of Nursing or designee will address all concerns identified during the audit. 4. The following Quality Assurance Programs have been implemented to achieve and maintain substantial compliance with the alleged deficient Practice: a. The Director of Nursing or designee will report audit findings to the Quality Assurance and Performance Improvement Committee monthly for at least three months, and thereafter as determined by the QAPI Committee. Completion Date: 05/20/2025

Based on observation, interview, and record review the facility failed to administer prescribed opioid medications, muscle relaxants, and anticonvulsants prescribed for pain control to two of three residents (R1 and R2) reviewed for pain in the sample of three. This failure resulted in R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy described experienced, symptoms of medication withdrawal, pain described as being ongoing, uncontrolled, excruciating, and unbearable to her head, neck, back and both lower legs, which resulted in an emergency room treatment for pain relief. This failure also resulted in R1 who suffers from cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome too described experiencing ongoing, uncontrolled, severe pain, rated 9 on pain scale (1 to 10) to left side of his body. Findings include: 1. R1's Admission Record, print date 5/14/2025, documents that R1 was admitted [DATE] and lists cervical spinal cord injury, disorder of right wrist tendon and chronic pain syndrome as diagnosis. R1's Care Plan dated, 1/28/2025, documents that the resident has pain. Interventions include Administer analgesia (specify medication) as per orders. Give 1/2 hour before treatments or care. Evaluate the effectiveness of pain interventions (FREQ). Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. R1's Minimum Data Set, (MDS), dated [DATE], documents that R1 is cognitively intact, dependent on staff for ADLs (activity of daily living). It also documents that R1 experience pain almost constantly that frequently interferes with day-to-day activities. It also documents that R1 receives pain medication routinely and as needed and has experienced pain at level of 7. R1's Progress Note, dated 4/9/2025 to 4/24/2025, documents that Orders -Administration Note, Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain not in stock. R1's Controlled Substances Proof of Use, dated 3/25/2025, documents last dose of Xtampza ER 18mg was administered 4/8/2025 at 4 PM. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents the first dose of Xtampza ER 18mg administered 4/26/2025 at 10 AM. R1's Progress Note, dated 4/21/2025, 4/22/2025, documents that Orders -Administration Note, Note Text: oxycodone HCl Oral Tablet 15 MG Give 15 mg by mouth six times a day for pain give 15mg PO q 4 hours routine for pain med out of stock(OOS). R1's Controlled Substances Proof of Use, dispense date 4/22/2025, documents that the first dose of Oxycodone HCL 15mg tab was administered on 4/23/2025 at 12 AM. R1's Progress Note, dated 4/28/2025 at 7:27 PM, documents that Orders -Administration Note, Note Text: Lyrica Oral Capsule 100 MG Give 100 mg by mouth every 12 hours for pain take 100 mg PO q12 hours med out of stock. R1's Medication Administration Record, dated April 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank 4/1 at 4 PM, 4/8 at 12 PM, 4/18 at 8AM, 12PM, and 4 PM. 4/19 at 12 PM and 4 PM, 4/20 at 8AM, 12 PM and 4 PM. R1's Progress Note, dated 5/6/2025, 5/8/2025, 5/9/2025 documents that Orders -Administration Note Note Text: Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG Give 1 capsule by mouth two times a day for Pain OOS. R1's Controlled Substances Proof of Use, dispense date 4/24/2025, documents that the last dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/5/2025 at 4PM. R1's Controlled Substances Proof of Use, dispense date 5/6/2025, documents that the first dose of Xtampza ER Oral Capsule ER 12 Hour Abuse-Deterrent 18 MG was administered on 5/7/2025 at 4AM and last dose administered 5/7/2025 at 4 PM. R1's Medication Administration Record, dated May 2025, documents 10/10/2024 Baclofen 20mg tablet 3 times a day. It also documents blank on 5/3 and 5/4 at 8AM, and 12PM. On 5/13/2025 at 11:50 AM R1 stated that when he doesn't have his pain medication his pain is ongoing, uncontrolled, and severe. R1 stated that his pain, is rated 9 on pain scale (1 to 10) to left side of his body. R1 stated that the pain gets so high that when he finally gets his medication it takes a while for the pain to lower. R1 stated that they don't do anything different for him he just waits till the medication comes in. R1 stated that he goes out of the facility but that can be difficult because of the pain. 2. R2's Admission Record, print date 4/14/2025, documents that R2 was admitted [DATE]. It lists R2, who suffers from spinal muscular atrophy, restless leg syndrome, neuralgia and neuritis, and muscular dystrophy as diagnosis. R2's Care Plan, dated 4/10/2024, documents (R2) has potential impairment to skin integrity. It also documents Administer Morphine and Hydrocodone as per orders. R2's MDS, dated [DATE], documents that R2 is cognitively intact. It also documents that R2 experience pain almost constantly that rates a 10 (1-10) on pain scale and receives routine and as needed pain medication. R2's Progress Note, dated 3/27/2025 and 3/28/2025, documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain HOLD IF PATIENT IS NODDING OR SHOWING S/S of BEING OVER-MEDICATED med out of stock, insurance issue, pharmacy notified. R2's Progress Note, dated 3/29/2025, documents that new order for liquid morphine given. Morphine Sulfate ER Oral Tablet Extended Release 60 MG discontinued. Morphine Sulfate(Concentrate) Solution 20 MG/ML Give 5 mg by mouth every 4 hours for pain med out of stock, pharmacy notified. R2's Progress Note, dated 3/30/2025 at 3:15 AM, documents that Health Status, Note Note Text: Resident c/o uncontrollable pain requesting to be sent to ER (emergency room ). Call placed to 911 at this time. 0330 Resident leaving facility with (local) Ambulance service at this time. Report giving to (local hospital). At 1:07 PM Health Status Note Note Text: Resident returned to facility via ambulance at 11:15am after being sent out r/t back pain. Hospital treated pain with medications this morning. No new dx or medication orders at this time. Resident is currently in her room sitting up. R2's Progress Note, dated 4/7/202508:50 Orders -Administration Note, Note Text: Gabapentin Oral Tablet 800MG Give 1 tablet by mouth four times a day for neuropathy MEDICATION CURRENTLY UNAVAILABLE R2's progress Note, dated 4/12/2025 12:25 PM, documents that Health Status Note, Note Text: Resident was able to find local pharmacy that had previous Morphine script in stock wanted to know if it would be possible to change Morphine script back to Morphine 60mg: 1 tablet by mouth every 12 hours for pain scheduled at 8AM & 8PM. Spoke with (V19's) office asked if she could notify the provider of this and asked if they did approve change if they could send over Morphine ER 60mg to (local pharmacy). (V19's) Morphine 60mg 1 tab every 12 hours was approved and sent to (Local pharmacy) Will update prescription changes in EMR (electronic medical record). R2's Progress Note, dated 5/11/2025, 5/12/2025, 5/13/2025, and 5/14/2025 documents that Orders -Administration Note, Note Text: Morphine Sulfate ER Oral Tablet Extended Release 60 MG Give 1 tablet by mouth every 12 hours for pain med unavailable. R2's Resident Controlled Substance Record, not dated, documents the last dose of Morphine ER 60mg was administered 5/11/2025 at 8AM. R2's MAR, dated April 2025, documents blank for Baclofen 10mg on 4/1, 4/14, 4/18, 4/19, 4/20 Baclofen 20mg 4/6 at 6AM, 4/19 at 2Pm and 8 PM, 4/20 at 6AM and 8 pm. Gabapentin 800mg 4/1 at 4pm and 8 pm, 4/14 at 4 8 pm 4/18, 4/19, 4/20 at 4PM and 8 PM. R2's MAR, dated May 2025, documents Baclofen 10mg at bedtime and 20mg 5/10 blank. Gabapentin 800mg 5/3 and 5/4 at 8AM and 12 PM. 5/10 at 8PM blank. On 5/12/2025 at 2:30 PM V3, LPN, stated that they have had some issues with medication. V3 stated that more on the other halls. V3 stated that they had a recent change in pharmacy and causes some delays with the change. V3 stated that when there is a blank in a routine medication the system highlights that and it alerts her to verify if the medication was given because at that time it would look as it was not. On 5/12/2025 at 3:00 PM V2, Director of Nursing, stated that the facility is chaotic. V2 stated that she has been at the facility for about 3 months. V2 stated that prior to the changeover it was difficult to get medications from the pharmacy. Communication was horrible. V2 stated that the medication would be ordered and not delivered. V2 stated that they would have to call the pharmacy and then they were told it was an issue with the script or insurance. V2 stated that the previous pharmacy had emergency boxes in the medication room, but it was no good if you can't access it. V2 stated that it was difficult to care for the residents. V2 stated that then the changeover happened and again there were some challenges with getting medication. V2 stated that there were delays with getting medication. V2 stated that she feels its getting better. V2 stated that she is aware of medications not being delivered. V2 stated that when the medications are administered, they are signed off. V2 stated that the medication being blank would indicate that it wasn't given. V2 stated that she expects the staff to administer medication as ordered. V2 stated that she was aware of R1's medication being out and difficulty with getting the medications. V2 stated that R1 has a lot of pain and withdrawals from not receiving his pain. V2 stated that R1 goes out of the facility and when this happened the medication are to have documentation there shouldn't be an empty space on the MAR. The system is set up to make you document. V2 stated that if it's not documented it's not given. V2 stated that R2 medication is out currently, and they are trying to get it. V2 stated that R2 takes a lot of medication for pain and needs her medication. V2 stated that she likes to stay in her room, but she is different and lays in the bed more. V2 stated that due to R2's pain and the amount of pain medication she takes to manage it when the medication is not administered her pain is horrible and she has withdrawals depending on the length of time she is without. V2 stated r1 and R2 did not received their medication as ordered and did not receive medication from emergency kit or pixis. On 5/12/2025 at approximately 3:30 PM R2 stated that the pain scale did not cover her pain, the pain is excruciating and continuous. R2 stated that she went to the emergency room for pain relief. R2 stated that she stays in bed due to the pain, it hurts to breathe. R2 stated that due to her diagnosis of spinal muscular atrophy her muscles in her head and face are continuously being pulled downward. The pain is already horrible but without the pain medication it is horrid. R2 stated that she smokes cigarettes but not as much. R2 stated that smoking cigarettes helps with her anxiety which is elevated due to pain, and she doesn't go out to smoke as much because of it. R2 stated that she feels forgotten and the pain gets so bad she wants to die. R2 stated that this is not the first time. R2 stated that she has experienced withdrawal symptoms as well. R2 stated that she is always nauseated and has anxiety but it is more its extreme and she can't stand it. On 5/14/2025 at 2:16 PM, V17, Pharmacist, stated that the pharmacy took over April 1st. V17 stated that R2's Xtampza is a medication that is not in the pyxis and not available in the facility. V17 stated that 2 doses were sent on 5/6/2025 and then 5/9/2025 a 2 week dosage was sent. V17 stated as soon as they received the request and script the medication was sent out. V17 stated that the were notified of refill needed for R2's Morphine on 5/8/2025. V17 stated that the script was written by a physician that was not Medicaid eligible. V17 stated that the facility was notified about this. V17 stated that they were awaiting a script from another physician. V17 stated that at this time the medication has not been filled. V17 stated that the medications are scheduled medications and would be a significant medication error. V17 stated that R2's medication was not taken from Pyxis. On 5/14/2025 at 2:45 PM V1, Administrator, stated that she was made aware by the pharmacy that there was an issue with script from V20. V1 stated that V19 was notified and requested a script from him for the medication. V1 stated that the medication is now being filled at a local pharmacy and awaiting call from pharmacy for pick up. On 5/14/2025 at 3:47 PM, V16, CNA, stated that R2 is having pain. Appetite has decreased. V16 stated that R2 usually sits up in her chair and has not been doing that as much. On 5/13/2025 at 4:00 PM V18, LPN, stated that she gave R2 the last dose. V18 stated that she ordered the morphine at that time. V18 stated that she has been off and today was her first day back. On 5/15/2025 at 9:40 AM V20, Nurse Practitioner, stated that she was aware that the facility recently went through and change and new pharmacy. V20 stated that there were some problems with getting medication when that transition occurred. V20 stated that she was made aware when a resident is getting low on the medication, and she will get the medication. V20 stated that R1 and R2 not receiving their schedule meds this is a significant medication error. V20 stated that obviously R1 and R2 would experience some discomfort related to not receiving the pain medication. V20 stated that it's obvious if they don't get the medication. V20 stated that she would expect the patients to get there medications as prescribed. V20 stated that she would expect the staff to address the pain with alternate interventions. V20 stated that she has ordered pain management in the past. On 5/15/2025 at 10:43 AM, V15, Medical Director, stated that he is usually notified of need for refills. V15 stated that he expects medication to be administered as prescribed. V15 stated that it is unfortunate that the medications were not available and administered to the patient as ordered. As of 5/15/2025 at 4:00 PM observed R2 outside leaning against wall crying. R2 stated that she is in so much pain that she didn't want to live like this and wanted to die. R2 stated that it hurts to sit and hurts to stand. R2 stated that it was miserable. R2 stated that her pain medication has not been delivered and she has not received her medication. The Administering Medication policy dated October 15, 2023, documents 3. Medications shall be administered according to physician written/verbal orders upon verification the right medication, dose, route, time and positive verification of resident identity when no contraindications are identified, and the medication is labeled according to accepted standards. 8. The individual administering the medication shall sign of the electronic Medication Administration Record date for the specific day before administering the medication.

Based on interviews, observations, and record reviews the facility failed to keep daily temperature logs for refrigerators/freezers, wear hairnets covering all hair, dispose of and store food according to policy and hold food temperatures according to policy. This failure has the potential to affect all 38 residents in the facility. Findings include: 1. On [DATE] at 8:52 AM, both V3(kitchen manager) and V10(dietary aide) had their hair outside of their hair nets in the kitchen while handling food. On [DATE] at 12:00 PM, V10, dietary aide, had hair outside of her net from her ponytail and bangs. V3 told V10 to put all her hair back in the net. V10 put her ponytail in the hair net but her bangs remained outside. V3 did not correct her. V10 picked up her personal cell phone with her left hand's fingers, ungloved, while preparing beverages for the residents, put the cell phone back down on the counter, and then used those same fingers to hold beverages to be served inside the cups with no hand hygiene. V12, dietary staff, did not have any hair net covering on his head or facial hair while working with food. V11, cook in training, did not have his facial hair net over his beard covering his facial hair. V3 did not correct V1 or V12 about their hair net use while preparing lunch in the kitchen. On [DATE] at 8:00 AM, V3, V11, and V12 were not wearing hair nets in the kitchen preparing breakfast. Biscuits were at 109.2 degrees Fahrenheit, and when gravy was placed on top of them, the biscuit and gravy were at 109 degrees Fahrenheit on the plate to be served. V12 stated the key will be to get the food out to the residents as fast as possible since they are losing heat fast. The food was placed on a tray and prepared to be served to the residents. R1's MDS dated [DATE] documented R1 to be moderately cognitively impaired. On [DATE] at 9:55 AM, R1 stated the food is not good and usually cold; eats in dining room and food is still cold. R2's MDS dated [DATE] documented R2 to be cognitively intact. On [DATE] at 10:10 AM, R2 stated the food is terrible and sometimes cannot identify what it is and is usually cold. R4's MDS dated [DATE] documented R4 to be cognitively intact. On [DATE] at 10:25 AM, R4 stated the food is typical Institutional Food and it has improved the past month but still needs a lot of work. R4 stated he eats in dining room and in his room and food is usually cold, even in the dining room. R4 stated he used to be a Federal Consumer Safety Officer and he is well aware of how to store and cook food. R4 stated they need to watch the temperatures of the food and no one in the kitchen monitors the food temps like they are supposed to. R7's Minimum Data Set (MDS) dated [DATE] documented him to be cognitively intact. On [DATE] at 2:48 PM, R7 stated the food varies in temperature, it is sometimes served warm but sometimes cold you just never know what you're going to get. R7 stated he would like the kitchen staff to wear their hair nets, proper fitted clothing, and use proper hand hygiene before working with the food also. R9's MDS dated [DATE] documented him to be cognitively intact. On [DATE] at 2:45 PM, R9 stated the food is not cold but could be warmer, it varies every day. On [DATE] at 9:10 AM, R9 stated the biscuits and gravy for breakfast was not hot, it was room temperature, and he only ate two bites of it; it wasn't good. Resident Council Meeting Minutes dated [DATE] documented the food comes out cold at dinner and food was not good quality. 2. On [DATE] at 8:45 AM, the kitchen freezer has 5 bags of frozen breaded chicken labeled Don't cook use for activity with no date. The beverage refrigerator has a gallon of two percent milk ,d+[DATE]'s the way used with a expiration date of [DATE]. On [DATE] at 8:49 AM, V3, stated the 5 bags of frozen breaded chicken are for the Certified Nursing Assistants (CNA's) to use for activities, they like to have food for the residents sometimes. On [DATE] at 8:50 AM, V3 and V10 stated the beverages in the refrigerator (containing the expired milk) is what they serve the residents. 3. On [DATE] at 12:15 PM, no active temperature logs in facility binder since December of 2024 for freezers and refrigerators. On [DATE] at 12:15 PM, V3 stated he was not aware that the freezers and refrigerators needed to having daily temperature checks. On [DATE] at 8:15AM, V1, Administrator, stated she expects the kitchen staff to be wearing hair nets properly, we just got in a whole order of nets for their beards in fact, they should know better. V1 stated we will have to provide more education to the kitchen staff on proper procedures. The Facility's Food Labeling and Storage Policy dated [DATE] documented all foods must be labeled and dated right away when going into the cooler, the expiration date is the most important. The facility's Storeroom/Freezer Food Storage Policy dated [DATE] documented all open food items in the freezer must be labeled and dated. The facility's Food Safety Policy undated documented foods or beverages that are past the manufacturer's expiration date should be discarded, foods should be stored at the appropriate temperature to maintain safety: hot foods should be held at 135 degrees or higher.

