Every finding on record at Loft Rehab of Rock Springs, The

Based on interview and record review the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day seven days a week. This failure has the potential to affect all 100 residents residing in the facility. Findings Include:Facility Nursing Staff Schedules reviewed from 4/4/26 through 5/4/26 documented seven days (4/5, 4/18, 4/19, 4/22, 4/23, 4/24, and 5/2) the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day. On 5/4/26 at 2:00 PM, V2 Director of Nurses (DON) stated she was on vacation 4/22/26 through 4/27/26, her normal scheduled workdays/hours are Monday through Friday 9:30 AM - 5:30 PM, and she hasn't covered any weekend RN shift in the last month. V2 DON confirmed V2 DON did not have eight hours of RN coverage on any weekend days that were vacant of RN staff in the last month. V2 DON also confirmed there was no RN staff coverage on the days she was on vacation and the facility's current census is 100 residents.The facility's Long-Term Care Facility Application For Medicare and Medicaid dated 5/5/26 documents one hundred residents reside in the facility.

Based on observation, interview, and record review, the facility failed to employ a clinically qualified Director of Food and Nutrition Services. This failure has the potential to affect all 100 residents in the facility. Findings include:On 5/3/2026 at 9:07AM, V3 (Cook) was actively supervising dietary operations in the facility kitchen and reported being the designated person in charge for the shift. V3 denied being a dietary manager or certified dietary manager and reported the facility dietary service does not currently have a dietary manager and the position is vacant. V3 denied the facility dietician works full-time in the facility dietary service and reported only seeing the dietician inside of the facility twice in the previous year. V3 reported the food prepared in the dietary service is available for all residents in the facility to eat. The Facility Assessment (1/15/2026) documents the facility will employ a full-time Dietician or other clinically qualified nutrition professional to serve as the director of food and nutrition services in the facility. From 5/3/2026 through 5/6/2026, the facility failed to effectively sanitize dishes, failed to prevent direct biological cross-contamination of food service equipment, failed to maintain a sanitary can opener, and failed to maintain sanitary floor and food preparation surfaces. The facility Long-Term Care Facility Application for Medicare and Medicaid (5/5/2026) documents 100 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to effectively sanitize dishes, failed to prevent direct biological cross-contamination of food service equipment, failed to maintain a sanitary can opener, and failed to maintain sanitary floor and food preparation surfaces. These failures have the potential to affect all 100 residents residing in the facility. Findings include:1. On 5/3/2026 at 9:20AM, the mechanical sanitizing dishwasher located in the facility food service was operating and washing food service dishes. A Survey Agency chemical test strip did not detect any sanitizer (a concentration of zero parts per million) was present during the sanitize portion of the dishwasher cycle. A manufacturer's nameplate was present at eye level on the front of the dishwasher and documented a minimum sanitizer concentration of 50 parts per million is required to effectively sanitize dishes in the dishwasher. A five gallon bucket of liquid sanitizer was located on the floor beneath the dishwasher and supplied sanitizer solution via tubing to the dishwasher. The bucket was entirely empty and did not contain any remaining sanitizer solution. 2. On 5/6/2026 at 11:31AM, two ice scoops were stored in a plastic wall-mounted caddy located adjacent to the ice maker in the kitchen pantry. No drain holes or riser platform were present in the bottom of the caddy to allow moisture from the ice scoops to drain and prevent the tips of the scoops remaining immersed in standing water. Dust, debris, and a dried green substance was located at the bottom of the caddy where the scoops were stored. The scoop tips were resting directly on top of three clear, oval insect wings with black venation resembling the wings of drain flies. 3. On 5/3/2026 at 9:07AM the facility kitchen table-mounted can opener and receiver were excessively soiled with heavy accumulations of food debris, grease, and metal shavings black in coloration. On 5/5/2026 at 3:21PM, the can opener remained soiled as above.On 5/6/2026 at 11:38AM, the can opener remained soiled as above.4. On 5/3/2026 at 9:15AM, flooring surfaces throughout the facility kitchen and dishwashing room were heavily soiled with accumulations of food debris, refuse, dishes, food utensils, and containers. Twelve disposable plastic cups, a plastic container lid, one container of an unknown brown substance, a cleaning brush, and multiple drink pitcher lids were located on the floor surface along the South kitchen wall. The flooring surface beneath the adjacent three-basin sink located in the main kitchen area was heavily soiled with accumulations of decomposing/rotting food debris. The accumulations completely obscured the surface of the floor tiles located beneath the three-basin sink at the floor/wall junction. On 5/3/2026 at 9:19AM, the floor and food grinder surfaces in dishwashing room attached to the main kitchen were heavily soiled with food debris. Chunks of decomposing food completely covered the entire surface of the food grinder and the legs and underside of the drainboards attached to the dishwasher. The wall surfaces beneath the drainboards were black in coloration from deposits. Heavy deposits of decomposed food and grease, black in coloration, completely obscured the tile surfaces of the tiles adjacent to the wall behind the dishwasher. Large amounts of debris including silverware, five cups, three buckets, a knife, scrub pad, and single-serve butter condiment containers were scattered on top of the tiles. Standing, gray-colored stagnant water was located beneath the dishwasher drainboards. A pile of black, rotting food debris approximately 3 in thickness was resting against the wall surface behind a drainboard table leg. On 5/5/2026 at 3:21PM, the dishwasher room floor and equipment surfaces remained soiled as above. On 5/6/2026 at 11:36AM, the dishwasher room floor and equipment surfaces remained soiled as above. On 5/3/2026 at 9:07AM, V3 (Cook) reported the food prepared in the dietary service is available for all residents in the facility to eat. On 5/6/2026 at 3:21PM, V21 (dietary aide) reported the food service flooring areas needed cleaned.The facility Long-Term Care Facility Application for Medicare and Medicaid (5/5/2026) documents 100 residents reside in the facility.

Based on interview and record review, the facility failed to develop a water management plan that clearly defined the ranges for control measures and testing protocols to reduce the risk of growth of Legionella and other pathogens in the facility's water system. This failure has the potential to affect all 100 residents in the facility.Findings include: On 5/5/26 at 9:48 a.m., V1 (Administrator) provided a copy of the facility's water management plan dated 1/21/26. The plan did not identify any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system. On 5/6/26 at 1:20 p.m., V1 confirmed the facility has not developed any specific testing protocols, acceptable ranges for control measures, or any corrective actions when control limits are not maintained to reduce the risk of waterborne pathogens in the facility water system.The facility Long-Term Care Facility Application for Medicare and Medicaid dated 5/5/26 documents 100 residents reside in the facility.

Based on interview and record review, the facility failed to employ a full-time Infection Preventionist as specified in the Facility Assessment. This failure has the potential to affect all 100 residents residing at the facility. Findings include: On 5/3/26 at 1:10 p.m., V1 (Administrator) stated the facility has not had an Infection Preventionist since 4/9/26. The Facility Assessment, dated 1/15/26, documents that the facility will employ a full-time Infection Preventionist. The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 5/5/26 documents 100 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program by failing to exclude and prevent flying insects in the facility food service areas resulting in direct cross-contamination of food preparation surfaces. This failure has the potential to affect all 100 residents in the facility.Findings include:On 5/3/2026 at 9:15AM, flooring surfaces throughout the facility kitchen and dishwashing room were were heavily soiled with accumulations of food debris, refuse, dishes, food utensils, and containers. Twelve disposable plastic cups, a plastic container lid, one container of an unknown brown substance, a cleaning brush, and multiple drink pitcher lids were located on the floor surface along the South kitchen wall. The flooring surface beneath the adjacent three-basin sink located in the main kitchen area was heavily soiled with accumulations of decomposing/rotting food debris. The accumulations completely obscured the surface of the floor tiles located beneath the three-basin sink at the floor/wall junction. On 5/3/2026 at 9:19AM, the floor and food grinder surfaces in dishwashing room attached to the main kitchen were heavily soiled with food debris. Chunks of decomposing food completely covered the entire surface of the food grinder and the legs and underside of the drainboards attached to the dishwasher. The wall surfaces beneath the drainboards were black in coloration from deposits. Heavy deposits of decomposed food and grease, also black in coloration, completely obscured the tile surfaces of the tiles adjacent to the wall behind the dishwasher. Large amounts of debris including silverware, five cups, three buckets, a knife, scrub pad, and single-serve butter condiment containers were scattered on top of the tiles. Gray-colored stagnant water was located beneath the dishwasher drainboards. A pile of black, rotting food debris approximately 3 in thickness was resting against the wall surface behind a drainboard table leg. Four or more drain flies were present beneath the drainboards and were flying back and forth between a sewer pipe in a floor drain and the dishwasher drainboard surfaces. Ten or more dead drain flies were floating in puddles of decomposed/rotting food saturated with water continuously leaking from the food grinder onto the floor surface. On 5/5/2026 at 3:21PM, the dishwashing room remained as above. Five or more flies were resting on and flying around the drainboard attached to the dishwasher and flying between the puddles containing decomposing food followed by landing on the drainboard surfaces. On 5/6/26 at 11:40AM, four or more flies were flying between floor drain sewer pipe openings to food preparation table surfaces adjacent to the three-basin sink located in the main kitchen area. On 5/6/2026 at 12:20PM, V23 (facility licensed pest control contractor) reported the flies in facility kitchen areas are due to unresolved sanitation concerns and those concerns have persisted for years at the facility. He reported that the kitchen needs to be better kept. On 5/3/2026 at 9:07AM, V3 (Cook) reported the food prepared in the dietary service is available for all residents in the facility to eat. The facility Long-Term Care Facility Application for Medicare and Medicaid (5/5/2026) documents 100 residents reside in the facility.

Based on observation, interview, and record review the facility failed to ensure resident rooms, hallways, and dining area were clean and in good repair for three of three residents (R18, R79, and R82) reviewed for homelike environment in the sample list of 42. Findings include:On 05/03/2026 at 9:59 AM, third floor hallways had paper debris on the floor, a white substance on several places of the walls appearing to be patched holes, and the dining area floor had food debris with splatters of sticky substance.On 5/4/26 at 8:55 AM, V6 CNA (Certified Nurses Aide) stated housekeeping doesn't clean every day in the dining room on third floor. V6 CNA stated V6 CNA cleans and mops sometimes, but housekeeping is supposed to. On 05/04/2026 at 11:19 AM, V7 CNA stated the housekeeping staff do not clean daily. V7 CNA stated we CNA's will clean if we can, but third floor is the 'nastiest' floor. On 5/4/26 at 2:05 PM, the third floor dining area remained dirty with food debris and a sticky substance on the floor. On 5/5/26 at 8:23 AM, while touring the third floor, hallways and resident rooms were noted to have food and debris on the floor. The dining area had a sticky substance stuck to the floor with food and debris noted as well.05/05/2026 at 8:38 AM, V12 Environmental Director (ED) stated the housekeeping department is fully staffed with four housekeepers a day during the week and two on weekends. V12 ED stated housekeepers clean the entire third floor, seven days a week. V12 ED stated V12 ED conducts in-services to educate the staff. V12 ED stated the company provides a cleaning solution that isn't strong enough to clean. V12 ED stated he has not put a work order in for different cleaning solution, but he discussed it with administration and was told that is the solution previously used. V12 ED stated all housekeepers work day shift, V12 ED took night shift housekeeping away, and V12 ED rounds on all floors to inspect cleanliness. On 5/5/26 at 9:53, V1 Administrator stated he has not been approached about the floor cleaning solution not being strong enough to clean.On 5/5/26 at 10:00 AM, R79's room had debris on the floor, walls had buckled drywall areas, several black scrape marks were present on three out of four unpainted walls, underneath the heater was a rust colored area, and the bottom trim was off the wall by the bathroom with flaking paint noted. Dark brown and black spotty substances were noted in the toilet bowl of the bathroom. R79 stated it grows in there, they clean it, and it grows back. Dark dirt debris was noted along the floor edge. Dark dust debris was noted under the soap dispenser in the bathroom. R79's Minimum Data Set, dated [DATE] documents R79 is cognitively intact.On 5/5/26 at 10:10 AM, R18's room was noted to have black scrapes throughout three of the unpainted walls, the corner wall by bathroom was missing trim and had peeling of paint. Debris and dust particles were noted under both beds right after housekeeper had cleaned. On 5/5/26 at 10:20 AM, V13 Housekeeper stated he has worked there for a couple years and had just cleaned room R18's room.On 5/5/26 at 10:30 am, R82's room was noted to have debris throughout on the floor, the floor in the bathroom had debris and a dark sticky substance. A large buckle was noted in the drywall of the lower wall by the bathroom. R82 stated R98 fell into the wall a long time ago. Three out of four unpainted walls had black scrapes and chips throughout. R82's minimum data set (MDS) dated [DATE] documents R82 is cognitively intact.On 5/5/26 at 10:32 AM, there was a chipped area with dark scrapes on the trim all around the elevator with a rust color substance present, and dark dirt debris, and a dark splattered substance was noted on the elevator floor.On 5/05/2026 at 2:35 PM, R82 stated the tables in the dining room on third floor are not moved when they sweep and mop. On 5/06/2026 at 8:05 AM, V1 stated there aren't any plans to renovate third floor.On 5/06/2026 at 8:30 AM, R79 stated the condition of the room doesn't look good, if the bathroom gets bad R79 goes to the shower room to use it because R79 worries about bacteria. On 5/06/2026 at 8:40 AM, R18 stated it would look better if the crack in the lower wall was fixed and painted.On 5/06/2026 at 8:45 AM, R82 stated it would look nicer if the crack in the wall was fixed. R82 stated it has been like that for a long time.On 5/06/2026 at 8:58 AM, V6 CNA stated the third-floor shower room has leaked for approximately six weeks now. The shower room was noted to have peeling paint on the ceiling and a floor tile missing in the shower area floor. On 5/06/2026 at 9:00 AM, V17 CNA stated housekeeping is rarely around, there are a lot of leaks throughout the building, and they have painted over black mold before. V17 CNA stated residents have complained about the filthiness. On 5/06/2026 at 11:30 AM, V7 CNA stated the environment affects the residents and staff. V7 CNA stated V7 CNA gets a runny nose when V7 CNA is at work. V7 CNA stated the condition of the building doesn't provide a comfortable environment for residents and their families.On 5/06/2026 at 11:34 AM, V19 LPN stated the condition of the building can potentially affect the residents because as their home, it should be nice. V19 LPN stated third floor could be cleaned a little more.On 5/06/2026 at 11:15 AM, V1 Administrator stated V10 Maintenance Director is on vacation and is unable to make contact.On 5/06/2026 at 11:39 AM, V12 Environmental Director (ED) stated V12 ED would expect a housekeeper to clean under resident beds and move anything lightweight to clean under. V12 ED stated V12 ED would expect housekeeping to move dining tables in the dining area to clean underneath. V12 ED stated there is a program staff are to use to report issues to maintenance. V12 ED stated V12 ED doesn't know if the buckled area in the wall of the resident room has been reported but V12 ED is having to do housekeeping and laundry because a housekeeper called off work.On 5/06/2026 at 1:00 PM, V1 provided work order review sheet dated 2/1/26 to 4/30/26 assigned to the maintenance manager along with copies of text messages but no orders or resolutions were noted for third floor walls to be fixed or painted.The Healthcare Policy dated 5/21/21 documents it is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. The Policy Explanation and Compliance Guidelines include routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge. Horizontal surfaces with infrequent hand contact (windowsills and hard surface flooring) in routine resident-care areas should be cleaned on a regular basis, when soiling and spills occur, and when a resident is discharged from the facility. The Healthcare Routine Bathroom Cleaning Policy dated 3/15/20 documents it the policy of this facility to establish policies, procedures, and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare-associated infection (HAI). Report areas of mold, cracked, leaking, or damaged items in need of repair.

Based on interview and record review, the facility failed to ensure residents were educated on and offered pneumococcal immunizations in accordance with current Centers for Disease Control (CDC) recommendations. This failure affects three (R7, R8, and R9) of five residents reviewed for immunizations on the sample list of 42.Findings include:1. R7's Face Sheet dated 5/6/26 documents R7 was admitted to the facility on [DATE], is [AGE] years old, and has diagnoses including Type 2 Diabetes Mellitus, Obstructive Sleep Apnea, and Chronic Obstructive Pulmonary Disease (COPD).R7's Immunization Record documents R17 has received Pneumovax 23 (PPSV23) on 2/17/14 and Prevnar 13 (PCV 13) on 8/13/19.Based on the CDC's Pneumococcal Vaccine Recommendations, R7 should have received one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose.There is no documentation in R7's medical record or immunization record that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined.2. R8's Face Sheet dated 5/6/26 documents R8 was admitted to the facility on [DATE], is [AGE] years old, and has diagnoses including Type 2 Diabetes Mellitus, COPD, Asthma, and Congestive Heart Failure.R8's Immunization Record documents R8 received PPSV23 on 1/25/17 and PCV13 on 4/23/18.Based on the CDC's Pneumococcal Vaccine Recommendations, R8 should have received one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. There is no documentation in R8's medical record or immunization record that the facility provided education regarding the Pneumococcal vaccine, offered the vaccine, or that the vaccine was given or declined.3. R9's Face Sheet dated 5/6/26 documents R9 was admitted to the facility on [DATE], is [AGE] years old, and has diagnoses including Type 2 Diabetes Mellitus, Congestive Heart Failure, and Morbid Obesity.R9's Immunization Record documents R9 received PPSV23 on 8/25/22.Based on the CDC's Pneumococcal Vaccine Recommendations, R9 should have received one dose of PCV15, PCV20, or PCV21 at least 1 year after the last dose of PPSV23.R9's Authorization and Release for Pneumococcal Vaccine (PCV13 and PPSV23) dated 3/14/22, documents R9 consented to receive the Pneumococcal vaccine.There is no documentation in R9's medical record or immunization record that the facility provided the Pneumococcal vaccine to R9 as requested.On 5/6/26 at 11:18 a.m., V2 (Director of Nursing) stated resident immunizations, consents, and/or refusals should be in the medical record. V2 further confirmed R7, R8, and R9 are not up to date with their Pneumococcal vaccinations and was unable to provide any documentation that R7 and R8 were educated or offered the vaccine or that R9 received the vaccine.The facility's Pneumococcal Vaccine policy, dated 1/1/25, specifies that vaccines will be offered to prevent infection in accordance with current CDC recommendations, specifically for residents with chronic heart and lung disease.

Based on interview and record review, the facility failed to accurately complete R5's comprehensive assessment. This failure affects one (R5) of two residents reviewed for accuracy of assessments on the sample list of 42.Findings include:R5's comprehensive assessment dated [DATE], documents R5 has an indwelling catheter. R5's Medical Record documents R5's indwelling catheter was discontinued on 12/25/25.On 5/5/26 at 10:51 a.m., V8 (Minimum Data Set Coordinator) confirmed R5 did not have an indwelling catheter.

Based on interview and record review, the facility failed to provide timely incontinence care for one resident (R18) of 32 reviewed for Activities of Daily Living (ADLs) on the sample list of 42 residents. Findings include:R18's Medical Diagnosis sheet (5/5/2026) documents R18's diagnoses include Lack of Coordination, Weakness, Abnormal Gait and Mobility, Anxiety Disorder, and Depression. R18's Resident Assessment (1/21/2026) documents R18 is cognitively intact. The same assessment documents R18, is always incontinent of bladder and frequently incontinent of bowel and requires substantial/maximal staff assistance to transfer to the toilet and for toileting hygiene. R18's Care Plan (5/5/2026) documents staff are to provide incontinence care to R18 after each incontinence episode. On 5/3/2026 at 1:27PM, R18 reported wearing an incontinence brief and facility staff are so slow getting me clean. R18 reported call lights sometimes take 2-3 hours to be answered by staff on third shift when R18 is waiting to receive assistance to change a wet brief. On 5/6/2026 at 1:24PM, R18 reported staff on third shift take over an hour to answer R18's activated call light and R18 sits in a wet brief for an extended period of time on third shift. R18 stated, I don't have a choice (to not sit in a wet brief). R18 reported that a CNA (not identified) working on third shift recently told R18 they were in their car and that is why they took so long to respond to R18's call light. R18 stated, I think they are just lazy and also don't care. On 5/6/2026 at 1:30PM, V7 (CNA) reported providing care to R18 for about the last six months and reported R18 does make reliable statements and is cognitively intact. V7 denied R18 makes false allegations or has behaviors. The facility Call Lights policy (2/6/2025) documents staff response times to activated call lights should be a priority.

Based on observation, interview, and record review, facility staff failed to verify proper gastrostomy tube placement by checking for gastric residual before administering medications for one of two residents (R6) reviewed for gastrostomy tubes in a sample of 42. On 5/4/2026 at 3:18 PM V15, LPN (Licensed Practical Nurse) administered medications to R6 via gastrostomy tube (g-tube). Medications administered were Gabapentin capsule 100 mg (milligram) one capsule and Docusate Sodium 100 mg 1 tablet. R6 was to receive 30 cc (cubic centimeter) of water flush before and after administering medication. V15 inserted the syringe with 30cc of water into R6's gastrostomy tube, pushed the water into the g-tube removed the syringe placed the prepared medications into the syringe and re-inserted into the gastrostomy tube and administered the medications. V15 then drew up 30cc of water and flushed the gastrostomy tube per physician's order. V15 failed to check for placement of the gastrostomy tube before administering the first 30cc of water into the gastrostomy tube by checking to see if R6 had residual content.The facility's policy titled Medication Administration via Enteral Tube with revision date 2/2/2026 states under the section titled (#9. Procedure: letter H) states: Enteral tube placement must be verified prior to administering any fluids or medication.)V2, Director of Nurses stated on 5/5/2026 at 10:48 AM Nurses needs to check for placement of the g-tube by checking residual before administrating any fluids or medications.

