Every finding on record at Lincolnwood Place

Based on observation, interview, and record review, the facility failed to follow the food storage policy by not removing lettuce that appeared rotten and waterlogged and not labeling, dating, and monitoring refrigerated foods. This deficient practice has the potential to affect all 31 residents who consume food prepared in the facility's kitchen.On 11/19/2025 at 9:55 AM, the second refrigerator contained a single-serve garden salad on a transparent plate that was not covered. Multiple single-serve red gelatin portions were uncovered on a large tray with no date. Two individual transparent containers of ranch dressing were covered but had no date. V6 (Director of Dining Services) stated the gelatin was poured the day before on 11/18/2025 and that all foods placed in the refrigerator should be covered and labeled. V6 stated he was unsure when the ranch dressing was placed in the refrigerator.On 11/19/2025 at 9:55 AM, V6 stated that the garden salad was prepared the day before and that both the garden salad and the gelatin should not have been left in the refrigerator uncovered and unlabeled.On 11/19/2025 at 10:02 AM, the walk-in refrigerator contained a large opened clear container holding multiple peeled white onions with no cover, label, date, or time. An opened package of prosciutto was also present with no date.On 11/19/2025 at 10:02 AM, V7 (Dietary Manager) stated that the peeled onions and prosciutto should have been covered and labeled with a date.On 11/19/2025 at 10:04 AM, the walk-in refrigerator was observed to contain 5 rotten lettuce heads (dark brown and yellow, soggy and moist) inside a transparent bag that was dripping fluid. The bag was placed on top of a brown carton box holding individual romaine lettuce heads in an unsealed transparent bag.On 11/19/2025 at 10:04 AM, V6 and V8 (Executive Chef) stated that the transparent bag containing rotten lettuce should not have been placed on top of the unsealed box of romaine lettuce. V6 stated the lettuce had arrived in a shipment that morning and that he was supposed to call the company to report that the lettuce arrived rotten. V6, V7, and V8 all stated that the rotten lettuce should not have been stored inside the walk-in refrigerator.On 11/21/2025 at 9:33 AM, Reviewed the facility's food purchase invoice from US Foods, ordered on 11/17/2025 and received on 11/19/2025. Invoice number 2195039, page 2, documented the purchase of lettuce, fresh, 24-count box.On 11/21/2025 at 10:04 AM, V6 stated that the shipment containing lettuce consisted of round, circular lettuce heads packaged inside a box.On 11/21/2025 at 9:15 AM, a record review of the policy Skilled - Food Safety Requirements, revised on 10/22/2025, documents: It is the policy of the facility to procure food from sources approved or considered satisfactory by federal, state, and local authorities. Food will be stored, prepared, distributed, and served in accordance with professional standards for food service safety.The policy defines food service safety as handling, preparing, and storing food in ways that prevent foodborne illness. Policy Explanation and Compliance Guidelines:1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following:a. Procurement (obtaining) of food from sources approved or considered satisfactory by federal, state, and local authorities.b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms.3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage.a. Follow contract/vendor procedures when food arrived damaged, or concerns are noted. Remove these foods from use.C. Refrigerated storage- food that require refrigeration shall be refrigerated immediately upon receipt or placed in freezer, whichever is applicable. Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/ discarded.v. Keeping foods covered or in tight containers. On 11/21/2025 at 10:10 AM, V1, V6, and V7 stated that all 31 residents consume food provided by the facility's dietary services.

Based on observation, interview, and record review, the facility failed to follow Medication Administration Policy by not labelling a multi-dose jar of petroleum jelly with the open date. This failure affected 1 resident (R35) of 12 reviewed for medications.Findings include:On 11-19-25 at 8:10 AM, surveyor observed V3 (Registered Nurse) apply petroleum from R35s jar without an open date. Surveyor and V3 verified there was not an open date on the jar.On 11-19-25 at 8:25 AM, V3 (Registered Nurse) said the nurse who opens the jar is responsible for writing the open date. V3 said significance of the open date is so staff can refer to how long the medication is good for.On 11-19-25 at 12:58 PM, V2 (Director of Nursing) said the significance of an open date allows staff to know when the medication expires. The staff who opens the medication is responsible for labelling the open date. V2 said all nurses are responsible for checking for open dates on multi-dose medications.Medication Administration Policy revised 2-23-24 documents: When opening a multi-dose container, the date shall be recorded on the container.

Based on observation, interview, and record review, the facility failed to follow the food storage policy by not labeling food products with (cook or open) dates. This failure has the potential to affect 36 residents with oral diets. Findings include: On 12/10/24 at 9:56 AM, Surveyor and V6 (Chef) noted 1 metal pan of cooked mixed vegetables without a date, 1 metal pan of meat sauce without a label or date, 1 metal pan of marinara without a label or date, 1 metal pan of barbeque sauce without a label or date, and 1 metal pan of beef base without a label or date, 7 trays of uncooked tilapia without a label or date, 1 pan of lasagna without a label or date, 1 tray of dinner rolls without a label or date, 1 open bag of tortellini without a label or date, 1 open bag of tater tots without a label or date, 1 open bag of sweet potato fries without a label or date, 1 open bag of raisin bran without a label or date, and 1 open bag of wheat cereal without a label or date. Surveyor noted V6 immediately labeling numerous food items with dates. On 12/11/24 at 9:45 AM, V6 (Chef) said food labels let you know when the food was handled and you can determine how long the food is good for. V6 said all (dietary) staff are responsible for labeling food items. On 12/11/24 at 9:55 AM, V7 (Dietician) said food is labeled and dated before and after food is handled. Dates let you know when food was prepared and when it was used. V7 said depending on the food, food can last 3-5 days. V7 said all dietary staff should label and date food items. On 12/12/24 at 9:44 AM, V8 (Cook) said food is labeled to say how long it has been there. V8 said all food should be labeled and all kitchen staff is responsible for labeling food. Food Storage Policy (revised 9-2016) documents: 1. All products should be dated upon receipt and upon use when the entire amount of a product is not prepared. Where requires by state regulations, use by dates are put on products. Leftovers should be date according to the leftovers policy. Dietary Spreadsheet documents 36 residents on oral diets.

Based on observation, interview, and record review, the facility failed to monitor the temperature of two of two medication refrigerators reviewed for medication storage. This failure has the potential to affect six of six Residents (R2, R3, R8, R14, R17, and R182) reviewed for medication storage in a sample of 14 residents. Findings include: On 12/11/24 at 9:30am, during a tour of the medication storage room, surveyor observed log A (Patient medication fridge) with a missing temperature date for 12/2/24, 12/3/24 and 12/10/24. Log B (House stock control substance fridge) was also missing temperature on 12/11/24. Surveyor, V2 (Director of Nursing/DON) and V13 (Registered Nurse/ RN) also observed medications for six residents in the fridge. (R2, R3, R8, R14, R17, and R182). On 12/11/24 at 9:30am, both V2 (DON) and V13 (RN) stated that, the night shift is responsible for checking the refrigerator at the end of the shift in the morning before leaving. Both stated that the temperature should have been checked. V2 stated that if the fridge is not in the right temperature it can affect the efficacy of the medications. The facility was unable to provide policy on medication refrigerator temperature monitoring.

Based on observation, interview and record review, the facility failed to adequately supervise a high fall risk resident for one of four residents (R26) reviewed for accidents in the sample of 14. Findings include: On 12/10/2024 at 10:09AM during facility rounds, V15 (Certified Nursing Assistant) was observed coming out of R26's room and R26 was observed sitting on the toilet with R26's wheelchair in front of her with no staff present. On 12/10/2024 at 10:15AM during interview with V15, V15 stated that he went out of R26's room because he needs to grab another pair of gloves because what he had was the wrong size. V15 stated that he does not usually leave the resident but R26 is not a fall risk so he trusts R26 will not fall. On 12/12/2024 at 9:30AM during interview with V2 (Interim Director of Nursing), V2 stated that staff is expected to gather all their needed supplies before proceeding to resident's room and before starting to provide care to any resident. V2 stated that staff cannot leave any resident unattended until the task is completed. V2 also stated that if the resident wants some privacy, the staff can stay outside the bathroom with the door slightly opened to be able to hear or peek as needed. V2 stated that supervision means that one staff must be present to oversee and monitor the resident while performing the task. V2 stated that extensive assistance means that the resident cannot really do the task for themselves, so one or two staff must be present to provide support and assistance to the resident during care. Review of R26's Fall Risk Review dated 11/18/2024 indicated R26 has fall risk score of 13 which is considered a high risk for falls. Review of R26's Progress Notes dated 06/12/2024 indicated a fall incident was noted. Review of R26's Minimum Data Set (MDS) Section GG - Functional Abilities dated 11/18/2024 indicated R26 needs supervision or touching assistance with toileting hygiene, and partial/moderate assistance with toilet transfer. Review of R26's care plan revised on 11/22/2024 indicated that R26 has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) weakness d/t (due to) dx (diagnoses) of dementia, cerebral infarction, depression, adult failure to thrive. R26 is an extensive assistance of one staff member for toileting, bed mobility, transfer. Review of facility's policy entitled Activities of Daily Living (ADL) Supporting - Skilled last revised 3/13/2023 indicated the following: Protocol: 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: c. Bowel and Bladder Elimination (toileting); 5. A resident's ability to perform ADLs will be measured using clinical tools, including the MDS. Functional decline or improvement will be evaluated in reference to the Assessment Reference Date (ARD) and the following MDS definitions: b. Supervision - oversight, encouragement or cueing provided 3 or more times during the last 7 days. c. Limited Assistance - Resident highly involved in activity and received physical help in guided maneuvering of limb(s) or other non-weight bearing assistance 3 or more times during the last 7 days. d. Extensive Assistance - while resident performed part of the activity over the last 7 days, staff provided weight-bearing support. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Review of facility's policy entitled Falls Program - Skilled last revised 09/13/2022 indicated the following: Avoidable Accident: The Community failed to: - Implement interventions, adequate supervision (consistent with the resident's needs), goals, plan of care, and current standards of practice in order to reduce the risk of an accident. An evaluation of the factors includes reviewing for previous falls and if so, are there any similarities. Intrinsic Risk Factors: - Previous fall Supervision - The Community is obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs, and identified hazards in the resident environment.

Based on interview, and record review, the facility failed to administer immunizations to 3 of 5 residents (R15, R28 and R132) reviewed for immunization in a sample of 14 residents. Findings include: During record review on 12/12/24 at 11:00am, R15's record was noted with a consent for influenza dated 11/22/24. The vaccine was not administered as of 12/11/24. R28 consented to pneumococcal vaccine on 11/13/24 and the vaccine was not administered as of 12/11/24 and R132 consented for influenza on 12/4/24 and did not receive the vaccine as of 12/11/24. The surveyor, V2(Director of Nursing/DON) and V13(Registered Nurse/RN) observed a house stock of 20 pre-filled (0.5ml (millimeter)) Influenza Vac Adjuvanted Fluad ([AGE] years of age and older) in the fridge during medication storage inspection. On 12/11/24 at 11:30am, Both V2(DON) and V4(infection Prevention) stated that the vaccines should have been given. V2 stated that the nurse who took the consent should have given the vaccines. V2 stated that residents' vaccine status is checked upon admission and given if they have not received any immunization. V4 stated that she is responsible for checking that residents' immunizations are up to date once admitted into the facility. V4 stated that she took over the position nine months ago. Facility policy dated 6/4 /2024 reads, title Resident Immunization policy: 3. Procedure: As appropriate residents will be offered the opportunity to receive the immunizations annually (October 1 - March 31st) for influenza. 4. As appropriate, residents will be offered the opportunity to receive a one-time dose of vaccine for pneumococcal pneumonia after the age of 65, or a second dose for those who received their first dose when they were under 65; or if 5 or more years have passed since that dose. Facility policy dated 7/14/2022 titled, Offering Pneumococcal. Policy: All residents will be offered the pneumococcal vaccine PCV 13 and PP SV23 to aid in preventing pneumococcal infection (e.g pneumonia) Protocol: 1.Upon admission residents will be assessed for eligibility to receive the pneumococcal vaccine (PCV 15 and PPSV23 one year later, or RPP SV20) and when indicated will be offered the vaccination within 5 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated.