Based on interview, observation and record review, the facility failed to have fall interventions in place and implement progressive interventions in 3 of 7 residents (R6, R19, R36), reviewed for falls in the sample of 24. This failure resulted in R36 sustaining a head injury, requiring emergency room evaluation and treatment including but not limited to glue and adhesive skin closure strips to the right temple area. Findings include: 1. On 9/17/24 at 9:05 AM, R36 was observed in her room in a low bed with a mat to left side of the bed, the call light was behind the bed, not within reach. R36 had bruising noted to the bilateral eyebrow areas with adhesive closure strips in place to the right eyebrow area. R36 stated she fell recently and that is how she got the bruising. R36 stated she has fallen 3-4 times and has gotten hurt each time. R36 stated she tries to get up on her own and falls, unsure of why she falls, she just does. R36 stated she uses her call button when she needs help and stated it's usually clipped here (reaching on the right side of the bed), but it's not here. Surveyor moved the call light within resident's reach and she pushed it. Staff came into the room to see what R36 needed and R36 stated she was just checking to make sure it worked. R36 stated she had a headache and would like something for it. R36's Face Sheet, undated, documents R36 has a diagnosis of Dementia, Tremors and Hypertension. R36's MDS (Minimum Data Set), dated 7/16/24, documents R36 has a BIMS (Brief Interview for Mental Status) score of 10, indicating R36 has moderate cognitive impairment, requires partial/moderate assist with toileting, requires substantial/maximal assist with sitting to standing, requires substantial assist with transfers and has a history of falls. R36's Care Plan, dated 5/23/24, documents R36 has actual/potential risks for falls with the following interventions: 5/23/24 be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; 8/24/24 continue to educate resident that she needs to be patient and wait for staff to be available to assist; 8/28/24 continue to educate resident to wait for staff to assist her and she will need to ask for assistance; 9/12/24 sent to the emergency room for evaluation and treatment, received 2 adhesive skin closure strips and glue to the right temple and then was sent back to the facility; 9/14/24 continue to educate resident on waiting for staff for transfer needs and encourage her as much as she will allow to stay in high traffic areas. The Care Plan goes on to document R36 has an ADL (Activities of Daily Living) self-care performance deficit with an intervention to encourage her to use the call light and she requires 1-2 staff to assist in all transfers using a mechanical lift. The care plan fails to identify progressive interventions to prevent falls but utilizing the same intervention for multiple falls. R36's Progress Note, dated 7/11/24 at 9:40 AM, documents the following: Writer called into residents room by CNA. Resident was attempting to transfer herself into bed unassisted, she stood up and slid down the front of her chair onto the fall mat on the floor. Skin assessment completed, no injury or wounds noted. Resident denies any pain or discomfort. Resident assisted up into bed and is now resting quietly in bed with HOB elevated and call light in reach. Fall mat in position and bed in low position, will continue to monitor. R36's Progress Note, dated 8/24/24 at 12:16 AM, documents the following: Resident roommate summoned this nurse to resident room. Upon entering room resident was found in a sitting position on floor near bed. No internal/external rotation noted. Fall unwitnessed neuro checks initiated at this time. Assisted off floor with the help of two and placed into bed. Resident able to [NAME] WNL. Denies pain or discomfort. R36's Progress Note, dated 8/29/24 at 9:56 AM, documents the following: Resident noted to be sitting on the floor in the hallway, in front of wheelchair. Resident noted with a 2 cm (centimeter) hematoma to the left side of the forehead. Resident stated I leaned forward to pick something up and fell out of w/c. R36's Progress Note, dated 9/12/24 at 4:35 PM, documents the following: Resident found on floor in room after this nurse was notified by resident's roommate. BP: 116/66, P: 76 Temp: 98.4, O2: 96, res complaining of head pain, 3 cm laceration noted to right temple, ecchymosis noted to left temple, no other injuries noted. MD and POA notified. EMS (Emergency Medical Services) transported resident to the hospital. report given to ER (emergency room ) charge nurse. R36's Progress Note, dated 9/12/24 at 9:46 PM, documents the following: Resident returned to facility from the hospital via EMS. Resident was transferred into bed via 2 EMS attendants. 2 Steri-strips and Dermabond was applied to resident's right eyebrow in hospital. Resident had no complaints of pain or discomfort. R36's Progress Note, dated 9/14/24 at 9:30 AM, documents the following: This nurse was alerted to resident being on the floor by resident's roommate. I went into room, found resident laying on the floor next to bed, resident was assessed for injuries, no injuries were found, resident's neuro-check was normal & vitals were stable. Once assessment was completed, resident was transferred from the floor to the bed. Resident states she was trying to transfer self from wheelchair to bed & fell , denies any pain or discomfort at this time, will continue to monitor for changes. POA, MD & DON notified. R36's Hospital After Visit Summary, dated 9/12/24, documents a diagnosis of Fall and Laceration to the Right Eyebrow. 2. R19 Fall Risk Data Collection Form dated 8/24/24 documents R19 is high risk for falls. R19 Minimum Data Set, dated dated dated [DATE] documents for rolling right to left R19 is dependent and going from chair to bed R19 is dependent. R19's Care Plan dated 8/5/24 documents (R19) is at risk for falls 7/30/24 fall with no injury and 8/9/24 fall with no injury. The resident will be free of minor injury through review date. The resident (R19) will be free of minor injury through review date. Interventions: The resident (R19) will be free of minor injury through review date. Hospice nurse to review medications resident has a floor mat next to bed while in bed. Bed in lowest position. Resident is in a broda chair R19's Fall Investigation dated 12/2/23 documents resident fell out of wheelchair to floor and hit head. R19's Fall Investigation dated 1/17/24 documents notified by CNA (Certified Nursing Assistant) that the resident (R19) had fell . Upon entry to the room resident (R19) noted sitting on the floor next to her bed. Sitting on floor on bottom with legs extended forward resident moving all extremities CNA stated resident (R19) fell backward onto floor. R19's Fall Investigation dated 2/8/24documents resident (R19) found on the floor lying on her left side near the bed. The fall (was) unwitnessed, (and) neuro checks started at this time. The resident (R19) assisted off the floor. R19's Fall Investigation dated 2/25/24 documents resident (R19) found on the floor near her bed, in her room there was a small goose egg area near the top of her scalp. small amount of blood from a small skin tear. Pressure applied, dry dressing applied, seemed a bit restless PRN tramadol and Ativan was given. R19's Fall Investigation dated 3/6/24 documents resident (R19) found on floor by her bed. R19's Fall Investigation dated 6/6/24 found resident (R19) sitting on her buttocks in the doorway resident unable to explain what happen. R19's Fall investigation dated 6/20/24 resident (R19) noted by staff sliding out of bed onto the floor mat. med review completed floor mat. R19's Fall investigation dated 7/30/24 resident (R19) taken to room to see if resident needed to be changed. Resident note to be screaming louder resident was noted actively sliding out of bed. R19's Fall investigation dated 8/3/24 resident (R19) found lying on her left side in the dining room. R19's untitled Fall Intervention form dated 1/17/24 documents the fall intervention is med review completed continue with med A. R19's untitled Fall Intervention form dated 2/1/24 documents continue with skilled therapy services for safety transfers. R19's untitled Fall intervention Form dated 2/8/24 documents care plan meeting held 2/7/24 via phone with POA (power of attorney) discussed hospice for next level of care. R19's untitled Fall Intervention form dated 3/6/24 documents contacted hospice nurse to perform a med (medication review). R19's untitled Fall intervention form dated 6/6/24 documents hospice nurse updated and came out for a visit will review medications. R19's untitled Fall intervention form dated 6/20/24 documents floor mat. The untitled Fall Intervention form dated 7/30/24 documents hospice nurse to review medications due to increased anxiety. R19'sUntitled Fall Intervention form dated 8/5/24 documents spoke with hospice nurse to review different medication for anxiety regimen. R19's POS (Physician Order sheet) Dated 8/5/24 documents Alprazolam 1mg every four hours when ever needed for anxiety. R19's untitled Fall Intervention form dated 8/24/24 documents resident is in a Broda chair. 0n 9/18/24 at 4:20 PM V3 Minimum Data Set (MDS) coordinator stated, she has had a lot of falls, and we have to reuse some of the interventions. We resolve them and use them again. 3. R6's Face Sheet documents R6 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, muscle weakness, unsteadiness on feet, and need for assistance with personal care. R6's Minimum Data Set (MDS) dated [DATE] documented R6 was severely cognitively impaired, independent with bed mobility and transfer, and used wheelchair. R6's Care Plan initiated 8/3/19 documents R6 is at risk for falls related to history of falls, need for assistance with activities of daily living, incontinence of bowel and bladder, and diagnosis of dementia with poor safety awareness. R6's Care Plan Intervention initiated 8/3/19 documents R6 will have anti-tippers to wheelchair at all times. On 9/18/24 at 11:30 AM, R6 was sitting in her wheelchair in the dining room with other residents. There were no anti-tippers on the wheelchair. On 9/19/24 at 12:40 PM, R6 was sitting in her wheelchair in the dining room feeding herself lunch. There were no anti-tippers on the wheelchair. R6's Fall Risk assessment dated [DATE] documented R6 was at risk for falls. R6's Unwitnessed Fall Report dated 5/10/24 documents, CNA came to the nurse saying res (resident) had blood all over her & was all over the floor beside the bed. Upon entering room, this nurse noted res's (resident's) face to be covered with dried blood and blood droplets were noted on the floor beside the res's WC (wheelchair). As CNA was wiping the dried blood off the res, a 2cm (centimeter) x 1cm hematoma with a 1cm gash in the middle was noted over the res's L (left) eyebrow. Resident Unable to give Description. R6's After Visit Summary from (Local) emergency room documents R6 was seen for a fall with the diagnoses forehead cut, head injury, and laceration repair with glue. R6's Care Plan Intervention updated 5/10/24 documented, Resident educated to ensure w/c (wheelchair) brakes are locked. (R6's 4/11/24 MDS documented R6 was severely cognitively impaired.) R6's Unwitnessed Fall Report dated 6/3/24 documents resident was found on the floor in her room sitting on bedside mat, and R6 was unable to explain what she was trying to do. R6's Care Plan Intervention updated 6/3/24 documents, (R6) will continue to work with Med B therapy services on strengthening. No new interventions were added following R6's 6/3/24 fall. R6's Unwitnessed Fall Report dated 6/13/24 documents Resident Unable to give Description. There was no Nursing Description, and there were no details of the fall or potential causative factors. R6's 6/13/24 Care Plan Intervention documents, Continue with therapy services. No new interventions were added following R6's 6/13/24 fall. On 9/18/24 at 1:12 PM, V17, Certified Nursing Assistant (CNA), stated most of R6's falls happened because she would forget to put on her wheelchair brakes when she was self-transferring. On 9/18/24 at 2:40 PM, V19, CNA, stated R6 does not let staff know when she needs to transfer, so they often do not know she needs help until she is already done. On 9/18/24 at 3:17 PM, V26, Occupational Therapist (OT), stated R6 has a tendency to do things herself and is unlikely to ask for help due to cognitive deficits, so they requested increased supervision by staff. On 9/19/24 at 12:10 PM, V16, Licensed Practical Nurse (LPN)/Wound Nurse, stated R6 forgets her limitations and can take herself to the bathroom, but sometimes she rushes, and that is the problem. She stated interventions have been put in place, but there have been no changes in her level of supervision. She was unsure if R6 ever had anti-tippers on her wheelchair. On 9/20/24 at 9:18 AM, V21, CNA, stated she does not think R6 has ever had anti-tippers on her wheelchair. On 9/19/24 at 1:44 PM, V1, Administrator, stated she will have to check into R6's anti-tippers. She stated she expects progressive interventions to be implemented after each fall and followed. The Facility's Fall Policy reviewed 9/2024 documents, The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls prevention approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both Staff and residents. The Facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the resident and promote independence and safety. Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be recorded and potential causal factors identified and investigated. Interventions will be implemented and Care Plan Updated. The Falls and Fall Risk, Managing Policy, dated 12/2007, documents the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 42636 45947

Based on observation, interview and record review, the Facility failed to ensure residents received nutritional supplements and proper portion sizes in 1 of 4 residents reviewed for nutritional status in the sample of 25. This failure resulted in R1 losing significant weight of 12% loss over three months. Findings include: R1's Face Sheet documents R1 has diagnoses including cerebral palsy, dependence on wheelchair, gastro-esophageal reflux disease (GERD) without esophagitis, constipation, vitamin B12 deficiency anemia due to intrinsic factor deficiency, anemia, hypothyroidism, oropharyngeal phase dysphagia (difficulty swallowing), age-related osteoporosis without current pathological fracture, and unspecified intellectual disabilities. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was severely cognitively impaired, required total dependence with two or more-person physical assistance, and required total dependence with one-person physical assistance for eating. R1's Care Plan documents, (R1) has potential for nutritional problem r/t cerebral palsy, PVD (peripheral vascular disease), seizure d/o (disorder), hyperlipidemia, vitamin B deficiency, intellectual disabilities, vitamin D deficiency, anemia, GERD, hypothyroidism, dysphagia, osteoporosis. (R1) has anemia r/t (related to) vitamin B12 deficiency. (R1) has osteoporosis. (R1) has GERD. R1's Monthly Weight Report documents R1 weighed 139.8 pounds on 6/23/23 and 123.0 pounds on 9/20/23. This is a 16.8-pound weight loss or 12% weight loss over 3 months. R1's Order Summary Report printed 9/28/23 documents order for Regular Diet with Pureed Texture and 90 cc (cubic centimeters or milliliters) Med Pass PO (by mouth). R1's Progress Note by V20, Registered Dietitian (RD), on 7/27/23 at 8:15 PM documents, Diet Order: Pureed with 90mL (milliliters) Med Pass Supplement BID (twice per day). R1's Progress Note by V19, RD, dated 9/17/23 at 8:44 AM documents, Diet is pureed with 90ml (mL) Med Pass Supplement BID. Regimen continues to provide supportive nutrition. Goal remains for stable weight pattern. Will monitor. R1's Medication Administration Records (MAR) from 6/1/23 through 9/27/23 were reviewed and do not list Med Pass Supplement or document the Med Pass Supplement was given. On 9/27/23 at 3:25 PM, V2, Director of Nursing (DON), stated there is no documentation that R1 received the Med Pass supplement. On 9/27/23 at 3:51 PM, V1, Administrator, stated, the Med Pass was on the POS, (Physician Order Sheet), but not the MAR, (Medication Administration Record). The Facility's Dietary Order Listing Report printed 9/28/23 documents, R1 has been on a Regular Diet with Pureed Texture since 4/6/23. R1's Dietary Card from 9/26/23 Lunch documents, R1 was on a Puree Diet with Double Portions. The Facility's Week 1 Tuesday Pureed Lunch documents, entree was 1/2 c, (cup), Pureed Ham with Pureed Bread and 1/2 c Pureed Mixed Vegetables with Pureed Bread. On 9/26/23 at 12:19 PM, V9, Cook, used a Number 16 Scoop to plate two scoops of Pureed Ham and Bread and two scoops of Pureed Vegetables and Bread on R1's plate. On 9/28/23 at 11:44 AM, V20, Registered Dietitian, (RD), stated, That's not right. They shouldn't be using the blue scoop for lunch or dinner meals. I set up the menus that way to make sure the portions are correct. The blue scoop is only used for breakfast. If they got what was listed on the menu, they should not be losing weight. On 9/28/23 at 2:03 PM, V1, Administrator, stated, she expects dietary staff to use scoop sizes listed on the menu and follow their food service policies. On 9/29/23 at 9:00 AM, V23, Nurse Practitioner, (NP), stated, she expects Facility staff to follow dietary orders and provide appropriate serving sizes. The Facility's Serving Utensils Portion Guide documents, the size of a Number 16 scoop is 1/4 cup. The Facility's Week 1 Tuesday Lunch portion for Mechanical Soft and Pureed Diets is 1/2 cup. The Facility's Therapeutic Diet Orders Policy revised 7/5/23 documents, The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically Altered Diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat, and thickened liquids. Therapeutic Diet is a diet ordered by a physician, or delegated registered or licensed dietitian, as part of treatment for a disease or clinical condition. It also may be ordered to eliminate, decrease or increase specific nutrients in the diet. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. The Facility's Nutritional Management revised 7/5/23 documents, The facility provides care and services to each resident to ensure the resident maintains acceptable parameters of nutritional status in the context of his or her overall condition.

Based on interview and record review the facility failed to ensure that residents are free from significant medication errors for 1 of 3 residents (R3) reviewed for significant medication errors in the sample of 8. This failure resulted in R3 not receiving seizure medications, having seizures, and being admitted to the hospital. Finding includes: 1.R3's Physician's Order (PO) dated 01/05/23 documents Epilepsy, unspecified, not intractable, without status epilepticus. R3's PO dated 03/23/23 documents Unspecified convulsions. R3's February 2023 Medication Administration Record (MAR) documents that R3 is to receive Levetiracetam (Keppra) Oral Tablet, 750 milligrams (Mg) 1 tablet by mouth every morning and at bedtime for seizures for 30 days. The MAR documents R3 should receive Phenytoin Sodium Extended Oral Capsule, give 200 mg by mouth every morning and at bedtime for seizures for 30 days. The MAR does not document R3 was given Phenytoin for the 8:00 PM dose on 02/27/23 and not document that Phenytoin was given the 8:00 AM or the 8:00 PM dose on 02/28/23. The MAR does not document that Keppra was given the 8:00 PM dose on 02/27/23. Does not document that Keppra was given the 8:00 AM or the 8:00 PM dose on 02/28/23. R3's March 2023 MAR does not document that Phenytoin was given the 8:00 AM or the 12:00 PM or the 4:00 PM doses on 03/01/23, 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/06/23, 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23, 03/12/23, 03/13/23, 03/14/23, 03/15/23, 03/16/23, 03/17/23, 03/18/23, 03/19/23, 03/20/23, 03/21/23, 03/22/23, 03/23/23, 03/24/23, 03/25/23, 04 03/26/23. R3's MAR dated March 2023 does not document that Levetiracetam was given the 8:00 AM or the 4:00 PM dose on 03/01/23, 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/06/23, 03/07/23, 03/08/23, 03/09/23, 03/10/23, 03/11/23. 03/12/23, 03/13/23, 03/14/23, 03/15/23, 03/16/23, 03/17/23, 03/18/23, 03/19/23, 03/20/23, 03/21/23, 03//22/23, 03/23/23, 03/24/23, 03/25/23, or 03/26/23. R3's PO, dated 3/24/23 documents Phenytoin Sodium Extended Capsule 100 MG (milligrams); Give 2 capsule by mouth three times a day related to epilepsy, unspecified, not intractable, without status epilepticus. R3's PO dated 03/24/23 documents levetiracetam Oral Tablet 750 MG (Levetiracetam); Give 1 tablet by mouth two times a day related to epilepsy, unspecified, not intractable, without status epilepticus. R3's Health Status Note dated 03/21/23 at 6:44 PM documents Resident sitting in dining room around 1800 when she got stiff and rigid. She began to twitch and began to seize. Resident continued to seize for the length of one full minute. She then began heavy breathing coming out of seizing for roughly 4-5 seconds then began to twitch and seize again This time she seized for 2 minutes and 38 seconds. With only a few seconds between resident began to seize again. EMS (Emergency Medical System) arrived. EMS administered medication to attempt to stop seizure. Resident continued to seize as EMS transfer out of building. Sent to (local hospital) hospital (local city) per POA (Power of Attorney,V18). R3's Health Status Note dated 03/21/23 at 10:30 PM documents Spoke with (Nurse) at (local hospital) resident admitted with the DX (diagnosis) of seizures. Meds secured in lock box and items secured in room. R3's Care Plan dated 01/10/23 documents The resident has Seizure Disorder. Intervention dated 01/05/23 - Give medications as ordered. Monitor/Document for effectiveness and side effects. R3's Minimum Data Set (MDS), dated [DATE] documents a BIMS (Brief Interview of Mental Status) score of 11 out of 15. The MDS documents R3 is moderately impaired, requires limited assistance of one-person for bed mobility, requires extensive assistance of one-person for transfer, dressing, toilet use, and personal hygiene, and is independent with setup help only locomotion on unit, locomotion off unit, and eating. The MDS documents R3 is not steady, only able to stabilize with staff assistance. R3's Initial Investigation undated documents At approximately 6:30 PM (R3) was noted to have seizure activity, followed by another seizure. Call placed to 911. EMS arrived and administered medications and seizure activity continued. Resident was transported to (local hospital) for further evaluation and was admitted for seizures. It was noted that residents' seizure medication was only ordered for 30 days when discharged from hospital on 1/5/2023. Investigation initiated to review for medication error. Final summary to follow. R3's Final Investigation R3's Final Summary undated documents (R3), [AGE] year-old female admitted on [DATE] with the diagnosis of cerebral palsy, epilepsy, HTN, and cognitive communication deficit with a BIMS score of 12, who is assist of one with a walker had a seizure on 3/21/23 resulting in hospitalization . At approximately 6:30 pm (R3) was noted to have seizure activity, followed by another seizure. Call placed to 911. EMS arrived and administered medications and seizure activity continued. Resident was transported to (local hospital for further evaluation and was admitted for seizures. It was noted that residents' seizure medication was only ordered for 30 days when discharged from hospital on 1/5/2023. Investigation initiated to review for medication error. Upon investigation it was noted that on admission 1/5/23 she was admitted with orders for her Keppra and Dilantin (seizure medications) x 30 days. On 1/10/23 she went to her neurologist who sent orders for her Dilantin and Keppra but had stop date of 2/27/23. On 2/23/23 (V16) LPN (Licensed Practical Nurse) sent a request via fax to continue Keppra to (V15) NP (Nurse Practitioner). (V15's) office stated that responded via fax to continue Keppra orders. That order was not received at the facility and therefore was not processed. A meeting was held on 3/23/23 with (V15) NP to discuss options to ensure orders are being received. An email was sent to the office manager for (V10), Physician and (V15). It was agreed that the office would also send orders via email to administrator to be able to verify orders have been received and processed. (V3) returned to the facility on [DATE]. Prior to her return I (V1) spoke with the case manager requesting that they do not send only 30-day order for her seizure medications. Upon arrival orders were confirmed to be correct with no stop date. Follow up labs for Keppra and Dilantin levels schedule. Resident seen by (V10) on 3/29/23. Neuro appointment scheduled for 7/12/23. On 04/12/23 at 11:03 AM, V10, Physician stated that (R3) missing 2 weeks of seizure medication was significant and probably caused her seizures and hospitalization . On 04/13/23 at 8:04 AM, V1, Administrator stated that (R3) first came to the facility with an order from the hospital for her seizure medication for 30 days. She saw her neurologist a short time later and he increased one of medications and put a stop date on them. The order fell off after the stop date. A nurse sent an order to the NP (V15) to continue the medication. (V15's) office sent a fax to continue the medication but we never received it. We have a backup system in place now. They fax everything and email it to me. I double check all the orders to make sure we got them. On 04/13/23 at 9:31 AM, V16, Licensed Practical Nurse, LPN, stated that she received a call the pharmacy stating that R3's Dilantin was only for 30 days and that it was expiring. She stated that she contacted V15's office to let them know that R3's Dilantin need to be continued. She said she never received anything back from the doctors during her shift. On 04/13/23 at 11:04 AM, V2, Director of Nursing, DON, stated that she would expect medications to be given as ordered and mark off in the MAR. Facility's policy Physician's Orders revised 04/2021 documents A. All medications, including non-legend medications (cathartics, headache remedies, vitamins, etc.) shall be given only upon the written order of the physician. All such orders shall have handwritten or electronic signature of the physician. These shall be given as prescribed by the physician and at the designated time. B. When necessary, telephone orders may be taken by a Registered Nurse or Licensed Practical Nurse. All such orders shall be immediately written on the Physician Order Sheet or Electronic Medical Record (EMR) and a Telephone Order Form and signed by the physician within 10 working days. Facility's policy Administration of Medication revised 04/2021 documents B. Immediately after a drug is ingested, it should be recorded in the MAR.

