Every finding on record at Lake Forest Place

Based on observation, interview, and record review the facility failed to ensure R1, who is dependent on the staff for bed mobility, did not fall out of bed while the staff was providing care for 1 of 3 residents (R1) reviewed for falls in the sample of 3.The findings include:On 06/03/2026 at 10:29AM, R1 was lying in the bed on an air mattress.On 06/03/2026 at 10:29AM, R1 stated, the nurse was changing me. I was lying on the edge of the bed, then she grabbed ahold of the sheet underneath me, she pulled it out and it shot me over the side. She was alone, she should have had another staff member, usually there are two assisting me in bed. Luckly I was not seriously hurt, I do have bruises from the fall.On 06/04/2026 at 12:20PM, V4 CNA-Certified Nursing Assistant said, I was changing R1 by myself. I turned the top part of R1's body, I was not able to get to the other side to stop him from sliding off the bed.On 06/03/2026 at 12:52PM, V2 DON-Director of Nursing said, on 05/26/2026 I was told the CNA was changing R1 after an incontinent episode and the resident slid down the opposite side of bed. R1 sustained a bump on forehead with drips of blood on the floor. R1 required an emergency room visit. The CNA said, R1 curled up into a C sliding off and landing on R1's right side and bumping R1's head. On 06/03/2026 at 1:15PM, V3 OT-Occupational Therapist said, the facility does not use side rails, the resident may utilize an enabler to pull to one's side. R1 does not qualify for the use of an enabler. R1 does not have good upper body function. R1's right shoulder is more impaired than the left. R1 is total assistance by staff for bed mobility. It would be harmful to the arm joints to have R1 use a bed enabler for positioning. In addition, R1 is on a pressure reduction air mattress, the mattress overlay creates a less stable platform.R1's MDS-Minimum Data Set, dated [DATE] shows, Section GG, Functional Assessment, Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed. Dependent-Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.

Based on observation, interview, and record review the facility failed to provide adequate supervision and implement swallowing precautions for a resident at risk for choking for 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 3.The findings include:On 4/23/26 at 9:37 AM, R1 was well-groomed, seated in his wheelchair in the foyer. R1 leaned to his right side, he was slow to respond, and had some drool in the right corner of his mouth. R1 said he had some trouble swallowing a few days ago. R1 said he was taking big bites and eating too fast. R1 said he couldn't catch his breath, and the staff had to help him. R1 stated, I wouldn't say they saved my life, but they helped. R1 said he was eating pureed food when he choked. At 12 PM, R1 was feeding himself pureed turkey chili, garden vegetables, corn bread, and fries with a spoon. V5 (Restorative Certified Nursing Assistant (CNA) was positioned next to R1, watching him. R1 attempted to take big bites and eat quickly. V5 provided verbal cues to take smaller bites and eat slower. The facility's Final Incident Report showed on 4/19/26 at 12 PM, R1 had a choking episode. This document showed R1 was alert and oriented x3 (to person, place, and time), was eating at the table in the dining room, and suddenly showed symptoms of a blocked airway witnessed by a CNA (V5). The CNA alerted the nursing supervisor. The nursing supervisor (V3) noted R1's face was turning red and lips to bluish color. The nurse supervisor performed two abdominal thrusts with a weak cough produced. The nurse supervisor gave three additional abdominal thrusts and pronounced cough and audible noises noted. No food particles came out of R1's mouth. R1 was able to talk and thanked the nurse. R1 was able to drink nectar thick liquids, had no adventitious lung sounds. The nurse called the Nurse Practitioner (NP) and orders were received for chest X-ray, NPO (nothing by mouth), Speech Therapy consult, IV (intravenous) fluids, and evaluation at the hospital. R1's wife was notified and refused NPO, hospital evaluation, and IV fluids. This document showed that Speech Therapy will talk to R1's wife/POA that choking episode cause was possibly progression of Parkinson's Disease. R1's Chest X-ray results showed, There is accentuation of the pulmonary vasculature with early interstitial infiltrates in both lung bases. Clinical correlation is requested. The lung fields are otherwise essentially clear.R1's Facesheet dated 4/23/26 showed diagnoses to include, but not limited to Parkinsonism, hypertension, wedge compression fracture of the thoracic vertebrae, anxiety disorder, insomnia, dysphagia (oropharyngeal phase), and dementia. R1's Speech Therapy Discharge summary dated [DATE] showed R1 demonstrated fluctuating cognition and the need for varying cues to implement safe swallowing strategies. The discharge recommendations showed close supervision for oral intake; cues for slow rate, small bites and sips; and cues for no talking while eating. R1's Speech Therapy Notes dated 4/20/26 showed he said he was eating too fast when the choking incident occurred. R1's Physician Order Sheet showed an order initiated 6/4/2025 for Swallow Guidelines. This order showed R1 should be seated upright at 90 degrees for correct positioning during food intake and 30 minutes after; alternate food and liquids; clear mouth before each next bite/sip; watch neck for swallowing; small bites/sips; slow rate; close supervision; and purred diet. R1's Nutrition Care Plan showed he was at risk for aspiration (choking) and R1's Swallow Guidelines dated 10/31/25 included oral care 2-3 times per day; provide cues for small bites and to slow down as needed; no straw; upright seated at 90 degrees during food intake; alternate food and liquid; slow rate; no talking while eating; and within reach for physical and verbal cueing.On 4/23/26 at 9:39 AM, V4 (Restorative CNA) said R1 was able to feed himself but needed supervision. V4 said R1 sits at the guy's table, and he feeds one resident while supervising the other two. V4 said he was seated at the table with R1, feeding another resident. V4 said he was focused on the resident he was feeding and not watching R1. V4 said he wasn't sure if R1 was alternating bites of food with liquids, eating too fast, or taking big spoonfuls because he was focused on the resident he was feeding. V4 said he heard noises and looked to his side where R1 was seated. V4 said R1 was turning red, and it looked like he was trying to cough, but he couldn't. V4 said he yelled for the nurse and V3 (Nursing Supervisor) came over and performed abdominal thrusts. V4 said V3 was able to get R1 coughing and after that he was completely fine. V4 said R1 said he thought he was eating a sandwich and took a big spoonful. V4 said R1 does like to eat fast and tends to take big spoonfuls of his pureed food. V4 said R1 was eating purred food and didn't have access to any regular textured food. On 4/23/26 at 9:12 AM, V3 (Nursing Supervisor) said R1 was not on 1:1 feeding assistance, but we stay in the dining room with him. V3 said R1 was known to eat fast. V3 said R1 had a pureed diet in front of him and she thinks he had a pureed sandwich, vegetables, and something else. There were three pureed items on his plate. V3 said she was seated at another table with a resident that needed guidance and reminders. V3 said V4 called out that R1 was choking. V3 said she went right to R1. V3 said R1's face was beefy red and his lips were changing color. V3 said she asked R1 if he was okay and she could tell he was in trouble, so she did two abdominal thrusts. V3 said a faint sound of air moving was noted, but the color of his face hadn't changed. V3 said she gave three additional abdominal thrust and R1 started coughing and drooling. V3 said R1 didn't produce any food, but it looked like he swallowed. V3 said R1 was following instructions and was fine after the choking incident. V3 said R1's lung sounds were clear, his vital signs were stable, and he was pleasant with her after the incident. V3 said he was back to baseline. On 4/23/26 at 11:56 AM, V6 (CNA) said R1 can feed himself but needs to be supervised. V6 said she was at a different table with her back to R1, feeding another resident. V6 said V4 (Restorative CNA) said R1 was choking and V3 (Nursing Supervisor) went over right away and helped him. On 4/23/26 at 11:28 AM, V7 (Speech Therapist) said R1 had Parkinson's disease, and his swallowing ability and cognition fluctuate throughout the day and during a session. V7 said when R1 was discharged from Speech Therapy in October 2025, swallowing recommendations (or strategies) were provided to the nursing staff. V7 said she expects the staff to implement the recommendations made in the Discharge Summary. V7 said if the recommendations aren't followed it increases the risk of aspiration or choking. V7 said close supervision means someone should be sitting with the resident with their eyes on him. They should be watching, so they can provide appropriate reminders to R1. He inconsistently takes big bites and can eat fast at times. V7 said R1 is inconsistent with his presentation and willingness to follow directions. V7 said when she asked R1 what happened he said he ate too fast. On 4/23/26 at 10:18 AM, V2 (Director of Nursing - DON) said R1 had times where he's lucid and times where he was confused and hallucinating. V2 said R1 had some coughing during meals, but never choking like this episode. V2 said facility staff must remind R1 to eat food and alternate with drinks and remind him to slow down. V2 said R1 will [NAME] up the food quickly, and lave the dining room. V2 said close supervision means the staff have eyes on the R1. V2 said the staff need must watch the R1 closely to provide the appropriate cues. V2 said he expected the staff to follow the swallowing recommendations made by Speech Therapy. The facility's Assistance with Meals Policy dated 2001 showed, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident.The facility's Meal Supervision and Assistance Policy dated 2025 showed, the facility will develop and implement an individualized care plan based on the Resident Assessment Instrument to address the resident's needs and goals, and to monitor the results of the planned interventions such as adequate supervision during meal time. Alternate food and liquids as needed to cleanse mouth of food.

Based on observation, interview, and record review the facility failed to ensure fall interventions were in place for a resident with a history of falls for 1 of 15 residents (R7) reviewed for safety in the sample of 15.The findings include:R7's Face Sheet printed on 1/26/26 listed a history of falling as a diagnosis.R7's Fall Care Plan with an initiated date of 7/7/24 showed R7 had fallen while at the facility and had a history of falling out of bed. Listed under interventions was the use a floor mattress. On 1/26/26 at 10:14 AM, R7 was in bed. There was no floor mattress on the floor next to R7's bed. The floor mattress was lying up against the wall near the head of the bed. There were no staff members, family, or care givers in the room. On 1/27/26 at 12:07 PM, V10 (Certified Nursing Assistant) said floor mattresses should be placed on the floor next to the bed when the resident is in bed.

