Every finding on record at Lutheran Home for the Aged

Based on observation, interview, and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were three (3) medication errors out of 30 medication opportunities, resulting in a 10% medication error rate. Findings include:On 01/21/2026 at 9:30 AM, Medication observation with V13 (Licensed Practical Nurse) completed for R178. R178 has a diagnosis of heart failure, hypertension, and chronic obstructive pulmonary disease. V13 gave Lamotrigine Oral Tablet 150 MG, Bumetanide Oral Tablet 1 MG, and Carvedilol Oral Tablet 6.25 MGPer the Physician order sheet dated January 2026, it reads:1-Lamotrigine Oral Tablet 150 MG, Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 8:00 PM.2-Bumetanide Oral Tablet 1 MG, Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 5:00 PM.3-Carvedilol Oral Tablet 6.25 MG. Give 1 tablet by mouth two times a day. Scheduled for 8:00 AM and 8:00 PM.On 1/21/2026 at 9:45 AM, V13 said, I am expected to administer medication one hour before or one hour after the scheduled times, and I am a float nurse, and I finished the other side, another hall away, and now I must finish this side. I have 24 residents on this unit.Facility Provided medication administration audit report, and V13 signed medication on 01/21/2026 at 9:43 AM for medications scheduled to be administered at 08:00.On 1/22/2026 at 9:57 AM, V4(Director of Nursing) said, I expect the nurses to administer medications within two hours window, one hour before the scheduled time and one hour after the scheduled time. Medications administered at 9:30 AM and scheduled for 8:00 are considered late.On 1/21/2026 at 1:06 PM, V1(Executive Administrator) provided Policy titled, Medication Administration General Guidelines dated 01/2025, which reads:14. Medications are administered within 60 minutes of the scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center. Medications should not be given at mealtimes or in the dining room unless specifically ordered with a meal.

Based on observation, interview, and record review, the facility failed to thoroughly investigate and maintain documentation of investigations for an unwitnessed fall for one resident (R2)Findings include: R2 is an [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: chronic obstructive pulmonary disease, type 2 diabetes, peripheral vascular disease, and anemia. Per R2's electronic medical record, progress notes dated 8-26-2024 at 5:23 pm read in part: R2 was taken to the bathroom, a few minutes later, R2 started yelling in the bathroom, and V22 (Registered Nurse) saw R2 on the floor. R2 reported pain in the lower back and verbalized hitting the head on the floor. R2 was transferred to a local Hospital for evaluation and computed tomography scan (CT SCAN). Per local hospital report dated: 8-26-2024 at 6:08 pm reads: Mild acute appearing compression deformity of the endplate of L1 with approximately 20% compression.On 11-29-2025 at 2:00 pm, V3 (Assistant Director of Nursing) said, this is the full investigation for the incident that R2 sustained on 8-26-2024. The folder presented had only one written statement from V22 (Registered Nurse). On 12-1-2025 at 1:30 pm, V1 (Administrator) said, I expect that a full investigation is done, the team members that are in the building will need to complete all the staff interviews, which will help piece the information together. I would have expected to have notes of the people who worked on that day. I only see a statement from V22 (registered nurse). I would like to see more information in the file to be able to determine the accurate reason for the fall that R2 sustained. The director of nursing at that time is no longer in the facility. On 12-1-2025 at 2:00 pm, V2 (Director of Nursing) said, I was not here in 2024. I expect to complete a detailed investigation, including all statements from the people who worked on the day of the accident. I can see the investigation into R2's fall has not been completely conducted. On 12-1-2025 at 1:40 pm V26 (Medical Doctor) said, my expectation is that the facility will complete a detailed investigation after an unwitnessed fall.V1 also presented a policy titled: Accident and Incident, investigation and reporting dated: 1-18-2025, reads in part: all accidents or incidents shall be investigated and reported. The nurse supervisor and or director of nursing shall promptly initiate and document an investigation of the accident. The following data shall be included: the names of witnesses and their accounts of the accident. The injured person's account of the accident. Any corrective actions taken? A file shall be maintained of all written investigation statements related to reportable accidents involving residents. The administrator and/or designee shall review the accident report and corresponding investigation documentation.