Based on interview and record review, the facility failed to maintain resident safety during a mechanical lift transfer, failed to ensure the mechanical lift sling was correctly applied during transfers, and failed to use a two person assist during a mechanical lift transfer. This affected one resident (R1) of three residents reviewed for safety and mechanical lift transfer. This failure resulted in R1 sliding from mechanical lift sling, sustaining a 3cm (centimeter) laceration to the posterior scalp, being sent to the local hospital where 3 staples were required to close the laceration. Findings Include: Facility reported incident with date of occurrence of 8/27/24, reads in part: R1 had a witnessed fall during transfer from bed to wheelchair and was sent to ER (emergency room ) for further evaluation. (R1) returned to facility with all diagnostic test negative for injury but required 3 stapled to back of head. Conclusion: on 8/27/24 at 1005, (R1) had a witnessed fall from mechanical lift. (R1) was placed into mechanical lift with sling, Agency CNA (Certified Nursing Assistant) was moving (R1) from bed towards wheelchair via mechanical lift when (R1) slid from mechanical lift sling. (V2 Director of Nursing/DON) called to the scene immediately and recognized that agency CNA incorrectly applied the sling to the lift. 911 (emergency response) was called, (R1) was sent to ER for evaluation, returned to facility with 3 staples to back of head. No other injuries identified. Hospital record dated 8/27/24, reads in part: (R1) status post fall at Nursing home, States the staff was moving her in her lift when she fell backward striking her head. (R1) had 3 cm laceration to posterior scalp. 3 cm in length and 2 mm (millimeter) in depth. Repaired with 3 staples. On 10/1/24 at 10AM, V2 (DON) stated that the incident was reported by V8 (CNA). V8 reported to V2 that there was a fall, and that V8 was observed to be visibly upset when V8 came to V2's office. V7 (Agency CNA) was transferring R1 and had a fall. V2 went to check on R1, R1 was on the floor, R1's head was resting on a towel but R1's head was closer to the metal leg based part the mechanical lift machine. V7 told V2 that R1 slid out of the sling. V2 observed the sling was still attached to the mechanical lift. It was apparent that V7 did not correctly attach and applied the divided leg sling to the resident and mechanical lift machine. The leg straps are supposed to crisscross and that is what would prevent the resident from sliding out of the sling. V7 used it as a chair sitting position, and straps did not go to a loop to prevent the resident from sliding out. V7 admitted V7 was doing the transfer by herself. V2 stated that V7 reported to her that at first, V7 asked for help and V8 came in the room and turned around and left. V2 interviewed V8 and stated that V8 was asked for help but when V8 went to R1's room, R1 was not prepared yet, not dressed or toileted, so V8 told V7 to get R1 ready and to let V8 know when V7 is ready to transfer R1. V8 left the room and assisted other resident, and when V8 walked passed the room of R1, observed R1 was on the floor and V7 was in the room. It was bad judgment and was rushed. V7 knew she needed second person for transfer. V7 made a bad decision, made the right call to ask for help at first but then did not wait and transferred R1 with one person assist. R1 had laceration on back of the head and returned in the facility with 3 staples. Facility provided a written statement from V7 (Agency CNA), reads in part: (V7) was working with (R1), trying to get (R1) ready. Asked another CNA (V8) for help with transfer. (V8) came in the room and left. (V7) put the sling underneath (R1), (V8) walked pass the room and asked do I have it as (V7) was listing (R1) with the mechanical lift. (V7) was using the control to adjusting (R1) (moving her so her head did not bum the bar) while up on mechanical lift. As (V8 ) entered the room, is when (R1) slid from the sling. (V7) stated that (V7) was not familiar with the type of (Mechanical Lift)/sling, and asked for assistance but the person left the room and said she would be back. No response when asked if aware that (V7) need 2 person assist with mechanical lift. Facility provided a written statement from V8 (Agency CNA), reads in part: (V8) was asked by (V7) to assist with the use of mechanical lift for (R1). (V8) went into the room to assist with the transfer, but (V7) did not have (R1) prepared, (R1) was not dressed or had sling underneath (R1). (V8) informed (V7) that (V8) have another resident at the toilet at the moment and will be back after (V7) has (R1) prepared for transfer. When (V8) came back about 10-15 minutes later, (V8) walk passed the room and see (V7) had (R1) in the mechanical lift. (V8) walked into the room to assist and as (V8) entered the room, (R1) just slid from the sling to the floor. (V8) went and got the nurse right away. R1's Care Plan, revision date 5/30/24, reads in part: that (R1) requires extensive assistance with ADLs (Activities of Daily Living) due to generalized weakness. Extensive assist with two members with transferring. Use of Mechanical Lifting Machine with a reviewed date of 2/23/24, reads in part: The purpose of this procedure is to establish the general principle of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training instructions. At least two (2) staff member are required to safely use mechanical lift. Place the sling under the resident. Visually check the size to ensure it is not too large or too small. Attach sling straps to sling bar, according to manufacturer's instruction. Facility provided a copy of instruction with picture observed to be attached on the mechanical lift machine, reads in part: Mechanical lift, 2 person assist. Place sling under resident. Take bottom straps and place under each leg. Connect the bottom straps to the bottom part of the lift. Connect the side straps to the middle part of the lift. Connect the top straps to the top of the list. Place resident arms on their chest. The colors on straps should match all the way around. Any questions should be addressed to CNA, Nurse, ADON (Assistant Director of Nursing) and DON before starting the transfer.

Based on interview and record review, the facility failed to transfer a resident using a mechanical lift to ensure resident safety. This failure applied to one (R1) of three residents reviewed for resident injury and resulted in R1 sustaining a laceration to the leg while being transferred from wheelchair to bed; R1 required emergent hospital transfer and treatment with 12 sutures. Findings include: R1 is an [AGE] year-old woman with a medical history that includes but is not limited to generalized weakness, lymphedema with +4 edema present, chronic kidney disease, and coronary artery disease. Review of R1's medical record documents that R1 is alert, able to make her needs known with forgetfulness. R1's MDS (Minimum Data Assessment) dated 12/18/23 documents that R1 has a BIMS (Brief Interview of Mental Status) score of 6 (severe cognitive impairment) and uses a manual wheelchair/walker. It is also documented that R1 has lower extremity impairment on both sides. Mobility and transfer assistance required is sit to stand - Dependent and on 2/9/24 documented as substantial/max assist (helper does more than half; helper lifts or holds trunk or limbs and provides more than half the effort); chair/bed-to-chair - Dependent; 2/9/24 substantial/max assist. R1's weight is documented as 193 lbs (pounds) on 2/6/2024 in EMR (Electronic Medical Record). Facility reported incident of 2/11/24 documents that at 12:30PM, two staff members were assisting with a wheelchair to bed transfer and R1 sustained a lower left leg laceration. R1 was sent to ER (emergency room ) and received 12 sutures. R1 returned to the facility on the same day. Treatment orders and pain management were in place. Facility states on report that a thorough review of medical record, therapy notes, and staff interviewes were conducted with the following findings: Staff reported they positioned the resident next to bed, locked wheelchair, removed leg rests. R1 was able to stand with assist, staff assisting with pivoting to sit on edge of bed. Left lower leg did not pivot as upper body was pivoting, as staff became aware of lower leg not pivoting, resident sat on edge of bed and left leg scraped against wheelchair, resulting in laceration .Interventions included to continue to work with skilled therapy and mechanical lift for all transfers. Facility provided documentation of POC (Point of Care) staff tasks for R1 for the month of February; documentation reads: GG-Chair/Bed-to-Chair Transfer: Extensive Assists with 2 People (Mechanical Lift); task is not marked off as being completed on 2/11/24, date is blank. Interview with V8 (Certified Nursing Assistant/CNA) on 5/26/24 at 2:26PM, V8 stated, I've worked at the facility for a year and four months; I work on both (shelter and skilled) floors. (On 2/11/24) I was working with two agency CNA's that day. I was the only regular staff on the floor that day. I was trying to help everyone out because they don't know the residents, they don't know how they like things, transfers, etc. R1 was not assigned to me that day but the agency CNA needed help transferring her, so I went to help her. If I remember correctly, there were actually two agency plus one trainee (CNA's), but the trainee never came back after that. I think that was her first day. I have worked with R1 before with therapy, so I said I know how to get her up. I went in the room and told her I was going to get her up for lunch. I didn't look at the page because I knew I had done it before with therapy. She usually gets up and we helped her, and she scooted on the side of the bed, we put the belt and the walker in front of her. She would grab the walker and stand and walk a few steps forward. But this time she did everything good but the only thing that went wrong was turning. She did stand and she grabbed the walker. I was in front, and the other CNA was on the side. She did stand and twist her body, but she did not move her legs. So, she failed to pivot. We didn't want her to fall, so she grabbed her from the back and swung her onto the wheelchair. I don't know if the wheelchair was too small, and her legs were too big. We sat her on the chair but then her leg got caught on the wheelchair. Nothing was out of the ordinary but the only thing that failed was the pivot. I didn't know at that moment since I had not worked with her for a while. I didn't know she was supposed to use the mechanical lift and I didn't know because no one told me, and I didn't see any (mechanical lift) pad in her room. I would have done the transfer with the mechanical lift if I had known but they didn't tell me until after the fact. V8 stated that staff normally know the residents' transfer status by looking at the binder at the nurses station but added, that she didn't look at it prior to transferring R1. V8 said that after the incident happened, she looked at the binder and saw that R1 should have been a mechanical lift transfer. V8 said, we need to look in the book to see if there are changes in resident status and ADL (activities of daily living) needs. Interview with V8 confirms information provided in CNA Occurrence Report completed by V8 on 2/11/24. On 5/24/24 at 12:36PM, V9 (Registered Nurse/RN) said that R1 is oriented times one or two with confusion. R1 is extensive assist and uses a wheelchair and mechanical lift for transfers. V9 said, we can't safely transfer her without the mechanical lift. She has needed the mechanical lift for at least two or three months that I can recall. She always requires two persons for transfer. On 5/25/24 at 1:59PM V6 (CNA) was interviewed and confirmed that there was a previous incident with R1, where she obtained an injury during a transfer but there was nothing done incorrectly, the issue was just that her skin is very sensitive. V6 said it was normal for R1's legs to be swollen and that R1's skin is very sensitive and easily to tear. V6 said, we always use a mechanical lift with her. The only incidents with her is her skin. On 5/24/24 at 2PM, V2 (Director of Nursing) said, the incident with R1 in February was a witnessed event, they had removed the leg rest. R1 didn't pivot her leg. She was doing therapy at that time. After this point, we made her a mechanical lift. At that point she would only ambulate with therapy; we (nursing) were no longer cleared to ambulate her due to her lack of consistency. It was a safety issue for her. On 5/25/24 at 2:08PM, V2 confirmed that during the incident with R1 in February, staff were not using the mechanical lift, they were doing a two-person pivot transfer. On 5/25/24 at 12:46PM, V10 (RN) was interviewed and stated that she did not recall much about the incident with R1. V10 said that she recalled that staff were present and that R1 obtained a skin tear. V10 confirmed that R1 requires two staff for transfers. Review of Incident Detail report completed by V10 (RN) for incident of 2/11/24 reads, under Description of Incident: two staff were assisting with a PIVOT transfer from wheelchair to bed. Leg rests were removed, wheelchair locked and positioned next to bed. Staff were able to stand resident and cued resident to pivot transfer and sit on edge of bed. Resident upper body pivoted leaned onto bed, when staff realized that lower extremity did not pivot, she sustained a laceration from the lower part of wheelchair. Staff assisted into bed and immediately notified nurse. Nurse assessed resident and sent out 911. Res returned to facility with 12 sutures to left lower leg. Review of R1's Physical Therapy - Therapist Progress & Discharge Summary dated 2/9/24 reads - Start of Care 12/14/23 and End of Care 2/9/24 Functional Deficits - Current Level for Transfers Mobility, E. Chair/bed to chair transfer requires, Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort; Goal for patient to safely transfer from bed <> wheelchair requiring maximum assistance x 2 (76-99% assist with 2 people) and End of Goal Status as of 2/9/24 is *GOAL NOT MET - on 2/11/24 The patient is able to safely transfer from bed to wheelchair requiring Max A (assist) to Max A x 2; Goal for the patient to safely transition from sit to stand requiring moderate assistance x 2 (26-75% with 2 people) and End of Goal Status as of 2/9/24 is *GOAL NOT MET - on 2/11/24 The patient is able to safely transition from sit to stand requiring Max A to Max A x 2 to Mod A x 2 - Inconsistent; Long Term Goals documents Impact on Burden of Care/Daily Life: Complicating factors, including Decreased cognition prevent the patient from achieving all established goals; Precautions: Fall risk, cog impairments. Discharge Summary is signed off by V3 (Physical Therapist). On 5/25/24 at 12:13PM, V3 (Physical Therapist) was interviewed regarding R1. V3 stated, R1 is a long-term resident. In February she was a max x2 for transfers from the bed to wheelchair. When a person is in PT (physical therapy) we try to manually transfer them to help make them strong. If we need additional help, we get another staff. For safety of the staff and patient we told nursing after the rehab, once they get discharged (from physical therapy) we recommend they use a mechanical lift for transfers. We (PT) communicate during the care plan meetings, and we sit with the patient and the family and let them know. We (PT) work with CNA's as well so they know, and we tell them verbally. Max A means with assistance and Max A times two people, this is more than 75% effort is called Maximal. R1 can fluctuate between Max one and Max two and Mod assist two person, which is 50-75%. These are terminologies for therapy, which is different from nursing terminology. If there is a sudden or urgent change then we have the physician put the order in the EMR so that everyone sees it. Surveyor asked V3, being that R1 was discharged from PT on 2/9/24 and this incident occurred on 2/11/24, would the expectation be that at the time of the incident on 2/11/24, staff should have been using the mechanical lift to transfer R1 from the wheelchair to the bed and V3 said, yes. Review of R1's care plan documents the following interventions: - TRANSFER: (R1) requires Mechanical Lift with 2 staff assistance for transfers. Date Initiated: 5/20/24 - (R1) uses (mechanical) lift for transfer. Date Initiated: 5/20/24 It is noted that there are no interventions listed in R1's care plan regarding transfer status prior to 5/20/24. Surveyor asked for documentation of R1's care plan to show transfer status prior to care plan intervention dated 5/20/24 and it was not provided during the course of this survey. On 5/25/24 at 3:15PM V1 (Administrator), provided facility One Person Transfer Policy and confirmed that while it is for a one-person transfer, many of the steps are the same for two-person transfer. The Facility Policy One Person Transfer - Skilled Last Reviewed: 07/08/21, reads: Protocol: UNLESS OTHERWISE SPECIFIED BY STATE REGULATIONS Residents who have been evaluated/assessed as requiring one-person manual assistance will also utilize a Transfer belt and/or assistive devices to promote safety of resident and employee. See Transfer Belt Policy. Procedure: 1) Review Therapy evaluation, physician order and/or Resident Tasks in Point Click Care for assistance required. 2) Explain procedure to the resident and how he/she could assist and what devices will be used. 3) Never perform a Chicken Wing Transfer . The facility policy Activities of Daily Living (ADL), Supporting - Skilled Last Reviewed: 3/13/2023, which reads: Policy: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the assistance necessary to maintain good nutrition, grooming, and personal hygiene. Protocol: 1. Residents will be provided with the assistance and care necessary to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their medical condition(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Bowel and Bladder Elimination (toileting) .