Based on interview and record review the facility failed to secure narcotic medication after delivery from the pharmacy. This applies to one of three residents (R1) in the sample of seven reviewed for medication storage.The findings include:The facility reported incident report dated 8/4/2025 shows a narcotic was delivered to the facility from the pharmacy on 8/2/2025 at 7:11 AM for R1. On 8/4/2025 the narcotics could not be located.The facility face sheet for R1 shows she was admitted to the facility after a stay in the hospital for pneumonia and respiratory failure. R1 had a Physicians order for hydrocodone (narcotic pain medication) to be used as needed for pain. R1 was discharged from the facility on 8/4/2025 as planned. On 8/13/2025 at 10:30 AM the door to the nursing station was locked. V7 Unit Secretary came and unlocked the door for this surveyor and said, It's locked today because the state is in the building.On 8/13/2025 at 10:01 AM, V3 Registered Nurse said she was the day shift supervisor working the morning of 8/2/2025 when the narcotic was delivered from the pharmacy. V3 said she was getting report, so the night shift supervisor (V4) took the narcotics from the pharmacy delivery driver. V3 said V4 should have delivered the narcotics to the nurse assigned to R1 that day so they could be secured in the narcotic lock box on the medication cart, but she put in a bin on top of the shredder in the nurses' station instead. V3 said she was very busy that day and never locked the narcotic medications up as they were supposed to be. V3 said when she left for the day, the narcotic was still in the bin on top of the shredder.On 8/13/2025 at 9:57 AM, a call placed with message left to V4 Registered Nurse (RN) was not returned. The undated facility interview with V4 shows she received the narcotic medication from the pharmacy on 8/2/2025 at 7:11 AM. V4 said she was very busy at the time so she put the medication on the medication tray inside the medication room and never signed in the narcotic or place the narcotic in a locked narcotic box.On 8/13/2025 at 12:17 PM V2 Director of Nursing said he became aware the narcotic for R1 was missing on 8/4/2025. V2 said he completed an investigation and could not determine what happened to the missing narcotic. V2 said he expects the nursing staff to immediately sign in narcotics when delivered from the pharmacy and deliver the narcotic to the assigned nurse so the narcotic can be locked up in the narcotic lock box of the medication cart. V2 said this is to ensure the narcotic is not lost or stolen. The pharmacy delivery invoice shows the narcotic for R1 was delivered and signed for by V4 on 8/2/2025 at 7:11 AM. The facility policy dated July 2024 for medication storage in the facility shows medications included in the Drug Enforcement Administration (DEA) classification as controlled substance are subject to special handling, storage, disposal and record keeping in the facility. Only authorized licensed nursing and pharmacy staff have access to controlled substances. Schedule 2 medications are stored in a permanently affixed, double locked compartment separate from all other medications. All controlled substances must be counted every shift.

Based on observation, interview and record review the facility failed to ensure a safe resident transfer and failed to ensure incontinence care was provided in a safe manner to prevent a fall. This failure resulted in R1 falling from bed during incontinence care and sustaining a femur fracture. This applies to 2 of 3 residents (R1 and R2) reviewed for safety in the sample of 3. The findings include: 1. R1's Minimum Data Set assessment dated [DATE] shows that her cognition is impaired, her vision is highly impaired, she is always incontinent of urine and stool, weighs 180 pounds and is dependent (Helper does all of the effort. Resident does none of the effort to complete the activity) for rolling left and right. On 2/26/25 at 11:24 AM, R1 was laying in bed. V5, Certified Nursing Assistant (CNA) and V4, Registered Nurse (RN) provided incontinence care to R1. R1 was confused and did not help with turning during the care. R1 was totally dependent on the staff during the care. R1 had a wound vac attached to her left upper leg. R1's Nursing Notes dated 2/15/25 shows, Around 1900 (7:00 PM) I was told by the nurse supervisor that the resident has fallen to the floor. Upon assessment resident was sitting on the floor by the window Per CNA she was changing the patient when she couldn't bare the weight when resident turned to one side and just lowered the bed On 2/27/25 at 12:24 PM, V7 (CNA) said that she was cleaning R1 up by herself because she had had a large bowel movement. V7 said that she turned R1 to the left side and her right leg was over her left leg and she began to fall off the bed. V7 said that R1 got too heavy to hold so she lowered her to the floor. V7 said that her legs hit the floor first but she is not sure what one. V7 said that she tried to get R1 back onto the bed when she started falling but she could not because she was too heavy. V7 stated, It was busy so I didn't have anyone to help me at the time. I usually do with two people. On 2/26/25 at 2:35 PM, V12 (RN Supervisor) said that she entered R1's room on 2/15/25 and saw R1 on the left side of her bed on the floor. V12 said that R1's buttock was sitting on top of V7's (CNA) feet and R1's back was on V7's legs. V12 said that V7 was the only staff member in the room when she came into the room. V12 said that she believes that R1 requires two staff members for incontinence care. On 2/26/25 at 2:11 PM, V13 (RN) said that she entered R1's room on 2/15/25 after she had heard that she had fallen. V13 said that when she entered, R1 was sitting on the ground on the left side of her bed and her back was leaning up against a recliner. V13 said that she asked V7 what had happened and she said that she was cleaning her and when she turned her to the side, her weight was put on one side and she couldn't hold her so she helped her down to the floor. V13 said that R1 is a little heavy and can not see very well so she is usually a two person assist for incontinence care. V13 said that she asked V7 if anyone was helping her and she said, no. R1's Nursing Notes dated 2/17/25 shows, At around 0300 (3:00 AM) while CNA assigned was giving care she noted that resident left knee is swollen ,night supervisor made aware and saw resident, upon assessment of this writer, noted resident left knee swollen, no bruising/redness but painful to touch,also noted that left leg appears shorter than RT (right) leg, and resident with facial grimacing and yelling ouch,ouch when area is touch. On 2/26/25 at 2:20 PM, V14 (RN) said that she was called to R1's room by the CNA. V14 said that when she did an assessment on R1, she noticed her left knee was swollen and her left leg appeared shorter than her right leg. V14 said that it was painful when she touched it. V14 said that she called the hospice nurse and notified her and the nurse said to give her ordered morphine and she will notify R1's routine hospice nurse. V14 said that she notified the oncoming nurse that she was awaiting a call back from hospice for additional guidance on what needs to be done. R1's Nursing Notes dated 2/18/25 shows, Late entry for 2/17/25. While siting in her [high back wheel chair] in the dining, resident stated I am not feeling well. Ask resident if in pain and where is the pain. No answer. Asked her again is your head hurting, again stated no this time. After breakfast resident was assisted by 2 CNAs back to bed and fell asleep right away. 2 RNs in the room to do an assessment. Found resident in the bed dorsal position with L (left) leg in the frog position. RN touched her dorsal aspect of L foot to feel pulse and she moaned, while resident is holding the L side of her pad. With 2 assist able to move her pant down below her knees and noted L thigh mid section with a hard bump, RN marked with a pen. Area is swollen and noted knee also edematous and bigger in size than the R (right) knee. Notified [Nurse Practitioner], in turn gave orders for xrays to be done. R1's X-Ray Report dated 2/17/25 shows, Impression: Left Hip: Metallic prosthesis in the left hip with mild protrusio acetabuli and oblique and slightly spiral fracture of the midshaft of the left femur. R1's Nursing Notes dated 2/17/25 at 5:28 PM shows, Call received at 17:28 (5:28 PM) from xray service to inform this writer that patient has a left femur fracture patient to be sent out to [Local hospital] for further evaluations. R1's Hospital History and Physical dated 2/18/25 shows, Her hospice nurse is at bedside. Hx (history) obtained from this hospice RN and also pt's daughter on the phone. Pt. reportedly is bed-bound, AAO (alert and oriented) x 0-1/4 at baseline and fell off her bed when she was being cleaned about 2 days pta (prior to arrival). Had persistent pain after this and an XR (X-Ray) was eventually done which showed a L (left) hip fracture so she was brought in. R1's Hospital X-Ray dated 2/17/25 shows, There is a complete fracture through the mid femoral shaft with marked displacement and angulation. R1's Orthopedic Surgeon Note dated 2/18/25 shows, The patient is a 90 y.o (year old) female who has left femur fracture; ready for surgery today. Plan on left open reduction internal fixation femur On 2/26/24 at 4:11 PM, V15 (Orthopedic Surgeon) said that R1's fracture was due to a fall. V15 said that the fracture was also slightly spiralized which means there was some type of twisting motion involved as well. V15 said that R1's fracture was not pathological in nature. On 2/26/25 at 1:12 PM, V9 (CNA) said that she always has someone help her with incontinence care for R1 because she is not able to help with rolling. On 2/26/25 at 1:30 PM, V10 (CNA) said when providing incontinence care to R1, she usually uses two people because R1 can not help do anything. On 2/26/25 at 2:40 PM, V2 (Director of Nursing) said that R1 is confused and is totally dependant on staff for cares. V2 said that R1 uses a mechanical lift for transfers which requires two people so she typically has two staff members in the room to provide incontinence after they transfer her back to bed. V2 said that after the fall, they updated the assignment sheet to note that she needs two person assist for bed mobility and transfers. V2 said that before the incident, her care plan said 1-2 staff member for bed mobility. R1's Incident Note dated 2/15/25 shows that she had a witnessed fall. The note shows, CNA statement: When I was changing the resident as I turned her on her left side, she put all her weight on one side, and I was trying to hold her, but I couldn't hold her anymore, so I lowered the bed before guiding her to the floor . R1's Kardex Report dated 2/14/25 shows, Bed mobility:Lock wheels, give verbal cues and assist as needed. Needs to total assist of 1-2 staff with bed mobility. 2. R2's Transfer Guide assessment dated [DATE] shows that she requires two person assist with transfers. R2's Nursing Notes dated 1/31/25 shows, Patient arrived to skilled floor via wheelchair .Patient is alert and oriented x 1, to person only. Patient is a high fall risk and was placed in common area at admission .Writer received quick report from 1st floor nurse on new admission . 2 person assist, high fall risk . R2's Nursing Notes dated 2/3/25 shows, This RN (Registered Nurse) was called to shower room in A hallway by CNA (Certified Nursing Assistant) to assist with patient that was lowered to the floor by CNA during a wheelchair to toilet transfer. On 2/26/25 at 1:19 PM, V11 (CNA) said that she was toileting R2 on 2/3/25 when she was lowered to the floor. V11 said that it was only her second day working with R2 and her assignment sheet said that she was a one person assist. V11 said that she brought her into the shower room bathroom and put a gait belt on her and had her stand and hold onto the bar next to the toilet. V11 said that when she went to move her hands on the bar, R2 started screaming and becoming irrational. V11 said that she then put her arms around R2 and gave her a hug from behind her and slowly lowered her to the floor. V11 said that she heard after the incident that R2 was supposed to be a two person transfer. V11 said that she was the only staff member in the shower room at the time of the incident. R2's Kardex as of 2/3/25 shows, Transfer: needs total assist with transfers. The facility's Assessment, Documentation and Care Planning for Residents at Risk for Falls or Who Have Fallen Policy revised 7/19/24 shows, Fall prevention interventions will be developed, documented in the care plan, communicated to involved staff, and implemented based upon the assessment of resident- specific risk factors for falls.

