Every finding on record at Landmark of Lincoln Park Rehabilitation and Nursin

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure a safe sanitary, and pest-free environment when one live cockroach was observed crawling on the wall and countertop at the first-floor nurses' station and one dead cockroach was observed in a cabinet in the first floor pantry located near the nurses' station, creating the potential to affect residents and staff utilizing those areas. Findings include:On 8/26/2026 at 11:27 AM, one live cockroach was observed crawling on the wall at the first-floor nurses' station.On 8/26/2026 at 11:30 AM, V12 (MDS Coordinator) confirmed live roach crawling on countertop at the first-floor nurses' station. V12 killed the roach.On 8/26/2026 at 4:40 PM, R50 said one of the cabinets in the first-floor pantry is filthy, I have seen roaches in there.On 8/26/2026 at 4:43 PM, surveyor accompanied by R50 and R128. R50 pointed out the cabinet that R50 said is filthy and where she has seen roaches (bottom, south wall). Surveyor and R50 observed one dead roach in cabinet.On 8/26/2026 at 4:45 PM, V16 (Registered Nurse) confirmed dead roach in cabinet.On 8/27/2026 at 9:50 AM, V15 (Environmental Director) said, I'm in charge of pest control. We were contracted for visits two times a month, but we changed it to weekly visits. I saw a roach yesterday in the bathroom next to the first-floor bathroom (next to the nurses' station). I saw one last week in the first-floor bathroom (rehab bathroom on west side of the unit). We write sightings in the logbook then call the exterminator. They usually come out in a day or two. There have been a few sightings of roaches, I don't want to say that there is a problem. It's been months since there have been reports of any sightings on the other units.On 8/27/2026 at 1:54 PM, V1 (Administrator) said, I have seen roaches in the facility. The exterminator is now coming once a week to the facility.On 7/27/2026 Service Inspection Report documents, in part: Clutter in rooms 211, 106 and 107 needs to be removed to prevent pest from harboring. Treated rooms 106, 107,112, 211, second floor shower room, third floor nursing station for roach prevention.Pest Control Policy (reviewed 5/1/2026) documents, in part:Purpose The purpose of this policy is to ensure a pest-free environment within our facilities by outlining procedures for the prevention, monitoring, and control of pest infestations.Prevention I. Sanitation Maintain cleanliness in all areas, especially food storage and preparation areas.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for one (R16) resident out of seven residents reviewed for physical environment in a total sample of sixteen. Findings include:On 06/02/2026 at 11:42 AM, V10 (Certified Nursing Assistant) was asked if any of the residents' rooms have paint chipping from their walls. V10 stated in R16's room there is chipped paint on the wall behind R16's bed. V10 stated V10 hasn't submitted a work order for R16's room yet. V10 stated, usually they also go around and make a list of what needs to be done. Majority of the residents are confused on this floor (3rd floor), I (V10) am usually on this side.On 06/02/2026 at 11:44 AM, R16's overbed table appeared unclean with several stains on the table and on the chrome base of the overbed table, privacy curtains noted with visibly dirty stains (light red, light brown colored), the wall (behind R16's bed) noted with several areas of chipped paint. Another part of the wall closest to right side of R16's bed was noted with dirty stains (light red, light brown), bed sheets noted soiled.On 06/03/2026 at 10:11 AM, R16 was lying on her bed. R16's overbed table appeared unclean with several stains on the table and on the chrome base of the overbed table, privacy curtains noted with visibly dirty stains (light red, light brown colored), the wall (behind R16's bed) noted with several areas of chipped paint. Another part of the wall closest to right side of R16's bed was noted with dirty stains (light red, light brown). R16's floor was unclean, a napkin under the bed/head of the bed, and other garbage items. On 06/04/2026 at 10:01 AM, R16's physical environment noted with unclean overbed table including several stains on the chrome base of the overbed table, privacy curtain still soiled (visibly dirty) with stains, the wall still noted with stains (light red and light brown color), and the head of the bed wall noted with chipped paint. Bed sheets clean and floor clean. On 06/04/2026 at 11:11 AM, V23 (Environmental Director) stated for daily cleaning, the staff are expected to go in and wipe their bedside table including the base of the tables. V23 stated the housekeeping staff would have to change dirty privacy curtains too. V23 stated, We have extra ones in the laundry room to switch those out (if the privacy curtains are visibly soiled). V23 stated if the wall is visibly soiled, they must wipe them down, even if it is not a deep cleaning day, so it does not pile up. V23 stated it is important for residents to have a safe, clean, and home-like environment because aside from it being their home, it helps maintain a pest free environment, maintain their moral about being here.On 06/04/2026 at 10:02 AM, V24 (Housekeeping Aide) stated if any area in the resident's room is visibly dirty, then it should and can be cleaned despite not being a deep cleaning day. V24 stated it is important because the residents can verbalize complaints. V24 stated, obviously yes, they have the right to have the wall clean even if they are confused. V24 stated the overbed table should be cleaned, even the legs/chrome base. V24 stated the importance of a clean and safe environment is to provide the residents with a more pleasant and more home-like and comfortable environment. V24 stated R16's wall stain, the privacy curtains and the overbed table should have been addressed. V24 stated we forgot to address those issues. V24 stated the chipped paint on the wall behind R16's bed is not taken care of by housekeeping but instead maintenance department.On 06/04/2026 at 10:15 AM V25 (Maintenance Director) stated for V25 to paint the room, housekeeping has to move curtains, beds, nursing has to move the resident. V25 stated the third floor is a big problem because there are residents who are not movable, have mental illnesses, and staff cannot move them easily. V25 stated there is no work order for R16's room. V25 stated R16's chipped paint on the wall has been there less than a month. V25 stated all the residents have the same rights.On 06/04/2026 at 10:40 AM, V2 (Director of Nursing) stated V23 (Environmental Director) communicate with the nursing department if a room needs to be deep clean. V2 stated the nursing department assists the residents getting up and transferring the residents to another unoccupied room so housekeeping can do task. V2 stated, When it is completed, they will let us know. If they are confused, usually they don't give me a problem. V2 stated two other residents on the third floor (did not mention R16) do not like to get up but have been able to get transferred for a small period. V2 stated the housekeepers were able to clean their rooms. V2 stated it is important to keep a resident's room safe and clean to reduce infection control.R16's current face sheet documents R16 is an individual with diagnoses not limited to: unspecified dementia, unspecified severity, with other behavioral disturbance, other reduced mobility, cognitive communication deficit, unspecified hearing loss, bilateral.Concern form dated 05/08/2026 documents in part resident council, concern related to housekeeping. Cleanliness of rooms in a timely manner.Facility document not dated titled general cleaning policies and procedures resident room-clean documents in part, to provide a clean, attractive and safe environment for residents, visitors, and staff. General inspection: inspect room and report all damage including to walls, furniture, cubical and window curtains (note cleanliness), resident belongings and sink. Clean and disinfect the room furnishings: clean all furnishings in the resident's room including the bed rails, IV (intravenous) poles, doorknobs, wheelchairs, walkers, and all other high contact surfaces. Bed- pull the bed at least 2 feet from the wall; spot clean the wall. Bedside tables- scrub all surfaces of the table including legs, base, stand, tabletop, and bottom.Facility document not dated, titled resident rights, documents in part, as a resident of this facility, you have the right to a dignified existence and to communicate with individuals and representatives of choice. The facility will protect and promote your rights as designated below. The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible.Reviewed the facility's work orders from March 2026 to June 2026, no work orders regarding R16 environment noted.Reviewed R16's census, R16 has been in the same room since January 2026.

Based on interview and record review, the facility failed to assure that a resident was free of unnecessary physical restraints; failed to identify the specific medical symptoms warranting the use of a physical restraint and failed to obtain physician orders with medical justification. This failure affected one resident (R4) out of five residents reviewed for abuse who was restrained by being placed in a Geri-chair with a sheet tied over the resident's body, restricting the residents ability to freely ambulate and causing bruising to the resident's body; with no physician order, no consent/permission, and no medical justification.Findings Include:R4's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Type 2 diabetes mellitus with hyperglycemia, chronic obstructive pulmonary disease, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, bipolar disorder. Minimum Data Set Section (MDS) section C (dated [DATE]) documents R4 has an Interview for Mental Status (BIMS) score of 9, indicating R4 has moderate cognitive impairment.MDS Minimum Data Set section GG (dated 03/24/2026) documents R4 requires supervision or touching assistance with (a) Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed and (b) walk 10 feet: Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space and (c) Walk 50 feet with two turns: Once standing, the ability to walk at least 50 feet and make two turns and (d) Walk 150 feet: Once standing, the ability to walk at least 150 feet in a corridor or similar space and (e) R4 does not use a wheelchair and/or scooter. Care plan (dated 03/11/2026) documents R4; ABUSE | NEGLECT | EXPLOITATION | TRAUMA SIGNIFICANT R1 is an adult living with chronic health conditions and co-morbidities requires the support, services and structure of this care setting to maintain stability and highest practicable level of functioning. It is recognized living with chronic medical/psychiatric illness, physical decline, the pandemic, and requiring LTC (Long Term Care) may be viewed as a form of trauma, although maintains not having been the perpetrator and/or recipient of mistreatment, abuse, neglect, and/or exploitation.R4's Final Facility Incident Investigation Report (dated 03/16/2026) documents in part: The facility investigated the 03/10/2026 facility reported incident. Through the course of the investigation the facility determined R1 was physically restrained in a Geri chair (specialized chair) using a sheet. The sheet was positioned around the resident's lap and back of the chair with the resident's arms and legs free. This was identified and reported to a licensed practical nurse (L.P.N) by the day shift certified nursing assistant (C.N.A) who reported for duty 03/10/2026 at 7:00 AM. The C.N.A assisted the resident from the Geri chair and provided incontinence care. Upon notification the administrator immediately began an investigation. The investigation included interviews with employees, residents and review of camera footage. The alleged wrongdoer and other employees potentially having knowledge of the occurrence were suspended throughout the course of the investigation. No employee involved or potentially having knowledge of the occurrence has worked in the facility during the course of this investigation. Employees remain suspended and terminated. The resident could not provide meaningful information when interviewed and was unable to provide a statement. On 03/27/2026 at 10:03 AM, V1 (administrator) stated, On 03/10/2026, during a morning meeting, I was informed by V7 (wound care nurse) that V6 (certified nursing assistant) shared with her they found R4 in a Geri chair tied with a sheet. We stopped the morning meeting, and we immediately called V6 down. We had V6 explain what she encountered when she came in. V6 explained she received R4 in a Geri chair, with the sheet tied. V6 said she called the supervisor, V8 (licensed practical nurse/house supervisor), to notify V8 of what she encountered when she came in. At that point, I initiated a report of the abuse allegation to the state agency (Illinois Department of Public Health). I went to the scheduler to find out who else worked on the night shift, 11:00PM to 7:00AM on 03/09/2026 into 03/10/2026. I began making phone calls, to find out each of the aides and nurses were assigned to floor. Then we instructed the morning shift nurse assigned to R4 to make a head-to-toe assessment. Social service went up to see the resident. I continued to make phone calls to obtain the staff statements. V2 (director of nursing) and I, went to check the security footage and we did see that R4 sitting in the hallway in the Geri chair with the sheet tied over R4's lap. The Geri chair is considered a restraint because the Geri chair is not assigned to R4. The sheet is also a restraint because it was tied over R4's lap. R4 is mobile and does not use a chair or any other devices. We went through and suspended the staff. V6 was also suspended because V6 did not notify me. I am the abuse coordinator and per the abuse prevention protocol, staff are required to notify me, the abuse coordinator. There was a total of 7 employees suspended. V6 was suspended for not notifying the abuse coordinator directly, because she was aware at 7:00AM. V7 was suspended because she failed to notify the abuse coordinator, as she was notified by V6 at 9:00AM. V7 did not notify me until about 10:45AM. V8 was suspended because she failed to notify me. V6 had notified her at 7:00AM, and V8 never notified me at all. V9 (licensed practical nurse) was suspended. V9 was the nurse assigned to R4 during the night shift. V9 said he did not know anything about the sheet being tied over R4, but he was aware R4 was in the Geri chair. V10 (certified nursing assistant) was suspended. She was the C.N.A working evening as well. V10 stated V10 saw R4 in the Geri-chair. V11 (certified nursing assistant) was suspended. R4 was a part of V11's assignment evening. V11 was suspended for not rounding on her assigned residents. V11 stated she saw R4 in the chair and walked past her several times. V11 stated she did not tie R4 to the chair. V12 (Certified Nursing Assistant) was suspended for using a sheet to keep a person from climbing in and out of the chair. V12 was the aide who placed R4 into the Geri-Chair. We proceeded to have social services conduct a resident interview to make sure everyone feels safe. We used a form to ask the residents if anyone caused them any harm, if they feel afraid or embarrassed since they have been here, and if they ever witnessed any other resident being treated or spoken to in a matter that was unacceptable. We also proceeded with in-services on the abuse policy and who to report to when staff see abuse or hear of abuse when it is reported to them. I notified the physician of the abuse of R4 being found in a Geri-chair with the sheet tied. V2 notified the family. The police were called and notified. The police report number is available. V7, V8, V9, V10, V11 and V12 were terminated. V6 was brought back with education to remind her abuse needs to be reported directly to the abuse coordinator. V9, the nurse assigned to the resident was not rounding on his residents. V9 stated he did not know a Geri-chair was a restraint when a Geri-chair is not assigned to them. At 2:29PM, V1 (administrator) stated,R4 was untied and removed from the chair around 7:10AM or 7:15AM, because V6 (certified nursing assistant) said she was doing her rounds and V6 removed R4 from the chair, and got R4 up to the bathroom. On 03/27/2026 at 11:21AM, surveyor observed R4 sitting in the 3rd floor dining room. R4 was observed to feel safe. R4 was observed clapping her hands and listening to music during resident activities. R4 stated she was doing fine. R4 was not able to recall the events that occurred during the incident on 03/10/2026. On 03/27/2026 at 1:03PM, V12 (certified nursing assistant) stated, On 03/10/2026, I was not assigned to R4, but I was a witness there. R4's room was on the third floor. R4 was in a Geri-chair, and she had a sheet around her waist that was tied. R4 does not utilize a Geri-chair. R4 walks, moves her arms around and is very alert. R4 was able to move her arms and legs. The sheet was used as a seat belt. No, we cannot use a sheet and tie it over residents. Wheelchairs don't even come with seat belts. It is not allowed because tying a sheet over a resident who does not use a Geri-chair is a restraint. I thought it was a safety precaution. I thought it was for safety and R4 does go to different rooms. I did not do anything because I thought it was a safety measure. R4 was not my resident, but I was keeping R4 with me when I was going from room to room. I was pulling her in the Geri-chair from room to room to keep an eye on her. I thought I was helping. R4's C.N.A. was somewhere else. I am the person that tied the sheet over R4. I didn't know how to keep her safe because she was walking around from room to room and pulling on residents while they were sleeping. R4 was sleeping and she kept walking into other resident's rooms. Other residents were getting upset. I placed R4 into the Geri-chair around 3:30AM, and I tied the sheet around R4's waist. R4 was able to use her arms and her legs, but she could not get out of the Geri-chair, because R4 was leaned all the way back like a couch. R4 was wide awake, she was clapping. I thought I was helping R4. After I placed R4 into the Geri-chair and tied her, R4 was leaned back and she was clapping. She did not attempt to get up. Nobody knew the sheet was tied over R4 in the chair. Around 5:30AM, the C.N.A from the day shift saw R4 was tied in the Geri-chair. C.N.A reported it to the nurse. I did not find out I was reported until I was at home around 9:00AM. Everybody from the day shift called me trying to find out who tied the sheet. V1 (administrator) told me I could not come back. I got fired because they told me not to come back. The morning C.N.A took a picture of the resident tied in the chair. At 5:30AM, I dropped R4 off to the assigned C.N.A. She asked me how I kept her in the chair. I walked off because I had to start my rounds before I left. I did not say anything. I don't know the C.N.A, and I did not even think about the question. I was upset that the assigned C.N.A was not with R4. She was supposed to be with R4, and she was not. I had to keep R4 company so she's safe. After a certain time, I placed R4 into the Geri-chair, and I tied the sheet over R4, so she did not fall out. I did not see anybody removing R4 from the chair because I had to start my work. On 03/27/2026 at 1:40PM, V2 (director of nursing) stated, We do not have a restorative director at this time. R4 is ambulatory. R4 does not use any assistive devices with walking. R4 does not utilize a Geri-chair. R4 is able to transfer herself. R4 does not require staff assistance with transfers. Placing R4 into a Geri-chair and tying a sheet over R4 would be considered a restraint.On 03/27/2026 at 2:12PM, V16 (attending physician) stated, I think this patient had some developmental delays. Apparently, someone took it upon themselves to place the resident in the Geri-chair. The more alarming thing was they used a sheet to tie the resident down. This is wrong. This is never okay. is considered a restraint. was the aide's misguided action. I was made aware R4 was a wonderer, and an aide took some bed sheets and tied the resident down. We want to protect the residents with developmental delays. We talked about this issue. We had a special meeting with the administrator and everybody about this. I know sometimes R4 sits in the Geri-chair in the mornings I think it was the aide's own independent action. It was inappropriate. On 03/28/2026 at 8:33AM, V17 (social services director) stated, R4 ambulates. R4's cognitive status is moderately impaired. R4's BIMS (Interview for Mental Status) score is 9. R4 ambulates independently. R4 does not require a wheelchair or a Geri-chair. I am aware of the incident that occurred on 03/10/2026. I know allegedly the resident was sitting in a Geri-chair and a chemical restraint or restraint was used. R4 had something wrapped around her legs or her thighs. It technically is a restraint. When I talked with R4, she was fine. R4 said she feels safe in the facility. R4 was not in any kind of distress. I have been checking on R4 every day. I continued to check on R4 closely for 72 hours. Staff have been assisting with the 1 to 1 care for R4 to make sure R4 is safe. It is never okay to use a sheet to tie over a resident.On 03/28/2026 at 9:00AM, V6 (certified nursing assistant) stated, On 03/10/2026, I came in the morning after 7:00 AM. I saw R4 sitting in the chair in the dining room. When I looked closely, I saw a sheet tied over R1's chair. Usually, R4 would get up out of the chair. It is R4's normal routine to sit in the chair, but she could not get out of the chair. I asked R4 why she can't get up. When I looked closer, I saw the sheet was restraining R4 from getting out of the chair. I went to look for the nurse and tried to report it. I don't remember if I un-tied her or someone else untied R4. I could have untied R4, but I just don't remember because there was a lot going on that morning. The next thing I know, R4 was walking. I reported this to the nurse. I did not inform the administrator directly. I was called downstairs by the administrator, the director of nursing and the department manager. I received abuse prevention training in this facility. The use of restraints is prohibited. It is considered abuse. There are different levels of restraints. When I went downstairs to speak to the administrator, the director of nursing and the manager, I was suspended. I was suspended because I did not go to the administrator right away, and I did not go to the chain of command when reporting abuse.On 03/28/2026 at 9:15AM, surveyor attempted to reach V11 (certified nursing assistant) via telephone, for an interview. V11 answered surveyor's call and said she would call the surveyor back. Surveyor did not receive a call back from V11. On 03/28/2026 at 9:26AM, V8 (licensed practical nurse/house supervisor) stated, On 03/10/2026, I did not work on the 3rd floor. I always work on the second floor. When I was going home at 8:00AM, V6 (certified nursing assistant) told me she found R4 in the Geri-chair and R4 was wet. I was on my way out the door. I told V6 to go and tell the nurse. I was not the nurse; I don't work on floor. I asked V6 what time she came in, and she told me she came in at 7:00AM. I did not hear R4 was tied to the chair with a sheet. V6 informed me on the phone. It was loud and maybe I did not hear it correctly. I did not hear part about the sheet being tied over R4. I told V6 to tell the nurse because I was not the nurse on duty anymore. I was leaving. I asked her why are you telling me now? I am not the nurse. If I would have heard the part R4 was tied to the Geri-chair, I would rush to assess R4 and I would let the administrator know immediately that is a restraint. I would call immediately to report it to the administrator. I would not wait. I would never delay reporting this. I would have immediately called the abuse coordinator, which is the administrator. When I got home around 9:00 AM, the assistant administrator called me. She called me and asked me if V6 told me R4 was tied to the chair. I told her I did not hear part. I told the assistant director of nursing (ADON) I only heard the part R4 was sitting in a chair, and she was wet. This is why I told V6 to inform the nurse. They told me they want to investigate it. According to V6, there were 2 nurses on the 3rd floor that day when the incident occurred. I was not working on the 3rd floor. I was not the supervisor day. When I am supervising, I need to make rounds on every floor. But that day, I was working on the 2nd floor. I did receive abuse prevention training. Restraints are not allowed. I would have called immediately if I heard the part that R4 was restrained because it is not allowed. R4 ambulates independently and she does not utilize a Geri-chair. I was terminated. I don't know why they terminated me. I think it's because I did not notify the administrator.On 03/28/2026 at 9:37AM, V10 (certified nursing assistant) stated, I remember the C.N.A coming in and I was on orientation. The C.N.A did not introduce herself and I don't remember her name. I came to work and I was on orientation. I saw the C.N.A roll R4 into the dining room, and I gave R4 a cup of water. I did not see a sheet being tied over R4. I did not see R4 being tied with a sheet. I was not paying attention. That would be considered a restraint. I got fired and it was my third day of orientation. V2 (director of nursing) said in the dining room I had dosed off. I was on the phone with the director of nursing. The C.N.A left me sitting in the dining room for maybe 2 or 3 hours. First, she was in there with me. It was too warm. She left me sitting in there. After a while you get tired if you're just sitting there. She did not show me anything. I was not fired for the restraint use because I did not see the resident restrained.On 03/28/2026 at 9:41AM, surveyor attempted to call V7 (wound care nurse) via telephone, for an interview. Surveyor left a voicemail. Surveyor did not receive a call back; therefore, surveyor was not able to obtain an interview. On 03/28/2026 at 9:45AM, V9 (licensed practical nurse) stated, I saw the resident in the Geri-chair and her hands were visible, she (R4) was not in distress. Both hands were visible. She was alert and oriented when I saw her. I did not see the sheet tied around R4's waist. I did not know R4 was tied, and I did not see any of that. I was not aware of R4 being restrained. I was notified about this incident when I got home. I did my rounds. The last time I saw her was 7:15AM, when I did my last rounds. R4 was in the day room. I left the building at 7:45AM. When I got home, they called me around 9:00 AM, but I am not sure exactly what time it was. V2 (director of nursing) called me. She was telling me about the incident, and I told her I did not know anything about it. Then, V2 called back when they were in the morning meeting, and I informed them I did not know anything about it. I think they suspended me the second time they called me. After 7 days, human resources and the administrator called me. They told me I cannot come back to the building because I am terminated. This is the only incident I had while working in this building. I received abuse prevention training. I received education pertaining to restraints.R4's Progress Note (dated 03/10/2026) documents, Writer was informed by administration staff alleged inappropriate care was displayed. Resident was immediately assessed with no skin injuries or pain. Resident expressed no mental/ emotional distress. Emergency contact updated with request for no police notification. Facility protocol implemented. Physician made aware. Well-being checks conducted by social services.R4's Progress Note (dated 03/10/2026) documents, Late Entry: Note Text: 72 Hours Follow-Up 1/3 writer was informed the resident claimed/alleged staff exhibited inappropriate care. Resident appears to be in a stable mood and does not show any signs of distress. Writer inquired whether the resident feels safe in her surroundings. The resident replied, Yes. Writer encouraged resident to establish appropriate boundaries with staff. Writer also urged the resident to seek assistance from staff when necessary. Furthermore, writer motivated the resident to engage in activities. Writer advised resident to utilize the call light as required. Writer encouraged the resident to communicate any advocacy needs, as we are here to provide assistance as necessary. Resident expressed her understanding. Writer will continue to follow up as needed.R4's Skin/Shower Worksheet (dated 03/13/2026) documents skin discoloration/bruising to R4's upper and lower extremity. Guidelines for Physical Restraints/Seclusion (dated 05/17/2023) states in part: It is the policy of the facility to use physical restraints only as a last resort and only after every other alternative to a physical restraint (based on assessment) seemed to have the potential for being used successfully, has been tried, and has failed. The use of a physical restraint and/or device is to enable and promote functioning at the highest practicable physical, mental, or psychosocial well-being. It will be used only after the resident has been assessed and it has been determined by the IDT the restraint to be used is the least restrictive and for the least amount of time. Abuse Prevention Program (revised 03/01/2021) states in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility. Employees are required to immediately report any incident, allegation or suspicion of potential abuse, neglect, exploitation, misappropriation of resident property, mistreatment, or a crime against a resident they observe, hear about, or suspect to the administrator if available or an immediate supervisor who must immediately report it to the administrator.

Based on observation, interview and record review, the facility failed to provide nail care and shave one (R2) of four (R1, R6, R7) residents reviewed for ADL's (Activity of Daily Living).Findings Include:R2 was admitted to the facility on [DATE] with diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Acute Embolism and Thrombosis of Unspecified Deep Veins of Lower Extremity, Bilateral, Schizoaffective Disorder, Bipolar Type, Anxiety Disorder, Major Depressive Disorder, Psychosis, Paralytic Gait, Lack of Coordination, Abnormalities of Gait and Mobility, History of Falling, Muscle Weakness (Generalized), Weakness, Pain in Right Lower Leg and Gastrointestinal Hemorrhage. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 14 indicating intact cognitive response. R2's Care Plan document in part: Focus: I have or am at risk for a Self-Care Deficit and requires/potentially requires assistance with ADLs to maintain the highest possible level of functioning. Interventions: Provide assistance with all ADLs as required per my dependence needs Personal Hygiene. MDS Section GG - Personal Hygiene (Substantial/maximal assistance).Foot and Ankle Clinic note dated 02/24/26 document in part: The patient was evaluated bedside today for elongated toenails and a foot check. The patient would like toenails trimmed today. Toenails are elongated and dystrophic with subungual debris x10 and pain on palpitation. Onychomycosis x10. Treatment: the patient was seen, evaluated and treated at bedside. All elongated nail margins were trimmed.Skin/Shower Worksheet dated 02/11/26 V25 (Certified Nurse Assistant) documented in part: Type of Condition: 22. Long Toenails (toenail request). Skin/Shower Worksheet dated 02/14/26 V26 (Certified Nurse Assistant) documented in part: Type of Condition: 22. Long Toenails. Skin/Shower Worksheet dated 02/18/26 V24 (Certified Nurse Assistant) documented in part: Type of Condition 15. Nail beds. 22. Long Toenails.On 03/03/26 at 09:37 AM V6 (Hospital Social Worker) stated I went to assess R2, and he was dischuffed with long facial hair and fingernails. The physical therapist said R2's feet looked to be in poor condition with long toenails. The primary concerns were R2's hygiene. R2 said that he used to have an electric razor but dropped and broke it and the facility will not let him use disposable razors.0n 03/03/26 at 01:47 PM R2 call light was activated upon entering R2's room. R2 was observed lying in bed with a long unshaven beard and mustache. Surveyor asked R2 when was the last time that he had been shaven. R2 responded it's probably been 2 months since they have shaved me. I asked my aide and I have requested to be shaved.On 03/03/26 at 02:02 PM When V7 (Certified Nurse Assistant) turned R2 in bed the fitted sheet underneath R2's body was observed to be yellowish and unclean with multiple small dark particles observed. V7 stated it has been a while since R2 has been up out of the bed. Surveyor asked V7 if R2's fitted sheet looked like it had been changed. V7 responded, looking at that sheet nope, not at all.On 03/05/26 at 1:39 PM V7 (Certified Nurse Assistant) stated From what I remember R2's mustache and beard were kind of grizzly; it was not trimmed and neat when he went to the hospital. On 03/05/26 at 02:17 PM V26 (Certified Nurse Assistant) stated I took care of R2 as soon as R2 came back from the hospital. R2's fingernails were probably beyond his skin. We did an assessment and there was a lot of black dried material on R2's fingernails. R2 told me it was poop. When R2 was vomiting they sent R2 right out to the hospital. R2's beard was not too long. In January I cut R2's beard and mustache but it had grown back. I would say it looked grizzly and not well maintained. R2 kept saying that he wanted his fingernails clipped. On 03/05/26 at 02:01 PM V25 (Certified Nurse Assistant) stated R2's toenails were long. I do not cut the toenails, the podiatry lady is supposed to cut them, but it is based on whoever is on the podiatry list. I don't want to lie but R2's toenails were long, and his toes were aching him.On 03/04/26 at 09:29 AM V10 (Certified Nurse Assistant) stated R2 asked me to cut his hair but his clippers were not working because somebody had dropped them, and a piece had come out. R2's mustache and beard were long and thick. V10 showed this surveyor a white disposable razor and said these are the razors we got, and they don't work. I did not want to, but I cut R2's mustache and beard down as much as I felt comfortable cutting. We usually have a barber, and they use to come once a month. R2 wants the facial hair all the way off but we don't have the clippers. V9 (Licensed Practical Nurse) told me to cut R2's fingernails last week.On 03/04/26 11:19 AM V2 (Director of Nursing) stated the certified nurse assistants are responsible for shaving R2's face. We use disposable razors. They have a barber, but the resident has to pay for the barber services.On 03/04/26 at 12:46 PM V2 (Director of Nursing) stated R2 has a goatee/beard and mustache. Certified nurse assistants are trying to cut R2's hair and trim his mustache and beard.On 03/05/26 at 02:49 PM V2 (Director of Nursing) stated When R2 returned from the hospital they came and got me because they thought it was blood under and on R2's fingernails. V26 (Certified Nurse Assistant) thought something was going on with R2's fingernails. It was from the vomitus, and they brought R2 back from the hospital with the coffee ground emesis. R2's fingernails were trimmed to get the brown stuff from under R2's fingernails the day that R2 came back to the facility.On 03/05/26 at 09:20 AM R2 was observed lying in bed. R2 stated I am doing okay. They shaved me yesterday and I feel a lot better because I felt depressed. Policy:Titled Guidelines for A.M. Care dated 03/21/23 document in part: It is the policy of the facility to see that residents receive A.M. care in preparation for the activities of the day. Equipment: Make-up or shaving equipment. Procedure: 12. Clean area under fingernails and maintain nails at a smooth/safe length. Titled Resident Rights undated document in part: As a resident of this facility, you will have the right to a dignified existence and to communicate with individuals and representatives of choice. Accommodation of Needs: You have the right to receive services with reasonable accommodations to individual needs and interests.

Based on interview and record review the facility failed to maintain a complete and accurate medical record for one (R3) of six (R1, R2, R4, R5, R6) residents sampled for record review.Findings Include:Based on interview and record review the facility failed to maintain a complete and accurate medical record for one (R3) of six (R1, R2, R4, R5, R6) residents sampled for record review.Findings Include:R3, formally known as R1, is the subject of this complaint being investigated for the allegation of Administration/Personnel. Three (R2, R4, R6) additional residents were reviewed for Administration/Personnel with no concerns.R3 was admitted to the facility on [DATE] with diagnosis not limited to Centrilobular Emphysema, Hypothyroidism, Nephropathy, Liver Disease, Abnormalities of Gait and Mobility, Weakness, Anemia, Pure Hypercholesterolemia, Primary Insomnia, Constipation, Fall, Nasal Congestion and Nicotine Dependence. R3's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R3's hospital records upon admission to the facility dated 12/13/23 document in part: Histories: Social History [NAME] Use: Smoking status: Some Days Types: Cigarettes.Social History and assessment dated [DATE] document in part: 9. Addictive Behavior: a. Is there a history with alcohol, street drugs, prescription over-the-counter drugs, nicotine/tobacco? No. c. Current use of smoking products? No.CT (Computed Tomography) Chest Lung Screening without Contrast dated 12/02/25 document in part: Nicotine Dependence, cigarettes, in remission.R3's Face Sheet and Medical Records Diagnosis Information document in part: Nicotine Dependence, Unspecified, Uncomplicated. Onset date: 12/21/25.Face Sheet present to the surveyor on 03/05/26 document in part: Diagnosis Information Nicotine Dependence, Cigarette in remission onset date 08/12/25.On 03/03/26 at 12:57 PM R3 stated F17.211 is the code for nicotine dependent in remission. I want them to put the right code in the proper area. I am trying to transition out of here and a lot of places do not accept anyone that smokes. I have not smoked since October 2023.On 03/04/26 at 11:19 AM V2 (Director of Nursing) stated R3's pulmonary paperwork has nicotine dependent and for assistant living R2 wants to have it taken off. The doctor will meet with her to resolve it.On 03/04//26 at 01:54 PM V15 (Former Nurse Practitioner) stated R3's diagnosis should be carried over from the resident's hospital stay and should be updated to manage the new problem.On 03/05/26 at 09:33 AM V18 (MDS Coordinator) stated I usually do the diagnosis when a resident is admitted or readmitted . Medical records upload the record, and I would have to wait until they are uploaded. The medical doctor and nurse practitioner also add diagnosis. I was here when R3 was admitted to the facility. We enter the diagnosis from whatever is on the hospital records. R3 makes her own appointments so it is hard to keep track. I did not know about R3 going to another hospital. The diagnosis should have been updated if I was aware of the appointment. I was aware that the nurse practitioner had inputted the nicotine diagnosis. The diagnosis should have been coded in remission instead of dependence. I was made aware yesterday when V15 (Former Nurse Practitioner) reviewed R3's records. I resolved the other diagnosis and input the correct diagnosis in R3' medical record. If the diagnosis is not updated there is a potentially that it will affect the resident's treatment, depending on the diagnosis. I have never known R3 to smoke and I did not know the diagnosis was there and inputted by the nurse practitioner.On 03/05/26 at 10:11 AM V18 (MDS Coordinator) presented the surveyor with a copy of R3's Face Sheet with the updated diagnosis: Nicotine Dependence, Cigarettes, in Remission.On 03/05/26 at 02:49 PM V2 (Director of Nursing) stated We were not aware of R3's CT (Computed Tomography) chest. R3 makes her own appointments and gives the records to my medical record lady, I did not even know. R3 has paperwork with other doctors, and it is confusing when she has multiple doctors with different diagnosis. R3 said I am trying to go to this assistant living and how does she get the pulmonary nicotine dependence diagnosis off her medical record. That was the doctor that input that diagnosis in R3's medical record and I don't know why the diagnosis was put in. V15 (R3's Attending Physician) said the diagnosis can be in the medical records for a 15-year time frame. The diagnosis is up to the doctor based on what they feel when he saw R3 on 12/21/25.On 03/05/26 at 11:19 AM V2 (Director of Nursing) stated I with V15 (Former Nurse Practitioner) about changing R3's smoking diagnosis and we resolved the problem and put R2's new diagnosis in yesterday.Policy:Titled Job Description revised 06/08/23 document in part: LPN (Licensed Practical Nurse) MDS Coordinator Essential Job Functions: Review all assigned quality report/activities that affect quality of care and quality of life for residents. Identify gaps in existing work processes and participate in a resolution.Titled IDT (Interdisciplinary) Care Planning Policy and Procedure revised 06/20/20 document in part: 11. The meeting format should be as follows. b. Review Diagnosis, medications, labs.Titled Resident Rights undated document in part: As a resident of this facility, you will have the right to a dignified existence and to communicate with individuals and representatives of choice. Self-determination: You may choose your own activities, schedules and health care and any other aspect significant to and affecting your life within the facility.