Based on observation, interview and record review facility failed to follow isolation procedures and usage of PPE (Personal Protective Equipment) for one (R5) resident. This failure has a potential to affect entire facility. Findings include: On 11/06/2023 at 9:42 AM, V1 (Administrator) stated that facility census is 26 at this time. On 11/06/23 at 12:09 PM, Surveyor observed V7 (Housekeeper) cleaning room [ROOM NUMBER], wearing mask and gloves, no gown. Visible contact isolation precaution sign posted and Personal Protective Equipment cart outside of the room [ROOM NUMBER] noticed. On 11/06/23 at 12:09 PM, Surveyor observed V8 (Maintenance staff) walking into room [ROOM NUMBER]'s bathroom with no Personal Protective Equipment, and no hand hygiene, before or after room entrance. On 11/06/2023 at 12:14 PM, Surveyor interviewed V7 who related the following in summary but non-verbatim: I just cleaned room [ROOM NUMBER]. This room is on contact isolation precautions, so I should wear a mask, and wash my hands before I go in and out of the room. My assignment consists off entire facility (skilled unit), including all 26 residents' rooms and common areas. On 11/06/23 at 12:25 PM, Surveyor interviewed V9 (Registered Nurse) who related the following in summary but non-verbatim: R5 is on contact isolation precautions for ESBL (extended spectrum beta-lactamase) in the urine. On 11/06/23 at 12:55 PM Surveyor interviewed V2 (Director of Nursing/Infection Preventionist) who related the following in summary but non-verbatim: V7 and V8 should have observed the sign and wore the appropriate Personal Protective Equipment, which would be gown and gloves. Additionally, they should have washed their hands with soap and water because R5 is on contact isolation precautions. Community Infection Control Policy - Assisted Living and Skilled dated 08/28/2023 reads in part, Contact Precautions - for known or suspected infections that represent an increased risk for contact transmission; Clean hands prior to entry and upon exit of resident room; Use personal protective equipment (PPE) including gloves and gown for all interactions that may involve contact with the resident or resident's environment.