Based on observation, interview, and record review the facility failed to ensure dishes were washed in a manner to prevent cross-contamination and failed store thickener in a manner to prevent cross-contamination. This affects all 44 residents residing in the facility. The findings include: The facility's CMS 671 Form dated 12/10/24 shoed there were 44 residents residing in the facility. 1. On 12/10/24 at 10:08 AM, the surveyor, V3 (Dietitian), V4 (Director of Dining Services), and V8 (Dietary Manager) returned to the main kitchen. The dishwashing area was inside the door, to the left. The dishwashing station was a small square shaped area, with an opening to enter the area. The dirty dishes were stacked to the left of the dishwasher and directly across the area, from the dishwasher. The clean dishes were removed from the right side of the dishwasher and stacked against the adjacent wall. The 3 compartment sink was positioned to the right of the clean dishes (or on the opposite wall from the dishwasher). The additional dirty dishes were stacked at the end of the 3 compartment sink. V5 (Dishwasher) applied green, rubber gloves that extended to his elbows. V5 sprayed food debris from a large, rectangular shaped plastic bin. The food debris and water sprayed back toward V5. V5 placed the plastic bin into the dishwasher and returned to spraying food debris from the dirty dishes. The dishwasher cycle completed and V5 moved directly from the dirty dishes to remove the clean, plastic bin and move it into the drying area. V5 did not remove the soiled gloves and he didn't not clean his hands. V5 moved back to the dirty dishes and continued to spray food debris from the mixing bowls and stainless steel containers. V3 (Dietitian) walked over to V5 and whispered to him. V5 stopped washing dishes. V4 (Director of Dining Services) tested the sanitizer levels of the 3 compartment sink and left the dishwashing area. V5 resumed spraying food debris from the dirty dishes. V5 placed a load of mixing bowls and stainless steel containers into the dishwasher and returned to spray food debris from the dirty dishes. When the dishwasher cycle was complete, V5 turned to the clean side of the dishwasher, removed the clean dishes, and stacked them in the drying area. V5 continued to wear the same green rubber gloves and didn't not wash his hands when moving from clean to dirty. V5 continued to move from clean to dirty and back to clean without washing his hands. V5 was observed until 10:17 AM. On 12/11/24 at 11:30 AM, V4 (Director of Dining Services) said she expects the dishwasher to scrub dishes and removed food debris and place the dishes in the dishwasher. V4 said if the dishwasher is moving from dirty dishes to clean dishes, then he should have washed his hands to prevent cross-contamination. V4 said he shouldn't have been going back and forth from clean to dirty without washing his hands. The facility's Hand Hygiene and Infection Control Policy revised 1/24 showed, In the Food & Nutrition Department: All associates associated with the handling of food shall wash hands. Hands are washed with soap and water and the following times: .Before handling food or clean utensils/dishes/equipment . Procedures: All Food Handlers: Use only sinks designated for hand washing . A Dishwashing Policy was requested and not received. 2. On 12/11/25 at 9:19 AM, V6 (Cook) was in the rear station chopping raw vegetables. There was a small, clear plastic bin of thickener along the back of the counter. The container had a lid on it. A stainless steel measuring cup was half buried inside the thickener. The handle of the measuring cup was under a layer of thickener. V6 prepared the buttered carrot puree. V6 said the consistency was too thin and he would need to add thickener. V6 removed the lid to the thickener container, left the buried measuring cup in the thickener, and obtained a clean measuring cup to scoop thickener. V6 added the thickener to the carrots and left second measuring cup inside the thickener container. At 9:28 AM, V6 pureed the pork carnitas for the quesadilla. V6 said the puree was too thin and he needed to add some thickener. V6 removed the half buried, measuring cup from the thickener, and used the handle to scoop thickener. V6 added the thickener to the pork mixture and blended the food further. V6 returned the measuring cup to the container of thickener. The thickener now had 2 measuring cups sitting inside the container. On 12/11/24 at 11:30 AM, V4 (Director of Dining Services) said scoops or measuring cups shouldn't be stored in the thickener due to the risk of cross-contamination. V4 stated, They know better than that. The facility's Storage of Pots, Dishes, Flatware, Utensils Policy reviewed 1/23 showed, Procedure: Pots, dishes, and flatware are to be stored in such a way as to prevent contamination by splash, dust, pests, or other means. Procedures: Dish Handlers, Trayline Area Associates: .Store utensils vertically, in a bucket with handles pointing up, to reduce opportunities for contamination .

Based on observation, interview, and record review the facility failed to ensure PPE (personal protective equipment) was worn in a manner to prevent cross contamination for 1 of 1 resident (R8) reviewed for infection control in the sample of 12. The findings include: On 12/10/24 at 11:19 AM, R8 had a PPE bin outside the door. There was a large sign on the door of the room that said, STOP Enhanced Barrier Precautions. The signage had illustrations to show gloves and gowns must be worn during high-contact resident care activities. The care activities included but were not limited to: dressing, transferring, and assisting with toileting when a urinary catheter was in use. This surveyor entered the room and R8 was standing at the sink while brushing his teeth. V11 (CNA-Certified Nurse Aide) was in the bathroom and wearing only gloves. V11 assisted R8 across the room using a gait belt and walker, then transferred him to an upright recliner. V11 emptied the garbage can and exited the room. V11 was not wearing a gown at any time during the care. R8 stated he has a catheter because he can't get to the toilet in time. R8 stated he needs help from the staff for all transfers and to get dressed. R8 stated V11 had just helped him use the toilet and put his pants on before this surveyor entered the room. R8 said staff usually wear gloves but do not always wear a gown when they empty his catheter or him use the toilet. R8's facility assessment dated [DATE] showed he was cognitively intact and the use of a urinary catheter. On 12/11/24 at 10:24 AM, V12 (Infection Control Preventionist) stated the enhanced barrier precaution signs show staff what they need to wear in the room. Residents with catheters have the precaution signs and PPE outside every room. Gowns and gloves should be worn during high-contact care which does include transferring, toileting, and dressing a resident. The PPE is important to help stop the transfer of germs from resident to resident. On 12/11/24 at 1:58 PM, V11 (CNA) stated she needs a gown and gloves on basically anytime she enters R8's room because he has a catheter. V12 said she did have a gown on yesterday during care but took it off while he was brushing his teeth. V12 said she should have still been wearing one while transferring him. On 12/12/24 at 10:39 AM, V2 (Director of Nurses) stated aides need to wear a gown and gloves when providing care to a resident with a catheter. Especially if they need to touch the lower part of the body. V2 said R8 is alert, oriented, and has no memory problems. V2 stated proper PPE is important in case urine splashes. It is an infection control issue. Urine on staff clothing can transfer microorganisms to other residents. The facility's Enhanced Barrier Precautions (EBP) policy last revision dated 9/3/24 states under the procedure section: 11. PPE, gloves and gowns, will be required for all staff providing high-contact care activities which include .dressing, transferring, providing hygiene, changing briefs or assisting with toileting. The policy listed the use of urinary catheters as an indication for the implementation of enhanced barrier precautions.

Based on observation, interview, and record review the facility failed to check placement of a feeding tube prior to administering a nutritional supplement for 1 of 1 resident (R25) reviewed for feeding tubes in the sample of 12. The findings include: R25's face sheet printed on 12/12/24 showed diagnoses including but not limited to Parkinson's disease, dysphagia (difficulty swallowing), dementia, epilepsy, and protein-calorie malnutrition. R25's facility assessment dated [DATE] showed severe cognitive impairment and the use of a G tube for nutrition (gastrostomy tube-soft, plastic feeding tube that goes into the stomach). R25's December 2024 order summary report showed an order start dated 7/2/24 for: .enteral feeding give 1 carton (237 milliliters) of Jevity 1.5 calorie at noon per G tube . The same report showed orders start dated 7/1/24 to check placement of the G tube before administering medication or feedings. On 12/11/24 at 1:27 PM, V9 (Registered Nurse) administered R25's enteral feeding while he was in bed. The end of the tube inserting into R25's stomach was covered with a white dressing and was not visible. V9 poured the liquid nutrition and water into a plastic beaker. V9 connected a plastic syringe to the end of the G tube and flushed the tube. V9 poured the liquids into the tube and flushed it again. V9 did not check placement of the tube prior to administering the feeding. At 1:45 PM, V9 stated she usually uses the aspiration method to check placement. She uses a stethoscope connected to the G tube and listens for a puff of air. V9 said she did not do it today because she did not have her stethoscope with her. V9 stated it is important the tube is in the right place, so the nutrition goes into the stomach. On 12/12/24 at 10:44 AM, V2 (Director of Nurses) stated nurses should be checking for placement using the aspiration method, residual method, or look for the mark on the tubing where it is inserted. They need to check placement prior to administering anything to reduce the danger of the tube having been dislodged. There is the potential for an infection in the abdominal wall if the tube is not in the right place. R25's care plan showed a focus area related to risk of aspiration pneumonia from the use of a feeding tube. Interventions included checking for placement and gastric contents/residual volume per facility protocol and record (start dated 10/14/24). The facility's Enteral Nutrition policy last review dated 3/31/24 states under the verifying placement of feeding tube section: 1. Tube placement is checked prior to administering medications tube flushes, or enteral formula.

Based on observation, interview, and record review the facility failed to ensure a homelike environment by allowing a damaged nightstand to remain in a resident room for 1 of 6 residents (R4) reviewed for environment in the sample of 6. The findings include: On 8/14/24 at 1:51 PM, V8 stated her aunt was a resident at the facility for about one week in July 2024. V8 said the nightstand in the room was damaged during the entire time. The top handle was hanging off and the left upper corner was missing a section. V8 said staff were repeatedly in and out of the room but the nightstand was never repaired or replaced. On 8/14/24 at 10:44 AM, the facility nightstand in the same room V8's aunt had resided in was observed. The handle was still falling off and the left, upper corner was heavily damaged. R4 was the resident currently residing in the room. R4 said it had been that way since she arrived at the facility. On 8/14/24 at 1:32 PM, V5 (Maintenance Technician) stated he was unaware of any complaints or work repair orders for the nightstand. V5 said items like nightstands can typically be repaired the same day it is reported. On 8/14/24 at 1:55 PM, V1 (Administrator) stated damaged resident items should be reported right away. All staff are responsible for reporting it. Damaged room items just look bad and are not how things are kept around here. The facility's Personal Possessions and Safe Environment policy last revision dated 3/31/24 states under the purpose section: (Facility name), to the extent possible, provides a homelike environment. Provides housekeeping and maintenance services necessary to maintain a sanitary, orderly (uncluttered environment that is neat and well kept), and comfortable interior.