Based on observation, interview and record review, facility failed to protect a resident from physical abuse. This failure affected one resident (R1) of 3 residents reviewed for physical abuse. This failure resulted in V4 (certified nursing assistant) physically attacking R1 by pulling R1's ear and dragging R1 out of his chair by his arms, resulting in R1 sustaining bruising on his upper arms, and R1 being scared to go to the dining room.Findings Include:The surveyor confirmed by observation, interview, and record review that the deficiency practice occurred 09/04/2025 and was corrected on 09/09/2025, prior to the start of this survey and was therefore Past noncompliance. The facility suspended and fired the perpetrator, reviewed footage on additional days past 09/04/2025, to make sure no other resident was abused. Skin checks were conducted for every resident on the third floor to make sure there were no other injuries or signs of abuse. All staff were educated on the abuse policy and were educated on tips for maintaining health and safety on residents with dementia. The facility created a questionnaire for their staff pertaining to abuse and witnessing abuse. The facility created a quality control tool to inspect for bruising and abuse. Monthly abuse training is now conducted during their all staff meeting. The facility is encouraging an open door policy to prevent staff burnout.R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: Disorder of the brain, dysphagia, oropharyngeal phase, cognitive communication deficit, unspecified lack of coordination, weakness, unspecified abnormalities of the gait and mobility, bipolar disorder. Minimum Data Set Section (MDS) section C (dated Sep. 25, 2025) documents that R1 has an Interview for Mental Status (BIMS) score of 4, indicating that R1's cognition is severely impaired. Care plan (dated 09/25/2025) documents that R1 is at a high risk for elopement/wandering R/T: Wandering tendencies, Impulsive, agitation, wander-guard per order. R1 is at risk for increasing confusion secondary to dementia, memory problems, usually understood and usually understands. Facility's Final Investigation Report (dated 09/19/2025) documents in part: R1 alleged V4 (certified nursing assistant) made contact in the dining room. The facility completed its investigation through medical record review and statements. R1 alleged that V4 made contact with him in the dining room. V4 was immediately suspended pending investigation, and the police were notified. A body assessment revealed bruising on R1's upper arms. The investigation determined the bruise resulted from contact by V4. R1 reports feeling safe, shows no sign of pain, distress, or discomfort, and does not recall the incident. V4 has been terminated from the facility. Other residents and staff were interviewed and expressed no concerns. Background and training records for V4 were reviewed, with no prior issues noted. The allegation of abuse is substantiated. On 10/08/2025, surveyor viewed a video tape of an incident that took place on 09/04/2025, involving V4 (certified nursing assistant) and a resident, R1, in the 3rd floor dining room of the facility. In the video, surveyor observed, V4 walking up to R1, V4 grabbing and pulling on R1's ear. Surveyor observed that after V4 pulled on R1's ear, V4 forcibly snatched R1 out of the dining room chair, resulting in R1 falling to the ground, and V4 forcibly picking R1 up. Surveyor observed that after V4 picked R1 up from the ground, V4 continued to forcibly push R1 out of the dining room. The video tape of the incident does not show any more footage of what occurred after V4 and R1 left the dining room. On 10/08/2025 at 10:17AM, V1 (Administrator) stated, On 09/04/2025, a certified nursing assistant noticed a scratch to R1's ears and notified V3 (registered nurse). V3 asked R1 what happened, and R1 did not know what happened. V3 noticed that R1's nails were long, and V3 trimmed R1's nails. On 09/05/2025, R1 was receiving a shower, and a certified nursing assistant noticed bruising on R1's arms. The certified nursing assistant reported the bruises to the nurse on duty, V3 (registered nurse). The nurse examined the bruises and noted that R1 had discoloration to the upper arms. V3 asked R1 what happened and R1 said that R1 bumped into the wall. On 09/07/2025, R1 appeared upset and alleged that some [NAME] touched him. The resident refused to sit in the dining room. V3 reported her concerns to the manager on duty. V3 was suspicious and wanted to know if anything had happened to R1 because he was refusing to sit in the dining room and acting strange. I (V1) am the abuse prevention coordinator, and this allegation was reported to me on 09/07/2025. I started the abuse investigation immediately. The manger on duty started to look through the footage to determine if anything happened. The manager on duty found a footage from 09/04/2025, which showed V4 (certified nursing assistant) pulling R1's ear and forcibly dragging R1 out of the dining room. We do not know where V4 was dragging R1 to or for what reason. We got statements from staff; however, nobody saw anything. The only thing that staff noticed was bleeding from R1's ear and bruising on the arms. After I received the footage, I did the reportable and reported this incident to the state agency. V4 (certified nursing assistant) was suspended immediately, on 09/07/2025, when we saw the footage. I spoke to V4 on 09/09/2025. I explained to V4 that I was conducting an investigation. V4 said to me that V4 did not know why V4 got suspended. I asked if V4 recalled any inappropriate interaction with a resident. V4 said, This is about R1. Most interactions are inappropriate with R1. Not on the staff's part but on R1's part. That day I did not let R1 get away with it. V4 then asked if we have a union representative on the phone and I said no, and that I would have to arrange it, and the call was disconnected. We spoke to the staff that worked on the shift, and nobody saw anything. V4 was terminated on 09/11/2025 for substantiated abuse, which is a violation of policy and a violation of code of conduct. V4 knew what we were talking about and admitted that there was an inappropriate interaction with R1. The police were called, and this incident was reported. V4 has worked in this facility from 10/04/2022. There were no previous incidents or complaints involving V4. All the employees that work in the facility receive abuse prevention training. V4 signed a copy of the abuse prevention training on 10/04/2022. V4 was not assigned to R1. V4 was the person that was assigned to watch the residents in the dining room. I (V1) am devastated by this incident. I provided the staff with abuse education. I educated the staff to make sure they understand different types of abuse and I went through the facility's policy on abuse. I educated the staff that they must report the allegation immediately. The abuse policy is talked about during every all-staff meeting. Sometimes I will focus on a particular area and educate the staff what the obligation is from the staff. I made sure that R1 is safe, and my immediate action is to suspend V4 and to make sure that he did not return to the building. If there is any suspicion of abuse, we don't wait to investigate. In this instance we follow our abuse policy. As part of the abuse prevention training, staff are educated on how to deal with residents with dementia. R1 is a resident with dementia. We checked all the residents on the 3rd floor for signs of abuse. We did not find any other residents who had any signs of abuse. R1's family and physician were notified. On 10/08/2025 at 11:55AM, V3 (Registered Nurse) stated, On 09/04/2025, I saw R1 scratching his ear, and he was bleeding from the ear. R1's nails were long so that is when I trimmed his ears. I notified the nurse practitioner, and she gave the order to put Bacitracin and leave the area open to air. The next day, on 09/05/2025, R1 had a shower, and some discoloration was noted. When I asked R1 what happened, R1 said that he bumped himself. Then I told the doctor about the discoloration. The doctor said for me to put margins on the discoloration and monitor to see if it spreads or changes color, or if it will stay the same. The doctor wanted the nurses to monitor it. On 09/07/2025, the discoloration stayed the same. The manger on duty was in R1's room with me and we were looking at R1's curtains, and that's when R1 reported that some man beat him. That's when we reported this allegation to the administrator. R1 reported that a man hit him, and the nurse manager reported this to the administrator right away. I never suspected V4 (certified nursing assistant) of abuse and I never had any negative encounters with V4. On 10/08/2025 at 12:15PM, V6 (certified nursing assistant) stated, I found bruising on R1 while giving him a shower. I was giving R1 a shower and I saw bruising on both of R1's forearms. They looked like fresh bruises. One arm looked purple reddish, and the other arm looked solid purple, and they appeared to be fresh bruises. I reported these bruises to V3 (registered nurse). On 10/08/2025 at 12:22PM, R1 stated, I don't remember what happened. I feel safe here. On 10/08/2025 at 12:44PM, V7 (Manager on Duty) stated, On 09/07/2025, I was the manager on duty. One of the nurses from the 3rd floor reported concerns that something may have happened to R1 in the dining room. V3 (registered nurse) asked me to review the cameras from the dining room. V3 put me in a separate room away from everybody and asked me to review the cameras from the dining room. After we reviewed the cameras, we saw that R1 was grabbed inappropriately by a staff member. I immediately called V1 (administrator) to report the misconduct that was caught on tape. In the video, I saw V4 (certified nursing assistant) walking into the dining room, then turn towards R1 and grabbed him inappropriately by the ear, then dragged R1 by his arms out of the chair. I remember R1 slipping to the floor while being dragged and I saw V4 picking R1 back up by his arms, in a forceful manner. I was shocked when I saw this. I know that R1 and V4 have interacted many times before and when the incident occurred it kind of seamed like it was out of nowhere. V3 got emotional when she saw how R1 was treated. We immediately made sure that R1 is safe. V4 did not work anymore after that incident occurred. All the residents were kept safe. I never had any negative encounters with V4 prior to this incident. On 10/08/2025 at 10:45AM, 11:43AM and 1:27PM, surveyor called to interview V4 (certified nursing assistant) and left a voicemail. Surveyor did not receive a call back from V4. On 10/09/2025 at 1:00PM, V12 (nurse practitioner) stated, I am not too familiar with the incident that occurred with R1 and V4 (certified nursing assistant). If an employee grabs a resident by the arms, a possible arm dislocation could occur. It would be a concern for dislocation and possible fracture. Those are the injuries that come to mind. It is never okay for an employee to grab a resident in that manner. It is never okay for any employee to grab a resident in that manner. R1's Progress Note (dated 09/05/2025) documents, Resident observed with small scratch in his right outer ear (fossa) area, small amount of blood noted, pressure dressing applied with effective, MD updated with orders. The area was cleansed with NS and bacitracin ointment applied. DON, POA made aware, continue to monitor the resident. R1's Progress Note (dated 09/07/2025) documents, Resident alleged clinical staff made inappropriate contact during care. Resident was immediately assessed with old discoloration noted on bilateral arms, ROM tolerate and denies pain. Resident expressed he feels safe in the facility. POA notified of clinical updates with police notification requested. Physician contacted with no additional orders to be given. Resident displays no mental/emotional distress. Facility protocol implemented. Wellbeing checks to be implemented. R1's Progress Note (dated 09/09/2025) documents, Resident is verbally alert, writer assessed discoloration to bilateral upper arm with no changes observed, resident denies pain or discomfort, resident is able to move all extremities at baseline. Resident consumed meals with good appetite, writer provided the resident with a nighttime snack when requested by the resident. Resident is currently resting in bed, rise and fall of the chest observed. Safety and comfort measures in place, call light within reach. Care continues. Abuse Prevention Policy (revised 03/01/2021) documents in part: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on observation, interview, and record review, the facility failed to ensure that a wet kitchen sanitation cloth is kept in the sanitizing bucket and failed to discard expired milk cartons from the walk-in cooler of the kitchen. These failures have the potential to cause food borne illness in residents with a potential to affect all 150 residents that receive food from the facility's kitchen. Findings include: On [DATE] after the entrance conference, V1 (Administrator) presented the facility census as 150. On [DATE] at 10:15 am during observation of the Walk-in cooler in the kitchen with V33 (Dietary Manager from Corporate Office), the following were observed: Two 8-ounce cartons of Skim Milk with expiration dates [DATE]. One 8-ounce carton of Skim Milk with expiration date [DATE]. V33 stated the two dietary aides on duty were supposed to look through the walk-in cooler and throw out expired food items. On [DATE] at 10:19 am, a white wet rag was observed on the food preparation counter in the kitchen. V33 stated that one of the kitchen staff used it to wipe the counter and that it was supposed be kept in the sanitizing solution in the red bucket. V33 added, I will in-service all of them to remind them. On [DATE] at 11:0 0 AM, V33 presented a Facility Document titled In-Service Sheet dated [DATE] states: All towels must be put back into sanitation bucket after use. Another Inservice sheet dated [DATE] states Look at all dates on milk. Facility's policy on sanitation and food safety states: To assure food quality and food safety, food products are rotated. Food products are used by the expiration date. Food products not used by the expiration dates are discarded. Facility's Policy titled sanitizing buckets states: Sanitation solution will be used on items too large to immerse in sink and areas of production. #5 states: When in use, sanitation clothes (wipes) can be left in sanitation bucket. #6 states: When not in use, sanitation buckets and clothes are stored clean and dry.

Based on observation, interview, and record review, the facility failed to ensure that the outside garbage waste dumpsters are closed with the lids to prevent pest infestation and foul odor. This failure affects all 150 residents residing in the facility. Findings include: Facility's Census dated 6/9/2025 documents that 150 residents are residing in the facility. On 6/10/2025 at 1:10 pm with V33 (Dietary Manager from Corporate Office), 2 of the 3 outside dumpsters were observed to be overfilled with garbage and the lids were left partially opened. V33 stated that it's not only dietary staff, but other departments at the facility also dump garbage into the dumpsters and was not sure who left the dumpsters open. V33 added that some of the items in those dumpsters are also recyclables. On 6/11/25 at 9:48am, V2 (Director of Nursing) stated that housekeeping staff dump garbage in the dumpsters and all staff will be in-serviced. On 6/11/25 at 10:47am, V16 (Housekeeping Director) stated all housekeeping staff throw garbage into the outside dumpster, and he (V16) would in-service all of the staff. Facility's Policy titled Garbage Disposal with latest review date of April 2022 documents in part, Dispose of garbage and refuse properly to reduce the risk of foodborne illness. #1: Keep dumpster closed at all times. #2: Keep the dumpster and surrounding area clean and free of debris. If the dumpster becomes full, contact the garbage service for removal.

Based on observation, interview, and record review, the facility failed to follow infection control protocols by not providing trash receptacles in transmission-based precaution rooms and not maintaining contact/droplet isolation for COVID-19 positive residents. These failures affected two (R20 and R126) of two residents reviewed for infection control and has the potential to place all 150 residents at risk for the spread of infection. Findings include: R126's Brief Interview Mental Status (BIMS) dated 03/26/25 shows R126 with a score of 14 which indicates R126 is cognitively intact. R126's face sheet has a diagnosis which includes but not limited to COVID-19. R126's Physician Order Sheet (POS) dated 06/03/25 shows R126 has orders for Contact/Droplet Isolation Precautions COVID positive every shift for infection prevention for 10 days. R126's care plan dated 06/04/25 documents in part: Focus R126 is on isolation related to (R/T) COVID. Interventions: Set up isolation per facility protocol. On 06/09/25 at 10:52 am, R126 was observed in R126's rooms in bed awake, with a conjoining shared bathroom with R63 and R72's room. R126 stated R126 uses R126 bathroom and also the Rehab bathroom in the hallway available for residents and staff use on the second-floor unit. R126 denied R126's room and bathroom is cleaned daily at the facility and explained housekeeping cleanse R126's room and bathroom [ROOM NUMBER]-3 times per week at the facility. R126's room was observed without a trash receptacle to discard Personal Protective Equipment (PPE). On 06/09/25 at 11:15 am, V15 (Certified Nursing Assistant, CNA) stated V15 is assigned to R126. V15 explained R126's room does not have a trash receptacle to discard PPE and there is nowhere for V15 or staff to discard PPE when prior to leaving R126's room. V15 explained V15 has asked for a trash receptacle to discard V15's PPE from management at the facility and V15 was not given an answer. On 06/09/25 at 11:16 am, V13 (Registered Nurse, RN) stated V13 is R126's nurse and has worked at the facility for three weeks. V13 stated V13 has asked where to discard PPE used for R126 and has not received an answer from management. V13 explained V13 takes V13's used PPE from R126's room and throws the used PPE in a trash receptacle in the hallway outside of R126's room after V13 is finished caring for R126. V13 is unsure of what bathroom R126 uses at the facility. On 06/09/25 at 11:28 am, V25 (Housekeeping) stated V25 is responsible for cleaning the residents' rooms and bathrooms on the second floor. V25 stated the residents' rooms and bathrooms should be cleaned once a day and as needed. V25 stated V25 cleans R126's bathroom once a day at the end of V25's shift and the detachment mop head is then sent to laundry for cleaning. V25 stated V25 was not aware of R126 having orders to only use the Rehab bathroom on the second-floor hallway. V25 stated the Rehab bathroom is unlocked, available for anyone to use, and should be cleaned once a day at the facility. When V25 was asked regarding R126's trash receptacle to discard used PPE, V25 stated, There is not one inside his (R126's) room. It is V5 (Infection Preventionist, IP, Licensed Practical Nurse, LPN) responsibility to ensure there are red bins in the isolation rooms to discard used PPE. I (V25) just remove mine and throw it in the trash can down the hall when I leave the room. On 06/09/25 at 11:40 am, V2 (Director of Nursing, DON) and V5 (Infection Preventionist/Licensed Practical Nurse IP, LPN) both stated residents on isolation should have a white trash receptacle to discard PPE inside the residents' room prior to leaving the isolation room. V5 stated if staff do not have trash receptacles to discard PPE, then there is nowhere to discard used PPE. V2 and V5 both stated R126 was instructed and agreed to use the Rehab bathroom on the second-floor unit. V2 and V5 both stated there is no sign posted on R126 room bathroom to redirect R126 to the Rehab hallway bathroom and they were not aware R126 was using the bathroom inside of R126's room is shared with R63 and R72. V2 and V5 both stated there is a potential for R126 to spread infection to R63 and R72 if R126 is sharing a bathroom with R63 and R72 and the bathroom is not properly cleaned. V2 and V5 was unaware of the cleaning schedule for R63, R72 and R126's shared bathroom. V5 (Infection Preventionist/Licensed Practical Nurse), stated the Rehab bathroom on the second-floor unit remains unlocked at all times, and anyone can use the bathroom. V5 stated there is no sign alerting/notifying staff, residents, or visitors to not use the Rehab bathroom on the second-floor hallway. V5 stated if staff, visitors, or other residents use the shared Rehab bathroom with R126 on the second-floor hallway, there is potential to spread infection throughout the entire facility. V2 and V5 was also unaware of the cleaning schedule for the Rehab bathroom on the second-floor hallway. The facility policy dated 05/23/23 and titled Post Public Health Emergency - Standard and Guidelines documents, in part: Policy: The facility will follow CDC (Center for Disease Control) guidelines including prompt detection, triage, and isolation of potentially infectious residents to prevent unnecessary exposure of COVID 19 . Resident placement: Residents with suspected or confirmed SARS-CoV-2 infection will be placed in a single person room if possible. The resident should have a dedicated bathroom if possible. The facility's job description document titled Housekeeper documents, in part: Under the direction of the Director of Housekeeping, the Housekeeper is responsible for cleaning resident rooms and other interior and exterior facility areas and assisting in maintaining a clean and attractive environment for the residents. The person holding this position is delegated responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Essential Job Functions- Job Knowledge /Duties: D. Role Responsibility- Infection Control: 4. Complies with all established infection control and standard precautions practices when performing housekeeping procedures. 49572 On 6/09/25 at 11:31am, a contact/droplet isolation sign was observed on R20's door. No trash receptacle was observed in or near R20's room for disposal of PPE (personal protective equipment). R20 was observed, in her (R20) room, sitting on the side of her (R20) bed. R20 said, Being on isolation sucks. I have COVID (coronavirus). I (R20) didn't need oxygen until now. I (R20) don't know why my (R20) stuff is on the floor. This place is gross. Everything about this place is gross. I'm (R20) just allowed to go smoke, but not with the other residents. I (R20) have to wear a mask when I (R20) leave my room. A mask, not sure if I (R20) need special one but I (R20) have this one. R20 showed surveyor a multi-colored cloth mask. R20's face sheet documents diagnoses that include but are not limited to Human Immunodeficiency Virus (HIV), anxiety disorder, bipolar disorder, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and pulmonary embolism. R20's Brief Interview of Mental Status (BIMS) score, dated 5/23/25, documents, in part, a BIMS score of 15 which indicates R20 is cognitively intact. R20's Respiratory Panel, result date 6/02/25, documents, in part, Positive for Human Coronavirus. R20's care plan, date initiated 6/02/25, documents, in part, Active Infection (R20) has tested positive for COVID-19. This places resident at high risk for developing Acute Respiratory Distress, Secondary infections such as Pneumonia, and increased risk for Fluid Volume Deficit. The following clinical symptoms have been noted: _Cough, _Fever, _SOB, _Fatigue, _Headache, _Congestion, or _Other . with interventions that document, in part, Encourage resident to remain room . oxygen per order . On 6/09/25 at 12:06 pm, observed R49 in a wheelchair, wheeling herself (R49) into R20's room. On 6/09/25 at 12:15 pm, observed R20 smoking on the wheelchair ramp of the facility, with other resident and employees walking by R20. On 6/09/25 at 12:10pm, V10 (Licensed Practical Nurse/LPN) said, Let me go get (R49) out of (R20's) room. She 9R49) should not be in there. There should be bigger white trash cans for the PPE equipment. Let me find out where they are. On 6/09/25 at 12:29 pm, with V2 (Director of Nursing/DON), observed R20 come in through the front door of the facility, walk through the hallway, with a multi-colored cloth mask not covering R20's nose. V2 said, (R20) please pull your (R20) mask over your (R20) nose. On 6/10/25 at 10:30 am, R20 was observed at resident council removing her (R20) mask and coughing. On 6/10/25 at 2:33 pm, V5 (Infection Preventionist/IP) said, (R20) is not supposed to be off isolation today. R20 comes out of isolation on the 12th (6/12/25). Residents with COVID can leave their room with a disposable blue mask, they (residents) should not be wearing linen masks. (R20) can leave her (R20) just to go smoke but must be 6 feet minimum from front of building, with no other residents. No, R20 should not be smoking on the wheelchair ramp. R20 should be in her (R20) room with the door closed. There should be white cans to dispose of the gowns and gloves. (R20) has been told all of this. This can affect everyone at the facility. Everyone has the potential to get COVID if (R20) isn't following procedure. Facility policy titled, Infection Control/Isolation Guidelines, revised date February 2023, documents, in part, Objective: To prevent unprotected exposure of residents, visitors and staff to potentially infectious microorganisms or diseases and to decrease the spread of in-house or community acquired infections .Droplet Precautions---intended to reduce the risk of respiratory droplet transmission of infectious agents. This involves contact of the mucous membranes with large-particle droplets generated from the infectious resident. Droplets are generated primarily from coughing, sneezing, talking, or during the performance of certain procedures involving the respiratory tract (e.g., suctioning). Transmission requires close contact because droplets do not remain suspended in the air and generally travel only short distances .F. Droplet Precautions requires the use of surgical/procedural mask when entering the resident's environment/room . Always use the highest level of PPE if the resident is on multiple isolations (Example: Airborne and Droplet, would call for the use of an N95 even though Droplet only requires a surgical mask) . Droplet Precautions . Limit resident transport outside of resident's environment/room only for medically necessary reasons . Ambulating outside of the room: A. Residents on Droplet or Enhanced Isolation Precautions must wear a mask when outside of the room and keep a distance of at least 6 feet from other residents and also from the staff as much as possible. These residents must also be accompanied by appropriate clinical or therapy staff . Facility policy titled, Respiratory Illness, updated date 10/24/24, documents, in part, .Once tested , and SARS-CoV-2 (only) is confirmed: Resident(s) should be placed on Transmission-Based Precautions. Resident(s) should be placed in a single room, if available, or housed with residents with only SARS-CoV-2 infection. If unable to move a resident (available rooms, refusal to move, etc.), he or she could remain in current room with measures in place to reduce transmission to roommates . Duration of Transmission-Based Precautions for Residents with SARS-CoV-2 Infection: Non-Test Based Strategy: Residents with mild to moderate illness: At least 10 days have passed since symptoms first appeared and At least 24 hours have passed since last fever without the use of fever-reducing medications and Symptoms have improved. Asymptomatic residents: At least 10 days have passed since the date of their first positive viral test . Facility policy titled, Resident Rights, undated, documents, in part, .The facility must care for you in a manner and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services .

Based on observation, interview, and record review, the facility failed to empty the lint compartment and filter. This failure creates an unsafe environment and a fire hazard which has the potential to affect all 150 residents. Findings include: On 06/09/25 at 1:03 pm, during tour of laundry area with V16 (Housekeeping/Laundry Director), observed the lint trap/screen compartment to the dryer for residents personal use not emptied with a large buildup of lint in the lint trap/screen compartment. V16 stated the lint trap does not have a log sheet and there is no procedure or schedule for the laundry staff to clean the lint trap/screen for the residents personal dryer. V16 stated, I check it when I can. I don't know when I'm not here who checks it. V16 explained if the lint trap/screen has lint build up it could overheat the dryer and/or cause a fire. On 06/09/25 at 1:08 pm, V17 (Housekeeper/Laundry Aide) stated the laundry aides do not check the dryer for residents' personal use. V17 stated the laundry staff only log and check the main dryers in the laundry area after every 2 loads. V17 explained that V17 has never checked the lint trap/screen dryers for residents' personal use when V17 works in laundry. The facility undated document titled Laundry Policies and Procedures for Laundry Personnel documents, in part: Drying: . All dryer lint screens must be cleaned by laundry staff after every 2 loads and documented on the Laundry Daily Lint Screen Cleaning Form. The facility's job description document titled Laundry Aide documents, in part: position summary: the duties of the laundry age shall be insured to ensure facility linen and residence personal clothing are properly collected, sorted, laundered, distributed and or stored according to facility policy. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with the current existing federal and state regulations and established company policies and procedures. Essential job functions: C. Role Responsibilities -Safety: use this facility equipment safely. The facility's job description document titled Director of Housekeeping documents, in part: Under the direction of the Administrator, the Director of Housekeeping, is responsible for daily operations of the housekeeping department, including staffing, supply ordering and supervision. The person holding this position is delegated the responsibility for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. Essential Duties and Responsibilities - Job Knowledge/Duties: B. Role Responsibility- Administrative Duties: Maintains pertinent records, manages budgets and supplies, and functions as a working supervisor in all areas of responsibility as the department's budgeted hours and workload.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents who depend on staff assistance for ADL (Activities of Daily Living) care and hygiene were provided oral care and timely incontinence care. These failures affected four residents (R74, R115, R132, and R140) reviewed for ADL Care assistance, in a total sample of 64 residents. Findings include: 1. On 6/9/25 11:25 AM, R140 was observed in bed. R140's teeth were observed to have accumulated creamy brown sediments. The surveyor inquired from R140 about mouth care, but R140 could not respond due to cognitive impairment. 2. On 6/9/25 11:29 AM, R74 was observed in bed. R74's teeth had accumulated brown sediments. R74 stated no staff has assisted him with mouth care in a long time. Two hours later (about 2pm) R74's oral care issue was still in the same condition. On 6/9/25 at 2:15pm, V2 (Director of Nursing) was notified. V2 stated she (V2) would ensure that staff do oral care for both residents. R74's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Hemiplegia and Hemiparesis, Paralytic Gait, Lack of Coordination, History of Falling, Polyosteoarthritis, Pain in Right Lower Leg, and Generalized Muscle Weakness. Care plan dated 3/21/22 states in part that R74 has self-care deficit related to diagnoses. Interventions states to provide extensive assistance with Oral Care, bathing, dressing and personal hygiene. Basic Interview for Mental Status (BIMS) Score is 14 out of 15(No Cognitive Impairment). R140's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited To Traumatic Brain Injury, Gastrostomy Status, Cerebral Infarction, Weakness, And Reduced Mobility. Care plan dated 4/9/25 states in part that R140 has self-care deficit related to diagnoses. Interventions states to provide assistance with ADL's as required including bathing, dressing and personal hygiene. Basic Interview for Mental Status (BIMS) Score could not be assessed due to Severe Cognitive Impairment. Facility's Policy on ADL Care states in part: Assisting the resident in personal care such as bathing, .oral care, nail care .as indicated and as per care plan. Facility's Document titled CNA (Certified Nurse Assistant) Job Description states in part: #C2: Assist residents with daily dental and mouth care like brushing teeth or dentures, oral hygiene and mouth care. #E7 states: Performs after meal care such as brushing teeth, and cleaning resident's hands and face. 52232 3. On 6/9/2025 at 11:05 AM observed R115 laying in the bed, fully clothed with shoes on and a left arm brace in place. R115 was watching TV. R115 stated that R115 does not get changed often. R115 stated the morning CNA (Certified Nurse Assistant) will come and get R115 up to the chair around 10:30 AM or later. R115 said that is when R115 gets incontinence care and change of undergarments and then R115 stays in the wheelchair for most of the day. R115 stated the next shift aide is the one that gets R115 back in the bed and that is usually when R115 gets another incontinence care. R115 stated R115 stays sitting in the wheelchair in the wet undergarment for a long time and doesn't get back to bed until evening hours. R115 said R115 feels that the incontinence care should be provided more often. R115 stated R115 is paraplegic and cannot move legs or feel sensation of urination, therefore R115 does not feel wetness. R 115s face sheet documents in part diagnosis included but not limited Quadriplegia, Neuromuscular Dysfunction of Bladder, Paraplegia, Ankylosis of Left Hip, History of Urinary Tract Infections. R115's Minimum Data Sheets (MDS), dated [DATE], in section C -Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 14, which indicates intact cognitive function. R115's MDS, dated [DATE], in section H - Bladder and Bowel, showed R115 always incontinent. R115's Care Plan, revised 11/19/2024 showed in part that R115 is paraplegic and needs assistance with activities of daily living (ADL) and that R115 need's cleaning perineal area when incontinent. 4. On 6/9/2025 at 12:05 the surveyor observed in R132's room, an unpleasant, strong, urine and feces odor. Surveyor observed the call light was on and working properly. Surveyor observed R132 laying in the bed unclothed, with no shirt on, covered with white bed sheet. R132 stated that R132 pushed call light about 5 min ago because R132 was incontinent and in need of incontinence care. R132 stated that sometimes the wait for the staff to answer the call light is longer than one hour. On 6/9/2025 at 12:30, V22 (Licensed Practical Nurse/LPN), was observed to answer the call light in R132's room. Stated that V22 was busy in another room. F132's face sheet documents diagnosis that includes but are not limited to Unstable Burst Fracture of T7-T8 Vertebra, Neck Fracture, Neurogenic Bladder, Neuromuscular Dysfunction of Bladder, History of Traumatic Fracture, Carpal Tunnel Syndrome bilateral, Weakness, Anxiety Disorder, History of Urinary Tract Infections, Diaper Dermatitis, Major Depressive Disorder. R132's Minimum Data Sheets (MDS), dated [DATE], in section C -Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. R132's MDS, dated [DATE] in section H - Bladder and Bowel documents that R132 is always incontinent. R132's Care Plan, revised 7/16/2024 showed in part that R132 is paraplegic and needs assistance with activities of daily living (ADL) and that R132 has self-care deficit and need's assistance with incontinence care. On 6/10/2025 at 14:35 PM V21 Certified Nurse Assistant (CNA) stated that residents that are paraplegic or dependent should be turned or have incontinence care performed every two hours or as needed, but not always it gets done. V21 stated that R132 might be getting up and get the incontinence care by the morning shift aide 10:30 AM, but then the resident might not get another change until next shift comes on. V21 said the next aide starts at 3pm and that shift usually gets residents back in the bed around 6pm. V21 said V21 worked pm shifts as well and that is how V21 is aware of when the dependent residents get returned in bed. On 6/10/2025 at 14:40 PM V2, Director of Nursing (DON) stated residents should be repositioned every 2 hours and the incontinence care should be also done every two hours for all dependent residents. Facility's policy titled Activities of Daily Living (Routine Care), undated, showed in part that residents should be given routine daily care and bedtime care by a nurse aides and nurses to promote hygiene. Activities of Daily Living (ADL) care is provided throughout the day, evening and night and as needed per care plan. Facility's policy titled Incontinence Care, undated, showed that residents receive as much assistance as needed for cleansing the perineum and buttocks after and incontinent episode or with routine daily care. The policy also showed the frequency of peri care should be every two hours, and as needed and as per plan of care. Facility's Director of Nursing Job Description, undated, showed in part that the Director of Nursing (DON) has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff. Document also showed in part that DON is responsible for the overall management of resident care 24 hours a day, seven days per week. Facility's Licensed Practical Nurse Job Description, showed in part that the licensed practical nurse (LPN), provides direct nursing care to the residents, and supervises the day-to-day nursing activities performed by nursing assistants. Facility's Certified Nursing Assistant Job Description, undated, showed in part that the nurse assistant performs all assigned tasks in accordance with facility's policies and procedures and as instructed by supervisors. The document also showed that one of the role responsibilities included but not limited to making resident comfortable and assists residents with bathing and daily hygiene, dressing and undressing, keeping residents dry, assisting residents with bowel and bladder functions and keeps incontinent residents clean and dry.

Based on observation, interview, and record review, the facility failed to ensure that the low air loss mattress ordered for a resident at risk for pressure ulcer is functioning while the resident is in bed. This failure has the potential to affect one resident (R71) of three residents, reviewed for pressure ulcer prevention interventions, in a total sample of 64 residents. Findings include: On 6/9/25 at 11:39 am, R71 was observed awake in bed. R71's low air loss mattress (LALM) was not functional, and the mattress was almost flat. V4 (Assistant Director of Nursing) was summoned to the room and stated that the machine was not working because the green light was off, and the power was off. V4 turned on the power for the LALM, and stated that if it's not turned on, it cannot work for the resident and that it's possible that someone mistakenly turned it off. V4 added that she (V4) believes the mattress will inflate according to the settings and will remind staff to always ensure that the power is not turned off for the machine. R71's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Protein Calorie Malnutrition, Venous Insufficiency, Dementia, Muscle Wasting and Atrophy, Poly-Osteoarthritis, and Dermatitis. POS (Physician Order Sheets) dated 5/2/25 shows that R71 has physician orders for low air loss mattress. Pressure Ulcer Risk assessment dated [DATE] stated R71 is at risk for pressure ulcer. Care plan dated 3/22/22 states R71 is at increased risk for alteration in skin integrity related to: Impaired Mobility Status, Comorbidities, Incontinence of bladder, Incontinence of bowel. Intervention states to use Pressure reducing/relieving mattress and Wheelchair Cushions. Basic Interview for Mental Status (BIMS) Score is 13 out of 15 (No Cognitive Impairment). Facility's Guidelines for Prevention Treatment of Pressure Injuries states: It is the intent of the facility to recognize the following information and to act on it in such a way as to practice evidence-based recommendations for the prevention treatment of pressure injuries to the residents who reside in this facility. Facility's Guidelines for Low Air Loss Mattress Use states: To provide the features of a support system for the resident that provides a flow of air to assist in managing the heat and humidity of the skin. While pressure ulcer/pressure injury prevention and treatment are paramount goals for all residents, it is imperative that facility comply with what is considered non-deficient practice as stated below: Provide preventive care, consistent with professional standards of practice, to residents who may be at risk for development of pressure injuries. Provide treatment consistent with professional standards of practice to an existing pressure ulcer/pressure injury.