Based on interview and record review, the facility failed to provide supervision during toileting; this failure resulted in R2 falling on 8-26-2024 and required a hospital transfer. Findings include: R2 is an [AGE] year-old male originally admitted on [DATE] with medical diagnoses that include and are not limited to: chronic obstructive pulmonary disease, type 2 diabetes, peripheral vascular disease, and anemia. Per Minimum Data Set (MDS) dated [DATE], reads Brief Interview for Mental Status (BIMS) results of 11/15, indicating moderately cognitively impaired. Section GG: functional abilities and goals dated: 6-27-2024, reads: R2 toileting hygiene: the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement, R2 required substantial/ maximal assistance. Unable to interview R2, out of the facility at the time of the survey.Per R2's electronic medical record, progress notes dated 8-26-2024 at 5:23 pm read in part: R2 was taken to the bathroom, a few minutes later, R2 started yelling in the bathroom. V22 (Registered Nurse) saw R2 on the floor. R2 reported pain in the lower back and verbalized hitting the head on the floor. R2 was transferred to a local Hospital for evaluation and computed tomography scan (CT SCAN). Per local hospital report dated: 8-26-2024 at 6:08 pm reads: Mild acute appearing compression deformity of the endplate of L1 with approximately 20% compression.R2 care plan dated 6-3-2024: R2 is resistant to care dressing changes, toileting assistance or transfers related to a difficult personality. Interventions: if the resident resists with activities of daily living, reassure the resident, leave and return 5-10 minutes later, and try again. On 11-29-2025 at 10:40 am V5 (Licensed Practical Nurse) said, R2 is alert with periods of confusion; most times R2 will be calling 911 instead of using the call light in the room. R2 needs to be supervised when in the toilet.On 11-29-2025 at 10:50 am V6 (Licensed Practical Nurse) said, I am familiar with R2, is a long-term care patient, dependent on staff for all ADL's requires a mechanical transfer with 2 staff members. I will expect for the staff to be with R2 if he is using the toilet, to make sure R2 is ok.On 11-29-2025 at 11:05am -V7 (Certified Nurse Assistant) said, R2 is alert and forgetful, does not use the call light consistently.On 12-1-2025 at 9:15 am, V22 (Registered Nurse) said, the day R2 had a fall. I was the nurse in charge. R2 was alert and forgetful, able to use the call light most times but inconsistently. I was in the hallway when I heard R2 yelling for help. I went to the bathroom and saw R2 was on the floor by the toilet after R2 tried to transfer to the wheelchair. R2 needed the assistance of two staff members to transfer into and out of the toilet and was dependent on staff to provide perineal care after he used the toilet. I did not put R2 in the toilet; I do not know who did. That is not my job. The Certified Nurse Assistant is responsible for transferring R2 into the toilet, I do not know why the staff left R2 alone. I do not have an idea how long R2 was on the toilet by himself. I do not know who saw R2 last prior to the fall. No other staff member was near the bathroom at the time R2 was on the floor. It is unacceptable for R2 to be left alone. I expect the staff to be by the bathroom door, available to help the patient if needed, and provide supervision. I have not worked at the facility since November 2024. I resigned.On 12-1-2025 at 9:45 am V23 (Director of Rehab #1) said, in the rehab documentation dated 8-22-2024, reads that R2 needed assistance from staff getting on and off the toilet, but the hygiene part during toileting, R2 was a Maximum assistant on staff, I think two people assistance. The expectation is for the staff to be in the area when R2 is in the toilet to ensure his safety and supervision, leaving the area is not acceptable.On 12-1-2025 at 1:30 pm, V1 (Administrator) said, R2's care plan indicates to leave R2 if any resistance to care and return 5-10 minutes later and try again. I do not know how long R2 was in the toilet before R2 had the fall. I will expect the staff to respect R2's privacy. I will expect the staff to be available to assist if the patient needs any help.On 12-1-2025 at 2:00 pm, V2 (Director of Nursing) said, the staff needs to assist the residents properly while in the toilet, to ensure the proper supervision and provide privacy, but they need to be near the bathroom, in case the resident needs any assistance. V1 presented policy: Falls prevention and post-fall management, dated 9-6-2025, reads in part: The staff, with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence, and cognition. The staff will seek to identify environmental factors that may contribute to falling.