Based on interview and record review the facility failed to ensure resident dignity was maintained during dining for 1 of 6 residents (R1) reviewed for dignity in the sample of 6. The findings include: R1's face sheet printed on 8/14/24 showed diagnoses including but not limited to atrial fibrillation, pulmonary embolism, malnutrition, Alzheimer's Disease, and dementia. R1's facility assessment dated [DATE] showed severe cognitive impairment and substantial/maximal staff assistance needed for eating. On 8/14/24 at 1:51 PM, V8 (R1's daughter) stated she was visiting R1 on the morning of 7/8/24 and found her seated in the group dining room wearing only a hospital type nightgown. V8 said R1 had a blanket draped over her shoulder's but nothing over the rest of her. V8 said she absolutely brought clothes to the facility including pajamas, the day prior. V8 said she immediately complained to staff. V8 was told that R1 was restless during the early morning hours and was taken to the nurse station in her nightgown. Staff reported R1 was sent to the dining room wearing the same gown when breakfast began. V8 said R1 looked ungroomed and her hair was a mess. On 8/14/24 at 12:49 PM, V3 (Social Service Director) stated she was at a staff morning meeting in July and was told R1's family member (V8) was unhappy with R1's care. V8 found R1 in the group dining room seated at the breakfast table wearing a hospital type gown and was poorly groomed. V3 said the entire morning team heard about it and knew V8 was unhappy about the situation. V3 said she met with V8 to further discuss the situation. V3 said it never should have happened. It is undignified and not the normal procedure. On 8/14/24 at 12:58 PM, V2 (Director of Nurses) stated all residents should receive morning cares, including face washed, hair combed, and appropriately dressed, before leaving their room. V2 said he was aware that R1 had been placed in the group dining room while still wearing her night gown. V2 said he knew V8 complained to staff when she saw R1 undressed and outside of her room. V2 said residents should be dressed before coming out of their rooms. It is the decent thing to do. The facility's Quality of Life policy last review dated 3/31/24 states under the dignity section: Nursing staff- 1. [NAME] resident as they wish to be groomed. Maintains personal privacy by keeping residents covered/clothed while being taken to areas outside their room. 2. Encourage/assists resident to dress in their own clothing rather than hospital-type gowns and to wear appropriate footwear according to their preferences.

Based on observation, interview, and record review the facility failed to ensure a resident with a complicated feeding problem was assisted to eat by a qualified staff member for 1 of 3 residents (R3) reviewed for safe dining in the sample of 3. The findings include: On 05/08/24 at 11:35AM, V6 Resident Assistant was providing R3 bites of pureed food with a spoon. On 05/08/24 at 11:35AM, V6 said, this is R3. I am an Activity Specialist; I am not a CNA-Certified Nursing Assistant. I am trained to feed residents as a Resident Assistant. On 5/08/24 at 1:13PM, V7 Speech Therapist said, R3 has a treatment diagnosis of dysphagia related to age, Alzheimer's (disease), and dementia. Because of his Alzheimer's (disease) he is at risk for choking if he is not fed appropriately. The problem I was treating R3 for is an oropharyngeal dysphagia (difficulty moving food in the mouth in preparation to be swallowed and moving the food safely past the trachea without aspiration into the lungs). R3's current Physicians Orders dated May 2024 shows, multiple diagnoses including dysphagia. Diet Orders: Pureed Diet, Nectar thick liquids. Clear mouth before each bite/sip: watch neck for swallow. R3's Speech Therapy Evaluation dated 01/24/24-02/19/24 shows, Diagnoses: Dysphagia, oropharyngeal phase. Reason for Referral: resident with decreased mobility with a decline in function as well as decline in swallowing ability with recent diet downgrade to puree consistency. The facility's Resident Attendants policy dated 05/01/24 did not show, Feeding Assistants/Resident Attendants should not provide dining assistance to residents with complicated feeding problems.

Based on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor and failed to secure the catheter tubing for 2 of 3 residents (R197 and R38) reviewed for catheters in the sample of 12. The findings include: On 1/8/24 at 11:22 AM, R197's urinary catheter bag was lying directly on the floor on the right side of her bed. On 1/8/24 at 11:41 AM, R38's urinary catheter bag was attached to her bed frame and her bed was low to the floor, therefore, resting directly on the floor, uncovered. On 1/8/24 at 2:03 PM, V6 and V7, Certified Nursing Assistants (CNAs) provided incontinence care to R38. R38's catheter tubing was not secured in any manner and was taut. After completing incontinence care, V6 and V7 positioned R38 on her back with the unsecured catheter tubing placed under her left leg. The drainage bag was hung on the bed frame, the bed was lowered and again the drainage bag was resting directly on the floor. On 1/8/24 at 2:31 PM, R197's urinary catheter bag was lying directly on the floor. On 1/10/24 at 2:25 PM, V6 said the first rule of catheter care is to not put the catheter on the floor. V6 said if the resident's bed needs to go low, we put the drainage bag in a dignity bag so it does not touch the floor directly and we hang it on the bed frame. V6 said we don't want it to touch the floor for infection control reasons; we don't want the patient to get a UTI (urinary tract infection). V6 said if the resident does not have the catheter secured, we tell the nurse, and they put the tubing in a secure holder on their leg so they don't pull it out and it's more comfortable. V6 said we position the tubing over the leg so it doesn't kink and to keep the urine from flowing back into the bladder. R38's Face Sheet printed 1/10/24 shows she is a [AGE] year old female admitted to the facility on [DATE]. R38's diagnoses include, but are not limited to acute and chronic kidney disease and urinary retention, heart disease, and heart failure. R38's Care Plan for 12/22/23 through 1/11/24 shows she is at risk for infection related to her indwelling urinary catheter status. R197's Face Sheet printed 1/11/24 shows she is an [AGE] year old female admitted to the facility on [DATE] after having a myocardial infarction (heart attack). R197's diagnoses include, but are not limited to, heart failure, diabetes, urinary retention, hypertension, and protein malnutrition. R197's Care Plan for 1/4/24 through 1/11/24 shows she is at risk for infection related to her indwelling urinary catheter status. The facility's Bowel and Bladder Incontinence/Urinary Catheters/UTIs Policy (last reviewed 6/30/23) shows residents with urinary catheters will receive appropriate care and services to prevent UTIs. Care includes keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodging the catheter and securing the catheter to facilitate the flow of urine.

Based on interview and record review the facility failed to ensure fall risk interventions were in place for a resident (R27) at risk for falls with a history of falls. This failure contributed to R27 falling and sustaining a impacted and comminuted left femur fracture and a dislocated left knee. This applies to 1 of 13 residents reviewed for safety in the sample of 13. The findings include: R27's face sheet shows she has diagnoses including: history of falling, unsteadiness on feet, need for assistance with personal care, dizziness and reduced mobility. R27's 10/24/23 fall risk assessment shows she is at high risk for falls. R27's active care plan effective 6/1/2022 shows that she is alert and oriented x 2-3 but forgetful, at risk for falls, has an unsteady gait and needs limited to total assist of 1-2 staff with her activities of daily living. A intervention effective 6/1/2022 shows R27's bed should be in the lowest and locked position. R27's fall risk care plan shows she had a fall from bed on 10/24/22 and an updated intervention was added for a floor mattress on the left side of her bed. R27's 1/28/23 nursing progress notes completed by V9 (Registered Nurse/RN) at 7:50 PM states, CNA {V6} noted resident {R27} laying on her back with the pillow under her head. Unable to recall what happened she was verbally responsive but confused. Complained of left leg pain and back pain. Resident left facility in a stretcher at 7:55 PM. A nursing progress noted dated 1/29/23 at 1:23 AM, shows R27 was admitted to the hospital. R27's hospital records from a local community hospital show that she was admitted on [DATE] and discharged back to the facility on [DATE]. The hospital records state the following, Patient is a 94 y.o. female with past medical history of hypertension, neuropathy, presenting from {the facility} after a fall. Patient's daughter was present throughout the encounter. Reports that she received a call from {the facility} advising that the patient had been found on the floor next to her bed. Notes she has fallen before and usually mattresses are placed on the floor as bed rails are not allowed. However there was no mattress on the floor when incident occurred. Patient had been served dinner while laying in bed. Was found 30 minutes after that on the floor. The same hospital records show R27 sustained a fracture of the left distal femur. A radiology note dated 1/29/23 shows R27 has a There is a impacted and comminuted fracture (a bone broken in at least 2 places as a result of trauma -Web MD) of the distal left femur and intercondylar region with moderate displacement and angulation. There is anterior subluxation of the lateral femoral condyle (dislocated knee) in relation to the tibial plateau. There is soft tissue swelling of the left knee region and small hemarthosis (bleeding in the knee). R27 was discharged from the hospital back to the facility on [DATE] with orders for no weight bearing and a leg immobilizer. A IDPH Long Term Care Facility Incident and Accident Report investigation was provided by the facility. The investigation shows that R27 was found on the floor on the left side of her bed at 6:30 PM, on 1/28/23. A Post Fall Occurrence Follow-up provided with the investigation shows that factors contributing to the fall included confusion and impaired cognition. Factors of how the fall could be prevented include Mats on floor to minimize injury. On 3/7/23 at 8:43 AM, R27 was in bed eating her breakfast. Her bed was up against the wall on the right side of the room and raised up approximately 1/4 of the way. The overbed table legs were underneath her bed and her tray was on the table. A large blue thick fall mat was folded up and moved out creating an approximate 2 inch gap between the base of the bed and the mat. R27's left leg was elevated underneath the covers and the outline of her immobilizer was visible through the covers. R27 said, I don't remember all of what happened that day I was more confused I guess you could say, but I had a fall from bed, hit the floor and broke my leg. On 3/7/23 at 1:43 PM, V3 (Assistant Director of Nursing) said, I think what happened with R27's fall was that they have to raise up her bed to get the overbed table to go underneath it and have to pull the fall mat away from the bed because the table cannot sit on it. A fall mat would have minimized the impact from the fall onto the floor. R27 broke her leg and dislocated her knee when she fell . On 3/7/23 at 2:15 PM, V4 (CNA) said, I was not here when R27 fell . But I know that when she is eating we have to raise the bed up and move the fall mat away. We do not usually stay in the room with her when she is eating. The purpose of the fall mat is to prevent her from hitting the floor if she has a fall. On 3/8/23 at 8:56 AM, V5 (Registered Nurse) said, prior to R27's last fall her bed was in the middle of the room and she was supposed to have a big fall mat down on the left side of her bed. We do have to move the mattress away when she eats and raise her bed to be able to get the bedside table underneath the bed. On 3/8/23 at 9:28 AM, V6 CNA said, The day that R27 fell she was confused and agitated and the lab had been in to draw blood. I took R27 her dinner tray and I did not stay with her, I would just go check in on her every 30 minutes or so. On one of the checks I found R27 on the floor on the left side of her bed. We do have to raise her bed to get the overbed table underneath and pull her fall mat away. R27's bed at the time of the fall was in the center of the room. There was 1 fall mat for the left side of her bed that was pulled away and was not right next to her bed. On 3/8/23 at 10:37 AM, V8 (R27's physician) said, This type of an injury a femur fracture and a dislocated knee is consistent with a fall yes. I would think had the large fall mat had been down it would have minimized the extent of the injury from the fall. I think the fall interventions do need to be followed. The facility provided policy titled Assessment, Documentation, and Care Planning for HC Residents at Risk for Falls or Who Have Fallen with a revised date of 1/24/23 states, Fall prevention interventions will be developed, documented in the care plan, communicated to involved staff, and implemented based upon the assessment of resident- specific risk factors for falls.