Based on observation, interview, and record review the facility failed to implement R1's care plan in providing assistance in transferring resident from bed to wheelchair and failed to follow its policy in transferring resident (R1). This failure caused a laceration of R1's right lower leg that required treatment at hospital of 18 staples to control bleeding. The facility failed to update R1's care plan after the laceration injury during transfer. The facility also failed to implement its fall prevention care plan, complete fall accurate assessment and update the fall care plan based on post fall investigation to prevent future falls. This deficiency affects all three ( R1, R2 and R3) residents reviewed for Resident safety. Findings include: 1. R1 is admitted on [DATE] with diagnosis listed in part but not limited to Spinal stenosis lumbar region with neurogenic claudication, Peripheral vascular disease, Chronic venous insufficiency, Diabetes Mellitus type 2, Congestive heart failure, Bilateral hearing loss. MDS (Minimal Data Set) /Resident assessment Section G Functional status G0110 Activity of Daily Living (ADL) assistance B. Transfer indicated: Self performance: Extensive assistance; Support: Two + persons physical assist. Care plan indicated: He has ADL self-care performance deficit related to weakness, decrease mobility, osteoarthritis, heart failure, obesity. He needs extensive assistance with 2 assists with transfer. He always utilizes wheelchair. Intervention: Transfer: he requires extensive assistance by 2 staff to move between surfaces. R1 has potential for an alteration in skin integrity. Intervention: Use caution during transfer and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. R1's care plan is not updated after laceration injury during transfer. R1's post incident investigation report completed by V3 RN indicated on 2/14/23 at 7:20am, V5 Agency CNA transferred R1 from bed to wheelchair after putting R1 to the wheelchair, CNA observed R1's right leg with laceration with bleeding. R1 stated that his right leg was caught on the wheelchair. Immediate staff intervention: ordered new wheelchair for R1. R1's incident report submitted to IDPH dated 2/15/23 indicated: On 2/14/23, V5 CNA transferring R1 from bed to wheelchair. Once in the wheelchair, V5 noticed right lower leg bleeding. V5 immediately called V3 RN to assess the laceration. V3 applied pressure dressing to control the bleeding. Physician notified and ordered to send R1 to the hospital for evaluation but R1 refused when paramedics arrived. R1 was educated by V3 on the importance of going to hospital to get leg looked at and treated. Laceration was monitored throughout the day and R1 was repeatedly encourage by staff to go to hospital. R1 finally agreed to be sent out to hospital. Physician and family made aware. Conclusion: R1 is alert and oriented x 3 and able to verbalize needs. R1 requires extensive assistance of 1-2 staff to move surfaces. When interviewed, R1 stated that while transferring from his bed into his wheelchair with V5 CNA, R1 obtained skin tear from the frame of his wheelchair. R1 originally refused to go to hospital but after repeated education and encouragement from nursing staff, R1 was agreeable. R1 was sent out to the hospital and received 18 staples in his leg and started on antibiotics prophylaxis to prevent infection. R1 returned to the facility and foam covering was placed on the identified area of the wheelchair. New wheelchair has been ordered for the resident. Physician and family updated. Facility continues to monitor skin laceration and follow treatment as ordered. Final incident report was submitted to IDPH on 2/16/23. R1's hospital record dated 2/14/23 indicated: An [AGE] year-old male, presented with chief complaint of laceration (right leg) that occurred while transferring between his wheelchair at the nursing home. Impression/plan as follows: 10 cm laceration. 18 staples placed. Return in 10-14 days. Return precaution including infection, bleeding. On 3/14/23 at 10:11am, Observed R1 sitting in front of his desk top computer. He is alert and oriented x3 but hard of hearing. He speaks softly and slow. Surveyor communicates with R1 using handwritten notes due to hard of hearing. R1 said that V5 CNA was transferring him to his wheelchair from bed when something sharp from his wheelchair caught his right leg. V5 held him using his hands when transferring him to bed. V5 did not use gait belt. He transferred him by himself. Observed R1's right leg with steri- strips, swollen with discoloration. Called V3 RN to R1's room. On 3/14/23 at 10:28am, V3 RN said that she is the nurse working when R1 has laceration incident on his right leg. She said that V5 CNA reported to her that R1 is bleeding from his right leg after he transferred him from bed to wheelchair. V5 did not know what happened. V3 said that his right leg probably caught from sharp bolts protruding from his wheelchair's leg/footrest. She said that they discarded the old wheelchair and got her a new one. R1 currently does not have leg/footrest attached to his wheelchair. She said that R1 needs 2 persons assist for transfer. R1 has diagnosis of PVD that is why she has discoloration and swelling of both legs. She said that V2 removed the sutures 10 days after the incident happened and applied steri-strips and keep it open to air. On 3/14/23 at 10:38am, V3 RN said that they don't have list of residents on high risk for falls/ fall precaution monitoring or resident who has recent injury. She said they communicate with 24 endorsement/report written each shift. Rounds made with V3 RN. 2. On 3/14/23 at 10:41am, Observed R2 lying in bed. Call light within reach. Her bed is on high position (approximately 27 inches from the floor) and the control of the bed is at the foot part of the bed. V3 RN said that R2 is just admitted yesterday with diagnosis of fracture of right leg from falling. V3 said that bed should be in lowest position for safety, but she has to check the care plan. V3 did not adjust the bed to the lowest position. R2 is admitted on [DATE] with diagnosis listed in part but not limited to Fracture of right lower leg, Syncope and collapse, History of falling, Hypertension. Admission fall assessment dated [DATE] indicated: low risk for falls. Care plan indicated: R2 is at high risk for falls related to deconditioning, history of falls, syncope, use of antihypertensive, psychotropic medications. On 3/14/23 at 10:44am, V4 Agency LPN said that she does not know who are the residents on her side on fall precautions or has recent injury. She did not receive report from the night nurse. On 3/14/23 at 10:52am, Review medical records of R2 with V3 RN. R2's admission fall assessment indicated low risk for fall. R2 is admitted with fracture right leg from fall. Her care plan indicated she is at high risk of fall. Review 24 hours endorsement report received by V3 RN from night shift that R1 and R2 are not in fall precautions or history of injury. R3 indicated high risk for fall. 3. R3 is admitted on [DATE] with diagnosis listed in part but not limited to Fracture of lower end of femur, Dementia with mood disturbance, History of falling, Macular degeneration, Presence of artificial right hip joint, Peripheral vascular disease. R3's care plan indicated she is at high risk for falls. Intervention: Follow facility's fall protocol. R3 had witnessed fall incident during transfer dated 12/12/22. Post investigation new interventions: Bed low position, Call light within reach, Continue PT for strength and mobility and use of gait belt while transferring. R3's fall care plan was not updated based on post fall investigation, Bed low position and use of gait belt while transferring were not written as interventions. On 3/14/23 at 11:08am, Observed R3 lying in bed in high position, bed control is at the foot part of the bed. V3 RN took the bed control and placed the bed in the lowest position. On 3/14/23 at 11:31am, V2 DON said that she is the also the Fall coordinator. V2 said that they have fall prevention program which included all residents on high risk for fall and those who has history of falls. They don't have binder or list of residents on fall prevention program. Residents on fall precautions should be indicated in the shift to shift 24 reports. Fall assessment is done upon admissions, quarterly and after each fall incidents. Asked DON how much assistance R1 needs for transfer. V1 said R1 needs 2 persons assist. Informed V1 that R1 was transferred by V5 CNA by himself instead of 2 persons assist, then she said R1 can be transferred 1-2 persons assist. V2 said that she did not remove R1's right leg staples, V8 LPN did on 2/24/23. On 3/14/23 at 12:27pm, V6 Executive Director presented policy on Safe resident handling and movement. V6 said that Safety transfer of resident is determined by licensed professionals and as indicated in MDS. On 3/14/23 at 12:46pm, V7 Physical Therapy said that he has taken care of R1 last year when R1 was on Therapy services. R1 was discharged from therapy with 2 persons assist for transfer. V7 said that the wheelchair's leg/foot rest should be removed so it will not be in the way when transferring resident from bed to wheelchair. The legs may be caught during the transfer. V7 added that the wheelchair should be in 45-degree angle to the bed and the leg/footrest sticking out will not ensure the wheelchair is close to bed, so its recommended to take it off. V7 said that they don't provide CNA training for transferring resident from bed to wheelchair/wheelchair to bed, it's the nursing department who provides training to CNAs and nurses. On 3/14/23 at 1:10pm, V2 DON said that CNA should use gait belt when transferring resident from bed to wheelchair. The floor nurse should give report to the agency CNA regarding assistance in resident's transfer. R1 needs 1-2 persons assist in transferring from bed to wheelchair. Informed V2 of the following concerns identified after interviewing with R1, V3 RN and V7 PT. R1 was transferred by V5 CNA by himself without using gait belt. V5 CNA did not remove R1's wheelchair leg/footrest prior to transferring him from bed to wheelchair. Per V3 RN and V7 PT, R1 is 2 persons assist for transfer. R1's MDS/Resident assessment and care plan indicates that he is 2 persons assist for transfer. R1 and V3 RN said that R1's right leg is caught from the sharp objects from his wheelchair leg/footrest causing laceration on right leg that needed treatment from the hospital. V2 said that outside therapy company did transfer in-service to CNAs and nurses last [DATE]. V2 denied that R1's right leg was caught from the leg rest. V2 said it caught from of the wheelchair's frame near the arm rest. Surveyor requested to see R1's old wheelchair. At 1:56pm, V2 said that R1's old wheelchair was thrown away already. On 3/14/23 at 2:51pm, Review R1, R2 and R3 medical records with V2 DON. Showed to V2 R1's MDS/Resident assessment and care plan indicating 2 persons assist for transfer. V2 said that after resident's fall incident IDT (Interdisciplinary team) will do the root cause analysis and formulate new care plan intervention to prevent future falls. IDT includes V2 DON, Care plan coordinator, Social Service, and floor nurse at times. Post fall investigation is completed by the floor nurse on Section A and V2 DON on Section B. Care plan updated by V9 Care plan coordinator. Post care plan investigation and care plan update for any incident is done within 24 to 72 hours. Informed V2 of observation during rounds made with V3 RN. Both R2 and R3's beds are on high position. R2's fall admission assessment indicated she is at low fall risk despite that she is admitted with fracture of right leg due to fall. R1 and R3's care plans were not updated based on post injury/fall investigation. V2 said that She does the post fall investigation/root cause analysis with new fall interventions and V9 does update the care plan. On 3/14/23 and 3/15/23, Attempted to call V5 CNA several times left message but did not call back. V2 DON aware. On 3/15/23 at 11:35am, Informed V2 DON of inconsistency of incident documentation of incident in regards with their policy. Per V3 and V2 DON, any incident report is not documented in resident's progress notes. It was documented in paper form of post investigation report, fall follow up assessment and change of clinical condition assessment. But facility's policy indicates: Incident documentation is documented in resident's progress notes. On 3/15/23 at 11:59am, V10 Maintenance Supervisor said that he has been working in the facility for 9 years. He said that they check for wheelchair safety weekly such as brakes, hand rest and leg rest. The one responsible for checking this is V11 Director of Plant Operation but he was let go last month. V10 said that he cannot find the log documentation that R1's wheelchair was checked for safety. V10 said that he recently took over this month because he was on vacation last month. He said that they don't repair wheelchair because it does not cover by insurance, they disposed it. Facility's policy on Safe resident handling and movement indicates: These guidelines are developed to assist staff when performing resident transfers, including manual transfer and transfer using assistive device and assisting residents with mobility. The procedures within these guidelines, as well as any other policies and procedures for resident care and services, must be followed whenever an employee provides assistance to residents with transferring and movements. Procedure: All residents are evaluated according to evaluation policy and procedure guidelines. The determination of the resident's transfer/movement ability will be determined by a licensed professional such as but not limited to : RN, PT, OT, MD, LPN/LVN. All staff responsible for assisting with resident transfers will be observed for competency on a routine and as needed basis. Facility's policy on Transfer belts indicates: Any resident who requires minimal assist or more to transfer or ambulate will utilize a transfer belt for resident and employee safety. Only transfer belts with handles should be utilized. Procedure: 1) Resident ambulating and transfer will be determined by an evaluation by an RN/PT/OT/MS/LPN/LVN. The evaluation/assessment will determine what size transfer belt the resident will utilize. The transfer belt will be resident specific. 9)Staff to place the transfer belt around the resident's waist. The belt should fit snuggly but not tight. Best practice is ensuring 2 fingers fit between belt and resident's body. Staff should place hands in transfer belt and handles and not between and resident's body. 11) If a resident needs assistance of 2 caregivers, staff are to follow the procedure for the one caregiver transfer with the second caregiver on the side/back of the resident. Staff to stand with a broad base of support, with feet shoulder width apart. Staff to place hands in transfer belt handles. Resident should move as close to the edge of the bed/chair as safety allows. Staff to ensure all applicable wheel locks are locked. Facility's policy on fall program- Skilled indicates: The community will have a system in place to ensure that the community's residents are assessed on admission for their potential fall risk and to guide in the implementation of interventions to assist in decreasing the frequency or severity in the event a fall does occur. Proper actions following fall include: *Revising the resident's plan care and/or community practices, as needed, to reduce the likelihood of another fall Supervision- The community is obligated to provide adequate supervision to prevent accidents. Adequacy of supervision is defined by type and frequency, based on the individual resident's assessed needs and identified hazards in the resident environment. Facility's policy on Fall management program guidelines indicates: Senior lifestyle is committed to minimizing resident falls and or injury and to maximizing each resident's physical, mental, and psychosocial well-being. While preventing all resident falls is not possible, the community will act in a proactive manner to identify and assess those residents who are at risk for falls, plan for preventive strategies and facilitate a safe environment. Procedure: 1. All staff will be responsible in assisting with the implementation of the community's Fall management program to maintain the safety of all residents in the community. The program will include measures which determine the individual needs of each resident by evaluating the risk for falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as necessary. Fall management program standards: 2. If a resident has a fall or continues to have falls, the Care plan will be updated with new interventions after each fall. Immediately following fall, the fall temporary service plans should be initiated by staff. Upon investigation completion, DON or designee will resolve the fall temporary service plan and update the current care plan with on-going interventions to reduce falls. 3. The goal is to identify interventions to reduce the number of falls and prevent serious injury from falls. 4. Current interventions and any new interventions added will be discussed with care staff to ensure full understanding. 6. All staff will be trained on the fall prevention program. Facility's policy on Documentation guidelines indicates: Approved staff will document concise and factual information regarding resident's care and condition. Incident Documentation: 1. DON/designee to complete progress notes for all resident incidents. 3. Monitor and document in progress notes a minimum of once daily for 72 hours.