Based on observation, interview, and record review, the facility failed to ensure a resident's call light was maintained in good working order. This failure affects one (R14) of 32 residents reviewed for call lights on a sample list of 42 residents. Findings include:On 5/3/26 at 9:45 a.m., R14 stated R14's call light is not functioning properly. R14 stated they have to hold down the button (on the call light) to get it to turn on. R14 stated although maintenance came to look at it and the light would turn on outside the door, it did not alert at the nurses' station.On 5/5/26 at 9:29 a.m., R14 was lying in bed and this surveyor asked R14 to press the call light. The light above R14's door failed to illuminate when the call light was activated. At this same time, V9 (Certified Nursing Assistant) was in the room and stated they would report the issue to the Maintenance Director. V9 stated not all call lights alert at the nurses' station. R14 stated, It hasn't worked for a while now. They [maintenance] came and looked at it before and nothing changed. I end up having to yell out, or it takes too long for someone to assist me [because they can't see that the call light is activated]. R14's Quarterly Assessment, dated 2/12/26, documents R14 is cognitively intact.The current Care Plan documents R14 is dependent on staff for activities of daily living.A review of facility work orders for the past three months (February, March, and April 2026) revealed no documented repairs or requests regarding R14's call light.The facility Call Light Policy, dated 2/6/25, specifies that the call system must alert staff members directly or go to a centralized staff work area to ensure an appropriate response.

Based on interview and record review, the facility failed to ensure a resident received the correct medication in accordance with their physician orders, one (R3) of four residents reviewed for medication administration, in a sample of 14 residents.Findings include:On 4/14/2026 at 2:12 PM, V6 Licensed Practical Nurse (LPN), stated R3 got R3's scheduled medication and one of R3's roommate's pills. V6 LPN stated V6 left R3's and R3's roommates' medication at the bedside and walked out to get R3 a glass of water and when V6 came back, R3 took all R3's roommates' medication. V6 stated everyone was notified, and R3's doctor wanted R3 to stay one more day at the facility before going to the new facility.On 4/15/2026 at 10:45 AM, V6 LPN stated medications are not left at the resident's bedside.On 4/15/2026 at 10:35 AM, V16 LPN stated medications are not to be left at the resident's bedside.On 4/15/2026 at 10:40 AM, V13 LPN stated medications are not left at the resident's bedside.On 4/15/2026 at 2:45 PM, V2 Director of Nurses, stated V2 would expect nurses not to leave medications at a resident's bedside.R3's Physician's order sheet, dated 2/2026, documented diagnoses of Atherosclerotic Heart Disease, Acute Diastolic Congestive Heart Failure and Type 2 Diabetes Mellitus without complications.R3's Medication error report, dated 2/9/2026, documented, Nursing Description: Resident found to have ingested roommate's medications while writer briefly stepped out to grab water off med cart. Resident reports taking one Lyrica 225mg (milligrams) prescribed to her (R3) and one Oxycodone 5mg with metoprolol 25mg, Citalopram 20mg, and Hydrochlorothiazide 25mg off of roommates bedside table prescribed to roommate at approximately 0749. Resident Description: When asked why she (R3) took medication from bedside table resident replied with Uh oh, I'm sorry.R3's Physician's order sheet, dated 2/2026, documented orders for Lyrica Oral Capsule 225 Milligrams (MG) (Pregabalin). Give one (1) capsule by mouth two times a day for pain and an order for Hydrocodone-Acetaminophen Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen). Give one (1) tablet by mouth every eight (8) hours as needed for Pain - Severe only three (3) doses. It did not document physician orders for metoprolol 25mg, Citalopram 20mg, and Hydrochlorothiazide 25mg to be given to R3.R3's Progress note dated 2/9/2026. V6 LPN documented, 2/9/2026 08:44 Health Status Note. Resident (R3) found to have ingested roommate's medications while writer briefly stepped out to grab water off of med cart. Resident (R3) reports taking one Lyrica 225mg prescribed to her and one Oxycodone 10mg off of roommates bedside table prescribed to roommate at approximately 0749.R3's care plan, dated 11/5/2026 documented Administer my medications as ordered & notify my MD of side effects.The facility's policy, Medication Administration, dated 2/2/2026, documented, 16. Observe resident consumption of medication.

Based on observation, interview and record review the facility failed to maintain a clean environment for one (R4) of five residents reviewed for housekeeping on the sample list of seven.Findings include:R4's undated census report documents an admission date of 4/9/2016. The same report documents R4's diagnoses as Personal History of Covid-19, Age-Related Nuclear Cataract, Homonymous Bilateral Field Defects, Right Side, Cerebral Infarction, Hyperlipidemia, Essential (Primary) Hypertension, Major Depressive Disorder, Single Episode, Bipolar Disorder, Current Episode Manic Without Psychotic Features, Moderate, Anxiety Disorder, Vitamin Deficiency, Intermittent Explosive Disorder, Nicotine Dependence, Alcohol Abuse, and Obsessive-Compulsive Disorder.On 03/09/26 at 10:45AM R4's room contained a black bookcase shelving unit which contained model cars that were covered in dust. The shelves were also covered with dust. The windowsill had cobwebs/dust from the plant containers to the windowsill as well as cobwebs surrounding a decorative light in the windowsill.On 03/09/26 at 10:45AM R4 stated housekeeping comes to clean the room every two or three days and they do not clean very well. R4 lifted up a half full trashcan stating that the trash has not been emptied for three days. R4 pointed to the windowsill and stated it has been dirty for a long time.On 3/10/2026 at 09:44 AM V12 Housekeeping Supervisor stated the housekeeping department is understaffed and resident rooms are not cleaned appropriately.The Room Change Cleaning and Disinfection policy dated 5/21/2021 documents It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment. The policy further documents: Cleaning refers to the removal of visible soil from objects and surfaces and is normally accomplished manually or mechanically using water and detergents. Policy Explanation and Compliance Guidelines: 1. Routine cleaning and disinfection of frequently touched or visibly soiled surfaces will be performed in common areas, resident rooms, and at the time of discharge.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for two of three residents (R6 and R7) reviewed for abuse in the sample of three.On 12/23/2025 at 1:15 PM V1, Administrator, provided an investigation file documenting a physical altercation between R6 and R7. The Abuse Investigation file dated 8/8/25 documents a physical altercation between R6 and R7. The file documents R6's statement of the incident involving R7 stating that R6 was grabbed and punched by R7 in the left arm. It documents R6 returned a punch hitting R7.On 12/23/2025 R6's care plan review documents R6's admission to the facility on [DATE] with the following diagnoses: End Stage Renal Disease, Chronic Diastolic (Congestive) Heart Failure, Type Two Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure, and Stage Five Chronic Kidney Disease.On 12/23/2025 at 11:02 AM R6 stated she had a physical altercation a few months ago involving her old roommate (R7). R6 stated she was approached by R7 and R7 was accusing R6 of having on a shirt that belonged to R7 when R7 began to hit R6 in the arm. R6 pointed to her right upper arm and stated she had a bruise on her arm after the altercation. R6 stated she hit R7 back as well and threw a glass of water on R7 in attempt to get R7 away from her. R6 stated the facility moved R7 to another room on another floor immediately after the physical altercation. R7's Minimum Data Set, dated [DATE] documents R7 with a brief interview for mental status score of 12 indicating moderate cognitive impairment. R7's care plan dated 11/17/2025 addresses physical aggression towards other residents.On 12/23/2025 R7's Care Plan documents an admission date of 8/21/2024 with admitting diagnoses of Hemiplegia and Hemiparesis following Cerebral Infarction affecting the left non-dominant side, Hyperlipidemia, and Chronic Obstructive Pulmonary Disease.On 12/23/2025 at 10:43 AM R7 stated she had a physical altercation with her old roommate, R6, regarding a shirt R6 was wearing claiming the article of clothing belonged to R7. R7 denied the ability to recall a specific date but added it was the day she moved to another floor. R7 stated R6 started to hit me so I hit her back. R7 denied being harmed during the altercation. R7 stated she left the area where the altercation took place to report it to staff. On 12/23/2025 at 1:15 PM V1, Administrator confirmed physical contact occurred between R6 and R7. V1 stated R6 and R7 were immediately separated by staff and a room change was executed to ensure further separation of R6 and R7.The Abuse, Neglect and exploitation policy dated 6/8/2020 documents the facility is to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property and the facility will make efforts to ensure all residents are protected from physical and psychological harm, as well as additional abuse, during and after the investigation regarding abuse. The abuse policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.

Based on observation, interview, and record review the facility failed to provide an environment that was clean and free from environmental hazards for thirteen (R1, R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19) of nineteen residents reviewed for Physical Plant Problems on a sample list of nineteen. Findings include:On 9/29/25 at 9:45 AM, R1's room where R1 resided during her stay at the facility was observed to have a ceiling in disrepair with evidence of a raised black substance with the appearance of mold present near a dirty sprinkler head. The toilet in the bathroom had a dark ring in the bowl and a dirty vent on the ceiling. On 9/30/2025 between 3:05 PM and 3:40 PM a tour of the resident rooms on the fourth floor was completed with V9 (Maintenance Director). V9 confirmed the ceiling tiles in rooms where R7, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19 currently reside contained a raised black substance growing on them and it had the appearance of mold.On 9/29/25 at 9:10 AM, R1 stated there were ceiling tiles missing, paint chipping, and a black substance on the ceiling and in the toilet of the room R1 resided in during R1's stay at the facility. On 9/30/25 at 9:30 AM, V11 (Housekeeper) stated she has tried everything to clean the gold/black sediment in the toilet bowl in the room where R1 formerly resided and nothing will remove it. V11 stated she thought the toilet needed to be replaced and that she reported it to the former maintenance director and to her supervisor, but it has not been taken care of.On 9/30/2025 at 11:14 AM, V2 (Director of Nursing (DON)) stated the maintenance department has been spotty for a while and that the cleanliness of the building could be better.On 9/30/2025 at 11:31 AM, V1 (Administrator) stated he was not aware of the raised black substance on the ceiling tiles in resident rooms on the fourth floor and agreed this is an environmental hazard.

Based on observation, interview, and record review the facility failed to implement pressure relieving interventions and re-evaluate the effectiveness of a pressure ulcer treatment when the wound did not improve for one of three residents (R2) reviewed for pressure ulcers in the sample of five. Findings include: The facility's Pressure Injury Prevention and Management policy revised 2/10/2025 documents, the facility is committed to the prevention of avoidable pressure injuries, and to provide treatment and services to heal pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The same policy documents the facility will monitor interventions and revise as appropriate. R2's Admission Record documents R2 was admitted to the facility on [DATE] after sustaining a fall at home and developing Rhabdomyolysis. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) documents R2 is at risk of developing a pressure ulcer due to limited mobility. R2's MDS (Minimum Data Set) assessment dated [DATE] documents R2 is cognitively impaired and had no pressure ulcers on admission (1/15/25). This same MDS documents R2 is dependent on staff for mobility. R2's Initial Wound Evaluation and Management Summary dated 2/5/25 documents a new unstageable pressure ulcer to R2's coccyx measuring 3.5 centimeters (cm) x 3 centimeters (cm) with adherent yellow and black dead tissue on the surface of the wound. The same evaluation includes a new order to apply Santyl (debridement ointment) to wound surface daily and cover with an adhesive bandage for 30 days and to offload the wound, reposition R2 per facility protocol, place R2 on a Low Air Loss Mattress, start Vitamin C 500 milligrams (mg) twice daily by mouth, Zinc Sulphate 220 mg once daily by mouth for 14 days and Multivitamin once daily by mouth, and consult dietary regarding protein supplements. R2's current Care Plan documents R2 should be on a low air loss mattress for her wounds. R2's Wound Evaluation and Management Summary dated 2/12/25 documents R2's Coccyx Pressure Ulcer as a Stage 3 measuring 5.5 cm x 3.8 cm and wound bed is soft. V4 Nurse Practitioner documents to continue the same treatment order to the pressure ulcer daily. R2's Wound Evaluation and Management Summary dated 2/19/25 documents R2's stage 3 coccyx pressure ulcer measurements are 5.5 cm x 4.5 cm x 2.2 cm. V4 documents the wound had moderate foul-smelling drainage and documents she manually removed a moderate amount of dead fat tissue from R2's pressure ulcer and that R2 appears to be declining. V4 documents new orders to apply Santyl once daily for 16 days to the wound bed; Sodium hypochlorite solution (Dakin's) apply to the wound bed twice daily for 30 days. Soak gauze dressing with .0125% Dakin's solution, wring out the gauze and apply to the wound bed only, twice daily for one week, until 2/26/25. If the wound is improved by 2/26/25, stop Dakin's and apply alginate silver once daily to the wound bed. R2's Wound Evaluation and Management Summary dated 2/25/25 documents R2's coccyx pressure ulcer is now a Stage 4 pressure ulcer measuring 3.7 cm x 3.2 cm x 2.5 cm. This same evaluation documents to discontinue the order for Santyl daily to the coccyx and start a new order for Sodium hypochlorite solution (Dakin's) apply to the wound bed twice daily for 30 days. Soak gauze dressing with .0125% Dakin's solution, wring out the gauze and apply to the wound bed only, twice daily. This evaluation further documents a new order for Tetracycline 500 milligrams twice a day, for 14 days for treatment of cellulitis to the coccyx wound. R2's Wound Evaluation and Management Summary dated 3/5/25 documents R2's coccyx pressure ulcer measurements were 3.4 cm x 4.2 cm x 1.5 cm with 6 cm of tunneling in the wound bed. The same evaluation further documents R2's coccyx wound is odorous, with heavy drainage and the wound tunneling has worsened with grayish/black drainage. V4 documents to continue with the same wound treatment order and oral antibiotics. This same evaluation further documents V4 manually removed black, dead tissue from the wound bed with a surgical blade. R2's Wound Evaluation and Management Summary dated 3/12/25 documents R2's coccyx pressure ulcer measurements were 2.9 cm x 3 cm x 1.5 cm with 4 cm of tunneling. V4 further documents a moderate amount of odorous drainage from wound bed. The same evaluation documents V4 manually removed dead tissue from the wound bed using a blade during assessment. V4 documents to continue the same treatment order to R2's coccyx pressure ulcer. R2's Wound Evaluation and Management Summary dated 3/19/25 documents R2's coccyx pressure ulcer measurements were 4.5 cm x 4.5 cm x 1.5 cm with 5.5 cm of tunneling. This same assessment documents R2's wound has heavy, grey, foul-smelling drainage coming from the wound with increased black, dead tissue to the wound bed which was manually removed with a blade. V4 documents to continue with the same treatment to the pressure ulcer and start Ciprofloxacin 500 milligrams by mouth, for 14 days for wound infection, and Flagyl 500 milligrams, crush and sprinkle into wound base, twice daily with dressing changes. R2's Wound Evaluation and Management Summary dated 3/26/25 documents R2's coccyx pressure ulcer measurements were 3 cm x 5 cm x 1 cm with 6.1 cm of tunneling. V4 documents R2's coccyx pressure ulcer still has moderate amounts of black dead tissue covering the wound bed, heavy drainage, and the wound tunneling is now opened at sacral area as well. V4 documents V4 manually removed dead skin tissue using a blade. This same evaluation documents to continue with the same wound treatment started on 2/19/25. On 4/2/25 at 10:00 AM, R2 is lying supine in bed on a perimeter mattress with no low air loss mattress, wearing a hospital gown. On 4/2/25 at 12:13 PM, R2 is lying in her bed supine with a hospital gown on. R2 stated she often has pain in her coccyx area and her feet. R2 stated she has a wound on her buttocks but was not sure how it started. On 4/2/25 at 1:15 PM, R2 has two separate stage four pressure ulcers on coccyx that are merging into one pressure ulcer. The original coccyx pressure ulcer is open and covered in yellow/gray tissue over the wound bed. The second pressure ulcer is on the left upper buttocks and is open with a red wound bed. Between the two wounds is a small layer of skin. The wound tunnels into R2's coccyx. V4 measured the tunneling to be 6 cm. There was a large amount of yellow and pink drainage on the adhesive bandage that was removed from R2's wound. On 4/2/25 at 1:05 PM, V4 stated R2 is supposed to be on a low air loss mattress to help with pressure distribution for wound healing. V4 stated R2 could probably benefit from having Negative Pressure Wound Therapy due to the increased amount of drainage from the wound, but V4 does not have much knowledge with using Negative Pressure Wound Therapy (wound vac). R2's Wound Evaluation and Management Summary dated 4/2/25 documents R2's coccyx pressure ulcer measurements were 4.5 cm x 8.3 cm x 2.5 cm with 6 cm of tunneling. V4 manually removed yellow colored dead skin with a blade that was covering the wound bed and documents a new order to place a Negative Pressure Wound Therapy on R2's coccyx due to increased amount of drainage to the wound site. On 4/2/25 at 1:00 PM, V3 Wound Nurse stated R2 is supposed to be on a low air loss mattress and the mattress she is on currently is not correct. V3 further stated that R2 had moved rooms over the weekend and the staff didn't move R2's low air loss mattress. On 4/2/25 at 2:00 PM, V1 Administrator and V2 Director of Nursing stated they would expect after two weeks of a wound not making progress that a new treatment would be ordered.

Based on observation, interview and record review the facility failed to ensure utensils, dishes, and cookware were sanitized prior to serving foods to residents, failed to prevent cross contamination of foods from staff clothing during meal service, and failed to maintain a cooking environment free from debris. This failure has the potential to affect 107 residents residing in the facility. Findings include: The Daily Resident Roster dated 3/23/25 documents 107 reside in the facility. On 3/24/25 at 11:15 AM V29 [NAME] plated resident meals and then passed the plates of food across the food line to the dietary aides. V29's shirt grazed the food in the warmer trays several times when V29 would lean over to pass the plated meal to the dietary aides. On 3/24/25 at 11:30 AM the wall behind and above the food prep area, cooking and fry area had two areas approximately one foot wide and long of peeling paint that was hanging from the wall. These same areas had several pieces of debris that fell into the fryer oil and on top of the food prep area. On 3/24/25 at 11:45 AM V27 [NAME] tested the Ph balance of the facility low temperature dish washing machine three times in a row by placing the litmus strip on the inside wall of the dishwasher during the wash/detergent cycle, prior to the sanitizing cycle. The facility dishwasher sanitizer tubing was connected but not running through the machine. V28 Dietary Manager primed the tubing on the sanitizer. The dishwasher was run again and had the sanitizer circulate through without any difficulty. V28 Dietary Manager then educated V27 [NAME] on how to properly test the Ph balance of the dishwasher and how to test if the sanitizer if working properly. On 3/24/25 at 11:50 AM V27 [NAME] stated he tests the Ph balance of the dishwasher several times per week regularly but was never trained on how to test the PH balance. V27 [NAME] stated he did not know how to see if the sanitizer was running or not. On 3/24/25 at 11:55 AM V28 Dietary Manager stated many of the kitchen staff are newly hired and have not been trained on how to use all the equipment. V28 stated she will provide in servicing on the equipment to all the kitchen staff. V28 Dietary Manager stated all the breakfast dishes were washed without being sanitized prior to serving the residents their lunch meal. V28 Dietary Manager stated serving food on non-sanitized dishes and cookware could cause resident illness. V28 Dietary Manager stated the facility has plans to remodel the facility kitchen including replacing the walls with stainless steel portions behind and above the cooking area. V28 Dietary Manager stated she will have V16 Maintenance Director fix the peeling paint as soon as possible. V28 Dietary Manager stated she will put up plastic guards to protect the foods from being contaminated by staff clothing. V28 stated she will also create a new line system so that the cook does not have to pass the plated meal across the food line. On 3/25/25 at 7:50 AM V16 Maintenance Director stated he is aware that the kitchen wall above the food prep and cooking areas has peeling paint. V16 stated he has already reached out to the facility's corporate office and is waiting for a response to be able to purchase the supplies to fix the wall in the kitchen.

Based on interview and record review the facility failed to hold one quarterly Quality Assurance Performance Improvement (QAPI) meeting for the [AGE] year and failed to include the facility's Infection Preventionist in all QAPI meetings. This failure has the potential to affect all 107 residents in the facility. Findings include: The facility QAPI sign in sheets dated 2/4/25, 7/12/24 and 4/5/24 does not include an Infection Preventionist documented as attending the QAPI quarterly meeting. The facility is unable to provide documentation of a QAPI meeting being completed for the third quarter (July, August, September) of 2024. On 3/25/25 at 4:00 PM V1 Administrator stated the QAPI meeting is supposed to happen at least quarterly and include the Infection Preventionist. V1 stated she was unable to find any documentation of the facility having a third quarter QAPI meeting for 2024.