Based on observation, interview, and record review the facility failed to ensure a residents insulin vial was stored with open/expiration dates for 1 of 13 residents (R146) reviewed for medication storage in sample of 13. The findings include: R146's Face Sheet printed on 3/7/23 showed R146 to be an [AGE] year old female admitted to the facility with diagnoses which include: disease of pancreas and type 2 diabetes mellitus. R146's Physician Order Sheet printed 3/7/23 showed R146 having a short acting insulin order for 6 units three times a day in addition to a sliding scale dose before meals. On 3/6/23 at 11:45 AM, V5 Registered Nurse (RN) opened the med cart. R146's vial of short acting insulin was opened with no open date or expiration date written on the vial or the storage bag. V5 stated the nurse who opened the vial should have put an open and expiration date on the vial. The expiration date is 28 days after opening for insulin. On 3/8/23 at 11:25 AM, V10 Nursing Supervisor (RN) stated when an insulin vial is opened the nurse needs to put an open and expiration date (28 days later) on the vial. The facility's Medication Storage Policy dated 3/2021 showed when a medication's vial is opened it needs to be labeled with an open and expiration date per manufactured recommendations to ensure the medication is still viable.

Based on observation, interview, and record review the facility failed to ensure the discharge process was completed for a resident who left against medical advice for 1 of 2 residents (R42) reviewed for discharge in the sample of 13. The findings include: On 3/8/23 at 9:30 AM, R42 was not observed in the facility. R42's Progress Note dated 12/15/22 shows admitted [AGE] year old female from hospital brought in by family in wheelchair with diagnosis of urinary tract infection, possible pneumonia, dementia with history of hypertension, heart murmur. There are no other progress notes in R42's electronic medical record. The facility census dated 3/6/23 does not contain R42. On 03/08/23 at 9:40 AM, V2 Director of Nursing (DON) stated I'm not sure what happened to R42. I will have to ask the admitting nurse. R42 is not here currently. R42's Face sheet dated 3/8/23 shows R42 was admitted [DATE] at 2:24 PM and then discharged [DATE] at 5:00 PM. On 03/08/23 at 9:54 AM, V2 said he spoke with V5 Registered Nurse who admitted R42, and after hour or so of being at the facility, the resident wanted to go home. V2 said R42 was very alert and her family wanted her to stay and she wanted to go home. V2 said V5 reported to him R42 left with family. V2 said V5 thought because she didn't finish the admission she didn't have to complete notes. On 03/08/23 at 10:07 AM, V5 stated R42 didn't want to be admitted and didn't want to stay. I started the admission and she said she didn't want to be in the nursing home. I didn't have her sign any papers. I don't recall how she left and I don't recall giving her any papers from the hospital or any discharge papers. I went into the room to finish her admission and she didn't want to stay so they left. I can't recall how long she was here before leaving. On 03/08/23 at 11:03 AM, V2 stated I would expect the nurse to have an Against Medical Advice form (AMA) signed by resident. The nurse should have documented everything in the progress note including the resident refusal to sign paperwork, how the resident left and with whom, what paperwork was sent with the resident, and the condition of the resident. V5 should have notified myself or the Assistant Director of Nursing and the doctor. This should be documented as well. The facility's Discharge of a Resident Against Medical Advice Policy dated 7/4/22 shows Any resident who communicated intent to leave the healthcare center AMA .notify the attending physician and social services .inform interdisciplinary staff of resident's discharge documents resident's.

Based on interview and record review the facility failed to ensure a resident was free of a significant medication error. This applies to 1 of 3 residents (R1) reviewed for medications in the sample of 3. The findings include: R1's Final Incident and Accident Report documents on 12/29/22 R1 is a [AGE] year-old female with diagnoses including after care following joint replacement right femur fracture, CHF, acute kidney failure, hyponatremia, atrial fibrillation and rheumatoid arthritis. On 12/29/22 V6 (Night Supervisor) noted a duplicate order for acetaminophen. R1 received medication from both orders .R1 was sent out to the local hospital and received acetylcysteine (antidote for acetaminophen overdose) with orders to hold acetaminophen for 24 hours . R1's Medication Administration Record (MAR) for December 2022 shows orders for Acetaminophen 500 mg give two capsules (1000 mg) prn (as needed) every 8 hours with instructions not to exceed 3 Grams per day . On 12/28/22 orders for Acetaminophen 650 mg scheduled every 4 hours scheduled for pain. R1's M.A.R showed on 12/28/22 she received four scheduled doses of Acetaminophen and one dose on 12/29/22 at 3:00 AM. The M.A.R shows she received an additional dose of Acetaminophen 1000 mg prn in the evening on 12/28/22. (R1 received a total dose of 4200 mg of acetaminophen in a 24-hour period). On 1/25/23 at 10:47 AM, V2 (Director of Nursing) said on 12/28/22, R1 was complaining of increased pain and V4 (LPN Agency) called the physician to obtain orders for pain medication. The physician ordered scheduled Acetaminophen and R1 already had orders for Acetaminophen prn. It was V4's first time working in the facility, and she must have not seen the order for Acetaminophen prn. She probably did not know where to look on the EMAR (Electronic Medical Record) for the prn medications. She did not look at the orders prior to calling the physician because the prn medications are listed on the EMAR. When I called her to get her statement, she never returned my call. R1 received the scheduled doses of acetaminophen in addition she received a prn dose of 1000 mg. A total of 4250 mg of acetaminophen was given over a 24-hour period. The orders include not to exceed 3 GM in a 24-hour period because it can cause liver toxicity. R1 was sent out to the hospital in the morning on 12/29/22 and returned back to the facility the same day. She received the antidote for acetaminophen overdose. On 1/25/23 at 11:09 AM, V3 (ADON) said agency staff are encouraged to come in early for additional training on our computer system. I would expect staff to notify the physician what pain medications the resident is already receiving when they call for pain medication. R1 had two different orders for the same medication and received the exceeded amount of Acetaminophen in a 24-hour period. On 1/26/23 at 10:30 AM, V7 (LPN) said when administering medications staff should check the five rights, right person, right time, right medication, and right order. If there is a duplicate medication with different doses nursing should call and the physician and the get the order clarified. The facility's Occurrence Report dated 12/29/22 documents night and dayshift supervisors noted V4 (LPN agency) obtained an order for scheduled acetaminophen every 4 hours. R1 was already receiving Acetaminophen 1000 mg every 8 hours as needed. R1 had already been give the prn dose twice yesterday and then the scheduled dose of acetaminophen which exceeded the recommended dose in 24 hours. R1's hospital records dated 12/29/22 documents she presents with suspected Tylenol (acetaminophen) overdose R1's Acetaminophen lab value is 25.6 (H). Range is 0- 25 .R1 received acetylcysteine and was discharged back to the facility. The facility's Administration and Documentation of Medications Policy revised 1/22, states Medications are administered as prescribed in accordance with good nursing principles and practices .FIVE RIGHTS- right resident, right drug, right dose, right route, and right time are applied for each medication being administered. A triple check of these Five Rights is recommended at three steps in the process of medication administration .Medications are administered according with the written orders of the prescriber