Based on interview and record review, the facility failed to follow their Medication Administration policy and Narcotic/Controlled Medication Management policy, and physician orders. This affected 1 of 3 (R1) residents reviewed for physician orders and medication administration. This failure resulted in R1 received unscheduled opioid medication without doctor's order. R1 was transferred to local hospital due to hypotension and altered mental status in the wound clinic appointment. Hospital final diagnoses of Opioid overdose, accidental or unintentional, Anemia, Lupus, Antiphospholipid antibody positive and elevated BUN. Findings Include: R1 was admitted in the facility on 1/21/23 for pain management, physical therapy services and wound vacuum treatment on her right leg for post traumatic hematoma of right lower extremity and required embolization of anterior tibial artery at the time and required debridement of the wound. R1 was admitted with pain medication in the facility on 1/21/23 such as: Acetaminophen 500mg three times a day and oxycodone 10mg every 4 hours as needed for maximum daily dose of 60mg. Oxycodone was changed on 1/24/23 to 10mg three times a day for 10 days. On 2/2/23 R1 had a wound doctor appointment in wound clinic. Was seen by V4 (NP for pain management) and saw changes in condition, suggested to V2 (DON) for hospital evaluation. V4 stated on 2/21/23 at 11:15am on February 2nd, seen the resident there was a change of condition, mildly slow response, reviewed labs and may have contributed to that slow response, remembers seeing abnormal levels and suggested for resident to go to the hospital from there I do not know what happened because the next thing I know, R1 was going for her wound doctor's appointment, and I guess my recommendation was not followed by the V2 (DON). All I heard was R1 diverted to the hospital that day. R1's progress notes reviewed and noted on 2/2/23 at 2224 documented that a nurse placed a call to local hospital emergency room and R1 is admitted with Anemia and opioid overdose. Facility reported this incident to State Agency (SA) and initiated investigation on 2/2/23. Facility's investigation concluded that R1 admitted with medication order of oxycodone 10mg by mouth every 4 hours as need for pain with a maximum daily amount 60mg. Oxycodone was changed by pain management Nurse Practitioner (V4) on 1/24/23 from as needed to three times a day. Since the medication changed, R1 has not received more than the maximum recommended dose of 60mg per day. V2 reviewed narcotic records. In-service will take place with skilled licensed nursing staff. Investigation documents reviewed and facility has an interview with V3 (Nurse) regarding administration of medication for R1. Written V3 stated she should have looked more thoroughly at the EMAR (Electronic Medication Administration Record) prior to administering medication. V1 (Administrator) and V2 explained the need to follow physician orders and if medication is not listed in PointClickCare (PCC, electronic charting), it cannot be administered. V3 expressed understanding and was very apologetic that V3 had missed it. Narcotic opioid medication of R1 reviewed with V2. V2 showed the narcotic sheet count and the medication card, the count was right, however on 1/25/23 at 2am, 1/26/23 at 4am, and 1/27/23 at 2am, V3 administered oxycodone 10 mg to R1. Oxycodone was already changed from as needed to scheduled three times a day on 1/24/23. There is no noted change of order sticker on the medication card and on the count sheet. On 2/16/23 at 1:45pm, Interviewed V3 (Nurse) and stated V3 stated R1 complained of pain those 3 nights that she worked and she gave pain medication without checking the EMAR of R1. V3 did not look at the EMAR for the order, V3 knows that R1 had a PRN oxycodone order and the medication is still in the cart so V3 assumed that there were no changes with R1's pain medication. V3 stated that facility practice they supposed to remove the medication out of the medication cart when it was discontinued to avoid medication error. V3 also stated that one of those days, the computer is not working but cannot recall which day, but still admit that she should have looked the EMAR. We are not supposed to give medication without doctor's order, I should have checked first before giving R1 her medication. V3 also denied calling the doctor or NP to get an order and denied documenting anything in the progress notes of R1 for giving unscheduled medication at the time. On 2/21/23 at 2:15pm V2 stated Discontinued medication, they supposed to remove it from the cart because there is a change of order. If the medication is changed and keeping the medication, they will put the sticker to let other nurses know that there is a change while waiting for the new medication supply. No sticker was placed in R1's oxycodone medication. If the narcotic is remove they give it to me, and then I will destroy it. Nurses cannot give medication if there is no doctor's order. If a resident is still in pain the nurse should call and follow up with the pain management or the physician and get a new order if needed. If there was a new order I still expect the nurses to put the new order and document that the new order was given. Hospital record dated 2/2/23 shows that R1 was transferred to emergency department due to altered mental status and hypotension while in her wound clinic appointment. R1 receive 4mg of Narcan (known prescription medication used for treatment of a known or suspected opioid overdose) via IV and one dose via nebulizer treatment. R1 is more arouse after the narcan was given but still lethargic. Admitting diagnoses of Opioid overdose, accidental or unintentional, Anemia, Lupus, Antiphospholipid antibody positive and elevated BUN. R1 was assessed to be drowsy with pin point pupils and decreased respiratory effort in the ER. On 2/21/23 at 11:15am, V4 also stated I would expect nurses in the facility to follow the order, and not to give medication if it is not ordered. Narcan is use to reverse opioid overdose. I am not aware that extra oxycodone was given to R1. On 2/21/23 at 11:45am, V5 (Nurse that discontinued the Narcotic medication of R1 on 1/24/23) stated When medication is discontinued we remove it out the medication cart and if the medication is the same dose, we can keep the medication while waiting for the new one to come. There is a sticker that we put in the medication bingo card. I do not remember if I put a sticker at that time. Facility policy for Medication Administration with last reviewed date of 7/12/22 reads in part: Medications shall be administered in a safe and timely manner and as prescribed. Only persons licensed or permitted by this State to prepare, administer and document the administrations of medication may do so. Medications must be administered in accordance with orders, including any requires time frame. The individual administering medications must verify the resident's identity before giving the resident his/her medications. The individual administering the medication must check the label three times to verify right medication, right dose, right time, and right method of administration before giving the medication. If drug is withheld, refused or given at a time other than scheduled time, the individual administering the medication shall indicate in PCC the appropriate/related code and also complete a progress note in the resident record. Narcotic/Controlled Medication Management with last reviewed date of 6/20/22 reads in part: when a controlled substance medication is discontinued, left over controlled medication are not to be stock-pies in the medication cart.

Based on observation, interview and record review, the facility failed to follow their fall precautions and care plans to prevent a cognitively impaired resident from falling. This failure affected 1 of 3 residents (R1) reviewed for falls and with a history of falls. R1 fell in the bathroom face first and sustained a nasal fracture. R1 had a recent history of falls on 11/24/22. Findings include: On 12/16/22 at 11:00 AM, R1 was observed in the day room area sitting in a wheelchair attending an activity. R1 appeared confused and could not respond to questions. R1 wore a pink sweat shirt and gray sweat pants with white socks that were observed sliding on to the wheelchair leg rests. The activity aide (V12 ) was focused on observing the television where an exercise program was in progress. V12 was observed exercising with the program on the television and was not focused on R1 or any of the other 9 residents that were present in the day room. At one end of the day room was a rectangular shaped pillar where a computer and desk set up were situated and V4 (CNA/Certified Nursing Aide) was sitting. Surveyor asked V4 to identify R1, and V4 stood up from her computer behind the wall in order to observe the resident. Surveyor asked if she was assigned to monitor R1 while she was in the day room and how she could do this sitting behind the wall, V4 stated, She's mine (referring to her assigned resident) but I'm not watching her because she's doing an activity. Surveyor asked if she knew about R1 and what the facility told her to do with R1 to keep her safe from falling, V4 stated, I don't know because I'm agency and I don't know anything about R1. Surveyor asked whether the nurse or any other staff informed her about any care concerns with R1, V4 stated, I don't know what you mean. Surveyor clarified and asked whether R1 was a fall risk, V4 stated, I have no idea. On 12/16/22 at Interview with V3 (Assistant Director of Nursing) at 10:30 AM, stated, I don't really know what happened to R1, I am new here and I am usually in charge of the second floor and the DON (V2) is in charge of the first floor. Surveyor asked whether She and the director of nursing communicate incidents that are reported to the health department, V3 stated, Yes, but we have a lot of residents here and I don't know all of them. Surveyor asked how many residents she was in charge of, V3 stated, We have 28 but they come and go. Surveyor clarified with V3 that it was the facility that reported a fall incident to Public Health, V3 stated, Oh okay. Yes, R1 fell and broke her nose. Surveyor asked whether R1 was a fall risk and if she had fallen before, V3 stated, No she has not fallen before and she is very high risk for falls. Interview with V3 on 12/16/22 at 10:30 AM affirmed R1 fell face forward and sustained a nasal fracture. V3 stated, (R1) was in the bathroom and I was told she was being helped by a CNA and she slipped out of her wheelchair and fell face first to the floor. We sent her out to the hospital and she had a nose fracture. Interview with V2 (Director of Nursing) on 12/16/22 at 11:30 AM, affirms V3's statement and stated, I interviewed V11( CNA) and she claimed she was with R1 in the bathroom when she fell face forward. Records reviewed showed R1 fell on [DATE] with minor injury, fell on [DATE] where she was sent to the hospital and treated for a nasal fracture; and fell again on 12/9/22 where she was found on the floor beside her bed. R1 is a [AGE] year-old with diagnosis of Alzheimer's dementia, hypertension and atrial fibrillation. R1's care plan dated 12/5/22 reads in part, (R1) has had an actual fall on 11/24/22. Interventions: Bed in lowest position when in use, Continue interventions on the at-risk plan, For no apparent acute injury, determine and address causative factors of the fall, Frequent visual monitoring by staff when in bed, Monitor/document /report as needed x 72 hours to MD for signs and symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Another care plan dated 12/5/22 reads in part, (R1) is risk for falls related to cognitive impairment, history fall, use of psychotropic medication. Interventions: Anticipate and meet R1's needs. Be sure call light is within reach and encourage to use it for assistance as needed. Needs prompt response to all requests for assistance. Complete fall risk screen on admission and PRN as indicated to identify risk factors. Ensure that R1 is wearing appropriate footwear. Facility Incident Report written and reported by V2 (DON) reads in part, On December 6, 2022, the resident was being assisted by V9 (CNA) when R1 fell in the bathroom face first to the floor, injuring her nose and was sent out to the hospital for treatment and diagnosed with a fractured nose.

Based on interview and record review, the facility failed to have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in the facility water systems. This deficiency has the potential to affect all the residents in the facility. Findings include: On 12/06/2022 at 1:05 PM during rounds, V6 (Director of Plant Operations) was asked if he can present water testing results and said that he has to check with his director. On 12/07/2022 at 12:45PM, V6 stated that as far as he knows no water testing was done since he started in the facility which was between June and July 2022. Water Management Plan Date: June 27, 2022 Procedures for Legionella Testing if specified by Program Team: Periodic sampling (at least quarterly) for Legionella in cooling towers, spa pools and decorative fountains is recommended to demonstrate that the biocidal control is effective for the organism.

Based on observation and interview the facility failed to properly store unopened insulins in the refrigerator for 2 of 17 residents (R9 and R29) reviewed for medication storage and labeling in 1 of 2 medication carts. Findings include: On 12/7/2022 at 9:40 AM with V4 (LPN) checking medication cart 1, surveyor observed 2 insulin Aspart pens unopened in the top drawer of the cart. One insulin Aspart pen does not have a label to identify who the insulin belongs to. The other insulin Aspart pen is labeled for R9. V4 states those medications were in the drawer when she got here this morning. V4 states that the insulin Aspart pens should be refrigerated if not opened. On 12/7/2022 at 10:26 AM while reviewing medication cart 1 with V5 (RN) surveyor observed an unopened Humalog multi-dose vial with red tag that says refrigerate and labeled for R29. V5 states that unopened insulins should be refrigerated. On 12/08/22 10:33 AM V2 (DON) states that unopened insulins should be stored in the refrigerator. On 12/08/22 11:39 AM V11 (Pharmacist) states that facility's should store unopened insulins in the refrigerator.