Based on observation, interview, and record review the facility failed to complete a risk assessment plan for Legionella and failed to prevent cross contamination during medication administration. These failures have the potential to affect all 107 residents who reside in the facility. Findings include: The Long Term Care Facility Application for Medicare and Medicaid dated 3/23/25 documents 107 residents reside in the facility. 1.) The facility provided water management program dated 2/1/25 documents it is the policy of this facility to establish water management plans of reducing the risk of Legionella and other opportunistic pathogens in the facility's water systems. The facility's Maintenance Director maintains documentation that describes the facility's water system, and a risk assessment will be conducted by the water management team annually to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water systems. The risk assessment will consider the following elements: Premise plumbing, clinical equipment, at-risk population and the supporting documentation of any areas will be kept in the binder. Based on the risk assessment, control points will be identified. Control measures will be applied to address potential hazards at each point. Testing protocols and control measures will be established for each control measure and the effectiveness of the water management plan will be evaluated at least annually. On 3/26/25 at 9:11AM, V16 Maintenance Director stated he does not have a risk assessment or plan for Legionella, nor any documentation indicating the areas of risk for Legionella growth in the entire facility. He does not have a map of the facility plumbing or testing logs other than on one floor of the building because he was told to do that. V16 stated he is unaware of any Legionella testing in the past year and stated that he has been told that an outside company is going to take over the Legionella program at the facility. 41970 2. R79's Physician Order Sheet (POS) dated March 2025 documents a physician order to administer Azelastine 0.05% eye drops one in each eye twice daily. On 3/23/25 at 3:40 PM V15 Licensed Practical Nurse (LPN) administered R79's Azelastine 0.05% eye drops to R79's eyes. V15 LPN did not wear gloves when administering R79's eye drops. V15 LPN used a tissue to wipe R79's eyes after administering the eye drops then laid the tissue on R79's contaminated bed sheets. V15 LPN stated she did not think R79 got all of his eye drops. V15 LPN then administered another drop to each of R79's eyes and then used the same contaminated tissue to wipe R79's eyes again. On 3/23/25 at 3:50 PM V15 Licensed Practical Nurse (LPN) stated she should have performed hand hygiene and worn gloves prior to administering R79's eye drops. V15 LPN stated she should not have used a soiled tissue to wipe the excess eye drops from R79's eyes. V15 LPN stated these errors could cause an infection in R79's eyes. On 3/25/25 at 10:10 AM V2 Director of Nurses (DON) stated nurses should wear gloves when administering eye drops and use a clean tissue to avoid causing an infection. The facility policy titled Eye Drop Administration dated 10/25/2014 documents staff are to wear gloves when administering eye drops. Wipe off tears or excess solution with clean gauze, cotton ball or tissue.

Based on observation, interview, and record review the facility failed to implement a physician order STAT (immediate) for orthopedic consult appointment, in a timely manner, for a resident (R1) with a right Humerus fracture. This failure resulted in a six day delay, which caused severe pain and swelling before the application of a cast could occur. This failure affected one of three residents (R1) reviewed for falls/physician orders on the sample list of six. Findings include: R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment. R1's Health Status Note dated 2/18/25 at 11:05 am, signed by V21, Licensed Practical Nurse (LPN) documents the following: Note Text: Writer approached by CNA (Certified Nursing Assistant) stating that on the way to the bathroom resident had trouble pulling her legs forward and fell to her knees. Writer performed full body assessment. Resident able to move all extremities but did c/o (complained of) pain to her R (right) arm during this assessment. Resident denied pain anywhere else. The same Health Status Note documents Writer notified MD (Physician), resident (R1) notified her emergency contact. R1's Health Status Note dated 2/18/2025 at 1:54 pm, documents the following: Note Text: Resident assessed by NP (V22, Facility, Nurse Practitioner) after fall. STAT (immediately) X- rays ordered for Right Elbow and Forearm. R1's Medical Practitioner Note (Physician/Nurse Practitioner) Note dated 2/19/2025 at 3:15 pm, with the date of service as 02/18/25 (the day of R1's fall), (unknown time) documents the following: R1 was assessed by V22, NP for a complaint of right elbow pain rating her pain intensity as eight out of ten (severe). The same report documents swelling in R1's right elbow, with moving it makes it worse, rest make it better. Tylenol (analgesic pain medication) is not making it better. The same note documents: Right elbow pain -- Will start Tramadol for pain 50 mg PRN. R1's Health Status Note dated 2/18/2025 at 1:55 pm, documents the following: Note Text: Resident c/o pain NP (V22, Nurse Practitioner) made aware NO (new order) rec'd (received) for Tramadol (Tramadol, narcotic pain medication) q (every) 12hrs (twelve hours), PRN (as needed). R1's X-Ray results dated 2/18/25 at 9:48 pm documents the following: PROCEDURE: ELBOW 2V (views) Interpretation: Reason for Study: Acute Pain Due to Trauma. Elbow 2V, right. FINDINGS: Acute transverse fracture involving right humeral condyles with modest displacement. There is associated joint effusion. CONCLUSION: Acute transverse fracture involving right humeral condyles with modest displacement. R1's Health Status Note dated 2/19/2025 at 00:30 am documents: Note Text: (V8, Medical Director/Physician) notified of res (R1's) X-ray results at this time. R1's Health Status Note dated 2/19/2025 at 05:22 am documents the following: Note Text: N.O. rec'd per MD to send to Orthopedic Stat (immediately) for rt arm fx (fracture). Res cont (continues) fall status. Res c/o (complained of) pain. N. O's rec'd to increase Tramadol (50 milligrams) to q 4hrs PRN for pain, and ice packs to Rt elbow q 4hrs. R1's Health Status Note dated 2/19/2025 at 11:34 am documents: Note Text: called and spoke with (V30, Orthopedic Office Staff) DOC (Local Orthopedic Center) and resident has appt (appointment) on 2/24/2025 at 1:45 pm for f/u (follow up) with RT elbow fracture. This appointment was not a follow-up appointment, this was the initial appointment. This was not the physician ordered STAT (immediate) appointment, post- fall 2/18/25. R1's Health Status Note dated 2/20/2025 at 1:28 pm documents the following: Note Text: (V8, Medical Director) gave N.O. for sling to right upper extremity r/t (related to the) fall. R1's Controlled Drug Receipt/Record/Disposition /Form count sheet documents R1 was administered 12 doses of Tramadol HCL, 50 milligram tablet used for moderate to severe pain, between 2/19/25 and 2/24/25 while waiting for her initial appointment with the Orthopedic Center on 2/24/25. R1' February 1-28, 2025 Medication Administration Record does not document R1 was administered R1's available Tylenol 1000 mg, every four hours for mild pain. R1's (Local) Orthopedic Center, Encounter Date report dated 2/24/25 and signed by V20, Orthopedic Nurse Practitioner documents the following: History of Present Illness: The patient (R1) is a (specific age) female who presents for an evaluation of elbow pain. She states that she fell a week ago on 02/18/2025. She landed directly on her right elbow. She states that she has been in severe pain ever since. She had X-rays done at her nursing home (the facility) that revealed a fracture in her elbow. She states that they have been icing it, and they put her on pain meds. These have given her moderate relief. However, whenever she moves her right arm, she has severe pain. She has her right arm in a sling. She has very noticeable swelling in her right arm compared to her left arm. The same report documents: Assessment & Plan, Fracture of Humerus, distal, right, closed. Today's Impression: (R1) is a (specific aged) female who presents today for evaluation of right elbow pain. She fell sustaining a distal Humerus fracture nearly one week ago. Her x-rays from today confirm a displaced, distal Humerus fracture. I discussed her treatment options. The patient has a multitude of risk factors upon consideration for surgery. The patient is morbidly obese as well as diabetic. We discussed that this could put her at increased risk for infection and delayed wound healing. The patient also uses a walker for assistance with ambulation at baseline. I discussed my concern that her hardware could easily be removed if she is putting all of her weight through her upper extremities when she is ambulating with a walker. Because of these multiple factors, I think it is best to treat this patient conservatively. She verbalized understanding and is agreeable with this. At today's visit, we placed the patient into a posterior splint. I would like for her to work on hand and finger range of motion of at the (facility). I would also like the (facility) to aggressively ice. I am hopeful these things will help her swelling. I would like to see her back in two weeks for re-evaluation. The same Report documents: Application of Long Arm Splint Routine and Cast Supplies, Long Arm Cast Plaster, Routine. On 3/13/25 at 3:20 pm R1 was lying in bed watching television. R1 had a cast on her full right arm, and a faint fading bruise on the right side of her nose caused by the fall 2/18/25. R1 stated, They did an X-ray later that day (2/18/25). I did not get the results until the next day. I don't know why I wasn't sent to the emergency room . I don't know why there was a delay in getting an appointment to see the doctor in the orthopedics department. At first, I did not know I had a fracture. I just knew my arm hurt a hell of a lot, every time I moved it. I tried to keep it still to keep my pain level down. It was twelve, on the scale of one to ten when I moved it. The pain never went away. I tried to keep my arm elevated on a pillow and placed ice on it, to reduce the swelling. It is hard to keep it still, if you can even get to sleep. The pain would wake me several times a night, before I got this cast. I consistently received a pain pill which helped very little with the pain. A couple days later, someone brought in a sling. I did not like the sling; it did not fit right or something. It made my arm pain worse. My arm was more comfortable without it (arm sling) on, if I kept it elevated and kept taking the pain medication. My arm had really swelled up over the next couple of days. I thought that person (unidentified) was going to bring in a larger one (sling) that fit. That did not happen. Several more days past, I ended up with this cast (full right arm cast). My pain went down from an average of seven or eight to a two or a three once, I got the cast. I still take the pain medications. Between the cast and the pain pill, I am relatively comfortable. Not pain free that is for sure. I have not been out of my bed except for the doctor's appointments. It is not worth it. I am somewhat comfortable now and want to stay that way while my arm heals. The CNA's (unidentified) have been washing me up in bed, so I don't have to get up. On 3/14/25 at 1:15 pm V2, Director of Nursing (DON) confirmed after V8, Physician reviewed R1's X-ray, V8, Physician gave R1's STAT order for R1 to be seen by Orthopedic Specialist. V2 stated, The Orthopedic office gave (R1) their first available appointment 2/24/25. (R1) should have been seen right away. I assumed the Ortho (Orthopedic Center) office knew this was a STAT order. I can see now the progress note documents this was a follow-up, but it was the first time (R1) was seeing them for her arm fracture. I guess we really should have let (V8, Physician) know they (Orthopedic Center) couldn't get her (R1) in until the 24th. He may have sent her to the ER (Hospital, emergency room ) had he known it would be that long (six days). (R1) has had a lot of pain. We had her Tramadol increased. She had a lot of pain and swelling in her arm, as you can imagine. Once she got the cast on at that appointment (2/24/25) she has finally had some relief from the pain. On 3/14/25 at 2:10 pm V20, Orthopedic Office Nurse Practitioner (NP) stated V20 had seen R1 for the first time on 2/24/25. V20, NP stated she was very frustrated when R1 came to V20's Orthopedic Center on 2/24/25, because R1's fractured arm was not positioned well in a sling. There was nothing to stabilize (R1's) arm and prevent the possibility of further damage. V20, Nurse Practitioner stated, (R1) had a significant displaced Humerus fracture. (R1) should have gone immediately to the emergency room (ER) after she fell . V20, NP stated the Orthopedic office had not been told of the Stat (immediate) order to be seen by us (Orthopedic Specialist), instead of waiting six days for the appointment. The office protocol for a STAT consult, is to have the X-ray sent to the office immediately for review and not wait for the first available appointment. (R1) had a significant displaced fracture. I would have reviewed the X-ray and sent (R1) to ER (emergency room ), immediately. V20, Orthopedic Nurse Practitioner confirmed the facility caused the delay in treatment, by failing to follow the STAT (immediate) referral for Orthopedic treatment. This failure resulted in a six day delay without a properly placed sling to prevent further damage. V20 stated, (R1's) arm was extremely swollen by the time I (V20, Orthopedic Nurse Practitioner) saw her (R1). She was in a lot a pain. How in the world did this situation slip through the cracks. They (the facility) knew she had fallen, and the X-ray showed the immediate need for treatment. She should have gone to ER. On 3/18/25 at 2:30 pm V8, Physician/Medical Director (MD) stated the facility should have known to call V8, if an appointment was not available until six days after R1 fell and fractured R1's right Humerus on 2/18/25. V8, MD stated R1 was not a good candidate for surgery with all R1's comorbidities. V8, MD was confident the sling would be effective to maintain stability of R1's fractured arm. V8, MD stated the swelling and pain would be the only complication, in waiting for the Orthopedic consult. V8, MD stated V8, MD had to increase R1's Tramadol to maintain R1 comfort while R1 waited for that appointment 2/24/25.

Based on observation, interview, and record review the facility failed to provide a safe environment and implement fall interventions which resulted in R3 falling out of bed and hitting her head on the bedside dresser on two separate occasions, both required emergency medical attention for head lacerations requiring closer with staples. The facility also failed to provide adequate assistance and a safe environment during resident ambulation, resulting in R1 sustaining a right arm fracture. These failures affected two of three residents (R1, R3) reviewed for falls on the sample list of six. Findings Include: 1. R3's Medical Diagnosis List dated March 2025 documents R3 is diagnosed with Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left non-dominate side, Restlessness and Agitation, Anxiety, Restless Leg Syndrome, and Insomnia. R3's Minimum Data Set, dated dated dated [DATE] documents R3 is cognitively intact and requires moderate assistance from staff for safe transfers. R3 is wheelchair bound. R3's State Report dated 2/24/25 documents on 2/24/25 R3 rolled out of bed and hit her head on the bedside dresser, sustaining a head laceration. R3 was sent to the emergency room where the laceration was closed with five staples. R3's Post Fall Evaluation dated 2/25/25 documents on 2/24/25 R3 was found lying on the floor beside her bed with her head against the bedside dresser. R3 had rolled from her bed onto the floor. R3 sustained a laceration to the back of her head and was sent to the emergency room where she received five staples to close the laceration. Contributing factors related to the fall and subsequent injury are documented as no floor mats in place, poor lighting, and bed was at an improper height. R3's Fall Interdisciplinary Team Note dated 2/25/25 documents on 2/24/25 R3 was found on the floor in her room beside her bed. R3 stated she was reaching for something and rolled onto the floor. R3 sustained a laceration to the back of her head, went to the emergency room and received five staples to the laceration for closure. It was determined that R3 hit her head on the bedside dresser when she rolled out of bed. New interventions regarding the fall include to ensure frequently used items are within easy reach and to modify the furniture layout in the room for safety. R3's Hospital Records dated 2/4/25 document R3 was seen in the emergency room for laceration to the back of her head after a fall to the floor which required five staples to close. R3's State Report dated 3/2/25 documents on 3/2/25 R3 again hit her head on the bedside dresser and sustained another head laceration. R3 was sent to the emergency room where this time the laceration was closed with four staples. R3 stated upon returning to the facility that she hit her head on the corner of the bedside dresser when she laid back in bed. New interventions regarding the R3's safety include to pad the corners of the bedside dresser and place two assist rails on R3's bed. R3's Emergency Department records dated 3/2/25 document R3 was seen in the emergency room after hitting her head and sustaining a laceration to the left side of her head requiring four staples for closure. R3's Care Plan last updated on 3/2/25 documents R3 is at risk for falls due to her medical conditions and requires staff assistance with transfers. The same Care Plan documents the following fall interventions for R3: Scooped mattress to help identify bed parameters, fall mats when in bed, call light extension cord, ensure frequently used items are within easy reach, modify furniture for safety, place bed in the lowest position, and pad the corners of the bedside dresser (nightstand), etc. On 3/14/25 at 12:30 PM V14 Licensed Practical Nurse (LPN) stated she was the nurse for R3 when she was injured on 3/2/25. V14 LPN stated she was aware R3 had hit her head on the bedside dresser previously on 2/24/25 and after that fall, the bedside dresser was moved and kept away from R3's bed. Instead, it was on the wall close to the door. V14 stated she in not sure who moved the dresser but when she observed R3's head bleeding on 3/2/25 the bedside dresser was positioned right up next to R3's bed. V14 stated other interventions not in place were the scoop mattress and R3's bed was not in the lowest position. V14 stated R3 has fallen out of bed and from her wheelchair many times and has poor safety awareness. V14 LPN confirmed if the bedside dresser would have been kept away from R3's bed like it was supposed to be, R3 would not have hit her head on the bedside dresser causing a laceration. On 3/13/25 at 3:45 PM R3 was lying in bed. There was no scoop mattress on the bed, no call light extension cord in place, no padding on the bedside dresser, and the dresser was close to R3's head of bed. R3 stated she has never had a scoop mattress or call light extension cord. R3 stated at the time of her fall on 2/24/25 her bed was not at its lowest position and fall mats were not in place. R3 stated on 3/2/25 she went to lay back in her bed and she hit her head on the bedside dresser. R3 stated she is not sure who moved the dresser back to beside her bed, but she knew they had previously moved it away for her safety. On 3/14/25 at 1:45 PM V2 Director of Nurses confirmed R3 is a very big fall risk due to her unsafe ability to get up on her own, he medical diagnoses, her poor safety awareness, and her resistance to asking for help. V2 stated on 2/24/25 when R3 rolled out of bed, there should have been a scoop mattress on the bed, fall mats on the floor, bed at the lowest position, and a call light extension in place. V2 confirmed when R3 rolled out of bed she sustained a right head laceration which required five staples to close. V2 stated after the 2/24/25 fall, R3's bedside dresser was to be moved and kept away from her bedside and placed towards to door. V2 confirmed on 3/2/25, R3's bedside dresser was somehow moved back next to the head of R3's bed. V2 is unsure of who moved the dresser back but stated they in-serviced all staff to not move residents' furniture around without verifying it is not a safety/fall intervention. V2 confirmed on 3/2/25, R3 laid back in bed and hit her head on the corner of the bedside dresser, sustaining a head laceration which required four staples to close. V2 stated all R3's fall/safety interventions should be in place at all times. Staff should be aware of what they are and ensure they are in place to prevent falls or injuries. The facility's Fall policy 2/12/25 documents, each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Staff are to implement universal environmental interventions that decrease the risk of resident falling, including, but not limited to clear pathway to the bathroom and bedroom doors, bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed. Bed should always be in low position when the resident is sleeping, call light and frequently used items are within reach and adequate lighting. 31642 2). R1's multi-dated Diagnoses Sheet documents the following: Weakness, Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb, Essential (Primary) Hypertension, Paroxysmal Atrial Fibrillation, Anemia in Chronic Kidney Disease, Diabetes Mellitus Type II with Hyperosmolarity With Coma, and Body Mass Index 45.0-49.9, Adult (Morbid Obesity). R1's Minimum Data Set (MDS) dated [DATE] documents the following: Brief Interview of Mental Status (BIMS) score of 15, out of a possible 15, indicating no cognitive impairment. The same MDS documents R1 requires substantial to maximum assist with toileting, is dependent on staff positioning, and had no impairment of the upper or lower extremities range of motion. R1's Witnessed Fall report dated 2/18/25, signed by V21, Licensed Practical Nurse (LPN) documents R1 was ambulatory with assistance. Nursing Description: Writer approached by CNA (Certified Nursing Assistant/unidentified) stating that on the way to the bathroom resident had trouble pulling her legs forward and fell to her knees. Resident Description: Resident stated that her leg wouldn't move as she was walking to the bathroom, and she went down. Immediate Action Taken Description: Writer performed full body assessment. Resident able to move all extremities but did c/o (complained of) pain to her R (right) arm during this assessment. Resident denied pain anywhere else. Writer obtained vital signs b/p (blood pressure): 153/97, P (pulse) :94 R (respirations) :18 T (temperature):97.9. Writer then assisted two CNA's with a (full-body mechanical) lift to get resident off of the floor and into the bed. Writer notified MD (Physician) resident (R1) notified her emergency contact. Predisposing Environmental Factors: None (observation and interviews documented below identified there was a damaged, metal, sharp threshold strip that caused R1's foot to get stuck) Predisposing Physiological Factors: Gait imbalance and recent illness. Predisposing Situation Factors: Ambulating with assist during transfer, standing and using walker. V13, Certified Nursing Assistants (CNA) statement as follows: I was walking resident (R1) to the bathroom and resident foot got stuck. Resident fell to the floor on her side and sat back up on her bottom, writer called for help and nurse (V21, LPN) and CNA came. Nurse did full body assessment and we obtained vitals. We then use (full-body mechanical lift) lift and got resident off the floor and into the bed. The facility State Report prepared by V1, Administrator, documents R1's fall incident occurred on 02/18/25. The same report documents the following: BRIEF DESCRIPTION OF INCIDENT: Resident had witnessed fall going to bathroom. Resident c/o (complained of) pain to right shoulder and antecubital space. X-Ray ordered to Rt. (right) Elbow and Rt. Forearm. XR(X-Ray) results stated acute transverse fracture involving rt. Humeral condyles with modest displacement. R1's fall investigation results as follows: Summary of the Investigation: At 09:36 (a.m.), 02-18-25 resident (R1) was observed falling to the ground landing on her right side. Resident stated her leg wouldn't move as she was walking to her bathroom, and she went down. Staff stated her foot got stuck causing resident to go down on her right side. Resident c/o (complained of) right extremity pain mainly in right antecubital space. Residents' pain was managed with Tramadol (narcotic, pain medication). Portable X-ray was done in facility and MD (Physician) ordered to see Ortho (Orthopedic Specialist). Resident saw Ortho on 2-24-25. Resident has soft cast in place on Right arm. Plan of care was updated. R1's X-Ray results dated 2/18/25 at 9:48 pm documents the following: PROCEDURE: ELBOW 2V (views) Interpretation: Reason for Study: Acute Pain Due to Trauma. Elbow 2V, right. FINDINGS: Acute transverse fracture involving right humeral condyles with modest displacement. There is associated joint effusion. CONCLUSION: Acute transverse fracture involving right humeral condyles with modest displacement. On 3/13/25 at 11:05 am R1 was asleep in bed with a cast on her full right arm. R1 also has R1's bilateral lower legs wrapped in compression type wraps. On 3/13/25 at 3:20 pm R1 was lying in bed watching television. R1 had a cast on her full right arm, and a faint fading bruise on the right side of her nose. R1 stated, The day I fell (2/18/25), someone I did not know (later identified as V13, Certified Nursing Assistant), answered my call light and walked me to the bathroom. I think it was a nurse, but it might have been a CNA (later identified as V13, Certified Nursing Assistant). That day was the only time I ever saw that girl. She did not use a gait belt like the other CNA do. I was using my walker. She just walked beside me and did not do anything to try to keep me stable. I am weak and it is obvious. My left legs always have these bandages on them. I was wearing my slippers the day I fell . As I walked through the bathroom door my left foot got struck on the raised, sharp part of the metal strip across the doorway floor. R1 pointed towards the bathroom. The damaged metal strip could be seen from R1's bed. This surveyor observed the quarter inch metal strip threshold adjoining the bathroom floor and bedroom floor. Six inches from the left side of the bathroom open doorway was a sharp bent section of metal sticking up. R1 stated, I asked that girl (V13, CNA) to help me get it loose, maybe lift my foot or bump it a little with her foot. That girl told me 'You will have to do it; I can't I am pregnant.' I tried and could not get it to move. I tried several times, for several minutes, I could not get the strip to release my house shoe. I was feeling weak from trying on my own. I lost my balance, and my right knee gave out. I did not feel this was abuse. I did feel this was an unnecessary fall. Had one of my routine CNA's been helping me, they would have done everything they could to keep me from falling. They would have had to bump my foot or pull it up off that strip. Almost every time I go to the bathroom, my foot gets caught there. I went down, hitting my face my walker and the whole right side of my body on the floor. It could have been prevented if she (V13, CNA) had even tried to break my fall. Since I did not have on a gait belt, she did nothing to break my fall or catch me. I get she was pregnant, but it was not safe for her to help me alone. On 3/14/25 at 11:25 am V13, Certified Nursing Assistant (CNA) confirmed she was with R1 when R1 fell . V13 stated, It was the first time I had taken care of (R1). (R1) used a walker to get to the bathroom. I was standing close to her while she walked. (R1) barely lifted her feet, took small steps, and kind of slid her feet across the floor on the way to the bathroom. (R1) was not able to lift her feet or slide her feet very well when we got to the bathroom doorway. I usually have a gait belt on residents when I walk with them (residents). I can't remember if I put a gait belt on (R1) or not. I am pretty sure I did. I am not positive, but I know we are supposed to (use a gait belt). (R1) asked me to scoot her foot for her, because it was stuck on the metal (threshold strip) in the doorway. I could not bend over, because I am pregnant. I told her to keep trying on her own. I did not know what to do. I couldn't reach the bathroom call light because her walker took up the whole doorway. I held on to the walker thinking that might help. She kept trying (to un-stick her shoe from the metal strip), several times and said she was getting worn out. I did not want to leave her, so I just kept holding onto her walker. (R1), all of the sudden, lost her balance and fell hard to the right. I couldn't help her because she weighs a lot. I am pregnant and have to be careful. She hit her face on the walker, and then hit her body on the floor. I went for help right away. (V17, CNA) and (V18, CNA) came right away. Then a nurse (unidentified) came in. I felt bad, but I couldn't stop the fall. After the nurse (later identified as V21, Licensed Practical Nurse) did an evaluation, they (V17, V18, CNA's and the nurse) used the (full body mechanical lift) to get her off the floor and back in bed. (R1) said her arm was hurting her really badly. I heard later her arm was fractured from the fall. I felt awful that I could not stop her from falling. On 3/14/25 at 11:50 am V17, Certified Nursing Assistant (CNA) stated, I take care for (R1) frequently. R1 has been weaker since she readmitted from the hospital in January. We can't get her wheelchair into the bathroom. The bathroom is too small. (R1) walks with a walker, real slow, because of the cellulitis in her legs and her increased weakness. She should not be rushed. I always use a gait belt. We are supposed to (use a gait belt) with all residents. (V13, CNA) did not have a gait belt on (R1) when she (R1) fell . I was here, I went in to help immediately, and I helped transfer her right after the fall. (R1) did not have a gait belt on. We used the (full-body mechanical lift) to get her off the floor. (R1) was in a lot of pain. She said it was in her right arm. Her (R1's) face was already starting to bruise a little by her nose. She said she hit her face on the walker on her way down to the floor. (V13, CNA) is big and pregnant. She did not know (R1) needed a little help to move her foot over the metal strip. I usually just give her shoe a little nudge. That metal strip has a sharp edge, and it is right where you have to walk in there. It does not take much to un-stick her house shoe. It does not always get stuck, but it happens often. She (R1) asks for help if she is having a hard time lifting or sliding over the strip in the doorway. It only takes a second to give her shoe a nudge. On 3/14/25 at 1:15 pm V2, Director of Nursing (DON) confirmed V13, Certified Nursing Assistant was the CNA who assisted R1 to the bathroom when R1 fell . V2 stated V2, DON had not been informed R1 asked V13 to raise R1's foot or scoot it over a damaged strip on the floor. V2 also stated she was not aware V13 did not use a gait belt for R1's transfer to the bathroom, 'as she should have'. On 3/18/25 at 11:25 am V21, LPN confirmed V21, LPN was R1s nurse on 2/18/25 when R1 fell . V21 stated, I don't remember (R1) having the gait belt on when she fell . I would have documented it, had one been on. I helped the CNA's transfer (R1) back to bed. We used the (full -body mechanical lift). (V13, CNA) is pregnant. Had I known she could not adequately assist (R1), I would not have had (R1) on (V13, CNA's) list. We change assignments for a variety of reasons. (R1) should have had on a gait belt and should have been provided full assistance to the bathroom. V21, LPN stated, I did not see that she hit her face on the walker, and I did not realize R1's foot was stuck on the metal strip in the doorway. I was focused on getting her comfortable and calling the provider for an X-ray (order). On 3/18/25 at 12:00 pm V18, CNA stated, (R1's) fall I can tell you that strip in her bathroom door has been a problem. Even the (mechanical stand lift) and wheelchairs get stuck on the rough edges of that thing (metal threshold strip). (R1's) foot gets stuck all the time and I either bend over or give her foot a little nudge. (V13, Certified Nursing Assistant) does not usually have that group. (V13,CNA) is also eight months pregnant. She did not know her (R1). I know (R1) can't stand very long. She leans on her walker after a couple minutes, (R1's) legs would give out. (V13, CNA) probably did not realize that. She (R1) will tell you is she is feeling weak. Knowing (R1), I am sure she told (V13, CNA that. We are supposed to wear gait belts with all transfers. I don't recall if (R1) had one or not. I don't remember seeing one. We were all rushing around trying to figure out how we would get (R1) off the floor. I may have just missed it (seeing the gait belt). I would do anything to prevent a resident from falling. Gait belts help stabilize people. Putting on the call light if we need extra help makes the most sense. (V13, CNA) probably couldn't fit through the bathroom doorway, to turn on the call light and ask somebody else for help. From seeing (R1) on the floor in the bathroom, I can see how (V13, CNA) would have a problem turning on the call light. (R1) is a large woman, her walker is pretty big, (V13, CNA) is big pregnant, and the bathroom is very small. On 3/19/25 at 8:58 am V26, Maintenance Director entered R1's room to assess the metal threshold strip in R1's bathroom doorway. R1 stated she was glad to see V26 is going to fix her walking path to the bathroom. Though R1 has not been out bed since her fall, she fully intends to be up and around as her therapy is going to make her strong enough to go home. She will be using that bathroom soon, she hopes. V26 swiped the metal strip and stated, It is rough and has a sharp edge. I will replace this with a rubber strip. Had I known it needed repair I would have already done it. I usually hear about issues in morning meeting. No one said anything. The staff also know they just need to let me know throughout the day as things come up. I'm here and make myself available right away if it is a safety issue like this. R1 stated once she starts getting out of bed and walking, she 'will have some peace about going into the bathroom'. R1 stated she is getting her leg dressings changed this morning and surveyor can observe. On 3/14/25 at 2:10 pm V 20 Orthopedic Office, Nurse Practitioner (NP) stated R1 is alert and oriented and had given the fall details to V20, NP at the appointment with V20, NP on 2/24/25. V20 stated, (R1) told (V20) she needed assistance from the staff member to lift her foot over a strip on the floor, and did not receive assistance, which resulted in the fall. It sounded like this fall, that caused (R1's) fracture (right Humerus), could have been prevented had she received the assistance she needed.