Based on interview and record review the facility failed to provide a safe environment and safe interventions during transfers to prevent falls for 1 of 3 residents (R3) reviewed for falls in the sample of 6. This failure resulted in R3 falling and fracturing his right hip, requiring hospitalization and surgery. Findings include: The facility's Initial Report of Accident with Injury to IDPH (Illinois Department of Public Health) dated 10/29/22 documents, On 10/29/22 at 12:57 PM (R3), age 81, sustained a fall during a transfer in his bathroom. Resident complained of right hip pain during assessment by the nurse. MD (Medical Doctor) notified of fall and order received to obtain x-ray of right hip. POA (Power of Attorney) updated on fall and new order for x-ray. X-ray results show acute intertrochanteric hip fracture. MD notified at 5:00 PM of results and new order received to transfer to (local hospital) emergency room for evaluation and treatment. POA notified of results and new order to transfer resident. Administrator notified of fracture at 5:10 PM by (V12) Licensed Practical Nurse (LPN). Initial report. Final to follow. The facility's fall investigation dated 10/29/22 includes the following documentation: V11's, Certified Nursing Assistant (CNA), handwritten statement dated 10/29/22, included in R3's fall investigation provided by V1, Administrator, documents, I was assisting (R3) to the toilet; he grabbed the bars as usual (both hands). I asked did he have his balance, he answered yes. I went to make sure the chair was locked because in order for him to back up close enough to the toilet, he has to hold the bar and transfer one hand to his wheelchair because the bar isn't long enough. As I was quickly checking the chair, he then let one hand go too soon and fell to the left side. The nurse was notified immediately. The facility's document, Investigative Guideline Fall documents the root cause of R3's fall on 10/29/22 as, Resident let go of bar during transfer. No gait belt on resident. R3's Physical Therapy note dated 10/28/22 documents, PTA (physical therapy assistant) providing CNA with Inservice training on transfers with patient. PTA educates CNA on use of gait belt, allowing patient increased time, and vc (voice commands) in left ear for greater stability. The facility's document, Statement of Education for Employees dated 10/31/22 at 11:30 PM documents, Inservice training presented by V1, Administrator to V11, CNA: The following areas of instruction were covered: (R3) transfer status, policy and procedure for transfers, and following interventions. R3's hospital records document x-ray results dated 10/30/22 at 12:58 AM as, Impression: 1. Compression deformity of L2 (lumbar 2) vertebral body with a 50% height loss in the midportion is new from 3/8/22 exam. The hospital records document, under Assessment and Plan, Right intertrochanteric hip fracture. R3's hospital records also document the results of x-ray of right hip dated 10/29/22 as: Comminuted, predominantly oblique intertrochanteric fracture of right proximal femur that is essentially non-displaced. The hospital records further document, Reason for Admission: Hip Fracture. History of Present illness (R3) is an [AGE] year-old male with past medical history significant for Atrial-fibrillation, hypertension, presents to ER following a ground level fall. Patient states he was in the bathroom and fell to his right hip. He had immediate pain and could not get up. He denied any head injury or loss of consciousness. X-rays showed right hip fracture. Orthopedics notified. He will need an intertrochanteric nailing of the right hip performed. His surgery will be scheduled for late Tuesday afternoon/evening. R3's Face Sheet documents his diagnoses include Nondisplaced Intertrochanteric Fracture of Right Femur, Aftercare Following Joint Replacement, Primary Osteoarthritis of Right and Left Hips, Muscle Weakness, Repeated Falls, and Heart Failure. R3's Minimum Data Set (MDS) dated [DATE], prior to his fall with a right hip fracture on 10/29/22, documents he was severely cognitively impaired and requires extensive assist of one staff for bed mobility and extensive assist of two staff for transfers and toileting. It documented he is always incontinent of bowel and bladder. R3's MDS dated [DATE], after his fractured hip, documents he is severely impaired cognitively, he requires extensive assist with bed mobility, and he is dependent on two staff for transfers and toileting. R3's Care Plan documents: The resident is at risk for falls: Gait/balance problems: 9/26/22 resident lost balance during transfer and fell . resident had on crocs with no back. 10/29/22: witnessed fall while being transferred off toilet. Resident let go of rail and fell resulting in fracture. 1/1/23: resident rolled out of bed resulting in subdural hematoma Interventions for this care plan include: 1/1/23: bolsters to be added to bed when resident returns 10/29/22: Resident sent to ER for tx (treatment). Staff education. Therapy to eval and tx (treat) as ordered was resident returns from hospital. 9/26/22 ensure resident has on appropriate footwear for transfers Area around the recliner/lift chair will be free from clutter/hazards Assistive devices will be within reach of resident while they are in the recliner/lift chair Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed Do not leave resident in bathroom unattended Provide Reacher/Grabber device On 1/3/23 at 2:50 PM V11 went to R3's bathroom to demonstrate how he fell and fractured his hip on 10/29/22. V11 stated R3 was holding onto the grab bar in front of the toilet, and she went to move his wheelchair (w/c) out of the way so he could sit down on the toilet, and during those few seconds she was moving his w/c, he lost his balance and fell against the door to his neighbor's room, falling through the door, breaking the door frame and falling onto the floor in that room. When asked why she did not use a gait belt while transferring R3 onto the toilet, V11 stated, That was totally on me. I was just moving too fast. V11 stated before he broke his hip on 10/29/22, (R3) was a fairly easy transfer of one assist with a gait belt. On 1/4/23 at 10:25 AM V1, Administrator, stated she would expect staff to use a gait belt when transferring any resident who requires assist of one or two staff to transfer. V1 stated she is not sure how much assist R3 was requiring at the time of his fall on 10/29/22 when he fractured his hip because therapy was frequently changing his transfer status but did not communicate the changes to nursing. V1 stated now, if therapy changes the transfer status of a resident, they provide nursing with a document that states how that resident transfers and how many staff is required to assist that resident. V1 stated staff should use a gait belt any time a resident requires physical assist w/transfer The facility's undated policy, Safe Lifting and Movement of Residents, documents 1. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. 3.Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, slide boards) and mechanical lifting devices. The facility's policy, Fall Policy revised 9/17/19 documents, Purpose: The purpose of the Fall Management Program is to develop, implement, monitor and evaluate an interdisciplinary team falls approach and manage strategies and interventions that foster resident independence and quality of life. The Fall Management Program promotes safety, prevention and education of both staff and residents. Policy: The facility shall ensure that a Fall Management Program will be maintained to reduce the incidence of falls and risk of injury to the residents and promote independence and safety.

Based on observation, interview and record review the facility failed to timely assess and unknown cause of pain delaying treatment for one of 5 residents (R41) reviewed for quality of care in the sample of 26. This failure resulted in R41 expressing pain on 12/27/21 in left groin and the facility not seeking medical treatment until 1/3/2, eight days later. R41 sustained a left femoral [CONDITION(S)]. Findings include: R41's Physical Therapy (PT) Treatment Note, dated 12/27/2021 documents R41 ambulated 20 feet with a wheeled walker. No complaint of pain documented. R41's PT Treatment Note, dated 12/28/2021, documents R41 ambulated 50 feet. No complaint of pain was documented. R41's PT Treatment Note, dated 12/29/2021, documents during therapy the resident stated, My L (left) groin hurts. PTA (physical therapy assistant) asked what happened with R41 stating, It happened this morning. The Treatment Note documented PTA attempted to have R41 stand with walker and pull up from parallel bar for standing act this day. The Note documented R41 was unable to reach standing and R41 complained of left groin pain. There was no documentation in the PT note that R41 ambulated that day. The Note documented PTA consults nursing (V13, Registered Nurse/RN) regarding R41's pain in left groin and inability to utilize full Active Range of Motion or come to full standing. The Note documented nursing states will keep an eye on resident throughout the day to monitor. On 8/24/2022 at 10:45 AM V13 stated she doesn't recall a PTA reporting R41 had pain in her left groin on 12/29/2021. V13 stated when a resident has a change in condition, she assesses the resident and administers a PRN (when needed) pain medication, documents the assessment in the resident's medical record and notifies the resident's physician and POA (power of attorney). R41's PT Treatment Note, dated 12/30/2021, documents R41 attempted to stand this day however unable to rise fully from wheelchair with R41 stating pain in left groin as cause. There was no documentation in R41's PT Note that R41 ambulated this day. R41's PT Treatment Note, dated 12/31/2021, documents R41 stated pain in left groin as cause. There was no documentation R41 ambulated this day. R41's PT Treatment Note, dated 1/3/2022, documents R41 complained of pain/tightness in left lower extremity knee to groin. The Note documented PTA alerts nursing to R41's pain complaint. The Note documented nursing staff states she will call the nurse practitioner and request an X-ray to resident's left leg. R41's Medical Record dated 12/2021 and 1/2022 has no nursing progress notes including an assessment as to why R41 was complaining of left groin pain. R41's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R41's Patient X-Ray Report, dated 1/3/2022 and electronically signed at 12:36 AM, findings: a left radiologic examination, femur. Impressions: femoral neck fracture. R41's Health Status Note, dated 1/4/2022 at 1:00 AM documented that R41's X-ray results documented a femoral neck fracture. The Note documented a call was placed to the POA to notify of x-ray results and need to transfer to hospital. The Note documented 911 was called at that time. R41's Situation, Background, Assessment and Recommendation (SBAR) Communication Form and Progress Note, dated 1/4/2022, documents fx. (fracture) left femur started on 1/3/2022. The Note documented Functional status changes: fall. Transfer to the hospital. On 8/24/2022 at 10:24 AM V1, the Administrator stated she expected staff to communicate when residents have a change in condition and the nurse should assess the resident immediately and document the assessment in the nurse's notes. V1 stated she expected staff to follow facility policies. On 8/23/2022 at 4:46 PM V26, R41's Physician, stated when R41 complained of pain to therapy staff, He expected therapy staff to report the new complaint of pain to the nurse and expected the nurse assess R41 and administer pain medication if available on R41's POS then notify him or the nurse practitioner of the change in condition. V26 stated the nurse should have documented the assessment in R41's progress notes. He expected staff to reassess R41 at least every shift and document the assessment in R41's progress notes. V26 stated he expected staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility's undated Significant Condition Change & Notification Policy, documents to ensure that the resident's family and/or representative and medical practitioner are notified of resident changes such as a significant change in the resident's physical status including abnormal, unusual or new complaints of pain. The Policy documents All significant changes will be recorded on the Communication Board in the electronic medical record and in the resident record. Charting will include an assessment of the resident's current status as it relates to the change in condition. Charting will be done each shift for 72 hours for residents with change of condition. Change of condition is reviewed by the DON (Director of Nurses) or designee for the continued need for additional documentation.