Based on interviews and record reviews, the facility failed to protect a resident from physical abuse during provision of care for one (R1) of five residents reviewed for abuse. This deficiency resulted in R1 feeling shocked and frustrated after being slapped on the face and sustained a bruise on the right side of lip. Findings include: R1 is a [AGE] year old, female, admitted in the facility on 06/04/22 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to progress notes dated 06/25/2022, R1 was found to have a bruise on the right side corner of her lips. R1 stated that a CNA (Certified Nurse Aide) was turning her in bed this morning during morning care and she (R1) screamed and CNA hit her right side of face. Facility's initial abuse incident report dated 06/25/22 documented that V2 (Director of Nursing) was informed that in the morning that CNA (Certified Nurse Aide) was turning from side to side during changing of incontinence brief, R1 screamed and CNA slapped her three times to the right side of her face. V5 (Agency CNA) was the CNA. On 10/18/22 at 2:00 PM, V5 was asked regarding incident on 06/25/22 with R1. V5 stated, That day, the nurse (V21) told me to get her (R1) up that morning. I set up my morning rounds, so I was preparing her clothes and getting her ready. She was a little terrible, irritated. I got her dressed, started to behave nicer and talking like normal. As soon as she's done dressed, as I am about to transfer her to her wheelchair, she threw herself back into bed and said she does not want to get up. Refusing to get up said she doesn't get up in the morning. She was screaming, hollering. I just assisted her back to bed. She was verbally aggressive to me but not physical. When that happens, I walk away from the situation. I told the nurse that she was screaming and does not want to get up. I didn't notice anything unusual to her skin or face, I wasn't paying attention. The nurses don't update CNAs regarding residents' behavior. V12 (CNA) told me that she (R1) was a screamer, combative because she usually does not want to get up in the morning. V21 (Registered Nurse, RN) was asked regarding R1 and incident on 06/25/22. V21 replied, That day, V5 told me that she (R1) does not want to get up from bed. Nothing was told about her (R1) screaming or being combative when she was trying to get her up. I did not actually tell V5 to get her (R1) up from bed that morning. Cause I know exactly that she does not want to get up from bed, she prefers to get up after breakfast. She (R1) has a behavior of screaming like if she wants to talk to V22 (Family Member) and unable to, she screams. When she gets frustrated like she cannot reach for something, she screams. All staff were aware of her behavior. Try to talk to her, calm her down. She just screams, yell but not combative during care or will throw herself back to bed. When she is alone, she will just scream but nothing that would do harm to herself. On 10/19/22 at 11:35 AM, V12 (CNA) was also asked regarding R1 and behavior. V12 mentioned She is alert, oriented, sometimes confused. She is a screamer, yells a lot. She starts screaming like six or seven in the morning, she just gets confused. She was not combative or resisting to any care. Sometimes, she gets anxious during patient care in the morning. V5 asked me about R1, in general. I told her (V5) that she easily gets very anxious during care. I told her (V5) that you need to talk to her (R1), calm her (R1) down and report to the nurse regarding behavior. She (R1) does not do anything harmful to herself but screams. It depends on her mood whether she wants to get up in the morning, I talk to her (R1) and ask if she prefers to get up in the morning or right after breakfast. She does get a little uneasy, anxious when a staff wakes her up in the morning. She has a behavior monitoring log, I know I reported her behavior to the nurse every time she has it. R1's MDS (Minimum Data Set) dated 06/10/22 documented: Section C (Cognitive Patterns) - BIMS (Brief Interview for Mental Status) score 14 which means cognition has little to no impairment. Section D (Mood) - Behavioral Symptoms E0200 Behavioral Symptom - Presence and Frequency Physical Behavioral Symptoms directed toward others (e.g. hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior not exhibited. Verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others): Behavior not exhibited. Other behavioral symptoms not directed toward others (e.g. physical symptom such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). E0300 Overall Presence of Behavioral Symptoms - none E0800 Rejection of Care - Presence and Frequency - behavior not exhibited R1'S Psychiatric Evaluation dated 06/13/22 documented: History of Present illness: Upon interview, she presents somewhat anxious. She tends to become calmer when being talked to, but when left alone she could be observed making noise. She manifests feelings of helplessness due to her situation. She gets upset when her needs are not immediately met. She complains of some difficulty of sleeping, which appears to be related to her discomfort. She denies overt hopelessness. She does not endorse any [CONDITION(S)] or plans. She does not present with any overt paranoia or [CONDITION(S)]. Assessment: Adjustment reaction with depressive symptoms/acute pain/mild cognitive impairment. Behavior monitoring logs dated June to September 2022 indicated that R1 does not exhibit any behavior most of the time but yells/screams on the following dates: 06/18/22 - 3 (yelling, screaming) 08/03/22 - 0 (frequent crying); 3 (yelling, screaming) 08/09/22 - 3 (yelling, screaming) 08/25/022 - 3 (yelling, screaming) R1's care plan regarding mood problem as exhibited by: verbal expression (s) of distress; anxious appearance: Interventions - Monitor/record/report to MD (medical doctor) PRN (when necessary) mood patterns signs and symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols. There were no other interventions addressing behavior of screaming and yelling. On 10/19/22 at 2:20 PM, V2 (Director of Nursing) was interviewed regarding incident on 06/25/22 between R1 and V5. V2 stated, I was the one who investigated R1's incident last 06/25/2022. I got a call from the nurse stating that V22 reported that she (R1) had an incident with V5 from the morning. She (R1) stated that V5 slapped her three times in the face while giving care. I came in and spoke to her (R1) and asked her what happened. She said she was not able to recall what happen but V5 was turning her side to side to change her incontinence brief, she (R1) was screaming and resisting to care. V5 continued to change her while she was screaming and resisting to care. I asked if she (V5) was mean or hit her in any way. She (R1) did not mention about slapping. I did assess her (R1), she had a bruise on the corner of the lip on the right side. There was an injury on the lips. I asked her (R1) about the bruise and said she does not remember. According to V5, she went to change her (R1) and she (R1) was screaming while she is being cared for. She (R1) was resisting to care. So she (V5) called another staff to guide her and was told not get her (R1) up during breakfast so she helped her (R1) back to bed. I asked V5 about slapping, said she (V5) did not slap her (R1) and did not notice any bruising on her face. I don't know how the resident got the bruise. The resident did not remember and V5 said she did not notice any bruise during care. I did investigate about the bruise but I don't have the documentation. If a resident is screaming and combative/resisting to care, CNA should stop providing care and let the nurse know and come back later. Make sure the patient is safe. Prior to the incident, I was not aware that she does not want to get up for breakfast. I was also not aware that she has a behavior of screaming. I don't have any care plans for the behavior. Reviewing V5's statements during interview and V2's investigation, discrepancy was noted. V5 stated that when she was about to transfer her (R1) to her wheelchair, she threw herself back into bed, saying she does not want to get up. That she (R1) was screaming, hollering, so V5 assisted her back to bed and walk away from the situation. She (V5) told the nurse (V21) that she (R1) was screaming and does not want to get up. However, V21 mentioned that she (V5) did not tell her about R1's screaming or being combative when she (V5) was trying to get her (R1) up. While V2's investigation stating that when V5 was turning her (R1) side to side to change her incontinence brief, she (R1) was screaming and resisting to care but V5 continued to change her (R1). On 10/20/22 at 12:07 PM, R1 was called and interviewed on what really happened on 06/25/22 with V5. R1 recalled, I can't remember the date, the CNA (referring to V5) apparently wants me to do something. I think I cannot respond to her demand. She was very demanding to me to do it. We were standing facing one another. Then she wants me to do something which I can't respond, I got anxious and scream and she slapped me on the right cheek, bottom of face. It did turn black and blue. I was shocked. I called V22 at home. I told V22 about what happened. I was in a state of shock, dumbfounded. I was shocked because somebody I don't know hit me and she was employed by the facility. She is supposed to take care of me. V5 stated in an interview that when she was about to transfer R1 to her wheelchair, she threw herself back into bed and said she does not want to get up, screaming, hollering. R1 stated she was standing, facing V5 when she (V5) asked her (R1) to do something which she cannot respond, made her (R1) more anxious and scream, which led V5 to slap her. Therefore, R1's screaming did not happen during incontinence care. Facility did not conduct a thorough investigation on the abuse incident between R1 and V5. There were discrepancies with the abuse report versus statements from V5 and R1. V22 was asked regarding the said incident between R1 and V5. V22 stated, I visited her (R1) that afternoon, around lunch time, I saw a bruise in the corner of her mouth. She (R1) told me that she was hit by the CNA into the mouth three times to quiet her down because she was screaming. I was shocked when she told me that. She was never manhandled with someone working in the facility. R1's Change in Condition Follow Up documentation dated 06/25/22 documented: A. Complaint - right lip bruise. Facility's final abuse report dated 06/30/22 did not include any investigation on how R1 got the bruise on her lip. There were no documentation pertaining to the investigation of R1's bruise on her right lip and no report was made to local state agency. On 10/20/22 at 2:59 PM, V25 (Physician) was asked regarding her expectations on staff regarding abuse. V25 verbalized, I expect all nursing home residents are cared for with kindness and compassion. I would never expect any abuse from staff to residents. Everybody should be treated with respect and compassion. Facility's policy titled Abuse and Neglect Reporting Policy Including Suspected/Confirmed Resident-Resident Abuse reviewed date 03/04/2022 stated in part but not limited to the following: Policy: Unless otherwise specified by state regulations. It is the policy of (name of company) to ensure that all reporting of abuse and neglect is handles in accordance with state rules and regulations. This policy will ensure that proper reporting procedures are followed when a case of abuse, neglect, or exploitation is reported. Prevention - Protection The Abuse policies and procedures of this community are developed to promote a safe living environment for all residents. Residents must not be subjected to abuse, neglect, or mistreatment by anyone, including, but not limited to facility or agency staff, other residents, family members or other visitors. Prevention of abuse/neglect requires the involvement of all staff to monitor, observe, intervene and report any behaviors/ situations that may lead to conflict or neglect.