Based on observation, interview, and record review the facility failed to implement a facility wide system to account for residents exiting and returning to the facility and failed to provide adequate supervision for two residents (R1, R2) of three residents reviewed for elopement in a sample list of three residents. These failures resulted in (R1) eloping from the facility without knowledge of facility staff as to (R1's) whereabouts for over 20 hours. R1 was located at (R1's) former residence, 0.3 Miles (per Internet Map) from the facility, which required R1 to cross an undivided four-lane roadway. The Immediate Jeopardy began on 2/1/24 at 9:29PM when R1 left the facility, unattended, in the dark and in the cold. V1, Administrator was notified of the Immediate Jeopardy on 2/13/24 at 4:53PM. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 2/14/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Finding Include: The facility's policy Elopements and Wandering Residents reviewed 12/6/22 states, Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. Policy Explanation and compliance guidelines: 1. The facility is equipped with door locks/alarms to help avoid elopements. 2. Alarms are not a replacement for supervision. Staff are to be vigilant in responding to alarms in a timely manner. 3. The facility shall establish and utilize a systemic approach to monitoring and managing residents at risk for elopement and unsafe wandering, including identification and assessment of risk, evaluation and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. 4. Monitoring and managing residents at risk for elopement and unsafe wandering: a. Residents will be assessed for unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team b. The interdisciplinary team will evaluate the unique factors contributing to the resident's risk, develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. Charge Nurses and Unit Managers will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff. 5. Procedure for locating Missing Resident: a. Any staff member becoming aware of a missing resident will alert personnel using facility approved protocol (e.g., Internal alert code) b. The designated staff will look for the resident. c. If the resident is not located in the building or on the grounds, Administrator or designee will notify the police department and serve as the designated liaison between the facility and the police department. The administrator or designee should also notify the company's corporate office. d. DON or designee shall notify the physician and family member or legal representative. e. Police will be given a description and information about the resident; include any photos. f. All parties will be notified of the outcome once the resident is located. g. All appropriate reporting to the State Survey Agency will be conducted. 1. R1's Medical Diagnoses List printed 2/7/24 at 4:25PM includes the following diagnoses: Left Femoral Fracture with Hip Replacement, Type II Diabetes Mellitus, Chronic Kidney Disease Stage IV with Hemodialysis, and bipolar disorder. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is moderately cognitively impaired with decreased range of motion to one lower extremity. R1's Hospital History and Physical dated 11/10/23 documents R1 was discharged home from the hospital against medical advice on 11/10/23 and R1 had been hospitalized for Uncontrolled Hypertension and Worsening Kidney Function. The History and Physical states R1 returned to the hospital 11/10/23 after experiencing a fall while walking home from the hospital resulting in a hip fracture requiring a hip replacement. R1's progress note dated 11/20/23 at 2:00PM documents R1 was admitted the facility on 11/20/23. R1's psychiatry note dated 12/29/23 documents, Social Worker feels (R1) is not safe to go home. R1's progress note by V18, Nurse Practitioner dated 1/25/24 documents, (R1) was seen in the facility today for routine monthly evaluation. Patient is in long-term care due to her not being able to care for herself at home due to her chronic medical conditions. TheWeatherChannel.com documents the temperature in (city) on 2/1/24 at 9:54 PM was 42 degrees Fahrenheit. The facility's Incident Documentation for (R1) dated 2/2/24 documents the security cameras were reviewed with the following timeline/information: 2/1/24 at 8:20PM (R1) was sitting in the lobby in wheelchair with a duffel bag on lap. (R1) appeared to be waiting on someone as (R1) kept looking at the door. (R1) was on her phone periodically as (R1) waited. 2/1/24 at 8:25PM (V9) Receptionist is seen taking (R1) to the elevator. 2/1/24 at 8:27PM (V9) arrives on third floor with (R1). (Certified Nurse's Aides) CNAs (V10, V11, V12) were present near the Nurse's Station. However, (V9) is seen walking down the hall to look for (V8). (V9) located (V8) next to room (Room Number) and appears to be having a conversation with (V8). (R1) is seen sitting by the Nurse's station and (V11) walks over to (R1) and hands (R1) something and they exchange words. A few minutes later (V9) gets on the elevator to leave. 2/1/24 at 8:37PM No staff is in the vicinity and (R1) gets self on the elevator and goes down to the first floor. 2/1/24 at 8:38PM (V10) Certified Nurse's Aide (CNA) passes (R1) as (R1) is getting off the elevator (on first floor) and (V10) is getting on it. (R1) makes way down to the lobby where (R1) sits in wheelchair and waits. 2/1/24 from 8:38 PM until 9:28PM (R1) remains in the lobby. (R1) alternates between sitting in wheelchair and getting up to walk around the lobby and continues looking out both doors. (R1) is seen on phone a few times and looks around on the front desk. 2/1/24 at 9:29PM (R1) picks up her Duffel bag and walks out [NAME] door facing (Street Name) Street. The Incident Documentation states, (V2) is unable to see if someone picks up (R1) or if (R1) takes off walking due to the angle/view of the camera. The facility's Incident Documentation states: 2/2/24 at 6:55PM to 7:10PM (V2) attempted to call (R1's) phone numerous times. 2/2/24 at 7:15PM (V2) Director of Nursing (DON) spoke with (V7, R1's Family Member) and asked if (V7) had any updates or if (V7) had been able to get hold of (R1). (V7) said 'no it just rings. no answer' (V2) asked if (V7) had any idea where (R1) could be. (V7) stated (V7) had no idea. On 2/8/23 at 9:00AM V2 reviewed the above dates and times and verified that the timeline documented in the facility's incident documentation dated 2/2/24 is correct per time stamped recordings. V2 stated, (R1) came to us from the hospital for rehabilitation after (R1) broke a hip. On 2/8/24 at 2:46PM V11, Certified Nurse's Aide (CNA) stated, I was working the night (R1) left the facility. I saw (R1) after (V9) brought (R1) back to third floor. (R1) was in the dining area watching TV. I then went to do my rounds and get everyone to bed. (V10) and (V12) (Also CNAs) were working the floor with me and they were down the hall. V8 the nurse was also down the hall, and I guess that is when (R1) just slipped out. I wondered why (R1) had her dialysis bag. (R1) was confused and had dialysis. (R1) used a wheelchair when (R1) got tired. I don't think (R1) was safe to cross (Street Name) Street in the dark. I really don't know how (R1) made it that far without getting hurt. On 2/8/24 at 3:00PM V8, Licensed Practical Nurse (LPN) stated, I was working 6:00PM to 6:00AM the night (R1) left the facility. (V9) Receptionist brought (R1) back up to the floor when (V9) locked the lobby doors. (V9) told me (R1's) family had not picked (R1) up. When I noticed (R1) was not on third floor later in the shift, I just assumed (R1's) family had picked (R1) up. I did not call family or the physician. I reported to the shift the next morning (R1) was with (R1's) daughter. (R1) was confused and used a wheelchair for distance but could walk short distances. I do not feel (R1) was safe to leave the facility alone, at night. On 2/8/24 at 3:15PM (V14), Certified Nurse's Aide (CNA) stated, I was told when I came to work 2/2/24 (R1) was out with (V7). I called (V7) and found out (R1) was not with family and (V7) did not know where (R1) was and could not reach (R1) by phone. I reported this to the nurse, and we became aware (R1) was missing. The nurse reported this to Administration, and they started to look for (R1). In no way do I think (R1) was safe to leave here alone at night. (R1) is weak after dialysis and she is recovering from a broken hip and can't walk that well. (R1) is pretty confused. On 2/8/24 at 12:11PM V22, Social Services Director stated, When psychiatry saw (R1) I told them (R1) was not safe to go home alone because (R1) was moderately cognitively impaired and did not show good judgement because of her mental illness. When asked if R1 had changed significantly between 12/29/23 and discharge V22 stated No. On 2/8/24 at 9:00AM V1, Administrator stated, The security cameras are only able to be monitored in real time from my office. When I'm not here my office is locked, and the floor staff do not have access to the camera images. On 2/8/2024 at 11:58AM, V21 (Licensed Practical Nurse) reported the first-floor entrance door alarms are not audible on the third floor. V21 reported residents who live on the third floor are free to access the third-floor elevator independently and go to the first floor whenever they want. V21 denied reception staff, who are in the lobby on the first floor adjacent to the facility entry doors, notify third floor staff when residents leave or return to the facility. On 2/8/2024 at 1:25PM, V16 (Receptionist) reported first floor reception staff do not notify staff on the third or fourth floors when a resident leaves or returns to the facility. On 2/9/2024 at 11:50AM, V16 (Receptionist) reported residents who reside on the third and fourth floors can access the lobby area near the facility exit doors independently. On 2/9/2024 at 11:50AM, V16 (Receptionist) reported the main facility exit doorways are only alarmed audibly in the immediate vicinity and do not have any visual alarm anywhere in the facility. On 2/9/2024 at 11:50AM, V16 (Receptionist) stated, As far as I know (staff are unable to hear the activated facility exit door alarms after 8:00PM because staff are no longer present on the first floor near the lobby after 8:00PM). On 2/9/2024 at 11:50AM, V16 (Receptionist) reported the facility has residents that know the exit doorway alarm disarm code because they see staff enter the code when residents are taken outside to smoke and hear staff shout out the code to vendors exiting the facility. On 2/7/24 at 7:20AM V7 stated, (R1) was gone (from facility) all night Thursday (2/1/24) and no one knew where (R1) was until the next day 2/2/24. (R1) lost her phone somewhere when (R1) was walking to the apartment complex where we finally found (R1). We were frantic. I told (V2) to call the police but they didn't, they went to where (R1) was staying and found (R1). Then I went over, and (R1) had a lot of swelling in (R1's) legs and feet but was OK. (R1) had dialysis the day (R1) left and that left (R1) weak. (R1) did not have any medications, not even insulin. Nobody let us know (R1) left alone and didn't return. (V9) helped (R1) call me (2/1/24). I made it clear that there was no family emergency, and we wouldn't be coming to pick (R1) up. On 2/7/24 at 1:27PM V18, Nurse Practitioner stated, (R1) was definitely not safe or mobile enough given her chronic medical conditions to be allowed to leave the facility unattended on 2/1/24 at night without the benefit of a wheelchair or a walker. I do not believe (R1) had the safety awareness or judgement to make the decision to leave the facility. 2. On 2/8/2024 at 10:29AM, R2, who resides on the third floor, reported routinely leaving the facility for outside visits with R2's spouse. R2 reported never signing any type of sign out sheet or log when R2 leaves or returns to the facility. R2 reported staff sometimes help R2 get on the third-floor elevator to go to the first floor to leave the facility and other times R2 accesses the elevator independently without staff present and R2 goes to the first floor alone to exit the facility through the lobby area where the main entrance doors to the facility are located. R2 reported R2 sometimes forgets to tell staff on the third floor when leaving to go to the first floor to exit the facility. R2 reported when R2 returns to the facility and third floor, staff will ask her where have you been?. R2 stated knowing R2 is, in trouble (for leaving the facility without informing third floor staff). Residents were observed independently accessing the first-floor lobby area adjacent to the facility entrance/exit doorways throughout the duration of the survey from 2/7/2024 and 2/8/24 on first and second shifts. On 2/7/24 to 2/8/24 third, fourth, and fifth floor residents were observed routinely using common areas on the first floor, including the main lobby area where the main entrance doorways to the facility are located. The Immediate Jeopardy that began on 2/1/24 was removed on 2/14/24 when the facility took the following actions to remove the immediacy. 1. On 2/13/2024 and 2/14/2024 V1 Administrator in-serviced all staff in the facility regarding Policies and Procedures on Elopement, Missing Resident, and Policies and Procedures for Residents Leaving the Facility for Appointments and/or Non-Medical Outings. In-servicing will continue to include all staff prior to next scheduled shift. 2. On 2/13/2024, V22 Social Service Director and V3 MDS Coordinator conducted audits to ensure all current residents at moderate to high risk for wandering and elopement have a care plan in place and interventions in place to ensure their safety. 3. On 2/13/2024 and 2/14/2024 V1 Administrator and V23 Director of Operations revised and updated the policy and procedure for Residents Leaving Facility for Appointments and/or Non-Medical Outings. 4. On 2/13/2024, V1 Administrator reviewed the communication book to ensure that it is updated with all residents at moderate to high risk of wandering. 5. V1 Administrator confirmed the Manager on duty will audit the communication book daily for 4 weeks to ensure procedure is fully implemented. 6. On 2/13/2024, V1 Administrator instructed V17 Maintenance Director to change the code on all exit doors. 7. On 2/13/2024, V17 Maintenance Director changed the code on all exit doors and ensured the alarms were working properly on all doors. 8. On 2/14/2024 Staff in the facility were educated on not giving the door codes out to any residents or visitors. In-servicing will continue to include all staff prior to next scheduled shift. 9. On 2/14/2023, V1 Administrator provided in-service to V3 MDS Coordinator regarding assessing all residents quarterly who wander/exit seek and with any changes in behavior. IDT (Interdisciplinary Team) will review 24/72-hour notes to assess for changes in behavior and possible completion of a current Wandering Risk assessment. 10. On 2/10/2024 V7, R1's POA came to the facility and picked up R1's medications 11. On 2/13/2024 V7, R1's POA was contacted, and facility staff offered to provide a walker for R1 to use at her home, POA accepted offer. [NAME] provided 2/14/2024. 12. On 2/13/2024 V7, R1's POA was called, and V22 Social Services Director offered to assist with referrals for transportation to Dialysis Center and home health services. Dialysis transportation has been arranged with public transportation. The facility presented an abatement plan to remove the immediacy on 2/14/24. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on 2/14/24 and the survey team accepted the abatement plan on 2/14/24.