Based on observation, interview and record review the facility failed to monitor, assess, and provide progressive interventions to prevent falls for 4 of 5 residents (R9, R30, R41, R146) reviewed for accidents in a sample of 26. This failure resulted in R41 falling and fracturing her left hip, dislocating her left hip, having an oblique fracture of the distal femur superior to the prosthesis with displacement, angulation and axial shortening and a comminuted fracture of her kneecap which required surgical interventions at the hospital. Findings include: 1. R41's Care Plan documents Resident is at risk for falls due to history of falls. She has a diagnosis of [CONDITION(S)] with tremors and [CONDITION(S)]. The Care Plan Goal documents Resident will remain free from injuries d/t (due to) falls through the next review. R41's Fall Care Plan Interventions documented 12/15/2021: ensure resident's feet are off the floor prior to pushing wheelchair or provide foot pedals if unable to keep feet off the floor. Keep resident by nurse's station or in viewing distance when in wheelchair for safety. R41's Care Plan Intervention added on 2/11/202 documents staff educated to ensure resident water pitcher within reach at all times. R41's Care Plan Intervention added on 3/18/2022 documents Check resident to be checked often for positioning, incontinence, with all need. Bring to nurse's station for closer observation. R41's Fall Risk Data Collection, effective date 10/6/2021 documents she had a fall within the last 90 days. The Form documented Resident is orientated to person. The Form documents Gait observation: resident unable to independently come to a standing position and requires hands-on assistance to move from place to place and decrease in muscle coordination. Staff documented she was high risk for falls. R41's Quarterly Minimum Data Set (MDS), dated [DATE] documents R41 is severely cognitively impaired. The MDS documents R41 is not steady, only able to stabilize with staff assistance for surface-to-surface transfers. The MDS documents R41 requires transfers and bed mobility extensive assist 2+ person physical assist. The MDS documents R41's balance during transitions and walking: not steady, only able to stabilize with staff assistance. The MDS documents R41 has had no falls and uses a wheelchair. R41's Health Status Note, dated 10/25/2021 at 4:31 AM documents This nurse was called into room by CNA (certified nurse assistant), noted res (resident) on the floor mat beside bed. Res. was assessed for any displaced hip or injury with none noted. Res. was then helped into chair with assist x 2. Neuro checks started r/t (related to) non witnessed fall. NP (nurse practitioner) notified. POA (power of attorney) to be notified in AM. R41's Fall Incident Report, dated 10/25/2021 at 4:26 AM documents Res was called to room by CNA. Res was on the floor beside her bed in sitting position on top of mat. Res was alert and wheelchair bound. Resident was assessed for any displaced hip or injury with none noted. Res was then helped into her chair with assist x2. Resident orientated to person and place. Neuro (neurological) checks stated r/t non witnessed fall. Nurse Practitioner notified in AM. No predisposing environmental factors were documented. Predisposing phycological factors: incontinent, confused and gait imbalance. Predisposing situation factors: staff checked none. No additional information was documented. R41's Physician's Order Sheet (POS), dated 12/2021, documents diagnoses: [CONDITION(S)], depression, peripheral [CONDITION(S)], [CONDITION(S)], [CONDITION(S)], low back pain, [CONDITION(S)], osteopenia, [CONDITION(S)] Disease, repeated falls, unsteadiness on feet and anxiety. R41's Health Status Note, dated at 12/13/2021 at 5:46 PM documents Res (resident) was attempting to stand up in common area. This nurse helped res. back into chair and was attempting to help res. propel down the hall to sit with nurse during med pass to monitor her. When pushing chair to hall res. foot got stuck under chair and res. slid from w/c (wheelchair) onto her knees. Skin tears noted to her right loser outer leg. Two 1.5 cm (centimeter) skin tears, areas cleaned, and dry dressing applied. R41's Fall Incident Report, dated at 12/13/2022 at 5:38 PM documents Res was attempting to stand up in common area. This nurse helped res back into chair was attempting to help res propel down the hall to sit with nurse during med pass to monitor her. When pushing chair to hall res foot got stuck under chair and res slid down w/c (wheelchair) onto her knees. Res stated, I fell . Resident alert and ambulatory with assistance. Orientated to person. Predisposing environmental factors: noise. Predisposing physiological factors: gait imbalance and impaired memory. Predisposing situation factors: using wheelchair. No additional information was documented. VS (vital signs) taken, and res assessed for any injuries. Noted two 1.5 cm skin tears to right lower outer leg. POA and MD (physician) notified. Area cleaned and dry dressing applied. R41's Fall Risk Data Collection, effective date 12/21/2021 documents R41 had a witnessed fall on 12/13/2021. The Data Collection documented 'The resident is orientated to person, she is incontinent. Gait observation: unable to independently come to a standing position. Staff documented she was a low risk for falls. R41's Health Status Note, dated 1/4/2022 at 2:36 PM documents a late entry note: 1/3/22 2:30 PM CNA reported that resident was c/o about pain regarding her left leg and left hip. Then therapy came to me and stated that she was standing and walking and now can't do that. Asked resident if she was in pain and she states yes on a scale of 1-10 she states the pain is a 10. Was put back in bed. Notified nurse practitioner for x-ray orders. Rec'd (received) new order for x-ray of Left femur/left hip (2 views) STAT (immediately.) Called X-ray company for STAT order. R41's Physician's Order Sheet (POS), dated 1/3/2022 at 5:00 PM, documents STAT L (left) hip X-ray 2 views and STAT left femur X-ray 2 views. R41's Health Status Note, dated 1/4/2022 at 2:45 PM documents a late entry note: 5:00 PM X-ray called stating that they are busy, and they might be 3-4 hours before they are here. Spoke to POA and let her know of new orders. X-ray tech here. Awaiting results. 9:30 PM called X-ray company called and asked if they could fax the results. They will fax when ready. R41's Patient X-Ray Report, dated 1/3/2022 and electronically signed at 12:36 AM, documents Findings: a left radiologic examination, femur. Impressions: femoral neck fracture. R41's Health Status Note, dated 1/4/2022 at 1:00 AM documents the facility received X-ray results, results showed fractured neck femoral. The Note documented a call placed to POA at this time to inform of X-ray results and need to transfer to hospital and 911 was called. R41's Health Status Note, dated 1/4/2022 at 5:33 AM documents resident admitted to local hospital with the DX (diagnosis) of fractured Lt (left) femur. R41's Situation, Background, Assessment Recommendation (SBAR) Communication Form and Progress Note, dated 1/4/2022, documents fx (fracture) left femur started on 1/3/2022. Functional status changes: fall. Transfer to the hospital. R41's Hospital Inpatient Consult, dated 1/4/2022, documents history of present illness Resident is an [AGE] year-old female presents to hospital for evaluation of left hip pain. Patient is nonverbal on evaluation this morning. Per report, nursing home states that she fell approximately 2 weeks ago but did not complain of significant pain. She is complaining of left hip pain today and subsequently brought in ER (emergency room .) Radiographs (X-rays) demonstrated a displaced left femoral neck fracture. Assessment/plan: this is an unstable injury that is generally managed operatively. To help improve clinical outcomes would recommend left hip hemiarthroplasty. Plan for surgery once medically cleared. We will continue to follow. R41's Health Status Note, dated 1/5/2022 at 11:46 AM documents Family called with update: resident is to have surgery tomorrow. Will keep us updated. R41's Health Status Note, dated 1/12/2022 at 8:00 PM documents Resident was returned to facility 1/12/2022 at 6:00 PM by ambulance with 3 attendances and went to resident's room. Resident appeared lethargic with eyes closed. Left hip fx - incision looks good slight discharge 20 staples intact. Dry foam dsg (dressing) applied. C/O (complaint of) pain on a scale of 1-10 rates it a 7. Pain med given as ordered. Call light in reach and resting quietly. R41's Fall Risk Data Collection, effective date 1/12/2022 documents Resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was high risk for falls. R41's Quarterly Minimum Data Set, dated dated [DATE] documents severely cognitively impaired. The MDS documents R41 is not steady, only able to stabilize with staff assistance for surface-to-surface transfers. The MDS documents R41 required 2+ staff physical assistance total dependence for transfers and bed mobility. The MDS documents R41 had no falls fall but had major joint replacement: hip replacement. The MDS documented R41 uses a wheelchair and R41 was not walking. R41's Health Status Note, dated 1/21/2022 at 6:40 PM documents R41 was found on the floor in her room by the CNA at 6:10 PM. The Note documented CNA alerted this nurse. Upon entering the room, resident was found face down in front of her chair with her head next to the nightstand. Resident was on her left side. The residents Foley catheter was seen hanging over the side of her chair, which was still reclined back, with the balloon still intact. Nurse assessed the resident. Breathing was normal and nonlabored. Resident was alert with confusion which is her baseline. Resident c/o (complaint of) hip pain. Resident stated she hit her forehead on the ground. 911 was called at 6:13 PM. Resident was left in the position she was in until EMS arrived. NP was made aware. EMS arrived and transferred resident to the hospital. Resident's POA was contacted twice, a message was left but there has been no call back. R41's Hospitalist Discharge Summary, dated 1/24/2022 documents R41's left hip fracture repaired by orthopedic surgeon on 1/4/2022. She was transferred to hospital for hip dislocation. Patient reportedly fell out of her chair at NH (nursing home.) ED (emergency department) attempted to reduce x 2 unsuccessfully. Transferred here to be evaluated by orthopedic surgeon for reduction possibly under anesthesia. Patient underwent left hip closed reduction under anesthesia on 1/22/2022 with orthopedic surgeon. She was discharged back to SNF (skilled nursing facility). R41's Health Status Note, dated 1/24/2022 at 2:47 PM documents Resident arrived back at facility from the hospital from L (left) hip repair at 2:15pm via ambulance. Two paramedics assisted resident back into bed. Resident was moved to room 304. Resident was alert and able to answer yes and no questions. DBS is being charged at this time. Resident has same medications minus new Iron and ASA orders, see POS. Resident has a leg abductor in place. It must be always on while in bed and in chair for 2 weeks. Foley catheter tubing in place draining yellow urine. Steri- strips intact to L hip. Slight redness noted around site, no drainage present. Scattered bruising noted to both upper extremities. Heels looked good, heel protectors on at this time. Per Administrator CNA must sit outside resident's room to be monitored. Weight baring as tolerated. Resident resting comfortably in bed currently. Bed in lowest position with call light in reach. Provider notified of re-admit. R41's Fall Risk Data Collection, effective date 1/24/2022 documents resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was high risk for falls. R41's Health Status Note, dated 3/13/2022 at 1:00 AM documents Res observed on the mat on the floor on the side of her bed on her left side, res states that she did not hit her head, but no witness noted, res able to Move all extremities WNL, res states she has a little pain but not from fall, PRN (when needed) Tylenol given @1P. Will start neuro checks & continue to mx (monitor). R41's Health Status Note, dated 3/14/2022 at 1:20 PM documents Resident complained of severe left hip pain. Nurse Practitioner notified and she ordered a 2 view X-ray of left hip and femur. R41's Patient X-Ray Report, dated 3/14/2022 and electronically signed at 8:46 PM documents left radiologic examination, femur findings: an oblique fracture is noted involving the distal femur. A patella (kneecap) fracture is also identified. Impressions: oblique fracture involving the distal femur and patella fracture. R41's Hospital Records, dated 3/15/2022 documents the resident had a dislocated left hip [CONDITION(S)] prosthesis. Oblique fracture of the distal femur superior to the prosthesis with displacement, angulation, and axial shortening. Comminuted fracture (a bone that is broken in at least two places. Comminuted fractures are caused by severe traumas like car accidents. You will need surgery to repair your bone, and recovery can take a year or longer.) of the superior patella with associated effusion and probable hemarthrosis. R41's Health Status Note, dated 3/14/2022 3:46 PM documents Wheelchair company called on this date and they will be delivering resident's new wheelchair on March 17 at 1:00 PM. R41's Health Status Note, dated 3/15/2022 at 8:43 AM documents X-rays results came back in POA notified. POA stated that she did not want resident sent out or to have any surgery until physician was notified. She wanted his opinion before anything further was decided. I called physician's office and talked with receptionist, and she stated she would leave physician's assistant a message to call facility back. R41's Health Status Note, dated 3/15/2022 at 2:24 PM documents POA was notified and wanted resident sent to hospital to be evaluated. I told her that physician does not treat her type of fx, she said she understands but this hospital is closer so she can be there and if need be, they can send her to specialty hospital. Ambulance was called, EMTS arrived at 2:20 PM and left with resident at 2:22 PM. R41's Health Status Note, dated 3/16/2022 at 1:00 AM documents resident returned to facility via ambulance. Placed into bed with the help of two. Cleaned and dried at this time. Immobilizer in place to left knee. No circulatory impairment noted. Ice placed on Lt knee for pain at this time and PRN [MEDICATION(S)] giving. Resting quietly currently. R41's POS, dated 3/16/2022 documents keep knee immobilizer on. Apply ice packs to left knee to help with pain and swelling every shift for fracture patella. R41's Fall Risk Data Collection, effective date 3/28/2022 documents resident had a fall within the last 90 days. The resident is orientated to person and incontinent. Gait observation: unable to independently come to a standing position and requires hands-on assistance to move from place to place. Staff documented she was high risk for falls. R41's Significant Change MDS, dated [DATE] documents the resident was severely cognitively impaired. The MDS documents R41 is totally dependent with 2+ persons physical assist for bed mobility and transfers. The MDS documents R41 was not walking. The MDS documents R41's balance during transitions and walking: activity did not occur. Surface-to-surface transfer: not steady, only able to stabilize with staff assistance. Mobility device: wheelchair. Falls: yes. Number of falls since admission or prior assessment- major injury: one. R41's Health Status Note, dated 4/5/2022 at 1:08 PM documents The resident's POA called this morning requesting follow up x-ray of Left femur and knee to see if fx (fracture) has gotten any better. Provider notified and gave okay for x-ray of left femur and knee. Order placed with X-ray company, stated a tech would call when they were on their way. R41's Health Status Note, dated 4/6/2022 at 9:05 AM documents X-ray results in- acute comminuted distal femoral fracture noted still. POA notified. R41's Health Status Note, dated 5/13/2022 at 11:07 AM documents Per POA's request she wants a follow up x-ray of left femur and knee. Also, she wants brace to be off at HS (night.) Nurse Practitioner aware and is okay with the brace being off at night and is okay with getting a follow up x-ray. R41's Health Status Note, dated 5/20/2022 at 8:40 AM documents nurse practitioner replied to X-ray with new order to continue NWB (no weight bearing) status and to repeat x-ray in one month to monitor progress. Cannot DC (discontinue) immobilizer D/T (due to) not being healed and would risk further harm and not healing. R41's POS, dated 5/20/2022 documents continue NWB status and repeat X-ray in one month to monitor progress. R41's Fall Risk Data Collection, effective date 6/27/2022 documents resident has no fall history. It documents R41 is orientated to person and incontinent. Gait observation: unable to independently come to a standing position. Staff documented she was low risk for falls. R41's Fall Risk Data Collection, effective date 8/2/2022 documents resident had a fall within the last 90 days. It documents R41 is orientated to person and incontinent. Gait observation: unable to assess was documented. Staff documented she was low risk for falls. On 8/21/2022 at 9:15 AM R41 was sitting up in a reclined position her a specialty wheelchair in her room alone. Signs above R41's bed read, No (full body mechanical lift) transfers, assist of 2 transfers. Floor mat on floor in front of bed. Resident didn't respond to IDPH surveyor's questions. On 8/24/2022 at 8:40 AM V24 R41's family, stated R41 broke bones in her hands and wrists prior to being admitted to the facility, she didn't have previous fractures in her lower extremities, including her hips or knees. On 8/23/2022 at 1:00 PM V2, Director of Nursing/DON stated when a resident falls, she expects staff to document a fall report and to document if the resident complained of pain, injuries sustained, environmental, footwear worn and a description of how the resident fell and what the nurse saw at the time of the fall. V2 stated the floor nurse is responsible for adding an immediate intervention so the resident doesn't fall again and then administration will add an intervention to the resident's care plan within 24 hours. On 8/23/2022 at 4:46 PM, V26, R41's physician, stated he was aware R41 fell a few times at the facility and had fractured her hip and knee cap. V26 stated he expected staff to document a thorough assessment of each fall and to add an intervention to R41's care plan after each fall to prevent the resident from falling again in the future. V26 stated he didn't know how R41 her hip in January 2022 but stated he thought she fell . V26 stated if the facility didn't know how she sustained the hip fracture they should have investigated and found out what occurred. V26 stated he was not certain if the fractures R41 sustained at the facility were pathological or not, he stated if they were pathological that would be documented on the X-ray report and/or in the resident's hospital medical records. V26 stated he expected staff to follow physician's orders and facility policies. 2.R30's Physician's Order (PO) dated 05/09/22 documents unspecified dementia with behavioral disturbance. R30's Fall Risk Data Collection dated 05/09/22 documents a score of 30.0, High Risk. R30's MDS, dated [DATE] documents that R30 has severe impaired cognition. R30's MDS documents that R30 requires extensive assistance of one-person for bed mobility, transfer, and toilet use. The MDS documents R30 requires limited assistance of one-person for walk in room, dressing, and personal hygiene. Resident is independent with setup help only for locomotion on unit, locomotion off unit, and eating. The MDS documents R30 needs physical help in part of bathing activity of one-person. The MDS documents R30 is not steady, only able to stabilize with staff assistance and uses walker and wheelchair for mobility. R30's Care Plan dated 08/18/22 documents The resident is at risk for falls R/T (related to) occasional Incontinence and confusion at times 7/7/22: slid out of bed trying to put pants on. (F/U (follow-up) til 8/4/22): Resolved 7/17/22: up without assistance in resident's room (F/U till 8/14/22), (resolved) 7/29/22: unwitnessed fall, self-transfer (FU till 8/26/22) 7/31/22: up without assistance (FU till 8/28/22). Interventions: -07/07/22: Encourage resident to call for assistance when needing to get dressed (resolved). -7/17/22: medication review Psych r/t behaviors. tearfulness:(resolved). -7/29/22 floor mat at bedside. -7/31/22: offer to lay down after breakfast. R30's interventions for fall on 07/07/22 is to encourage resident to call for assistance. Resident is confused and her cognition is severely impaired. The intervention for fall on 07/29/22 is floor mat at bedside. During this investigation, no floor mat was noted at bedside. R30's Health Status Note dated 05/09/22 at 7:35 AM documents Resident was found on the floor in her room. CNA (Certified Nurse Aide) stated that the resident was in the sitting position on the floor next to her bed. Resident had no pants or shoes on and was hanging a depend up on a hanger. Fall was unwitnessed but resident denies pain and no injury noted. Neuro assessments started. DON (Director of Nursing) and POA (Power of Attorney) made aware. R30's Health Status Note dated 06/29/22 at 1:51 AM documents CNA and this nurse responded to call light. Res. found sitting on the right side of her bed with socks on, light activated. no clutter on floor, and well lit. Res. states, 'I slid out of my bed, I didn't hit my head, I'm ok.' and giggled. 97.9 T (temperature) 76 P (pulse) 18 R (respirations) 134/82 BP (blood pressure) 97% (oxygen saturation on room air). Pain denied. limbs symmetrical. Neuro assessment WNL (within normal limits). PEERLA (pupils equal, round, reactive to light, accommodation). Hand grips equal. No apparent injury upon skin assessment. This nurse and CNA assisted her back to bed. MD (Medical Doctor) notified. POA to be notified in morning. Incident protocol initiated. Bed in low position with call light in reach. Will continue to monitor. R30's Health Status Note dated 07/07/22 at 2:15 PM documents Res observed on floor in upright position on the side of the bed. Res states that she was trying to put her pants on & slid out of bed. Resident assessed, no open areas or skin issues noted, res stated that her buttocks was a little sore, Res states that she did not hit her head & that she felt ok. Neuro checks initiated. Floor mat placed on the side of bed, call light within reach, Res brought out into dining room & received snacks & did activities. All parties notified. Will continue to monitor. R30's Fall Investigation dated 07/07/22 documents CNA called for a nurse to come down to resident's room, upon arrival resident was noted in a sitting position on the floor on the side of the bed. Resident states that she was trying to put her pants on and forgot to call for assistance, resident call light was in place. Resident assessed, no open areas or skin issues noted. States that she did not hit her head and that her bottom was just sore. VS (vital signs) initiated. BP-145/86, P-85, R-18, T-97.8, O2-97% RA, was start neuro checks and notify MD, POA, DON, Administrator. Resident educated on using call light for assistance, floor mat placed on the side of the bed. Resident brought into dining room for activities and snack. Will continue to monitor. Notes 07/08/22 - Resident slid out of bed trying to put her pants on. Encourage resident to call for assist to get dressed. R30's Health Status Note dated 07/17/22 at 11:02 AM documents CNA notified nurse that res was on the floor. Res noted sitting on floor in front of WC (wheelchair). Feet extended toward WC with back facing recliner. Res assessed and able to MAE (move all extremities) WNL. No internal or external rotation noted. When asked if she hit her head, res said, 'No.' When asked if she was trying to get into her recliner, res said, 'No.' This nurse asked res what happened, and she said, 'I was trying to get into bed.' Res assisted up & into wheelchair by 3 staff with gait belt. Res brought to the DR (dining room) for 1:1 monitoring. R30's Fall Investigation dated 07/17/22 documents CNA came to this nurse and said resident was on the floor. This nurse and coworker went with CNA back to resident's room. WC in middle of room. Resident noted sitting on the floor in front of WC facing it. Legs extended toward bathroom door. Back in front of recliner. Resident balancing self on R (right) hand. This nurse asked resident if she was trying to get into her recliner. Resident shook head, No. This nurse asked resident if she hit her head. Resident shook head, No. This nurse asked resident what she was doing. Resident said, 'I was trying to get in bed.' Resident able to move all extremties within normal limits. No internal or external rotation noted. No c/o pain or discomfort noted. Resident assisted up into wheelchair by 3 staff with gait belt. Resident brought to the dining room to keep visual of resident. Notes: 07/18/22 - Medication review and psych eval. R30's Fall Investigation dated 07/29/22 documents Resident unable to give description. Notes: 08/01/22 - Staff to encourage resident to stay out in high traffic areas for supervision. R30's Health Status Note dated 07/30/22 at 12:09 AM documents CNA summoned this nurse to resident room. Resident found on floor in a stretched-out position. Denies hitting head. Fall unwitnessed neuro checks initiated. No internal/external rotation noted. Assisted off the floor with the help of two and placed into bed. Call light within reach. Denies pain or discomfort. R30's Health Status Note dated 07/31/22 at 11:17 AM documents CNA came to the DR (dining room) & said res was on floor in her room. No call light sounding. This nurse went to the room and noted res lying on her R side with R arm under the bed. L hand was holding onto top of mattress. Legs were extended towards wall @ HOB (head of bed). No internal or external rotation of legs noted. When asked if she was trying to get in bed by herself, res shook her head yes. No injuries noted. Res assisted up and into bed by 2 staff members. DON, ADON (Assistant Director of Nursing), MDS & MD notified of resident's fall. On 08/21/22 at 2:50 PM, there were no floor mats noted in R30's or on floor. On 08/23/22 at 8:50 AM, R30 was sleeping in recliner. observation of no floor mats in room. On 08/23/22 at 9:00 AM, V7, CNA stated, She doesn't have a floor mat. On 08/23/22 at 1:02 PM, R30 was lying in bed. There were no floor mats in R30's room. On 8/23/2022 at 1:00 PM V2, the DON stated when a resident falls, she expects staff to document a fall report and to document if the resident complained of pain, injuries sustained, environmental, footwear worn and a description of how the resident fell and what the nurse saw at the time of the fall. The floor nurse is responsible for adding an immediate intervention so the resident doesn't fall again and then administration will add an intervention to the resident's care plan within 24 hours. Facility's policy revised February 2021 documents The S.A.F.E program promotes Safety, Assessment, Fall Prevention and Education of both staff and residents. The Policy documents 3. Residents found to be at high risk for falls are placed on the S.A.F.E. program, and specific interventions are implemented to meet individual need. Under Program heading 3. documents Following any falls, the facility staff completes an Occurrence Report. Details of the fall will be reported, and potential casual factors identified and investigated. Interventions will be immediately implemented following each fall and added to the resident's care. The staff will review the resident's Fall Risk Data Collection. An update or change to the data collection form would be made only if the resident had previously been identified as low risk. 3. R146's Physician Order Sheet dated August 2022 document diagnoses of Hydronephrosis with renal and [CONDITION(S)] calculus obstruction, chronic obstructive pulmonary disease, type 2 diabetes, and hypertension. R146's Progress Notes document R146 was admitted to the facility on [DATE] at 6:43 PM. R146's MDS dated [DATE] Admission documents R146 was moderately impaired for cognition. R146's MDS also documents, R146 does not need help from staff oversight at any time for bed mobility, and transfer. R146's MDS documents R146 did not walk in her room during this assessment period. The MDS documented locomotion on unit and locomotion on unit was marked as independent. The MDS document R146 had a fall prior to admission/entry or reentry. R146's balance was not steady, but able to stabilize without staff assistance from moving from seated to standing and walking, moving to and from toilet. R146's MDS does not document R146 uses a walker. R146's Care Plan documents, The resident is at risk for falls related to unaware of safety needs. (Date initiated 8/19/2022). On 8/22/2022 at 11:55 AM, V4, MDS Coordinator, stated, (R146) when she came in was a stand and pivot only. She was in her wheelchair most of the time and could only stand and pivot only. She did not walk and or use a walker. R146's Progress Notes dated 8/1/2022 at 9:49 AM, documented When I was getting ready to start medication pass, I heard someone yelling down Oak hall. I followed the sound to (R146's) room where I found resident lying on the floor. Upon entering the room, I seen that the bed side table was flipped over and was lying on the ground. Resident denture cup and dentures were lying on the floor close to the floor. Water was spilled on the floor from the denture cup. Resident was lying on left side. Feet were towards her roommate bed. Roommate was fast asleep. Resident head was towards dresser that had TV on it. She had non-slip socks with grips on at the time. She was also incontinent at the time of the fall. Lights were on in her room, but bathroom light was on. Resident said she was unsure what happened. She said she thought she heard someone call her name. She said the only thing that hurt was her heel and that she did not hit her head. Call light was in reach on bed rail closest to the door. Another nurse and I assessed resident. No apparent injuries and Range of Motion Within Normal Limits. Neuro checks initiated. Resident assisted to bathroom and changed then brought to the dining room. Notified Power of Attorney, Medical Director, and Director of Nursing and Assistant Director of Nursing. R146's Progress Note dated 8/2/2022 at 11:29 AM, documented Bruise noted to right inner ankle from fall yesterday. No complaint of pain or discomfort. No swelling or tenderness notes. Able to move ankle without pain or difficulty. Range of Motion, within normal limits. R146's Incident Report dated 8/1/2022 at 6:06 AM, documented When I was beginning to start medication pass I heard someone yelling down the hall. I followed the sounds to (R146's room) where I found resident lying on the floor. Upon entering room, I seen that the bed side table was flipped over and was lying on the ground. Resident denture cup and dentures were lying on the floor close to the floor. Water was spilled on the floor from the denture cup, Resident was lying on left side. Feet were towards her roommate bed. Roommate was fast asleep, Resident head was towards dresser that had TV on it. She had non-slip socks with grips on at the time [TRUNCATED]