Based on observation, interview, and record review the faciliy failed to follow their policy and procedure for fall prevention by not completing a comprehensive fall care plan, not identifying necessary fall interventions, not accurately completing fall assessments, not having the necessary amount of staff to provide care for a resident who required two person staff assistance with bed mobility and transfers for three of six residents (R4, R6, and R10) reviewed for accidents/injuries. This failure resulted in R4 having a fall that resulted in a fracture. Findings include: 1. R4 is a [AGE] year-old male with a history of [CONDITION(S)] (Present on Admission 03/20/2021), Dementia without Behavioral Disturbance, Alzheimer's Disease, History of Falling, Abnormalities of Gait and Mobility, Lack of Coordination, and Dysphagia who was originally admitted to the nursing facility 2/8/2018. R4's progress note dated 6/9/2021 9:04 PM (21:04) documents Chief Complaint includes Deficits in Mobility and Self Care Skills, History of Present Illness: [AGE] year-old male admitted to the Hospital after an unwitnessed fall and altered mental status. In the emergency room the patient had an episode of weakness on one side as well as acute mental status changes, code stroke was initiated. The patient was stabilized medically and admitted to nursing facility for subacute rehab therapies, for muscle weakness and deconditioning. R4's fall risk assessment dated [DATE] documents he has a score of 8 and is at low risk for falls; and records him to be receiving 1-2 medications including Anesthetics, Anti-histamines, Antihypertensives, Antiseizure, Benzodiazepines, Cathartics, Diuretics, Hypoglycemics, Narcotics, Psychotropics, Sedatives/Hypnotics currently or within the last 7 days. R4's most current physician order sheet documents active orders as of 03/20/2021 for more than two medications considered in the fall risk review assessment including antihypertensives, hypoglycemics, and psychotropics. R4's fall risk assessment dated [DATE] documents he has a score of 8 and is at low risk for falls; and records him to have no predisposing diseases present such as [CONDITION(S)]. R4's Discharge Summary dated 08/02/2021 documents he was sent to the hospital via emergency medical services related to a fall and was admitted to the hospital with a diagnosis of broken left femoral neck fracture. Director of Nursing and Physician made aware. R4's most current care plan reviewed 10/19/2022 documents he is at risk for falls related to Confusion, Deconditioning, Gait/balance problems, Incontinence, Psychoactive drug use, history fall, dementia, Alzheimer with interventions including: R4 needs a safe environment with: (even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low Position; Follow facility fall protocol; Ensure that R4 is wearing appropriate footwear - non skids socks, shoes when ambulating or mobilizing in wheelchair. R4's Hospital Record dated 08/02/2021 documents he lived at the facility and was admitted through the emergency department after a fall and sustained a left femoral neck fracture that will require surgical repair. Written incident report dated 08/02/2021 documents R4 experienced an unwitnessed fall at 1:30PM and was unable to explain what happened due to cognition and language barrier; R4 was using a wheel chair at the time of the incident; During rounds at 7AM, R4 was still in bed, at 8AM he was in the dining room for breakfast, at approximately 9:50AM administered medication to R4 and R4 was in the television room and participated in activities; at approximately noon R4 was brought to the dining room then to the television room after lunch; at approximately 1:20PM heard a scream In the television room while at the nurses station and upon getting up to check observed R4 in left sideline position on the floor with head not touching the floor and raised up; no loss of consciousness or apparent injury noted. R4's Incident investigation report dated 08/03/2022 documents on 08/02/2021 at around 1:30PM the nurse heard a loud sound in the living room and immediately ran to assess the situation, R4 was observed on the floor in front of his wheelchair, on his left side; R4 was sent to the emergency room for further evaluation per physician's orders; report received from the hospital 08/02/2021 around 8PM documented R4 sustained a left femoral neck fracture and was admitted to the hospital for further treatment and remains in the hospital at this time; R4 is a pleasant man with past medical history of Alzheimer's Dementia, [CONDITION(S)], Muscle Weakness, and Lack of Coordination, and Transient Strokes who has a tendency to get up without asking for help due to his impulsivity. Certified Nursing Assistant Occurrence Report Statement dated 08/02/2021 included with incident report documents regarding R4's fall incident at 1:30PM V7 (Certified Nursing Assistant) reported R4 was sitting in the television room after lunch and fell about 1:30PM. V7 reported she had been with other patients and when she was finished, she observed the nurse with R4. On 10/19/2022 at 12:22PM V16 (Family Member) reported R4 has Alzheimer's, and needed supervision because he can't recall things. V16 report she believes R4 would attempt to get out of his chair without assistance because when he was home with her and their family they had to watch him all the time because he would try to eat things even if they weren't actually food. V16 stated R4 needed constant supervision. 2. R10 is a [AGE] year-old female with a diagnoses history of Contusion of Head Subsequent Encounter, [CONDITION(S)], Peripheral Vascular Disease, Polyosteoarthritis, and Dependence on Other Enabling Machines and Devices who was originally admitted to the facility 8/5/2022. On 10/18/2022 from 12:47 PM - 1:24 PM, Observed R10 sitting in the television room in her wheelchair being served lunch. Observed R10 with bruises on her forehead, near temple, and underneath her left eye. R10 stated she experienced a fall as a result of a Certified Nursing Assistant (CNA) raising her out of her bed with her bed sheet. R10 stated she told the Certified Nursing Assistant multiple times that she requires at least two CNA's for transferring her and the CNA insisted she was strong enough and could do it by herself. R10 stated the CNA then snatched her sheet from underneath her which caused her to fall and hit her head on the table and floor. R10 stated she tried grabbing the nightstand when she was falling. R10 stated her roommate was present during the incident but won't likely be able to report anything because of her mental status. R10 stated she was sent to the hospital after the incident. R10 stated she was afraid she had cracked her skull and asked to go to the hospital. R10 stated she also injured her toes when she fell . R10's current care plan reviewed 10/19/2022 documents she is High, risk for falls related to use of diuretics, hypoglycemic, [CONDITION(S)] and antihypertensive medications, other diagnoses including Peripheral Vascular Disease, [CONDITION(S)] with interventions including: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance; Follow facility fall protocol; Care plan initiated 09/11/2022 documents R10 has had an actual fall with minor injury, with interventions including: Monitor/document /report as needed for 72 hours, report to physician signs and symptoms of: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. R10's fall assessment dated [DATE] documents she has a score of 11 and is at high risk for falls. R10's admission Minimum Data Set, dated dated dated [DATE] documents she requires extensive 2-person assistance with transfers from bed, chair, wheelchair, standing position; requires extensive 2-person assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture). R10's progress note dated 9/11/2022 7:10 PM (19:10) documents: resident had assisted fall at 7-3 shift and was transferred to the Hospital via ambulance as ordered by physician. Nurse made a follow-up on resident's status. Informed by at Hospital that resident was admitted with initial diagnosis of [CONDITION(S)]. R10's hospital record dated 09/11/2022 documents she was received from the nursing home after a fall and was unable to recall the incident; per history she was being assisted to the restroom and slipped. Incident Investigation Report dated 09/11/2022 documents at 12:30 PM, R10 was witnessed to experience a fall and reported the reason she fell was because my knees gave way,; she was noted to be using a wheelchair during the incident and while being assisted by a Certified Nursing Assistant (CNA) her knees buckled and she was assisted down to the floor. Certified Nursing Assistant Occurrence Report Statement dated 09/11/2022 included with incident report documents regarding R10's fall incident at 12:30 PM, V15 (Agency Certified Nursing Assistant) reported she transported R10 to the bathroom using sit to stand equipment and while attempting to transfer R10 from the bathroom after toileting to put a diaper on her she noticed R10 was going down,; V15 reported she began shouting for help but no one came to assist; V15 reported she ran out and started shouting before seeing a therapist who followed her back to R10's room. V15 reported upon returning to the room she and the therapist immediately began releasing R10's hand from the sling and she sat on the floor. V15 reported she noticed R10 was short of breath and laid her down and began administering oxygen; V23 (Physical Therapist) reported while in another room treating a patient, the physical therapist heard a CNA yelling for assistance. V23 reported they came to assist because the CNA couldn't find anyone at the time. V23 reported upon initially seeing R10 during this incident she was already lowered to the floor in a seated position by the mechanical lift. V23 reported not observing what occurred prior to this and once R10 was safely positioned and confirmed not to be in distress or unconscious, the therapist ran to alert the lead nurses for assistance. V23 reported the lead nurse contacted the emergency department. R10's fall risk assessments dated 09/30/2022 and 10/04/2022 documents she had no falls in in the past 3 months. R10's Hospital Report 10/04/2022 documents she reports she fell on her left side hitting the side of her head while she was being rolled over for a bed sheet change; observed with left forehead swelling, x-ray scan performed for head contusion; nursing home notified of fall incident R10 sustained local injury to the left side of the head with hematoma; post fall sustained local forehead injury. R10's Incident Report dated 10/04/2022 documents she experienced a witnessed fall at 5:20AM from her bed; R10 reported the fall happened because I was turning on my side.; V13 (Licensed Practical Nurse) reported during rounds she heard a certified nursing assistant call out for help from the next room, as she entered R10's room she observed R10 on the floor face down next to her bed. When she asked R10 what happened the certified nursing assistant explained she was changing R10 and she rolled on her side, the resident kicked her feet over and fell out of the bed. R10 reported to V13 that she hit her head. V13 observed a raised area on the left side of R10's scalp and notified the physician. The physician ordered R10 be sent to the hospital and R10 was transferred to the hospital. Certified Nursing Assistant Occurrence Report Statement dated 10/04/2022 included with incident report documents regarding R10's fall incident at 5:29 AM, V14 (Certified Nursing Assistant) reported while in R10's room changing her diaper the resident lifted her left leg over her right and the momentum made both her legs fall out of the bed; V14 reported she tried to grab R10's legs and it was too late and her body had fallen out of the bed and hit the cabinet and the floor. On 10/19/2022 at 10:00 AM, Observed R10 in her room lying in her bed with her call light attached to her bed. Observed R10 crying. R10 stated she overheard two staff laughing stating she rolled herself out of bed when she fell . R10 stated why would she hurt herself like that. R10 stated look at all these bruises and knots on my head. Observed R10 with multiple bruises on her forehead and under her eye and a raised area on her forehead. R10 stated nobody believes her. R10 stated her injuries came from when a Certified Nursing Assistant raised the sheet from under her and caused her to fall and hit her head. R10 stated she was given the bed she is in now that is a larger bed with wings on each side to prevent her from rolling out of bed because they believe she rolled herself out of bed and won't believe her. On 10/19/2022 at 1:03 PM, V2 (Director of Nursing) stated if a fall assessment is not filled out correctly it may affect the resident's care by not having supervision and interventions in place for them as needed. V2 stated based R4's incident investigation report dated 08/03/2022 he required constant supervision. V2 stated R4 should have been closely monitored during his fall incident. V2 stated supervision should have been included in R4's fall care plan. V2 stated R10 should be assisted by two Certified Nursing Assistants (CNA) for transfers, and this should be included in her care plan in order for the certified nursing assistants to be aware of this need. V2 stated she is not sure why there was only one CNA assisting R10 with transferring from the toilet on 09/11/2022 and while being changed on 10/04/2022. V2 stated there has not been any issues with having enough staff to care for the residents and possibly the other available CNA's were assisting other residents during R10's incidents. On 10/19/2022 at 2:10 PM, R10 stated after the incident of falling as a result of the Certified Nursing Assistant pulling her sheet from underneath her, she was fearful whenever the CNA's would attempt to move her and didn't feel as safe when being repositioned or transferred. On 10/20/2022 at 11:39 AM, V11 (Licensed Practical Nurse) stated R10 requires two person assistance. V11 stated on 09/11/2022 when R10 was transferred from her bed to her wheelchair there were two Certified Nursing Assistants (CNA) assisting. V11 stated however, when R10 was being transferred from the toilet back to her wheelchair there was only one CNA who performed this activity. V11 stated during that time that CNA used the sit to stand equipment to assist R10 and she was not aware the CNA was performing this activity by herself because she had informed the CNA that R10 required two-person assistance for transfers. The facility's Fall Policy received 10/20/2022 states: The facility is committed to minimizing resident falls and/or injury and to maximizing each resident's physical, mental and psychosocial well-being. While preventing all resident falls is not possible, the community will act in a proactive manner to identify and assess those residents who are at risk for falls, plan for preventative strategies and facilitate a safe environment. All care staff will be responsible in assisting with the implementation of the community's Fall Management Program to maintain the safety of all residents in the community. The program will include measures which determine the individual needs of each resident by evaluating the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as necessary. 3. R6 is a [AGE] year old male admitted to the facility 6/23/22 with diagnoses that include [CONDITION(S)] and [CONDITION(S)] affecting the left side, [CONDITION(S)] following cerebral infarction, and dementia. R6 was assessed on 9/28/22 to have mild cognitive dysfunction with a BIMS of 10. R6 functional assessment indicates that he requires extensive one person physical assistance with all activities of daily living and uses a walker and wheelchair for mobility. R6 was admitted to the facility after sustaining a fall at home and upon admission was assessed on 6/23/22 as being a high fall risk with a score of 14. R6 suffered a fall while in his room on 7/10/22, sustained a laceration to the left forearm and was sent to the hospital for evaluation with no further orders upon return to the facility. On 10/17/22 at 1:41 PM, R6 was observed in bed, alert and oriented to person with confusion. R6 is not on isolation and has a roommate who is alert and able to make needs known. R6's bed was noted to be in a low position in relation to the floor and had a cushioned floor mat on each side of the bed. Call light was within reach. The facility was unable to provide an initial or current care plan for fall prevention. Post Fall investigation for R6 dated 7/10/22 was reviewed. DON reviewed and signed this investigation on 8/06/22 and on review noted that R6's fall may have been caused by the resident being impulsive. The assessment asks, what interventions were previously in place? to which the DON answered N/A and goes on to indicate that new interventions placed will include having the bed in the lowest position with floor mats.