Based on interview and record review the facility failed to safely reposition a resident during care. This failure resulted in R1 falling from her bed and sustaining a right patella fracture. This applies to 1 of 4 residents (R1) reviewed for safety in the sample of 6.The findings include:R1's face sheet shows she has diagnoses including Cerebrovascular Accident, hemiplegia of the right side, dysarthria and pain in right leg.R1's active care plan initiated on 5/29/23 she has impaired cognitive and decision making, limited physical mobility, is at risk for falls, and requires staff assistance for turning and bed mobility with instruction cues and hand guidance. A nursing progress note completed for R1 on 8/25/25 at 10:00 PM states, @ 9:15 pm someone calling this writer's name. I immediately attended to the room where the name calling coming from and upon entering the room noted resident (R1) on her back lying on the floor with both legs extended with {V6) holding resident's head. Per {V6} she's giving a bed bath and resident rolled off the bed and fell on the floor. A nursing progress note completed on 8/26/25 at 6:40 PM, shows that R1 had continued to complain of pain to her right knee and an X-ray was ordered which confirmed a patellar fracture. A Radiology Results Report dated 8/26/25 confirms that R1 has a mildly displaced fracture of the superior margin of her patella. R1's Physician Order Summary shows an order dated 8/28/25 for R1 to be non-weight bearing and use an immobilizer for her right lower extremity at all times for her Patella fracture. On 9/15/25 at 10:53 AM, R1 said she was getting a bed bath and when the staff person rolled her to her right side she fell from the bed. R1 said she hit her right knee, and it still hurts. R1 said she cannot use her right arm at all and needs help to turn from side to side and that day she felt close to the edge of the bed. R1 said she has a big bed now but her bed before was much smaller. On 9/15/25 at 11:04 AM, V6 (Certified Nursing Assistant/CNA) said when they are changing R1 in bed they have been using 2 people because she cannot use her right side to help turn. V6 said R1's former bed was small and R1 would come close to the edge. On 9/15/25 at 12:45 PM, V14 (CNA) said she was the only person in the room giving {R1} a bed bath and she had a basin of water that R1 wanted to feel the temperature of in the process of that she spilled the basin of water over the bed and the mattress. V14 said she did not have enough towels to get everything dry, so she was going to change her sheets. V14 said when she had R1 turn to her left side everything was fine, and then she had R1 turn to the right side and would be facing her, but everything was wet and slippery and R1 could not hold the side rail and lost her balance and started falling off the bed. V14 said she also lost her balance trying to prevent R1 from rolling off the bed. V14 said she did not physically see R1 hit her knee during the fall, but she must have because she has a fracture from the fall. V14 said R1 cannot use her right side at all and needs staff help to turn and R1 had a much smaller bed before the fall and now her bigger bed it is much better. V14 said she does feel that the mattress being wet slippery contributed to R1 rolling off the bed. V14 said R1 can make her needs known and uses her call light but she can be forgetful.On 9/15/25 at 2:19 PM, V2 (Director of Nursing) said she would expect a CNA to go get a second person to assist in turning a resident if water had spilled on the mattress and it was slippery.The facility provided Fall Prevention and Post Falls Management policy last revised on 9/6/24 shows factors that could contribute to a residents fall include, wet surfaces, cognitive impairment and poor grip strength.

Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift, resulting in the resident sustaining a fractured toe. This applies to 1 of 3 residents (R1) reviewed for mechanical lift transfers in the sample of 3. R1's BIMS-Brief Interview of Mental Status dated 07/16/25 shows, R1 is Cognitively Intact.On 07/16/2025 at 9:51AM, R1 was sitting in her wheelchair. R1 was wearing a surgical shoe on her right foot. R1's right great toe had a grey/black bruise.On 07/16/2025 at 9:51AM, R1 said, I have used a wheelchair for the past 8 years. I used to be able to use a slide board with two persons assist. Currently, I am a full body mechanical sling lift. I have a displaced fracture to my right toe. On Sunday (07/13/2025) after lunch I was being transferred from the wheelchair to the bed with a full body mechanical sling lift. I was sitting back in the sling with my feet dangling in the air. Usually, the staff will guide my feet, this time my foot got caught between the center bars of the lift. As I was being lowered my foot got pinched between the bars forcing my great toe backward. The pain was very bad. I do not remember who was with me or how many staff were in the room. I remember saying, MY TOES! MY TOES! MY TOES! It hurt. It was a 9/10 painful pinching burning feeling. They had to lift my toes out from between the bars of the lift. It bothered me the rest of the day. About an hour later I noticed my toe was still hurting and it had turned purple.On 07/16/2025 at 10:45AM, V1 Administrator said, R1's injury is still being investigated. We do not know who was in the room performing the transfer. The facility's Staffing Schedule dated 07/13/2025 shows, V4 RN-Registered Nurse, V6 CNA-Certified Nursing Assistant, V7 LPN-Licensed Practical Nurse, V8 CNA, V5 CNA, worked in the facility on R1's unit 07/13/2025 on the day shift.On 07/16/2025 at 10:55AM, V4 RN-Registered Nurse said, I was the day shift nurse for R1 on 07/13/2025. Today is the first I have heard about R1's foot injury. Two people are needed for a mechanical lift transfer.On 07/16/2025 at 11:02AM, V6 CNA-Certified Nursing Assistant said, I did not take care of R1 on 07/13/2025. R1 is a full body mechanical sling lift transfer. R1 cannot transfer herself.On 07/16/2025 at 11:25AM, V7 LPN-Licensed Practical Nurse said, I have not provided any care to R1. I'm not even sure who she is.On 07/16/2025 at 11:33AM, V8 CNA-Certified Nursing Assistant said, I work in the opposite hallway. I was not called to assist R1 on Sunday (07/13/2025).On 07/16/2025 at 12:16PM, V5 CNA said, I was R1's CNA on Sunday (07/13/2025). Towards the end of my shift 5:30PM to 6:30PM, R1 started complaining of toe pain. R1 said, it happened when she was transferred back into bed when I was on break. I think V6 CNA transferred her. I do not know anything past that. I do not know who assisted V6 CNA with R1's transfer. I was working the middle hall, when I went on break V6 CNA took over my assignment. When I came back from break R1 was in bed. R1 is a full body mechanical sling lift. R1 cannot transfer herself. On 07/16/2025 at 12:40PM, V2 DON-Director of Nursing said, we obtained an order for a Xray at 9:30PM, 07/13/2025. The resident claimed she bumped into the mechanical sling lift when being transfer. I was not there; I do not know. Staff report there was no complaint of pain during the transfers.On 07/16/2025 at 12:44PM, V1 Administrator said, we are still looking for the source of the injury. R1 is stating her toe was bumped on the mechanical sling lift.R1's Progress Notes dated 7/13/2025 at 7:21AM, shows, General Nursing Note, Note Text: Patient reports 4/10 pain to her right foot. When this writer assessed her right foot, there was bruising and swelling on the right foot. She claims that when she was being transferred from the mechanical sling lift to her bed around 1:30 pm by AM CNA, her right foot was pushed into the bar. She told the CNA, so he pushed her foot and toe so she can get down.R1's Radiology Results dated 07/14/2025 at 10:17AM, shows, Reason for study: Pain in Right Foot. Right Foot 2 view Findings: 1st proximal phalanx fracture with mild displacement. Soft tissues appear swollen. Conclusion: Acute appearing 1st proximal phalanx fracture.R1's MDS-Minimum Data Set, dated [DATE] shows, R1 is dependent on two staff members for transfers. Mobility: Transfers dependent on 2 or more staff with no effort from the resident during transfer.