Based on observation, interview and record review, the facility failed to prevent [CONDITION(S)] by following physician's orders regarding indwelling catheter care for 1 of 3 (R10) reviewed for [CONDITION(S)] in the sample of 26. This failure resulted in R7 experiencing unnecessary [CONDITION(S)] and severe abdominal pain. Findings include: R10's Care Plan dated 4/14/2021, documents R10 has an indwelling catheter. R10's Care Plan Goal documents he will remain free from catheter-related trauma through review date, and he will show no signs or symptoms of urinary infection through review date. R10's Care Plan Interventions documents Catheter care every shift and PRN (when needed), 16 FR (French) indwelling catheter. Position catheter bag and tubing below level of the bladder and away from entrance room door. Monitor for s/s (signs and symptoms) of discomfort on urination and frequency, monitor/record/report to MD (physician) for signs/symptoms of [CONDITION(S)] (urinary tract infections): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. R10's Admission Minimum Data Set (MDS) dated [DATE] documents he was alert and had an indwelling catheter. R10's Urology Follow Up Noted, dated 7/5/2022 documents history and physical: Resident is here for a follow-up. Resident had significant urethral erosion from chronic indwelling catheter. He wants to remove the catheter because it is bothering him and causing his penile pain and [CONDITION(S)] erosion is worse. The assessment/plan documents resident is a [AGE] year-old male with hx (history) of non-obstructive prostate. I am still not sure he has [CONDITION(S)] or if catheter was placed out of convenience. He has CHF (chronic heart failure), and bladder scan won't be reliable. My recommendation is to remove the catheter and managed with diaper or bedside urinal. We can consider clean intermittent catheterization if needed to be. Follow up in 6 months. R10's July 2022 Physician's Order Sheet (POS), documents a new order, dated 7/5/2022, to remove catheter due to penile urethral damage and recurrent UTIs (urinary tract infections.) Void (urinate) and occasional straight catheterize. Bladder scan not reliable d/t (due to) CHF and fluid retention. Can consider condom catheters or depends (incontinence briefs.) Call urologist with further questions. Another physician's order dated 7/5/2022 documents remove indwelling catheter one time only for 1 day d/t (due to) penile urethral damage. End order date 7/6/2022. R10's Health Status Note, dated 7/5/2022 and 7/6/2022 has no documentation if staff removed R7's indwelling catheter, if staff performed a straight Cath on him, if he was able to urinate in a urinal, wore incontinence briefs or if staff administered R7 a condom catheter. R10's Health Status Note, dated 7/7/2022 at 7:47 PM documents Res. straight cathed after c/o (complaint of) extreme lower abd (abdominal) pain. 800 cc urine out. This nurse left in foley catheter and attached to drainage bag and called MD (physician) exchange. Awaiting response. At 7:52 PM NP (Nurse Practitioner) ordered to leave in indwelling catheter d/t (due to) [CONDITION(S)] and frequent straight cathing. Notify Urologist of [CONDITION(S)] and catheter being put back in. 9:50 PM 400 CC out after indwelling catheter put in at 7:30 PM. 1950 cc out this entire shift. Urologist to be notified in morning. R10's Health Status Note, dated 7/8/2022 at 2:14 PM documents Urologist office notified of res having [CONDITION(S)] and of indwelling catheter being left in place. R10's POS, dated 7/20/2022 documents a new physician's order: start date 7/7/2022 for catheter 16 F for [CONDITION(S)]. One time only for [CONDITION(S)]. Catheter care, check catheter anchor placement every shift and as needed and catheter output every shift: start date 3/18/2022 end date 7/6/2022. R10's Physician's Order Sheet (POS), dated 7/22/2022 documents order to remove catheter due to penile urethral damage and recurrent UTIs (urinary tract infections.) Void (urinate) and occasional straight catheterize. Bladder scan not reliable d/t (due to) CHF and fluid retention. Can consider condom catheters or depends (incontinence briefs.) Call urologist with further questions was discontinued on 7/22/2022. On 8/23/22 at 1:35 PM, V7, Certified Nurse's Assistant (CNA) and V18, CNA administered catheter care for R10. R10's penis was reddened, split on the right side, and sometimes bleeds according to R10 On 8/23/2022 at 9:20 AM R10 stated, I've had a catheter for a long time, and I don't want it anymore because my penis is fractured, and it hurts really bad to have the catheter in. My penis is split in half, and I have major penile damage to the hole on my penis due to the long-term catheter use. I went to the urologist in July and came back to the facility and my catheter was taken out, but I didn't urinate for 2 days, no staff straight cathed me or asked me if I had urinated, it wasn't until days later that I told staff I was having severe abdominal pain and they put the indwelling catheter back in. It hurts so bad to have the catheter in, but staff didn't straight Cath me those days and I could feel the urine building up in my body, who knows how long I would have gone without urinating if I wouldn't have told staff I was hurting. No staff have discussed the catheter with me since they put a new catheter in in July 2022. I haven't had any current UTIs, but I have had them in the past. On 8/23/2022 at 1:00 PM V2, the Director of Nurses (DON) stated R7 was assessed by his urologist on 7/5/2022 and he ordered to take R7's catheter out to see if he had [CONDITION(S)], it was a trial. V2 stated she expected staff to document when R7's catheter was removed and how he responded to it. V2 stated she expected staff to follow the physician's order and to straight Cath him PRN (when needed.) V2 stated staff reported to her that R7 was not urinating on his own so they reinserted the indwelling catheter and notified the facility's nurse practitioner. V2 stated she expected staff to document when they straight cathed R7 and to document the output so they would know how was doing without the indwelling catheter in. On 8/23/2022 at 9:38 AM V19, the Urologist stated he assessed R7 in his office on 7/5/2022 and instructed the facility to take his indwelling catheter out due to penile urethral erosion. V19 stated R7 complained the indwelling catheter hurt and he wanted it out. V19 stated in July V19 wrote a physician's order to have staff straight cath, use a urinal or wear Depends to allow the penis to heal. V19 stated he wanted to make sure R7 had true [CONDITION(S)] and not having an indwelling catheter for staff convenience. V19 stated his nurse called the facility on 7/8/2022 and R7's nurse reported R7 wasn't able to urinate on his own, so he ordered the indwelling catheter for true [CONDITION(S)]. V19 stated when he ordered the indwelling catheter to be discontinued on 7/5/2022 he expected staff to straight cath R7 every 6 hours and to document how much urine was removed and to continue assessing the resident R7 to ensure he could urinate so he could assess R7's ability to urinate on his own. V19 stated he expected staff to follow physician's orders and facility policies. On 8/24/2022 at 2:34 PM V1, Administrator stated the facility doesn't have a [CONDITION(S)] policy.

Based on interview and record review the Facility failed to assess risks and monitor the appropriate use of side rails for 1 of 12 residents (R28) reviewed for bed rails/side rails the sample of 26. This failure resulted in R28's face being found on the side rail causing R28's nose to bleed, facial swelling, and an opened area to her nose. Finding include: On 8/23/2022 at 2:00 PM, R28 was not able to respond to any questions, was not moving in bed and laying on her back staring into straight ahead with no responses and or expressions. On 8/23/2022 at 10:39 AM, R28 was lying in bed with her head elevated at a 40-degree angle. The side rail towards the window was attached at the top of the mattress towards her head and there was no covering on it. On R28's opposite side of the bed towards the entrance door the side rail was staggered and started at her shoulder level. The side rail did not have any padding on it. The side rails were 15 inches in length and 5 inches wide in the largest opening towards the top of the siderail and there was no padding present on either side rail. (This exceeds the of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendation for side rails). R28's Minimum Data Set (MDS) dated [DATE] document R28 was severely impaired for cognition. R28's MDS documents R28 is total dependent on two plus staff for turning and reposition, bed mobility, and transfer, dressing and eating. R28's MDS documents R28 has an impairment on both her upper and lower extremities. R28's Restraint Evaluation dated 8/1/2022 document, side rails for bed positioning or transferring. No other, lesser restrictive restraints have been attempted. No restraint reduction been attempted since last review: used for bed positioning. Benefits of restraint use include prevention of injuries, reduced fall potential and functional enhancement. IDT (Interdisplinary team) recommendations continue with current restraint. No benefits versus risks were documented for the assessment/evaluation. R28's August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's POS, dated 8/22/2022 documents a new order, resident had full bilateral side rails an assessment was completed and a reduction was made, and bilateral quarter side rails were applied to maintain safety while in bed. On 8/22/2022 at 12:40 PM, V22 Maintenance Director was in R28's room and stated he was changing R28's bed. The long side rails were on the floor and new side rails were on the resident's bed. V22 stated V2, Director of Nursing, told him to change R28's side rails because they aren't supposed to use those side rails. R28's Progress Notes dated 7/21/2022 at 10:30 PM, When rounding at 2 PM this nurse found resident laying with her lower face on the siderail and oxygen tubing off her face. Scan amount of blood in left nostril. Left cheek and jaw reddened from lying on side rail and a 0.25cm open area to bridge of nose. MDS Coordinator notified. The nurse was instructed to write a progress note and not an incident report. On 8/22/2022 at 2:20 PM, V9, Licensed Practical Nurse (LPN) stated, I remember finding (R28) laying on her left side, her face was against the left side rail and the side rail was in her mouth. I immediately repositioned the resident on her back and assessed the left side of her face. (R28's) face was red and swollen and she had a laceration on the bridge of her nose. Her oxygen via nasal cannula was off and her oxygen saturation was 90% on room air. At the time I felt this could be abuse and neglect because the resident must have been laying like this for long periods of time because her left side of her face was red and swollen. (R28) can't move on her own at all, both of her arms are contracted, and she is unable to remove the nasal cannula off on her own. I notified the MDS Coordinator about the incident and she told me not to write an incident report on it, but I progress note which I did. On 8/22/2022 at 2:40 PM V4, MDS Coordinator stated she recalled the nurse notified her that R28 was found with her head on the side rail and an abrasion on the top of her nose. She didn't know how it occurred because she wasn't here at the time. (V1), the Administrator told her to do a reassessment of R28's side rails today and when she did, she noted the side rails were not appropriate because the resident cannot turn/reposition herself and she needed to do a restraint reduction. The side rails went from full side rails to quarter length side rails. On 8/22/2022 at 2:58 PM V2 stated she didn't know about the regulation for side rails. V2 stated V1 Administrator told the maintenance man to change out the side rails because she thought they were too long for R28. V2 stated R28 can't move on her own, staff turn and reposition her every2 hours and as needed. V2 stated she didn't know why R28 had side rails. On 8/22/2022 at 3:02 PM V1 stated she went to look at R28's side rails when the State surveyor requested the side rails manufacture guidelines and she noted her side rails didn't look stable. V1 stated she will have to read the long-term care regulations to see if the side rails were within regulation. V1 had staff change the side rails from full side rails to quarter length side rails after lunch on 8/22/2022. V1 stated she wasn't at the facility when staff assessed R28 laying on the side rail so she can't say how it occurred. V1 stated she spoke to the V2 and V4 and they came to the conclusion that R28 slid down in bed due to gravity depending on or perhaps she wasn't positioned quit at the right angle. V1 stated she was told the laceration on R28's nose was from her hitting the side rail. V1 stated she expected the side rails to be addressed on R28's care plan and for V2 to educate staff to ensure R28 was positioned away from the side rails so this doesn't happen again. V1 stated she didn't know how long R28 the long side rails had, she's had them since she started as the administrator in December 2021 or why she had them because the resident doesn't move on her own at all so she wouldn't use them for mobility. On 8/23/2022 at 10:00 AM V15, Nurse Practitioner stated she doesn't know why R28 has full side rails, and she wasn't aware if R28 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . V15 stated she would expect staff to notify her or the physician if they wanted to make changes to R28's side rails because it was a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V15 stated she expected staff to assess R28's risks and benefits to the side rails quarterly and when there is a change in R28 she also expected staff to assess R28 for a reduction inside rails every quarter. V15 stated she was not aware R28 was found lying on her left side with her head on the side and a laceration on the bridge of her nose side rail in July 2022 she would expect staff to notify the provider so they can ensure R28 is safe with the side rails. V15 stated if the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V15 stated this may have prevented R28 from acquiring the laceration on her nose in July 2022. V15 expected staff to follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The Guidance Industry and Food and Drug Administration (FDA) Staff Hospital Bed System and Assessment Guidance to Reduce Entrapment dated 3/10/206 documents, To reduce the risk of head entrapment, openings in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 95 mm (3 ¾ inches). A dimension of 120 mm (4 ¾ inches) encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations and includes 1st percentile female head breadth as reported in some data sources. FDA is therefore using a head breadth dimension of 120 mm (4 ¾ inches) as the basis for its dimensional limit recommendations. This dimension is consistent with the dimensions recommended by The Hospital Bed Safety Workgroup. On 8/24/2022 at 10:18 AM, V2, Director of Nursing stated, I expect all Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . I am not sure what happened with (R28). On 8/24/2022 at 10:22 AM, V1 stated, I would expect physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Proper Use of Side Rails Policy with a revision dated of 2/2021 documents, Side rails are conserved a restrain when they are used to limit the resident's freedom of movement (prevent the residents from leaving his/her bed). (Note: The side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstance.) Side rails with padding may be used to prevent resident injury in situations of uncontrollable movement disorders but are still restraints if they meet the definition of a restraint.