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident (R1) during activities of daily living (ADL) care, failed to ensure fall prevention measures were in place for a resident (R3). These failures apply to 2 of 3 residents reviewed for safety and supervision in the sample of 3. The findings include: 1) R1's electronic face sheet printed on 6/1/22 showed R1 has diagnosis including but not limited to Alzheimer's disease, dementia, overactive bladder, sebaceous cell [CONDITION(S)], and [CONDITION(S)] of left knee. R1's facility assessment dated [DATE] showed R1 has severe cognitive impairment, requires one staff member assistance for bed mobility and dressing. R1's care plan dated 3/14/22 showed, (R1) presents with a self-care deficit in ADL related to decline, mobility, weakness, and unsteadiness, dementia. Refuses care & can be combative with care. May spit on staff. Needs 1-2 assist with ADL's, assist with meals, non-ambulatory. If combative & refuses care, leave her room and come back with different approach. Use 2 assist when uncooperative with cares. Transfers with use of full mechanical lift & 2 assistance. R1's care plan dated 3/14/22 showed, (R1) is a high risk for falls related to pain, weakness, decreased balance & coordination. She is incontinent of bowel & bladder, non-ambulatory, needs assistance with ADL's and unaware of safety. Diagnosis of Dementia. No falls in past 5 months, has recliner wheelchair to prevent sliding and better positioning. 5/30/22 fall from bed- laceration to back of head. Was sent to hospital & returned. Air mattress changed. R1's fall risk assessment dated [DATE] showed R1 as a low fall risk. R1's nursing progress notes dated 5/30/22 showed, 5/30/22 Writer was in the hallway passing morning medications when aide ran out and called for assistance. CNA (Certified Nursing Assistant) reported that (R1) fell (incident time 0615). Writer rushed into resident's room with another aide and found resident lying in bed on her right side; blood was observed on resident's right lateral head. Nurse supervisor called right away, first aid provided. Nurse supervisor called physician and 911 around 6:20am. Daughter called & voicemail left at 0635. Body assessment done, vitals checked, nursing staff remained in the room until paramedics arrived. Resident transferred to local emergency room around 0630. R1's local emergency room notes dated 5/30/22 showed, Witnessed fall at nursing home, posterior occiput laceration measuring 6cm. Computerized tomography scan of spine showed partially imaged small right sub occipital scalp hematoma. Laceration repair 5/30/22 foreign body not noted, wound explored through full range of motion, extensive cleaning with sterile water & syringe. 10 staples-simple repair-tolerated well, no immediate complications. Reassessment/updates: caregiver is at bedside. Discussed with caregiver, they are unsure of what happened at the nursing home, they note that patient is not mobile and thus would be unlikely to fall out of the bed on her own. Clinical impressions as of 5/31/22 1336: scalp laceration, fall as cause of accidental injury in residential institution. On 6/1/11 at 10:15AM, V4 (R1's daughter) stated, I had a meeting with (V2-Director of Nursing) this morning. From what I understand, an agency aide was not aware that she shouldn't have mom on her left side. The aide went to get a sweater and mom rolled out of bed and hit her head on the floor. Mom got sent to the hospital and got 10 staples to the back of her head. The facility's initial interview with V10 Certified Nursing Assistant (CNA) dated 5/31/22 showed, CNA started dressing and preparing resident to get up. CNA was aware that resident is using full body mechanical lift for transfer. Bed was in mid position in reference to height. Resident was in the middle of the bed, turned resident to her side facing the door, CNA realized she needed a sweater, turned her back to the resident and was grabbing a sweater from the closet, it was in that moment CNA felt resident was on her feet. CNA noted resident's head was bleeding. CNA lowered the bed and transferred resident from the floor to the bed and compressed back of resident's head to control bleeding then called the nurse for help. On 6/1/22 at 12:17PM, V10 (CNA) stated, I went into (R1's) room around 6:10AM and I was getting her dressed and realized I needed a sweater for her. This was my first time working with her. I turned her to her left side and went to reach for a sweater and then she fell out of bed. Her bed was in the mid position. I didn't lower her bed to the floor before turning around because I was only a few steps away from her. I saw she was bleeding and turned her over so I could put pressure on the wound. I lowered the bed and lifted her back into bed. I shouldn't have moved her but I panicked. Then I took her vitals and called for the nurse. I know what I did wasn't right. On 6/1/22 at 12:29PM, V5 (Licensed Practical Nurse) stated, I was working early Monday morning when (R1) had her fall. I was out in the hallway passing medications when (V10) came out and told me that (R1) fell . When I went into the room, (R1) was lying in bed on her right side. I notified the nursing supervisor who then called 911, physician, and family. I applied gauze to the back of (R1's) head and did my assessment until paramedics arrived. (V10) should not have transferred (R1) after the fall as she could have caused further injury to (R1). When staff are taking care of a resident in bed, they should position the resident safely and lower the bed before walking away in case the resident moves in the bed. On 6/1/22 at 12:36PM, V9 (Restorative Nurse) stated, It was ok for (V10) to turn around a leave (R1's) bed up in the neutral position because she didn't go far away from the bed. She should not have put (R1) back in the bed because she could have injured her further. She was agency so she probably didn't know our practice. (R1) also has an air mattress so that may have contributed to the fall. On 6/1/22 at 12:40PM, V2 (Director of Nursing) stated, (V10) was about to get (R1) up for the day and was changing her clothes. She remembered that (R1) needed a sweater so she turned to get one from the closet. She probably took one step away from the bed to reach the closet. (R1) was turned to her left side facing the door at the time. She normally has a pillow under her legs so she won't roll but she didn't have one under her legs at the time of the fall. She has an air loss mattress but we didn't find any defects with it. I would expect the CNA's to lower the bed before leaving the bedside of a resident that moves in the bed but (R1) cannot move herself in the bed. (R1) can move her arms and maybe her legs a little but not enough to move herself over in the bed. Once (V10) noticed (R1) was on the floor she lowered the bed and put her back in it because she was bleeding. We think (R1) hit her head on either the bedside table or the brakes on her bed. (V10) should not have moved (R1) at all before the nurse assessed her as she could have caused more severe injuries. On 6/1/22 at 1:03PM, V7 and V8 (CNA's) were providing transfer and bed mobility assistance to R1. Both CNA's stated R1 is a 1 assist for bed mobility but can be combative so they use 2 staff most of the time. V7 stated R1 cannot move herself in the bed on her own but the staff always put pillows on all sides of R1 to keep her secure. V7 and V8 stated they would not leave R1 alone during cares without lowering her bed. Both CNA's stated they do not believe R1 could move herself in the bed but she can get pretty agitated at times during cares. V8 was standing on the left side of the bed near R1's closet and was unable to reach the closet from the bedside without leaving the bedside. The facility's policy titled, Assessment, Documentation and care planning for health center residents at risk for falls or who have fallen dated, 1/11/22 showed, Purpose: In the event a resident has fallen, to assess for injury and avoid complications, follow approved procedure list below .In the event of fall any employee witnessing shall: 1. Notifies nurse in charge of event of location, or discovering a resident who has fallen. 2. Does not attempt to move the resident. 3. Covers the resident with a coat or blanket to maintain warmth if needed. 4. Remain with the resident until help arrives. 2) R3's electronic face sheet printed on 6/1/22 showed R3 has diagnosis including but not limited to chronic systolic heart failure, chronic kidney disease stage 3, [CONDITION(S)] heart disease, and type 2 diabetes. R3's facility assessment dated [DATE] showed R3 has severe cognitive impairment and requires 2 staff assist for bed mobility. R3's fall risk assessment dated [DATE] showed R3 is a high fall risk. R3's care plan dated 5/9/22 showed, (R3) is at risk for falls due to weakness, unsteady gait, back pain. Needs assistance w/ ADL's, history of fall, incontinent of bowel & bladder. 5/9/22 noted on the floor, floor mattress provided. Staff to make frequent rounds on her, keep bed wheels locked & bed in lowest position. R3's nursing progress notes dated 5/9/22 showed, 9:20PM CNA called this writer informing that resident was on the floor. Observed the resident on the floor with the right side of the face resting on the floor with both her legs still on the bed. Resident verbally responsive. Noted redness on right side of face, right shoulder, and abrasion to right shoulder. On 6/1/22 at 10:09AM, R3 was observed laying in her bed, leaning to the right side. R3's floor mat was placed up against the wall inside of R3's doorway. R3 had no floor mats on either side of her bed. On 6/1/22 at 11:32AM, R3 continued to lay in bed with no floor mats located on either side of her bed. On 6/1/22 at 11:33AM, V6 (Registered Nurse) stated, (R3) is a fall risk, she had a recent fall and we now have a floor mattress next to her bed and the call light within reach. If these interventions are not in place she could have another fall or get seriously injured. On 6/1/22 at 12:27 PM, R3's floor mat was observed next to her bed. On 6/1/22 at 12:40PM, V2 (Director of Nursing) stated, Residents who have care plans for fall mats or mattresses should have them in place at all times except when receiving care or during meal times when they are receiving assistance. Failure to implement fall prevention measures could lead to a resident sustaining a fall or getting injured. The facility's policy titled, Assessment, Documentation and Care Planning for Health Center Residents at Risk for Falls or Who Have Fallen dated 1/11/22 showed, III. Procedure: Fall prevention interventions will be developed, documented in the care plan, communicated to involved staff, and implemented based upon the assessment of resident-specific risk factors for falls.

Based on observation, interview, and record review the facility failed to provide peri-care in a manner to prevent infections. This applies to 1 of 6 residents (R145) reviewed for incontinence care in the sample of 12. The findings include: On 3/13/22 at 11:13 AM, V6 (CNA) provided incontinence care to R145. R145's incontinent brief was soiled with urine and stool. V6 cleansed R145's peri-area wiping up and down several times with the same area of the wipe. V6 then cleansed R145's backside of stool wiping up and down several times with the same area of the wipe (not using a clean area with each wipe). On 3/14/22 at 1:38 PM, V5 (CNA) said incontience cleansing should be from front to back and use a clean area with each wipe to prevent infections. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R145's current Minimum Data Set assessment shows she requires extensive assist with toileting. The Facility's Bowel and Bladder Incontinence Policy revised 5/19/21 states, To ensure that residents receive appropriate teatment and services to prevent urinary tract infections .

Based on observation, interview, and record review the facility failed to ensure protective treatment dressings were in place for residents with pressure ulcer injuries. This applies to 2 of 4 residents (R144, R2) reviewed for pressure ulcers in the sample of 12. The findings include: 1. R144's Wound Skin assessment dated [DATE] shows she has a stage 4 coccyx/sacral pressure injury measuring 4.50 cm (centimeters) x 3.80 cm x 1.5cm with undermining of the wound present. R144's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/13/22 at 12:34 PM, V4 (Certified Nursing Assistant) and V14 (Restorative Aide) transferred R144 from her wheelchair to her bed. V4 pulled down R144's incontinent brief and a golfball sized deep open area was observed on her sacrum without a dressing in place. On 3/13/22 at 1:55 PM, V3 (LPN) said R144 has a pressure ulcer on her sacrum and should have a dressing in place. V3 said staff did not notify her R144's dressing was off. V3 said if a treatment dressing comes off staff should notify nursing. 2. R2's wound assessment dated [DATE] shows R2 has a facility acquired mid back pressure injury measures 3 centimeters (cm) x3 cm x0.1cm, unstageable, with serosanguinous drainage. R2's POS dated 3/22 show R2 has a wound treatment order to cleanse mid back wound with NSS, pat dry, then apply Santyl to wound bed cover with foam dressing change every 2 days and as needed. On 3/13/22 at 1:33 PM, R2 was in bed. V9 (Certified Nursing Assistant-CNA) turned R2 to her side. R2's back area was noted to be bleeding. Blood was also noted on R2's bed linens. R2's mid back had an open area with no dressing in place. V9 (CNA) said R2's open area should have a dressing. At 1:50 PM, V11 and V12 ( Registered Nurses- RN) said R2's mid back pressure injury was acquired in the facility. V11 said there should be a dressing on at all times to protect the wound. The facility policy entitled Prevention and Healing of Pressure Injuries dated 5/19/21 show, Residents with . pressure injuries will receive care and services to promote healing and prevent further injuries.