Based on interview and record review, the facility failed to administer prescribed pain medication to a resident in a timely manner. This failure affects one resident (R1) on the sample of eleven residents reviewed for abuse/medications. This failure resulted in R1 experiencing excruciating pain for twelve hours in the facility following a partial foot amputation requiring hospitalization for pain management and medical treatment. Findings include: R1's Nurses Notes dated 1/12/24 document R1 was admitted to the facility on [DATE] from (local hospital) at 6:49 PM. R1 had his left toes removed due to a prior bone infection and poor blood circulation in his foot. R1's Physician Order Sheet dated for 1/12/24 and 1/13/24 (printed 1/30/24) documents R1 was admitted to the facility with physician orders for pain medications including Oxycodone- Acetaminophen 10- 325 milligrams (mg) every 8 hours as needed for pain, and Hydrocodone- Acetaminophen 10- 325 mg every 6 hours as needed for pain. R1's (local hospital) History and Physical documented R1 had a surgical procedure to remove the front portion of R1's left foot and toes by cutting through the bones connecting the toes to the bones on top of the heel area (trans metatarsal amputation). On 1/30/24 at 10:38 AM, V10, Licensed Practical Nurse, stated, I was on duty and took care of (R1) the day he was admitted (1/12/24). The normal process for new admissions is the nurse faxes the medication orders to our pharmacy, then pharmacy delivers the medications that night but the medications doesn't get to us until around 5:00 AM or 6:00 AM the following morning. (R1) did ask for pain medicine but we didn't have it there yet. I tried to access the CAPSA (pharmacy back-up emergency supply system), but my code wasn't working. I called the pharmacy and was on the phone with them for 15 minutes, but still couldn't get into the system, so I didn't have anything to give him. (R1) did say he was in pain, I know it was nerve pain from the amputation, and he did look like the pain was excruciating. On 1/30/24 at 11:03 AM, R1 stated, In a nutshell, exactly the way it happened was that the nurse didn't give me any pain medication. I had just had my foot amputated. The nurse said a doctor was the only one who could prescribe it and she offered me a Tylenol, but Tylenol doesn't work for anything and especially not the pain I was having that night. The nurse told me she didn't have any pain medication and couldn't get any. I am out of the hospital now but I didn't want to go back there and my sister didn't want me to go back there, so I am at (alternative local nursing home) and getting therapy and pain medication like I am supposed to. On 1/30/24 at 11:26 AM, V2, Director of Nursing, stated, The way our pharmacy system is supposed to work is when a resident gets admitted here, all of the medication orders from the hospital get faxed to our pharmacy, then the pharmacy fills the orders and sends us the medications which get here typically around 5:00 AM or 6:00 AM the next morning. If a nurse needs a certain medication before the pharmacy delivers it, the nurse can get into the CAPSA emergency box to get it. I did speak with (V10) the night (R1) was admitted . I guess (V10) was having some trouble accessing the CAPSA box so I told her she needed to call the pharmacy, and if she still couldn't get into the CAPSA, then one of the other nurses could access the CAPSA for her with their code. We also have some local pharmacies that are good about delivering something we need quickly. I then told (V10) that if she couldn't get (R1's) pain managed and under control, she needed to send him back to the hospital. I found that (R1) didn't get any pain medication through the night until around 5:52 AM on the 13th (1/13/24), so that is the unfortunate part, then he ended up needing to go back to the hospital. R1's Medication Administration Record dated for January 2024 (printed 1/30/24), and R1's Nurses Progress Notes dated 1/13/24, confirm R1 did not receive any pain medication from his admission on 1/12/24 at 6:49 PM until 5:52 AM on 1/13/24. R1's Nursing Progress Notes dated 1/13/24 at 7:02 AM, document R1 told the facility nursing staff, Something isn't right with my foot. I shouldn't be having this much pain and look at the swelling. Something isn't right. R1's Nursing Progress Notes dated 1/13/24 at 11:16 AM, document R1 was being admitted to (local hospital) for pain management and intravenous antibiotics. The facility's Pain Management policy dated 7/1/21 documents, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. R1's Minimum Data Set, dated dated dated [DATE] (section J) documents R1 was experiencing frequent pain which was frequently interfering with sleep and limiting daily activities. This same Minimum Data Set section documents R1 rated his pain at 10 out of a possible 10, the worst pain ever felt. This same Minimum Data Set (section C) documents R1 has no long term nor short term memory problems and is independent with decision making. On 1/30/24 at 1:07 PM, V1, Administrator, stated, I agree with that (R1 could have been and should have been treated for pain much earlier than 12 hours after admission) and I don't have any argument for that.

Based on observation, interview and record review the facility failed to complete accurate and thorough wound assessments, notify physician of wound development, obtain treatment orders, administer physician ordered treatments and implement pressure ulcer prevention measures for three of six residents (R303, R7 and R8) reviewed for pressure ulcers on the total sample list of 62. This failure resulted in R303 not receiving any treatment measures to a Stage IV pressure ulcer for 3 days, then developing a wound infection. Findings include: The facility's policy, with a revision date of 9/5/22, titled Pressure Ulcer Prevention and Management documents, Policy- the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. 1- There are multiple term used to describe this type of skin damage, including pressure ulcer, pressure injury, pressure sore, decubitus ulcer and bed sore. For the purpose of this policy, pressure injury, as the current standard terminology, will be used. 2- The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions, and modifying the interventions as appropriate. 3- Assessment of Pressure Injuries- c- licensed nurses will conduct a full body skin assessment on all residents upon admission/readmission, weekly and after any newly identified pressure injury. Findings will be documented in the medical record. d- Assessment of pressure injuries will be performed by a licensed nurse, and documented on the Skin Assessment, staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. 4- Interventions for prevention and promote healing: a- After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. c- Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. d- Evidence based treatment in accordance with current standards of practice will provided for all residents who have a pressure injury present. ii- treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate, presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics. 5- Monitoring- b- the attending physician will be notified of: i- the presence of a new pressure injury upon identification. The facility's policy, with a revision date of 12/6/22, titled Wound Treatment Management documents, 1- Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing changes. 2- In the absence of treatment orders, the licensed nurse will notify the physician to obtain treatment orders. This may be the treatment nurse or the assigned licensed nurse in the absence of the treatment nurse. 7- Treatments will be documented on the Treatment Administration Records. R303's medical record documents a readmission back to the facility on [DATE]. R303's hospital records documents on 4/4/23, patient has a stage IV pressure injury to coccyx measuring 3 centimeters by 3 centimeters by 0.5 centimeters. Wound base is whitish gray in center and pink edges, bone palpable. R303's admission summary note documents on 4/7/2023 3:15 PM, Resident arrived at facility per ambulance on stretcher and readmitted to room. R303's Braden skin risk assessment completed on 4/7/23 documents a risk score of 6, indicating at very high risk for skin breakdown. R303's Admit/Readmit Screener assessment form documents under section C: Skin integrity- Site Coccyx (sacrum), Type: Pressure. Length, Width, Depth are blank, Stage: III (3). Site: Right Heel, Type: Pressure. Length, Width and Depth are blank, Stage is blank. Site: Left Heel, Type: Pressure. Length, Width and Depth are blank, Stage is blank. R303's medical record does not document physician notification was completed upon the identification of R303's pressure injury wound on 4/7/23. R303's medical record does not document wound assessments, measurements or descriptions from readmission on 4/7/23 through 4/9/23. R303's physician order summary does not document treatment orders were received for R303's pressure injury to the coccyx/sacrum area and bilateral heels until 4/10/23. R303's Treatment Administration Records do not document the completion of treatments to R303's Coccyx/Sacral pressure injury area until 4/10/23. R303's medical record documents on 4/10/23, seen during wound rounds, new orders given. R303's Wound Weekly Observation tool dated 4/10/23 Sacrum, Stage IV, 3.5 by 4 by 1.5 centimeters. Right Heel, Unstageable Deep Tissue Injury, 2 x 2. Left Heel, Unstageable Deep Tissue Injury. R303's medical record documents on 4/11/23 at 12:41 PM, resident noted to be running temp for shift, temp running 101-101.5 degrees Fahrenheit, Tylenol given throughout shift, seen by Nurse Practitioner, orders given to culture wound, possible infection noted to wound, wound cultured today. R303's medical record documents on 4/11/22 at 9:30 AM by V22 Advanced Practice Nurse. Chief Complaint: Initial visit, to establish care with provider, and readmit from hospital 4/7/2023, with new onset of lethargy. HPI (history of present illness): Patient admitted to facility 2/9/2020 for delusional disorders and unspecified dementia, and readmitted [DATE] for surgical aftercare following gastrostomy placement, after 3/10/23 hospitalization for COVID pneumonia. PEG (percutaneous endoscopic gastrostomy) tube was inserted for patient's nourishment while ill with COVID and it remains in place. Patient also developed a stage 4 decubitus ulcer on her sacrum while in the hospital. She was seen 4/10/23 by Wound care and the ulcer was cleaned and debrided. ADON (assistant director of nursing) requested visit to assess patient's alertness. Patient was alert and confused prior to hospitalization and is barely responsive today. Wound cultured today. ASSESSMENT/PLAN: Patient is lethargic and weak but seems to be tracking minimally. Heart sounds are tachy with normal S1, S2. Skin is hot and patient has a temp of 101.76 F. Gastrostomy tube is nicely healed. Decubitus has a foul odor. R303's Wound Culture Lab report collected on 4/11/23 documents, Final results on 4/16/23- Moderate Proteus Mirabilis, Moderate Escherichia coli, Extended Spectrum Cephalosporin. Isolation for: Extended Spectrum Cephalosporin Resistant (ESCR) is required. On 5/02/23 10:20 AM Wound Care observations were conducted with V24 Wound Nurse. V24 removed R303's old dressing. R303's wound had a foul odor. R303 had an open area approximately 6 centimeters by 3 centimeters with a 2 centimeter depth, wound bed was beefy red tissue with a scant amount of yellow slough present in the wound, the wound had macerated white edges surrounding the area. V24 stated, when a resident admits with an area, the floor nurses do the initial wound assessment (including measurements and description) and if they do not have a treatment order, then notify the doctor for a treatment order, sometimes they will notify me, but I am newer to the position so not everyone knows that. They (staff) most definitely should have measured R303's pressure areas and gotten a treatment order. R303 was seen by V23 Wound physician on 4/10/23, V23 wanted to wait a week for the treatment to be effective and then get a wound culture, but then R303 got the temperature, and the Nurse Practitioner ordered the wound culture. It showed the ESCR (infection) in the wound. On 5/03/23 at 8:30 AM V24 confirmed not able to locate measurements or physician orders 4/7/23 through 4/9/23. On 5/4/23 V22 APN stated, I saw R303's wound on 4/11/23, the wound had a foul odor, you could tell the wound had recently been debrided, it was a Stage 4, you could see muscle. I think the nursing staff could have documented wound care better with R303. 34201 2.) R7's April Physician Orders documents an order to cleanse R7's sacrum, apply a Bacteriostatic Foam Wound Dressing (cut to size, and pack into wound cavity), then apply 2-3 dry woven gauze pads over the Bacteriostatic Foam, then cover with a thick absorbent pad and secure dressing with retention tape daily and PRN (as needed) for wound healing. R7's Wound Notes dated 5/1/23 by V23 Wound Physician document R7 has a stage IV pressure ulcer to the sacrum measuring 3.5 cm (centimeters) by 2 cm by 0.5 cm that is covered in 15% slough and 55% viable tissue (muscle). On 5/02/23 at 11:40 AM, V24 Wound Nurse and V35 CNA (Certified Nursing Assistant) both entered R7's room to complete the ordered dressing change. R7 was lying in bed on R7's left side with an undated thick absorbent dressing to the sacrum. R7 also had an uncovered full thickness open wound to the upper left posterior thigh. V24 removed the dressing and the inner dressing consisted of gauze pads, that were saturated in a greenish drainage. The ordered Bacteriostatic Foam primary dressing to pack the wound was not in place. V24 confirmed the dressing in place was not what was ordered and that it was not dated. V24 completed the treatment as ordered. At this time, V24 confirmed R7 had an additional pressure ulcer/shear that V24 was not aware of, which did not have a dressing on it. V24 stated, V24 would guess it was 0.5 cm by 1 cm. V24 explained R7 use to have a pressure ulcer in that same location which has since healed. V35 CNA stated V35 noticed the wound this morning while performing cares around 9:00 am and that V35 reported it to V25 RN (Registered Nurse), who is R7's primary nurse. At this time, V24 stated that when a new wound is observed, the primary nurse should assess the wound, measure it and obtain a treatment order. V24 left the new pressure ulcer uncovered and left the room. As of 5/02/23 at 12:46 pm, there is no documentation of R7's new pressure ulcer in R7's Progress Notes and no new wound assessment completed. 35510 3. R8's Admission Record dated 5/4/23 documents R8's diagnoses including Adult Failure to Thrive, Cerebral Palsy, Disorder of the skin and subcutaneous tissue, Contracture to the Right Ankle, and a history of multiple different Pressure Ulcers. R8's Wound Evaluation and Management Summary dated 10/17/22 documents R8's pressure ulcers including a Stage 1 pressure wound with partial thickness to the right ankle with recommendations for R8 to wear a heel protector while in bed. This summary documents R8 also has a Stage 3 pressure wound of the right proximal dorsal foot deteriorated due to larger and deeper, full thickness with recommendation of heel protector while in bed. R8's Hospice orders dated 10/27/22 document R8 does not need seen by a wound physician per V52, R8's Guardian. R8's Care Plans dated 3/24/23 document R8 has a Stage 1 pressure wound of the right lateral ankle and an Unstageable pressure wound of right proximal dorsal foot related to rubbing. These Care Plans document to administer treatment per physician's order and monitor for effectiveness. These Care Plans also document R8 is at risk for skin breakdown related to friction and shear and requires extensive assist of ADLs (Activities of Daily Living) and transfers with interventions to maintain adequate nutrition & hydration and to provide R8 with any and all treatments/dressings if ordered by the physician. The facility's wound log documents date of 4/17/23 with R8 having the following wounds: trauma/injury to R8's right foot with measurements of 0.4 x 0.3cm (centimeters), and no change in the wound. This wound log also documents R8 has a trauma/injury to R8's right ankle with measurements of 0.2 x 0.2cm, and no change in the wound. This wound log does not document these wounds are pressure related. R8's Registered Dietician (RD) assessment dated [DATE] and 3/23/23 document R8 has multiple diagnoses including a history of skin breakdown, but that R8 is no longer on the facility's wound report. This assessment documents R8 requires increased calories related to weights as evidenced by review including history of skin breakdown and that R8 has multiple supplements ordered for additional protein and calories. R8's RD assessment dated [DATE] and 4/20/23 that document R8 has a treatment to the right foot and right ankle. R8's Order Summary Report dated 5/4/23 documents R8 is to have bilateral heel protectors on when in bed and while up in wheelchair. This summary documents an order dated 4/5/23 to cleanse R8's Right Dorsal Foot with Normal Saline solution and apply Petroleum gauze and bordered gauze daily and as needed. These orders document R8 is to receive a fortified frozen nutritional treat twice daily for decreased diet. These orders document R8 is to receive a regular diet, mechanical soft texture, thin consistency with double protein for all meals, offer magic cups x 2 daily and fortified soup at lunch. On 5/1/23 at 09:04 AM R8's meal tray was delivered to R8 by V20, Certified Nursing Assistant (CNA). This tray contains a tray ticket that documents R8 is to receive double protein at all meals, and one carton of whole milk. There was one thin slice of French toast, sugar free syrup, oatmeal and a small portion appeared around the size of a half dollar of mechanically ground sausage with gravy. V20, CNA stated there have been multiple on-going issues with portions mechanical soft/mechanically ground meats, and that dietary is aware. V20 stated the facility consistently serves very small portions, and this has been going on for a while. V20 confirmed R8 did not receive the carton of whole milk. R8 did not receive a frozen nutritional supplement at this time. On 5/1/23 at 9:20am, V20, Certified Nursing Assistant (CNA) assisted to remove R8's covers to R8's feet. R8's right foot and ankle were covered with a rolled gauze dressing with the outside of the gauze dated as 4/28/23. V20 confirmed the date on the dressing to R8's right ankle. R8 did not have heel protectors on at this time. There is no documentation R8's dressing to R8's right foot had been changed daily as ordered on 4/29/23 or 4/30/23. On 5/3/23 at 4:25pm, V2, Director of Nursing stated R8's wounds were classified at one time by V23, Wound Physician as traumatic injury. V2 stated the hospice company refused to allow the wound physician to treat R8 anymore. V2 stated R8's wound documentation would be updated to accurately reflect they are pressure related. V2 stated the facility should be providing R8's double portions and diet as ordered and agreed these dietary interventions would benefit R8's pressure ulcer wounds.

Based on observation, interview and record review the facility failed to provide behavioral services to meet the emotional and psychosocial needs of one (R4) of 21 residents reviewed for behavioral services from a total sample list of 62. This failure resulted in R4 inconsolably screaming, crying, and preventing care for herself for the past year without effective intervention. Findings include: R4's electronic medical record dated 7/1/21 documents admission to the facility. R4's Minimum Data Set, dated dated dated [DATE] documents that R4 is severely cognitively impaired with the following diagnoses include: congestive obstructive pulmonary disease, lack of normal childhood development, paranoid schizophrenia, Barrett's esophagus, diabetes and dementia. R4's progress notes dated from 8/12/21 through 4/30/23 document R4 screaming at staff, sobbing uncontrollably, preventing cares, preventing maintenance of her room and threatening staff with physical harm. On 4/30/23 at 10:00AM, R4 was lying in bed screaming, Get out! Get out! I'm gonna kill you! R4's face was angry and posture was defensive. On 4/30/23 at 10:10AM, R4 was sitting at the nurse's station screaming and sobbing. This behavior continued for another 15 minutes with R4 saying, They are going to kill me! On 4/30/23 at 10:05AM, V16 Licensed Practical Nurse (LPN) stated that R4 has exhibited the behaviors of uncontrolled screaming and crying since admission. R4's physician orders dated 8/4/21 document Risperidone (antipsychotic) 1 milligram per milliliter to be given twice a day. R4's physician orders dated 2/15/23 document Risperidone 1 milligram per milliliter to be decreased and given once a day. On 5/1/23 at 3:36PM, V50 Certified Nursing Assistant (CNA) stated, I have worked here for four years and during this time, (R4) has been difficult to handle. She yells at people, hits and has stabbed a staff member with a butter knife. She has to be left alone when she doesn't want to do something. Only V51 CNA can get her to do things. On 5/2/23 at 10:00AM, V31 Licensed Practical Nurse stated, (R4) just calmed down from really getting upset. She was screaming and crying because we just took her meal tray out of the room. We have to hide her medications in her food and if she sees them, she won't take her medicine. On 5/2/23 at 12:00PM, V33 CNA stated, (R4) has a meltdown at least 3 x a week. She screams and gets really upset; she will threaten to kill you. On 4/30/23 at 10:00AM, V48 guardian/family member stated that there is only one employee who can get (R4) to do anything. R4's electronic medical record documents that R4 has only seen behavioral health one time in the last year, dated 3/16/23. On 5/1/23 at 2:25PM, V21 Social Services Director said, When I came into this role in September 2022, there was no one providing psychiatric services to the residents. I reinstituted the program. I don't know how long that the residents had been without psychiatric services before that. On 4/30/23 at 10:52AM, V48 guardian/family member stated, My sister is slow, she always has been. She only went through sixth grade and she just doesn't like to be bothered. She is worse now; she didn't used to be like this. She just yells all the time. I'm not aware of her having psychiatric services but if she needs them, I want her to have them. I don't want her to be miserable. The facility Behavioral Health Services policy dated 12/5/22 documents the behavioral health care plans shall be reviewed and revised as needed, such as when interventions are not effective.