Based on interview and record review the facility failed to ensure a resident was safely transferred using a mechanical sit to stand lift for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 being assisted to the ground and sustaining a proximal tibia and fibula fracture of her right leg. The findings include: R1's Nursing Notes dated 6/28/25 shows that at 1:00 PM, the Certified Nursing Assistant said that R1 passed out while providing care to R1 after having an extra large bowel movement while using a sit to stand lift and R1 was assisted to the floor with two person assist. R1's Right Tibia/Fibula X-ray dated 6/28/25 shows, There is a fracture involving proximal tibia and fibula (bones of the upper shin) with minimal displacement. On 7/2/25 at 10:12 AM, V3, Certified Nursing Assistant (CNA) said that on 6/28/25 after lunch, she was assisting R1 to use the toilet. V3 said that she placed R1 on the toilet from her wheelchair using the mechanical sit to stand lift. V3 said that once R1 was done using the bathroom, she lifted her up from the toilet with the lift and moved her to the side so she could clean her up. V3 said R1 then had another bowel movement all over herself and the floor. V3 said that as she was cleaning her up, R1 slumped over and her hands went down from holding onto the lift and would not respond to her. V3 said that she immediately started calling for V4 (CNA) and the nurse. V3 said that R1 was brought out of the bathroom and into her room area. V3 said that she tried to lower her to her wheelchair but the lift was not lowering and the emergency release button was not working as well. V3 said that V5, Registered Nurse (RN) and V6 Licensed Practical Nurse (LPN) Supervisor showed up and said to put her on the ground. V3 said that her and V4 both grabbed under R1's arms and lowered her to the ground while the nurse used the control to lower the machine. V3 stated, I guess the nurse was able to get the machine to work to be able to lower her as we were lowering her. On 7/2/25 at 10:34 AM, V4 (CNA) said that she was by the shower room waiting for her resident to get done going to the bathroom when V3 came to the door of R1's room and said to call the nurse. V4 said that she immediately went into R1's room and R1 was hooked up to the sit to stand lift and was located outside of the bathroom door. V4 said that R1 was unresponsive and her right leg was off of the platform of the lift and her foot was turned inward. V4 said that the leg strap was not around R1's legs. V4 said that they were not able to sit her into her wheelchair because her leg was in the way and they did not want to twist it anymore. V4 said that V3 told her that they were going to have to put her onto the floor. V4 said that she was worried about putting her onto the floor because of the way her leg was positioned. V4 stated, I was worried that putting her on the floor would break her leg based on how it was already positioned. V4 said that they proceed to slowly lower her to the floor by holding under her arms. On 7/2/25 at 10:51 AM, V5 (RN) said that she heard V4 yelling for help. V5 said that she went into R1's room and saw R1 hanging from the sit to stand lift and unresponsive. V5 said that she did not pay attention to the positioning of R1, she was more worried about her being unresponsive. V5 said that she immediately called V6 (LPN Supervisor) to help. V5 said that she then exited the room and went and got R1's code status and oxygen. V5 said that when she returned, R1 was on the floor. V5 said that she did an assessment and found R1 to have a bruise with an abrasion on her right shin area. On 7/2/25 at 11:08 AM, V6 said that V5 called her while she was on the elevator. V6 said that she immediately went to R1's room and saw R1 still harnessed into the sit to stand lift. V6 said that R1 was unresponsive, her left arm was hanging down and her right arm was elevated above her head due to the harness slipping up and pushing her arm up. V6 said that she tried to put the wheelchair under her but she had slipped down too far so was unable to get the wheelchair under her. V6 said that they then lowered her to the ground. V6 said that during the transfer, her right leg was bent and turned but they were unable to straighten it so when she was lowered to the ground, her right lower leg was bent and under her. On 7/2/25 at 11:40 AM, V3 said that when R1 was taken out of the bathroom, her right leg came off of the platform. V3 said that the leg strap was on but it was loose. V3 said that she removed the strap to try and get R1's right leg back onto the platform but she was unable to. On 7/2/25 at 11:49 AM, V4 said that when they got R1's bottom to the floor, her left leg was straight out and her right lower leg was under her and to the side. V4 said that V3 moved her leg to a straight position and then they laid her flat on the floor. On 7/2/25 at 1:27 PM, V9 (R1's Physician) said that she saw R1 immediately after the fall. V9 said that R1 had some bruising and swelling of her lower leg right below her knee which is where the fracture was found. V9 said that R1's leg must have twisted during the fall. V9 said that the fracture is directly related to the fall. On 7/2/25 at 1:45 PM, V8 (Restorative Aide) said that residents should be secured