Based on observation, interview and record review the facility failed to transfer a resident in a safe manner. This applies to 1 of 12 residents (R96) reviewed for safety in the sample of 12. The findings include: On 3/13/22 at 10:25 AM, R96 was wanting to go to bed. V7 (Certified Nursing Assistant CNA) -applied a gait belt to R96's waist and placed a walker in front R96. Then V7 lifted R96 under R96's arms instead of using the gait belt. R96 was trying to steady herself and said Uh uh hold me, hold me please! V7 instructed R96 to hold unto the walker and for R96 to move her legs and turn. R96 responded, I can't! I cannot move my legs, hold me, I can't!. R96 tried to move her legs but unable to. V7 then turned R96's body and pushed R96 to bed. On 3/14/22 at 1:34 PM, V13 (R96's daughter) was with R96. V13 pointed R96's board in the room that said 2 staff needed when transferring. On 3/14/22 at 1:43 PM, V10 (CNA) said R96 gets tired easily, she is weak and unsteady. She needs 2 person assist for safe transfers. R96's latest facility assessment shows R96 needs 2 staff assist for transfers. The facility policy entitled Safe Resident Handling dated 11/30/21 show, (Facility) will implement Safe Handling of residents which establishes a framework for staff and residents safety during handling and movement of residents.

Based on interview and record review the facility failed to ensure a resident was transferred in a safe manner for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining transverse tibial and fibular fractures. The findings include: R1's Minimum Data Set (MDS) dated [DATE] shows R1 is severely cognitively impaired and dependent of two staff for transfers and bed mobility. This same MDS shows R1 has impairment on both sides of her upper and lower extremities. The facility's Incident and Accident Report dated 1/26/22 shows R1 is [AGE] year, has diagnoses of Alzheimers disease, history of a [CONDITION(S)], seizures, and hospice, is non-ambulatory, and a total body lift with two assist for transfers. On 1/26/22 PM shift Certified Nursing Assistant (CNA) reported she was preparing to get R1 up for dinner. Noted R1's left lower extremity was larger than the right lower extremity. R1 was wearing slipper socks at the time which were not removed. CNA did not assess any further at this time. R1 nonverbal but had facial grimacing and shaking when turned from back to side for changing R1 was total body lifted back to bed after dinner. CNA removed R1's slipper socks for evening care. R1 noted to have swelling and purplish colored bruising to left ankle and foot. Left lower extremity was warm to touch compared to right lower extremity. Nurse and Nursing supervisor notified Investigation into incident- 2 CNA's went to R1's room the morning of 1/26/22 to give shower. R1 had slid down in reclining chair off of the total body lift sling and was sliding out of the chair. The 2 CNA's did a manual body lift of R1 into the shower chair so she would not fall. R1 was showered and then 2 CNA's did manual body lift of R1 back into bed. CNA did not report .Doctor was notified and orders obtained for an x-ray of left ankle. On 2/23/22 at 11:10 AM, V2 Assistant Director of Nursing (ADON) said she did the investigation and the report of the incident with R1. V2 said she interviewed the staff that worked with R1 on 1/26/22 during the day to see when the ankle fracture could have transpired. V2 said V4 CNA (R1's assigned CNA that day) gave R1 a shower in the morning. V2 said V4 reported when she went to transfer R1 to the shower chair, R1 was not on the total body lift sling. When R1's reclining chair was raised up, R1 was sliding out of the chair. V2 said V4 with V5 CNA's help, manually lifted R1 up and into the shower chair and gave R1 a shower. R1 was then manually lifted from the shower chair to R1's chair. V2 said V4 and V5 reported they did not notice anything with R1's legs or ankle. V2 said neither V4 or V5 reported the incident. V2 said R1 is a mechanical lift transfer with two persons. V2 said V4 and V5 should have called for help to transfer R1. V2 said V4 and V5 were written up for not following R1's Care Plan for the proper way to lift R1 and for not notifying anyone of the incident. V2 said this was the only unusual occurrence that happened to R1 that day the ankle fracture was found. On 2/23/22 at 12:15 PM, V4 CNA said herself and V5 CNA were preparing to transfer R1 to the shower chair for a shower. V4 said the total body lift sling was only half under R1's bottom and was not positioned correctly . V4 said when the head of R1's chair was raised up, R1's bottom began sliding down the chair. V4 said both herself and V5 grabbed R1 by the arms, catching R1 before she hit the floor. V4 said her and V5 lifted R1 up from the chair and then transferred R1 over to the shower chair. V4 said everything happened so fast, R1 didn't hit the floor but she could not recall the positioning of R1's legs/feet during the incident. V4 said she gave R1 a shower and than manually transferred R1 from the shower chair to the bed with another CNA by grabbing R1's arms. V4 said she should have transferred R1 using the total body mechanical lift to be safe. On 2/23/22 at 10:55 AM, V5 CNA said she was helping V4 with R1's transfer for a shower. V5 said R1 was in her reclining chair and when the chair was raised up, R1 slid down the chair. V4 said they caught R1 when R1's bottom was barely on the edge of the chair but R1 did not fall on the floor. V5 said her and V4 grabbed R1 by the arms (one CNA on each side) and lifted R1 up and then swung R1 over to the shower chair. V5 said she could not recall where R1's legs or feet were during the transfer. V5 said V4 took R1 for a shower and she didn't help with R1 after that. V5 said they should have reported what happened to the nurse. V5 said were not supposed to transfer R1 that way, R1 is a total body mechanical lift with two person transfer for safety. R1's first Progress Notes dated on 1/26/22 was at 7:23 PM and shows CNA called me to patients room after dinner, patient was in bed, left ankle was bruised. There was also some swelling and some grayish/purple discoloration. Skin was warm to touch. The primary doctor and the family was made aware. Orders followed through. R1's left ankle X-ray report dated 1/27/22 shows there are transverse fractures evident in the distal tibia and fibula several inches above the mortise joint. Each fracture shows posterior angulation at the major apex. R1's Care Plan dated 1/26/22 shows R1 is alert and oriented to self, needs extensive to total assist with activities of daily living due to cognitive impairment, non ambulatory .unable to follow commands due to cognitive impairments .has limitations to both lower and upper extremities transfer:use 2 person assist and mechanical lift. R1 is able to rarely/never understand others, she is non verbal all needs are anticipated by staff .assess for non verbal indicators of pain and discomfort monitor for signs of restlessness or agitation. The facility's Notice of Disciplinary Action forms shows V4 was disciplined on 2/2/22 and V5 on 2/15/22 for Poor Job Performance Failure to observe resident safe transfer. Resident was transferred without proper equipment, failed to report to the supervisor or nurse in charge that device not in proper position for total body lift. R1's Progress Notes does not contain any documentation on 1/25/22 or 1/26/22 prior to 7:23 PM, when R1's left ankle was found bruised and swollen. The facility's Safe Resident Handling/Use of Mechanical Lifts Policy dated 11/31/21 shows implement a Safe Resident Handling Program which establishes a framework for staff and resident safety during the handling and movement of residents .direct care staff will assess high risk resident handling task in advance to determine the safest way to accomplish them All staff shall report to a supervisor any and all injuries or incidents involving themselves or a resident that were sustained while performing resident handling tasks.