Based on record review, observation and interview the facility failed to monitor a resident during wheelchair transport and failed to ensure post fall interventions were in place for one of three residents (R2) reviewed for falls in a sample list of three residents. Failing to monitor R2 during transport resulted in R2 falling out of the wheelchair and obtaining a head laceration which required sutures. Findings include: R2's undated Face Sheet documents medical diagnoses of Parkinson's Disease, Muscle Wasting and Atrophy, Abnormal Posture, Lack of Coordination, History of Falling, Difficulty in Walking, Cognitive Communication Deficit and Need for Assistance with Personal Care. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 as requiring extensive assistance of one person for bed mobility, transfers, locomotion on unit, dressing, eating, toileting and personal hygiene. R2's Fall Risk assessment dated [DATE] documents R2 as a high fall risk. R2's Final Incident Report to Illinois Department of Public Health (IDPH) dated 2/3/23 documents, (R2) was observed laying on ventral side in (R2's) room near doorway. (R2) had on proper footwear, no obstacles were noted on floor and the floor was clean and dry. At the time of fall, (R2) was being pushed in wheelchair by (V9) Certified Nurse Aide (CNA), (R2's) foot slipped off the foot pedal and (R2) lunged forward. (V9) CNA was unaware that (R2's) foot slipped off. (R2) was seen in emergency room with a diagnosis of Laceration of Forehead. (R2) received three sutures and returned to facility. R2's Care Plan documents fall interventions reviewed on 12/29/22 of Do not rush (R2). Allow extra time to complete Activities of Daily Living (ADL). Anticipate and meet (R2's) needs. R2's Post Fall Observation dated 1/25/23 documents, While being pushed to room in wheelchair, (R2) put foot down upon coming into room and tumbled forward. R2's Nurse Progress Note dated 1/25/23 at 7:25 PM documents, (V9) Certified Nurse Aide (CNA) was pushing (R2) and (R2's) feet got tangled in foot pedals and (R2) stumbled over hitting forehead on floor. (R2) received laceration to forehead. Emergency services called and transported (R2) on stretcher. R2's Hospital After Visit Summary dated 1/25/23 documents R2's reason for visit as Head Injury and Diagnosis of Laceration of Forehead. R2's Hospital Record dated 1/25/23 documents R2's Chief Complaint: Head Injury. This same record documents [AGE] year-old female brought to hospital per emergency services for evaluation after falling. (R2) has an injury to (R2's) head. This same report documents Procedures: The wound was cleaned and irrigated with Normal Saline. Wound edges were infiltrated with 1% Lidocaine. Using sterile technique wound edges were approximated with 4.0 Nylon three sutures. R2's Computerized Tomography (CT) of Head without Contrast results dated 1/25/23 document, Impression: Subcutaneous soft tissue swelling and emphysema in a bifrontal distribution, left greater than right crossing the midline. R2's Fall Interdisciplinary Team Note dated 1/26/23 at 11:00 AM documents, Root Cause: (R2) was being pushed in wheelchair by (V9) CNA, (R2's) foot slipped off foot pedal and resident lunged forward. (V9) CNA was unaware that resident foot slipped off. On 2/10/23 at 4:10 PM V3 Licensed Practical Nurse (LPN) stated, (R2) fell while (V9) Certified Nurse Aide (CNA) was pushing (R2) back to her room. (V9) CNA was not watching (R2's) feet. (R2) had foot pedals on that day but (R2) put her feet down on the ground while she was being pushed into her room by (V9). (R2's) feet got caught up under the wheels of the wheelchair and (R2) got thrown out of the wheelchair straight on her head. (R2) got stitches from that fall. (V9) felt so bad about that. (V9) was crying saying 'it was all (V9's) fault (R2) fell '. (V9) should have been paying closer attention to (R2) and that would not have happened. On 2/10/23 at 4:50 PM R2 was sitting in a wheelchair in the dining room with no foot buddy in place. On 2/10/23 at 4:55 PM V3 Licensed Practical Nurse (LPN) stated, (R2) is supposed to have foot pedals with a foot buddy in place. I do not know where they are. I looked in (R2's) room and they are not there. (R2's) CNA should have put her foot pedals and foot buddy on. That is supposed to keep (R2) from falling like that again. On 2/10/23 at 5:00 PM V5 Certified Nurse Aide (CNA) stated, I did not know (R2) was supposed to have foot pedals and the foot buddy. I guess I will have to go find those and put them on (R2's) wheelchair. On 2/14/23 at 11:30 AM V2 Director of Nurses (DON) stated, (V9) Certified Nurse Aide (CNA) was pushing (R2) in her wheelchair down the hall heading into (R2's) room. (V9) must have been going too fast when turning into (R2's) room because that is when (R2) put her feet down. (V9) was not paying attention to (R2). (V9) should have been going at a slower pace and watching the body mechanics of (R2). That would have prevented that fall to begin with. Because (V9) was not watching (R2), (R2) got her feet caught in the front wheels, fell forward landing on her face and ended up getting stitches on her forehead. That fall was absolutely preventable. (V9) CNA felt so bad but really, she could have avoided the whole thing if she were only watching (R2). I don't know what (V9) was thinking or maybe she wasn't. V2 DON stated facility staff have been educated on R2's fall interventions. V2 DON stated, I went to the floor 2/10/23 after you (surveyor) left and saw that (R2) was not even in her right wheelchair. (R2) did not have the foot pedals or foot buddy on either. I took the staff aside right then, educated them and then had to go get all the correct things for (R2). Communication in this facility is a real problem and unfortunately as in the case of (R2) the residents suffer for it. The facility policy titled 'Fall Prevention Program' revised 1/24/23 documents the following: Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. Monitor for changes in resident's cognition, gait, ability to rise/sit and balance.

Based on observation, interview, and record review the facility failed to prevent falls by failing to ensure for a room environment free from accident hazards and failed to complete a thorough post fall investigation for residents. This failure affects two of three residents (R47, R63) reviewed for falls on the sample list of 59. These failures resulted in R47 sustaining a left [CONDITION(S)] and R63 sustaining bruising to left forehead/scalp area and entire posterior left shoulder area Findings include: 1. R47's fall investigation report dated 6/29/2022 at 3:15 AM documents R47 had a fall with no injury. R47's fall prevention care plan includes an intervention dated 6/29/22 to ensure pathways are well lit and clutter free. R47's nurses notes dated 7/16/22 at 7:23 AM documents R47 was sent to the emergency room due to a fall. R47's undated fall report documents on 7/16/22, R47 tripped over a mattress laying on the floor in her room. This report documents the mattress is a safety device for the other resident in the room. This report documents R47 will be placed in a room by herself without a fall hazard. R47's radiology report dated 7/16/22 documents R47's complained of pain after tripping over a mattress on the floor. This report documents R47 has an impacted left femoral neck fracture ([CONDITION(S)]) with a large subcutaneous hematoma lateral to the left hip. On 8/01/22 at 12:12 PM, when asked how R47 broke her hip, R47 stated, It was storming, and I got frightened and tripped over the corner of a mattress lying on the floor. I fell backwards and hit the floor. On 8/3/22 at 10:02 AM, V10 Assistant Director of Nursing stated R47 fell on [DATE] at 3:15 AM looking for the restroom. V10 stated R47 was ambulatory. V10 stated R47 is on oxygen and will take it off to go to the restroom. V10 stated when R47 takes it off she will get confused looking for the bathroom. V10 stated R47 fell on [DATE] and an intervention to ensure pathways are well lit and clutter free was put into place. V10 stated after her fall on 6/29/22 and prior to her fall on 7/16/22 she was moved to a different room. V10 stated R47 was in the second bed. V10 stated this room had a mattress on the floor in front of the other bed in the room. V10 stated prior to moving R47 into the room an evaluation of the safety of the room should have been done. V10 stated since she would get up on her own and become confused, the mattress on the floor would be a hazard for her. V10 confirmed R47's room and bed placement. On 8/3/22 at 10:00 AM, the room in which R47 resided prior to 7/16/22 had a bed (1) up against the wall on the left side of the room. There was another bed (2), R47's former bed, up against the back wall of the room. Bed (1) and bed (2) were in an L shape positioning within the room. The safety floor mattress (full twin size) for a bed laid alongside bed (1) - on the floor. The space between bed (1) and bed (2) and the mattress on the floor and the middle of bed (2) was 3 feet. 2. On 8/1/22 at 9:32 AM R63 had bilateral half bed rails in the upward position towards the head of the bed, there was a pillow positioned sideways between the edge of the mattress and the bed rail. Both bed rails were shifted and unparallel to the mattress. R63 stated those bed rails are to protect me and help me move in the bed, they are not on the bed right, they move all over the place and there is a big gap. When grabbing ahold of R63's bed rails, both rails moved back and forth and shifted side to side. R63 stated, Last week I was in the bed, and I dropped something on the floor to the left, I grabbed ahold of the rail while I was leaning over to pick it up, the rail was loose and moved, I fell face forward on my left side onto the floor. R63 pointed to her head and left shoulder area and stated I got this (R63 had dark purple, maroon discoloration to the entire left forehead/scalp area and dark maroon, purple discoloration covering the entire posterior left shoulder area). R63's medical record documents, 7/25/2022 at 7:10 AM by V9 Licensed Practical Nurse, Resident was heard calling for help from her room. Resident was observed sitting on the floor by the window. Resident informed writer that she was reaching for her personal lancet and tumbled on her left side out of the bed. Resident was assessed and assisted safely back to her bed. Resident stated that left shoulder felt tender. Bruising observed on left shoulder where shoulder made contact with the ground. Resident educated on waiting for assistance and utilizing call light. R63's medical record documents on 08/01/22 11:05 AM, Interdisciplinary team met to discuss fall on 7/25/22. Root cause was resident reaching out of bed to get item. Intervention is for staff to ensure that needed items are in reach. On 8/02/22 at 1:53 PM V13 (Vice President of Clinical Operations) stated, I was on the phone with the team yesterday (8/1/22) to complete (R63's) fall investigation. On the call was V24 Sister Facility Director of Nursing and V10 Assistant Director of Nursing. V13 stated, the information entered into R63's medical record when R63's fall occurred was what we based our information on to determine the root cause and intervention. No one interviewed R63 or V9 LPN again. The information V9 LPN had documented from R63 was from when the fall occurred. I did not re-interview R63 since the fall, nor did V9 LPN or V24. R63's medical record did not document R63 had discoloration to the left forehead area between 7/25/22 through 8/3/22. R63's fall investigation did not document R63's hit her head during the fall on 7/25/22. It did not document R63 had bed rails or if bed rails were functioning or in use during R63's fall on 7/25/22. R63's Brief Interview Mental Status form score dated 6/30/22 was a 15 indicating R63 was cognitively intact. On 8/02/22 at 1:15 PM V10 ADON stated, (R63) tumbled out of bed on her left side last week, and (R63) had a lump on her head, so the bruise on R63's head is probably a result of her fall. V10 confirmed R63's medical record did not document information related to R63's discoloration to the left forehead area. On 8/2/2022 at 10:10 AM V1 Administrator stated, we don't have (bed) rails unless the resident is assessed and needs them. V1 stated, maintenance puts the rails on the beds. V1 grabbed ahold of R63's (bed) rail on the right side of the bed, the rail moved in a back-and-forth motion and shifted left to right. On 8/2/2022 at 10:15 AM V15 Maintenance grabbed ahold of R63's half bed rails and the rails moved in a back-and-forth motion and shifted left to right. V15 stated, I think the [NAME] pins are worn out. On 8/03/22 at 9:35 AM V1 Administrator stated, R63's bed was swapped out with a new bed with different rails. V1 confirmed R63's bed rails were not secured. V1 also confirmed R63's bed rails were not in a safe working condition. V1 confirmed there was at least a hands width gap (approximately 8 inches) between R63's bed rail and the edge of the mattress. On 8/3/22 at 9:40 AM V15 Maintenance stated, R63's bed rails were not fastened to the bed correctly. The facility's policy, dated 1/1/2020, titled Incidents, Accidents, and Supervision documents, Policy: The resident environment remains as free of accident hazards as is possible, and each resident receives adequate supervision and assistive devices to prevent accidents. This includes: 1- Identifying hazard and risk, 2- Evaluate and analyzing hazards and risks, 3- Implementing interventions to reduce hazards and risks. Policy Explanation and Compliance Guidelines: The facility shall establish and utilize a systemic approach to address resident risk and environmental hazards to minimize the likelihood of accidents.

Based on record review, observation and interview the facility failed to follow their transfer policy and care plan interventions to ensure safe mechanical lift transfers for two of three residents (R1 and R2) reviewed for accidents in a sample list of eleven residents. These failures resulted in R1 suffering a fractured ankle when staff failed to utilize two staff members for a transfer and R2 suffering a laceration requiring sutures when staff failed to monitor and stabilize R2's legs during a transfer. Findings include: The facility policy titled 'Safe Resident Handling Transfers' implemented 7/21/21 document the following: It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. Two staff members must be utilized when transferring residents with a mechanical lift. 1.) R1's Undated Face Sheet documents medical diagnoses of Closed Fracture of Distal Right Tibia, Closed Fracture of Distal Right Fibula and history of Non-Rheumatic Mitral Valve Insufficiency, Non-Rheumatic Aortic Valve Insufficiency, [CONDITION(S)], [CONDITION(S)] (DVT), Left Hand Contracture, [CONDITION(S)] and [CONDITION(S)] Following Cerebral Infarction Affecting Left Non Dominant Side, Dementia Without Behavioral Disturbances and Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and requires extensive assistance of two people for bed mobility and dressing. This same MDS documents R1 requires total dependence of two people for transfers. R1's Care Plan intervention dated 10/26/21 instructs staff to assist R1 to maintain body in functional alignment when in mechanical lift sling and support lower extremities as necessary until R1 is placed on intended surface (bed, wheelchair, toilet). R1's Nurse Progress Note dated 6/29/22 at 12:47 PM documents Staff reported to writer that (R1's) right ankle appears swollen. R1's X-Ray Report dated 6/29/22 documents Impression: Fracture of the Distal Fibula at the juncture of the diaphysis and metaphysis. There is some displacement and angulation present. There is an additional Fracture of the Distal Tibia with slight cortical angulation but no significant displacement. On 7/5/22 at 12:35 PM V5 Licensed Practical Nurse (LPN) removed R1's blanket. R1's Right Ankle was much larger than R1's Left Ankle. R1's Right Ankle area was bruised over approximately half of Right Ankle area. On 7/5/22 at 2:10 PM V4 (Family Member) stated there have been several times that a staff member will ask family to step out of R1's room to reposition R1 from bed to a wheelchair or from wheelchair to bed. V4 stated one staff member goes into the room, closes the door and then leaves the room and (R1) is in a different position. (R1) is supposed to have two staff help get (R1) up or lay (R1) down since (R1) uses a mechanical lift. I can tell you that does not happen. On 7/6/22 at 8:50 AM V19 Certified Nurse Aide (CNA) stated V19 first saw R1's right ankle injury on the morning of 6/29/22. V19 stated V19 remembers clearly because V19 had been on vacation and V19's first day back to work was 6/28/22. V19 stated R1 did not have any right ankle swelling or pain on 6/28/22. V19 stated V19 worked 6:00 AM-2:00 PM on 6/28/22. V19 stated V19 returned to work at 6:00 AM on 6/29/22 and noticed R1's Right Ankle was twice its normal size and R1 seemed to have more pain in that area. On 7/6/22 at 1:10 PM V26 Certified Nurse Aide (CNA) stated V26 transferred R1 from the wheelchair to the bed using a mechanical lift on the evening of 6/28/22. V26 stated V26 transferred R1 without another staff member present during the transfer. V26 stated during the transfer R1's lower Right Leg got caught on R1's wheelchair. V26 stated V26 stopped and repositioned R1's leg. V26 stated that is when R1's leg was hurt. V26 stated (staff) should always use two staff members when transferring with a mechanical lift but (I) just got in a hurry that evening. On 7/7/22 at 9:25 AM V20 Physician stated R1 has not been able to walk for several years. V20 stated R1 is completely dependent on the staff at the facility for all cares. V20 stated the staff should always use two staff members when transferring a resident with a mechanical lift or the resident has a higher risk of being injured. V20 confirmed R1's Distal Tibia and Distal Fibula fracture were both acute injuries. V20 stated the Tibia bone is a larger bone in a person's body and is difficult to fracture. V20 stated if the staff would be more careful this kind of thing would not happen. V20 stated, This is a real setback for (R1). The staff caused harm for this resident (R1) by not maintaining (R1) safety during the transfer. If the staff would have transferred (R1) safely, this might not have happened. 2.) R2's Undated Face Sheet documents medical diagnoses of Right Shin Laceration and history of Dementia Without Behavioral Disturbance, Hypertensive Heart Disease with Heart Failure, Generalized [CONDITION(S)] and Epileptic Syndromes, Type II Diabetes Mellitus, Abnormal Posture, Muscle Weakness and Altered Mental Status. R2's Minimum Data Set (MDS) dated [DATE] documents R2 as having moderately impaired cognition and requiring extensive assistance of two people for bed mobility, dressing, eating, toileting and total dependence on two people for transfers. R2's Care Plan focus area dated 6/28/22 documents, Skin tear of the Right Lower Shin with four sutures related to extremely thin skin and is noted to move legs while in mechanical lift due to confusion (R2) is unable to be educated on not doing this. This same Care Plan instructs staff to use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. R2's Physician Order Sheet (POS) dated June 1-30, 2022 documents a Physician order for [MEDICATION(S)] (anticoagulant) 5 milligrams (mg) twice per day for Hypertensive Heart Disease with Heart Failure. R2's Nurse Progress Note dated 6/26/22 at 2:17 PM documents (V12) Certified Nurse Aide (CNA) was getting ready to do care on (R2) after being transferred by mechanical lift with assist of two and noted (R2) open area to right shin. R2's Nurse Progress Noted dated 6/26/22 at 6:57 PM document received update from hospital on (R2), (R2) received sutures, x-ray showed nothing broken. R2's Hospital Record dated 6/26/22 documents Chief complaint: Laceration. Review of Systems: Five centimeter (cm) curvilinear laceration into subcutaneous tissue on the anterior surface of the Right Shin. This same Record documents R2 received five sutures to Right Shin Laceration. R2's Final Incident Report to Illinois Department of Public Health (IDPH) dated 6/29/22 documents Disposition: Care Plan reveals (R2) requires a mechanical lift for transfers and has an extensive history of skin tears during care due to frail skin turgor. The injury is consistent with placement of where the mechanical lift most likely caused the injury, and that (V12) Certified Nurse Aide (CNA) did not stabilize (R2's) body during the transfer. On 7/5/22 at 1:30 PM V17 Licensed Practical Nurse (LPN) removed an undated dressing from R2's Right Shin. A two-inch half moon shaped laceration with five sutures was present on R2's right shin. R2 also had a golf ball sized dark purple area just below the sutures with pink intact skin separating the two areas. On 7/6/22 at 3:10 PM V3 Assistant Director of Nurses (ADON) stated R2's laceration was first noted on 6/26/22. V3 ADON stated R2 has extremely fragile skin which tears and bruises easily. V3 stated R2 is also on an anticoagulant which causes bruising to be more severe. V3 ADON stated V12 Certified Nurse Aide (CNA) accidentally caused the laceration while transferring R2 from wheelchair to bed using a mechanical lift. On 7/6/22 at 3:50 PM V12 Certified Nurse Aide (CNA) stated, V28 CNA and V12 both assisted R2 to get out of the bed with a mechanical lift on the morning of 6/26/22. V12 stated there were no marks on R2's lower legs when getting R2 out of bed in the morning. V12 stated V28 helped transfer R2 from the wheelchair back to bed that same afternoon using the mechanical lift. V12 stated after transferring R2 to the bed, V12 was attempting to remove R2's pants to provide incontinence care when V12 noticed R2 had a laceration to the Right Shin. V12 stated it looked fresh. There was not much blood, but I could see red flesh in the wound. V12 stated R2 has very thin skin that tears easily. V12 stated I must have hit (R2's) leg on the mechanical lift because the wound was fresh, and it wasn't there earlier. It couldn't have been from the sling because that was too high up. It had to have hit against the machine. On 7/7/22 at 9:29 AM V20 Physician stated R2 is known to have very fragile skin which tears easily. V20 stated R2 has been on anti-coagulant long term therapy which can sometimes cause the tissue to be more delicate. V20 stated Even if there were two staff member transferring (R2) the staff still need to be careful with someone like (R2) who is so prone to skin injuries. In this case, (R2) was harmed by the staff and received several sutures due to the staff not properly transferring (R2). If the staff were watching (R2's) legs, this would not have happened.

Based on interview and record review the facility failed to provide supervision and keep the environment free from accident hazards in order to prevent a fall and failed to provide staff assistance to prevent a fall for two of seven residents (R15, R27) reviewed for falls on the sample list of 65. This failure resulted in R27 sustaining a left femoral neck fracture. Findings include: 1.) R27's Admission Record dated 10/20/21 documents R27 is diagnosed with a Displaced Left Femur Fracture, [CONDITION(S)], Lack of Coordination, Ataxic Gait, Muscle Weakness, Muscle Spasm, History of Falling, and Difficulty in Walking. R27's Minimum Data Set (MDS) dated [DATE] documents R27 requires supervision to transfer and walk off the unit. The same MDS documents R27 is not steady while walking and is only able to stabilize with staff assistance. The same MDS documents R27 uses a walker and wheelchair for mobility assistance. R27's Resident Post Fall Review dated 9/28/21 at 9:30 AM, documents R27 fell while smoking outside on the patio. R27's surroundings were not free from clutter (landscaping material) and R27's walker became obstructed by a landscaping tie causing him to fall. The State Report dated 9/28/21, documents R27 fell on [DATE] at 9:30 AM when he was outside in the smoking area. The fall was observed by housekeeping staff (V33). The resident (R27) began to stand up and grabbed his walker and tripped over the landscaping tie and fell . R27 was sent to the emergency room and x-ray revealed a fracture of the left hip. R27 was admitted to the hospital for surgical intervention and repair. R27's Progress Note dated 9/28/21, written by V34 Licensed Practical Nurse (LPN) documents R27 and V33 Housekeeper both stated R27's walker was obstructed by a piece of decorative landscaping located in the smoking area causing R27 to lose his balance and fall. R27 was transported to the emergency room for unbearable left hip pain post fall. The Computed Tomography Pelvis for Bone Detail without Contrast dated 9/28/21, documents findings of severe [CONDITION(S)] and a displaced foreshortened trans-cervical femoral neck fracture. On 10/20/21 at 12:50 PM V33 Housekeeper stated on 9/28/21 she took R27 outside to the smoking patio to smoke. V33 stated R27 was sitting on the seat of his wheeled walker to smoke his cigarette. When R27 was finished smoking, he got up off the seat to stand. R27 started to turn around and his walker moved, and the wheel got wedged up against the landscaping tie. This caused R27's walker to tip to one side and the walker and R27 fell over to the left. R27 fell hard onto the concrete. V33 stated she doesn't think the landscaping ties should be there on the smoking patio because they create uneven ground and pose a fall risk hazard to the residents. The Incident, Accident, and Supervision policy dated 01/01/20, documents the resident environment should remain as free of accident hazards as possible and each resident should receive adequate supervision to prevent accidents. The same policy documents the facility shall address resident risk and environmental hazards to minimize the likelihood of accidents. 2.) The Physician Order Sheet dated 10/21/21 documents R15 has diagnoses of [CONDITION(S)], Obesity, Reduced Mobility, Lack of Coordination, Intellectual Disabilities and Abnormal Posture. The Minimum Data Set, dated dated dated [DATE] documents R15 is moderately cognitively impaired and R15 requires extensive assistance of two staff members for bed mobility. V26's (Licensed Practical Nurse) Note dated 8/7/21 documents, Writer was called in the room at 10:55 am. CNA (V27 Certified Nurse Aide) had turned the resident to put the (mechanical lift) sling underneath (R15) after a bed change. Resident rolled off the bed in high position onto the floor. CNA thought resident may have hit (R15's) head and writer notified MD (V5 Physician) at 11:12 am. MD gave permission to send resident out for evaluation. V26's note also states As a precaution writer spoke to CNA staff about coming to get help when turning a person who has little control over their body movements, and another person should be standing on the other side of the bed because there are no bed rails. The Post Fall Review dated 8/7/21, documents R15 rolled out of bed during care and that falls can be prevented by using two staff for cares. On 10/20/21 at 10:28 AM, V26 stated that on 8/7/21 a CNA (V27) came to get V26 and when V26 arrived at R15's room R15 was on the floor. V26 stated the CNA told V26 that (V27) was turning R15 by V27's self and R15 rolled off the edge of the bed. V26 stated R15 does not have good body control and does not have good hand grasp. V26 stated V26 educated V27 to use two staff for turning R15.