Based on observations, interviews and record reviews, facility failed to contain and label oxygen equipment properly; failed to display oxygen in use signage and failed to follow physician order for oxygen use. These failures affected six (R17, R20, R24, R41, R102, R124) of six residents reviewed for respiratory care in the sample of 64 residents. Findings include: 1. On 6/9/2025 at 11:25 AM, observed in R124's room, nasal cannula on the top of the oxygen tank, not contained, not labeled nor dated, hanging curled on the top of the canister. R124'S Face sheet documented diagnosis that included but are not limited to Centrilobular Emphysema, Nephropathy, Liver disease, Weakness, Nasal Congestion, Primary Insomnia. R124's Minimum Data Sheets (MDS), dated [DATE], in section C -Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. R124's care plan dated 2/19/2024, showed in part that the nasal cannula and/or mask should be monitored. R124's Order Summary Report, included active orders as of 6/11/2025, but not limited to oxygen nasal cannula at 3-4 liters for shortness of breath every day and night. 2. On 6/9/2025 at 11:45 AM, observed R24's room empty with oxygen nasal cannula, wrapped around the bed's rail and touching the floor. Nasal cannula was not labeled or dated. R24's face sheet documents in part diagnosis included but not limited to History of Sepsis, Chronic Kidney Disease, Acute Kidney Failure, Seizures, Obstructive and Reflux Uropathy, Hypertensive Heart Disease, Hypothyroidism, Myoneural Disorder, Personal history of COVID 19, Localized swelling, mass and lump in a trunk, Functional Quadriplegia, TIA. R24's Minimum Data Sheets (MDS), dated [DATE], in section C - Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 7, which indicates severe impaired cognitive function. R24's care plan, revised on 9/8/2023, showed in part that R24 receives oxygen 2 liters per minute via nasal cannula and showed to administer oxygen as ordered per MD. Care plan also showed in part, to monitor that nasal cannula and/or mask is properly positioned. R24's Order Summary Report from 6/11/2025, showed in part an active order dated 3/30/2025, to change oxygen tubing and bottle weekly on Sunday. Order Summary Report also showed active order dated 4/28/2025, for Oxygen 2-3 liters/minute per Nasal Cannula every day and night. On 6/9/2025 at 11:27 AM, R24's said that R24 uses nasal cannula at night and that the R24 coiled it on the top of the oxygen tank, so it does not touch the floor because there was no bag to place the tubing into. On 6/11/2025 at 10:17 AM, V2 (Director of Nursing) stated that oxygen tubing should be changed every week and according to MD's (medical doctor) orders, or as needed. V2 stated, that the oxygen tubing should be contained in a plastic bag when not in use, and labeled with a date on the bag so the staff would know when to change the tubing next. V2 also said, that containment of Oxygen tubing in a plastic bag, helps with infection control. The oxygen canisters should also be labeled and dated and replaced every 30 days. Facility's Director of Nursing Job Description, undated, showed in part that the Director of Nursing (DON) has the authority, responsibility, and accountability for the functions, activities, and training of the nursing services staff. Document also showed in part that DON is responsible for the overall management of resident care 24 hours a day, seven days per week. 49572 3. Review of R17's physician orders documents an active physician order for Oxygen at (2) L/Min (liters per minute) per Nasal Cannula. On 6/9/2025 at 11:05 AM, R17 was observed lying in bed receiving oxygen from an oxygen concentrator via nasal cannula at 2 liters per minute. No sign was observed on R17's door or in the near vicinity of R17's room to alert others of oxygen in use. V6 (Registered Nurse) observed the resident's door and affirmed that there should be an oxygen sign on the door and the sign must have fell off. V6 searched the nearby vicinity of R17's room and affirmed that there was no sign that fell . V6 stated, I will go get a sign and put it on now. 4. On 6/09/25 at 11:31am, R20 was observed, in her (R20) room, sitting on the side of bed. Observed R20's nasal cannula tubing hanging over the oxygen concentrator laying on the floor. Also observed was R20's nebulizer mask connected to the nebulizer laying on the floor. R20 said, I (R20) don't know why my (R20) stuff is on the floor. This place is gross. Everything about this place is gross. R20's face sheet documents diagnoses that include but are not limited to chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, and pulmonary embolism. R20's Brief Interview of Mental Status (BIMS) score, dated 5/23/25, documents, in part, a BIMS score of 15 which indicates R20 is cognitively intact. R20's Order Summary Sheet, dated 6/11/25, documents, in part, Oxygen at (2) L/Min per Nasal Cannula as needed for Shortness of Breath maintain O2 sats above (92%). R20's care plan, date initiated 6/02/25, documents, in part, Active Infection (R20) has tested positive for COVID-19. This places resident at high risk for developing Acute Respiratory Distress, Secondary infections such as Pneumonia, and increased risk for Fluid Volume Deficit. The following clinical symptoms have been noted: _Cough, _Fever, _SOB, _Fatigue, _Headache, _Congestion, or _Other . with interventions that document, in part, . oxygen per order . On 6/11/25 at 10:17am, V2 (Director of Nursing/DON) said, Oxygen tubing is changed weekly and as needed. The oxygen tubing should be labeled with the date it was changed. Resident's oxygen tubing and masks should be put in a bag when not in use to keep it clean and for infection control. Facility policy titled, Guidelines for Transporting And Storage Of Oxygen, dated 10/12/22, documents, in part, It is the policy of the facility to ensure that oxygen is stored and transported safely . Facility policy titled, Resident Rights, undated, documents, in part, .The facility must care for you in a manner and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services . 51772 5. On 6/9/2025 at 11:26 am, observed R102 with a nasal cannula applied to his face and connected to R102's oxygen concentrator which was set at 5 Liters Per Minute. R102 stated, My oxygen should be set at 3 Liters Per Minute. On 6/9/2025 at 11:31 am, V13, (Registered Nurse-(RN) stated R102's oxygen concentration is supposed to be set on 2-3 Liters Per Minute as needed. V13 stated oxygen concentration levels set higher than physician's order recommendations can result in hyperoxygenation. V13 stated all staff nurses are assigned to check their resident's oxygen concentration settings daily and/or every shift. On 6/9/2025 at 11:36 am, V13, (Registered Nurse-(RN) affirmed R102's nasal cannula tubing connected to R102's nebulizer machine was not labeled and not bagged. R102's Face Sheet dated 6/11/2025, documents in part a diagnosis of but not limited to Chronic Obstructive Pulmonary disease, Barret's Esophagus without Dysplasia, Shortness of Breath, Chest Pain, and Hypertensive Heart Disease without heart failure. R102's Physician Order Sheet dated 6/11/2025 documents an active order dated 5/20/2025, O2 at 2-3 Liters via nasal cannula as needed for shortness of breath. 6. On 6/9/2025 at 12:01 pm, R41's oxygen tank was observed in a holder next to his bed with a nasal cannula undated and unbagged hanging on the oxygen tank's handle. V14, (Certified Nurse Aid) stated the oxygen tank belonged to R41. On 6/9/2025 at 12:07 pm, V13, (Registered Nurse-(RN) assessed R41's nasal cannula tubing attached to R41's oxygen tank and affirmed the tubing was not labeled and not bagged. V13 stated all oxygen tubing, masks, and nasal cannulas should be labeled and bagged. V13 stated undated and unbagged oxygen supplies poses an infection risk to the resident. R41's Face Sheet dated June 11, 2025, documents in part a diagnosis of but not limit Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Essential Hypertension. R41's Physician's Order Sheet documents an active order dated 2/19/2024 for Oxygen 2-3 Liters Per Minute Per Nasal Cannula continuously for shortness of breath. R41's Physician's Order Sheet documents an active order dated 3/19/2023 Change Oxygen tubing and bottle weekly on Sunday. Facility's Policy undated and titled Oxygen Administration documents It is the policy of the facility to provide oxygen to maintain levels of saturation the resident as needed and as ordered by the attending physician. Portable oxygen units are used to support resident mobility in the facility and for outside the facility. 1. Check orders for accurate oxygen liter flow. 2. Tubing, Humidifier bottles and filters will be changed, cleaned and maintained no less than weekly and PRN. Each will be labeled with date, time and initiated by staff completing this service to equipment.

Based on observation, interview, and record review, the facility failed to refrigerate unopened insulin pens, label multi-dose medications, discard expired medications, and monitor refrigerator temperatures. These failures affected seven residents (R1, R50, R64, R67, R74, R97, R100) and has the potential to affect all 57 residents on the 3rd floor. Findings include: The (06/09/2025) 3rd floor census was 57 residents. On 06/09/2025 at 11:34 am, during the medication storage and labeling task with V6 (Registered Nurse) of the 3rd floor Team 1 cart with the following observations: 1. R67's Latanoprost has no open date. 2. R64's unopened Insulin Glargine in the med cart. R64's unopened Glargine has pharmacy auxiliary label which read Refrigerate. 3. R50's fluticasone nasal spray has no open date. On 06/09/2025 at 11:43 am, V6 stated her (R64) unopened Lantus (Insulin Glargine) should be stored in the refrigerator. Latanoprost and Fluticasone should have open dates, so V6 knows how long these have been opened to prevent giving expired medications to residents. On 06/09/2025 at 11:50 am, during the storage and labeling task with V7 (Licensed Practice Nurse) of the 3rd floor medications storage room observed 'The (June 2025) 3rd floor Daily check Refrigerator Temperature Log has missing entries on Date: 7, Temperature, and Initial.' This observation was pointed out to V7. V7 stated the night shift nurse are supposed to check the refrigerator temperature nightly to ensure the medications in the refrigerator are kept in correct temperature so medications will not go bad. V7 said, We keep our unopened insulin pens in the refrigerator. The refrigerator is used to keep medications that need refrigeration for all the residents on the 3rd floor. On 06/09/2025 at 11:58am, during the medication storage task with V9 (Licensed Practice Nurse) of the 2nd floor Team 2 medication cart with the following observations: 4. R1's Artificial Tears with open dated 5/6/25 5. R74's Artificial Tears with open date 4/25/25. On 06/09/2025 at 12:25pm, during the medication storage task with V10 (Licensed Practice Nurse) of the 1st floor medication room. The (June 2025) 1st floor daily check Refrigerator Temperature Log was monitored once daily. Inquiring if there are vaccines in the refrigerator. V10 took out from the refrigerator the following vaccines: 6. R97's Prevnar 20. 7. R100's Prevnar 20. On 06/09/2025 at 12:26pm, inquiring how often the facility should check the temperature if vaccines were in the refrigerator, V10 stated, I have to check with my supervisor. On 06/10/2025 at 2:56pm, V34 (Clinical Nurse Consultant) stated the expectation is to the follow the pharmacy auxiliary label on the Lantus which is to refrigerate. On 06/11/2025 at 10:01am, V2 (Director of Nursing) staff are expected to check the refrigerator temperature daily to maintain proper temperature for medications to prevent bacterial built up and to keep potency of medications. On 06/11/2025 at 10:03am, V2 stated eye drops should be labeled with the date it was opened so we can monitor when the medications expires and to prevent giving expired medications. R1's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) nervousness, ocular manifestation of Vitamin A deficiency, and hyperlipidemia. Order Summary: Artificial Tears Ophthalmic solution. Order Status: Active. Order Date: 03/15/2025. R50's (Active Order as of: 06/10/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hypoxemia, personal history of covid-19, and Gastroesophageal reflux disease. Order Summary: Fluticasone allergy relief. Order date: 09/05/2023. R64's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) cerebrovascular disease, primary hypertension, and Type 2 Diabetes Mellitus. Order Summary: insulin glargine inject 10 units subcutaneously at bedtime. Order Date: 05/16/2025. R67's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) Type 2 Diabetes Mellitus, primary hypertension, and benign prostatic hyperplasia. Order Summary: Latanoprost Ophthalmic solution. Order date: 05/02/20255. R74's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) hemiplegia and hemiparesis, cerebral infarction, and blepharoconjunctivitis. Order Summary: Artificial Tears Ophthalmic solution. Order Date: 10/08/2024. R97's (printed on: 06/12/2025) completed Order Summary Report documented that R97's Diagnoses: (include but not limited to) acute respiratory failure, primary hypertension, and personal history of Covid-19. Order summary documented R97 was ordered Prevnar 20 on 04/09/2025 and on 04/13/2025. R100's (printed: 06/12/2025) Completed Order Summary Report documented R100's Diagnoses: (include but not limited to) convulsion, dysphagia, and anemia. Order Summary documented R100 was ordered Prevnar 20 on 04/09/2025 and 04/13/2025. The (06/11/2025) email correspondence with V34 (Clinical Nurse Consultant) documented, in part, We don't have specific policies as you requested but please see below our expectations. We expect nurses to follow the pharmacy labels on the multi dose vial medications. For insulins, they should be refrigerated upon receipt from the pharmacy. Artificial tears expire 30 days after opening. Also, if there are vaccines in the med-room refrigerators, refrigerator temps should be monitored twice daily. For refrigerators with no vaccines, it will be once daily temp monitoring. Should Artificial Tears and Fluticasone be labeled with Open Date? V34 responded 'They should be dated when opened. The (May 2024) Medication Storage in the facility documented, in part Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: 11. Medications requiring refrigeration or temperatures between 36 degrees F and 46 degrees F are kept in the refrigerator. Medications requiring storage in cool place are refrigerated unless otherwise directed on the label. 14. Outdated drugs will be immediately withdrawn from the stock by the facility. 18. Facility staff will assure that the multidose vial is stored following manufacturer's suggested storage conditions.

Based on observation, interview, and record review, the facility failed to provide thermometers and maintain refrigerator logs for four residents' personal refrigerators. These failures affected four (R112, R120, R132, R550) of four residents reviewed for safe storage of personal food in a sample of 64. Findings include: On [DATE] at 10:54am during observation of R120's personal refrigerator the following was observed: R120's Refrigerator Temperature Log Month/Year ,d+[DATE] had missing initials and temperatures on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. R120's Refrigerator Temperature Log Month/Year ,d+[DATE] with missing initials and temperatures on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 10:54 am, R120 said, Yes, this is my (R120) fridge. My friend brings me food in all the time. They (staff) don't check my fridge every day. Only certain staff check it. Unless they're (staff) checking it (personal refrigerator) when I'm (R120) not here but doubt that. R120's face sheet documents diagnosis that include but are not limited to weakness, abnormalities of gait and mobility, repeated falls, and mononeuropathies of bilateral lower limbs. R120's Brief Interview of Mental Status (BIMS) score, dated [DATE], documents, in part, a score of 15 which indicates R120 is cognitively intact. On [DATE] at 11:08am, during observation of R112's personal refrigerator the following was observed: R112's Refrigerator Temperature Log Month/Year : (Blank) had no documentation of temperature checks and employees' initials. There were no other Refrigerator Temperature Log Month/Year observed. Surveyor attempted to interview R112 but was unable to complete interview due to R112's altered mental status. R112's face sheet documents diagnosis that include but are not limited to weakness, abnormalities of gait and mobility, repeated falls, and mononeuropathies of bilateral lower limbs. R112's Brief Interview of Mental Status (BIMS) score, dated [DATE], documents, in part, a score of 99 which indicates R112 was unable to complete the interview. On [DATE] at 1:50 pm, V2 (Director of Nursing/DON) said, Yes, residents' personal refrigerator's temperature should be checked daily. The purpose of checking the temperatures is to make sure foods are stored correctly and so bacteria doesn't build up. Each resident's personal refrigerator should have a temperature log and a thermometer. The temperature should be checked every shift by housekeeping. On [DATE] at 10:47 am, V16 (Housekeeping Director) said, My staff (housekeeping) and maintenance take care of residents' personal refrigerators, but usually us (housekeeping staff). We (housekeeping staff) check whether or not temp (temperature of refrigerator) is 40 degrees, and if not we (housekeeping staff) adjust it. We (housekeeping staff) tell all the staff and patients to properly label outside food with dates and if (outside food) more than 3 days old we (housekeeping staff) toss (dispose of) the items. Expiration dates are checked so all the items aren't spoiled and kept at healthy temps (temperatures) and not freeze or get too warm to a point that the food is not healthy to eat. If patients (residents) eat foods past expiration they (residents) can get sick like a stomach illness. Temperatures of personal fridges are checked daily. Staff should put temp (temperature reading) and their (staff) initials on the refrigerator log sheet daily. All personal fridges should have thermometers and if not they (staff) should notify me (V16). Facility policy titled, Unit (Resident Room) Refrigerators, undated, documents, in part, It is the policy of the facility to assure that perishable food requiring refrigeration is stored at the proper temperature . All unit refrigerators will be maintained regarding temperature and cleanliness . Each refrigerator will be provided with a thermometer to ensure that the refrigerator is maintained between 35 degrees and 40 degrees Fahrenheit . Refrigerator temps will be checked and documented daily . Facility policy titled, Resident Rights, undated, documents, in part, .The facility must care for you in a manner and environment that enhances or promotes your quality of life . You have the right to receive services with reasonable accommodations to individual needs and interests . The facility must provide a safe, clean, comfortable, home-like environment, allowing you the opportunity to use your personal belongings to the extent possible. The facility will provide housekeeping and maintenance services . 52232 On [DATE] at 11:46 AM, in R550's room, surveyor observed personal refrigerator had a missing log sheet form. Inside of the fridge the food items observed with no concerns. On [DATE] at 11:47 AM, R550 stated, when R550 got admitted , the staff cleaned the fridge and put R550's food items inside and must have forgotten to put the log sheet on the side of the fridge. R550's face sheet documents in part diagnosis included but not limited to Type 2 Diabetes Mellitus, Pyoderma Gangrenosum, Weakness, Atherosclerosis, Peptic Ulcer, Abdominal pain, Atherosclerotic Heart Disease, Cardiac Pacemaker, Hyperlipidemia, Hypertension. R550's Minimum Data Sheets (MDS), dated [DATE], in section C -Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. On [DATE] at 12:05 PM in R132's personal refrigerator, surveyor observed no thermometer inside and missing refrigerator' s daily log sheet. Items inside a fridge observed without concerns. On [DATE] at 12:06 PM R132 stated, that R132 is not sure where the thermometer is, or why the log sheet is missing, the staff should be maintaining it. R124'S Face sheet documented diagnosis that included but are not limited to Centrilobular Emphysema, Nephropathy, Liver disease, Weakness, Nasal Congestion, Primary Insomnia. R124's Minimum Data Sheets (MDS), dated [DATE], in section C -Cognitive Patterns, documents Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicates intact cognitive function. On [DATE] at 13:51 PM V2 (DON) stated that the refrigerators in the resident's rooms should have thermometers and temperature's log sheets. V2 stated that refrigerator's temperatures should be checked and documented on the forms. These log sheets should be checked daily every shift and should be the housekeeping's responsibility. The reason for the checks is to make sure that the food in the refrigerators don't get spoiled, or expired and so residents won't get sick, or the food won't spread infection. Facility's policy titled Unit (Resident Room) refrigerators, undated, showed in part, that each refrigerator should be provided with a thermometer to ensure that the refrigerator is maintained in proper temperatures and that the temperatures should be checked and documented daily.

Based on observation, interview, and record review, the facility failed to ensure that the call lights were accessible as stated in the care plans. This failure affected two (R14 and R88) of two resident reviewed for accommodation of needs in a sample of 64. Findings include: 1. On 6/9/25 at 11:38 am, R88 was observed awake in bed trying to feel where his call light was located. R88 stated, Please, can you help find the call light? Do you know I'm blind? I think the staff that came to change me this morning did not put the call light back here. V4 (Assistant Director of Nursing) was notified at the nursing station. V4 came and got the call light from between the siderail and the floor and stated that staff will be reminded to always put resident's call light where he can reach it. R88's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Encephalopathy, Weakness, Acquired Absence of Left Leg Below Knee, Osteomyelitis, And Reduced Mobility. Care plan dated 10/5/22 states in part that R88 have self-care deficits. Interventions states to be sure the resident's call light is within reach and encourage the resident to use it for assistance. Basic Interview for Mental Status (BIMS) Score is 9 out of 15 (Moderate Cognitive Impairment). On 06/09/25 at 10:42 AM, R14's was lying on a low air loss mattress. R14 stated, I don't know where my call device is. V7 (Licensed Practice Nurse) came to check for R14's call device. V7 checked the back of R14's headboard and stated, It is literally stuck on the headboard. V7 clipped R14's call device on R14's blanket, within reach of R14. R14 then stated, Now I can reach it. 43351 2. On 06/09/25 at 10:42 AM, R14's was lying on a low air loss mattress. R14 stated, I don't know where my call device is. V7 (Licensed Practice Nurse) came to check for R14's call device. V7 checked the back of R14's headboard and stated, It is literally stuck on the headboard. V7 clipped R14's call device on R14's blanket, within reach of R14. R14 then stated, Now I can reach it. On 06/11/2025 at 9:59am, V2 (Director of Nursing) stated the expectation is call light should be within reach of a resident so the resident can ask for assistance. The purpose of keeping the call light within reach is to prevent falls. R14's (Active Order as Of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) primary osteoarthritis, essential hypertension, and history of falling. R14's (05/27/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. C0700. Short-Term memory Ok: 1 memory problem. C0800. Long-Term Memory Ok: 1. Memory Problem. C1000. Cognitive Skills for daily decision making: 3 severely impaired. R14's (Revision on: 04/04/2025) care plan documented, in part Focus: I'm at Risk for Falls as evidenced by the following risk factors and potential contributing Diagnosis: Decreased Safety Awareness, General Weakness. Intervention(s): Place my call light within reach and encourage me to use it for assistance as needed. Focus: I could benefit from use of 'non-restrictive' side rails. Intervention(s): place my call light within reach and encourage me to use it for assistance. The (undated CNA (Certified Nursing Assistant) job description documented, in part The certified Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by supervisors. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out established duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures. H. Role Responsibilities - Safety: 4. Keeps the nurse's call system within easy reach of the resident. The (undated) Call Lights documented, in part Purpose: 1. To respond promptly to resident's call for assistance. Procedure: 10. Be sure call lights are placed within resident reach.

Based on record review and staff interview, the facility failed to provide clinical rationale or physician documentation justifying the increase in dosage of a psychotropic medication. This affected one of one resident (R102) reviewed for appropriate and necessary use of psychotropic medications in a sample of 64. Findings include: R102's Face Sheet dated 6/11/2025 documents in part a diagnosis of but not limited to Depression, Schizoaffective Disorder/Bipolar Type, Major Depressive Disorder, Alcoholism-Dependence/Withdrawal, and anxiety disorder. R102's Physician Order Sheet dated 6/11/2025 documents an active order dated 5/14/2025 with a start date of 5/15/2025, Venlafaxine HCL ER Oral Tablet Extended Release 24 Hour 150 MG Give 300 mg by mouth one time a day related to major depressive disorder, single episode, severe psychotic features. R102's Minimum Data Set-Section C dated April 15, 2025 documents a BIMS (Brief Interview Mental Status) of 15 which indicates R102 is cognitively intact. R102's Primary Physician: All Progress Note Type with an Effective date of 5/8/2025 authored by V2, (Director of Nursing-(DON) documents Note text: IDT (Interdisciplinary Team) completed GDR (Gradual Dose Reduction) Meeting with MD (Medical Doctor) and recommends for Venlafaxine 225 mg (milligram) to be reduced to 150 MG daily. Per MD resident has a good response to treatment and requires this dose for condition stability. Behavior Monitoring remain implemented. Resident made aware of clinical updates. No GDR indicated at this time. On 6/11/2025 at 1:34 pm, R102's Medication Administration Record for the month of May documents a scheduled order for Venlafaxine HCL ER Oral Tablet Extended Release 24-hour 75 mg (Give 1 tablet by mouth one time a day related to Major Depression Disorder, Single Episode, Severe Psychotic Features Take Along with 150 mg ER to equal 225 mg. Start date 1/9/2025 0900 Discontinue date 5/14/2025. On 6/11/2025 at 1:38 pm, V2, (Director of Nursing-(DON) affirmed R102's Medication Administration Record (MAR) documents a schedule order for the month of May for Venlafaxine HCL Extended Release (ER) Oral tablet Extended Release 24 Hour 150 mg (Venlafaxine HCL) Give 300 mg by mouth one time a day related to Major Depression Disorder, Single Episode, Severe Psychotic Features with a start date of 5/15/2025. V2 could not provide a progress note documenting an IDT Meeting describing the need for behavior interventions for increasing R102's psychotropic medication Venlafaxine HCL. On 6/11/2025 at 1:41 pm, V2, (Director of Nursing-(DON) affirmed that according to R102's June Medication Administration Record (MAR), R102 received Venlafaxine HCL Extended Release 300 mg orally at 9 o'clock am on the following dates: 6/1/2025, 6/2/2025, 6/3/2025, 6/4/2025, 6/5/2025, 6/6/2025, 6/7/2025, 6/8/2025, 6/9/2025, 6/10/2025, and 6/11/2025. Facility's Policy titled Policy and Procedure Psychotropic Drugs Usage undated documents the following: 1. Psychotropic drug use is based upon the comprehensive assessment of the resident. Psychotropic medications are given as necessary to treat a specific condition that is diagnosed and documented. 2. Residents receiving psychotropic medications will have gradual dose reductions and behavioral interventions implemented unless contraindicated. 3. Dosage reduction of psychotropics, anxiolytics, and hypnotics are attempted per CMS guidelines unless clinically contraindicated.

Based on observations, interviews, and record reviews, the facility failed to provide range of motion exercises and apply restorative devices, potentially contributing to the progression of contractures. This deficient practice affected three (R57, R73, and R74) of three residents reviewed for restorative care in a sample of 64. Findings include: 1. On 06/9/25 at 10:08 AM, R73 was observed in bed no hand protector/splint in place. On 6/11/2025 at 9:45 AM, R73 was observed in bed resting with contractures to R73's right and left hand. No hand splits, hand rolls or other restorative braces/services observed in place. V30 (Restorative Nurse, Licensed Practical Nurse) and V31 (Certified Nursing Assistant) entered the room, observed R73 and affirmed that no hand protectors, braces, or other restorative braces/services were in place. V30 stated R73 is on Passive range of motion programs for all extremities and is to receive two sets of 10 reps (repetitions) and wear bilateral splints for hands but can alternate with palm protectors. V30 checked the dresser of R73 and stated that there was no splint or palm protector in available and that she (V30) was informed this week and informed the administrator to order the devices. V30 stated a kerlix or towel could be used in place for temporary use until device arrives at the facility and was not sure why these interventions were not put into place. V31 explained R73 tolerates all rehab but has not had splint available for use in a while. R73's face sheet dated June 11, 2025, documents in part diagnosis information: Contracture of right and left hand, contracture of muscle of left upper arm, quadriplegia, dementia, major depressive disorder, anxiety, unspecified intellectual disabilities. R73's Minimum data set (MDS) dated [DATE], documents in part that R73 has impairment with short term and long-term memory, is rarely/never understood, and has impairment of both upper and lower extremities. R37's care plan (12/27/2022) identifies R73 benefits from a splint/brace due to impaired range of motion/loss of functional movement and has an intervention including but not limited to, staff to apply splint/palm protector for 4-6 hours daily or as tolerated. R73's Physician order summary report dated 6/11/2025, documents in part that R73 may use right palm guard for 4-6 hours, if palm guard unavailable may use rolled hand towel. Purchase form dated 6/9/2025 documents Palm guard x 4 was ordered by V30 (Restorative Nurse, Licensed Practical Nurse) . On 06/11/25 at 10:14am V2 (Director of Nursing) stated it is the expectation for the restorative nurse/aide to check the resident's skin and perform range of motion exercises to prevent further breakdown, a rolled hand towel that could be stabilized with a kerlix should be utilized if a splint/ palm protector isn't available. V2 stated V2 was just informed today by V30 that there were no available splints/palm protectors available in the facility, V30 is responsible to track supplies and order all restorative supplies and equipment, Job description titled Restorative nurse undated, documents in part; . the restorative nurse is responsible for the development, implementation, monitoring, and supervision of the restorative nursing program; .Essential job functions: . 9. maintain current listing by resident of all assistive devices and care plan each .18. ensure that restorative equipment and supplies are available as needed .21. Educate and manage the facilities activity of daily living documentation and training program . Job description titled Restorative aide undated, documents in part; .4. Assist residents to apply and remove splints or protheses . 32338 2. On 6/9/25 at 11:26 am, R74 complained that staff has not been giving range of motion exercises for the left arm and left leg. R74 explained he has left side weakness from the stroke, and he does not want to get contracted. 3. On 6/9/25 11:41am, R57 complained staff has not helped him with range of motion exercises for more than 2 weeks. On 6/9/25 at 12:45 pm, V29 (Restorative Aide) stated that he (V29) is the restorative aide for the second floor and R57 is not on the list of residents he performs range of motion (ROM) exercises for. The surveyor asked V29 for the list of residents on range of motion exercises for the second floor. V29 Presented a list titled Restorative Hot List dated 6/26/24, that did not include R57 but includes R74. V29 added that the list needs to be updated. In the presence of R74 (cognitively intact resident), V29 stated he (V29) has not been able to do ROM (range of motion) exercises for everyone on the list because of time. V29 added, Sometimes, I go on escort with residents. Sometimes, I work on the floor if there is a call off. Today, I have to do escort at 12:15pm. On 6/9/25 at 1:10pm, V30 (Restorative Nurse) stated all residents are supposed to be on restorative range of motion exercises. V30 stated the list presented by V29 was an old list. At this time, V30 presented another list titled Restorative Nursing Programs Master Log that includes almost all residents. This list shows R74 is supposed to have passive range of motion (PROM), active range of motion (ROM), splint or brace, and receive assistance with bathing and dressing. The list also shows R57 is supposed to have passive range of motion and bed mobility exercises. R74's records reviewed are as follows: Face sheet shows diagnoses which include but are not limited to Hemiplegia and Hemiparesis, Paralytic Gait, Lack of Coordination, History of Falling, Polyosteoarthritis, Pain in Right Lower Leg, and Generalized Muscle Weakness. Care plan dated 9/14/22 states that R74 would benefit from participation in range of motion and that the restorative aide or unit aide will complete range of motion for resident. Brief Interview for Mental Status (BIMS) Score is 14 out of 15 (No Cognitive Impairment). R57's records reviewed are as follows: Face sheet shows diagnosis which include but are not limited to lack of coordination, abnormalities of gait and mobility, weakness, are still arthritis, and reduced mobility. Care Plan dated 8/3/22 States that R57 would benefit from bed mobility restorative nursing program. Intervention states that the restorative aid or certified nursing assistant will provide bed mobility restorative program six to seven days weekly. BIMS Score is 11 out of 15(Mild Cognitive Impairment). Facility's Policy and Procedure on Restorative Nursing Program states in part: The facility must ensure that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline in range of motion. Facility's Document titled CNA (Certified Nurse Assistant) Job Description states in part: #D7: Provides daily range of motion exercises and records data as instructed. #C21: Performs restorative and rehabilitative procedures as instructed.

Based on observations, interviews, and record review, the facility failed to ensure controlled medications were stored in a double locked setting, failed to ensure completed controlled medications were returned to the pharmacy, and failed to ensure out going nurse signed the Narcotic/Controlled Substance Shift-to-Shift Count Sheet. These failures affected 3 (R14, R106, and R150) residents reviewed for controlled medications in the total sample of 64 residents. Findings include: On 06/09/2025 at 11:52 am, during the medication storage task with V7 (Licensed Practice Nurse). V7 opened the 3rd floor medication storage room using a key code. There was a small refrigerator inside the 3rd floor medication storage room. V7 opened the small refrigerator by unlatching the door. This surveyor inquired if the refrigerator was locked. V7 stated there is no lock, I just unlatched it. Requested V7 to check if the small refrigerator has controlled substances. V7 showed R14's two boxes of Lorazepam 2mg/ml. V7 stated the refrigerator should be locked because we have controlled medications in the refrigerator. V7 searched for the lock and stated the lock is on the floor. R14's (printed: 06/11/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) primary osteoarthritis, essential hypertension, and history of falling. Lorazepam oral concentrate 2mg/ml give 0.5 by mouth every 2 hours as needed for 14 days. Order Status: completed. End date: 06/04/2025. Lorazepam 2mg/ml give 1ml by mouth every 15minutes as needed for active seizure for 14 days. Order Status: Completed. End date: 06/04/2025. Lorazepam 2mg/ml give 1mg by mouth every 2 hours for 14 days. Order Status: completed. End date: 06/04/2025. Of note, R14's Lorazepam was completed on 06/04/2025. On 06/11/2025 at 11:52 am, V34 (Clinical Nurse Consultant) stated the expectation is if the controlled medication is already completed, it should be completely out of the facility. Meaning, the controlled medications should be returned to the pharmacy and not kept in the cart or storage room. On 06/09/2025 at 12:05 pm, during the medications storage task with V9 (Licensed Practice Nurse) the (June 2025) 2nd Floor Team 2 Narcotic/Controlled Substance Shift-to-Shift Count Sheet had missing entries on Date: 7, 3rd shift, Off going Nurse and on Date: 8, 3rd shift, Off-going Nurse. This observation was pointed out to V9. V9 stated (V11 - LPN) did not sign when she got off on 06/07/25 and 06/08/25. The expectation is to sign the shift to shift count sheet to document the oncoming and outgoing nurses counted the controlled medications during shift change to ensure the count is good. V9 stated they only have two residents in Team 2 that have controlled medications. They are (R106 and R150). On 06/11/2025 at 10:00am, V2 (Director of Nursing) stated, Controlled medications should be double locked to prevent theft. It is also a safety issue if controlled medications are not properly stored. We are using the key now on our refrigerators in our medication storage rooms. No more codes so nurses don't have to memorize the codes. On 06/11/2025 at 10:10am, V2 stated at the beginning of the shift of the incoming nurse and end of the shift of the outgoing nurse, they must count all controlled medications to ensure all controlled medications in the cart are accounted for. The incoming nurse is taking responsibility of all the controlled meds in the cart. The outgoing nurse and incoming nurse must sign in the shift to shift count sheet to document the controlled medications were counted. R106's (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) neuralgia and neuritis, hemiplegia and hemiparesis, and low back pain. Order Summary: Clonazepam Oral tablet give 0.25mg by mouth three time a day. Order Date: 05/21/2025. Zolpidem 10mg. give 10mg by mouth at bedtime. Order Date: 05/01/2025. R106 (05/01/2025) Controlled Drug Receipt/Record Disposition Form documented, in part Zolpidem Tab 10mg. R106 (06/07/2025) Controlled Drug Receipt/Record Disposition Form documented, in part Clonazepam 0.5mg take 1/2 tab by mouth three times daily. R150s' (Active Order as of: 06/09/2025) Order Summary Report documented, in part Diagnoses: (include but not limited to) post-traumatic stress disorder, sleep disorder and wedge compression fracture of first lumbar vertebra. Order Summary: Oxycodone 5mg. give 5mg by mouth every 6 hours. Order Date: 06/04/2025. R150's (Controlled Drug Receipt/Record Disposition Form documented, in part Oxycodone 5mg every 6 hours. The (undated) Licensed Practical Nurse Job Description documented, in part Position summary: The Licensed Practical Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. C. Role Responsibilities - Drug Administration: 6. Ensures that narcotic records are accurate for your shift. 10. Dispose of drugs and narcotics as required, and in accordance with established procedures. The (undated) Registered Nurse Job Description documented, in part Position summary: The Registered Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulations and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times. C. Role Responsibilities - Drug Administration: 6. Ensures that narcotic records are accurate for your shift. 10. Dispose of drugs and narcotics as required, and in accordance with established procedures. The (May 2024) Medication Storage in the facility documented, in part Policy: Medications and biologicals are stored safely, securely, and properly following the manufacture or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure: 9. All drugs classified as Schedule II of the Controlled Substance Act will be stored under double locks. The (May 2024) Controlled substances documented, in part Policy: Medications classified by the FDA (Food and Drugs Administration) as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping. Procedure: 4. While a controlled substance is in use, the nursing staff will maintain the following medication records: b. All schedule II controlled substances (and other schedules, if facility policy so dictates will be counted each shift of whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will 2. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet. 4. Both nurses will sign the Shift/Shift controlled substances count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.