appropriately in the sit to stand lift before performing any transfers. V8 said that a harness is applied to the torso and secured with a strap. The strap should be snug. V8 said that the feet should be placed flat on the platform and their knees should be up against the knee pad. V8 said that once the resident's legs are in proper position, the leg strap should be applied snuggly. V8 said that the resident should be lifted a little bit and the torso harness strap should be tightened more. V8 said that resident's should only be moved short distances with the sit to stand lift. V8 said that if a resident becomes unresponsive during a transfer, the staff should immediately lower the resident back to a seated position on whatever surface is closest to the resident. V8 said that if a resident is secured correctly on the sit to stand lift, the torso should not be able to slip from the harness and the feet would not be able to fall off of the platform. V8 said that it could be very dangerous if a resident was transferred with a sit to stand lift and not secured appropriately. On 7/2/25 at 2:22 PM, V2 (Director of Nursing) said that when using a sit to stand lift, the resident should have the harness strap secured tightly around their waist and should have the leg strap secured tightly around their lower legs. V2 said that if the leg strap is on securely, a resident's foot would not be able to come off of the platform. The facility's Mechanical Lift Policy dated 5/23/24 shows, The purpose of this policy is to establish the general principles and procedure of safe lifting using mechanical lifting devices Position the top of the harness around the upper body of the resident (approximately 4-5 inches below the underarm). Securely fasten the harness safety strap around the resident's chest . Position the unit in front of the resident and have the resident place their feet on the foot plate and position their shins into the shin pad Secure the shin straps around the resident legs .

Based on observation, interview, and record review the facility failed to safely transport a resident in their wheelchair. This applies to 1 of 5 residents (R1) reviewed for safety in a sample of 5. The findings include: R1's Facility assessment dated [DATE] showed R1 is an eighty-year-old female with severe cognitive impairment. R1 admitted to the facility on [DATE] with diagnoses which include severe dementia with agitation. The facility's Final Incident Report dated 5/12/25 showed on 5/6/25 at 6:15 PM R1 had fallen forward from her wheelchair which resulted in R1 receiving 3 sutures above her right eye. On 5/14/25 at 10:30 AM, R1 was sitting with V5, (R1's Power of Attorney-POA), at the end of the hallway. R1 was in her wheelchair with her legs behind the leg rests with her feet flat on the ground. R1 had 3 sutures along her outer right eyebrow closing a laceration approximately a half to one inch long. R1 had a bruise approximately 3-4 inches around the laceration, in various stages of healing. On 5/14/25 at 10:35 AM, V5 stated R1 will put her feet on the ground when R1 is at the table. (R1) sometimes will put her feet down when you are trying to push her in her wheelchair. (R1) did it this morning when we were coming down the hall to sit here (end of the hallway). On 5/14/25 at 10:45 AM, V8 Licensed Practical Nurse (LPN) stated they were the nurse taking care of R1 when she fell . R1 was in her wheelchair waiting to be brought to the shower. V11 Certified Nursing Assistant (CNA) went to push R1 in her wheelchair toward the shower room. R1 put her feet down to the floor when the chair was moving forward, and R1 fell out of the wheelchair. R1 will sometimes put her feet on the floor when you propel R1 in the wheelchair. R1 did it earlier this morning when V5 was taking R1 down the hall, and when R1 was being moved to the dining room for lunch. V8 stated We had to put R1's legs back on the footrests. V8 stated R1 does self-propel with her feet on the unit. R1 has had the behavior of putting her feet down on the floor when being pushed in the wheelchair as long as R1 has been on the unit. On 5/14/25 at 11:30 AM, V9 CNA stated they were working on 5/6/25. V9 said they heard V11 yell out for help. When they looked R1 was on the floor. V9 stated in the past when they have pushed R1 in the wheelchair R1 has put her feet on the floor. V9 stated R1 has done that for a long time. On 5/14/25 at 2:15 PM, V11 CNA stated they usually work night shift. V11 has taken care of R1 before, but on night shift R1 is usually in bed. V11 stated they went to push R1 toward the shower room, R1 planted her feet on the floor, and R1 fell forward out of the wheelchair. R1 was bleeding from a cut on her face. V11 stated they were not made aware R1 would put her feet down to the floor when being pushed in the wheelchair. R1's Fall assessment dated [DATE] showed R1 is at a moderate risk for falling. R1's current Care Plan printed 5/14/25 showed no focus, goals, or interventions related to R1's behaviors of noncompliance with wheelchair leg rests until 5/7/25. The facility's Fall Prevention Policy dated 1/27/25 showed The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and other members of multidisciplinary team, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information.