Based on observation, interview and record review, the Facility failed to identify residents at risk for falls, provide safe transfers, implement effective/progressive fall prevention interventions, determine the root cause of falls, and follow the Facility Fall Prevention Policy for 3 of 3 residents (R1, R2, R4) reviewed for falls in the sample of 9. These failures resulted in R1's fall sustaining a skull fracture and brain bleed; R2's fall sustaining a right distal femur fracture and left periprosthetic femur fracture both requiring surgical intervention and hospitalization . Findings include: 1. R2's Minimum Data Set (MDS) dated [DATE] documents that R2 is severely cognitively impaired and requires two assist for transfers and is totally dependent on staff for bathing. R2's Progress Notes dated 10/23/21 documents, CNA came to this nurse stating that when transferring resident from wheelchair to shower chair, balance became unsteady so she lowered resident to the ground. Resident did not hit her head. On 10/28/21 at 1:50 PM, V10, CNA (Certified Nursing Assistant), stated, I only heard rumors of what happened. (R2) fell during a transfer during her shower. The CNA said she lowered her to the ground. It seems odd that if she was lowered to the ground, how did she get that hurt? On 10/28/21 at 2:49 PM, V13, Care Plan Nurse, confirmed that R2's Care Plan did not address R2 as being a Fall Risk, nor list any fall prevention interventions. On 10/28/21 at 2:50 PM, V13, CNA, was being interviewed by V1, Administrator, for the fall investigation report. At this time V13 stated, (R2's) fall happened on a Saturday. I was giving her a shower. I was in the room the whole time. I should have put a blanket down because the floor was wet. I did not use a gait belt. I got her pants halfway down when one of her legs went in between mine and the other one slid the other way. (R2) did complain of knee pain when I stretched it out. (R2) said, I think my leg is broken. It looked like the knee cap went to one side and there was swelling on the other side. (R2) is normally one assist. I am not sure what fall interventions are in place. On 11/1/21 at 3:00 PM, R2 was observed lying in bed. The bed was not in the lowest position and could be lowered further. There was no fall mat present. R2 did not have socks on. On 11/2/21 at 1:15 PM, the report sent to the Illinois Department of Public Health (IDPH) , that had previously been requested on 11/1/21, was provided. The report was titled, Summary of Findings to Reportable Injury 10/23/21. It documents that V13 was transferring R2 from her wheelchair to the shower chair, V13 held onto the back of R2's pants, and that due to loss of balance and a wet floor, V13 lowered R2 to the floor. It further documents that X-rays were ordered for R2's bilateral knees which revealed a distal femur fracture to the right leg. It does not mention the fracture to the left femur. The documents lists placing non-ski strips in the shower to prevent falls due to wet floors as an intervention. On 11/2/21 at 1:30 PM, V15, Licensed Practical Nurse (LPN), stated that R2 uses the shower on her hall. At this time, the shower room on the hall which R2 resides on was observed. There were no non-skid strips in the bathroom by the showers or the toilet. This observation was verified and confirmed with V2, Director of Nursing (DON). On 11/2/21 at 1:45 PM, V18, Nurse Practitioner (NP) stated, (R2) used to use her legs/arms well and was able to wheel herself around in chair. If they were not using a gait belt and she slipped in water, that's not safe. It absolutely caused her harm if she's got broken bones now. R2's metropolitan hospital Encounter Information, dated 10/29/21, documents Admission 10/24/21 to Geriatric Trauma Surgery Team, Discharge 10/29/21. It also documents R2 had a right distal femur fracture and a left periprosthetic femur fracture both requiring surgical interventions. 2. R1's Care Plan documents, (R1) has a potential for falling related to fall history, cognitive impairment, non-compliance with safety needs and high-risk medications. The Facility's Incident/Accident Log dated October 2021, documents an incident resulting with a laceration on 10/14/21. R1's Progress Notes dated 10/14/21 at 9:53 PM documents, This nurse was called over to (R1's) table in dining room. (R1) was on the ground. Per CNA resident stood up and lost her balance. Resident was assessed for injury and helped back into dining room chair. Area to head was cleaned and dressing was applied. POA (Power of Attorney), nursing management and Nurse Practitioner notified. R1's Progress Notes dated 10/15/21 at 10:38 AM documents, IDT (Interdisciplinary Team) met to review event from 10/14/21 when resident had a witnessed fall resulting in a superficial laceration to the back of the head. It continues to document, Fall assessment updated and continues to show resident at high risk for falls. Root cause determined to be increased behaviors requiring redirection that resulted in resident loosing her balance. SS (Social Services) to contact psych to have medications reviewed. R1's Care Plan does not reflect a intervention being implemented after the fall that occurred on 10/14/21. R1's Progress Notes dated 10/27/21 at 8:07 AM documents, CNA alerted the nurse that (R1) was having a hard time ambulating and was complaining of pain. Upon assessment, it was noted that the right hip looked like it was rotated inwards and (R1's) right knee was more swollen than the left knee. The nurse practitioner ordered STAT (Immediately) x-ray of right hip/femur. The Facility never provided the X-ray results, although, they were requested multiple times. On 10/28/21 at 12:45 PM, R1 was lying on her back on the floor in her room. R1 was complaining of pain. V9, LPN, V10, CNA, and Emergency Medical Technicians were present in the room. R1 was heard complaining of pain and there was blood on the pillow beneath R1's head. On 10/28/21 at 1:15 PM, V10, CNA, stated, (R1's) fall was unwitnessed. I found her, laying on her back on the floor when I delivered her tray. She cried out when we tried to move her. She said her back, head and hip hurt. I heard just (R1) also had a fall on the 14th (10/14/21). There are no fall interventions in place. She is in a low bed though. R1's Progress Notes dated 10/29/21, documents, Call placed to (local hospital) to see what resident was admitted with. Spoke with nurse who said resident was admitted with a subdural hematoma, subarachnoid hematoma and a skull fracture. (Nurse) also said family is considering hospice. On 11/2/21 at 9:30 AM, V10, CNA, stated, I had last seen her a little bit before her fall. She was up ambulating in the hall. She was not in bed when I saw her last. On 11/2/21 at 10:00 AM, V3, Social Services, stated, I did contact pysch. That was one of the interventions for her falls, which I think is ridiculous. They said keep her meds the same. I contacted them on 15th. She has not had any med changes recently, they were working. The Facility never provided a fall investigation or any report sent to IDPH regarding this fall and the outcome of it. 3. The Facility's September and October Incident/Accident Reports document several incidents/accidents involving R4. R4's Progress Notes dated 9/28/21 documents, Called to residents room and found resident on floor next to bed. The bed was deflated at the time. Unknown how that happened. Was assisted back to an inflated bed with 3 assists. R4's Progress Notes dated 9/29/21, documents, IDT met to review event from 9/28/21 when resident was found on the floor of the room beside her bed. Investigation shows resident has diagnoses of [CONDITION(S)], [CONDITION(S)], [CONDITION(S)]/[CONDITION(S)], weakness and [CONDITION(S)]. Fall assessment shows resident to be at high risk for falls. Initial inspection of the environment shows air mattress was unplugged and deflated. Upon further review, it was noted the position of the bed blocks the room door from being opened fully. Because of this the bed is frequently moved and could easily cause the plug to be pulled out. Bed has been repositioned against the wall to allow better access to a clutter free environment. Resident did not receive injuries. Neuros have been WNL (within normal limits). Care plan reviewed and updated. R4's Progress Note dated 10/14/21 at 1:27 PM documents, Resident had a fall on 9/28/21 when she rolled out of bed. Interventions implemented have been effective. R4's Progress Notes dated 10/20/21 documents, IDT met to review event from 9/28/21 when resident fell from bed. Previously implemented interventions have been effective. No new recommendations at this time. R4's Progress Notes dated 10/30/21 at 4:30 PM documents, Was called to room (#) by roommate and found resident on the floor leaning against the bed. Resident unable to say what happened. Left side of air mattress was deflated and it appears that resident slid out of bed. No injuries noted. Resident put in WC (wheelchair) and brought to the Dining room to monitor. Neuro checks started. On 11/3/21 at 1:45 PM, V2, DON, stated, If they haven't sent you the investigations related to the falls by now, they don't have them. The Facility's Fall Prevention Policy dated 2/2021 documents, Following any falls, facility staff will complete an Occurrence Report. Details of the fall will be reported and potential causal factors identified and investigated. Interventions will be implemented following each fall and added to the residents plan of care.

Based on observation, interview and record review, the Facility failed to timely assist a dependent resident off the bed pan and relieve pressure to her buttocks and coccyx for 1 of 2 residents (R2) reviewed for pressure ulcers in the sample of 9. This resulted in R2 acquiring two unstageable pressure ulcers to her coccyx and a deep tissue injury to her left buttock. Findings include: On 7/5/19 at 1:50 PM V7 and V8, Certified Nurse's Aides (CNAs) assisted R2 to stand, while V20, Licensed Practical Nurse (LPN) removed the dressing from an irregular shaped Stage II pressure ulcer with a dark red base on R2's coccyx. The pressure ulcer was located at the top of a horseshoe shaped bruise that went down both of R2's buttocks and connected at the top at her tailbone area. The bruises were purple in color, with the bruise to R2's right buttock darker than the one on her left buttock. R2 stated she got the pressure sore from being on the bedpan too long and stated that she could not remember who had put her on the bedpan that night. R2 stated, My butt hurts where I sit on it. There was a plastic bedpan under R2's bedside table that matched the shape and size of her bruises. R2 stated that's the bedpan she uses at night. On 7/9/19 at 1:00 PM, R2 was turned by V19, CNA, there was a dressing covering the pressure ulcer to her coccyx and a new dressing covering her left buttock. There was bruising noted the length of R2's right buttock, and a bruise extending above and below dressing to left buttock wound, but fading further down her left buttock. R2 stated, It still hurts when I sit. On 7/10/19 at 9:35 AM, V23, Family Nurse Practitioner from the Consultant Wound Management Company, completed R2's initial pressure ulcer assessment. V23 stated there were two unstageable wounds to R2's coccyx, one on each side of her butt crack. The unstageable ulcer on the right coccyx measured 0.5 cm by 1.6 cm by unstageable; the ulcer on the left coccyx measured 2.0 cm by 4.2 cm by unstageable. V23 stated these wounds are unstageable because the wound beds are obscured by slough (dead tissue usually cream or yellow in color). V23 stated the wound on the left buttock is a deep tissue injury (intact skin with localized area of persistent deep red, maroon, purple discoloration due to damage of underlying soft tissue). V2, Director of Nursing (DON) was present during V23's visit to R2 and V2 informed V23 that the wounds were pressure injuries from a bedpan. R2's Minimum Data Set (MDS), dated [DATE], documents, in part, a Brief Interview for Mental Status (BIMS) score of 15, indicating she is alert and oriented. The same MDS also documents she is dependent on staff for transfers and toileting and bed mobility, including turning and repositioning while in bed, and is frequently incontinent of urine and occasionally incontinent of bowel. The MDS lists R2's diagnoses, which include [MEDICAL CONDITION] (blood clots), Diabetes, and Stroke. According to her MDS, R2's clinical skin risk assessment score documents she is at risk of developing pressure ulcers but did not have any pressure ulcers at the time of that assessment. R2's Nurse's Note dated 6/28/19 at 10:00 AM documents, Resident noted with purple discoloration from lower left buttocks, up and around top of right buttock and down to lower right buttocks. Skin intact. New orders to discontinue Flexiciol (wound dressing) and start Meplilex (wound dressing) to be changed every three days. This area noted by Power of Attorney when toileting done in AM. Bruised areas are noted to be approximately 1 centimeter (cm) in width. R2's Incident Investigation dated 6/28/19 documents Resident has linear purple bruising the shape of bedpan wall. Nurse reported after family member saw bruise this morning. The Incident Investigation documents, under, What Corrective Actions Were Taken: Staff educated to monitor all residents closely while on bedpan. Do not allow a resident to stay on a bedpan for a long period. R2 was hospitalized for [REDACTED]. The hospital records include physician progress notes [REDACTED]. Skin intact. The hospital reports also include a Registered Dietician consultation report which documents, Pt (patient) with a deep tissue injury on coccyx. R2's readmission Skin Assessment, dated 7/3/19, documents, 3 centimeter (cm) w (wide) by 1 cm (long) open area; marks from bedpan 54 cm. This description has a line drawn indicating the wound is in R2's coccyx region. R2's readmission Nurse's Notes dated 7/3/19 at 8:00 PM documents, (R2) has open areas to coccyx and to bedpan marks - marks measure 54 cm. R2's Nurse's Notes dated 7/6/19 at 12:05 AM documents an open area to R2's buttock marks on left side that measures 1 1/2 cm by 3 1/2 cm. A Nurse's Note on 7/7/19 at 10:20 AM documents a new order was received from the Nurse Practitioner for the Facility's contracted Wound Specialist to evaluate and treat R2's wounds. R2's Care Plan dated 6/13/19 documents a problem that R2 is at risk for skin impairment and includes an update on 6/28/19 to apply [MEDICATION NAME] to coccyx and change every three days, but it does not include current pressure ulcers to her coccyx and left buttock, or the bruising to her buttocks from the bedpan. On 7/9/19 at 8:55 AM V2 stated she had the night nurse, V13, Registered Nurse (RN) question the CNAs on the night shift and none of them knew who had put R2 on the bedpan on 6/28/19, or who took her off it. V2 stated she would expect staff to keep checking on a resident who was on the bedpan every 4-5 minutes to see if they were finished. V2 stated her worry was that a CNA put R2 on the bedpan that night, and then got busy and R2 fell asleep and did not call to remind staff to take her off the bedpan. V2 stated R2's daughter had been in on the evening shift on 6/27/19 and toileted R2, cleaned her up and put her to bed around 7:30 PM per her usual routine. V2 stated R2's daughter informed her that R2's skin on her buttocks and coccyx were clear at that time. V2 stated she was appalled that R2 was left on the bedpan long enough to get the wounds she has. On 7/9/19 at 1:45 PM V21, R2's Physician, stated if the family saw R2's coccyx and buttocks the evening before and her skin was clear, and then the next day she had bruising from the bedpan, and has since developed open areas on the bruise lines, it is most likely the wounds were caused by pressure from being left on the bedpan for an extended length of time. On 7/9/19 at 2:00 PM V2 stated she classifies R2's coccyx wound as a Stage 2 Pressure Ulcer and the wound on her left buttock is an unstageable pressure ulcer. This is not documented in R2's medical record, nor is there a description of the wounds to the coccyx and left buttock. The Facility's undated policy, Decubitus Ulcer (Care and Prevention) documents, in part, under Purpose: To prevent and treat further breakdown of pressure sores. According to this policy, documentation should include: Preventative measures used; Condition of the resident's skin; Physician notification, if appropriate; Preventative equipment used; and if decubitus is present, the licensed nurse is responsible to record condition of the skin, including stage, size, depth, color, drainage, and odor as well as the treatment provided. Notification of the physician is required when a new decubitus is identified as well as when treatment is not effective.

Based on observation, interview and record review the Facility failed to supervise a cognitively impaired resident, failed to ensure resident equipment was in place and in good working condition, and failed to provide progressive interventions after falls to prevent further falls for 4 of 4 residents (R1, R2, R3 and R4) reviewed for falls in the sample of 9. This failure resulted in R4 falling and receiving a laceration to her left eye that required 9 sutures. Findings include: 1. R4's Face Sheet, dated 1/2/19 documents her diagnoses, in part, as [MEDICAL CONDITION] and Fracture of left hip on 12/14/18. On 7/5/19 at 10:00 AM R4 was sitting in her wheelchair in the dining room. She was noted to have a laceration to her left forehead with steri-strips over it. R4's Minimum Data Set ((MDS) dated [DATE] documents Brief Interview for Mental Status (BIMS) score of 6, indicating she is severely cognitively impaired, and she requires extensive assist with bed mobility, transfers, dressing, eating, toileting and bathing. It documents R4 is dependent on staff for locomotion in and outside of the facility and uses a wheelchair. R4's Care Plan, dated 6/13/19, documents the problem, (R4) is at risk for falls related to: she requires assist with ADL's (Activities of Daily Living). (R4) has a history of falls and has had two falls since last assessment. (R4) will attempt to stand unassisted. The Care Plan Intervention dated 12/31/18 documents Check on (R4) frequently. The Care Plan Intervention dated 4/17/19, documents Instructed CNAs (Certified Nurse's Aides) to make sure call light in reach and chair pad alarm in wheelchair and turned on. The Care Plan Intervention dated 6/15/19, documents Utilize wheelchair only for locomotion. R4's Fall Risk assessment dated [DATE] documents a fall risk score of 12, indicating R4 is at a high risk of falls. A written summary, dated 6/19/19, of R4's fall incident on 6/15/19 at 9:30 AM documented, R4 fell in her bathroom on 6/15/19 and sustained a laceration to her right forehead (nurses notes document left forehead) and a skin tear to her left forearm. The Summary documented prior to her fall, V9, Certified Nurse's Aide (CNA) had assisted R4 into the geriatric reclining chair to take her to the shower, but instead went to assist another CNA on the hall, leaving R4 alone in the geriatric reclining chair in the hall. The summary of R4's fall included written statements from the staff who were working at the time of R4's fall on 6/15/19. V9 gave a written statement, dated 6/15/19, documenting that she was in the other resident's room for 3 minutes and when she came out of that resident's room, R4 was no longer in the hall. V9 documented she heard a thud and went to R4's room and found her lying on the floor with her pants and adult clothing protector around her knees. According to the summary, the geriatric chair was in the doorway of R4's bathroom, in semi-reclined position, and the wheels were not locked. Per the report, R4 was sent to the emergency room where she received stitches to the laceration to her right side of her forehead. The summary did not document if the chair pad alarm was in the reclining geriatric chair and sounded at the time of R4's fall. An untimed Nurses Note dated 6/25/19 documents that 6 stitches above R4's left brow and 3 to left brow line removed with sterile technique. Steri-strips applied to secure wound. On 7/10/19 at 2:30 PM, V2 stated, (R4) should never have been in that (geriatric chair). She should have been in her wheelchair. V2 continued to state that R4 should not have been left in the hall. 2. On 7/5/19 at 9:27 AM R1 was transferred from his wheel chair to his bed by V8, CNA, and V9, CNA using the mechanical lift. The lift sling was under R1 in his chair and V8 and V9 fastened the sling straps to the lift. Without double checking that the straps were correctly applied to the lift and that the sling did not have any rips or tears, V8 raised R1 in the air with the lift, and he hung there while V9 pushed his wheel chair out of the room. R1 was hanging in the sling across the room from his bed, and then V9 came back into the room and assisted V8 to maneuver the lift over to the bed and lower R1 down onto the bed. V9 stated she did not double check the sling before lifting R1 because it was a new sling and they had been checked a lot lately. V9 stated, We are supposed to double check them (slings) before we get a resident up with a mechanical lift. R1's MDS dated [DATE] documents, in part, a BIMS score of 4, indicating he is severely cognitively impaired. The same MDS documents R1 is dependent on staff for transfers. R1's Fall Risk assessment dated [DATE] documents his risk score is 14. According to the Fall Risk Assessment, a score of 10 or more represents a high risk of falls. 3. According to the Facility's Resident Fall Log, dated (MONTH) 2019, R2 fell on [DATE] at 8:10 AM. On 7/9/19 at 1:00 PM, V19, CNA and V26, CNA transferred R2 from her wheelchair to her bed. During the transfer, R2 told the CNA's, I hate this thing. I was up in the air and the strap broke and I fell . It was very bad. I still hurt from it. The Facility's Investigative Report Summary dated 5/23/19 documents, in part, that while V24 and V25, CNAs, were transferring R2 from her bed to her bedside commode, the loop near R2's head/shoulder area gave way and R2 fell to the floor, striking the back of her head on the floor, and landed with her legs over one leg of the lift, laying on her right buttock and back, tilted to right side. R2 was sent to the local hospital for evaluation. The Investigative Report Summary documents that the lift pad that tore during R2's transfer and another pad that had a tear in the handle was removed from use. R2's MDS, dated [DATE], documents, in part, a BIMS score of 15, indicating she is alert and oriented. The same MDS also documents she is dependent on staff for transfers. R2's Fall Risk assessment dated [DATE] documents her fall risk score is 13, indicating she is at a high risk for falls. R2's Care Plan dated 6/13/19 documents (R2) is at risk for falls related to she requires assist with her ADL's (Activities of Daily Living), incontinent of bowel and bladder, takes routine meds that have a black box warning and has a history of falls. The care plan also documents R2 has a [DIAGNOSES REDACTED]. The interventions for R2's Fall Care Plan documents an intervention dated 3/13/19 (MONTH) use (mechanical) lift for transfers. An additional intervention was added, 5/23/19 Fall-(mechanical lift) pad removed from floor-all (mechanical lift) pads inspected. If frayed or worn- remove from floor. On 7/5/19 at 1:10 PM V2 stated, I would absolutely expect staff to double check straps to ensure they are correctly hooked to the mechanical lift before lifting a resident. We have double checked all our slings and gotten rid of a couple that had loose threads. On 7/9/19 at 2:39 PM, V22, Maintenance Supervisor, stated he did not have a manual for the mechanical lifts in the building because the lifts are so old. He stated he did use the serial number from the lift and looked up some information on the internet regarding the mechanical lifts. The incomplete user, manual provided by V22 identifies the mechanical lifts by their model numbers and documents, on the cover page of this manual, This manual must be given to the user of the product. Before using this product, this manual must be read and saved for future reference. According to this manual, under Maintenance, it documents, Slings and Hardware- Check all sling attachments each time it is used to ensure proper connection and patient safety. Inspect sling material for wear. Inspect straps for wear. The Facility's undated policy, Transfers and Lifts documents, in part, The facility will ensure that all staff members are instructed in safe transfer and lifting techniques and how to report suspected injuries. This policy includes a hand-written direction, dated 5/23/19, which documents, Prior to use, staff will check for fraying or holes on sling and remove from use. 4. According to the Facility's Fall Logs dated (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019, R3 has had multiple falls: On 5/17/19 R3 had an unwitnessed fall to the floor in his room. According to the Incident Investigation dated 5/17/19 the corrective action taken, Instructed to use call light. After this fall R3 was sent to the hospital for evaluation and was diagnosed with [REDACTED]. Upon return from hospital, according to the Incident Investigation, R3 was instructed again not to get up unassisted and documented, Resident confused. R3's care plan was not updated with progressive interventions after this fall. On 5/28/19 R3 fell when attempting to take self to the bathroom. According to the Incident Investigation dated 5/28/19, R3's wheelchair was outside his room in the hallway. His chair alarm did not sound to alert the staff he was getting up. V27, Physical Therapist, stated the chair alarm was not working the previous day either, when R3 was in therapy. V27 stated there was a towel on top of the alarm pad, and when she removed it the alarm worked correctly. The Incident Investigation documents that staff has been instructed to keep pad next to patient/do not cover pad with towel or blanket; instructed Therapy Department to communicate these situations to nursing staff; administrator has ordered new chair and bed alarm. The corrective action taken, Resident should be taken to dining room after toileting- continue to remind to summon help if needed-check on resident every two hours or less-offer toileting every two hours-ensure chair and bed alarms are on at all times. R3's care plan was updated on 5/28/19 chair alarm to be in place and on while up in chair, but chair alarm was already being utilized when R3 fell on [DATE]. No progressive intervention was initiated after this fall. On 6/17/19 R3 fell out of bed. According to the Incident Investigation dated 6/17/19 resident was crying for help and was found on a mat on the floor next to his bed. The report documents, There was no bed alarm. According to R3's Care Plan intervention dated 5/16/19, R3 was to have a bed alarm in place at all times. R3's MDS dated [DATE] documents, in part, a BIMS score of 6 indicating he is severely cognitively impaired, and also documents he is dependent on staff for transfers and toileting. The Facility's undated policy, Fall Protocol and Procedure does not document that falls need to be investigated to determine root cause of falls and to update the resident's plan of care with progressive interventions to prevent additional falls.