Based on interview and document review the facility failed to ensure resident the right to be free from abuse in 2 of 4 residents included in a total sample of 8 residents. Findings include: R2 is a [AGE] year old female with a diagnosis including Emphysema, Hypothyroidism and Liver disease. R2 was first admitted to the facility on [DATE]. R2's BIMS (Brief Interview of Mental Status) score is 15/15. R2 care plans include conflictual, difficult behavior with other persons. Symptoms are manifested by covert/open conflict with of repeated criticism of staff. Behavior is manifested by unprovoked expressions of anger towards staff and peers. Behaviors of false allegations, initiates false reports and allegations of mistreatment perpetrated by others. History of aggression, accused of being inconsiderate to her roommates feelings as well as being discourteous. R2 is also care planned for being susceptible to abuse. R3 is a [AGE] year old male with a diagnosis including Vertebra fracture, Neurogenic bowel, Anxiety disorder, Depressive disorder, and Angina pectoris. R3 was first admitted to the facility on [DATE]. R3 has a BIMS (Brief Interview of Mental Status) score of 15/15. R3's care plan includes R3 is susceptible to abuse due to his past trauma and current physical limitations. Displays socially inappropriate & maladaptive behavior as evidenced by being involved in a verbal disagreement with a peer, as evidenced by playing his radio/music at a high volume despite redirection. Demonstrates behavioral distress related to ineffective coping mechanisms. Problems manifested by use of profanity demeaning statements, verbal threats and yelling at others. Facility Abuse prevention investigation dated 5/14/25, shows that on 5/8/25, R2 and R3 had a verbal encounter, and R3 spilled water on R2. This prompted investigation into the incident which was found to have caused no harm to either party. Both residents received psychiatric services with respect to behaviors. R3 is on a medication to help manage anxiety and agitation. After R2 had provided a signed statement that she feels safe and that nothing detrimental had occurred, CPD (Chicago Police Department) was notified. No further action was taken by CPD. R2 was satisfied with the outcome and voiced no other concerns. The facility verified that there was no harm to either R2 and R3 and both residents expressing feeling safe and having experienced no mental/emotional harm. R2 and R3 attested they have not experienced any type of abuse at the facility. Both residents refused a room change. Other residents were interviewed, and they raised no safety concerns. Family and MD's will be notified of the outcome of the investigation. R2's progress note dated 05/05/2025, states nurse (V4) observed resident and peer having a verbal disagreement. Residents were separated and kept safe. Psych made of aware of behaviors. Resident was able to be redirected and remain calm and cooperative. Resident alert, oriented. Resident offered a room change in which resident refuse. Resident prefers to stay in room. Social worker to follow up. On 5/27/25, at 1:20 PM, V4 (LPN) stated, I heard commotion. I was at the nurses station I heard R2 say 'you poured water on me'. Then I heard R3 say now who is the wetback. I separated them and reported to V5 (Last administrator/abuse prevention coordinator). R2 called police and they arrived. That is all I know about the incident. R2 and R3's room were next to each other. R2 had an issue with R3's music being too loud. R3 was moved a few rooms down and now there are no issues between the both of them. On 5/27/25, at 11:55 AM, R2 stated, Yes R3 threw water at me in the corridor when we got into a verbal altercation. It got me wet but didn't hurt me. I called the police, and they came. I was in the room next to him. He played his radio too loud, so I called police on him. We got into a verbal altercation where he called me a lot of bad names. I moved to a new room, and I don't hear the loud radio anymore. I feel safe now, but he did assault me with the water. On 5/27/25, at 1:00 PM, R3 stated Yes, I threw water at R2 from my water cup. She called me a wetback mother------. She is a real problem since she came from another floor. I play my TV and radio and she keeps complaining that it's too loud. She called the police on me several times. I actually apologized to her for the water incident, but she keeps complaining about me. Facility policy titled Abuse Prevention Program Policy includes: It is the policy of this facility to prohibit and prevent resident abuse, neglect, exploitation, mistreatment, and misappropriation of resident property and a crime against a resident in the facility.

Based on interviews and record reviews, the facility failed to protect two (R1, R2) residents' rights to be free from physical and verbal abuse out of three sampled residents. This failure resulted in R2 experiencing right foot pain and sustaining subacute fracture of distal right fourth metatarsal. Findings Include: The facility's abuse reportable dated 6/28/24 documents that on 6/24/24, R1 and R2 had a verbal disagreement regarding the washroom in R1 and R2's room. R2 stated that contact was made to R1's face. R1 stated R2 did make contact with R1's face, but stated R1 was not physically harmed, not in pain, not mental or emotionally distressed. R1's clinical records show R1 went out on pass on 7/9/24. R1's face sheet shows an admitted [DATE] with diagnoses not limited to Bipolar Disorder, Anxiety Disorder, Alcohol Use, and Depression. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is cognitively intact and is independent with activities of daily living. R2's clinical records show an initial admitted [DATE] with diagnoses not limited to Alcohol Abuse and Muscle Weakness. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact. R2's Sit to stand functional abilities in the MDS was answered, Not attempted due to medical or safety concerns and R2 uses a manual wheelchair. R2's psychiatric hospital records dated 6/24/24 shows R2's assessment was aggressive behavior and right foot injury. R2's X-Ray result dated 6/30/24 shows, New healing subacute fracture distal right 4th metatarsal. Correlate clinically. Soft tissue swelling. R2's hospital records dated 7/1/24 History of Present Illness (HPI) reads in part, R2 is a [AGE] year old presenting to the emergency department who presented with complaints of right foot pain. [R2] says that [R2] was involved in an altercation about 1 week ago. [R2] said that [R2] had foot pain at the time. [R2] is currently using his wheelchair because [R2] has an injury in the past and [R2] is in a nursing facility because of that. The patient endorses pain of the right foot but denies any numbness or tingling. On 7/10/24 at 1:05 PM, R2 stated R1 and R2 had a fight on 6/24/24 at around 1:00 PM. R2 stated, I was eating lunch and [R1] was defecating in the bathroom with the door open and I could smell it. I got mad. I went up the nurse's station and talked to [V10 Licensed Practical Nurse]. I said [R1] got to go. [R1] was being disrespectful to me. I came back to the room and [R1] started talking sh*t. [R1] was disrespecting me. I went back to the nurses' station and told [V10] that [R1] was cursing at me. [R1] followed me at the nurses' station. [R1] stood up by the elevator yelling at me saying 'fu*k you'. [V10] heard. Everybody heard. They did not do anything. Nobody could do anything. Everybody was ignoring [R2]. [R1] walked up to me from the elevator aggressively. I felt threatened so I scooped [R1] up from his legs and slammed [R1] on the floor then I landed on top of [R1]. I accidentally stood up from my wheelchair when I grabbed [R1]. It had bad impact on my right foot. They sent me to the hospital for psych eval but my right foot kept hurting. The hospital didn't do anything because I was just there for psych. I came back to the facility, and I kept complaining to the nurses that my right foot was hurting. They kept ignoring me. I don't remember who the nurses were. I told a lot of nurses. What I did was I wrapped it because it hurts. Then finally [V10] listened to me and [V10's] the one that made the appointment for my right foot for the X-ray. It was a week that I was hurting. It's healing now but I was hurting for a week. I didn't hurt my foot anywhere or bumped it anywhere only that time with [R1] when I stood up and picked [R1] up and slammed him on the floor. I was not supposed to stand up but out of anger I did so I hurt my foot. On 7/9/24 at 10:49, V12 (Social Service Director) stated that V12 heard a commotion and witnessed R1 was grabbing R2's shirt. On 7/9/24 at 11:20 AM, V14 (Certified Nursing Assistant) stated V14 witnessed R1 and R2's altercation. V14 stated that it was around 1:00 or 1:30 PM, R2 came out the room and asked if someone can get R1 out of the bathroom because R1 was using the bathroom with the door open and R2 was eating in the room. R2 said R1 was making noises. R2 was talking with V14 and V10 at the nurses' station when R1 came out the room and heard R2. R1 said something to R2 and then R2 rolled towards the elevator, and they were verbally arguing in the hallway. R1 and R2 were swearing at each other. V14 said R1 and R2 always going 'back and forth at each other' and do not get along. R1 and R2 were roommates. On 7/10/24 at 2:03 PM, V14 stated that R2's right foot looked swollen and red right after the incident that happened with R1. V14 stated that R2 could not stand up. V14 stated that R2 used to stand up on his own before, but after the altercation with R1, R2 could not stand up anymore. V14 stated R2 told [V4 Licensed Practical Nurse] that R2's right foot was hurting. On 7/10/24 at 9:49 AM, during a phone interview V10 (Licensed Practical Nurse) stated that V10 witnessed R1 and R2 in the first-floor hallway on the floor grabbing each other and fighting. V10 stated, [R2] and [R1] were in the room arguing. So, I was walking towards the front of the nurses' station, I could hear that the arguments getting loud. Then [R2] came up to the nurses' station and informed us that [R1] was using the bathroom with the door opened. As I heard them arguing I began to proceed at the front by the time I got there they were grabbing each other. [R2] was saying, This rude motherfu*ker [R1] made a bowel movement in the bathroom and I was eating and [R1] didn't close the door. At 1:46 PM, a second phone interview conducted with V10. V10 stated that V10 saw R2's right foot wrapped with an All-Cotton Elastic (ACE) wrap on 6/28/24. V10 asked R2 what happened and R2 said R2's right foot was hurting. When V10 assessed R2's right foot, it looked swollen. V10 stated that V10 informed V25 (Physician) and ordered an X-ray of the right foot. On 7/10/24 AT 2:36 PM, interviewed V4 (Licensed Practical Nurse) and stated that after the altercation with R1, R2 complained of pain on R2's right foot. V4 stated that V4 administered R2's pain medication on 6/27/24, but there was no documentation that V25 was notified of R2's right foot pain and no documentation that it was assessed. On 7/9/24 at 11:36 AM, interviewed V1 (Administrator) and stated when there's abuse, V1 expects the staff to first intervene immediately and separate the residents and report to the supervisor immediately. V1 stated, First is the safety of the residents. Separate them and keep an eye on them. V1 stated the types of abuse are physical, financial, verbal, involuntary seclusion, emotional, mental abuse, and sexual. V1 stated that an example of a physical abuse between resident to resident is physical interactions that are not welcomed by the resident. V1 stated that examples of verbal abuse are yelling, calling names, or swearing. V1 further stated that every single resident has the right to a safe environment and has the right to not experience unwelcome physical or verbal interactions. The facility's policy titled; ABUSE PREVENTION PROGRAM dated 1/19 reads in part: The facility desires to prevent abuse, neglect, exploitation, misappropriation, and a crime against a resident by establishing a resident-sensitive and resident-secure environment. Verbal Abuse: Any use of oral, written, or gestured language that includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend or disability. Physical Abuse: Hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment.

Based on observation, interview and record review, the facility failed to follow professional standards of practice and facility policy in maintaining a safe environment free of injury, failed to follow a resident's (R2) care plan, and failed to follow up on residents' complaints of pain for two (R2, R5) out of a sample of three residents. These failures resulted in R2 experiencing new onset of right foot pain which started on 6/24/24 and R2's physician was notified four days later on 6/28/24. X-Ray was obtained for R2 on 6/30/24 with findings revealed a new healing subacute fracture of distal right fourth metatarsal. These failures also resulted in R5 experiencing left knee pain for one week and a left femoral condyle fracture diagnosed on [DATE], 7 days after injury on 7/3/2024. Findings Include: On 7/9/2024 at 10 AM R5 stated on 6/20/2024, R5 went down the outside ramp of the facility while sitting in her wheelchair. R5 stated, I plowed into a brick wall, and I broke my knee cap. R5 stated both knees hurt after the incident, but the left knee hurt worse than the right knee. The facility sent R5 to the hospital where R5 stated she was diagnosed with a left broken knee cap. R5 stated, They gave me a knee brace for my left knee. R5 stated on 7/3/2024 a Certified Nurse Aide (CNA) was assisting her to bed and R5's right knee bumped into the bedframe. R5 stated, It hurt. It was a '10' on a scale of 1-10. I was in such agony. They have been giving me pain medicine and pain patches, but I would like an x-ray to see if something has been broken or fractured. R5 stated during the day on 7/3/2024, R5 was starting to do good in therapy. R5 stated, The therapist said the next time I would stand for 10 minutes. I walked from the bed to and from the bathroom twice and the physical therapist was very pleased. He said I would do more tomorrow and then I bumped the bedframe with my right knee evening. Since I bumped my knee, I have not been able to do much in therapy. R5 stated, I am not currently walking. I am very dependent now. I was walking prior to hitting my right knee on the bedframe. The therapist was a bit dismayed they haven't taken x-rays of the right knee. R5's right knee was observed to be swollen and had ecchymosis with a pea-sized scabbed area at medial-lateral distal right knee. A white patch with the word Lidocaine was observed rolled in a trifold on the right lateral knee with a handwritten date of 7/7/2024 on the patch. R5 stated, That pain patch has been on a few days. The left knee was observed to be swollen with a white patch with the word Lidocaine across the distal left knee. R5 stated, They put pain patch on the other day. There was no date on left knee lidocaine patch. On 7/9/2024 at 10:30 AM V4 (Licensed Practical Nurse) measured an ecchymosis area on the right knee as two inches by one half inch. V4 described the right knee as Discolored, purple, bruised, swollen. Rt knee is very swollen with a little gash is scabbed over. There is no drainage. V4 described the left knee as swollen. V4 removed the lidocaine patch on the left knee and stated there was no opening to the skin and no bruising. V4 stated, There may be a little redness under the lidocaine patch. V4 stated, I am not sure how often we are changing the left knee pain patch. I will check the right knee pain patch. The patch on the left knee is dated 7/7/2024. [R5] was out with activities and tried to go down the ramp along and hit the wall. is what happened with the left knee. Both knees were x-rayed on day and the left knee was fractured, not the right. This is the first I am aware of the right knee. I got no report about the right knee. V4 reviewed R5's progress notes and stated there were no notes of an injury to the right knee on 7/3/2024. On 7/9/2024 at 10:50 AM, V5 (Physical Therapist) stated, I was working with R5 last week. Occupational Therapy (OT) was working with R5 too. I was taking care of R5 before R5 fell down the ramp. When R5 fell , R5 hurt her left knee. R5 hit the right knee too, but the fracture was of her left knee. I saw R5 on 7/1/2024 and 7/2/2024. R5 was hesitant on 7/1/2024, but she was able to shift weight on both sides and stand for 2 minutes. She did better and had more confidence on 7/2/2024. V5 stated when he saw R5 on the 7/5/2024, R5 Could not even move her right knee. That was a change. She wasn't able to stand up because of right knee pain. She said she hurt her right knee when she hit it on the bed on Wednesday night 7/3/2024. V5 stated, I talked to the nurse and told them there was new swelling and bruising on the right knee. I recommended an x-ray. I think I spoke to a different nurse on 7/8/2024 and told her about the swelling. The CNAs said they had the same observation. We used a mechanical lift on the 7/8/2024 to get R5 up to the wheelchair. We haven't tried to put weight on the right leg. Once the issue with the right leg is cleared up, we will work with her on walking again. I don't know if they notified the doctor or if an x-ray was done. On 7/9/2024 the Physical Therapy (PT) note dated 7/5/2024 stated in part: Comments: Subjective/objective: noted with swelling and 10/10 pain on right knee. Pain and tenderness upon palpation and upon active/passive movement of the affected joint. Nurse on Duty (NOD) made aware, recommending x-ray to rule out fracture. Patient reports hitting right knee on the bed during bed to/from wheelchair transfer. Provided right leg rest to support and protect right lower extremity for comfort when sitting in wheelchair. Review of PT progress note dated 7/8/2024 stated in part: Comments: Subjective/Objective: noted with swelling and bruising on right knee with 10/10 pain upon active and passive movement of affected joint. Ability to reposition self greatly limited due to pian on right knee. Defer weight bearing on right lower extremity due to complaints of pain, to rule out possible fracture from acute injury. NOD made aware. On 7/9/2024 at 11:15 AM V2 (Director of Nursing) stated at the time of the fall down the ramp, both knees were x-rayed. V2 stated there has been no report of further injury or accident since R5 fell down the ramp. V2 stated there has been no verbal report or incident report of an injury to R5's right knee on 7/3/2024. Surveyor and V2 visited R5 and R5 stated she hit her right knee on the bedframe when the CNA was transferring her to bed on the evening of 7/3/2024. R5 stated since time, R5 has not been able to get out of bed other than with a mechanical lift transfer into the wheelchair so R5 can take a smoking break. On 7/9/2024 at 11:57 AM R5 observed with no movement, lying in bed, the pain in the right knee is seven on a scale of one to ten with one being little to no pain and ten being the worst imaginable pain. The pain on the left side is five out of ten with no movement when lying in bed. R5 stated with movement, the pain worsens, but it is hard to rate the pain because it depends on the type of movement. On 7/9/2024 at 3:08 PM V22 (Certified Nurse Aide) stated on 7/3/2024, another CNA asked V22 to help her transfer R5 into the bed. V22 stated R5 did not say anything during the transfer and had no complaints. On 7/9/2024 at 3:12 PM V23 (Certified Nurse Aide) stated she helped R5 back to bed. V23 stated, We transferred R5 from the chair to the bed with two-person assist. R5 could walk and stand. We put on the gait belt and two of us transferred R5 to the bed. It was easy. The nurse came to check R5 because the other CNA told V23 sometimes the nurse has to see if the person is ok. R5 was already in bed. V23 stated R5 did not have any complaints after the transfer. When V23 was asked if any part of R5's body hit the wheelchair or the bed during the transfer, V23 stated, No Ma'am. V23 stated R5 asked for water and ice, but V23 did not know what R5 needed the ice for. On 7/10/2024 at 9 AM, review of R5's electronic health record include a general note by V2 (Director of Nursing) and was dated 710/2024 at 5:30 AM. The Note Text stated: X-ray report impression completed and reviewed with medical doctor. Impression: Intraarticular fracture involving the right femoral condyle. This appears to be a complex fracture, please consider CT scan for further evaluation. Soft tissue swelling and joint effusion. New orders given for resident to be transferred to outside facility for a CT scan. Clinical Team made aware. On 7/10/2024 at 9:22 AM the MDS dated [DATE] was reviewed and stated the R5's BIM score was 15. On 7/10/2024 at 9:26 AM V19 (Activity Aide) stated, R5 went down the ramp and got hurt. R5 went outside. I told R5 to wait for me. R5 didn't listen and R5 went down the ramp. R5 was sitting in the wheelchair with her knees against the wall when V19 got to her. V19 stated R5 listens most of the time, but R5 likes to do things on her own. V19 stated there are usually three staff working during smoke breaks. On 6/20/2024, there were two staff working during the smoke break. V19 stated the other activity aide was on the porch with R5 when R5 went down the ramp. On 7/10/2024 at 10:04 AM V18 (Director of Life Enrichment) stated, R5 was unable to propel so she needed assistance going up/down the ramp. R5 was dependent in her movement in the wheelchair. V18 stated V18 was not physically there when R5 fell , but the life enrichment aides were helping other residents down to the porch to smoke. V18 stated, R5 was supposed to be next to go down to the porch, but R5 didn't wait. R5 was non-weight-bearing so she could not keep herself from falling. R5 was impulsive. On 7/10/2024 at 11:53 AM V2 (Director of Nursing) stated R5 was sent local hospital this morning where she will undergo a CT of her right knee. It is an ER visit. They are going to do an ER visit too. On 7/10/2024 at 1:27 PM V2 (Director of Nursing) stated V2 followed up about R5's complaints of right knee pain and R5's report of a 7/3/2024 incident. V2 stated, I spoke to V5 (Physical Therapist) yesterday. He should have let me know, or his supervisor know, R5 complained of an injury on 7/3/2024 and had pain in the right knee. V5 thought the nurse knew what was going on with R5's right knee. V2 stated, I have suspended two nurses and one certified nurse's aide for not reporting a change in condition pending my investigation of what happened to R5 on 7/3/2024. The staff have had in-services, so they know they have to let me know if an incident occurs. V2 stated V5 had moved R5 from ambulating to a mechanical lift transfer after the 7/3/2024 incident. V2 stated, I wasn't aware. On 7/11/2024 at 8 AM R5 was observed lying in bed with bilateral knee immobilizers in place. R5 stated, The doctors said my right knee is fractured. They put a brace on my right knee. The pain is not as bad with the brace on. On a scale of one to ten with zero to one being little to no pain and ten being the worst imaginable pain, R5 stated the pain in her right knee was an eight and the pain in her left knee was a five. On 7/11/2024 at 10:49 AM V1 (Administrator) and V2 (Director of Nursing) stated the 6/20/2024 event resulted in a fracture of the left knee, but both knees were injured. When R5 was sent to the hospital, R5 was diagnosed with a left knee fracture. On 7/5/2024 Physical Therapy worked with R5 and R5 complained of right knee pain. V2 stated R5's pain was being addressed on 7/5/2024. The doctor was called for complaints of pain and Tylenol was ordered. V1 stated he spoke to R5 on 7/9/2024 and R5 stated both knees were hurting after the 6/20/2024 incident. The left knee was hurting more than the right knee. V2 stated R5 told her on Monday the right knee was hurting. Lidocaine was ordered on 7/8/2024 and V2 knew R5 was seeing the orthopedic physician on 7/11/2024 so V2 told R5 to talk to the doctor about the right knee pain. V1 stated he suggested x-rays of the right knee on 7/9/2024. V1 stated, The assumption is the right knee fracture occurred on 6/20/2024. R25 (Physician) thinks the fracture of the right knee occurred on 6/20/2024. V1 stated, Because I am a nurse and I saw the right knee on 7/9/2024, I knew as a nurse we needed to look at the right knee and get an x-ray. On 7/11/2024 at 12:17, CT of the right knee dated 7/10/2024 was reviewed. Findings/impression: Acute inter-articular, displaced fracture of the lateral femoral epicondyle and condyle. There is some cortical irregularity and buckling noted within this region. A large fracture plan extends into the lateral aspect of the femoral notch posteriorly and lateral femoral trochlear anterolaterally. This extends into the patellofemoral joint laterally and knee joint centrally within the notch region. Moderate-sized lipohemiarthrosis is present within the knee joint. Diffuse decreased bone density is noted some areas of suspected hemorrhage are noted within the distal femur. Moderate lipohemarthrosis and adjacent subcutaneous fat stranding/edema. Extensive arterial calcifications. On 7/11/2024 at 12:30 PM, V25 (Physician) was interviewed and stated, If there are new findings, then it is new. CT scan is saying acute. This appears to be acute. I will say the resident probably had injury to the right knee on 6/20/2024. The incident on 7/3/2024 made it worse. I cannot tell whether the fracture occurred on 6/20/2024 or 7/3/2024. It is hard to know whether there is an acute fracture occurred on 6/20/2024 and 7/3/2024. There was probably a contusion on 6/20/2024 was worsened by the 7/3 incident. On 7/11/2024 at 1:23 PM V29 (Orthopedic Physician) was interviewed and stated V29 saw R5 last month for a left knee fracture. V29 stated R5 was in the emergency room at an outside facility yesterday for acute onset of right knee pain. V29 stated the right knee findings are a new injury occurred after the 6/20/2024 injury. Policy titled Change in Resident's Condition or Status with no date stated in part: Policy: It is the policy of the facility to ensure the resident's attending physician or representative are notified of changes in the resident's condition or status. Procedure: 1. The nurse will notify the resident's attending physician when: Bullet number 1: The resident is involved in any accident or incident results in injury including injuries of unknown origin. Bullet number 3: There is a significant change in the resident's physical, mental or psychological status. 2. Unless otherwise instructed by the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: Bullet number 1: The resident is involved in any accident or incident results in an injury including injuries of unknown origin. Bullet number 3: There is a significant change in the resident's physical, mental or psychosocial status. Policy titled Outside Community Pass Privileges Policy revised 11/2014 stated in part: Policy: Facility emphasizes the safety of all residents, visitors and staff .Many individuals admitted to the facility have a medical need requiring clinical supervision. Procedure: b. Bullet point two: Yellow Pass: Residents who may go out in the community with a responsible party. Policy titled Standard Supervision and Monitoring dated 5/17/2023 stated in part: Purpose: This guideline emphasizes a proactive intervention promoting enhanced physical and psychosocial well-being. The facility recognizes supervision and guidance to the resident is an essential part of nursing care in which standard approaches are successful in meeting the resident's physical and psychosocial needs. Policy titles Incidents/Accidents/Falls with no date stated in part: Policy: It is the policy of the facility to ensure any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge .The facility will ensure incidents and accidents occur involving residents are identified, reported, investigated and resolved. Procedure: 1. If a resident is involved in an incident/accident an immediate assessment of the resident will be completed by the nurse. 4. The nurse will notify the resident's attending physician, nurse practitioner, director of nursing, administration and the resident's responsible party. 7.The occurrence will be documented (usually in the Risk Management section of the electronic health record). The progress note within the resident's medical record is to be included. Documentation in the medical record should include the following: Description of the occurrence to include time and place, physical and mental status of the resident, time of physician notification and physician response/orders, time of notification of resident's family/representative-including all attempts made until successful. 10. The occurrence is to be communicated shift to shift as part of the report until the resident is stabilize. 44103 On 7/10/24 at 1:05 PM, surveyor interviewed R2. R2 stated that R2 and R1 had a fight on 6/24/24 at around 1:00 PM. R2 stated, [R1] walked up to me from the elevator aggressively. I felt threatened so I scooped [R1] up from his legs and slammed [R1] on the floor then I landed on top of him. I accidentally stood up from my wheelchair when I grabbed [R1]. It had bad impact on my right foot. They sent me to the hospital for psych eval but my right foot kept hurting. The hospital didn't do anything because I was just there for psych. I came back to the facility, and I kept complaining to the nurses that my right foot was hurting. They kept ignoring me. I don't remember who the nurses were. I told a lot of nurses. What I did was I wrapped it because it hurts. Then finally [V10 Licensed Practical Nurse] listened to me and [V10's] the one that made the appointment for my right foot for the X-ray. It was a week that I was hurting. It's healing now but I was hurting for a week. I didn't hurt my foot anywhere or bumped it anywhere only that time with [R1] when I stood up and picked [R1] up and slammed him on the floor. I was not supposed to stand up but out of anger I did so I hurt my foot. On 7/10/24 at 9:49 AM, a phone interview conducted V10 (Licensed Practical Nurse). V10 stated that V10 witnessed R1 and R2 in the first-floor hallway on the floor grabbing each other and fighting. At 1:46 PM, a second phone interview conducted with V10. V10 stated that V10 saw R2's right foot wrapped with an All-Cotton Elastic (ACE) wrap on 6/28/24. V10 asked R2 what happened and R2 said R2's right foot was hurting. When V10 assessed R2's right foot, it looked swollen. V10 stated that V10 informed V25 (Physician) and ordered an X-ray of the right foot. On 7/10/24 at 2:03 PM, interviewed V14 (Certified Nursing Assistant). V14 stated that R2's right foot looked swollen and red right after the incident that happened with R1. V14 stated that R2 could not stand up. V14 stated that R2 used to stand up on his own before, but after the altercation with R1, R2 could not stand up anymore. V14 stated that R2 told [V4 Licensed Practical Nurse] that R2's right foot was hurting. On 7/10/24 AT 2:36 PM, interviewed V4 (Licensed Practical Nurse) and stated that after the altercation with R1, R2 complained of pain on R2's right foot because R2 stood up and R2 was not supposed to stand up. V4 stated that V4 administered R2's pain medication on 6/27/24, but no documentation that V25 was notified of R2's right foot pain and no documentation that it was assessed. On 7/10/24 at 6:38 PM, a phone interview conducted with V25 (Physician). V25 stated if a resident is having a new complaint of pain, the expectation is for the nurses to assess the resident and provide complete information and description of the resident's pain to the resident's healthcare provider. V25 stated that depending on the location of the pain for example if it's a bone, an X-ray would be ordered. V25 stated that if there was a visible injury or looks like possibility of injury or fracture X-ray is ordered. V25 stated that healthcare providers rely on the nurses to assess and notify the providers of the residents' condition so that providers can address and provide orders appropriately. Surveyor asked V25 what the meaning of R2's X-ray result of New healing subacute fracture distal 4th metatarsal. V25 stated it means the fracture is some time ago because healing cannot occur a day or two after the fracture. V25 stated after a day or two, the swelling might not be seen in the first few hours or even after a day. On 7/11/24 at 11:35 AM, interviewed V2 (Director of Nursing) and V1 (Administrator). V2 stated that after the altercation with R1, R2 went to Psychiatric hospital and was assessed for behaviors. V2 stated Psychiatric hospital does not do X-rays and only addresses behavioral issues. V2 stated the facility did not receive R2's discharge summary report from the psychiatric hospital. V2 stated that V2 expects the nurses to assess and call the doctor if any resident has new onset of pain. V1 stated that any staff can report the residents complains of pain to the nurses and the expectation is for the nurse to assess and notify the doctor. R2's clinical records show an initial admitted [DATE]. R2's Minimum Data Set (MDS) dated [DATE] shows R2 is cognitively intact. R2's Sit to stand functional abilities in the MDS was answered, Not attempted due to medical or safety concerns and R2 uses a manual wheelchair. R2's pain care plan interventions read in part, Assess physical as well as, psychosomatic reasons for the pain. Recognize that psychosomatic pain may cause physical distress. Explore possible causal factors for pain and Notify MD for any new resident complaints of pain and/or S/S of pain to obtain new order for medication regimen or break-through pain management. R2's psychiatric hospital records dated 6/24/24 shows R2's assessment was aggressive behavior and right foot injury. R2's progress notes dated 6/24/24 to 6/27/24 do not show that V25 (Physician) was notified of R2's right foot pain and no documentation on a follow up related to R2's right foot injury. R2's progress notes dated 6/24/24 at 9:45 PM written by V32 (Registered Nurse) revealed that R2 came back from psychiatric hospital with no discharge paper. No documentation if facility did any follow up of R2's assessments from the psychiatric hospital. R2's progress notes revealed R2 received pain medications on 6/25/24 at 8:06 PM, 6/26/24 at 8:03 PM, and 6/27/24 at 12:29 PM, but no documentation of where the pain was and no documentation of notification to R2's healthcare provider. R2's electronic health records do now show a clinical pain assessment was completed from 6/24/24 to 6/28/24. R2's X-Ray result dated 6/30/24 shows New healing subacute fracture distal right 4th metatarsal. Correlate clinically. Soft tissue swelling. R2's hospital records dated 7/1/24 History of Present Illness (HPI) reads in part, R2 is a [AGE] year old presenting to the emergency department who presented with complaints of right foot pain. [R2] says that [R2] was involved in an altercation about 1 week ago. [R2] said that [R2] had foot pain at the time. [R2] is currently using his wheelchair because [R2] has an injury in the past and [R2] is in a nursing facility because of that. The patient endorses pain of the right foot but denies any numbness or tingling.