Based on observation, interview, and record review the facility failed to provide adequate pain control for a resident with a history of cancer and compression fracture. This failure resulted in R1 experiencing increased pain from 4/21/2025 to 4/24/2025. This applies to 1 of 3 (R1) residents reviewed for pain in the sample of 3. The findings include: R1's current Admission Record shows R1 is an [AGE] year-old female resident with a history of lung cancer and compression fracture who was admitted on [DATE]. On 4/30/2025 at 10:00AM, R1 was observed lying in bed resting comfortably and showing a slight grimace with movement. On 4/30/2025 at 10:00AM & 10:18AM, R1 said her pain was 4 out of 10 and a 4 was acceptable. R1 said her pain is more controlled now. R1 said she doesn't like using the numbers to describe the pain. R1 said she had increased pain when she came into the facility because the facility had trouble getting her medication. On 4/30/2025 at 11:04PM, V5 Nurse Practitioner (NP) said she saw [R1] on 4/24/024 for the first time and she had reported increased pain in the previous days but stated her pain was better controlled now after she got a dose of medication this morning. On 4/30/2025 at 1:30PM, V3 Licensed Practical Nurse (LPN) said [R1] was admitted on [DATE] and [R1] complained of 10/10 pain in the evening at 10:30PM. V3 said she gave [R1] Tylenol for her pain because she didn't have the morphine order from pharmacy yet. V3 said she would normally give a narcotic for that type of pain. V3 said she did get the morphine tablets that night and gave [R1] her morphine pills at 2:00AM on 4/22/2025. V3 said she never received the PRN (as needed) morphine from pharmacy that night. V3 said she couldn't get into the controlled substance box because her morphine order wasn't the right concentration and needed to be clarified. V3 said she did not contact the doctor to get a different as needed medication. V3 said [R1's] pain was an 8/10 when she gave her the morphine tablet and the resident was resting comfortably in bed with her eyes closed. On 4/30/2025 at 12:54PM, V4 Physician said Tylenol is not adequate for a patient complaining of 10/10 pain because Tylenol is a very mild analgesic. The facility provided Electronic Shipping Manifest shows the Morphine Sulfate 100mg/5mL was delivered on 4/24/2025 at 12:51AM and the Morphine Sulfate ER 15mg tablet was delivered on 4/22/2025 at 1:28AM. On 4/30/2025 at 9:52AM & 10:10AM, V6 LPN said he normally works the unit [R1] is on and has seen her since she came. V6 said [R1's] pain is more controlled now compared to where she was when she first came. V6 said [R1] is still working with therapy and pain medication is given prior to receiving therapy services. R1's Progress Notes dated 4/22/2025 at 11:22AM states the resident declined to get out of bed, complaining of back pain. R1's Weights and Vitals Summary dated 4/30/2025 shows the following pain scores 4/21/2025 10:32PM score of 10, 4/22/2025 [2:00AM verified by V3] score of 8 and 6:37AM score of 2. R1's Medication Administration Record dated 4/1/2025 to 4/30/2025 showed R1 received Morphine Sulfate Oral Tablet 15mg was scheduled on 4/21/2025 at 9:00PM but didn't receive the medication until 4/22/2025 at 2:00AM.