Based on observation, interview and record review, the facility failed to ensure hot water temperatures are maintained at safe levels in areas accessible to cognitively impaired, mobile residents. This has the potential to affect three of three residents (R1, R9, R12) who are cognitively impaired and mobile in the sample of 13 and six residents (R15, R17, R26, R39, R40, R41) in the supplemental sample. This failure resulted in an Immediate Jeopardy which was identified to have begun on 9/14/16 when the facility failed to follow their policy regarding Hot Water monitoring to protect residents from potential injury from the hot water. While the Immediate Jeopardy was removed on 9/22/16, the facility remains at Severity Level 2 as the facility continues to in-service staff and update policies and procedures as needed. Findings include: On 9/19/16, water temperatures were monitored throughout the facility using a calibrated digital metal stemmed thermometer. On 9/19/16, at 10:21 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R3 and R9 was 132.4 degrees Fahrenheit (°F). On 9/19/16, at 10:25 AM, the hot water temperature taken with a metal stemmed thermometer at the shower head in the unlocked 300 hall shower room was 125°F. On 9/19/16, at 10:30 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R7, R10 and R11 was 130.8°F. On 9/19/16, at 10:33 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R12, R13, R14, R15 and R16 was 131.5°F. On 9/19/16, at 10:35 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R17, R18, and R19 was 131.6°F. On 9/19/16, at 10:39 AM, the hot water temperature taken with a metal stemmed thermometer at the first stall shower head in the unlocked 200 hall shower room was 123.5°F and the hot water temperature at the hand sink was 134°F. On 9/19/16, at 10:43 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R20, R21, and R22 was 133.5°F. On 9/19/16, at 10:47 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R8, R23, R24, and R25 was 132.5°F. On 9/19/16, at 10:50 AM, the hot water temperature taken with a metal stemmed thermometer at the hand sink in the bathroom shared by R26, R27, and R28 was 133.1°F. On 9/19/16, at 11:00 AM, E4, Maintenance Supervisor, stated that the Facility has two hot water heaters. One is to run the kitchen and the other is to run the rest of the building and both have mixing valves. E4 then stated that he monitors water temperatures daily and takes temperatures using a digital metal stemmed thermometer. E4 stated he takes temperatures of 1 room on each hall. E4 stated that he documents temperatures on a log which he maintains in his office. E4 then stated that hot water temperatures in resident rooms should range between 100 to 110 degrees Fahrenheit. (F.) E4 stated that he has not calibrated his thermometer and is not sure how, he just knows to change out the battery. E4 stated he normally takes temperatures in the afternoon and hasn't taken any temperatures today. E4 stated that the last temperature he took was on Friday, 9/16/16, before he left for the weekend. E4 stated that temperatures are not taken on the weekend. E4 then stated that we have had some issues with the mixing valve. E4 stated that last week he tried to adjust the mixing valve and in doing so realized he was turning the valve counter clockwise making it hotter instead of colder. On 9/19/16, at 11:15 AM, while on tour with E4, the following temperatures were checked using a digital metal stemmed thermometer by E4: The hot water temperature at the hand sink in the restroom shared by R29 and R30 was 136°F. At that time E4 stated, We are way hot. Wowza! We are over. The hot water temperature at the hand sink shared in the restroom shared by R31, R32, and R33 was 132°F. At that time E4 stated, The water temperatures have never been that high. The hot water temperature at the hand sink in the restroom shared by R2, R34, R35, R36 and R37 was 132°F. At that time, E4 stated that he was going to turn the mixing valve way down immediately. On 9/19/16 at 11:27 AM, E1, Administrator, stated that E4 just informed her that the hot water temperatures in the building were really hot. E1 then stated that she told E4 to order a new mixing valve for the hot water heater. E1 stated that the mixing valve was only a year old, but they started having some issues with it last week. E1 stated that she will usually monitor water temperatures daily by testing the water with the hands and will tell E4 if she has concerns. E1 stated that E4 just turned the mixing valve down on Friday and it had not been adjusted since then. On 9/19/16 at 11:30 AM E2, Director of Nursing (DON), came into R6's room and stated to R6 not to use the water in her room, because E4 is fixing it. R6 then stated, Yeah- the water is hot. On 9/19/16 at 11:40 AM, E1 stated that E4 was in the process of the draining the hot water heater and that she had notified all staff about the hot water issue and they were to monitor residents closely even though most of the residents were currently sitting in the dining room at this time. E1 stated that no showers were to be given to residents at this time. On 9/19/16 at 11:42 AM, E4 stated that he was told by the plumber to adjust the valve by turning it way down and to open the faucets to let the hot water flush out of the tank. E4 stated that at that time he was getting temperature reading of 128°F. E4 then stated, I think I was turning it the wrong way and it's my fault. On 9/19/16 at 1:25 PM, E4 stated that I first noticed a problem with the hot water last Wednesday, 9/14/16, after (E1) mentioned to me that the water seemed a little hot. E4 stated that at that time he turned the mixing valve and got normal temperature readings. E4 then stated that on Thursday, 9/15/16, in the morning the water was hot again. E4 said that he used a thermometer and checked it and temperatures were ranging from 115-120 °F. E4 then stated that he did not log those temperatures down on his log sheet. E4 then stated he realized he must have been turning the valve the wrong direction and turned it the opposite way. E4 then stated that he took temperatures that afternoon and they were within acceptable range. E4 then stated temperatures were taken Friday, 9/16/16, during the afternoon and were within acceptable range. On 9/20/16 at 8:38 AM, E6, Certified Nursing Assistant (CNA), stated that she had notice the hot water temperature had been a little hotter than normal lately. E6 stated that when she helps residents with showers she has to adjust the temperature for them and the temperature on the gauge gets up to at least 115°F sometimes. E6 then stated that residents all have hand sinks in their restrooms and many of them use them independently. On 9/20/16 at 8:41 AM, E5, CNA, stated that she has noticed problems with hot water since she started here about four weeks ago. E5 stated I have noticed some resident sinks were so hot I couldn't even wash my hands in them, so I know it was way too hot for the residents. E5 then stated that she had reported it to maintenance and believes most have been fixed. On 9/20/16 at 9:30 AM during the Group Interview, R6 stated, The hot water is too hot! You can't even hold your hands under the water. R6 stated that the water has been too hot in my room since I came here in January. R6 stated that she told the maintenance man and he said he would take care of it, but it is still hot. R6 stated, I decided to just turn on the hot and cold at the same time to adjust it when I use it. R6 then stated, I assume since it is hot at my sink it is hot in all the sinks in the residents rooms. On 9/19/16, at 11:00 AM, the facility's water temperature logs were reviewed. The log indicated that maintenance checks the water temperatures of one resident room on each hall daily except for weekends. Facility's undated Hot Water Policy documents, Water temperatures will be taken daily by maintenance supervisor from random areas throughout facility. Temperatures will be maintained between 100-110 degrees. If temperatures are found to be out of that parameter, staff will be alerted to immediately not give any showers until all temperatures are returned to acceptable range. Independent residents will be informed to not utilize sink/hot water until temperatures are returned to acceptable range. If hot water is above 110 degrees, hot water will be drained out and temperatures monitored throughout building by being taken every 15 minutes until acceptable temperature is achieved throughout building. If water is below 100 degrees, Maintenance will adjust temperature and monitor temperatures throughout building every 30 minutes until acceptable temperature achieved and maintained for at least 2 hours. Katcher, L.K. (1981). Scald Burns from Hot Tap Water. Journal of Am Med Assoc., 246 (11), 1219-1222), documents Many residents in long-term care facilities have conditions that may put them at increased risk for burns caused by scalding. These conditions include: decreased skin thickness, decreased skin sensitivity, peripheral neuropathy, decreased agility (reduced reaction time), decreased cognition or dementia, decreased mobility, and decreased ability to communicate. Studies of Thermal Injury: II. The Relative Importance of Time and Surface Temperatures in the Causation of Cutaneous Burns, written by Moritz and A.R. Henriques F.C. Jr., dated 1947, documents the damage to skin causing a 3rd degree burn in relation to the temperature of the water and the length of time of exposure as follows: 155 degrees F for 1 second (sec) ; 148 degrees F for 2 sec; 140 degrees F for 5 sec; 133 degrees for 15 sec; 127 degrees for 1 minute (min); 124 degrees for 3 minutes; and 120 degrees F for 5 minutes. On 9/21/16, the facility provided a list of residents who were cognitively impaired and mobile. The following residents were on this list: R1, R9, R12, R15, R17, R26, R39, R40 and R41. The Immediate Jeopardy began on 9/14/16, when the facility failed to implement the Hot water policy when the hot water exceeded 110 degrees F in areas accessible to residents. On 9/21/16, at 4:05 PM, E1, E2 and E3, Assistant Director of Nurse's were notified of the Immediate Jeopardy. On 9/22/16, surveyors determined through observation, interview and record review, the facility took the following actions to remove the Immediacy: 1. All staff was notified of issue of water temperatures and to not allow residents to use sinks until further notice. 2. All independent, alert residents were immediately notified to not use their sinks until further notice of temperatures being acceptable. 3. All hot water in system was drained under supervision with water temperatures being taken and recorded every 15 minutes by Maintenance Supervisor (E4) until acceptable safe temperature reached. Water temperatures were continued to be monitored every 30 minutes throughout the day to ensure temperatures remained safe. 4. Licensed plumber contacted and came out to evaluate and will give recommendation. Facility will follow his recommendation regarding plumbing. 5. Water temperatures continue to be monitored and recorded 2 times daily with areas of reading being staggered throughout facility, 3 readings on each hall for a total of 9 per day. 6. Director of Nursing (E2) has inserviced all nursing staff regarding hot water policy and safety issues. 7. Administrator (E1) has inserviced laundry and housekeeping staff regarding hot water policy and safety issues, as well as kitchen, social services, and activity personnel. 8. Maintenance Supervisor (E4) will be responsible for taking water temperatures throughout week with housekeeping staff inserviced to obtain readings on Saturdays and Sundays, and logging temperatures. Any issue or problems noted will be reported directly to Maintenance Supervisor (E4) and/or Administrator (E1) and policy will be followed.

Based on observation, interview, and record review, the facility failed to assess and document the risks versus benefits and medical symptom justifying the use of restraints for 1 of 1 residents (R7) reviewed for a wedged mattress in the sample of 15. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 7/10/13, the facility remains out of compliance at severity level two, while the facility continues to educate staff on observing for potential risks of improper positioning. Findings include: On 7/9/13 at 10:10 AM, R7 was observed asleep in bed with her face against a mat on the wall. The left side of the bed was against the wall. There was a mat propped between the bed and the wall, extending just above R7's head on the mattress. The right side of the mattress had 2 vinyl covered foam wedges that covered the length of the mattress between the mattress and the bed frame. These wedges raised the length of the right side of the mattress 45 degrees off of the bed frame. This created a V-shaped crevice in which the resident was lying. The wedges were not secured to the bed frame. The wedges were not secured to the mattress. The mattress was not secured to the bed frame. There was also a pressure pad alarm on the bed and another mattress on the floor beside the bed. On 7/9/13 at 12:00 PM, R7 was awake in bed, flailing her right leg about, rubbing her right foot on the wall on her left side, and pushing her right foot against the wall at the foot of the bed. R7 was lying in the V-shaped crevice between the mattress and the wall with the mattress in the wedged position 45 degrees above the bed frame. There was a pressure pad alarm on the bed and another mattress on the floor beside the bed. On 7/9/13 at 1:10 PM, after completing perineal care for R7, E9 and E10, Certified Nurses Aides (CNA's), repositioned R7's mattress to the wedged position. E10 lifted the right side of R7's mattress while R7 was in the bed. E9 pushed wedges between the mattress and the bed frame along the length of the right side of mattress, raising the mattress 30 degrees off of the bed frame. R7 had 2 scabbed areas and an abrasion on her left knee, and a scabbed area on her right foot second toe. E9 stated these areas were from R7 rubbing against the wall. On 7/10/13 at 11:37 AM, R7 was awake in bed, flailing her right leg about, rubbing her right foot on the wall on her left side, and pushing her right foot against the wall at the foot of the bed. R7 was lying in the V-shaped crevice between the mattress and the wall with the mattress in the wedged position 30 degrees above the bed frame. There was a pressure pad alarm on the bed and another mattress on the floor beside the bed. R7's July 2013 physician's orders [REDACTED]. The POS does not have a physician's orders [REDACTED]. R7's Care Plan, dated 1/28/13, has no documentation of the approach of the wedged bed positioning. There is no assessment for the wedged bed positioning. There is no Restraint Assessment for the wedged bed positioning. R7's Quarterly Minimum Data Set (MDS), dated [DATE], documents no restraints are used for R7. In an interview on 7/9/13 at 10:10 AM during the initial tour of the Facility, E3, Assistant Director of Nurses (ADON), stated, "(R7) has a history of a [DIAGNOSES REDACTED] and has random flailing movements. This (the wedged bed positioning) is what we came up with to keep her (R7) from flipping out of bed." In an interview with E9, CNA, on 7/9/13 at 1:10 PM, when asked how much they are supposed to raise the mattress, E9 stated, "We tip it more if she (R7) tries to roll over that (pointing to the wedged mattress)." The mattress was raised 30 degrees off of the bed frame at the time of the interview. On 7/10/13 at 12:45 PM, E2, Director of Nurses (DON), stated "(R7) probably had this (wedged mattress positioning) since 12/5/12. She (R7) was having such issues with getting out of bed, this keeps her from getting out of bed. This decreases it. (Z1) (R7's Physician) and (Z3) (R7's Psychiatrist) worked together with us to come up with this to use. We attempted prior: floor mat, floor mat alarm, mattress on floor, 2 mattresses on floor because she (R7) would just roll. She (R7) can just roll right out of a scoop mattress. We are slowly trying to remove things, but she (R7) actually kicks the mat up on the wall. I worry that (R7) will remove the wall pad and pull it over herself. She (R7) can and did that on 6/18/13. I worry about suffocation from the wall pad. I don't see the wedging of the mattress as a potential for (R7) to suffocate. I reviewed (R7's) Chart. I don't see that we had anything in the Care Plan about wedging the mattress or an assessment for this. We are doing this to keep her from getting out of bed, but she can get out, so how can that be a restraint? She (R7) got herself out of bed with it wedged two times in April (2013). She (R7) ended up on the floor mattress and had no injuries." On 7/10/13 at 12:45 PM, E3, ADON, stated "She (R7) is at risk for injury with her repetitive movements. That is why we have been putting a mat against the wall. This (wedged mattress positioning) is the result of IDT (Interdisciplinary Team) working on progressive interventions for her (R7). I don't think the mattress could slide out from under her (R7) and wedge her (R7) between the mattress, the wall, and the bed frame because the wedges under the mattress are up against the rail of the bed frame." In an interview on 7/17/13 at 11:20 AM, Z1, Medical Director and R7's Physician, Z1 stated she wasn't aware of the positioning of the mattress for R7 and had no input on how they did it. On 7/17/13 at 3:20 PM, Z3, R7's Psychiatrist, stated regarding R7's wedged mattress, "I had no input on that. I know she (R7) has been on that (the wedged mattress) a long time." The facility's undated Restraint Policy documents, in paragraph 3, "A restraint is any manual method or physical or mechanical device, material or equipment attached or adjacent to the residents body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body." In paragraph 4, "If a restraint is used to enable the resident to attain or maintain his or her highest practicable level of function, this facility will be evidence of consultation with appropriate health professionals, such as occupational or physical therapists. This consultation will consider the use of less restrictive therapeutic prior to using restraints. The use of therapeutic intervention will be justified through the care planning process and will demonstrate that these interventions promote the care and services necessary for the resident to attain or maintain the highest practicable well-being." The Immediate Jeopardy situation was identified and determined to have begun on 7/9/13 at 1:00 PM, when an investigation of the wedged mattress positioning was started by the survey team. The wedged mattress positioning was determined to be a restraint, an entrapment and suffocation hazard. E1, Administrator, E2, DON, and E3, ADON, were notified of the Immediate Jeopardy on 7/10/13 at 2:20 PM. The surveyor confirmed through interview, observation, and record review, that the facility took the following actions to remove the Immediate Jeopardy. 1. On 7/10/13 at 1:20 PM, the wedges were removed, and R7's mattress was positioned flat on the bed frame with an additional mattress on the floor beside the bed. 2. On 7/10/13, the facility reassessed all residents for appropriate positioning and safety. 3. On 7/10/13 at 3:15 PM, the survey team completed an audit of R7's mattress position to verify it did not present a hazard to R7 and she was no longer restrained.