Based on observation, interview and record review, facility failed to ensure a resident (R3) with history of unsafe and self-harmful behaviors was supervised and monitored while in the day room. This failure affected one resident (R3) out of a sample of three residents resulting in R3 sustaining a nasal fracture. Findings: On 7/9/2024 at 10 AM, R3's Electronic Health Record was reviewed. R3's diagnoses with onset of 4/8/2024 included schizoaffective disorder, depressive type, autistic disorder, gastroesophageal reflux disease without esophagitis, pain in left shoulder, delirium due to known physiological condition, weakness and other abnormalities of gait and mobility. R3's additional diagnosis with onset date of 6/19/2024 was fracture of the nasal bones. R3's Care Plan included the following areas of focus: paranoia, suicidal ideation, rummaging, severe mental illness, history of physically aggressive behavior towards nursing staff, unsafe behavior, mood distress, agitation, cognitive loss, maladaptive behavior symptoms, history of self-harmful behavior, psychosocial well-being. R3's Minimum Data Set Section C dated 4/15/2024 documents a Brief Interview for Mental Status (BIMS) score of six. On 7/9/2024 at 10 AM, R3's facial bone x-ray report was reviewed. Impression was a very subtle fracture lucency with irregularity along distal tip of the nasal spine. No acute osseous findings. On 7/9/2024 at 1:15 PM R3 was observed to have a pea-size discoloration to the corner of R3's right eye. R3 was unable to state name. R3 provided verbal tones, but no words. On 7/9/2024 at 3:28 PM V2 (Director of Nursing) stated that on 6/17/2024, staff said R3 was observed hitting himself in the face in the dining room. On 6/19/2024 it was noticed he had discoloration to his facial area. V28 (Licensed Practical Nurse) noticed the discoloration, called the doctor and the doctor ordered x-rays to the facial area. X-rays were completed and showed a fracture of the nasal bridge area. V2 stated, There were no other incidents around this time would have created the fracture. V2 stated, V30 (Certified Nurse Aide) was in the dining room when this happened when R3 started hitting himself. V30 called for help which is when V27 went in to the dining room. On 7/11/2024 at 9:43 AM V10 (Nurse) stated, I worked with R3 on 6/19/2024 and sent him to the hospital. I got report we were monitoring him and laying eyes on him and documenting his actions. It was a safety precaution for himself and the other residents. There was an incident prior to day. V10 stated, There was yellow bruising to R3's eye which is why we were monitoring him. There was an incident where R3 was found in the dining room hitting himself. I am not sure if anyone was with him. is what was endorsed to me. He became agitated in the dining room and was hitting himself. I can't recall specific date happened. It was before 6/19 because I came in at 7 AM he was already being monitored. On 7/11/2024 at 9:13 PM V30 (Certified Nurse Aide) was interviewed and stated, I found R3 in the day room by himself. R3 was scratching his face. I went immediately to R3 and held his arm and called V27 for help. V30 stated, It was last month, but I don't remember the date or the day of the week. I was not assigned to R3 day. I just saw R3 in the day room. On 7/11/2024 at 9:15 PM V27 (Licensed Practical Nurse) stated, I don't remember the date. I remember I was coming off the elevator and V30 called me and said R3 was banging himself on his face. I called the nurse and stayed with R3. The nurse gave R3 a medication. V27 stated, R3 was aggressive on day. R3 was trying to punch himself and trying to move the table. The only thing I saw was R3 punching his face. V27 stated, I looked at R3's face, but I didn't see anything. The next day, a nurse told me to look at his face and I noticed yellow and redness to his face. The other nurse called the doctor and got an order for the x-ray. On 7/12/2024 at 8:35 AM V28 (Licensed Practical Nurse) stated, Back in June, R3 was noted to have discoloration to his face. It was a light-yellow discoloration under the eye and around the nose on the left side of the face. It was super faint. The doctor ordered x-rays. R3 doesn't voice too much pain. We just have to observe him. When I noticed the discoloration, I don't recall if he was on monitoring like every 15-minute checks. We are constantly monitoring him though because of his behavior. In general, R3 has psych issues. He can't express himself. He expresses himself through body languages. Watching him is hard because of staffing. We try to check on R3 as frequently as possible. On 7/12/2024 at 11:33 AM, V2 (Director of Nursing) stated the day R3 hit his face was 6/17/2024. V2 stated, R3 was being supervised. He was in the dining room. Staff were with him. V30 (Certified Nurse Aide) was present when R3 started to hit himself. On 7/12/2024 at 2:47 PM, outside facility records were reviewed. History or Present Illness dated 6/20/2024 at 5;16 AM stated: Sent from nursing home because of self-injurious behavior. Has been striking his head against the wall. Lakeview Nursing Observation Sheet documented 15-minute checks on R3 were initiated at 6:30 PM on 6/17/2024. Review of Electronic Medical Record entry by V2 (Director of Nursing) dated 6/17/2024 at 22:56 as a late entry stated in part: Writer was contacted resident was observed on the unit hitting himself in facial areas while in supervised dining area. 6/19/2024 eInteract Transfer form completed 19:22 stated, Wondering into other resident rooms combative. Not easily directed, self-harming hitting self in the face. 6/24/2024 Admission/Readmission Alterations in Skin Integrity completed at 21:03 - No alterations in skin integrity documented. Policy titled Change in Resident's Condition or Status with no date stated in part: Policy: It is the policy of the facility to ensure the resident's attending physician or representative are notified of changes in the resident's condition or status. Procedure: 1. The nurse will notify the resident's attending physician when: Bullet number 1: The resident is involved in any accident or incident results in injury including injuries of unknown origin. Bullet number 3: There is a significant change in the resident's physical, mental or psychological status. 2. Unless otherwise instructed by the resident (if the resident is alert and oriented and their own representative) the nurse will notify the resident's representative when: Bullet number 1: The resident is involved in any accident or incident results in an injury including injuries of unknown origin. Bullet number 3: There is a significant change in the resident's physical, mental or psychosocial status. Policy titled Guidelines for Handling and Addressing Behavioral Emergencies dated 3/18/2023 stated in part: 1. the first step involves recognizing and handling behavior in the earliest stages: A. Assess whether the anger/acting out is related to mental illness, dementia or other probable and perhaps transient factors. 2. The Escalating Resident A. Staff need to be aware of how likely a resident is to lose control and exhibit a behavior- especially a behavior will escalate-this comes from knowledge obtained on resident assessment as well as care plan. 1.The duration of 1:1 supervision or every fifteen minute checks will be based on each individual/resident.

Based on interviews and records review, the facility failed to conduct an ongoing assessment of one resident (R4) following an incident, out of 3 residents reviewed for improper nursing care. This failure resulted in a delay in care for R4, who sustained a left femur fracture, causing R4 to suffer pain level of 10 out of 10 and not receiving care for the fracture until being sent to the hospital on 9/30/23. Findings include: On 11/14/23 at 09:50 AM, R7 stated, It wasn't like a big sound; it was more like R4 slid in slow motion to the floor. It was not a hard fall. R4 has fallen before. I called the nurse (R7's room is right in front of the nursing station). They came right in. I don't remember their names. I think it was an agency nurse and a Certified Nurse Assistant (CNA). They pulled R4 up and put her in bed. R4 was yelling my leg, my leg in Spanish. I called R16 (CNA)to translate. R16 is the one who said R4 was saying my leg in Spanish. R4 was sitting in the floor because I could see her legs and her shoulder. I saw her leg, there was nothing there, there was no visible injury at that time. I put the sheet on her. I saw her leg and there was no visible bruise or anything there. I think it was evening. The niece (V43) came in the next day and uncovered R4's leg and it was black and blue and swollen. I think she slid out of bed. The fall was on the west side of the bed. V45 (nurse) didn't know about the fall; apparently the nurse (V46) did not write it in the chart. V45 was worried V45 was getting in trouble because nobody wrote down as an accident. We have a lot of agency people. On 11/14/23 at 10:20 AM, R8 (R4's roommate) said R4 fell and had just come out of the hospital. R8 said, I heard when she (R4) fell . She was laying down in the floor. R7 called the nurse to help R4. R4 wasn't yelling. On 11/14/23 at 12:31 pm, V43 (R4's Power of Attorney/niece) stated, (R4) fell on [DATE]th, Friday night. It was after dinner because the roommate, R7 told me. R7 said she heard the fall. I went to visit R4 just to make sure everything was okay with her. I arrived there on 9/30/23 around 3:30 pm and it was a normal visit. No one had called me. I found R4 distressed, she was showing pain in her facial expression, she was grimacing, about to cry, and she was saying that she was in pain 10 out of 10. R4 said in a shaky voice that she had fallen last night. When I asked where, she showed her knee, and it was black. I told V45 (Nurse) and he said, no, she didn't fall, and that no one had reported it. V45 continued denying the fall. 'I said look at her knee!' Several people, including Certified Nursing Assistant (CNA), said they thought it was strange that R4 hadn't gotten up that day and wasn't in the dining room for breakfast and lunch. Someone said R4 complained of pain, and they gave her Tylenol, but I don't think they checked why she was in pain. The case manager, V25, came after I talked to V45. V45 called V39 (nurse coordinator) and V25 (case manager). V25 went to see R4, they couldn't believe R4 had fallen that bad and hadn't been reported. They called the ambulance, which I waited for 6 hours. When R4 arrived at the hospital, she had not been treated for a femur fracture for 24 hours. When I arrived, her leg (R4) was swollen, and she smelled like urine. After I made a big deal, everyone was there. The CNA was changing her. I helped them change R4 and noticed her feces was dry and stuck to her butt. The urine was already dry on the bed. I don't know, but this wasn't her first fall. R4 had fallen several times, I know that. Every time she fell , they called me, so I was surprised when she fell , and they didn't call me. On 11/14/23 at 01:53 pm V17 (nurse consultant) stated, In case of fall we have to do neuro checks and observation for 72 hours after the fall. Since we have 12 hours shift, it should be twice a day, every 12 hours, and as needed. We must stay with resident. The nurse should do the assessment, check if there is no injury or pain that it is a concern. The nurse should move the resident up off the floor with the Hoyer lift. If there is a concern of injury, we are not moving the resident and should let the doctor know and transfer to ER per MD orders. The assessment should include a skin check, range of motion, pain, neuro checks. We would ask the resident to move the extremities, see if the resident is in the base line. If there is any pain indication, such as touching their limbs, grimacing or showing any other signs of pain. The assessment should be one time initially, neuro check should be 72 hours and the range motion checking while you're doing the neuro checks. As needed, we should check if the resident is complaining of pain or you see anything that is abnormal. We should check based on that. If a fall happened after dinner time, we should check again the next day morning. Neuro checking should be every time 30 minutes for a certain time and then, after 12 hours. We also check the range motion since you are there, you want to access your resident, see if there is any change of the baseline assessment. I believe they are doing the neuro checks on paper. Obviously, there should be progress notes. For a fall there is a document on the portal. A risk management is different for fall risk assessment form. It tells you what happened and what and actions taken, if there any statement, family notification, we put it in there. We did report it to the State agency. If someone is in the floor, they need to report to lets us know so you can guide them. The CNA should report to the nurse, the nurse report to the doctor. At minimum the nurse assesses the resident and let the family knows and call the doctor. What I do know is that we observed a skin alteration and swollen of R4's leg and she was having pain. We sent her to the hospital for evaluation since she had an injury. The resident herself (R4) said she had fallen. I believe she said to the family in the day she was sent out. That is the day she said to staff. Maybe she thought she fell , and it was a misinterpretation is what the staff told us is in the risk manager report. Surveyor asked to whom R4 verbalized she had fallen, V17 said, I don't know could be the niece, but she verbalized in general, she had a fall. I don't know if she is falling risk. There should be a fall risk form completed, care plan and intervention should put in place. On 11/15/23 at 11:39 am V17 said, We found out about the incident on 9/30/23, the day of the incident report was filled out. The incident report is our investigation. The incident report contains the name of the nurse who was at the facility when the incident happened. On 11/15/23 at 12:12 PM V34 (CNA) stated, The nurse asked me to help her pull the resident. The bed was flat. R4 was lying at the bottom of the bed. I'm not sure who helped before. When I got there R4 wasn't on the floor, she was lying at the foot of the bed. We grabbed the chucks (disposable pads) and slid her up. The resident was saying dolor and she was kind of holding her leg, I said to the nurse I think she is saying she is in pain. The nurse said I already have pain meds for her. I'm pretty sure it was around 9:50-10pm because I had done my work and was available and that's why I helped the nurse. I was not the CNA for R4. V18 was the CNA assigned to R4. The only thing I noticed she was holding her leg and saying dolor. R4 is easy going and never complains. R4 is not one of those people who yells. Once I saw her saying pain out loud and she was trying to get my attention (V34 then demonstrates with body language how R4 was trying to get her attention by touching V34 in his arms), so I knew that she was in pain. I told the nurse what she meant by 'dolor' because I don't think the nurse understood. I spoke to V39 almost a week later. That happened on Friday, and I think I came back Tuesday. V39 asked me what happened. V39 asked if I remember coming into the room because they checked the cameras. I told them that the nurse had asked for general help and I told V39 what I saw. On 11/15/23 at 2:22 pm, V25 (Social Services) stated, As I recall, the POA (V43) was there and had reported to staff in general, that R4 was in pain and her leg was swollen and bruised. V39 was there and we both noticed that R4 had a bruise on her knee. They (nurses) were giving her pain meds. I saw a big bruise on her knee and they (nurses) were doing everything they have to do to send her to the hospital. When I saw R4 she was in kind of pain. If there is any family concern, we (social services) got involved. That's why they called me. I spoke to V43 and let her know we would send R4 to the hospital and update her on any changes. On 11/17/23 at 12:06 V39 (Nurse Coordinator) stated, At the time I was made aware is the time I charted. V24 (RN) came to get me, but V45 (RN) was the nurse in charge of R4. V24 told me they wanted me to look at R4, to assess R4. They did not say R4 had a fall. I looked in R4's leg. R4's leg was swelling, warm and bruised. I initiated an investigation to see what may have caused the injury. I notified management and I interviewed staff that were working that day and went back to see who was working the day before. They told me R4 did not fall, that she was not complaining any pain and they didn't observe her in the floor. The staff notified me because R4's leg was swelling. I don't know how the staff learned about the swelling. The niece maybe told them. All this information is in the incident report. The incident report form is the investigation. I don't remember, the exact date I reported to Illinois Department of Public Health (IDPH) but was in the frame which is in 24 hours When I saw R4 she was complaining of pain, and I called the NP and got an order for pain medication. The pain level R4 was presenting is the pain level documented in the pain assessment. I assume a bruise, and swelling is a type of injury. I wasn't sure what had cause it, not at the time. Based on the investigation, it was concluded that she potentially could had hurt herself when she is scooting or trying to sit on the side of the bed. She was not observed on the floor. I interviewed all the staff and they did not observe R4 on the floor. I also spoke with roommate who did not observe either. I spoke with the nurse from the previous shift (V46), and she said there was no fall and no need for documentation. I think the nurse had been repositioning R4 by herself the first time, and then called for assistance from another staff the second time. R4 had a knee replacement and femur, she has severe osteopenia. R4 did not fall. The reason of the delay in transfer R4 to hospital, would be the transportation. I have no control of that. I called for the ambulance. I don't remember the time. I think the nurse documented it. V39 stated regarding V39's expectation of what the nurse should have done or not done, I think the nurse (V46) did what was supposed to be done. The nurse ultimately assessed the resident for pain, and it there was no obvious sign, bruise or swelling. Ideally, the nurse should have written a note saying what she did. Because there is no observation the resident was in the floor, she did not document it. R4's progress notes reviewed and there is no documentation dated 09/29/23 in regarding any incident or R4's complaining of pain. Pain Review documentation dated 9/30/23 at 4 pm documents R4 was presenting pain 10/10 with pain documented 1-2 days, non-verbal pain scale showing hurts a whole lot, face expression, site lower left extremity/knee and saying the pain had initiated the day before and it was constant, and the pain last since the last night. The medication Administration Record (MAR) review shows no medication for pain was given to R4 on 09/29/23. MAR documents pain scale is documented as zero, no pain on 9/29 on both 12 hours shifts, and zero in the 12 hours (7 am -7pm) of the 9/30/23. V46 (nurse) documents pain zero on 9/29/23 second shift - no pain med given at any time. There is no pain medication recorded as given on 9/29/23 7 pm to 7 am PRN (as needed). MAR documents pain was documented on 9/30/23 on the second shift as level 6 (moderate) and acetaminophen was given on 9/30/23 at 20:47 pm. MAR documents pain medication (Norco) was given on 9/30/23 at 05:49 pm after facility made aware by R4's niece of R4's leg injury. Physician Order sheet shows order for Norco 10-325 mg one time for left knee dated 9/30/23 at 16:05 R4's progress note dated 10/1/23 at 05:24 am reads: Writer spoke with RN and was informed resident will be admitted for a traumatic femur fracture. NOD made aware. R4's progress note dated 10/1/23 at 08:49 AM signed by V 39 reads: Nurse Practitioner updated on resident's status, communicated resident admitted to IMMC with diagnosis traumatic femur fracture. Hospital records reads: R4 is an [AGE] year-old female with past medical history of dementia, hypertension who presents status post unwitnessed fall at nursing home. Per Emergency Medical Services (EMS), nursing home residents reported hearing patient yelling for help last night. Unclear from Nursing Home report whether pt fell . Power Of Attorney (POA)/patient's niece visited patient today and called EMS due to pt's complaint of headache and Left knee pain. Mental Status at baseline per POA. Impression and plan: Injuries: Left intra-articular distal femur fracture. Consults: Orthopedic Surgery Procedure: Left complex total knee arthroplasty with distal femoral replacement Exposure: Left knee swelling and ecchymoses; Physical exam: Musculoskeletal: Left knee swelling and ecchymoses, left thigh swelling. Left thigh compartments soft and compressible. Pre -op diagnosis: Left commuted distal femur fracture and left knee arthritis; Procedure: Left complex total knee arthroplasty with distal femoral replacement. Facility policy titled Incidents/Accidents/Falls reads Policy: It is the policy of the facility to ensure that any incident/accident to include falls is reported immediately to the nurse or appropriate person designated to be in charge. After the resident has had immediate attention and their safety is established, a written report will be entered into Risk Management (usually Risk Management section of pcc). The facility will ensure that incidents and accidents that occur involving residents are identified, reported, investigated, and resolved. The facility will create a data base related to incidents/accidents as part of the QAPI process to enable trending and tracking. This information will be used to implement corrective actions to include any needed training to prevent reoccurrences when possible. It will be part of the QAPI (Quality Assurance-monthly meeting) Agenda. Procedure: 3. The nurse responsible for the oversight and care of the resident will complete an incident/ accident report (usually Risk Management section of PCC). When possible, a descriptive statement(s) will be obtained from the resident and/or any witnesses, 6. The incident/accident report will be completed as soon as information is obtained. The report should be finished as much as possible before the nurse ends the shift. The nurse who completes the report is the nurse who signs the report. An exact description of the circumstances (not opinion or conjecture) surrounding the incident/accident are to be documented. 9. Documentation of the physical and mental status of the resident(s) involved will be completed each shift (every 8 hours minimally) over the next 72 hours or until the resident(s)'s condition improves. Neuro checks will be completed after any head trauma as well as after any unwitnessed fall (even if the resident states they did not hit their head) as per policy. 10. The occurrence is to be communicated shift to shift as part of the report until the resident is stabilize.

Based on observation, interview, and record review the facility failed to 1.) provide appropriate staff assistance to transfer one resident (R2) of three residents reviewed for falls. This failure resulted in R2 sustaining a right ankle fracture and a fracture of right distal tibia. 2.) The facility failed to follow fall care plan interventions and provide appropriate assistance for a resident (R1) with multiple history of falls; and failed to properly transfer a resident (R1) back to bed after a fall. These failures resulted in R1 sustaining a hip fracture. Findings include: 1. R2 was admitted to the facility on [DATE] with diagnosis including but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, acute embolism, and thrombosis of unspecified deep veins of lower extremity, bilateral, lack of coordination, paralytic gait, unspecified abnormalities of gait and mobility, history of falling, and generalized muscle weakness. R2's care plan dated 04/01/22 documents in part R2 is at risk for falls as evidenced by history of Cerebrovascular Accident with hemiplegia/hemiparesis, generalized weakness, incontinence of bladder and bowel, paralytic gait, and anxiety with intervention to utilize two person assist transfers with (total body mechanical lift) and provide support to legs as needed during transfer. R2's care plan dated 06/21/22 documents in part R2 has been assessed for transfer self-performance and support and needs and requires mechanical lift assistance with two staff members to operate a (total body mechanical lift) to complete the transfer and intervention includes R2 will be transferred with a two person transfer when using a (total body mechanical lift). Fall Risk Review dated 02/14/23 documents R2's score at 15, Fall Risk Review dated 04/02/23 documents R2's score at 13. Fall Risk Review form documents that a score of 10 or above represents high risk. Restorative Nursing Review assessment dated [DATE] document in part R2 requires total dependence with transfer with two+ persons physical assist using (total body mechanical lift). R2's fall report dated 06/21/23 completed by V26 (Agency LPN) documents, V26 called to room by staff and observed resident on the floor, assessed resident, has no open wounds or bruising noted, vitals within normal limits and staff assisted resident to bed, called the doctor for x-ray order. Witnesses listed as V25 (Certified Nursing Assistant) who provide the following statement, (R2) was scheduled for a shower and was transferring him (R2) from the bed to the shower chair. He (R2) became unsteady and was lowered to the floor. V16 (Housekeeper) document the following statement, I was moving on to clean the next room and I heard a loud noise, I opened the door and observed resident (R2) on the floor. R2's nurse progress notes dated 06/21/23 by V26 (Agency Licensed Practical Nurse) documents in part, Writer called to room by staff and observed resident on the floor connected to the (total body mechanical) lift machine. Resident assessed by writer and accompanying staff. Resident has no open wounds or bruising noted resident vitals are within normal limits. Writer called the doctor for x-ray orders. Writer gave resident pain medication. Resident says his pain is at a ten. R2's nurse progress note dated 06/22/23 by V30 (Registered Nurse) documents in part, V30 received call from portable diagnostic company regarding abnormal x-ray results. V28 (R2's Nurse Practitioner) notified with order to send resident to hospital. R2's Radiology report dated 06/22/23 completed at the facility documents in part acute nondisplaced transverse fracture of the distal right tibia. Acute fracture of the lateral malleolus was slight interior and lateral displacement of the distal fracture fragment. R2's hospital records of CT (Computed Tomography) Lower Extremity on 06/22/23 documents in part impression mildly displaced lateral malleolus fracture, and nondisplaced and/or minimally displaced distal tibial fractures. R2's MDS (Minimum Data Set) dated 07/03/23 indicates R2 has intact cognition and requires extensive assistance with two+ persons physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. On 07/25/23 at 11:27 AM, R2 was lying in bed with right leg in cast. R2 stated, V25 (CNA) came into R2's room on the day R2 fell with the total body mechanical lift and said V25 was going to give R2 a shower. R2 stated V25 was alone, there were no other staff in the room. R2 stated usually when the staff bring the lift into R2's room they come in with two CNAs. R2 stated that R2 asked V25, Aren't you supposed to have another person with you when you do this? R2 stated V25 responded, No, I know what I'm going. R2 stated, V25 got R2 up into the Hoyer machine but V25 kept turning the top where the straps hook and R2 could tell it was twisted. R2 stated V25 was alone, there was no other staff in the room during this time and V25 was operating the total body mechanical lift on her own. R2 stated the next thing R2 realized is R2 was falling onto the floor and the rest of the total body mechanical lift just collapsed right on top of R2. R2 stated, I hit the floor hard. R2 stated V25 just stood there like a deer in headlights. On 07/26/23 at 8:18 AM, V1 (Interim Director of Nursing) stated a resident being transferred using a total body mechanical lift requires two staff members to be present during the transfer. V1 stated two staff are always required for safety to prevent the resident from falling. V1 stated R2 requires a total body mechanical lift with two people assist for all transfers. V1 stated on 06/21/23, R2 was being transferred from the bed to the shower chair using the total body mechanical lift and that V25 (CNA) was the only staff member in the room with R2. V1 stated there should have been two staff members in the room when V25 was transferring R2. V1 stated if two staff members were in the room there is a possibility the resident could have been eased to the floor and prevented the injury. On 07/26/23 at 8:46, V16 (Housekeeper) stated V16 was in the next room next to R2's doing V16's daily cleaning routine when V16 heard a big heavy thump sound from R2's room. R2 stated R2 went right away to R2 room, opened R2's door and saw R2 lying on the floor. V16 stated there was only R2 and R2's CNA (V25) in R2's room. V16 stated there was no other staff in the room and that V25 was standing over R2 who was lying on the floor. On 07/26/23 at 1:45 PM, V8 (Restorative Director) stated R2 needs to be transferred via total mechanical lift with two staff members. V8 stated V8 was working on the unit the day of R2's fall but did not witness the fall. V8 stated V8 interviewed V25 that day as part of the post fall investigation and stated V25 told V8 that V25 was by herself in the room with R2 during the time of the fall. V8 stated V25 was transferring R2 so V25 could give R2 a shower. V8 stated V8 worked the floor that day and V25 did not come to V8 or any of the other CNAs to ask for help to transfer R2. On 07/26/23 at 2:50 PM, V28 (R3's Nurse Practitioner) stated R2 has contractures, is immobile and bed bound. V28 stated R2 is dependent on total body mechanical lift for transfers and there should always be two staff members when R2 is transferred. V28 was notified by the facility on 06/21/23 that R2 had sustained a fall and x-rays were ordered. V28 stated on 06/22/23 R2 was sent to the hospital due to x-ray results which showed acute right ankle distal fracture of tibia and fibula. V28 stated having only one staff present when R2 was being transferred in the mechanical lift could have contributed to R2 falling and that there should have been two staff present. On 07/27/23 at 9:45 AM, V7 (CNA) stated V7 was working on the unit the day of R2's fall. V7 stated V25 did not ask V7 to help when transferring R2. On 07/27/23 at 9:56 AM, V31 (CNA) stated via phone interview that V31 was working on the unit the day of R2's fall. V31 stated V25 did not ask V31 to assist V25 with transferring R2 on that day. On 07/27/23 at 10:08 AM, V44 (CNA) stated via phone interview that V44 was working on the unit the day of R2's fall. V44 stated V25 did not ask V44 to help transfer R3 that day. On 07/27/23 at 12:11 PM, V25 (CNA) stated via phone interview, This is not a good time for me. I don't want to talk about that incident. I already wrote a statement with respect to the fall. I don't want to talk to you. Attempts to contact V26 (Agency LPN) via phone at the following dates/times: 07/26/23, 8:59 AM, 07/26/23, 12:02 PM, 07/27/23, 12:13 PM were unsuccessful. V26's voicemail box not set up to leave messages. On 07/27/23 at 12:16 PM, V1 stated V1 took V25's statement because V1 was in the building when R2's fall happened. V1 stated V25 told V1 that V25 was the only staff in the room at that time of R2's fall. V1 stated V1 has texted V26 three times to request V26 to call the facility to talk to surveyor and can see that V26 read the text messages but V26 never responded. Facility policy and procedure titled, Mechanical Lift Transfer (Full Size/Hoyer Type Lift) dated 10/10/11 documents in part the purpose is to assure that all residents that are assessed to require extensive assistance high (with minimal to no ability to bear weight of bilateral lower extremities and/or total assistance in transfer are transferred safely with no injury to resident or care handler and the operating of the lift requires a minimum of two trained operators. 44103 2. R1's Fall incident report dated 6/17/23 at 5:14 PM shows R1 was observed on the floor leaning to R1's left side, with R1's wheelchair behind R1. Prior to the incident R1 was sitting in the hallway in R1's wheelchair. R1's Fall incident report dated 5/27/23 shows at approximately 10:00 PM, R1 was observed on the floor on a sitting position and leaning to the right side (location not indicated). Prior to incident R1 was sitting in the hallway in R1's wheelchair after refusing to go to bed. R1's clinical records show R1 had a multiple history of unwitnessed falls on 4/1/23 and 4/10/23. R1's Minimum Data Set (MDS) dated [DATE] shows R1 had severe cognitive impairment and required extensive two staff assistance for transfer and locomotion off unit. R1's MDS dated [DATE] shows R1 had severe cognitive impairment, required extensive two staff assistance for transfer, and required extensive one person assist for locomotion on and off unit. One of R1's fall care plan interventions initiated on 5/27/23 reads, When out of bed have resident supervised in common area, engage as able. Offer resident color activities. R1's comprehensive care plan also shows R1 has a self-care deficit with interventions initiated on 3/22/22 to provide extensive assistance with one person support for locomotion on unit with wheelchair. On 7/25/23 at 3:50PM, a phone interview conducted with V18 (Agency Licensed Practical Nurse) regarding R1's 5/27/23 fall. V18 stated V18 was the nurse in charge for R1. V18 stated nobody saw how R1 fell , and it was around 8:00 PM to 10:00 PM. V18 stated before the fall, R1 was sitting in the wheelchair in the hallway because R1 refused to go to bed. V18 stated V18 was passing medication and did not witness how R1 fell . V18 stated V18 was made aware that R1 fell , V18 went in the room and found R1 sitting on the floor. On 7/27/23 at 10:23 AM, a phone interview conducted with V20 (Nurse) regarding R1's fall on 5/27/23. V20 stated, Actually, I was not the nurse, but I was coming from the elevator, and I heard someone screaming for help. The nurse was passing meds in the hallway. I went in the room and I found [R1] on the floor. [R1] was sitting on the floor by the wheelchair. V20 stated V20 is not sure how R1 got inside other resident's room. V20 stated R1 knew how to get around in R1's wheelchair. V20 stated V19 was assigned to R1 and was doing patient care with another resident and also did not witness how R1 fell . V20 stated R1 had no injuries and did not complain of pain. On 7/27/23 at 12:09 PM, during phone interview conducted with V19 stated, V19 does not remember R1's fall on 5/27/23. R1's Fall incident report dated 6/22/23 at 12:15 PM documented by V15 (Agency Licensed Practical Nurse) shows R1 had an unwitnessed fall in R1's room, was found lying on the floor attempting to walk while holding onto the bedside table. R1's hospital records dated 6/23/23 shows R1 sustained a left hip fracture. On 7/25/23 at 12:06 PM, V8 (Restorative Director) stated on 6/22/23 around a little after noon, V8 heard a loud noise and immediately went in R1's room with V41 (Former Assistant Director of Nursing). V8 stated R1 was found in the bathroom sitting on the floor with R1's head against the wall by the grip bar and the bedside table was flipped over on top of R1's waist. V8 stated R1 kept saying R1 had pain on R1's head. V8 stated V8 and V41 moved the bedside table, brought the wheelchair in the bathroom, lifted R1's arms and legs and sat R1 on the chair to put R1 back to bed. V8 stated R1 kept holding R1's head. V8 stated V15 (Agency Licensed Practical Nurse) assessed R1 and called the doctor On 7/26/23 at 7:09 AM, a phone interview with V19 (Certified Nursing Assistant/CNA). V19 stated R1 had fallen several times and at the time of R1's fall on 6/17/23, V19 was on the 3rd floor nurses' station doing something in the computer. V19 stated that R1 was in the hallway in front of R1's room. V19 stated that no one saw R1 when R1 fell . V19 stated V19 was not watching R1 because V19's back was turned away from R1. V19 stated R1 was not assigned to any one-on-one staff supervision. V19 stated R1 had gotten up off the chair, V19 heard the noise, and found R1 on the floor by the door of the nurses' station. V19 stated V19 yelled for help, and everybody came to assist R1. On 7/26/23 at 10:13 AM, a phone interview conducted with V7 (Certified Nursing Assistant) for R1's 6/17 fall. V7 stated it was before dinner R1 was sitting in the hallway. V7 was in another room with a different resident. V7 stated that 15-20 minutes before R1 fell , V7 locked R1's wheelchair and placed R1 in the hallway a few feet from R1's room. V7 stated V7 heard a noise, and someone yelled that someone fell . V7 stated V7 came out the room and saw R1 on the floor by the nurses' station. V7 stated when R1 was in the hallway R1 would just sit there. On 7/27/23 at 9:30 AM, V17 (Licensed Practical Nurse) stated when R1 fell on [DATE], V17 was doing medication pass in another resident's room. V17 stated V17 heard V19 said something that R1 was on the floor. V17 stated V17 did not see how R1 fell . V17 stated R1 did not sustain any injuries. V17 stated V17 walked past R1 approximately 10 minutes before R1 fell , and R1 was sitting in the wheelchair in the hallway by the nurses' station. V17 stated R1 was calm at that time. V17 stated V17 is not sure who was watching R1 when R1 was in the hallway. V17 stated, With [R1] age we have to watch [R1]. At 1:55 PM, V1 (Interim Director of Nursing) stated, If a resident has fallen on the floor after the nurse has does an assessment the resident would be transferred from the floor to the bed or from the floor to the wheelchair using a [Mechanical] lift with 2 staff members regardless if the resident requires using a [Mechanical] lift or not before the fall. If their limbs are out of alinement or if the resident is complaining of neck pain, the nurses would not move the resident from the floor and would call 911. The facility's policy titled; Fall Prevention Protocol dated 8/03/17 reads in part: Risk Assessment III. Fall Prevention B. Implement individualized approaches/interventions based upon resident risk V. Care plan A. Interdisciplinary care plan is implemented for residents at risk and may include 1. Interventions to prevent falls The facility's policy titled; Post Fall Management Protocol dated 8/03/17 reads in part: I. Post fall physical assessment A. If fracture or head injury is suspected, DO NOT MOVE resident and advise resident not to move affected area; complete assessment.

Based on observation, interview, and record review, facility failed to follow their policy to ensure fall prevention interventions in the care plan are updated and followed for 1 (R1) out of 3 residents reviewed for accident and prevention. This failure led to R1 falling and hitting her head against the wall twice in a month where both falls resulted in a subdermal hematoma in her head. Findings include: On 05/16/2023 at 11:00 AM, surveyor observed R1 sitting in wheelchair in the dining room. R1 stood up by herself and pushed her wheelchair back. CNA helped R1 to sit back down. On 05/17/2023 at 10:07 AM, surveyor observed R1 sleeping in her bed with no supervision. On 05/16/2023 at 12:10 PM, V3 (Restorative Director) stated, that V3 is the falls coordinator and that she updates the care plan. V3 stated she is familiar with R1. Fall risk assessment are done quarterly, annually, at admissions and after a fall. After the assessments are done the fall risk care plan are done. V3 stated that R1 has had two falls. V3 stated that any time a resident falls, she updates the care plan with the date of the fall and any updated interventions. V3 stated, Today R1 was irritated, she is pushing herself around, and there is no telling what she might do. She (R1) needs to have eyes on her at all times. For R1's fall on April 10th, 2023, we did the incident report on 04/12/2023. She fell at 6:10 PM. R1 was in bed and in an upright position. At 6:10, R1 was found in the bathroom on the floor with her head against the floor. When she (R1) fell , it was an unwitnessed fall. V3 stated R1 was unable to state what happened. V3 stated, R1 was sent to hospital when the Doctor ordered R1 to be sent out to the hospital and that's where they found the (R1's) hematoma. V3 stated. So, when she (R1) fell she was by herself. At that time, we didn't have anyone watching her (R1). All falls can be prevented. After the fall on 04/01/2023 we put her on 1 on 1. One on one intervention is not added in the care plan. We were going to put it in there but the interdisciplinary team decided not to because we don't have the staff for it. On 05/16/2023 at 1:28 PM, V2 (Director of Nursing) stated, upon admission there is a nursing assessment form, skin and body check, baseline care plan, fall risk assessment. Whoever does the fall risk assessment, determines whether the resident is a high fall risk or a moderate fall risk. V2 stated, If it is not documented, then it is not done. We can't put someone on 1 to 1 supervision all the time because we do not have the staff for it. But we started frequently monitoring R1. The intervention we added after her first fall on 02/2023 was taking her to bathroom before meals because we noticed a pattern that she wound tend to get up right when she is about to eat. R1 was placed 1 on 1 after her second fall on 04/01/2023 for a short while and once we continued to notice a pattern that she would get up around meal times we enforced the intervention of taking her to the bathroom right when the food got to her and after she eats. That 1 on 1 intervention was never added on R1's care plan. I want someone to always keep an eye. I don't know if it is documented that V8 (Agency Certified Nursing Assistant) toileted R1 on 04/10/2023 when she got her dinner meal tray. 05/17/2023 at 1:15 PM, V7 (Registered Nurse) stated she was the nurse for R1 when R1 fell on [DATE] in the bathroom. V7 stated that she checked on R1 at 5:00 pm and at 6:00 PM she heard a big sound in her (R1's) room. When V7 and a CNA ran in there, they found R1 laying on the bathroom floor with her head against the wall. V7 stated V6 was the CNA who gave R1 her dinner tray on 04/10/2023 prior to her fall. On 05/17/2023 at 1:30 PM, V4 (R1's primary doctor) stated, most falls will be prevented if staff are checking on the residents frequently and seeing if there is a pattern when resident is getting up out of wheelchair or bed. Interventions such as going to the bathroom before or after meals can help prevent falls. Interventions in care plan are to be followed. On 05/18/2023 at 11:40 AM, surveyor observed R1 laying in her bed. Surveyor also observed V7 (Registered Nurse) sitting at the 3rd floor nurse station with her back to R1's room talking on the phone through her Bluetooth headphones. Surveyor also noticed a call light going off on the 3rd floor with no nurses attending to the call light. On 05/18/2023 at 12:52 PM, surveyor observed R1 eating lunch on her bed in her room. V9 (3rd floor Certified Nursing Assistant) stated that she is R1's CNA for today. V9 stated the last time she took R1 to the bathroom was this morning and not when her lunch was brought up. Reviewed R1's falls record: 1. Fall on 2/8/2023 2. Fall on 4/1/2023 resulted in hematoma to the head, evidenced by CT 3. Fall on 4/10/2023 led to hematoma in the head, evidenced by CT. R1's hospital record on 4/1/2023 documents in part: CT scan findings - complex acute on subacute left sided subdural hematoma measuring up to approximately 2.2 cm. R1's hospital record on 04/10/2023 documents in part: CT of head: CT findings - Left cerebral convexity acute on chronic subdural hematoma measuring up to 1.6 cm. 4 mm rightward midline shift. 2. Small acute subdural hematoma over the right posterior temporal lobe measures 3 mm in maximal thickness. CT of the head shows acute on chronic subdural hematoma with small amount of midline shift. Discharge instructions - Patient will require 24/7 supervision at discharge. Patient would benefit from subacute rehab. Facility's final investigation report for R1's fall on 4/10/2023 documents in part: Statement from V7 stated she saw resident at approximately 5:00 PM and resident was in bed with no complaints. At approximately 6:10 PM, R1 was noted on the floor in her bathroom. She was unable to verbalize what happened. Statement from V8 (Agency certified nursing assistant) states, I toileted R1 approximately 2 hours before her dinner. Conclusion: R1 was transferred to an acute care setting for further evaluation post fall and was admitted for subdural hematoma. R1 returned to the facility on [DATE] with no changes to plan of care. R1's care plan documents in part: On 2/8/2023, R1 placed on toileting program with focus on toileting before meals. offer assistance with toileting before lunch. Added 4/1/23, when patient in bed monitor for positioning and ensure patient in center in bed for comfort. Added 4/10/23, place resident on toileting program with focus on toileting before meals. No new interventions documented. R1's progress notes by V7 (4/10/2023) documents in part: At 6.10pm the resident was observed in the bathroom in a sitting position with head against the wall. Resident unable to state what happened or when the incident occurred. Physical assessment completed. Immediate fall intervention of mat was initiated and put into place. V10 (R1's Nurse Practitioner) covering for V4 (R1's PCP) notified. New orders to transfer residents to outside hospital received. R1's progress note on 4/1/2023 documents in part: Prior to the fall writer assisted resident back to bed approximately two minutes before fall occurred. Patient confirms hitting her head. Order received to transfer resident to outside hospital for CT-scan. R1's MDS Section C (3/3/2023) documents in part: R1's BIMS score is 5. R1 is not cognitively intact. R1's MDS section G (3/3/2023) documents in part: R1 needs oversight, supervision and cuing when eating. R1 is also an extensive assist for transfer and walking. R1 requires two person assist for transfer and walking. Facility's fall policy (undated) documents in part: All falls will have a site investigation by appropriate staff in an effort to define the root cause of the fall. This will help provide information to enable staff to roll out interventions to prevent another similar occurrence. Each fall needs a new intervention rolled out. Based on the results of the fall, the resident' care plan will be addressed to ensure that any needed points of focus have measurable goals with appropriate interventions in place.