Based on observation, interview and record review, the facility failed to ensure visitors wore face masks while in Resident care areas and failed to ensure staff were screened prior to coming on to the Resident Care area with active COVID19 infection in the building. This failure has the potential to affect all 28 residents residing in the facility who are at risk of contracting COVID19 from visitors and staff. Findings include: On 10/17/22 at 12:46 PM, V27 CNA/Medical Records was observed entering the facility, past the receptionist and walking onto the unit and directly into the breakroom. The staff was not screened by anyone prior to entry. At 1:00 PM, V27 was seen working on the unit going in and out of resident rooms and said, I just got here a few minutes ago and got on the unit. At 1:49 PM, V26 Medical Doctor was observed walking down the corridor with no face covering on and face mask in hand. V9 CNA greeted V26 and did not properly correct V26 regarding properly wearing the face mask. At 1:55 PM, V27 was seen at the exit and said, I wasn't aware that there were any active COVID cases in the building. I was distracted coming into the building and for some reason I took the mask from the sign in desk and put it in my pocket. I'm so used to always having it on already in the clinic that I forgot to put it on. On 10/18/22 at 11:52 AM, V20 Receptionist said, When staff come in, some use the kiosk for screening and some people go upstairs to the other unit. They come through these doors and have to walk through the first floor unit to get to the elevators or stairs and they sign in there. On 10/19/22 at 1:09 PM, V2 DON said, when everyone enters the building, they check in at the kiosk answer the questions, put on a mask and sanitize their hands. The employees should have their mask on upon entry and they will fill out the questionnaire at the nurse's station. The receptionist should supervise this. The employees should always be screened either at the kiosk for agency staff or at the nurse's station for regular staff prior to going anywhere or walking through the unit. If a visitor is seen by staff not wearing the proper PPE, staff should alert, stop and direct the visitor to be screened and come back to the lobby to have a face mask. After several request, the facility did not provide the COVID19 policy for proper screening and wearing of PPE. Staff screening tool reviewed for 10/17/22 which showed V27 signed the self-screening form at 12:30 PM, however, she was observed to come into the building shortly later at approximately 12:46 PM.

Based on interviews and record reviews, the facility failed to initiate a thorough investigation on the nature and cause of a resident's injury of unknown origin for one (R1) of two residents reviewed for abuse and abuse investigation. Findings include: R1 is a [AGE] year-old female, admitted in the facility on 06/04/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to progress notes dated 06/25/2022, R1 was found to have a bruise on the right side corner of her lips. R1 stated that a CNA (Certified Nurse Aide) was turning her in bed this morning during morning care and she (R1) screamed and CNA hit her right side of face. Based from the facility's investigation report dated 06/25/22, V5 was the assigned CNA to R1. On 10/18/22 at 2:00 PM, V5 (CNA) was interviewed regarding incident with R1 on 06/25/22. V5 stated, That day, the nurse told me to get her (R1) up that morning. I was preparing her clothes and getting her ready. She was a little terrible, irritated. I got her dressed up, she started to behave nicer and talking like normal. As soon as she's done dressed, as I am about to transfer her to her wheelchair, she threw herself back into bed and said she does not want to get up. Refusing to get up and said she doesn't get up in the morning. She was screaming, hollering. So I just assisted her back to bed. She was verbally aggressive to me but not physical. I walk away from the situation. I told the nurse that she was screaming and does not want to get up. I didn't notice anything unusual to her skin or face, I wasn't paying attention. V21 (Registered Nurse, RN), who was the assigned nurse to R1 on 06/25/22 was also asked regarding the bruise. V21 verbalized, During medication pass, I went to her room, checked her vitals, administered the medications. I did not notice any bruises, scractches or lacerations on the face. On 10/19/22 at 2:20 PM, V2 (Director of Nursing) was asked regarding R1's bruise on the lips. V2 replied, I was the one who investigated her incident last 06/25/2022. I don't know how she (R1) got the bruise. She (R1) cannot remember how she got it and V5 said she did not notice any bruise during care. I did investigate about the bruise on her lips but I don't have the documentation. Facility's final abuse report dated 06/30/22 did not include any investigation on how R1 got the bruise on her lips. Also, R1's bruise on her lips was not reported to local state agency. Facility's policy title Injury of Unknown Origin last reviewed 07/14/2022 documented in part but not limited to the following: Policy: The facility will have a protocol in place to ensure complete investigation of any injury of unknown origin. This investigation should assist in determining if the injury can be explained as to its occurrence or if the potential for abuse is evident, and if abuse is suspected then the abuse protocol is followed.

Based on observation, interview and record review, the facility failed to monitor persons entering and exiting the facility during open hours. This failure has the potential to affect all 28 residents residing in the facility and poses a safety risk to all staff and residents. Findings include: At the time of entrance on 10/17/22 at approximately 10:00 AM, surveyors walked into the lobby and noted that no person was monitoring the area. The door to the nursing unit was unlocked and Surveyors had to get the attention of staff for acknowledgement. On 10/18/22 at 11:52 AM, V20 Receptionist said, I was in the storage room at the time when you all came in yesterday. I'm not sure how long I was in there exactly. The doors are on an automatic timer and are opened from 8am to 8pm. On 10/19/22 at 1:12 PM, V2 Director of Nursing said, we try to keep someone at the front desk at all times so that they can monitor who is coming in and out of the facility. There are times that the receptionist steps away and there should be someone there to replace her. Facility unable to provide policy regarding monitoring peoples entering and leaving the facility

Based on interview and record review the facility failed prevent an avoidable accident while transferring a resident from the bed to the wheelchair for 1 of 3 residents (R1) reviewed for accidents. This failure resulted in R1 sustaining a laceration to the left leg that required 5 sutures. Findings Include: On 5/21/22 at 10:49 am, V1 DON (Director of Nursing) said she conducted the investigation for the incident for (R1) on March 30,2022. V1 said during a transfer from bed to wheelchair (R1) sustained a skin tear to the left leg. V1 said the aide was transferring (R1) by herself. V1 said (R1) needs one person assist with transfers. V1 said the root cause analysis is in the investigation report. V1 presented the initial and final investigation. V1 identified the aide conducting the transfer to be V7 CNA (Certified Nursing Aide), V7 was not available for interview during this investigation. Several calls were made in the attempt to interview V7 during this survey. On 5/22/22 at 4:34 pm, V1 said (R1) sustained a laceration to the leg from the leg rest of the wheelchair, V1 said staff should remove the leg rest from the wheelchair before doing a transfer, the leg-rest could get in the way when performing a transfer and could potentially cause an accident. The facility initial and final incident report dated 3/30/22 shows in-part (R1) name, date of incident 3/30/22, diagnosis shows dementia and [CONDITION(S)], (R1) is a [AGE] year-old female. She is alert and oriented x1 and able to verbalize needs. The resident is x1 assist with transfers and with her ADL care. On March 30, 2022 the nurse on duty was called to the resident room by the CNA. The CNA was transferring resident from bed to wheelchair and obtained a laceration to the lower leg from the wheelchair leg rest. Nurse applied pressure dressing and was not able to control the bleeding. The resident reported pain to the lower leg. Primary physician and POA were notified of incident and received order to send out to hospital for further evaluation and treatment. The resident (R1) returned to the facility the same day with 5 sutures to the left leg. No sharp edges noted on the wheelchair leg rest. POA (Power of Attorney) updated on resident status. CNA occurrence report statement for V7 dated 3/30/22 shows V7 name, 6:00 am shift, R1 name, room number, time of occurrence at 7:00 am, no, is documented for discovering or witnessing the incident, position of resident is documented in the wheelchair, in the client room, last activity engaged with the resident is documented as clean and dressing the client. Last time resident was toileted 6:50 is documented. At about 7:00 am when I transferred the client to the wheelchair, I found her leg with blood coming out of her leg, so I went to call the nurse, date 3/30/22. R1 change in condition evaluation dated 3/30/22 at 7:31 a.m. shows in part, other change in condition, L leg laceration, started on 3/30/22, send to ER. R1 progress note dated 3/30/22 at 12:12 pm, shows in-part resident returned to facility with 5 sutures to L (left) leg laceration to remove in 10 days, site is intact no signs/symptoms of infection noted. Resident denies any pain nor discomforts at this time. POA updated on resident's status, DON made aware. On 5/21/22 at 10:50 am, V11 (Nurse) said she was the nurse working with (R1) on 3/30/22 for the morning shift (7:00 am), V11 said minutes to her arriving to the unit she was summons to R1's room by the night nurse, V11 said upon arriving to R1's room she noticed that R1 was bleeding from the leg, and she applied a pressure dressing. V11 said she could not control the bleeding. V11 said the physician was notified and gave orders to send R1 to the local hospital for further evaluation. V11 said R1 needs extensive assist with transfers but she does not know how many staff is needed to provide the extensive assist with transfers. V11 said V7 told her that she transferred R1 and she noticed R1 bleeding from the leg. On 5/21/22 at 1:47 pm, during a wheelchair to bed transfer observation for R1 conducted by V4 (CNA) and V5 (CNA). R1 agreed to allow the observation of care. Observation took place in R1 room. After entering the room V4 removed the footrest from R1 chair. V4 wheeled R1 parallel to the bed, V4 and V5 ensured the wheelchair was in the locked position. V4 place the black gait belt around R1 waist/ upper body, tightened the straps, V5 insured that she could put two fingers between the belt and R1's body. V4 stood in front of R1 while V5 was on R1 right hand side. V4 ask R1 was she ready, V4 and V5 lift R1 simultaneously using the gait belt and pivot R1 to the bed. R1 feet was not observed to touch the floor. V4 then lift R1 legs to position R1 in the lying position. V4 and V5 was observed to provide the weightbearing support for R1 during this surface-to-surface transfer. V4 said R1 has always been a two person assist with transfers and when R1 is feeling more tired than usual R1 is transferred with mechanical lift. R1 was observed to have a healing scar noted to her left lower leg. R1 said she does not know what happened to her leg. Facility policy Titled Resident Transfers/ Movement with reviewed date 10/22/21 shows in-part that the community is dedicated to providing a safe and healthful working environment for its employees and residents. This policy applies to assistance with resident movement including resident transfers, both manual transfers using assistive devices. The degree to which a resident can reposition, transfer and/or ambulate will be identified upon admission and ongoing, to determine the type and amount of assistance needed. Interventions and methods to assist a resident will be communicated to designated direct care staff and include on the residents individualized service plan. R1 plan of care with revision date of 03/17/2022, initiated date of 09/06/2021, and target date of 06/01/2022 shows R1 requires extensive assistance with ADLs due to generalized weakness. She is also diagnosed with dementia, [CONDITION(S)], [CONDITION(S)] and HLD, DVT, [CONDITION(S)]. R1 will improve current level of function in ADLs through the review date. Bathing/showering: R1 requires extensive assistance by staff with bathing/showering. Bathing/showering: Use short, simple instructions such as hold your washcloth in your hand; Put soap on your washcloth; Wash your face; to promote independence. Bed mobility: R1 requires extensive assistance by staff with bed mobility. Dressing: R1 requires extensive assistance by staff to dress. Eating: R1 requires tray set up assistance by staff to eat. Personal hygiene R1 requires extensive assistance by staff with personal hygiene and oral care. Toilet use: R1 requires extensive assistance by staff for toileting. Transfer: R1 requires extensive assistance by staff to move between surfaces and as necessary. Discuss with R1 /family/POA care any concerns related to loss of independence, decline in function. Encourage to use call light to call for assistance. Encourage R1 to fully participate possible with each interaction. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Praise all efforts at self-care. PT/OT evaluation and treatment as per MD orders. Facility policy Titled Care Plans, Comprehensive skilled with last review date of 8/22/2018 shows in-part that a comprehensive, person centered care plan that includes measurable objective and timetables to meet the resident physical, psychosocial and functional needs is developed and implemented for each resident. The Interdisciplinary Team (IDT) in conjunction with the resident and his/ her family or legal representative, develops and implements a comprehensive, person centered care plan for each resident. Review of R1 current individualized plan of care for ADL (Activity of Daily Living) assistance, there is no documentation noted for how many persons assist, R1 needs for transfers.