A. Based on observation, record review, and interview, the facility failed to properly assess, evaluate, and monitor the use of side rails and failed to follow the U.S. Food and Drug Administration guidelines to reduce the risk for entrapment for 2 of 3 residents (R10, R11) reviewed for side rail entrapment hazards in the sample of 15. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 7/10/13, the facility remains out of compliance at severity level two, while the facility continues to educate staff on side rail assessment and recognition of potential hazards related to the use of side rails as positioning devices. Findings include: 1. The U.S. Food and Drug Administration (FDA) publication "Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment - Guidance for Industry and FDA Staff" issued March 10, 2006 documented "To reduce the risk of head entrapment, opening in the bed system should not allow the widest part of a small head (head breadth measured across the face from ear to ear) to be trapped." The publication documented "FDA is therefore using a head breadth dimension of 120 mm (millimeters) (4 3/4 inches) as the basis for its dimensional limit recommendations." The publication documented regarding neck entrapment "To reduce the risk of neck entrapment, openings in the bed system should not allow a small neck to become entrapped." The publication documented "The FDA is recommending 60 mm (2 3/8 inches) as an appropriate dimension for neck diameter." The publication documented regarding chest entrapment "The openings in a bed system should be wide enough not to trap a large chest through the openings between split rails. The FDA's dimensional limit for the chest is 12 1/2 inches." The publication documented a potential area for entrapment as "Zone 1: Within the Rail." 2. R11's Quarterly Minimum Data Set (MDS), dated [DATE], documents R11 is severely impaired for decision making. R11's July 2013 physician's orders [REDACTED]." R11's Care Area Assessment Summary, dated 6/10/13, documents, "She (R11) does utilize 1/2 side rail x 1 to help aide in her bed mobility. She (R11) will grasp the side rail." R11's Fall Care Plan, dated 12/17/12, documents R11 has a history of falls. Approaches include: 1/16/11 - bed pad alarm, 1/16/11 - 1/2 side rail up x 1 while in bed, 4/2/11 - bed against the wall, 5/20/11 - floor mat and floor mat alarm next to bed while resident is in the bed. R11 is able to propel self independently. R11's Nurse's Notes dated 5/20/13 document, "Res (resident) hit and bit staff, continues to be agitated and abusive to staff." On 7/10/13, upon request for R11's Side Rail Assessment, E3 presented an untitled document for R11 dated 3/12/13 with "startling" and "create sense of being trapped or jailed" marked as risks. "Entanglement of limbs in rail, trauma or injury if limb/body strikes rail, death, and entrapment" are not marked as risks for R11. In an interview on 7/10/13 at 9:45 AM, E11, Certified Nurses Aide (CNA) stated, R11 "rolls side to side in bed and sits straight up in bed. She (R11) uses the side rail sometimes. She (R11) gets agitated sometimes when being put to bed, she likes to be up to roam the hallways." In an interview on 7/10/13 at 11:40 AM, E5, CNA, stated, "It has been 6 months or so since (R11) has tried to get out of bed. She (R11) rolls over and sits up but she doesn't try to get out of bed." On 7/9/13 at 10:05 AM during initial tour of the facility, R11 was asleep in bed. R11's bed was against the wall on the right side and the left half side rail was up. R11 also had a bed alarm, a floor mat, and a floor mat alarm in place. 3. On 7/9/13 at 9:30 AM during initial tour of the facility, R10 was lying in bed positioned on his back with Oxygen at 4 liters by nasal cannula. R10 had bilateral half side rails up on his bed. On 7/10/13 at 11:35 AM, R10 was seated in a geriatric chair moving his arms. R10's Quarterly MDS, dated [DATE], documented R10's cognition was severely impaired. R10's Nurse's Notes, dated 6/30/13 9:30 AM, documents "In geri (geriatric) chair and attempting to get up by self out of chair. Stating, help me, help me. Anxious. Roxanol and Ativan given. Layed down in bed." R10's Nurse's Notes, dated 7/3/13 7:40 PM, documents "up in gerichair (geriatric) this shift. Very restless this shift, kept throwing legs off of chair." On 7/10/13 at 11:50 AM, E5 stated "He (R10) is unable to turn by himself. We turn him from side to side. He (R10) will grab the side rails when we ask him to. He (R10) does move his arms." 4. On 7/9/13 at 1:00 PM, R10's right side rail and R11's left side rail were measured. These side rails were of the same type. There were two areas which measure 8 inch wide x 8 inch long between the bars of the rails and another area with 7.5 inch wide x 17 inch long between in Zone 1. These side rails did not meet the FDA dimensional limit recommendations. 5. In an interview on 7/10/13 at 12:45 PM, E3, Assistant Director of Nurses (ADON), stated, "these are new ones we just got in, we weren't aware there was a problem with the side rails." 6. In an interview on 7/10/13 at 12:45 PM, E2, DON, stated, "She (R11) has had this side rail since her admission. I don't know how long R10 has had them." 7. The Immediate Jeopardy situation was identified and determined to have begun on 7/9/13 at 1:00 PM, when an evaluation and measurement of the side rails in the facility was started by the survey team. Measurements indicated the side rails to be a potential entrapment hazard. E1, Administrator, E2, DON, and E3, ADON, were notified of the Immediate Jeopardy on 7/10/13 at 2:20 PM. The surveyors confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy. 1. On 7/10/13 at 1:20 PM, the side rails were removed and replaced with appropriate rails. 2. On 7/10/13, the facility reassessed all residents using side rails to verify they were necessary for mobility and are a reflection of the needs of the residents. 3. On 7/10/13 at 3:15 PM, the survey team completed an audit of all facility beds to verify any remaining side rails were safely attached and did not present any hazards to the residents using them. 4. On 7/10/13, the facility inserviced all direct care staff and staff that perform functions in residents rooms on recognition and reporting of potential bed related hazards. B. Based on observation, interview, and record review, the facility failed to implement progressive fall interventions for 1 of 5 residents (R1) reviewed for falls in the sample of 15, and failed to safely transfer 1 of 4 residents (R12) reviewed for transfers in the sample of 15. Findings include: 1. R1's Fall Care Plan, dated 1/20/13, documents (in part), R1 "is at risk for falls related to she has an unsteady gait, has a history of falls, DX (diagnosis) of gait disturbance and receives psychotropic meds." Approaches, dated 1/20/13, include: "Assist (R1) with ambulating and transfers, assist (R1) with all ADL's (activities of daily living), encourage (R1) to utilize call light for assistance." Falls listed by date with approach include: "2/24/13 Fall - 15 min (minute) checks, neuro checks; 3/23/13 Fall- bed pad alarm; 4/16/13 Fall; 4/20/13 Fall- 15 min check, ortho, neuro checks; 5/23/13 Fall- changed out bed pad alarm; 6/2/13 Fall- 15 min check, monitor; 7/3/13 Fall- chair pad alarm." R1's 1/19/13 MDS documents R1 has severe cognitive impairment, is independent with transfers and walking, and is steady at all times. R1's 4/15/13 MDS documents R1 has severe cognitive impairment, requires assistance of one person for transfer, requires supervision and assistance of one person for walking in her room, R1 did not walk in corridor, and requires assistance of one person for locomotion on the unit. R1's MDS documents she is not steady, only able to stabilize with staff assistance. R1's admission Fall Risk Assessment documents R1 is at moderate risk for fall. R1's 4/16/13 Fall Risk Assessment documents R1 is at high risk for fall. R1's Fall Investigation, dated 1/14/13, documents "New Interventions: Safety re-education." R1's Incident Investigation, dated 1/15/13, documents "Res (resident) states was walking in room and slid on floor. No injury." Corrective Actions: "15 min checks." R1's Fall Investigation, dated 2/24/13, documents "What was resident doing at the time of the fall? sleeping - slid out of bed." No new interventions are documented. R1's Incident Investigation, dated 2/25/13, documents "No injury. Corrective Action: 15 min checks." R1's Nurse's Notes, dated 2/24/13 10:15 PM, documents "Neuro checks initiated. Orthostatic BP's (blood pressure) for next 3 days et (and) 15 minute checks initiated." R1's Care Plan was not updated after this fall with any new intervention to prevent further falls. R1's 3/23/13 Fall Investigation documents "what was resident doing at the time of the fall? trying to set in w/c (wheelchair)." No new interventions are documented. R1's 3/25/13 Incident Investigation documents as Corrective Action: "Bed pad alarm added. " R1's Care Plan was updated after this fall with this new intervention. R1's 4/16/13 Fall Investigation documents "Personal alarm or pressure pad in place? N/A (not applicable)." "What was resident doing at the time of fall? In bed sleeping." This Report documents resident stated, "I wanted to lay in the floor where it's warmer." "New Interventions: bed in low position or a low bed." R1's 4/17/13 Incident Investigation documents as Corrective Action: "15 min (checks). No injury." There is no documentation that the previously implemented intervention of bed pad alarm was in use at the time of this incident. R1's Care Plan was not updated after this fall with any new intervention to prevent further falls. R1's 4/20/13 Fall Investigation documents "resident last observed sitting in w/c. What was resident doing at the time of fall? taking herself to the toilet." New Interventions: "Bed in low position or a low bed, floor mat, chair or bed alarm or alarm pad." R1's 4/21/13 Incident Investigation documents as Corrective Action: "15 min (checks). No injury." R1's Care Plan was not updated after this fall with any new intervention to prevent further falls. R1's 5/23/13 Fall Investigation documents "Personal alarm or pressure pad in place? yes. Describe: she ws found on the floor next to her bed. New Interventions: Chair or bed alarm or alarm pad." R1's 5/24/13 Incident Investigation documents "No injury. Bed pad alarm didn't sound, alarm changed out." R1's Care Plan was not updated after this fall with any new intervention to prevent further falls. R1's 6/2/13 Fall Investigation documents R1 stated "I tried to get into my w/c and fell on my bottom." New Interventtinons: "Bed in low position, chair of bed alarm or alarm pad." R1's 6/3/13 Incident Investigation documents "No injury. Bed alarm on and working. Corrective action: 15 min checks." R1's Care Plan was not updated after this fall with any new intervention to prevent further falls. R1's 7/3/13 Fall Investigation documents R1 was "trying to change pants." R1's 7/4/13 Incident Investigation documents "No injuries. (R1) attempted to stand up and change her pants unassisted. Corrective action: Chair pad alarm." R1's Care Plan was updated after this fall with this new intervention. The facility's undated Fall Risk Assessment and Prevention Policy and Procedure documents (in part), "If a resident has a fall an intervention is implemented to attempt to prevent any further falls immediately and this intervention is added to the plan of care. This will occur after each fall and include non-restraint interventions unless all other interventions have been exhausted." On 7/12/13 at 2:05 PM, E4, MDS/ Care Plan Coordinator, stated "(R1's) fall on 2/24/13 - she (R1) was more independent at the time. 4/16/13 fall - we felt it was her (R1) deliberately putting herself on the floor as she (R1) stated. 4/20/13 fall - she (R1) didn't have a chair pad alarm then. She (R1) transferred herself from the wheelchair to the bathroom. We just did the 15 minute checks. I think they are done for 8 hours. 5/23/13 fall - the alarm didn't sound so they changed out the alarm box. 6/2/13 fall - her alarm was on and working, we just did the 15 minute checks. 7/3/13 fall- we added the chair pad alarm. She (R1) tried to get up from her wheelchair." On 7/9/13 at 9:45 AM, R1 was lying in bed. The bed was against the wall on the left side with a bed alarm in place. On 7/9/13 at 12:05 PM, R1 was in the dining room, asleep in her wheelchair with a chair alarm in place. On 7/9/13 at 1:25 PM, R1 finished eating lunch and was propelling herself in her wheelchair, using her feet, out out of the dining room. On 7/9/13 at 1:30 PM, E10, CNA, assisted R1 to stand and transfer from wheelchair to bed with a gait belt. 2. On 7/10/13 at 9:30 AM E6, Certified Nurses Aide (CNA) propelled R12 into her room in a wheelchair. E6 and E9, CNA, placed R12's wheelchair close to the bed and placed a gait belt around R12. E6 and E9 held onto the gait belt and transferred R12 onto the bed. R12's feet were dangling and never touched the floor during the transfer. In an interview on 7/11/13 at 11:00 AM, E7, Therapy Program Director stated, "(R12) came to us using a mechanical lift for transfer. She is unable to be safe with standing transfer. (R12) is to continue using a mechanical lift for transfers." The Physical Therapy Evaluation, dated 2/14/13, documents R12 is to be transferred with a (mechanical lift). The Physical Therapy Evaluation dated 3/05/13 documents R12 has severe bilateral lower extremity contractures. R12's Care Plan, dated 2/25/13, fails to address or document how R12 is to be transferred, but is at risk for falls and should utilize a geriatric chair when out of bed. The facility's policy and procedure entitled, 'Transfers and Lifts' documents, in part, "The resident's care plan should be very explicit on exactly how the resident is to be transferred and or lifted. If you think changes need to be made to the way the resident is lifted, discuss this with the charge nurse. Know the resident's weight bearing status and balance problems."

Based on record review and interview, the facility failed to implement fall interventions for one of five residents (R1) reviewed for falls in the sample of 13. This failure resulted in R1 falling and being hospitalized with a laceration to his right eyebrow, a traumatic left intracranial hemorrhage, and subdural hematoma. Findings include: R1 was assessed by the facility as "High Risk" for falls on 6/1/11, with a score of 17 (10 or above indicates High Risk). R1's Care Plan dated 6/1/11, documented the problem of risk for falls, history of falls, incontinence and impaired cognition. The approaches and interventions of the Care Plan included (in part) a bed alarm, chair alarm, and siderails. R1's 5/31/11, Minimum Data Set (MDS) assessed him as needing extensive assistance of two or more staff for transfers. On 6/28/11, R1 was sent to the hospital after falling at the facility. The facility's Incident Investigation dated 6/28/11 documented (in part) "CNA (Certified Nurses Aide)...was attempting to assist him to stand.....she noted he was not assisting her, so she assisted him to lie back on his bed and she left room to get assistance. .....as the 2 (CNAs) entered room ...they noted resident lying face down beside his bed." There is no documentation that R1's bed alarm was activated or the siderails pulled up before the CNA left the room. The Hospital Discharge Summary dated 6/29/11 documented (in part), "This is a [AGE] year-old white male who was found down at the nursing home next to his bed. He had a laceration to his right eye. In the ER, he was found to be hypertensive with a blood pressure of 224/104 initially. CAT scan showed a small left frontal intracranial hemorrhage with minimal subdural hematoma. His eye laceration was repaired with sutures..." The facility's Incident Investigation dated 6/28/11 stated (in part) "All CNA's have been reminded and inserviced informally to be mindful of leaving a resident unattended even for a brief time - to ensure they will be safe until return." E2, DON, stated on 9/15/11 at 9:55 AM, that the CNA was attempting to get R1 up from bed, saw that she couldn't, and put him back to bed to get assistance. "She didn't turn the alarm back on when she left to get assistance. I'm assuming the siderails were put back up but it is not documented."

Based on record review and interview it was determined that the facility failed to use a gait belt according to facility policy for 1 (R1) of 3 residents in the sample reviewed for falls. This failure resulted in R1 being lowered to the floor, and sustaining a displaced fracture of the femur. The findings include: R1 was admitted to the facility on [DATE] with diagnoses, in part, of fractured right ankle, osteopenia, rheumatoid arthritis, and history of motor vehicle accident. The fractured ankle was sustained at home. R1 had orders for physical therapy at the facility. R1 was assessed on the 2/13/11 Minimum Data Set as requiring extensive assistance of 1 person for transfer and walking. R1 was identified as alert and oriented for cognition. E7, Physical Therapy Aide, stated in an interview on 3/24/11 at 11:30 AM that she had worked a lot with R1, and R1 could stand on her own and walk with a walker. R1 was usually stand by assist, but at times would need contact guard assist. R1 was weak on the right side due to an accident [AGE] years ago. E7 stated R1 was pretty independent with care, had done well with therapy and was planning on going home soon. The facility incident report dated 3/22/11 noted "As CNA (Certified Nurse Assistant) was assisting res. (resident) to stand both CNA (and) res heard a "snap" sound-Resident could no longer bear weight and c/o (complained of) pain. Transferred to hospital and admitted w/ (with) fx (fracture) femur". E3, Certified Nurse Aide (CNA), stated on 3/24/11 at 9:25 AM, during an interview, that she was alone assisting R1 in her room on 3/22/11. E3 stated R1 was on the edge of her bed, and pushed herself up to a standing position with her walker. E3 stated R1 had a brace on her right ankle, and non-skid sock on the other foot. E3 stated R1 stood there for a minute and could not get her right leg to work. E3 stated R1 stated she needed to sit down. E3 stated she could not get R1 back onto the bed as it was too high, and lowered her to the floor. E3 stated when she lowered R1 that R1's right leg would not slide out in front of her, and the right leg was to the side and behind R1. E3 stated the leg appeared broken, and the leg looked "separated". E3 went to get the nurse immediately and did not move the leg. E3 was very upset during the interview and stated she could not recall if she heard a pop. E3 confirmed she did not use a gait belt to assist R1. E1, Administrator, confirmed in an interview on 3/24/11 at 10:45 AM that E3 was disciplined due to failure to use a gait belt when assisting R1 according to facility policy. E6, Care Plan Nurse, stated in an interview on 3/24/11 at 12:15 PM, that she and the Director of Nursing, E2, went into R1's room immediately after E3 came and told them R1 was on the floor. When they entered the room, R1's legs were extended in front of her. R1 stated she thought her leg was broken. E6 stated R1 told her E3 had to lower her to the floor after her legs gave out. E6 confirmed that there was no gait belt on R1. In an interview on 3/24/11 at 11:55 AM, E5, Licensed Practical Nurse, stated she was summoned to R1's room by E3. When she went into the room both of R1's legs were directly in front of her, and R1 was not complaining of pain. E5 stated both R1 and E3 told her they heard a pop, and then R1 was lowered down. E5 stated R1 told her when she stood up she heard a pop. E5 stated none of the nurses would have moved her leg, and this would have been painful to R1. E2, Assistant Director of Nursing, stated in an interview on 3/24/11 at 12:09 PM, that she came into the room and R1 was seated on the floor with her back against the bed. Both legs were extended out in front of her. R1 was calm and had called her husband on the phone. E2 stated she thought the fracture may have been a spontaneous fracture. E4, Director of Nursing, stated on 3/28/11 by phone interview that she and E6 went to R1's room, and she was seated on the floor with her legs out straight. E4 stated E3 and R1 both stated they heard R1's leg snap. E3 kept saying the leg was not attached and was hysterical. E4 confirmed that E3 did not use a gait belt with R1. E4 stated R1 could not move her right leg and was lowered to the floor. E4 stated R1 has osteopenia. E4 stated on 3/29/11 at 9:00 AM that she did talk to R1 last night when she returned from the hospital, and R1 said she thinks she heard the "snap" when she was being lowered to the floor. R1 stated on 3/29/11 at 9:10 AM that she heard the "snap" when she was going down. R1 stated she could not recall any pain. The hospital History and Physical dated 3/22/11 noted R1 was admitted with a "displaced and angulated distal one-third femoral shaft fracture" of the right leg and underwent surgical repair of the fracture. Xray results confirmed the fracture and generalized demineralization of the bone. Z1, Orthopedic Surgeon, stated on 3/29/11 at 10:35 AM by phone, that R1 had a "spiral fracture" to the femur and that is a twisting injury. Z1 stated the spiral fracture may have started when R1 was standing, but the fracture was completed when she fell to the ground. Z1 stated R1 had significant osteopenia, and R1 had "rotational stress" to the leg. Z1 stated he was unsure if the use of the gait belt would have helped, but the facility has policies in place to follow. The facility "Policy and Procedure for Transfers" states "It is the policy of (facility) that all employee's will use a gait belt during resident transfers. Staff will use a gait belt when transferring in/out of bed, on/off commode, or walking in facility".