Based on observation, interview, and record review, the facility failed to follow their policy to administer anti-[CONDITION(S)] medications according to physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R1 having a [CONDITION(S)] and a fall with a serious head injury. Findings include: R1's Facility Investigation Report (7/17/2022) documents in part: A full investigation was completed including a review of the resident's medical record, care plan and interviews with staff. Plausible cause determined as resident was observed in the room shaking and unresponsive during an unwitnessed fall with a laceration to the back of the head. R1 was transferred to hospital and later returned with 6 staples to the back of his (R1) head. Approximately two hours after the return, R1 experienced an additional episode of shaking and unresponsiveness and transferred back to the hospital. V7's (Certified Nursing Assistant) statement form for the Facility Reported Investigation (7/17/2022) documents in part: I (V7) was making my rounds when I heard a loud sound and I observed R1 on the floor and I called the nurse. On 08/23/2022 at 11:00 AM, surveyor observed R1 laying on his bed low position, call light within reach and floor mats on the floor. There were no padded side rails. R1 stated that the floor mats were not there when he (R1) fell . He (R1) stated that he (R1) is not able to walk on his (R1) own. They put him (R1) on the side of the bed where they give him (R1) time to pivot to the chair. R1 stated that sometimes they are late giving him (R1) medications. They have missed giving him (R1) medications one time as he (R1) can remember. On 08/23/2022 at 11:05 AM, R2 stated that, some nurses have missed medications. Sometimes I don't receive my medications at night. I have complained to the state about nurses missing my medications. At one time, I had to go to the hospital because my blood pressure was so high because nurses didn't give me my blood pressure medications. On 08/23/2022 at 12:05 PM, V2 (Interim Director of Nursing) stated he (V2) had sent in a reportable for the fall of R1. V2 stated has was an Interim DON at Lakeview Rehab for a couple of weeks. V2 was not present at the time of the incident. The report was that the nurse noted an open area to the back of his (R1) head after he (R1) had fallen, and the nurse had to send him to the hospital via 911. R1 then returned with staples to the back of his head. The expectation is for nurses to administer medications by following the physician orders by administering the correct medications, correct dose, correct route, correct time, and correct patient. In an occasion a medication is ordered to prevent certain symptoms, if the medications is not appropriately administered then adverse reactions can occur. On 08/23/2022 at 12:55 PM, V3 (R1's Primary Care Physician) stated that depending on [CONDITION(S)] medication we don't do medication blood levels. V3 stated, I (V3) don't usually test [MEDICATION(S)] levels because it is not a level related medication. We adjust the dose based on if he (R1) has a [CONDITION(S)] based on the current dose and then increase it if he has a [CONDITION(S)]. Usually if [MEDICATION(S)] is continued 5-6 days, it is less likely of him (R1) to have a [CONDITION(S)]. If medications are missed, then adverse reactions can take place. Fall can cause [CONDITION(S)] to precipitate. Once you have injury your risk of risk of [CONDITION(S)] becomes higher. The fall is definitely a factor to the [CONDITION(S)]. On 08/23/2022 at 1:11 PM V4 (Registered Nurse) is familiar with R1 on the night that he (R1) fell . When she (V4) came on shift, she (V4) received report that he (R1) was sent out to the hospital after he (R1) fell . Then he (R1) came back that night and we received him (R1) with staples on the back of his (R1) head due to fresh wound. He (R1) was able to communicate and oriented. V4 stated (V4) did the neuro check on him (R1) with vital signs, then placed call lights within reach and he (R1) was not in any distress. R1 is weak and unsteady on his (R1) feet. He (R1) is not allowed to ambulate by himself (R1). We heard a noise and saw him (R1) on the floor having seizures. We stayed with him (R1), monitored him (R1), and then placed him (R1) on the bed using the Hoyer lift and made him (R1) comfortable. Immediately after that he (R1) had another [CONDITION(S)]. If the [CONDITION(S)] comes back to back then that was a concern to me (V4) to send him to the hospital. The CNA had to monitor him 1:1 closely because he (R1) keeps getting up. V4 stated the facility is expected to give him the anti-[CONDITION(S)] medication every day. If the [CONDITION(S)] medications are not administered every day, the level would be low in his (R1) and that would trigger a [CONDITION(S)]. On 08/23/2022 at 1:36 PM, V5 (Registered Nurse) stated she is expected to administer every scheduled [CONDITION(S)] medication. She (V5) stated that she does do lab draws to monitor the effectiveness of the of the medications. She (V5) stated she does do lab draws on [MEDICATION(S)] medications. If [MEDICATION(S)] medications are not administered regularly the resident's [MEDICATION(S)] levels will drop and they can have multiple seizures. On 08/23/2022 at 1:40 PM, V6 (Director of Nursing) stated that the ordered medications are administered at the proper time and sign off on the medications within a prescribed time frame. The prescribed time frame is an hour before and an hour after. If a Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . As ordered by the physician, we do lab draws to monitor the effectiveness of the medication. To prevent a fall, we remind him (R1) to stay in bed, with bed in low position. If he (R1) was someone who was a high risk for fall and someone who was constantly getting up, I would have brought him (R1) out to the nurse's station and watched him (R1) over there. When he (R1) came back from the hospital, he (R1) was placed on 1:1 supervision. Seizures could be from head trauma and/or it could be from missed medications. On 08/23/2022 at 2:00 PM, V1 (Administrator) stated no one was supervising R1 before he (R1) fell . He (V1) stated according to his (V1) knowledge no one brought R1 out to the nurse's station to watch him (R1). R1's progress note (7/17/2022) documents in part: Resident was in room with bed in lowest position call light and urinal in reach. Writer heard a thump while at the nurses station. Proceeded to see what happened. Resident was observed on the floor near door. Residents head was bleeding no other injury noted. Open area to back of head cleansed with normal saline solution and pressure dressing applied. Resident was able to stand and was assisted by writer and CNA back to bed. Head to toe assessment and neuro checks completed. site was cleaned and dressing was applied. MD/NP, ADON made aware. Reviewed R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] not administered on 6/16/2022 and 6/26/2022. Reviewed R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] not administered on 7/03/2022, 7/04/2022, 7/6/2022, 7/7/2022, and 7/11/2022. R1's hospital record after fall (7/18/2022) documents in part: In the floor R1 evaluated with EEG and [MEDICATION(S)] levels were found to be therapeutic. R2's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] ER tablet not administered on 7/4/2022, 7/7/2022, 7/11/2022, 7/17/2022, 7/18/2022. R1's care plan documents in part: Medication levels as ordered by MD. Administer medications as directed and follow pharmaceutical recommendations. Ambulatory: I'm non-ambulatory. I require extensive assistance and 1 person support for Locomotion on unit with wheelchair. Facility's Medication Administration Policy documents in part: Purpose: to ensure that resident medications are administered in a timely manner and documentation is completed to substantiate administration. Licensed professional nurses administer medications according to times documented on Medication Administration Record. Medication administration pass may begin sixty minutes before the scheduled times of administration but may not exceed sixty minutes after the scheduled time of administration. Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The reason for not administering the medication will be documented on the back of the Medication Administration Record.

Based on observation, interview and record review, the facility failed to ensure that staff followed the facility's fall protocol for two (R1, R4) residents reviewed for falls. This failure resulted in R1 sustaining a 4 cm frontal hematoma with mild abrasion and transferred to local trauma hospital. Findings include: 1) R1's Admission Record documents, in part, R1's diagnoses of [CONDITION(S)] and [CONDITION(S)] following cerebral infarction affecting left non-dominant side, [CONDITION(S)], altered mental status, cognitive communication deficit and lack of coordination. R1's Minimum Data Set (MDS), dated [DATE], documents, in part, that R1's Brief Interview for Mental Status (BIMS) score is a 4 which indicates that R1 has severe cognitive impairment. R1's MDS (9/6/21) documents, in part, for Functional Status for Activities of Daily Living (ADL) Assistance that R1's Bed Mobility - How resident moves to and from lying position, turns side to side, and positions body while in bed for Self-Performance is coded as Extensive Assistance and for Support is coded as Two + (plus) persons physical assist. R1's Functional Limitation in Range of Motion for Upper Extremity is coded as Impairment on one side, and Lower Extremity is coded as Impairment on both sides. On 7/5/22 at 2:34 pm, V3 (Former Licensed Practical Nurse, LPN) stated that V3 recalled R1's fall from the bed on 10/20/21 at approximately 5:00 am. V3 stated that V4 (Former Certified Nursing Assistant, CNA) physically came to the nurse's station where V3 was located and informed V3 of R1's fall from the bed. V3 stated that both V3 and V4 then went back to R1's room. When asked when V3 entered R1's room after being notified by V4 about R1's fall, which other staff members were in R1's room, V3 stated, Just the CNA (V4). V3 stated, V4 told V3 that V4 turned R1 in bed, and R1 fell out of the bed. V3 stated that R1's bed was open on both sides where staff can perform care (not up against the wall on one side), and that R1 fell off the bed to the floor closer to the outside wall of the room. V3 stated that V3 did a full body assessment and observed R1 with a forehead hematoma and that R1 complained of pain. When asked about R1's injury and size of R1's forehead hematoma, V3 stated, It (hematoma) must have been visible if I (V3) saw it. V3 stated, (V3) I remember what (R1) told me: '(R1) fell off'. V3 stated, (R1) was verbal. I (V3) remember (R1) spoke to V19 (R1's Family Member) on the phone after the fall. V3 stated that V3 notified V27 (Nurse Practitioner, NP) who ordered for R1 to be sent to the local hospital for evaluation. When V3 was asked about V3's documentation in R1's EMR (Electronic Medical Record) about the ambulance routing R1 to a trauma hospital, V3 stated, If I (V3) wrote it, it is what happened. In R1's Incident Note, dated 10/20/21 at 4:57 am, V3 documented, in part, (V3) called by (V4) that (R1) in on the floor. Per (V4), (R1) fell when (R1) was turned over to be changed. Per (R1), 'I (R1) fell off.' Full body assessment done, bump noted to (R1's) forehead . (R1) complained of pain 5/10 (5 out of 10 pain scale) . MD (V27, NP) notified with order to send (R1) to (local hospital emergency room ) for evaluation . 5:22 am: (V19) made aware and was able to speak to (R1). In R1's Nursing Progress Note, dated 10/20/21 at 8:41 am, V3 documented, Per (Ambulance Company), (R1) was transferred to (trauma hospital). On 7/6/22 at 2:32 pm, V19 (R1's Family Member) was interviewed and stated that V19 was informed by V3 of R1's fall from the bed in the facility on 10/20/21 at approximately 6:00 am and that V19 requested to speak with R1. V19 stated that the facility staff have always brought an intercom or speaker phone into R1's room to allow R1 to speak to V19 since R1 is unable to hold the telephone with R1's right hand, and R1's left side is paralyzed. V19 stated that R1 was saying to V19 over the phone, I (R1) told (V4) that I (R1) was falling. And (V4) was saying 'I (V4) got you (R1). I (V4) got you (R1).' Then (V4) dropped me (R1) on the floor. On 7/6/22 at 1:03 pm, V6 (Former Director of Nursing, DON) stated that V6 was the DON of the facility on 10/20/21 and remembered R1. V6 stated that V6 was notified on 10/20/21 by V3 (Former LPN) about R1's fall, but that V6 could not recall any details of R1's fall. After this surveyor read to V6 the incident note authored by V3 on 10/20/21 at 4:57 am, V6 stated, That information, what you (surveyor) just said is what I (V6) was made aware. V6 stated that per the facility's fall protocol, the nurse will complete an incident report after a resident fall, and any interviews (statements) from the staff members present during the fall will be typed into the incident report. When asked if V4 (Former CNA) received an in-service about proper turning and bed mobility after R1's fall on 10/20/21, V6 stated, Yes. In R1's Fall Incident Report, dated 10/20/21, V6 documented, in part, Notes: IDT (Interdisciplinary Team) met to discuss (R1's) fall . Conclusion: (R1) was being changed by (V4). (V4) turned (R1) to (R1's) side and while cleaning (R1), (R1) rolled of (off) the bed . (V4) returned demonstration training. In R1's Fall Incident Report, dated 10/20/21, V3 documented, in part, Injuries Observed at Time of Incident: Injury Type: Other. Injury Location: Forehead . Witnesses: Name: (V4). Date: 10/20/21. Statement: While changing (R1). (R1) was turned to the side, my hand never left (R1) body. During this time, I (V4) felt (R1) slipping and I (V4) tried to catch (R1) but was unable to completely break (R1's) fall. I (V4) alerted (V3) for help. Name: (V3). Date: 10/20/21. Statement: Per (V3), I (V3) was at the nursing station when (V4) alerted me (V3). I (V3) then got up and went to assist (R1). On 7/6/22 at 1:25 pm, V17 (CNA) stated that V17 remembers caring for R1 as a CNA while R1 resided in the facility. V17 stated that V17 would get another staff member to assist with turning R1 in bed for incontinence care because (R1) was not really able to maintain his body alignment. V17 stated, If a CNA does (turning in bed) with one person then that can worsen the situation. Some residents don't turn at all, and they don't understand how to turn. That's why I (V17) need the help of another. The other CNA will be on one side and hold them (the resident) and so I (V17) can give care. On 7/7/22 at 11:53 am, when V25 (Covering Physician) was asked where a resident should be positioned in the bed during care, like R1 with [CONDITION(S)], paralysis on R1's left side, as an extensive assist, V25 stated, Resident should be positioned nearest the middle of the bed for safety. When asked if a resident like R1 who is coded as a two-person assist is being turned in bed for nursing care with only one staff, what is the likelihood that the resident could experience injury from a fall from the bed, V25 stated, Well ideally, the railing should be up. There should not be a fall. This is a standard of care. This is for safety. In R1's trauma hospital records, on 10/20/21 at 8:39 am, V30 (Emergency Hospital Physician) documented, in part, Chief complaint: Trauma, s/p (status post) fall . Per EMS (Emergency Medical Services), (R1) was getting rolled and changed at nursing home when (R1) fell off the bed and hit (R1's) head . Exam: . 4 cm frontal hematoma with mild abrasion. In R1's trauma hospital records, on 10/23/21 at 7:54 am, V29 (Hospital Physician) documented, in part, that on 10/20/21, R1 presented to ED (Emergency Department) as a trauma activation s/p mechanical fall at NH (Nursing Home). Per EMS, the NH staff were rolling (R1). (R1) got rolled too far and fell off the bed. R1's Fall Risk Care Plan, dated 8/28/21, documents, in part, a problem statement of (R1) is at risk for falls R/T (related to): Cognitive Impairments, Communication Impairments, Decreased Safety Awareness . Requires ADL assistance for Transfers and Mobility, Impaired Range of Motion and/or Loss of functional Movement of joints, Incontinence, Decreased Strength and Endurance, DX (Diagnosis): [CONDITION(S)] (Cerebral Vascular Accident) with possible [CONDITION(S)] or [CONDITION(S)] with approaches/interventions listed as Anticipate and meet needs with an added intervention on 10/20/21 (after R1's fall) as Assessment for siderails. R1's Restorative Nursing Care Plan, dated 9/6/21, documents, in part, a problem as (R1) have been assessed for my bed mobility self-performance needs and support and (R1) require the following assistance: (R1) will be designated as 'Extensive Assistance' with '2 staff member(s)' with R1's goal as (R1) will receive my current bed mobility needs assistance and will maintain my current level of function with no avoidable decline in bed mobility abilities. R1's Restorative Program Care Plan, dated 9/6/21, documents, in part, a problem statement of Self-Care Deficit: Requires Extensive to Total Staff Assist with ADL's d/t (due to) contributing diagnosis: [CONDITION(S)] and [CONDITION(S)] following Cerebral Infarction affecting left non-dominant side, Dysphagia, Unspecified Convulsions, [CONDITION(S)], Altered Mental Status with approaches/interventions listed as Provide set up for task such as bathing, dressing, grooming, oral care. In R1's Occupational Therapy Evaluation and Plan of Treatment, dated 8/30/21 at 10:31 am, V22 (Occupational Therapist Registered, OTR) documented, in part, Initial Assessment: . Functional Skills Assessment - Mobility During ADLs: Bed Mobility - Prep for ADLs: Bed Mobility = Max/2 (Maximum Assist with 2 Persons Assist); Rolling = Max/2 . Functional Mobility During ADLs = Max/2 . Risk Factors: Due to the documented physical impairments and associated functional deficits, (R1) is at risk for falls. R1's Fall Risk Review, dated 8/28/21, documents, in part, a fall risk category for R1 as High Risk for Falls. R1's Order Review Report, dated October 2021, was reviewed with no orders for side rails. Per this surveyor's request for R1's assessment for bed side rails, V1 (Administrator) emailed that V1 was not able to locate a bed rail assessment for R1. In this surveyor's review of R1's EMR for a bed rail assessment, a message was noted and highlighted in red, 313 days overdue: 8/28/21 Side Rail Review (Nursing). R1's Census List, documents, in part, that R1 was admitted to the facility on [DATE] and was discharged from the facility on 10/20/21. 2) R4's Admission Record documents, in part, R4's diagnoses of [CONDITION(S)] disease, [CONDITION(S)], vascular dementia with behavioral disturbance, lack of coordination, and weakness. R4's MDS, dated [DATE], documents, in part, that R4's BIMS score is a 6 which indicates that R4 has severe cognitive impairment. R4's MDS (6/1/22) documents, in part, for Functional Status for ADL Assistance that R4's Bed Mobility - How resident moves to and from lying position, turns side to side, and positions body while in bed for Self-Performance is coded as Extensive Assistance and for Support is coded as Two + persons physical assist. R4's Functional Limitation in Range of Motion for Upper Extremity is coded as Impairment on both sides, and Lower Extremity is coded as Impairment on both sides. On 7/6/22 at 9:31 am, this surveyor observed only V10 (Agency CNA) turning and holding R4's body to the side while applying a clean incontinence brief. V10 then rolled R4 flat on R4's back and straightened out R4's flat sheet under R4 in the bed. R4's bed height is elevated from the floor while V10 was standing on top of R4's elevated floor mat on left side of the bed. On 7/6/22 at 9:33 am, V10 stated that V10 will get some help to pull R4 up in the bed. While R4's bed height is in the highest position from the floor, V10 physically walks out of R4's room, through the nurse's station to the opposite hallway and returns with V28 (CNA). V10 and V28 (standing on both sides of R4's bed which remains high) then use R4's flat sheet and pull up R4's body in bed. On 7/6/22 at 9:38 am, V10 (Agency CNA) stated that since R4 is contracted and has a low air mattress, there's no pad (draw sheet) underneath R4 so V10 needed help pulling R4 up in the bed. When asked V10 about staff assistance for bed mobility with R1, V10 stated that V10 turned R4 by V10's self in bed. On 7/6/22 at 9:41 am, When V11 (CNA Supervisor) was asked about fall precautions relating to a resident's height of their bed, V11 stated that CNAs are to put the bed all the way down in the lowest position and should not be left up with no staff in the room. V11 stated that if staff leave the bed height elevated with no staff present in the room, this could cause greater risk of injury from a fall. On 7/6/22 at 1:25 pm, V17 (CNA) stated that V17 is very familiar with R4's care. V17 stated that R4 is a high fall risk, keeps the floor mats in place, and maintain the lowest height of R4's bed after rendering care. On 7/5/22 at 12:25 pm, V15 (LPN) stated, (R4) leans when (R4's) in bed. (R4) will rock in bed until (R4) moves off the bed. V15 added that R4 is visually impaired. R4's Fall Risk Review, dated 6/29/22, documents, in part, a fall risk category for R4 as High Risk for Falls. R4's Care Plan, dated 3/31/22, documents, in part, a focus of (R4) at risk for falls as evidenced by the following risk factors and potential contributing diagnosis: Cognitive Impairment, Decreased Strength and Endurance, Diagnosis: H/O (history of) or S/P (status post) [CONDITION(S)] (Cerebral Vascular Accident) with [CONDITION(S)] or [CONDITION(S)], Heart Failure, Dementia, [CONDITION(S)], Depression, Lack of Coordination with an intervention of (R4) would like staff to provide me with . my bed in the lowest position. R4's Care Plan, dated 6/20/22, documents, in part, a focus of (R4) require extensive assistance x (times) 2 staff with bed mobility, transfer, dressing, toileting, personal hygiene, bathing with an intervention of Staff will assist me in positioning. R4's Care Plan, dated 3/21/22, documents, in part, a focus of (R4) have a 'Self Care Deficit' and (R4) require assistance with ADLs to maintain the highest possible level of functioning AEB (as evidenced by) the following limitations and potential contributing factors: [CONDITION(S)], [CONDITION(S)], Weakness, Lack of Coordination with an intervention of Provide assistance with all ADL's as required per the residents need dependence: . Bed Mobility. Facility document listing resident fall incidents from 5/1/22 to 7/5/22 includes two fall incidents for R4 on 5/3/22 and 6/29/22. Review of R4's Fall Incident Reports for 5/3/22 and 6/29/22 indicate that R4 had fallen from the bed. On 7/7/22 at 10:54 am, V2 (Interim DON) stated that fall precautions, the bed should be in the lowest position. V2 stated, Staff can raise the height of the bed while they are with the patient, but if they (staff) walk away, they must put the bed back in the lowest position for the resident's safety. When asked if staff are walking away from a resident in bed with the bed height in an elevated position, is there a greater possibility of a resident falling, and V2 stated, Yes. When V2 was asked about bed mobility during care, V2 stated that staff should align the resident's body in the middle of the bed for safety. V2 stated that when a resident is coded for a two person staff assistance for bed mobility, the resident wouldn't be able to provide but minimal assistance if any. When asked if a resident is coded for a two person staff assistance for bed mobility, is it your expectation that two staff members turn and reposition the resident in bed, and V2 stated, Yes. Facility policy dated 8/3/17 and titled Fall Prevention and Management, documents, in part: Fall Prevention Protocol: Risk Assessment: . III. Fall Prevention. A. Identify risk factors. B. Implement individualized approaches/interventions based upon resident risk . V. Care plan. A. Interdisciplinary care plan is implemented for residents at risk and may include: . 4. Supervision as appropriate. Facility policy, undated and titled Activities of Daily Living, document, in part, Policy: . ADL care is provided throughout the care planned and/or as needed . Assisting with movement . as indicated and care planned. Facility Job Description, undated and titled Certified Nursing Assistant, documents, in part: Position Summary: The Certified Nursing Assistant provides each assigned resident with routine daily nursing care and services in accordance with the resident's assessment and care plan . The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulation and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times . Essential Job Functions: . C. Role Responsibilities - Personal Nursing Care: . 3. Assists residents with bath functions (i. e. 'that is', bed bath .) as directed . 10. Position bedfast residents in correct and comfortable position . 19. Assists with lifting, turning, moving, positioning, and transporting residents into and out of beds . H. Roles Responsibilities - Safety: . 6. Follows established safety precautions in the performance of all duties. Facility Job Description, undated and titled Licensed Practical Nurse, documents, in part: Position Summary: The Licensed Practical Nurse provides direct nursing care to the residents and supervises the day-to-day nursing activities performed by nursing assistants. The person holding this position is delegated the administrative authority, responsibility, and accountability for carrying out the assigned duties and responsibilities in accordance with current existing federal and state regulation and established company policies and procedures to ensure that the highest degree of quality care is maintained at all times.

Based on observation, interview and record review the facility failed to follow policy on treatment documentation per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Facility failures includes lack of monitoring when R1's sacral pressure injury was first identified already as Stage 3. And for lack of performing treatments as ordered by physician that resulted to R1's sacral pressure injury worsening from Stage 3 to Stage 4. Findings include: Facility's policy on Wound Cleansing and Dressings reads: It is the policy of this facility to cleanse all wounds to clear exudates, bacterial contamination, and debris from the wound bed. Optimal wound healing cannot proceed until inflammation producing substances are removed from the wound bed. Wound cleaning is completed as indicated in the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional documentation may be completed in the nurse's notes. R1's care plan on wound was documented that resident (R1) intervention for sacral wound treatment was to provide treatment as order by Medical Doctor (MD). Per weekly wound evaluation: R1 has pressure injury on the sacrum that was facility acquired and was first identified on 1/28/2022 as Stage 3. As documented on 1/28/2022 R1's sacral pressure injury was staged as a 3. Measurement was as follows: Length 3.0 centimeters, Width 1.0 centimeter and Depth 0.0. On 2/5/2022 R1's sacral pressure injury was still stage as 3. Measurement was as follows: Length 1.2 centimeters, Width 1 centimeter and 0.4 centimeter. On 2/17/2022 R1's sacral pressure injury was increased to stage 4. Measurement was as follows: Length 2.5 centimeters, Width 1.6 centimeters and Depth 1.1 centimeters. Sacral pressure injury depth increased from 0 on 1/28/2022 to 0.4 centimeter on 2/5/2022 to 1.1 centimeters on 2/17/2022. There was an increased on R1's sacral pressure injury depth from 0.4 to 1.1 centimeters. On 3/2/2022 at 11:26 AM. V7 (Wound Care Nurse / Licensed Practical Nurse) stated, that when she assessed R1's sacral pressure injury it increased from stage 3 to stage 4 because the bone and muscle are exposed. V7 said, Yes, R1 has a pressure injury on her sacral, and it increase from stage 3 to stage 4 because during my assessment bone and muscle were exposed. I work weekdays only and during week end we did not have any treatment nurse before. Yes, there was no treatment nurse designated during weekend. But now the facility hired treatment nurse assigned for the weekend. But still nursing staff working on the floor must do the dressing when there is no treatment nurse. And dressing change or treatment should be signed by the nurse performing the treatment on the TAR (Treatment Administration Record). I know that if it is not documented, it means it is not done. And as I said, we don't have treatment nurse during weekend. In my notes I charted that R1's pressure injury on her sacral has an odor that is why I asked wound doctor for Daikins solution because it helps with the odor. On 3/2/2022 at 1:38 PM. R1 was seen in her room by writer with V7. R1 sacral pressure injury was seen with bone and muscle on the sacral area were visible that fits the definition of Stage 4 pressure injury. On 3/3/2022 at 10:08 AM. V2 (Director of Nursing) stated that in the event there is no wound care nurse on the floor it is the responsibility of the nurse that is working on the floor to do dressing change or treatment. And after each dressing change or treatment, TAR (Treatment Administration Record) must be signed or documented. Per R1's Wound Assessment: Sacral Pressure Injury was identified on 1/28/2022 with physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . No treatment was documented as done for the above order until 2/1/2022 or 5 days after R1's sacral pressure injury was identified. Then R1's sacral pressure injury was changed on 2/5/2022 to Calcium Alginate after cleansing with Dakins Solution per physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per R1's Nurse's Notes dated 2/22/2022 was documented by V7 reads: Noted odor from sacral pressure injury.

Based upon observation, interview and record review the facility failed to ensure that treatments were administered as ordered for three of four residents (R1, R4, R7) reviewed for pressure ulcers. Findings include; 1) R7's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R7's (10/8/21) BIMS (Brief Interview for Mental Status) determined a score of 15 (Cognitively Intact). R7's (10/8/21) functional status assessment affirms extensive assistance (2-person physical assist) is required for bed mobility. R7's 1/1/21 (pre-admission) wound evaluation includes a sacrum (stage 4) pressure injury measuring 13 x 15 x 5cm (centimeters). 40% granulation, 30% slough, and 30% necrotic tissue [bone exposure is not inclusive]. R7's (12/2/21) physician wound evaluation includes; stage 4 pressure wound (sacrum) >318 days. 4.3 x 4.5 x 0.5cm. Skin 10%, granulation tissue: 70% and 20% bone, dermis. This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of a biofilm. Surgical excisional debridement procedure: Debridement into a margin of healthy tissue is required to remove biofilm including the bacteria, senescent cells, and foreign material that are present and allow for wound healing. Curette was used to surgically excise biofilm from the entire wound surface. R7's (12/9/21) weekly wound evaluation also includes; (back) shearing 3.0 x 2.0 x 0cm. [Identified 7/6/21]. R7's (10/8/21) care plan states; resident requires assist with bed mobility, intervention: assist in turning and repositioning every two hours. R7's POS includes; (9/15/20) Back: Cleanse with NSS (Normal Saline Solution), apply, 'Medihoney' foam dry dressing (wound treatment dressing) every Tuesday-Thursday-Saturday and PRN (as needed). (12/16/21) Sacral: Cleanse with NSS, apply 'Iodosorb' (wound treatment), calcium alginate ABD pad, dry dressing daily and PRN. On 12/16/21 at 10:44am, surveyor inquired about R7's wounds V13 (Wound Care Coordinator) stated, She now has her sacrum stage 4 and a back shear from them sliding her. Her (R7) sacrum is quite stubborn, she (R7) has some exposed bone. On 12/16/21 at 2:24pm, R7 was lying in bed on her back, the surveyor inquired if she (R7) gets turned every 2 hours R7 responded I'm not sure. On 12/16/21 at 2:39pm, V13 (Wound Care Coordinator) removed a dressing from R7's mid back and a large, circular, (dark red) discoloration was observed near the spine. Surveyor inquired about concerns with the appearance of R7's skin V13 stated It's red. V13 removed the dressing from R7's sacrum the wound bed was dark red, and bone was exposed. R7's (November-December 2021) TAR's (Treatment Administration Records) include aforementioned treatments however the 11/9, 12/1, 12/7, 12/8 and 12/14 entries were blank. On 12/21/21 at 12:11pm, surveyor inquired how residents develop skin integrity impairments. V17 (Medical Director) stated Skin breakdown can happen from injuries, pressure, and multiple co-morbidities. Surveyor inquired about the required frequency for turning/repositioning residents. V17 responded. The rule is every 2 hours depending on the patient, like if they are bed bound and cannot move. Surveyor inquired about potential harm to a resident if treatments are not administered as ordered. V17 responded, If daily dressing with special material is not done, the wound can worsen. 2) R1 was admitted on [DATE] and discharged [DATE]. R1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's (10/1/21) BIMS determined a score of 14 (Severely Impaired). R1's (10/1/21) functional status assessment affirms extensive assistance (2-person physical assist) is required for bed mobility. R1's (10/1/21) care plan states; resident has alteration in skin integrity, interventions: pressure reducing mattress and wheelchair cushion. Reposition resident frequently when in bed. R1's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (9/22/21) Cleanse with NSS, apply [MEDICATION(S)], dry bandage, daily and PRN. (10/5/21) Cleanse with NSS, apply 'Santyl' (wound treatment ointment), calcium alginate, dry dressing daily and PRN. (10/12/21) Cleanse with NSS, apply [MEDICATION(S)], dry dressing daily and PRN. R1's weekly wound evaluations include; sacrum (stage 2) pressure injury (in-house acquired) measuring 2.5 x 1.5 x 0.1cm. 100% partial thickness. Identified 9/12/21. R1's (10/21/21) Physician wound evaluation includes; unstageable (due to necrosis) sacrum full thickness wound measuring 7.1 x 9.9 x 0.1. This wound is in an [CONDITION(S)] stage and is unable to progress to a healing phase because of the presence of biofilm. Surgical excisional debridement procedure; With clean surgical technique, 15 blade was used to surgically excise 42.17cm of devitalized tissue and necrotic subcutaneous fat and surrounding connective tissues along with slough and biofilm were removed at a depth of 0.1cm. R1's (September-October 2021) TAR includes aforementioned sacral treatments however the 9/24, 10/6, 10/9, 10/10, 10/11, 10/15, 10/16, 10/17, 10/21, 10/22, 10/23, and 10/24 entries are blank. On 12/21/21 at 11:50am, surveyor inquired where treatments are documented V13 (Wound Care Nurse) stated, When we perform the treatment, administration is in the TAR. Surveyor inquired what blank entries indicate on the TAR V13 responded Either the wound care nurse or the nurse on duty didn't sign it. Surveyor inquired if treatments are not documented on the TAR, can we assume that the treatment was done? V13 replied No we cannot. If it is not anything that is documented, it is not done. Surveyor inquired about R1's wound V13 stated She developed a stage 2, she ended up going to the hospital a few days after. It was something systemically going on with her and she had a poor appetite, so her skin broke down. When she returned to the facility it was then unstageable. Surveyor inquired about potential harm to R1 if treatments were not done daily as ordered. V13 responded Assuming that the dressings were not done daily, it leaves room for the wound to decline. 3) R4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's (9/6/21) BIMS determined a score of 14 (Cognitively Intact). R4's (9/6/21) functional status assessment affirms extensive assistance (2-person physical assist) is required for transfers. R4's (12/6/21) care plan includes; alteration in skin integrity MASD (Moisture Associated Skin Damage), interventions: skin will be checked during routine care. Any concern to be conveyed to charge nurse for interventions. R4's (11/25/21) POS includes; left medial thigh: cleanse with NSS, apply foam dry dressing daily and PRN. R4's (December 2021) TAR (Treatment Administration Record) affirms the 12/8 left medial thigh entry was blank. On 12/11, 12/12, and 12/13 9 (see nurse notes) is documented however the (12/11/21-12/13/21) progress notes affirm nothing was documented concerning R4's treatment. On 12/16/21 at 10:52am, surveyor requested to observe R4's dressing change V13 (Wound Care Coordinator) removed R4's incontinence brief and there was no dressing present. Surveyor inquired why R4 did not have a dressing in place V13 responded, That's an area that sees a lot of friction. So, it probably came off when they changed her last time. The (5/19/17) pressure injury prevention policy states residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. Support surfaces including pressure relief devices will be used as appropriate. Positioning devices will be used to keep bony prominences from direct contact with each other. Residents will be moved in a manner that limits friction and shearing forces.