A. Based on observation, record review and interview the facility failed to provide resident specific interventions, reevaluate the effectiveness of interventions and provide adequate supervision to prevent reoccurring falls. This is for 2 of 8 residents sampled for falls in a total sample of 14. (R1, R9). These failures resulted in R1 sustaining laceration on right side of the head and R9's fracture of right hip. Findings include: 1) R1 has [DIAGNOSES REDACTED]. Review of occurrence report documents that R1 had falls on the following dates: - 11/12/11 at 9 PM found in the bathroom - 11/21/11 at 3:45 PM at R1's room, CNA ( Certified Nursing Assistant ) found the resident on the floor in a lying position. Denies hitting head but noted a laceration on right side of the head. R1 was sent to hospital and returned to facility on the same day with 6 staples in the scalp at right side of the head. - 11/23/11 at 3:15 PM, CNA found resident on the floor in the bathroom in lying position with walker at her side. Per resident stated that she was going to use the toilet and lost her balance - 12/14/11 at 2:45 PM, resident noted on the floor infront of recliner chair. Per resident she was reaching for some thing on the floor and slid off the floor. -1/10/12 at 6:15 PM, CNA was taking the resident to the bathroom. Resident asked the CNA to move the bedside commode outside the room. The CNA moved the commode and that's when resident lost her balance. Resident hit her head in the nearby dresser sustaining a skin tear on top of the R1's head. CNA left resident standing while assisting R1 to move the commode outside the room resulting in R1 loosing balance and falling. Follow up report: Resident is very unsteady on her feet. She has poor posture and at times resident is dizzy and unsafe to walk alone. She tries to be independent and do things alone but needs someone with her. Staff moved away from the resident to take the commode away per resident request and resident lost her balance and fell . Staff may need to call for help or seat the resident before attempting to leave to prevent the resident from falling. Review of MDS ( Minimum Data Set ) dated 11/25/11 reflects R1's transfer and walking was scored 2/2 meaning R1 needs limited assistance with one physical assist. Toilet use scored 3/2 meaning R1 needs extensive assistance with one physical assist for transferring to toilet and back. poor balance during transitions and walking. R1 is coded 2 in walking, moving on and off toilet and surface to surface transfer ( transfer between bed and chair or wheelchair). This means that R1 is not steady, only able to stabilize with human assistance. Review of R1's care plan showed that on 11/23/11 bed alarm and chair alarm was initiated. R1's care plan lacked resident specific interventions after each fall. For example; After the 11/21/11 fall the facility repeated an initial intervention, "Encourage to call for assistance prior to attempting to transfer or walk, orient in call light use, orient to room and bathroom." On 02/08/12 R1 was observed up in wheel chair during group meeting with no alarm on and again at 12 noon in R1's room with no chair alarm. This observation was shown to E14 ( Nurse) and E14 acknowledge. E13 Donna CNA was asked if she is aware that R1 need to use chair alarm. E13 stated that she was not aware that R1 is to have an alarm when up in wheel chair. 2. R9 was admitted on [DATE] at 10 PM from assisted living after multiple falls. R9 had previous fall on 8/22/11 at 6:50 PM and 7:45 PM all occurring in her room. MDS assessment dated [DATE] documents that under transfer and toilet use, R9 is coded 3/3 meaning extensive assistance with 2 people. Walking in room and corridor coded 2/2 meaning limited assistance with one physical assist. Review of occurrence report documents that R9 had falls on the following dates: - On 8/24/11 CNA found resident on the floor in her room. R9 had no preventive measures and care plan was not updated. - On 09/08/11 at 2 PM resident found sitting on the floor. Again care plan was not updated and no preventive measure. - On 09/18/11 resident found on the floor next to bed. No care plan update and no preventive measure. - On 09/25/11 at 7:30 AM, R9 noted lying flat on floor in resident's room. R9 was found on the floor complaining of right hip pain. This resulted in hospitalization with [DIAGNOSES REDACTED]. R9 was readmitted to the facility on [DATE] with ORIF (Open Reduction Internal Fixation). No care plan update and no preventive measure. - R9 fell again on 11/30/11 at 8:30 PM in her room. Care plan preventive measure was to put a personal alarm to be applied. R9's MDS assessment dated [DATE] was incomplete and 11/10/11 MDS assessments reflect transfer was scored as 3/2 indicating a need for extensive assistance with one physical assistance and toilet use as 3/2 indicating a need for extensive assistance with one physical assistance. R9 also has a short term memory problem. These identified needs were not applied in R9's care plan and preventive measures. - On 12/01/11 at 9:25 PM, resident found on right side lying on the bathroom floor. Nurses notes dated 12/01/11 at 9:25 PM documents that R9 called CNA to assist her to go to the bathroom. E11 CNA responded and assisted in sitting her on the toilet bowl with call light in her hand. E11 went to the help another resident across the hallway leaving R9 unsupervised. R9 was then found lying on the floor holding wheelchair. E11 left R9 who was already identified as needing physical assistance, supervision with poor memory, safety awareness and periods of confusion This resulted in another fall. Nurses dated 12/06/11 at 6:50 PM documents, CNA took tray, done eating dinner. Sat up in wheelchair in room with TV on. -On 12/06/11 7:10 PM found resident on the floor in resident's room on left side with wheel chair closed to the bed and walker by the dresser with TV on. Preventive measures include making sure proper posture and putting personal alarm in the chair. The facility policy for fall prevention include evaluate the care plan and modifies it as needed. B. Based on observation, interview, and record review the facility failed to keep a safe environment for residents by having medications at the bedside, and leaving a hazardous chemical unlocked and accessible to resident. This has a potential to affect residents residing in all 4 wings on the third floor. Findings include: During the initial tour of the facility with E10 (Nurse) on 2/7/12 from 11:15 am to 12:30 pm the following observations were made: 1. In Room 3327 under the sink in the bathroom, there was a 32 fluid ounce container of All Purpose Cleaner and a 33.8 fluid ounce container of glass cleaner. Both containers had a caution to Keep Out of Reach of Children. 2. In the hallway opposite to room 3337 there was a house keeping cart which had a container of Lysol Disinfecting wipes (170 wet wipes) and a 16.6 ounce container of Comfort Gel which contained 85 % of ethyl alcohol. Both containers were kept on top of the house keeping cart and had a caution to Keep Out of Reach of Children. There was no staff visually monitoring the house keeping cart. 3. In Room 3342 under the sink in the bathroom, there was a 1.42 gallon container of Bleach with caution to Keep Out of Reach of Children. The label of the container also stated that it is corrosive and harmful if swallowed. 4. In Room 3344 on the night stand there were two containers of Icy Hot Cream 1.25 ounce each. The resident stated that he uses the medication for arthritis. 5. In Room 3349 on the night stand there was a container of Systane lubricant eye drop (1/3 fluid ounce). 6. In Room 3350 there were three 30 gram (gm) used containers of Triamcinolone cream kept in a water pitcher insert on the bedside table. On 2/9/12 at around 12:00 pm E1 (Administrator) stated that there were 43 residents on the third floor. The facility's HCFA-672 (Resident Census and Condition of Resident) documented that there were 31 residents with Dementia. .

Based on record review, observation and interview, the facility failed to implement measures to prevent and treat pressure sores, for 1 of 4 residents (R3) reviewed for pressure ulcers, out of a sample of 14. This failure resulted in R3 developing 3 pressure ulcers, the most involved being a Stage 4 with tunneling. Findings include: Facility policy titled " Pressure Ulcer Prevention, NRS - 23 " dated 3/13/07, required " Residents at risk for the development of pressure ulcers will be identified and managed in such a way that tissue damage will be prevented or minimized. All residents with a score of 12 or below (High Risk) on the Braden scale will be considered at risk. The RN or designated skin care provider may determine the need for and implement appropriate skin care treatment. Procedure assessment: Nurse - 2) Visually assess all bony prominences (heels, ankles, hips, sacrum ...) at least daily. 5) Assess educational needs." Facility policy titled, " Pressure Ulcer Treatment, NRS - 24 " dated 3/13/07, requires " To promote healing and to prevent further tissue breakdown by relieving pressure ...and educating the resident and / or significant others. Nurse: 8) Assess resident ' s educational needs and significant other ' s ability to provide treatment. Intervention: 1) Avoid positioning patient on pressure ulcer. Limit sitting time to one hour at a time whether in bed, chair or wheelchair. Inspect skin at least once a day. 10) Provide education for the resident and / or significant others: b. Observe resident and / or significant other perform treatment. " According to the Physician order [REDACTED]. R3's Nursing Admission Assessment, dated 12/10/10, did not identify any past or present pressure ulcers. The facility provided a Pressure Ulcer Report, dated 2/7/12, which documented that R3 had an Unstageable left (lt) bunion pressure ulcer, and a Stage 4 Right (rt) ischial tuberosity (buttocks / hip area) pressure ulcer with tunneling. On 2/9/12, at 10:15 AM, R3's rt. ischial tuberosity dressing change, done by E3 (Wound Care Nurse), was observed. The skin around the wound was moist, reddened and excoriated. This excoriation extended around the perineal area, the sacrum, the coccyx and the left upper thigh. An area, approximately 2 x 1 centimeters of this excoriated skin, was open near the pressure ulcer. E3 was asked during the dressing change, what caused this broken skin area. E3 stated it occurred when she took off the tape, which was anchoring the old dressing. A second wound was noted on R3's left foot, on the interior bunion area. The middle of this site was dark brown / black in color. A nurse's progress note, dated 9/15/11 at 2 PM, stated "Noted unstageable wound right ischial tuberosity. Treatment started". E3's Wound Assessment Report (WAR), dated 9/15/11, documented this wound as, "Pressure Ulceration, Facility acquired, Unstageable, 60% necrotic tissue, No tunneling." E3's WAR, dated 11/1/11, identified the wound as "Stage 3, Tunneling present". The WAR, dated 12/6/11, identified the wound as "Stage 4, Tunneling present with a depth of 4.0 cm." The most current WAR, dated 2/7/12, continues to list the wound as "Stage 4, Tunneling present with a depth of 3.8 cm." Progress notes, dated 9/30/11, at 2:30 PM and 9:30 PM, document that an indwelling (urinary) catheter was inserted because of this pressure sore. A Wound Culture report, dated 11/4/11, showed that the wound became infected and oral antibiotics were started. The Minimum Data Set ((MDS) dated [DATE], documents R3 is occasionally incontinent and does not have a urinary catheter. E3 was interviewed on 2/9/12, at 12 PM. She confirmed the above documentation and stated that she was notified of the wound by a Certified Nurse Assistant (CNA), but not until it was Unstageable. Another progress note, dated 12/22/11, documented that R3 had developed a second pressure ulcer. This was to the coccyx, measuring 2.5 x 0.5 cm. The WAR, dated 12/22/11, identified the coccyx wound as, "Facility acquired, Stage 2." A progress note, dated 1/17/11, list the coccyx wound as healed. On 1/2/12, at 10 AM, a progress note documented that a third pressure ulcer had developed. It stated, "Noted with closed blister on left foot, 1x 2 cm". On 1/3/12, 11AM, a progress note stated the physician checked the wound and found it having black eschar. The first WAR, dated 1/3/12, identified the wound as, "Unstageable with 0% necrotic tissue." The Physician wound care note, dated 1/26/12, stated the wound was debrided at the Wound Care Clinic. The most current WAR, dated 2/7/12, identifies the wound as, "Unstageable with 80% necrotic tissue." Review of MDS, dated [DATE], and the following MDS, dated [DATE] (annual), identifies that R3 had no pressure sores before admission, had no current pressure sores, but was at risk for developing them. Both MDS state R3 needs "Extensive assistance" with bed mobility and transferring, needing one person's physical assistance. Review of R3's recent careplan for "potential for skin breakdown" dated 3/29/11, stated, "Assist / teach resident to reposition self. Encourage / Assist to turn and reposition at least every 2 hours in bed and every hour when up in chair to relieve pressure points." The Wound Care Treatment Plan, dated 10/18/11 and 12/20/11 state, "Nursing interventions: Keep patient off sacrum" and "Reposition every two hours." A Progress note, dated 11/14/11, state that R3 spends most of her day time up in the wheelchair. The POSs, dated 9/11, 10/11, 11/11, 12/11, 1/12, and 2/12 all list the following orders, "Turn and Reposition every 2 hours while in bed. Reposition every 1 hour while up on wheel chair. Wheel chair cushion". The Treatment Administration Records (TAR), dated 8/11 (1 month before the first pressure sore was identified), 9/11, 12/11, and 1/12 included a daily check off section for the physician's orders [REDACTED]." These TAR sections identifying that this order was carried out, were blank. The TARs also include a daily check off section, "Check skin weekly and document." The record lacked documentation that R3's skin was assessed more frequently once she developed pressure ulcers. This was confirmed by E3, Wound Care Nurse during an interview on 2/9/12 at 12 PM. She said that only the nurses document skin checks, and at the time R3 acquired the three pressure ulcers, the CNA's had no place to document skin checks. According to E3, the CNAs should assess resident's skin when they provide care and notify nursing of any skin alterations. She said that once R3 developed the wounds, her skin was still checked by nursing weekly, except when E3 evaluated the wound condition with dressing changes. E3 said that there is no documentation of skin checks being done more frequently than weekly. E2 (Director of Nursing) was interviewed on 2/9/12, at 1:15 PM. She said that once a resident has developed a pressure ulcer, their skin should be checked daily, however there is no documentation of this being done for R3. She confirmed that there is no documentation of a careplan revision for R3 following the development of the three pressure ulcers. According to E2, the resident has been instructed regarding changing position in the chair and keeping pressure off the sacrum, but she has been uncooperative. E2 confirmed that there is no documentation that pressure is being relieved hourly when R3 is up in the wheelchair, according to physician orders. E2 validated that there was no alternative for interventions to off load pressure when R3 was non compliant with repositioning while up most of the day in the wheelchair.