Based on interview and record review, the facility failed to protect residents from mental abuse for one of six residents (R1) reviewed for abuse on the sample list of 10. The facility posted a video of R1 displaying behaviors on social media. This failure resulted in humiliation and psychological harm to R1. Findings Include: The facility Abuse, Neglect and Exploitation Policy dated 6/8/2020, documents each resident has the right to be free from abuse. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends or other individuals. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes abuse that is facilitated or caused by nursing home staff taking or using photographs or recording in any manner that would demean or humiliate a resident(s). R1's State Report dated 10/1/21, by V1 Administrator documents this writer was notified that an agency CNA (Certified Nursing Assistant) took a video of a dementia resident (R1) and posted to social media. On 10/5/21 at 11:43 am, V1 stated that on 9/30/21, V18 Agency CNA was placed on DNR status (Do Not Return) by the facility due to a derogatory social media post V18 made about the condition of the facility on 9/29/21, under the name of V26 (V18's Social Media Users Name). V1 stated then on 10/1/21, V20 Agency CNA and V21 CNA made V1 aware of another social media post that V18 made on 10/1/21, under the name of V26, which showed R1 displaying behaviors. V1 explained that the 10/1/21 social media post was a video of R1 sitting in a wheelchair shouting bang, bang, bang, bang, bang repeatedly. V1 stated that after watching the video, V1, V2 Interim DON (Director of Nursing), V3 ADON (Assistant Director of Nursing), V5 Infection Preventionist, and V27 Corporate Nurse all interpreted that the video was made and posted to make fun of (R1's) behaviors. V1 stated the video showed R1's face, so the viewer could see who the resident was. V1 explained V1, V2, V3, V5, and V27 all agreed that it was considered resident mental abuse. V1 stated the facility notified V18's agency about the second social media post and wrote a summary statement for the agency detailing the video. V1 stated that after sending the written description of the video, the agency sent V18's rebuttal, in which V18 denied posting the video. V1's letter to V28 Agency's Management dated 10/1/21, documents this morning I was notified that a CNA from your agency had taken, and posted to (social media), a video of one of my resident's on our dementia unit. I personally viewed the video which included footage of behaviors. I'm sure you realize the gravity of this situation. The CNA from our agency is (V18) under the (social media) name of (V26). (V18) had previously been DNR'd (Do Not Return) for derogatory verbal postings regarding this building. The evidence of the video was only revealed this morning. Per our previous discussion, (V18) is not allowed to work at any of the company's facilities from this day forward. This incident has been reported to the Decatur Police Department and will be sent to IDPH (Illinois Department of Public Health). R1's MDS (Minimum Data Set) dated 7/5/21, documents R1 has severe cognitive impairments. On 10/5/21 at 10:12 am, R1 was sitting in a wheelchair on the dementia unit. R1 was talking to R1's self. When asked a question regarding the abuse allegation and staff taking videos of R1, R1 would keep repeating what was asked but would not answer the questions. On 10/5/21 at 1:07 pm, V20 Agency CNA stated V20 had seen a social media post that V18 made under the user name of V26 regarding how nasty the building was. V20 explained V20 is friends with V18 on social media so V20 knew it was V18 even though the video was posted under the user name of V26. V20 then stated, a couple days later, V21 CNA asked V20 if V20 had seen V18's second social media post. V20 had not seen it but went onto social media at that time and watched V18's posted video, which showed R1 having behaviors. V20 stated V20 immediately reported it to administration. On 10/5/21 at 1:22 pm, V2 confirmed V20 came to V2 with a social media video of R1 displaying behaviors that had been posted by V18 under the name of V26, and that V2 viewed the video. On 10/5/21 at 1:29 pm, V19 Scheduler stated V19 knows V18 outside of the facility and knows that V18 has multiple social media accounts under different names, including that of V26. On 10/6/21 at 10:25 am, V23 (R1's Family) stated the facility called V23 on 10/1/21 to report that an unidentified CNA had taken a video of R1 and posted it on social media. V23 stated V23 has witnessed R1's behaviors of repeatedly saying bang, bang, bang in the past. V23 stated, if R1 was not cognitively impaired, R1 would be appalled, just devastated if R1 knew a video had been taken of R1 and posted to the Internet. R1 always had a compassionate heart for people with memory issues. (R1) would just be beside (R1's self).

Based on observation, interview and record review, the facility failed to administer a resident's pain medication as ordered for one of three residents (R1) reviewed for pain medication administration in the sample of three. This failure resulted in R1's pain being uncontrolled for multiple days to where R1 cried and felt tortured due to the severe uncontrolled pain as well as being sent to the emergency room for pain control. Findings include: R1's Physician order [REDACTED]. This report documents R1's medication orders including the following: 2/3/21 [MEDICATION NAME] (Narcotic) 30mg (milligrams) one tablet (tab) by mouth twice daily (BID) with an order end date of 2/4/21. 2/4/21 [MEDICATION NAME] 30mg one tab by mouth every 12 hours for one week, then decrease to 15 mg for 14 days and discontinue (d/c) with an order end date of 2/10/21. 2/12/21 [MEDICATION NAME] 15mg one tab by mouth twice daily with an order end date of 2/26/21. R1's Medication Administration Record [REDACTED] 2/3/21 8:00pm 2/4/21 8:00am 2/7/21 8:00pm 2/8/21 8:00am and 8:00pm 2/10/21 8:00pm 2/11/21 8:00am and 8:00pm 2/12/21 8:00am 2/23/21 8:00pm R1's hospital records dated 2/9/21 R1 was sent to the emergency room with [DIAGNOSES REDACTED]. These records document Chronic Pain is when pain lasts longer than 6 months that is present even when the body has healed. On 2/24/2021 at 9:30am R1 became tearful and stated R1 had an appointment on 2/23/21 which was 2 hours away and the ride in the transport vehicle was a nightmare and awful due to R1's severe pain. R1 stated R1 was in so much pain from being up in the wheelchair and the roads were not smooth and had a lot of bumps and holes. R1 stated R1 spoke with V1, Administrator related to medications not being given but R1 is still having issues. R1 stated R1 feels R1 is being tortured by the facility because R1's pain medications have been not given at all sometimes. R1 stated R1 has been treated by V14, R1's Pain Specialist Physician for years. R1 stated all R1 can do is cry sometimes because (R1) hurts so bad from not receiving R1's [MEDICATION NAME]. R1 stated it is inhumane to not ensure residents are receiving the pain medications as ordered for pain control. On 2/25/2021 at 9:40am, V14, R1's Pain Specialist Physician stated V14 began providing care for R1 due to R1's Advanced [MEDICAL CONDITION] of bilateral hips and knees in June 2016. V14 stated V14 has seen (R1) for many years and when R1 initially started with V14's practice, R1 was still living independent at home. V14 stated V14 has never had any concerns related to R1's [MEDICATION NAME] dose or use and that there has never been any evidence suggesting R1 was abusing the [MEDICATION NAME] medication. V14 stated R1 was eligible for chronic pain control due to the Advanced [MEDICAL CONDITION] and taking the medication as prescribed and was doing well. V14 stated if R1 is not receiving the [MEDICATION NAME] medication as ordered and/or goes without the [MEDICATION NAME] for a day or more, R1 will go through withdrawal symptoms which may include nausea, vomiting, increased pain and anxiety. V14 stated R1 needs the [MEDICATION NAME] medication due to the pain related to R1's Advanced [MEDICAL CONDITION]. V14 stated you cannot abruptly stop or miss doses of an opiod medication or the resident will have increased pain and withdrawal symptoms that will occur. V14 stated R1 went to the office on 2/10/21 however R1 complained of a sore throat and due to COVID (human coronavirus infection) V14 was unable to see R1 in an exam room. V14 stated V14 went to the waiting room to explain the inability to see R1 to which R1 became very emotionally upset and cried. V14 stated if R1 was not receiving R1's [MEDICATION NAME] as ordered R1 would also have withdrawal as well as an increase in anxiety which could contribute to an increase in R1's pain.

Based on interview and record review, the facility failed to administer 10 doses of scheduled Narcotic pain relief medication to R1 and failed to administer 20 doses of a scheduled Benzodiazepine, Anti-Anxiety medication to R1. These failures affect one of three residents (R1) reviewed for pain control in the sample of three. These failures resulted in R1's uncontrolled pain and anxiety causing R1 to require emergency room treatment and being unable to sleep. Findings include: R1's Physician order [REDACTED]. This report documents R1's medication orders including the following: 2/3/21 [MEDICATION NAME] (Narcotic) 30mg (milligrams) one tablet (tab) by mouth twice daily (BID) with an order end date of 2/4/21. 2/4/21 [MEDICATION NAME] 30mg one tab by mouth every 12 hours for one week, then decrease to 15 mg for 14 days and discontinue (d/c) with an order end date of 2/10/21. 2/12/21 [MEDICATION NAME] 15mg one tab by mouth twice daily with an order end date of 2/26/21. 2/4/21 [MEDICATION NAME] (Benzodiazepine) 0.5mg tab, one tablet by mouth daily at bedtime. R1's Medication Administration Record [REDACTED] 2/3/21 8:00pm 2/4/21 8:00am 2/7/21 8:00pm 2/8/21 8:00am and 8:00pm 2/10/21 8:00pm 2/11/21 8:00am and 8:00pm 2/12/21 8:00am 2/23/21 8:00pm R1's MAR indicated [REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 has had trouble falling or staying asleep. R1's hospital records dated 2/9/21 R1 was sent to the emergency room with [DIAGNOSES REDACTED]. These records document Chronic Pain is when pain lasts longer than 6 months that is present even when the body has healed. On 2/24/2021 at 9:30am R1 became tearful and stated R1 had an appointment on 2/23/21 which was 2 hours away and the ride in the transport vehicle was a nightmare and awful due to R1's severe pain. R1 stated R1 was in so much pain from being up in the wheelchair and the roads were not smooth and had a lot of bumps and holes. R1 stated R1 spoke with V1, Administrator related to medications not being given but R1 is still having issues. R1 stated R1 feels R1 is being tortured by the facility because R1's pain medications have been not given at all sometimes. R1 stated R1 has been treated by V14, R1's Pain Specialist Physician for years. R1 stated all R1 can do is cry sometimes because (R1) hurts so bad from not receiving R1's [MEDICATION NAME]. R1 stated it is inhumane to not ensure residents are receiving the pain medications as ordered for pain control. R1 stated R1 has not received the [MEDICATION NAME] as ordered and has been having a difficult time sleeping as well as increased anxiety. On 2/24/2021 at 1:15pm, V6, Nurse Practitioner (NP) stated V6 is in the facility Monday through Friday. V6 stated the facility is aware and the staff should have came to me/contacted me to write a prescription so pharmacy would send R1's [MEDICATION NAME] medication. On 2/25/2021 at 9:40am, V14, R1's Pain Specialist Physician stated V14 stated V14 began providing care for R1 due to R1's Advanced [MEDICAL CONDITION] of bilateral hips and knees in June 2016. V14 stated V14 has seen (R1) for many years and when R1 initially started with V14's practice, R1 was still living independent at home. V14 stated V14 has never had any concerns related to R1's [MEDICATION NAME] dose or use and that there has never been any evidence suggesting R1 was abusing the [MEDICATION NAME] medication. V14 stated R1 was eligible for chronic pain control due to the Advanced [MEDICAL CONDITION] and taking the medication as prescribed and was doing well. V14 stated if R1 is not receiving the [MEDICATION NAME] medication as ordered and/or goes without the [MEDICATION NAME] for a day or more, R1 will go through withdrawal symptoms which may include nausea, vomiting, increased pain and anxiety. R1 stated R1 needs the [MEDICATION NAME] medication due to the pain related to R1's Advanced [MEDICAL CONDITION]. V14 stated you cannot abruptly stop or miss doses of an opiod medication or the resident will have increased pain and withdrawal symptoms that will occur. V14 stated if R1 was not receiving R1's [MEDICATION NAME] as ordered R1 would also have withdrawal as well as an increase in anxiety which could contribute to an increase in R1's pain. The facility's Controlled Substance Prescriptions policy dated 10/25/2014 documents the prescriber is contacted to verify or clarify a prescription when needed. If changes to a controlled substance prescription are necessary the prescriber must communicate the new order to the facility for documentation in the chart and communicate or transmit the new prescription to the pharmacy prior to dispensing. The facility's Back-up Pharmacy Policy dated 6/18/18 documents facilities specify that pharmaceutical services must be responsive to the needs of a resident. Timely delivery of drugs is necessary so that a resident's prescribed treatment plan is not disrupted.

Based on observation, interview, and record review the facility failed to sufficiently supervise one resident (R2) to prevent a fall. This fall caused (R2) to sustain a fractured shoulder resulting in pain and immobility. In addition, the facility failed to investigate and determine root cause for fall for one resident (R3). R2 and R3 were two of three residents reviewed for falls in a sample list of 15 residents. Findings include: 1. R2's Continuity of Care document dated 2/9/21 includes the following Diagnoses: [REDACTED]. R2's Minimum Data set ((MDS) dated [DATE] documents R2 requires extensive assistance of two or more staff with bed mobility and transfer. R2's MDS documents R2 as completely cognitively in tact. R2's Progress Note dated 2/5/21 at 5:51PM documents (V20) Certified Nurse's Aide (CNA) was assisting (R2) and resident rolled off bed landing on floor, full assessment and vitals done within in normal limits. Neurological check done with no abnormalities. (V20) left side is paralyzed Voices no complaint of pain at present. R2's Progress Note dated 2/5/21 at 7:54PM documents Ambulance service called in regard to (R2's) increase in pain to right shoulder from previous incident. Family notified. Medical Doctor notified. Will notify Director of Nursing (DON). On 2/9/21 at 1:00PM R2 stated Last Friday (2/5/21) I needed cleaned up. There was an agency CNA (Certified Nurse's Aide) who came in. The CNA turned me to my left side. I am paralyzed on my left side. I gripped the side of the bed with my right hand to help her hold me over. All the CNA had was the wipes. I felt cold and wet and asked her to dry me off. She left me on my side while she went into the hall to get a towel. My right leg slipped off the bed and I fell to the floor. When I fell I landed on my right arm. They got a lift and got me back in bed. The nurse didn't think I was hurt, but I had a lot of pain and had them send me to the hospital. Now I will have surgery to fix my right shoulder. The bad thing is I can't even feed myself now. My right arm was my good side and now it won't work. This has been painful and frustrating to me. Look they brought me pizza and just left it there. How do they expect me to eat? There was a piece of pizza sitting on the over bed table. R2 was wearing a sling to immobilize her right shoulder and arm. On 2/9/21 at 3:00PM V20, Certified Nurse's Aide (CNA) stated I was on the same hall with the agency CNA who was taking care of (R2) on the night (R2) fell out of bed (2/5/21). The agency CNA called out for help after (R2) was on the floor. Both the agency CNA and (R2) told me (R2) had slipped out of bed when the agency CNA left (R2) on her side to go out into the hall and get a towel. When the CNA came back (R2) was on the floor. We got (R2) back to bed with the lift and (R2) was in a lot of pain right away. (R2) told the nurse a little later she needed to go to the hospital. R2 is a little slow to answer, but she is completely aware of what is happening and how she feels. The agency CNA was not available for interview. On 2/9/21 at 11:27AM V2, Director of Nursing (DON) stated As DON it is my expectation that staff provide assistance as documented on MDS and Care Plan. R2 should have had the assistance of two or more staff. On 2/10/21 at 3:00PM V24, Orthopedic Surgeon stated (R1) has a fracture of her right humerous (upper arm). We are planning to do a open reduction internal fixation to repair this. If (R1) rolled out of bed because of what staff at the nursing home did or didn't do it is unfortunate. This injury is certainly painful. I believe (R1) is capable of telling you how her injury occurred. The facility's undated Fall Reduction Program documents Safety interventions will be determined and implemented based on the assessed individualized risks and in accordance with standards of care. This policy also states If resident is not able to maintain proper sitting balance, staff shall remain with the resident allowing as much privacy as is safe for the resident. 2. R3's progress notes document on 06/13/2020 at 6:22 AM, resident observed on floor of bedroom laying on (R3's) stomach resident not noted to readily move on (R3's) own, assisted back into bed, raised area on left cheek noted, no discoloration noted at this time. R3's progress notes document on 7/18/2020 at 7:56 PM, At about 4.45 PM, attention was drawn to resident by (R3's) room mate. (R3) was found on the floor left face down and with about 0.5cm skin tear to the left eye brow. R3's medical record did not contain post fall investigations with root cause analysis for R3's falls on 6/13/2020 and 7/18/2020. On 2/9/21 at 11:35 AM V2 Director of Nursing stated, I am not able to locate fall investigations with root cause for R3's falls on 6/13/20 and 7/18/20. When a resident falls a fall investigation should be completed to determine the root cause and develop further interventions. The facility's undated Fall Reduction Program documents Attempts shall be made to implement new or modified interventions to enhance safety and consistent with root cause analysis.