Based on interview and record review, the facility failed to implement effective fall prevention interventions for one of three residents (R6), reviewed for falls. This failure resulted in R6 experiencing an unwitnessed fall and sustaining a right intertrochanteric femur fracture (hip fracture), requiring surgical intervention, and acute subarachnoid hemorrhage (bleeding in space between brain and surrounding membrane). Findings include: R6's medical record (Face Sheet) notes resident is an [AGE] year old admitted to the facility on 04.01.2021 with diagnoses including but not limited to: Cerebral Infarction, Dysphagia Following Cerebral Infarction, [CONDITION(S)] and [CONDITION(S)] Following Cerebral Infarction Affecting Right Dominant Side, Attention and Concentration Deficit Following Cerebral Infarction, Unspecified Abnormalities of Gait and Mobility, Unspecified Lack of Coordination and Weakness. MDS (Minimum Data Set, 4.8.21) documents severely cognitively impaired with worsening of current behavior symptoms. R6 requires extensive assist of two for bed mobility and transfer; is totally dependent with assist of one for locomotion on unit; only able to steady self with staff assistance when moving from seated to standing position/moving on and off toilet/surface-surface transfer (transfer between bed and chair). Resident has limited range of motion effecting both upper and lower extremities on both sides and is frequently incontinent of urine and stool. R6's Admission Fall Assessment (04.01.2021) documents R6 receives medication that affects awareness, judgement or safety; has altered level of consciousness that fluctuates; balance problem while standing/walking and history of stroke that places R6 at high risk for falls. R6's fall risk score was assessed as 16. Per document, a score of 10 or above represents high risk (for falls). Facility's Final Incident Report of 04.15.2021 documents R6 was observed on floor next to bathroom door, unable to recall how the fall occurred. Resident was sent to (local hospital) and admitted with right femur fracture and subarachnoid hemorrhage. R6's hospital record (04.09.2021-04.22.2021-Progress Notes) confirms R6 was admitted to the hospital after falling at the facility on 04.09.2021. Resident sustained a right intertrochanteric femur fracture (hip fracture) requiring surgical intervention and acute subarachnoid hemorrhage (bleeding in space between brain and surrounding membrane). 05.06.2021 at 2:32 PM, V10 (LPN-Licensed Practical Nurse) described R6 as a fall risk due to resident's unsteady gait and frequently getting up without staff assistance. V10 said, She (R6) wouldn't stay in bed. She got up at least 10 times during the shift. I tried to check on her every 15 to 30 minutes, but I had other things to do and couldn't always check on her. I told the staff to keep an eye on her, of course, we can't do that all the time. I told the CNA (Certified Nursing Assistant) to watch her. He was feeding another resident when she (R6) fell . He should have gone back after he was done feeding that resident. V10 was unable to tell this writer which CNA was instructed to supervise R6 or what fall prevention interventions were in place prior to R6's fall. V10 responded, I did not read the care plan, I was too busy that day. 05.06.2021 at 3:44 PM, V23 (CNA) said I never took care of her (R6) before. That was the first time I saw her. No one asked me to watch her. V15 (CNA) said to me, I was trying to avoid this all day (resident's fall), trying to prevent this from happening. She was taking care of R6. 05.06.2021 at 4:47 PM, V15 (CNA) denied taking care of R6. There was someone on the floor. I ddin't know it was her. I wasn't assigned to take care of her. 05.06.2021 at 6:02 PM, V22 (CNA) said, I don't remember anything. V20 (CNA) was not availble for interview. 05.07.2021 at 9:15 AM, V2 (Director of Nursing) said that she expects CNAs to follow nurses' directions. R6's Fall Risk care plan (dated 04.08.2021) documents R6 is at risk for falls related to: Cognitive Impairments, Decreased Safety Awareness, Requires ADL (Activities of Daily Living) assistance for Transfers and Mobility, Incontinence, Decreased Strength and Endurance and, diagnosis of CVA (Cerebral Vascular Accident) with possible [CONDITION(S)] or [CONDITION(S)]. Approaches/Interventions include: Call light within reach, encourage to use for assistance as needed; respond promptly to all requests for assistance. Anticipate and meet needs. The facility did not implement fall risk approaches/interventions. 05.07.2021 at 7:49 AM V21 (Family Member) said, They were one of the only facilities that would take (R6) because of her behavior. She wouldn't follow commands (instructions/directions). She had a sitter when she was in the hospital. She was tied down at the hospital (described wrist restraints) after they got rid of the sitter. R6's hospital record( Progress Notes 3.21.2021, 03.29.2021) document R6 required a sitter and restraints

Based on interview and record review, the facility failed to ensure that a resident is free from mental abuse for one of three residents (R1) reviewed for abuse. This failure resulted in R1 feeling ashamed and unsafe in the facility. Findings include: R1's Face Sheet documents R1 is [AGE] years old with [DIAGNOSES REDACTED]. R1's BIMS (Brief Interview for Mental Status) documents R1 is cognitively intact. On 01/06/2021 at 1:27 PM, R1 said It was sometime at the end of December. I was visiting R4. He (V8) came up on me real fast. He told me to get out of R4's room. V8 (CNA) said, I'm going to knock the black off your a**. On 01/07/2021 at 10:47 AM, R1 said,It made me feel .I was angry .he wanted me to respond when he walked up on me. He (V8) tried to intimidate me. I don't feel safe in the facility now. I feel ashamed. 01/06/2021 at 12:22 PM, R3 said, she overheard staff member (V8) being verbally abusive towards resident. R3's signed statement documents, I was in my room on a video chat with patient (R4). I heard patient R1 arguing with V8. I heard V8 threaten R1 saying I'll slap the black off your a**. On 01/07/2021 at 10:59 AM, R4 said, I was sitting in my wheelchair, on a video call with R3. She asked me to invite R1 into my room so that she could say hello to him. R1 came into my room. V8 told R1, you can't be in here when I'm going to do patient care. He (V8) chased him out of my room, R1 got irate with him (V8). V8 went into R1's room and threatened R1. V8 said I'm going to knock the black off your a**. On 01/07/2021 at 2:03 PM, V6 (Housekeeper) said, I took (R1) to his room. Four or five minutes later, R1 left his room and went into R4's room. (V8) was passing trays and said to R1, You better get your a** in that room. On 01/07/2021 at 1:05 PM, V1 (Administrator) I think it's going to be unfounded (abuse). I haven't spoken with him (V8, CNA) because I haven't had a chance to call him. I thought I would call him today. It's unfounded. I want to speak with him about his standing in the facility. If it was founded, I would have terminated him already. We haven't disciplined him yet. It's unfounded but there needs to be some resolution. I have to determine if he's going to be re-educated, re-assigned or terminated. I don't feel that I should do anything until I talk to him. The situation could have been better handled, he could have asked for help from staff. He shouldn't have raised his voice to the resident. Facility's final incident report of 01/04/2021 (for incident of 12/31/2020) documents, (R1) reported allegations of a staff member treating him inappropriately. Staff intervened immediately, separated and suspended staff member pending investigation. Thorough investigation was completed which involved interview of residents and staff. (R1) stated that staff member (V8, CNA) spoke with him inappropriately. Based on the findings of the investigation the facility will discipline (V8) per facility protocol. V1 submitted the final investigation to the Illinois Department of Public Health on 01/04/2021 without speaking with V8. V8 was terminated on 01/08/2021, 4 days after the final report was submitted Facility's Abuse Prevention Program policy and procedure (undated) notes, it is the policy of this facility to prohibit and prevent resident abuse.

Based on interview and record review, the facility failed to provide adequate supervision during meal time for 2 of 3 residents (R7 and R9) reviewed for assistance during meal time. This failure affected R7 and R9 and has the potential to affect all 32 residents identified as needing assistance during meal time. R7 has a [DIAGNOSES REDACTED]. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy was identified on 11/30/2020. While the immediacy was removed on 12/22/2020, the facility remains out of compliance at a severity level two. The facility continues to educate licensed staff, certified staff, and interdisciplinary team members on supervision and assistance of residents during meal time. Findings include: On 11/30/20 at approximately 11:13am, R9 was observed in his room seated in an electric wheel chair, R9 complained to the surveyor he was not receiving quality care. R9 stated he is dependent on staff's assistance with feeding during meal time and no one is helping him. R9 stated his restorative care was not being done. R7 was observed in bed across from R9. R7 stated, They (referring to nursing staff) don't help with setting up my tray, they just put it on the bedside table and I can't reach it. R8 or R29 help set me up and will help feed me if I need help. R9 stated the facility have been using agency staff who are not familiar with the necessary care he needs so they don't know what to do. R9 complained regarding the feeding issue several days in the last two weeks, the staff will leave the food tray on the bedside table. R9 stated that when R8 saw this R8 decided to help feed him (R9). R9 stated after R8 has finished feeding himself he will come and help in feeding him. R9 stated at times R29 will come to feed him because he was unable to use his fingers to grab the utensils on the food tray. Most times the necessary adaptive devices are not provided to aid in feeding. R9 stated the adaptive feeding devices are not placed on the tray. R9 stated he complained to V8 (Restorative Director) about it, V8 told him that there is nothing he can do about it because there is a strike going on. R8 stated that both R7 and R9 are not being cared for in a timely manner, R8 stated he had to feed them and at times perform incontinent care for R7. R8 stated both R7 and R9 are not getting restorative care. R8 stated in part the staff will place R7 and R9's food tray on their bed-side table and they will not come back to fed them. Review of video submitted anonymously shows R9 being fed by another resident R29. R29 is not trained in feeding techniques and is feeding R9 without staff supervision. On 12/1/20 at 11:50am, V8 (Restorative Nurse/ Director) stated, that restorative programs are provided by the CNA (Certified Nurse's Aide) assigned to each resident. V8 stated the CNA's are trained in performing the task involved in the restorative programs that includes but not limited to AROM active range of motion), PROM (passive range of motion), Eating and ADL's. When the surveyor asked V8 who monitors these tasks to ensure they are provided and done utilizing proper techniques, V8 replied V2 DON (Director of Nurses) and V5 ADON (Assistant Director of Nurses). On 12/1/20, V8 presented R7 and R9's Look Back Report on restorative program that shows that these tasks were not being done. AROM not done 11/28/20, 11/29/20, 11/30/20 and 12/1/20. No entry under bathing and assisting with eating from 11/16/20 to 12/1/20. When the surveyor asked what the entries on the report represented, V8 stated it's not being done, referring to R7 and R9 not receiving a bath, not being monitored/supervised during meal time, and not getting assistance to eat. V8 explained that R9 needs adaptive devices for holding utensils to feed himself partially. V8 stated one of the staff still need to assist him in picking up the residuals from the plate and in drinking from the cup or a milk carton. On 12/2/20 at approximately 12:56pm, R29 was noted during lunch time trying to wheel herself into R9's room asking R9 if he had eaten. When R29 saw the surveyor in the hallway by R7 and R9's room while the CNA (Certified Nurse's Aide) was feeding R9, R29 stated Hum, they are feeding him now. R8 and R29 then told the surveyor that R29 has been helping feed R9 every day, they both explained that the CNA's just place the food tray on the table and walk away when the surveyors are not in the facility. R8 stated at times it takes 40 minutes to 1 hour for the staff to come back into the room. R29 stated the nurses (referring to nurses and CNA's) don't come to feed R9. R9's facility tool used in assessing the residents MDS (Minimum Data Set) dated October 8, 2020 section G Self-Performance coded R9 as 3/2 for eating which shows that R9 needs extensive care with one person physical assistance. Under section G0400 for functional limitation R9 was coded 2 for upper extremities and 2 for lower extremities which showed that R9 has impairments on both sides that interferes with daily functioning or placed R9 at risk for injury. R9 BIMS (Brief Interview Mental Status) recorded as 15 indicating R9 is cognitively intact. On 12/3/2020 at approximately 1:15pm R8 stated, I feed him referring to R7 and sometimes him referring to R9, no one comes to feed them. They wait over one hour and a half for food. I make sure they eat. On 12/4/20 at 2:48pm, V22 (Speech Therapist) during interview stated she was working with R7. V22 stated R7 was complaining that he could not clear something out of his throat so a swallowing evaluation was done. V22 stated R7 has history of dysphagia. When the surveyor asked whether it is appropriate for another resident to feed R7 during meal time, V22 replied that's not in my field but I disagree with that (referring to residents feeding each other during meal time). On 12/4/20 at approximately 3:15pm, V45 (Physician) was interviewed, V45 stated R9 had a stroke history and it is a standard of practice for R9 to have therapy. When asked about whether it is appropriate for another resident in the facility to feed R9 during meal time, V45 stated I'm a professional I will never give an order to have R9 fed by another resident. R9 should be fed by either a CNA (Certified Nurse's Aide) or a Nurse (referring to a licensed Nurse). V45 explained that he is a firm believer in PT, OT and restorative therapy and that is why he routinely ordered rehab (Rehabilitation) therapy for R9 to prevent further contractures, improve his skills in daily living and prevent him from falls because R9 is also at risk for falls. On 12/06/20 at 12:59pm, surveyor observed V42 RN (Registered Nurse) go into R9's room placing the lunch tray on R9's side table and left the room and did not assist in setting up the food on the tray and did not ask whether R9 needed help. R9 was noted with hand strap (adaptive Device). R9 told the surveyor that R8 helped him in applying the device. On 12/7/20 at 10:20am, V46 OT (Occupational Therapist) was interviewed. V46 stated she is responsible for assessing all the residents in the facility in regards to occupational therapy. V46 stated R7 had issues with swallowing, a goal for self-feeding with set up and staff supervision was put in place. V46 stated R7 is now in a rehab program. V46 explained that R7 was in OT for approximately four weeks. V46 stated R9 uses a universal cuff to hold utensils, guard plates (adaptive equipment) in eating. When the surveyor asked V46 about the facility protocols concerning residents assisting in feeding another resident during meal time, V46 replied, during this pandemic I will not recommend that residents feed each other. V46 further stated we have care staff to do that (referring to the task). V46 stated she did not witness any resident feeding R7 or R9. On 12/7/20 at 10:35am, V2 DON (Director of Nurse's) was interviewed concerning facility protocol on supervision and assisting residents in feeding tasks at meal time. V2 stated the CNA's and the licensed nurses are responsible in assisting residents during meal time. When asked about whether it is appropriate for residents to feed each other during meal time, V2 replied it is not a safe situation because how will the resident know what the other resident can tolerate or what was ordered? V2 stated the OT department evaluates the resident and let's the nursing department know what each resident needs. V2 stated it is not safe for a resident to feed each other due to the risk of aspiration and choking. V2 stated none of the staff has informed her that residents are feeding each other during meal time. On 12/1/20 at 4:03pm, V5 stated V8 is responsible for making sure the restorative programs are being done with each resident and in charge of making sure the charting on assistance rendered are charted correctly in the resident's chart. V5 stated feeding assistance should be done by CNA's and licensed nurses. On 12/7/20 at 11:13am, V22 (Speech Therapist) was interviewed concerning the reason for having a swallowing evaluation done, V22 replied there are lots of reasons like pneumonia but if you're talking about R7, he was having food caught in his throat. The surveyor asked V22 in her professional opinion, is it appropriate for a resident to feed another resident and what are the risks of residents feeding each other without supervision and training? V22 stated I will not advise that residents feed each other because there are lots of things that can happen like aspiration and choking. On 12/7/20 at 11:31am, V36 NP (Nurse Practitioner) stated R7 had an old [DIAGNOSES REDACTED]. When the surveyor asked V36 in his professional opinion should R7 be assisted in feeding during meal time by another resident? V36 replied, No it should be the staff feeding R7 and any other resident (referring to CNA's and Licensed Nurses).V36 explained that during this COVID-19 pandemic residents are at risk for spread of COVID-19, aspiration and choking. R7's MDS (Minimum Data Set) facility assessment tool used in assessing residents dated showed that R7 had a BIMS (Brief Interview for mental Status) score of 14 R8's MDS (Minimum Data Set) facility assessment tool used in assessing residents dated December 8, 2020 showed that R8 had a BIMS score of 15. R29's MDS (Minimum Data Set) facility assessment tool used in assessing residents dated October 14, 2020 showed that R29 had a BIMS score of 14. R7's order summary showed that R7 is on swallowing precautions effective 10/08/20 with no end date. R7's speech therapy notes dated 10/8/2020, V22 (Speech Therapist) documented that R7 was under her care and found to have a swallowing disorder involving the oral phase, pharyngeal phase and the [MEDICAL CONDITION] phase. V22 documented that R7 has a history of aspiration Pneumonia and definite risk for aspiration, choking and a delayed or slow swallowing reflex. V22 recommendations includes but not limited to Dysphagia treatment, and a Video-fluoroscopic swallow study. V22 was not sure whether the video-fluoroscopic swallow test was done. On 12/10/20, the facility presented Modified [MEDICATION NAME] Swallow study final report dated 5/22/2019 that listed pertinent medical history [DIAGNOSES REDACTED]. Summary of the evaluation showed R7 marked for oral phase mild, pharyngeal phase mild and recommendations for diet to be Mechanical soft with thin liquids. No current test results were presented. On 12/16/20 at 10:45am, R29 told the surveyor she was not trained on feeding techniques and did not know what to do if a resident is choking or aspirates. At 10:47am, R8 also was interviewed in regards to education received when assisting in feeding resident with dysphagia and stroke and what to do if resident is choking or aspirates. R8 stated he had no training and would not know what to do. On 12/16/20 at 10:51am, when asked V8 (Restorative Director)whether R8 and R29 were trained in feeding techniques and on what to do when a resident is choking or aspirated. V8 replied, R8 and R29 were not trained because the facility does not train residents to assist in feeding their peers. Only the resident who is on swallowing precautions and assistance is trained to prevent aspiration and promote their independence with feeding. V8 then explained again that we (referring to staff) don't train residents on restorative programs, R8 and R29 were not trained. On 12/16/20 at 11:00am, during interview with V45 (physician), when asked in V45's professional opinion what is the risks with R9 being fed by peers who are not trained in feeding techniques in residents with a stroke and dysphagia. V45 stated I don't condone it, it's not a good idea. V45 explained that R9 had a stroke which makes dysphagia a probability and R9 can choke or aspirate. V45 stated the peers can feed an improper diet not equal the specific diet recommended which can result into malabsorption because the roommate wants to please R9. The facility Job Description for position title Restorative Nurse presented with no date documented that the Restorative Nurse is responsible for development, implementation, monitoring and supervision of the restorative nursing program for the facility. Ensure that the necessary assistive feeding and or ADL devices are obtained as needed. Make in sure daily rounds are done to oversee and monitor the restorative programs. And reports to the DON. The facility policy and procedure on Feeding Assistance presented with no date pointed out in part that the purpose of the policy includes but not limited to feeding techniques will be coordinated with the speech therapist as needed. The facility policy and procedure for Restorative Nursing Programming with no date pointed out that the facility must have evidence that staff and volunteers carrying out restorative programs must be supervised under a licensed nurse. And there is a written evidence that staff and volunteers carrying out the programs have been trained in techniques (Competency training). The Immediate Jeopardy was identified on 11/30/20 at approximately 11:13 AM when R8 stated he and R29 assist and feed R7 and R9 during meal time, and the facility did not provide assistance or supervision to R7 and R9 who are at risk of choking and/or aspirating. On 12/16/20 at approximately 12:00 PM, V1 (Administrator), V2 (Director of Nursing) and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review that the facility took the following actions to remove the Immediate Jeopardy. On 12/22/20, all staff present were in-serviced by V2 DON (Director of Nurses) on identifying residents requiring assistance and proper supervision during meal time. V2 stated all the staff who were not available will be in-serviced upon return to work. On 12/22/20, V8 (Restorative Nurse) showed restorative programs for all the facility residents were completed on 12/18/20. R7 and R9's record were reviewed and it showed they were re-assessed. All staff that were present were in-serviced on symptoms of swallowing difficulties and aspiration. This initiated on 12/17/20. On 12/22/20, during lunch time, staff were noted checking the yellow card placed on individual food trays and the list of resident's binder at the nurse's station identifying residents that needs feeding assistance. All the departmental heads present were noted monitoring the staff and assisting in making sure those residents needing feeding assistance were provided with assistance. On 12/22/20, R8 and R29 were interviewed and they said they were in-serviced by V3 (Social Service Director) and V8 (Restorative Nurse) on the risk of not being trained to feed other residents. Staff on the floor were also interviewed and staff were able to identify residents needing assistance during meal time, the risk of not using proper techniques and supervising to make sure residents are not assisting other residents in feeding during meal time. On 12/22/20, V3 stated the town hall meeting has not taken place but the residents R7, R8, R9 and R29 have been educated on this issues. Majority of staff have been in-serviced with a plan to in-service staff upon return to work, in-service provided on feeding assistance and supervision at meal time, and in-service to residents that were feeding other residents. Therefore the immediacy was removed on 12/22/20. Based on observation, interview and record review conducted on 12/22/20 the facility completed measures on the abatement plan including providing staff supervision during meal time, assessing for resident with difficulty in swallowing, and updating resident restorative programs during meal time. Surveyor: Amorim, Ducilene

Based on observation, interview and record review, 1) the facility failed to conduct comprehensive assessments and provide appropriate services needed relating to complaint of chest pain; failed to administer routine medication in accordance with the established medication administration of within 60 minutes of the scheduled time for one of three residents (R11) in the sample reviewed for pain. This failure affected R11 who has a pain score of 10, chest pain, headache, facal grimacing and did not recieve any interventions for pain. R11 was sent to the local hospital and admitted with [DIAGNOSES REDACTED]. 2) Based on interview and record review, the facility failed to document and promote good hygiene and to ensure that the resident receives treatment and care related to residents needs. This failure affected R7 & R9 reviewed for quality of care. 1) Findings include: R11's medical record face sheet documented that R11 was originally admitted to the facility on [DATE] and the latest admission was 10/29/20 with [DIAGNOSES REDACTED]. On 11/30/20 at 11:00am, R11 is noted in her room, in bed. R11 has facial grimacing, holding her chest and appears to be in discomfort/pain. Surveyor asked R11 on a scale of 1-10 what is her pain level? R11 stated, Pain is a 10. When asked what kind of pain are you having, R11 replied chest pain. R11 stated the pain is from not getting her blood pressure medication in the past three to five days and now she is having chest pain and a headache. R11 stated she told V20 LPN (licensed Practical Nurse) about it and she (V20) is not doing anything about it. When the surveyor approached V20 about the complaint, V20 stated that R11 has refused her medication. As V20 was about to walk away, R11 said to her I did not refuse my medicine, I refused the psych-medicine but I know I need my blood pressure medication. R11 stated my [MEDICATION NAME] and [MEDICATION NAME]. At 11:07am, R11's blood pressure read 163/88, pulse 78 and respirations 18. V20 then stated these medications are not available that she will have to go and get them from the convenient box. The surveyor then asked V20 what is the standard recommended time for medication administration in nursing and the facility protocol on medication administration. V20 replied medications should be administered one hour before and one hour after scheduled time. V20 then stated the medication was late because it was not available in the medication cart. When the surveyor asked V20 about physician notification about R11 refusing her scheduled medicine, V20 replied, R11 is known for refusing medicine. Review of R11's chart did not show any PRN order of medication to be administered for chest pain. V20 stated, there is no order recorded for PRN medicine. V20 then stated I'm going to call the physician now and the V2 DON (Director of Nurses). Review of R11's medical records progress note dated 11/30/20 timed 13:16 (1:16pm) showed that [MEDICATION NAME] HCL ([MEDICATION NAME]) tablet 25mg was not administered until 1:16pm, three hours sixteen minutes past the scheduled time. R11's Interdisciplinary Plan of care showed that R11 is at risk for elevated blood pressure. Blood pressure should be maintained within normal limits with interventions that includes but not limited to administering medication as ordered and monitoring for symptoms that includes headache, SOB (Shortness of Breath), chest pain or lightheadedness with last revised date 11/7/20. R11's plan of care for pain documented that R11 has the potential to have pain related to co-morbidities. Under the goal it was pointed out that R11 can have episodes of pain and it should be rated at less or equal to 2 within one hour of intervention. Interventions includes but not limited to assessing pain level on the 1-10 scale. On 12/4/20 at 2:16pm, in an interview with V36 NP (Nurse Practitioner), asked about what can happen to a resident with an order to receive anti-hypertensive medications and the medication is unavailable and is not administered at the right time? V36 stated that, when the antihypertensive medications are not given or not given at the right time, the resident can develop high blood pressure with symptoms of chest pain, headache and distress. V36 stated the medication should be readily available at all times even when the resident is refusing to take them just in case the resident decided to change their mind. When the surveyor asked V36 about what the nurse should do with a resident complaining of chest pain, V36 replied stating that when a resident experiences these symptoms with complaint of chest pain, it is an automatic referral to the hospital. V36 stated Chest pain is not something to be taken lightly. At 2:42pm, when asked V36 that in his professional opinion about R11 not having any PRN (As needed) medication on a stand by order for treatment of [REDACTED]. On 12/7/20 at 10:35am, an interview with V2 DON (Director of Nursing) concerning the facility protocol on medication refills. V2 stated when any medication is getting low to about four tablets the nurses should pull the re-order tab and send the same day to the pharmacy or make a telephone call to pharmacy. When the surveyor's observation about R11 not having [MEDICATION NAME] and [MEDICATION NAME] medication available and not administered at the right time, V2 stated R11's medication should be available at all times. V2 stated, there is facility convenient box where medications are kept for emergency use. V2 stated V20 should have given these medications at the right time and should have checked the convenient box. V2 stated medications are professionally acceptable within one hour before and one hour after the scheduled dose. When asked V2 about the facility expectation of licensed nursing staff when a resident complains of chest pain. V2 stated the licensed nurses should assess the resident by taking the vital signs (referring to blood pressure, respiration, and temperature). V2 stated based on assessment, an emergency telephone call should be placed to send the resident to the hospital for further assessment and also call the attending physician. V2 stated R11 should have been sent to the hospital in a timely manner for the complaint of chest pain and headache. The facility policy on Management of Pain presented with no date documented in part that the mission of this policy is to promote resident comfort and preserve resident's dignity. The purpose is to accomplish this mission includes but not limited to providing effective pain management program and provide residents means to necessary comfort. Procedure includes but not limited to nursing involvement that includes comprehensive pain assessment. The facility policy on Ordering Medication presented dated December 2018, stated that medications and related products are to be ordered in a timely basis. Procedure includes but not limited to requesting refill medications 72 hours prior to the last dose. The facility policy presented on Physician order [REDACTED]. The facility policy titled 2.6a Ordering Medications (Electronic) with no date documented that the medications and related products are ordered on a timely basis and procedure includes but not limited to re-ordering medications three days in advance of need to assure an adequate supply is on hand. 2) Findings include: On 12/6/20 at 12:00 pm, R9 states I usually have a shower (bed bath) on Tuesdays and Fridays. For two weeks I haven't had a shower at all. They don't want to do it. Every day is a new Certified Nursing Assistant (CNA), and they don't want to give me a bed bath. I did not ask to have a shower today, because if I do ask out of my scheduled days they will say It is not your day to have a shower (bed bath). I don't remember the name of the CNA, it was an agency CNA. I never had a shower in the shower room. They say they don't have enough people to give me a shower. Last Friday I asked, can you please at least wash my underarms? They did, but if I don't ask, they do nothing. Before the strike, sometimes they would feed me. If I have the tool, I can feed myself. Last week I didn't have it, and CNAs did not feed me. R8 fed me. He and my friend (R29), they are the ones who helped me. On 12/06/20 at 12:22 pm, R8 I help them (and points to R9 and R7). Every day the CNAs come here, they put the tray on their tables and leave. They don't open the milk, the juice. If they have hard-boiled eggs, they don't open it. Then I help them (R9 and R7). I open the milk carton, I put the straw in the juice, I open the boiled eggs. Sometimes R7 can't feed himself. He got a lot of shaking, so I feed him. Before, there were 2 CNAs in the evening, now sometimes there is no CNA. Sometimes I have to pull R7 up in bed. They told me not to do it, but when I asked the CNA to do it two days ago, because he was slipping down, she got mad. Sometimes R7 calls me and says I need to be changed, I'm wet. Sometimes in the middle of the night, then I say I'll go get the CNA, but they are not there, then I go to pick up the diapers and change him. They don't move him. He always on his back. These people are from agencies. They don't have the experience or they don't care. On 12/06/20 at 12:32 pm V41 (Certified Nursing Assistant- CNA) states I'm agency, I didn't have any training. You just show up for the job. On 12/06/20 at 1:38 pm V41 (agency CNA) states This is my second time here, but weeks apart. R9 can feed himself. He is just a set-up, you know open his food, milk cartoon, juice. He got something in his hand. I have no idea who puts the device on his hand, probably restorative? He can't put it on himself. I have not put it on his hand. I did not give him a shower today. The last time I had him I gave him a bed bath. V41 couldn't tell the date. Honestly, I have no idea why he is not getting his shower. I don't know what is going on. R9 Comprehensive MDS dated [DATE] section G - functional /ADL assistance documents Extensive assistance/one person for eating; bathing- two person assistance. Section C - BIMS 15. On 12/06/20 at 2:55 PM V2 states Every floor has a binder with the shower schedule and the shower sheets. Upon observation, no shower sheets or shower schedule was found in the binder on the second floor on 12/6/20. The shower schedule later provided by the facility shows R9's room/bed number hand written. All the rest of the room numbers were typed. On 12/06/20 at 4:12 PM, V2 (DON) states absolutely, it is not acceptable that the resident has not had a shower for two weeks. They have a shower sheet where the CNAs writes the day they gave the shower and the nurse should sign it as well. Skin observation/assessment (shower/bath) policy reads: Procedure: 1) showers/bath will be offered to residents at minimum of 2x weekly and as needed to promote good general hygiene unless the resident has another preference. (Ex. A request of daily showers). 2) Resident preference will be honored as much as possible to include the day and the time of day as well as any physical considerations or limitations or restrictions. 5) The care giver completing the bath/shower will indicate on the Shower Sheet any observations that they have made during the resident's shower/bath that appear to be new or worsening. This will be given to the nurse in charge. Restorative care plan reads: R9 has a self-care deficit; requires assist with ADL's to maintain highest possible level of functioning as evidenced by the following limitations and potential contributing Diagnosis: [REDACTED]. Interventions reads: assist with meals, as needed. Use of adaptive equipment with meal Plate guard and Utensil hand strap. R9's shower care plan dated 10/8/20 reads: The resident presents with a functional deficit in: related to a [DIAGNOSES REDACTED]. Interventions don't reflect the level of assistance R9 needs based on his [DIAGNOSES REDACTED].

Based on observation, interview and record review, the facility failed to ensure that a resident identified at high risk for pressure ulcers, was adequately assessed by facility staff. This facility failure resulted in a delay in the identification of an alteration in skin integrity and the implementation of treatment, for one resident (R3) in a sample of three, who was admitted to the hospital for the treatment of [REDACTED]. Findings include: R3 is [AGE] year old with [DIAGNOSES REDACTED]. On review of the Braden Scale pressure ulcer assessment tool dated 11/29/2019, it was documented that R3 was at moderate risk (score 14) for the development of pressure ulcers. The Minimum Data Set ((MDS) dated [DATE], as documented in the section titled Functional Status, facility staff identified that R3 was totally dependent and required the assistance of two staff persons for physical assistance during transfers, bed mobility and toileting. On review of the section titled Skin Condition, facility staff documented that R3 had no ulcers, wounds or skin problems. On review of the Progress Notes dated from 11/16/2019 to 1[DATE]19, there was no documentation that R3 was identified to have any alterations in skin integrity. R3's Bath and Skin Report Sheet dated 1[DATE]19, 11/13/2019, [DATE], 11/28/2019, 12/4/2019, 1[DATE]19, indicated that R3's skin was intact. On review of the Bath and Skin report dated 12/23/2019, facility staff documented R3 was noted to have open wound. R3's Weekly Wound Evaluation dated [DATE], documented R3 had an Unstageable pressure ulcer to the sacrum measuring 3.0 cm (centimeter) x 3.0 cm 0.0 cm. On review of the Progress note dated 1/2/2020, facility staff documented that R3 was admitted to a local hospital with [DIAGNOSES REDACTED]. On review of the hospital record, it was documented in the Discharge Summary, that R3 was admitted from nursing home, secondary to worsening sacral wound. On 1/22/2020 at 3:22 PM, V4 (Wound Care Nurse) stated, If the skin is intact I don't do a skin assessment. I only do it when there is a wound. V4 further stated that a wound assessment would only be done when there is an issue with the skin. On 1/22/2020 at 4:07 PM, V2 (Director of Nursing) stated, The nurses do a skin assessment as noted on the Skin assessment on the MAR (Medication Administration Record). If there is any skin alteration, then they would tell her (V4 Wound Care Nurse). So on the day that they saw the wound on her (R3), V4 was made aware so she can do the documentation. V2 further stated, that R3 has history of a coccyx wound, which resolved years ago. CNAs (Certified Nursing Assistants) should check the skin at least every shift or when they shower or change the resident. On 1/22/2020 at 3:40 PM, V15 (Wound Physician) stated, It is possible that there would be manifestations on the skin before it develops to Unstageable pressure ulcer, you may see some signs such as redness. Staff needs to monitor the skin more closely especially if they have poor nutrition. On 1/22/2020 at 9:46 AM, a wound treatment observation was conducted with V4 and wound measurements were obtained. On review of the Weekly Wound Evaluation dated [DATE]20, facility staff documented that R3 has a Stage 4 pressure ulcer to the sacrum that measured 8.5 cm x 5.5 cm x 1.0 cm. The Facility policy titled, Risk and Skin Assessment undated, stated in part but not limited to the following: Procedure: II. C. Skin check is completed on each shower day by nursing assistant staff. 1. Shower sheet maybe used to document skin check. 2. If an area is identified, the nurse is notified and the Stop and Watch Tool may be used to communicate this information. D. The nursing assistant visually inspects the skin daily and with care.

Based on interview and record review, the facility failed to implement interventions to ensure the safety of a resident with bilateral above the knee amputations of the lower extremities; and failed to follow the facility policy related to the identification of risk factors for fall prevention, for one resident (R2) in a sample of three, who was sent to the hospital for a dislodged [MEDEQUIP] tube, as a result of a fall related incident and was determined to have sustained a fibula [MEDICAL CONDITION] below the knee stump, as a result of the fall incident. Findings include: R2 is an [AGE] year old admitted in the facility on [DATE], with [DIAGNOSES REDACTED]. On review of the hospital records dated 11/24/19 to [DATE], the Discharge Summary indicated that R2, who previously had an amputation of the left leg, recently had surgery for [REDACTED]. On review of the Fall Risk assessment dated [DATE], facility staff documented R2 had a total score of 12-16, which indicated the resident was at High Risk for falls. R2's Baseline Care Plan, on admission to the facility on [DATE] included: E. Safety Goals and Interventions/Safety/Fall History 1. History of Falls: n/a (not applicable) 3. Interventions for Fall Prevention: n/a On review of the progress note dated [DATE] at 3:53 PM, staff documented, R2 was admitted to the facility with [MEDEQUIP] tube (Gtube) in place and intact. R2 had an admitting [DIAGNOSES REDACTED]. At 7:30 PM, R2 had a fall incident. R2 was observed on the floor by his bedside in a sitting position with no injuries noted. On review of the facility Incident Report dated [DATE], R2 was assessed to be confused, impulsive, had decreased strength/endurance and safety awareness as predisposing physiological factors. During an interview on 1/22/2020 at 3:10 PM, V9 (Licensed Practical Nurse, LPN) stated, that she was the admitting nurse when R2 was initially admitted in the facility. V9 verbalized, He is alert, oriented to self. I did his admission. The hospital report didn't tell me that he is a high fall risk, only that he has bilateral amputation. So when he came, I did the assessment and I can see that one of the legs was done recently, the right leg. After he was put into bed, I went back to his room to do my assessment, then later, I left the room to get a Gtube pole. When I came back into the room, I found him on the floor, sitting by the bedside. There were no injuries noted upon assessment. He was not in any form of pain as I observed from his facial expression. I notified V10 (Nurse Practitioner, NP) regarding his fall and was just told to monitor him (R2). Upon admission, he was not assessed as high risk, but after the fall incident, he was now considered high risk. During the interview, V9 stated, We use mechanical lift device for his transfers, make sure floor mats are placed on both sides of his bed, bed in lowest position, his call light should be within reach with prompt responses for call light requests and continuous monitoring. V9 further stated, Maybe the bed is new to him, because in the hospital, the bed has side rails that he can hold onto while he moves himself in bed. He can still move while in bed. Maybe the cause of his fall was he rolled out from bed. On review of an Incident Report dated 11/24/19, facility staff documented, R2 had another unwitnessed fall incident from bed. He was again observed in a sitting position on the floor mat on the right side of his bed. There were no injuries noted neither pain or bleeding on the right BKA. It was also noted from the report that R2 requires staff assistance for all transfers and was noted to have cognitive deficits and impulsive behavior status [REDACTED]. Facility staff also documented that R2's PEG tube was noted dislodged during this fall incident and the resident was transferred to a local hospital for PEG tube reinsertion. R2's Fall Risk Care Plan dated 12/03/2019 included the following: Approaches/Interventions: Be sure call light is within reach and encourage it for assistance as needed. Respond promptly to all requests for assistance. Anticipate and meet needs. Complete Fall Risk Assessment per Facility protocol [DATE]: Floor mats 11/25/19: Gather information on past falls and attempt to determine cause of falls. Anticipate and intervene to prevent future recurrence; bariatric low bed; floor mats (9 inch) and hospital evaluation. During an interview on 1/22/2020 at 2:34 PM, V7 (Registered Nurse, RN) confirmed that R2 had a 2nd fall related incident. V7 stated, On that day (11/24/2019), I was notified that patient was on the floor. I went to the room and noted him in a sitting position on the floor mat with his back leaning on the bed. Upon assessment, I asked him, dolor? (meaning pain) and he shook his head. I checked his vitals and all within normal limits. I inspected his whole body and extremities, no injuries were noted. I noticed that his Gtube was dislodged. I asked him what happened but he wouldn't say anything with regards to his Gtube. There was no bleeding noted on the Gtube site. Then, he was put into bed using the mechanical lift device. It was an unwitnessed fall, don't know how he fell . He was transferred to the hospital as ordered for further evaluation. He (R2) was still awake and alert, no pain was noted and reported. I don't know him (R2) enough, he was just admitted in the facility. On review of the hospital record, the emergency room department notes included documentation from the History and Physical dated 11/24/19, which stated R2 was transferred to the hospital due to concerns related to Gtube dislodgement and right BKA (below knee amputation) stump pain, after an unwitnessed fall in the facility. R2 had an X-ray of the right lower extremity stump, which concluded status [REDACTED]. V10 was interviewed on 1/22/20 at 3:58 PM regarding R2 and fall interventions. V10 stated, I didn't see him at the time. It was reported to me that he had a fall incident on [DATE] with no injuries. Usually, if there are injuries noted after fall, we send residents to the hospital. If there is pain or discomfort, we do X-rays. If there is nothing serious, we do body checks and [AGE] hours monitoring post fall. Depending on the condition of the resident,like if he or she is not alert and has no self-awareness, they have to be monitored closely and implement interventions like low bed, call light within reach, identification of the risk factors that could lead to falls and lab work-ups to rule out infection. There should be a care plan that should be initiated at the time of admission. Any change in condition, care plan is formulated and or updated. He (R2) was admitted with A[CONDITION] (Altered Mental Status) with bilateral amputation so safety is a big concern. In order to prevent falls, he should be secured while in bed. If he rolls out from bed, side rails can be put up. I have residents who roll when they sleep. The basic thing is to make the patient secure; fall precautions should be observed, do an update for any change in status and if there is any immediate concerns, send to the hospital. Upon admission, staff needs to do a head to toe assessment to identify risk factors leading to fall occurrences, it's on a case by case basis, therefore, interventions are tailored to patient's needs. Not all fall interventions are applicable to a specific resident, like for residents with A[CONDITION], they cannot use the call light. Staff needs to identify the real cause. On [DATE]20 at 10:05 AM, V2 (Director of Nursing) was interviewed regarding falls. V2 stated, I head the Fall committee. We all meet weekly to discuss the fall incidents that happened in a week. But if there is a fall, we meet the next day unless it's a weekend. We meet to discuss in making sure the interventions implemented are appropriate. For newly admitted residents, the floor nurses are responsible for completing a fall risk review assessment. It gives you a number and the higher the number, the higher the resident is at risk for falls. If we know that prior to coming here that they are high risk for falls, we implement an intervention right away like floor mats, low bed especially if they are not ambulatory. However, in the event that the nurse considered them high risk upon admission, the nurse would implement appropriate interventions for the resident. Baseline care planning for safety is based on the information that the admitting nurse gathered during admission assessment. Over-all, thorough assessment should be performed on a newly admitted resident for individualized fall interventions. The baseline care planning was accomplished at the time the resident was admitted . The interventions are relayed to the staff through verbal communication from the nurse. In his (R2) baseline care plan for safety/falls,there should be interventions documented for fall prevention. On [DATE] at 1:56 PM, V17 (LPN) stated, I did his baseline care plan. The baseline care plan was done within the first hour of getting here and what happened was we have 48 hours to do a complete one. That might have been a mistake that I did but there were interventions in place like fall mats and low bed. There should be documented interventions for fall prevention in his baseline care plan. When he fell second time, I ordered a bariatric bed. He is a bit larger in size. He was placed on a regular bed. When he turns, he could not reposition himself, and he can roll out from bed. The bariatric bed is not available in the facility, it has to be ordered. MDS (Minimum Data Set) dated 11/24/19, R2's weight was recorded as 211 pounds and has a height of 71 inches. Facility's policy titled Fall Prevention Protocol dated 08/03/17 stated in part but not limited to the following: Risk Assessment III. Fall Prevention A. Identify risk factors B. Implement individualized approaches/interventions based upon resident risk 1. The Fall Prevention Strategies/Interventions list may be used to identify appropriate interventions 2. Approaches/interventions should focus on risk factors identified V. Care Plan A. Interdisciplinary care plan is implemented for residents at risk and may include 1. Interventions to prevent falls 3. Assistive devices as appropriate 5. Adaptive equipment C. Evaluation of the interventions is completed 2. Post fall 3. Interventions are modified as indicated based upon evaluated efficacy of the interventions Facility's Fall Prevention Strategies/Interventions documented in part: Staff intervention - observe for potential interventions appropriate for the resident Facility's policy titled Care Plan Policy and Procedures dated 11/26/19 documented in part but not limited to the following: 5. New admissions will have a preliminary care plan initiated with actual and potential problems identified as the comprehensive care plan will continue to be developed in conjunction with the completion of the MDS (Minimum Data Set) Assessment.

Based on interview and record review, the facility failed to follow their fall prevention and management policy to include: development, implement and re-evaluate effectiveness of individualized fall prevention interventions; provide an assistive device to minimize the risk of falling; and provide supervision for a resident with repeated falls. These failures affected one out of three residents (R1) reviewed for falls. These failures resulted in R1 sustaining a 10 centimeter laceration requiring sutures and another fall sustaining an acute right shoulder fracture. Findings include: R1's initial MDS (Minimum Data Set) with Assessment Reference Date (ARD) of 12/28/2017 shows the following: -BIMS (Brief Interview Mental Status) = 14/15, Cognitively intact -Requires Extensive assistance and one person physical assist with bed mobility, transfers, walking in room, locomotion on unit, dressing, toilet use, and personal hygiene -Not steady, only able to stabilize with staff assistance for walking, moving on toilet, surface-to-surface transfer, and moving from seated to standing position -Impairment on one side for both upper and lower extremities -Always continent of urine and occasionally incontinent of bowel -[DIAGNOSES REDACTED]. -No history of falls R1's Fall Risk Review dated 12/21/2017 shows: -History of falls within last six months: 3 or more falls -Exhibits loss of balance while standing, requires hands-on assistance to move from place to place, uses short discontinuous steps and/or shuffling steps, has lurching, swaying, or slapping gait, exhibits jerking or instability when making turns, uses an assistive device, decrease in muscle coordination -High risk for fallsOn 5/23/2018 at 10:14am, R1 stated: I've urinated on myself many times and I hurt my arm, because I have to wait 20-30 minutes for staff when I press the call light. I can't hold in my pee for that long, and I don't want to wet myself. I fell on e time trying to stand using a urinal and I fell another time when I was walking with my cane. I also fell other times waiting to go to the bathroom, but waiting too long and trying to do things myself. It's frustrating. On 5/23/2018 at 9:45am, V7 (Family member) stated: (R1) fell around 5-7 times, and he's falling too much at the nursing home. He had 12 sutures and a broken shoulder already. The facility knew that since he came in, he has had surgery and cannot be walking or doing things on his own. One time, I did place R1 in the room but no one would answer the call light, so I stepped outside to call staff for help because R1 needed to use the bathroom. The staff takes too long because they are busy and understaffed, that R1 couldn't hold in his urine and tried going to the bathroom himself. When R1 needs to go, he needs to go and can't wait 30 minutes or so for someone to answer the call light. On 5/23/2018 at 10:06am, V5 (LPN/Licensed Practical Nurse) stated, If R1 doesn't wait, he will try to transfer himself. Sometimes he won't use the call light and we keep encouraging him to use the call light. On 5/23/2018 at 10:08am, V4 (Certified Nursing Assistant/CNA) stated: R1 is continent and he knows when he has to go, and will call for help. In January, R1 used to do things on his own and would walk with a cane and only needed supervision. R1 is on the falling star program, because he's had around 2 falls or so, but I don't know exactly why he fell . R1 needs monitoring, because if he feels he's been waiting too long for the call light to be answered, then he will do things on his own. R1's progress notes show R1 had the following five unwitnessed falls: 1. (1/13/2018 4:30pm) Late Entry: NOD (nurse on duty) while assessing another resident heard a noise in the room immediately checked and found resident laying on his left side with his face down, Initial assessment done and found a 2-3 linear laceration on the left forehead just above the eyebrow, pressure dressing was applied . R1 sent to local Emergency Department (ED) 2. 1/25/2018 at 8:21pm: Heard a thump coming from resident's room, saw resident on the floor next to wheelchair urinal on the floor, attempting to use urinal .Assisted with three staff without difficulty . 3. 3/24/2018 6:16pm: Late Entry: Resident sister was visiting and she wheeled res (resident) to the room and came to the nursing station to talk to staff quickly, when she returned to the room resident was on the floor in sitting position. Sister came and notified this writer that res was on the floor. This writer went to assessed res. When res was asked what happened he stated? He wanted to get up to use the bathroom and I slide off wheelchair. 4. 3/27/2018 9:24am: Writer received report from overnight nurse that resident had a fall this AM (7:29), upon assessment resident c/o (complained of) right (arm) pain 7/10 and was noted with a bruise to right hand. when asked what happened resident states I was trying to get from my bed to the w/c (wheelchair) when I fell on the floor, now my arm hurts. 5. 5/12/2018 at 7:18pm: Resident observed in room laying on his right side between bed and nightstand. Resident verbalized trying to get to bed, had no strength fell forward, Resident stated hitting back of his head right side MD called with orders to be send out for CT (computed tomography) scan R1's five incident reports show:1. 1/13/2018 - Resident is independent with ambulation with cane . After interviewing the resident it was determined that as resident was ambulating, his leg got caught on his cane, causing him to lose balance and coordination and fall to the floor. Resident returned from local hospital, after receiving 7 stitches to lacerations site. Resident educated on safety precautions and verbalized understanding. Resident to be evaluated by therapy department.2. 1/25/2018- Attempting to use urinal, lost balance, slid off and was noted sitting downAs a result of the accident/incident, the plan of care has been updated to decrease potential for future falls:Encourage to use urinal safely if unsure ask for assistance, call light within reach encourage use, check if gait and transfer ability declining or improving3. 3/24/2018 - Got up the wheelchair unassisted towards bathroom, lost balance.As a result of the accident/incident, the plan of care has been updated to decrease potential for future falls:-Resident instructed to ask for help, he is alert and able to use call light and alert to ask for help4. 3/27/2018 - Got up unassisted, reaching for objectAs a result of the accident/incident, the plan of care has been updated to decrease potential for future falls:Remind to use call light and not to transfer self without assistance, pain management, x-ray to right arm, continue physical therapyIDT reviewed incident and analyzed root cause, resident is instructed to ask for assistance as he can use call light, wheel self around and transfer with minimal assist. He can use urinal at bedside. Resident's x-ray right arm requires orthopedic evaluation, discussed with (V10/Attending Physician), no acute fracture noted. X-ray result reviewed by doctor and concluded that right [MEDICAL CONDITION] and polio contributed to abnormal right arm X-ray. Recommend to send resident for evaluation at hospital. 3/28/2018 - Resident returned from hospital with no new intervention, right arm sling on and pain medication as needed.5. 5/12/2018 - Resident failed to use call light for assistance, educate, continues refusalAs a result of the accident/incident, the plan of care has been updated to decrease potential for future falls:falling star program and frequent rounding R1's hospital physician progress notes [REDACTED]. 10 cm (centimeter) laceration on the left frontal scalp, repaired with suturesOn 5/23/2018 at 11:14am, V6 (Physical Therapist) stated the following: Initial PT assessment was on 12/21/2017. R1 has history of having right hempiplegia, where his right arm cannot move at all, his arm just hangs there and he doesn't have much control at all. R1 first came in with a quad cane that has four prongs, and needed minimal staff with one person assist. R1 was discharged after six sessions (1/3/2018), and needed stand-by assistance at all times and was to ambulate with a hemi-walker. R1 was not safe to ambulate without supervision and was not stable with a quad cane. R1 was safer and more steady ambulating with a hemi-walker, because it has a wider base support. After R1 was discharged from therapy, R1 started having decreased balance and increased falls, due to behavior and being a very impulsive person. R1 had a tendency to use the call light and wouldn't wait, so he would attempt to do things himself, which is not safe. We have one hemi-walker in the building, and restorative would come down to borrow it, when walking R1 and would return it. R1's x-ray results show: 1/26/2018- Right shoulder: No subluxation or dislocation, normal visualized humeral head 3/27/2018- Correlative films provided: 1/26/2018, Right shoulder, Impression: 1. There is acute [MEDICAL CONDITION] humerus with slight impaction at the level of the neck 3/27/2018- Right humerus, Impression: 1. [MEDICAL CONDITION] humerus R1's Emergency Department discharge instructions dated 3/27/2018 shows: There is a [MEDICAL CONDITION] of the humerus. Wear the sling at all times. Follow-up with orthopedic surgery on 4/4/2018.R1's rehabilitation physician progress notes [REDACTED]. Neuromuscular deconditioning 2. Activities of daily living dysfunction 3. Gait dysfunction 4. Falls 5. Right [MEDICAL CONDITION] Functional status updates: Contact guard wheelchair mobility. Plan/recommendations/status: initial evaluation, plan and goals reviewed today. Patient has an appointment with orthopedic surgery on 4/4/2017 in regard to findings on x-ray. R1's medical record does not contain any documentation clarifying if R1's x-ray results was due to [MEDICAL CONDITION] or polio as documented on the incident report on 3/27/2017.On 5/24/2018 at 9:03am, V1 stated, I can't find any documentation about R1's x-ray being due to Polio or [MEDICAL CONDITION] or why the injury was not reported to IDPH. On 5/24/2018 1:10pm V10 stated the following: I received a call in (MONTH) that R1 had a fall and they left a message instead of paging me right away. Initially, R1 and V7 didn't want to go to the ER, so I ordered an x-ray. I saw a previous x-ray in (YEAR), and R1 did not have a fracture then. It does seem that R1 had an acute fracture, I can't say it's a chronic fracture because that was an event that R1 fell and had arm pain associated with the fall. R1 is able to give information, is very impulsive and has history of [MEDICAL CONDITION], Polio and having many falls at home. R1 came to the facility for subacute rehab, and is doing well now considering. R1's primary care physician did note that R1 has an enlarged prostate, and has urinary frequency and urgency. R1's comprehensive care plan shows:-12/28/2017 - Transfer needs- Quad Cane, Educate resident on benefits and risk factors associated with non-compliance with use of adaptive equipment, transfer devices and refusal for restorative programming participation as indicated when refusals occurR1's care plan was not updated to reflect the use of hemi-walker when discharged from physical therapy on 1/3/2018. Falls were listed for 1/13/18 and 1/25/18 and interventions include education and evaluation by therapy department. Falls were listed for 3/24/2018 and 3/27/2018, and the same interventions included to ask for assistance and use of call light. R1's care plan does not address R1's [DIAGNOSES REDACTED]. R1's care plan was not updated after his fall on 5/12/2018. On 5/23/2018 at 1:39pm, V8 (Restorative Director) stated the following: the previous Director of Nursing was in charge of investigating falls, and we discussed falls as an interdisciplinary team (IDT) to assess what happened and what we will do to update the care plan. R1 fell the first time on 1/13, the interventions were a referral to the therapy department and educate on safety awareness. During that fall, R1 was using a cane that he brought from home. The hemi-walker was only used during therapy and restorative sessions. I would borrow the hemi-walker from therapy, because R1 is on an ambulating program. I just recently ordered a hemi-walker for R1 , but it has not arrived yet. We provided R1 with a wheelchair instead so that R1 would not walk on his own. After R1 fell on ,[DATE], the intervention was to encourage the safe use of a urinal, to ask for assistance, and to check if there's a decline or improvement with gait. R1 fell again on 3/24, and interventions were to instruct to ask for assistance and encourage use of call light. R1 fell on ,[DATE], and interventions were to ask for assistance and encourage use of call light when transferring. R1 fell again on 5/12, but my signature isn't on the IDT report, so I wasn't aware of these new interventions and didn't update the care plan. On the incident report, it says to implement falling star program and another intervention I can't read, but R1 was already on the falling star program, which started in (MONTH) (YEAR). We have the IDT meetings after every fall, but we don't have another meeting to follow up and re-evaluate effectiveness of interventions, which is something we can do and work on. R1 also was not on a toileting schedule to address his urinary urgency. We should have included more supervision in the interventions, because R1 still keeps falling even though his room is near the nurse's station. I was not aware that R1 had a fracture on the shoulder, I was told it was from his history of Polio and [MEDICAL CONDITION]. R1's MDS for significant change in status with ARD of 3/30/2018 shows: -BIMS (Brief Interview Mental Status) = 11/15, Moderate cognitive impairment -No rejection of care -Requires Extensive assistance and two plus person physical assist with bed mobility, transfers, walking in room and corridor, toilet use -Requires Extensive assistance and one person physical assist locomotion on and off unit and dressing -Impairment on one side for both upper and lower extremities -Mobility device: wheelchair -Not steady, only able to stabilize with staff assistance for walking, moving on toilet, surface-to-surface transfer, and moving from seated to standing position -Occasionally incontinent of bowel and urine -Number of falls since admission (most recent Assessment) - A. 2, two or more falls with no injury; B. 2, two or more falls with injury (except major); C. 0, No falls with major injury (bone fractures .) On 5/23/2018 at 4:08pm, V9 (MDS and Care Plan Coordinator) stated: the previous MDS Coordinator did a significant change MDS for R1 due to a decline and multiple falls. Based on the x-ray results and history of falls, R1's falls should have been coded as A. 2, two or more falls with no injury, B. 1, one fall with injury (except major) for the laceration, and C. 1, fall with major injury for the shoulder fracture. The fall interventions should have been analyzed and investigating falls involves a lot of critical thinking. They are the same interventions for 3/24 and 3/27, but should have addressed toileting and supervision. The facility's policy and procedure titled, Fall Prevention and Management version 8/3/2017 reads: (Through) an interdisciplinary approach, this facility will provide fall prevention assessment, implement interventions to prevent falls as much as possible, and manage post-fall treatment. The facility will achieve these goals through:1. An individualized fall risk assessment2. Interventions that are implemented based upon the identified risk factors.4. Reassessment of risk after a fall with modification and/or additional interventions as appropriateV. Care PlanA. Interdisciplinary care plan is implemented for residents at risk and may include1. Interventions to prevent falls3. Assistive devices as appropriate4. Supervision as appropriate B. Evaluation of the interventions is completed3. Interventions are modified as indicated based upon evaluated efficacy of the interventionsVI. DocumentationB. Fall risk and care plan are reviewed and updated4. Revise or implement additional individualized interventions as appropriate

Based on record reviews and interviews with resident, staff, and physician, the facility failed to meet the guidelines for transferring a resident without due cause and refused readmission back to the facility when the resident expressed the desire to return for three of five residents (R22, R23, R24) reviewed for involuntary transfer/discharge in a sample of five. R22 suffered mental anguish as a result. Findings include: R22 is a [AGE] year old resident originally admitted to the facility on [DATE] for long term skilled nursing care and rehabilitation and involuntarily discharged to the hospital on [DATE]. R22's Physician order [REDACTED]. MDS(minimum data set) dated April 26, 2017 shows a BIMs (brief interview for mental status) at 15 for cognitively intact with no memory impairment. This same MDS assessment shows R22 with verbal behavior occurring 1 to 3 days but overall behavioral symptoms not impacting the resident, others, and that there was no rejection of care exhibited. This same assessment shows that there was a change in behavior as a 1 designating an improvement in the behavior. Facility progress notes dated 1/20/17 authored by E22 (former social service director) states in part, [AGE] year old male admitted from hospital with [DIAGNOSES REDACTED]. Patient is alert and oriented x3 as exhibited 14 out of 15 on BIMS assessment and has intact short and long-term memory. He has moderate difficulty hearing and speaker needs to speak louder or closer to his ear. He denies any alcoholic/substance abuse history. He is a low risk for self harmful and aggressive behaviors and is not an elopement risk. Facility quarterly progress note dated 5/1/17 authored by E22 (former social service director) states in part, [AGE] year old male resident on the facility with [MEDICAL CONDITION] difficulty walking and chronic [MEDICAL CONDITIONS]. (R22) remains alert and oriented x3 and does not present with any significant memory impairments. He is able to communicate verbally but does not present with any significant memory impairments. He is able to communicate verbally but does have significant hearing problems in his left ear. He currently wears hearing aids but express they are no longer helping him. He is scheduled to be assessed by the audiologist. He reports feeling a bit depressed due to his current living situation and is eager to be living out in the community again. (R22) behavior has improved since his admission, however he still can be have periods where he raises his voice if he is anger. He presented with an outburst toward social service recently because of communication misunderstanding. He is low risk for self-harmful or aggressive behaviors. He is very easy to re-direct as long as one talks with him about his frustrations. Currently, social service is working with a program to have (R22) assessed for services to promote his independence and a place to live back in the community. R22's care plan dated 4/26/16 shows in part, The individual appears stable and is considered appropriate for residence in the facility; Patient had altercation with his previous roommate. He also presented with verbally aggressive symptoms toward his nurse regarding medications. Goals: The resident will comply with staff redirection and behave in a safe and respectful manner 7 of 7 days per week by 7/26/17. Approaches: Conduct an evaluation of the behavioral symptoms to determine what strengths or abilities and needs are communicated via the behavior (e.g., verbal abuse often communicates a need to feel in control and assertive.) Provide supportive group, 1:1 or prn intervention, 2 times per week; intervene when any inappropriate behavior is observed. Communicate that the resident is responsible for exercising control over impulses and behavior. On 5/19/17 per nurses notes and authored by E2(Director of Nursing), Resident back from out on pass, approached nurse on duty yelling about a blanket missing from his room, writer attempting to assist resident. Resident became verbally aggressive with staff, yelling and using profanity. Resident got up from wheel chair and threatened to hit the housekeeper, unable to redirect resident. Resident attempting to run over housekeeper with his wheelchair, calling him names. Resident threatening to hit staff. Dr. contacted with order to send resident out risk of harming to others. Petition filled out. Signed interview on 6/22/17 with E16 (Housekeeper) who was involved in the alleged incident on 5/19/17 states, I've worked here for 2 years. I remember (R22). I didn't interact with him too much as he was not on my floor. I was making my rounds, when I came down he was loud. He was looking for his blanket so I went down to the laundry to check. When I came back up he was being loud with the PM nurse. I decided to watch and I saw him stand up and cursing the nurse. He said something like, This is all BS and this place is BS. Asked if (R22) made any physical contact with him, E16, stated, No, not at all. Asked if he observed (R22) making any physical contact with any resident or staff, E16 stated, No, sir. Asked if he at ever saw (R22) harming himself, E16 stated, No, I don't take care of him Asked if (R22) tried to run him over with his motorized wheelchair, E16 responded, No, he doesn't even have a motorized wheelchair just a regular one. Asked again to clarify if R22 tried to run him over with a wheelchair E16 replied, No sir. Asked if he felt threatened at all by (R22) during that incident or any past occasions, E16 responded, No. Interview with E20 (Registered Nurse) on 6/28/17 states in part, Yes I signed that I was a witness to the incident with (R22) but I only heard him shouting and I didn't see anything going on. Asked why she was asked to sign the involuntary discharge as a witness, E20 responded, I don't know sir, I just heard him shouting. Asked if she could speak to whether R22 was a danger to himself, staff or other residents, E20 responded, No sir I don't know that. Interview on 6/22/17 at 12:10 pm with E2 (Director of Nursing), states in part, (R22) came back from out on pass around 5 or 6 pm and later he was in front of my office, he was yelling about his blanket and stated one of his blankets is gone. He came to me a lot and I'd help him and he was comfortable with me. He even checked in with me first when he goes out on pass. When he came to my office this time I was trying to calm him down and he kept shouting 'Who would take my blanket, where is it'? Asked if (R22) made any physical threats to her or other residents, E2 stated, No, not to my knowledge. Asked if (R22) was a harm to himself or others, E2 stated, Well no but I don't know what he's capable of doing and I don't feel safe with him here. Surveyor asked E2 whether resident rooms were supposed to be home-like and items in residents should be treated as their personal items, E2 responded, Well yes of course we do that here. Asked what the normal reaction would be, if someone came to their home and discovered something was missing or stolen from their room, E2 responded, Well I guess it would bother me and I might get angry. E2 was asked why this reaction would warrant a call to the doctor to get R22 an involuntary transfer for a psychological evaluation, E2 responded, I felt he was a threat. Telephone interview on 6/22/17 at 1:00 PM with Z1 (R22's Physician) states in part, I did receive a call from the DON regarding (R22). Z1 stated in part, I remember seeing (R22) at the hospital and we kept him for 4-5 days, I think he had fallen or something but I cannot recall. When I found out he was placed at that facility I was quite surprised actually because I know he can be a handful. He's not violent or anything like that and he's never been physical with anyone but he can be a challenge to take care of so I was surprised the facility accepted him. Asked if he could recall the reason the facility called him for an order to send (R22) involuntarily Z1 stated, I believe when I spoke to E2(Director of Nursing) she said that he (R22) was being loud and threatening staff. Asked if he believed (R22) was capable of physical violence, Z1 stated, oh no. You see (R22) is severely hard of hearing so he talks loudly and will raise his voice because he can't hear himself or others talking to him. Z1 was told that the E2 (DON) obtained his order for discharge claiming he was a harm to others, Z1 responded, Well that's not correct. Like I said, he is not a violent person. R22's physician progress notes [REDACTED]. On 6/29/17 at 3:30 PM, R22 came by facility to obtain some of his personal items left at the facility. R22 was asked to come sit and speak with the surveyor to talk about the events leading to his discharge. R22 stated in part, My stuff is still here and I came back to get them because they just kicked me out like that. I went out on pass and when I got back late in the afternoon, my blanket is gone. They actually tried to blame my roommate, can you believe it. Now my roommate can't even move on his own, in diapers, and they expect me to believe that this guy probably took it so I was p**** and I went over to (E2) and she just makes light of it and says well we'll try to find it. Then this big guy (E16/housekeeper) who comes out of nowhere says, He'll look for it later so that p**** me off even more. He leaves for a bit and comes back and starts hovering in the background as if I was going to do something to E2 or something. I turn around and told him, What the heck are you looking at and he just stands there instead of looking for my blanket. Asked if he threatened the DON, staff, or any resident, R22 states, Of course not. You know this place has had it for me since I got here. They told me several weeks ago I don't need any more nursing so ever since that they've been trying to find any reason to get rid of me. Asked if he wanted to come back, R22 stated, Yes of course I do. I fell and I need therapy because I still need help to walk. I can't hear so I need to see a doctor for that, I use an inhaler so I need help with that. I was so close to getting placement in an apartment, and now I can't get one because this place is making it more difficult because now I'm labeled trouble. They've just destroyed me, I'm telling you, just destroyed me. (At this point, R22 starts crying) and asks, please you gotta help me, I'm in the streets now. Asked if he was ever provided information at any point during the transfer to the hospital or before about his rights for appeal of the involuntary transfer, R22 stated, No, that's why I called you. They didn't give me anything, just called the paramedics and I was escorted out almost like some common criminal. I mean they're the ones that stole from me, and I'm the one kicked out? 2. R23 is a [AGE] year old resident originally admitted to the facility on [DATE] and served an involuntary transfer on 6/15/17 to the hospital for a psychological evaluation. Per physician order [REDACTED]. Per facility notes dated 6/15/17 written by E18 (Social Service Assistant) states in part, Resident was informed she would be getting a new roommate. Resident became very adamant about not wanting a new roommate. Resident became increasingly agitated and did not allow staff to come into her room to check in on her. Nurse on duty attempted to conduct her rounds and resident became physically and verbally aggressive towards nurse. Social Service attempted to speak to resident, however resident began yelling and continue to be verbally aggressive. Nurse informed MD and he gave order to have resident sent out for psychiatrist evaluation. Ambulance arrived and resident was not being cooperative with paramedics. Nursing staff and paramedics assisted resident to stretcher due to resident not cooperating. Signed interview dated 6/28/17 with E10 (licensed practical nurse) states in part, (R23) she's demanding and she needs what she needs and wants it right now. I'm not sure why she's here. She requires medication management. She was hypertensive. I float and I started work here in January. I was finishing my report to the first floor nurse and I didn't see what happened. I knew management wanted to move a fall risk resident into her room when I realized I heard screams but didn't know what about. I don't recall what she said but it sounded very aggressive. To my knowledge, she did not hit anyone and no one told me that also. I never witnessed before her screaming in an aggressive manner before this one incident. She and I got along very well when I took care of her. Asked why he was named as a witness to petition for involuntary transfer for R23, E10 stated, Well I was asked to sign that petition, well I guess I didn't really witness it just heard her. 3. R24 is a [AGE] year old resident originally admitted to the facility on [DATE] served an involuntary transfer on 5/2/17 to the hospital for a psychological evaluation. R24 currently resides at an alternate facility offering Spanish speaking intervention therapy according to E1(administrator). Facility face sheet dated 4/12/17 has R24's [DIAGNOSES REDACTED]. Per nurses notes dated 5/2/17 written by E21(licensed practical nurse) states in part, The nurse on duty observed resident standing up by dirty trays after dinner, collecting dirty utensils from the trays. Nurse on duty redirected resident. Resident became verbally aggressive towards nurse. Resident hit nurse twice and threw a cup at the nurse, staff member redirected resident to her room. MD made aware and ordered resident to send to hospital for psych evaluation. Resident son and daughter, doctor made aware. Signed interview with E21 on 6/28/17 states in part, She usually is in a wheelchair, old lady, she's small, thin, frail. She was here for nursing rehabilitation. She was a long time patient. She only took medications by mouth and she eats by herself. She moves by wheelchair. She cannot walk. Her general mood is that she's annoyed. When the family is here she's happy. She had about two incidents with me. The first incident she was in the dining room doing activities and she was yelling. If someone goes to her particular spot, she will yell. Second time I was trying to redirect her and she was collecting spoons on a cart. She threw the spoons on me. She was hitting my arm. She didn't hurt me. I told the director of nursing I was okay. She does not hit herself. She did not touch any of the other residents. After social service called the doctor and they told me they are going to send her to the hospital and just told me the room in the hospital. So if any residents hits anyone, our staff will have to send patient out. Facility's policy dated 11/28/16 titled Transfer and Discharge Policy and Procedure states in part, The facility shall permit each resident to remain in the facility unless such transfer or discharge is made in recognition of the resident's rights to receive considerate and respectful care; to receive necessary care and services and to participate in the development of the comprehensive care plan and in recognition of the rights of other residents in the facility. Procedure: The facility reserves the right to transfer a resident deemed acutely ill by the physician to a hospital or other facility staffed for skilled care. Non-emergency transfers or discharges not within the same certified facility will receive notice 30 days before or discharge. Notice will be given to the resident/responsible party. The written notice will include the following: A statement that the resident has the right to appeal the action to State Department of Health including a current phone number of the department; the name, address and telephone number of the State Long Term Care Ombudsman; A statement that, if the resident may appeal the transfer or discharge to the Department of Heath within 10 days of being notified of transfer/discharge. The resident may remain in the facility pending an appeal determination or 30 days if the department agrees that the transfer is appropriate. The resident may be transferred from the facility when it's been determined that: the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The resident being at the facility endangers the safety of self or other individuals in the facility.