Based on observation, interview and record review the facility failed to complete daily skin checks and monitor and treat a pressure injury (R1), failed to implement pressure relieving interventions (R2), and failed to assess for the risk of skin breakdown (R3) for three of three residents (R1, R2 and R3) reviewed for facility acquired pressure sores in the sample of three residents. These failures resulted in R1 developing an avoidable stage four pressure sore to R1's right calf. Findings include: The Pressure Ulcer Prevention Protocol dated 5/2018 states Newly admitted residents will have a Pressure Ulcer Risk assessment completed upon admission weekly thereafter for the next three weeks after admission. The Policy also states Interventions necessary to maintain skin integrity or to promote healing will be incorporated into the plan of care based on each resident's individual needs and risks which may include: [NAME] daily skin checks conducted by either the CNA (Certified Nurses Aide) or Licensed Nurse to ensure early identification of potential problem areas and C. Use of pressure reduction devices. The Pressure Ulcer Treatment and Management policy dated 5/2017 states 1. Residents with pressure ulcers will have a physician's orders [REDACTED]. The licensed nurse will document the treatment as given on the Treatment Administration Record. 1. The physician's orders [REDACTED].>The Minimum (MDS) data set [DATE] documents R1 is severely cognitively impaired and R1 requires extensive to total assistance with transfers and bed mobility. The Progress Note dated 4/10/19 documents R1 returned to the facility with a new cast on right foot. There is an open area on right leg (posterior thigh) and a dry dressing is to be applied daily. The Progress Note dated 5/15/19 documents R1 was seen in V13 Orthopedic Physician's office and that R1's right leg cast was replaced with a knee immobilizer. The Weekly Wound Note dated 5/20/19 documents R1's right posterior thigh wound is healed. The After Visit Summary dated 7/29/19 documents R1 was seen in V13's office on that date and that V13 wrote an order stating Keep dry dressing to the right area on the right leg. Please change dressing daily and monitor (for) signs of infection. R1's Physician order [REDACTED]. R1's Treatment Administration Records dated 7/29/19 through 9/1/19 do not document a dry dressing was applied to the wound on R1's right leg. V5's (Licensed Practical Nurse) Progress note dated 9/2/19 documents Writer called to resident room per CNA's (Certified Nurses Aides), writer observed open area on posterior right calf. V3's (Wound Nurse) Wound Management Note dated 9/2/19 documents an unstageable wound measuring 9.5 centimeters (cm) in length by 5.5 cm in width with a depth of 1.5 cm was identified on R1's right calf on 9/2/19. The Note documents the wound is foul smelling and that the wound has black/brown slough throughout the wound bed. V14 Facility Wound Doctor's Note dated 9/9/19 documents V14 evaluated R1's right calf wound on that date and V14 surgically excised 9.6 cm of devitalized tissue and necrotic muscle and surrounding fascial fibers were removed. V13's Note dated 9/11/19 documents Patient (R1) is an 86-year -old female who presented today for a follow up of tibia fracture. (R1) was last seen 7/29/19 and at that time had a small, 1 cm scab to the back of (R1's) right lower extremity. Instructions were given to place a dry dressing and continue to monitor. Today there is a stage four pressure wound in the same area. V13 9/11/19 note also documents (R1) Back of right leg shows 9x3 (cm), 5x2 cm wound that is to the bone. The Hospital History and Physical dated 9/11/19 documents R1 was admitted to the hospital with [REDACTED]. V17 Infectious Disease Doctor's Note dated 9/13/19 documents Impression nonhealing pressure ulcer right calf, secondary infections. Posttraumatic ulcer secondary to application of a brace. The Hospital Discharge Summary dated 9/17/19 documents R1's stage four pressure sore was treated with surgical incision and debridement and intravenous antibiotics and that R1 was discharged to another facility on oral antibiotics. On 9/17/19 at 12:26 PM V4 Licensed Practical Nurse stated V4 did not remove R1's immobilizer when completing R1's daily skin checks. V4 stated V4 thought the immobilizer was like a cast and should not be removed. On 9/18/19 at 8:00 AM V8 LPN stated it was V8's understanding that R1's immobilizer should stay on except for ADL (activity of daily living) care. V8 stated when V8 checked R1's skin V8 opened the immobilizer and rolled R1's leg side to side. V8 stated V8 did not check the underside of R1's leg under the immobilizer. V8 stated the wound (on R1's calf) must have been there and V8 missed it. V8 stated V8 assumed the immobilizer was being removed and the skin under R1's immobilizer was being checked by the CNA (certified nursing assistant) staff during showers. V8 stated prior to the calf wound being found (on 9/2/19) no treatment was being completed for a wound on R1's right calf. On 9/18/19 at 1:45 PM V12 Certified Nurse Aide stated R1 received bed baths and V12 did not remove R1's immobilizer even for baths because V12 was instructed not to remove the immobilizer. V12 stated (on 9/2/19) the odor from R1 was outstanding. V12 stated V12 reported the odor to the nurse (V5 LPN) and V12 and V5 found the wound on R1's right calf. On 9/17/19 at 12:32 PM V5 LPN stated on 9/2/19, V5 had the CNA staff lay R1 down so V5 could look for the source of the odor. V5 stated V5 found the wound on R1's calf and that the wound was a big area with some necrotic tissue. V5 stated the wound was draining and had a bad odor. V5 stated prior to finding the wound V5 was not removing the immobilizer to complete skin checks on R1's right leg. On 9/17/19 at 1:08 PM V3 Wound Nurse stated on 4/11/19 R1 developed an abraded area to R1's to right posterior thigh that was documented as healed on 5/20/19. V3 stated no other treatment is documented to a wound on R1's right leg. On 9/19/19 at 8:10 am V3 stated V3 expected staff to remove R1's immobilizer and do skin checks daily or at least on shower days. V3 stated staff should have rolled R1 on R1's side and looked at the back of R1's leg. V3 stated the skin under the immobilizer was clearly not checked at all. V3 stated staff should always check the skin under an immobilizer. V3 stated V13's orders for treatment and monitoring of R1's right leg wound from 7/29/19 were not transcribed into the medical record so they were not done. V3 stated R1's calf wound was grayish black and sloughy with a foul odor when V3 assessed the wound (on 9/2/19.) V3 stated too much dead tissue and slough was present to visualize the wound bed. V3 stated the stage four pressure wound could have been avoided if staff had followed V13's orders. V3 stated the wound would not have progressed to a stage four wound if staff were treating and monitoring the wound. On 9/17/19 at 3:30 PM V11 Registered Nurse (V13's Nurse) stated on 7/29/19 V13 found a small 1-2 cm area on R1's right calf during an office visit and V13 wrote orders for facility staff to to continue the immobilizer with a daily dressing change to the area and to monitor for infection. V11 stated facility staff should have removed R1's immobilizer to clean and check skin at least daily. V11 stated verbal instructions were given to facility staff on 5/15/19. On 9/19/19 at 8:50 am V11 stated that V13 stated that not removing the immobilizer for skin checks obviously contributed to R1's skin breakdown and R1's wound would not have been as extensive if facility staff had followed V13's orders. At that time V11 confirmed that the area found on R1's calf by V13 on 7/29/19 became a stage four pressure wound. V11 also stated R1 had no chronic diseases that would have contributed to the development of the wound. 2. The Physician order [REDACTED]. The Minimum (MDS) data set [DATE] documents R2 is cognitively impaired and requires extensive assistance with transfers and bed mobility. The Care Plan dated 8/15/19, reviewed by the surveyor on 9/18/19, documents R2 has a pressure ulcer to R2's left outer heel and documents an intervention dated 7/18/19 of use heel protectors to relieve pressure on the heels. The Care Plan revised 9/18/19 documents R2 has a history of a pressure sore to R2's right outer heel and documents an intervention of heel protectors to both heels as resident tolerates and Keep bony prominences from direct contact with one another. On 9/18/19 at 1:55 PM V12 and V19 both Certified Nurses Aides (CNA) used a mechanical sit to stand lift to transfer R2 from the wheel chair to the bed. V12 then provided perineal care for R2 and positioned R2 on R2's left side with R2's left outer heel resting on the bed and R2's right inner heel resting on R2's left foot. V12 did not attempt to put heel protectors on R2. On 9/18/19 at 3:40 PM R2 was in bed with no heel protectors on and R2's heels resting on the mattress. On 9/18/19 at 3:55 PM V18 LPN stated the wounds to R2's right and left heels were healed in (MONTH) (2019). At that time R2 was laying in bed with R2's heels resting on the bed and R2 was not wearing heel protectors. R2's heels were red and small dark areas were present on R2's left middle heel and R2's right outer heel. V18 stated R2 should be wearing heel protectors in bed. V18 searched R2's room and could not locate any heel protectors. On 9/19/19 V3 Wound Nurse confirmed R2 should be wearing heel protectors while in bed. 3.) R3's Face Sheet documents an admission date of [DATE] with [DIAGNOSES REDACTED]. R3's Admission assessment dated [DATE] documents a skin risk assessment score of 16 which indicates R3 was at risk for skin alterations. R3's next skin risk assessment is dated 6/13/19 and documents R3 is at high risk for skin alterations. R3's Admission MDS (Minimum Data Set) dated 2/19/19 documents R3 requires extensive assistance of two people for bed mobility and requires total assistance of two people for transfers. This MDS documents R3 has a stage 4 pressure ulcer and documents R3 is frequently incontinent of bowel. R3's Care Plan dated 2/12/19 documents R3 is at risk for skin breakdown related to R3 being chair fast, having decreased mobility, being a quadriplegic, R3 has a low air loss mattress. This Care Plan documents interventions of conducting a systemic skin inspection weekly, daily, etc. (et cetera) pay particular attention to the bony prominences. R3's Nurse's Progress Notes dated 3/18/19 documents a new pressure area identified as a stage 1 to the left ischium that was not present on admission. This Progress Note documents R3 was seen by the V14 Wound Physician. R3's Wound documentation dated 3/18/19 documents this pressure ulcer on the left ishium measures 3.5 cm (centimeters) x (by) 3 cm. R3's Care Plan dated 3/28/19 documents R3 is non compliant with repositioning despite staff education. On 9/19/19 at 10:12 AM, R3 was in R3's electric wheelchair and R3 had heel cushion boots on both feet. On 9/19/19 at 11:49 AM, V16 Regional Nurse confirmed there were no skin risk assessments documented in R3's medical record where they should be. On 9/19/19 at 2:20 PM, V15 Registered Nurse stated there is an admission skin assessment in the nursing assessment for R3 but R3 should have had a skin risk assessment done weekly for three weeks. V15 stated there are no other skin risk assessments in the computer until (MONTH) 2019. On 9/19/19 at 2:26 PM, V3 Wound Nurse confirmed R3's electronic medical record does not document any skin risk assessments being completed after the initial risk assessment on admitted d 2/12/19 until 6/13/19. V3 confirmed there should have been weekly skin risk assessments completely after R3 was admitted .

Based on observation, record review, and interview, the facility failed to rapidly cool potentially hazardous food to a safe internal temperature of 41 degrees Fahrenheit (F) or below within the maximum permitted six hours to prevent food borne illness on 2-5-18. This failure resulted in the facility preparing to serve unsafe food without recognizing the potential for food borne illness to all 149 residents. This failure resulted in an Immediate Jeopardy starting on 2/5/18, when the beef was not cooled appropriately. This situation of improperly cooled beef was observed being prepared for meal service. While the immediacy was removed on 2-6-18, the facility remains out of compliance at a severity level 2, while the facility is in the process of training and retraining staff on the facility's policy and procedure for rapidly cooling potentially hazardous foods after preparation. Findings include: According to the menu for the noon meal on 2-6-18, Roast Beef was the protein source for all residents. On 2-6-18 at 9:20 A.M., V8, Day Cook was preparing to puree roast beef for the noon meal. V8 stated that the roast beef was cooked on 2-5-18. V8 stated V8 prepared six, 12 to 14 pound beef flat roasts on 2-5-18. V8 stated that the beef roasts were placed into the oven around 11:00AM on 2-5-18. V8 was off duty at 3:00 P.M. on 2-5-18. V8 told V11, Evening Cook to remove the roasts from the oven at 5:45 P.M., remove from the pans, drain the broth, and cool the beef. V8 stated V8 did not specify to V11 how the beef was to be cooled, under what conditions, and within what time frames. On 2-6-18 at 1:10 p.m. V11 stated that the cooked beef was removed from the oven at 6:15 p.m. on 2-5-18 at which time it was permitted to rest on the counter. V11 stated the beef roasts internal temperature was 186 degrees F. when V11 tightly covered it with foil and placed it into the walk-in refrigeration unit. V11 stated at this time that no rapid cooling measures were used. V11 stated that V11 did not recall being trained on any rapid cooling measures to be taken. On 02/06/18 V8 further stated that when V8 got the roast beef out of the walk in refrigerator, the beef was tightly covered with foil and internal temperatures were taken at that time. V8 stated that there were no time or temperatures recorded regarding any rapid cooling measures taken for the cooked roast beef. V8 stated that the facility has a policy and procedure for cooling potentially hazardous that includes monitoring, time and temperature. The facility's undated policy Cooling Cooked PHF/TCS Foods (Potentially Hazardous Food/Time Temperature Control For Safety) states Hot foods are cooled in the refrigerator from 135 degrees F to 70 degrees F within two (2) hours, within four (4) more hours the food is cooled to 41 degrees F. Cooling time from 135 degrees F to 41 degrees F does not exceed a total of six (6) hours. The policy further offers methods and procedures to facilitate rapid cooling including the use of shallow pans, separating food into smaller portions, placing the container in an ice water bath, stirring food periodically, using ice paddles, and adding ice. The policy specifies that hot foods cooled in the refrigerator are loosely covered. The policy specifies that time and temperatures are recorded at the beginning of the cooling process. The timing of the cooling process begins when the temperature of the food is at 135 degrees F. Two (2) hours later the temperature is taken and recorded. The food is 70 degrees F. or lower. The person is charge is notified if the temperature is greater than the standard. The temperature is taken and recorded again four (4) hours later. The food is 41 degrees F. or lower. The person is notified if the temperature is greater than the standard. Time and temperature are recorded on labels affixed to the pan and/or on a Two-Step Cool-Down Temperature Monitoring Log. On 2-6-18 at 9:20 a.m. V8 was in the process of preparing slices of the cooked beef and preparing beef for mechanical alteration (puree, ground consistencies) for service to residents. There were also two large steam table pans filled with sliced roast beef and covered with gravy ready for service to residents. Since there was no evidence that the beef had been rapidly cooled, V8 was asked if all the beef had been sliced. V8 indicated that there were two beef roasts still covered in a pan in the walk in refrigerator. There was 3/4 to one inch of oily fat and broth in the bottom of the pan. The facility's digital thermometer and the surveyor's dial stem thermometer recorded the internal temperature of the center of the roast to be 66 degrees F. at 9:30 a.m. on 2-6-18, over 15 hours from when the cooked beef was placed into refrigeration. V9, Corporate Dietician was also present. V9 stated We can't serve this. V9 directed V8 to discard the beef. The Resident Census and Conditions of Residents form completed 2-4-18 specifies that 148 residents reside in the facility. The facility Administrator was notified of the Immediate Jeopardy on 02/08/17 at 4:00PM. On 2-13-18 the surveyor confirmed the facility took the following actions to remove the immediacy: 1. The beef roasts were discarded. No residents were served food that had not been properly cooled down. Completed 02/06/18 2. IDT(Interdisciplinary Team) team including Registered Dietician reviewed Policy 4.25- Cooling Cooked PHF/TCS Foods. Policy is appropriate within the scope of the regulation. Completed 02/06/18 3. The Cooling of Cooked Potentially Hazardous Foods Procedure has been posted in the kitchen preparation area for cooks to use as a reference. Completed 02/08/18 4. All kitchen staff have received in-service education completed by facility Registered Dietician on following the facility's policy for serving food safely by following the proper cool down procedure. The facility Food Service Director will be notified by the cook in case of food not reaching appropriate temperature. Failure to meet the temperature will result in the food items being discarded. Initiated 02/08/18, whole house to be completed on 02/09/18 5. Facility has a monitoring form for logging temperatures of potentially hazardous foods that are prepared in advance in place. Completed 02/07/18 6. All kitchen staff will/have been tested for competency for serving food safely by following the proper cool down procedure and will be completed by facility Registered Dietician. Initiated 02/08/18, whole house to be completed on 02/09/18. 7. The Food Service Director and or the designee will complete a QA audit for 4 weeks related to the cool down process when applicable. Findings will be submitted to the QA Committee for review and will provide additional recommendations for corrective action as needed. Initiated 02/08/18 8. Food Service Provider has been contacted and all large quantity meat products such as Beef Roasts, Pork Roasts, etc. have been changed to a pre-cooked product. Completed 02/08/18. 9. The Administrator is to monitor audit tools weekly until substantial compliance is achieved. Initial Observation Completed 02/08/18, to be continued and ongoing 10. A Quality Assurance meeting was held with the Medical Director, RD consultant and members of the IDT to discuss and present the removal plan. Completed 02/08/18

Based on interview, and record review the facility failed to immediately answer a ventilator machine alarm for one of three residents (R4) reviewed for specialty care on the sample of six. This failure resulted in R4 requiring cardio-pulmonary resuscitation. Findings include: R4's History and Physical dated [DATE] documents R4 has diagnoses' of [MEDICAL CONDITION] with Hypercapnia, Acute and Chronic [MEDICAL CONDITIONS], Ventilator Dependant, and [MEDICAL CONDITION]. Nursing notes written by E3 Registered Nurse, dated [DATE] at 7:30 P.M. documents, (R4) was in bed sitting with head of bed up at (6:00 AM) when writer administered morning medications. (R4) alert and oriented with (complaints of) back pain. (As needed) [MEDICATION NAME] administered per (physician) order. At approximately (7:00 AM) vent alarm heard and call for help almost simultaneously. Upon response respiratory therapist found in room and resident found to be unresponsive and cyanotic. Skin was warm and clammy. Radial pulse present. Writer immediately called for more help and instructed staff to call 911. Abnormal respiration pattern present. Respiratory provided respirations per ambu bag. AED (Automated External Defibrillators) applied to resident. Resident began to cough and open eyes after approximately two minutes of manual respirations. At three minutes resident responsive to sternal rub and was pulling arms up. Resident quickly able to follow basic commands. Continued to provide support until arrival of (emergency services). Before leaving resident was completely responsive and confirmed she tried to go to commode alone and became disconnected. Daughter/POA notified per facility manager. MD notified. pending return. cont to observe. On [DATE] at 10:05 AM, R4 stated that on the morning of [DATE] (R4) was sitting on the side of the bed. (R4) was putting on shoes and socks. (R4) was wearing (R4's) ventilator. (R4) heard the hose to the ventilator pop off. (R4) couldn't reach it to put it back on. (R4) heard the ventilator alarms sounding. (R4) pushed her call light. No one was coming and then (R4) felt like (R4) was going to black out. The next thing (R4) knew, (R4) woke up in the hospital. (R4) felt like (R4) waited at least five minutes for someone to come into the room before (R4) blacked out. (R4) stated that (R4's) chest is sore from the CPR (cardio-pulmonary resuscitation). (R4) stated that the tubing to the ventilator has popped off before and (R4) has reported it. (R4) stated that the staff are slow to answer the alarms. (R4) stated that (R4's) chest really hurts from the CPR and that (R4) has never been so scared in (R4's) life. On [DATE] at 1:24 PM, E3/Registered Nurse stated, On [DATE], I (E3) went into (R4's) room at 6:00 AM to give (R4), (R4's) morning medications. (R4) received some pain medications so I went back and checked on (R4) at 6:30 AM. I asked if (R4's) pain was relieved and (R4) gave me a thumbs up. (R4) was still lying in bed. I went to the desk and I was getting (another resident's) paperwork ready so he could be sent to the hospital. I heard alarms going off, but I am new to the facility and my preceptor (E4, Licensed Practical Nurse) said that it must be (E5, Respiratory Therapist) working with the other resident. I heard the alarm again. Then I heard (E5) yelling to get the crash cart. When I got to the room (R4) was laying across the bed and was cyanotic. We then began to do CPR. I feel like the alarm sounded for around two minutes. We didn't respond immediately because we thought it was a different resident's alarm. On [DATE] at 9:31 AM, E4 LPN stated, I (E4) was working on the other side of the hall. I walked up to the desk and heard the alarm sounding. I saw the respiratory cart sitting outside another resident's room. E3 stated an alarm was going off and we thought it was coming from the other resident's room. I walked around the nurse's station to sit down at the desk and then heard (E5) call for the crash cart. I grabbed the crash cart and assisted with R4's CPR. I am not sure how long the alarm sounded because I was on the other side of the hall. On [DATE] at 12:36 PM, E7 Certified Nurse's Assistant (CNA) stated, On [DATE] at 7:00 AM, I (E7) was in a room with E5 and E6 (CNA) taking care of a resident. I stepped out to get a sheet and heard alarms sounding. I walked around the corner of the hallway and noticed it was (R4's alarm). I went back into the room and told (E5) that the alarm was sounding. (E5) finished caring for the other resident. It took four to five minutes for (E5) to finish. (E5) then went to (R4's) room and called a code. When I got into the room (R4) was purple. (R4's) alarms were sounding for about six minutes before E5 went into the room. When I started working at the facility I was trained to listen for the alarms. If an alarm goes off I will usually get an RT (respiratory therapist). On [DATE] at 1:34 PM, E5 stated that she was in a room with E6 and E7 taking care of another resident. E5 stated she was giving the other resident [MEDICAL CONDITION] care. E5 stated the door to the resident's room was closed. E5 stated that E7 walked out into the hall and returned to the room and told her that an alarm was going off. E5 stated she removed her gloves and walked out of the room and seen R4 lying on the bed sideways. E5 stated that she seen a nurse and a CNA sitting at the desk. E5 stated she yelled for the crash cart. E5 stated R4's hose popped off the ventilator. E5 stated they did CPR on R4 and then sent (R4) to the hospital. E5 stated that they have problems with the staff answering the ventilator alarms. E5 stated that the staff rely on the respiratory therapists to answer the alarms. E5 stated that the staff need retrained. E5 stated that (E5) is unsure why they (the nurses as the nurses station) didn't answer R4's alarms. E5 stated that when (R4's) alarm sounds it needs to be answered immediately. E5 stated that if someone would have answered the alarm immediately the hose to the ventilator could have been reconnected and R4 would have not required CPR. On [DATE] at 7:44 AM, E8 Respiratory Therapist stated there are two alarms connected to the ventilators. The ventilator has an alarm on the machine that will sound if a change in pressure occurs. The ventilator also is connected to an alarm outside the door and if pressure to the ventilator is lost it will alarm outside the door. E8 stated the tubing to the ventilator will occasionally come disconnected. E8 stated the respiratory therapists are usually the only staff that answer the alarm. E8 stated R4 requires oxygen to maintain her saturation level and if R4 does not have oxygen on R4 quickly desaturates. R4 typically requires between five to eight liters of oxygen. E8 stated when the tubing became disconnected from the ventilator machine R4 stopped receiving oxygen which caused R4 to desaturate. E8 stated E8 has worked with R4 since R4's admission. E8 stated E8 has issues with the staff answering R4's alarm since R4's admission. R4's face sheet documents that R4 was admitted on [DATE]. On [DATE] at 8:00 AM, E8 set off the R4's ventilator alarms and pushed R4's call light. At that time, both ventilator alarms could be heard from the nurse's station, and the call light board showed that R4's call light was on. R4's emergency room report dated [DATE] at 7:40 AM documents, (R4) arrived to (emergency room ) for shortness of breath. (R4) has [MEDICAL CONDITION]. EMS (Emergency Services) states that (R4) normally wears a ventilator at night and got up this morning and fell off the vent (the tubing fell off). EMS also states that the nursing home staff were doing CPR prior to arrival. EMS states that (R4) had a pulse on arrival so they did not continue CPR. (R4) was being bagged by EMS on arrival. Bagging continued until respiratory placed (R4) on the vent. EMS states that the nursing home staff stated that (R4) only wears the vent at night. (R4) complained of chest tenderness. This report documents R4's clinical impression as Chronic [MEDICAL CONDITION] and Chest Wall Pain.