Based on interview and record review, the facility failed to ensure misappropriation of resident funds did not occur for 1 of 3 residents (R1) reviewed for misappropriation of resident funds in the sample of 9. The findings include: R1's Admission Record, provided by the facility on 2/21/25, showed she was admitted to the facility on [DATE] for aftercare following joint replacement surgery. R1's Progress Note dated 2/17/25 showed R1 was discharged home with a caregiver. R1's progress note dated 2/7/25 showed R1 had a follow up appointment with her orthopedic PA (Physician's Assistant) on 2/10/25. The note showed transportation was set up through Wheels on Wheels to take R1 to her appointment on 2/10/25. R1's 2/10/25 Progress note showed R1 went to her orthopedic appointment on 2/10/25. R1's facility assessment dated [DATE], showed she was cognitively intact and required substantial/maximal assistance from staff for dressing, toileting, and transfers. R1's care plan initiated on 1/30/25 showed she had limited physical mobility related to weakness after right hip surgery and required one staff assist with transfers. R1's care plan initiated on 2/2/25 showed she was on contact isolation related to shingles, and all services were to be provided in her room. R1's inventory list dated 1/29/25 was reviewed. No credit card was listed on the inventory list. On 2/21/25 at 10:40 AM, V1 (Administrator) said It was an odd scenario. V1 said V7 (R1's niece) claims she dropped the credit card off in a white hallmark envelope at the nurse's desk. V1 said V7 was not able to identify what the person looked like, only that it was a nurse in colorful clothing and was wearing two face masks. At 11:18 AM, V1 said she spoke with staff, and no one was aware of R1's credit card. V1 said the facility would have reimbursed R1, however, R1 said no, the credit card company was reimbursing her. On 2/21/25 at 11:23 AM, V7 (R1's niece) said she took R1 her credit card on 2/8/25. V7 said she put a piece of paper around the credit card and sealed it in a large white envelope like you would put a birthday card in. V7 said R1 was on isolation for shingles and she (V7) had a virus. V7 said she did not want R1 to get sick, so she left the envelope with R1's name and room number on it with a nurse at the second-floor rehab unit's nurse's desk. V7 said the nurse had on burgundy-colored scrubs, and two face masks. V7 said the nurse had on glasses, had her hair pulled back, and she believed the nurse was Filipino. V7 said the nurse was medium height and build, sitting at the nurse's station at a computer. V7 said the nurse took the envelope from her (V7) and set it next to her. V7 said the nurse said she would give the envelope to R1. V7 said she spoke to R1 before dropping it off and let her know that she was going to drop it off. V7 said R1 did not say anything about not getting the envelope until later. V7 said there were charges on R1's credit card that neither R1, nor her family made. V7 said after she dropped of the credit card, she left the facility. V7 said the reason she dropped the card off at the nursing home was because R1 had an appointment on 2/10/25 that she needed the credit card for to pay for the transportation to and from the appointment. On 2/21/25 at 12:29 PM, R1 said when she filled out the inventory sheet, she did not put down that she had a credit card with her because she did not bring it to the facility with her. R1 said she was on isolation due to having shingles. She had an appointment coming up that she needed the credit card for to pay for the transportation. R1 said she phoned her niece (V7) and asked her to drop off the credit card she had with the same account number, to pay for the transportation. R1 said V7 put the card in an envelope and dropped it off at the nurse's desk. R1 said she paid for her transportation on 2/10/25 by having V7 give her the credit card number over the phone, and she wrote it down. R1 said when she called to cancel the card, there were charges on the card that neither she, nor her family made. R1 said she believed the charges were at local stores and restaurants. At 5:19 PM, R1 called back and said she spoke with someone at the fraud department for her credit card company and identified the charges to her card that were not made by herself, or her family were the following: On 2/10/25 at a Dollar Tree Store for $27.50 On 2/10/25 at a Michael's store for $36.28 On 2/10/25 at a Target store for $149.12 On 2/10/25 at Chick-fil-A for $22.15 On 2/10/25 at Ross Dress for Less for $60.47 On 2/11/25 at Five Below store for $16.01, and On 2/11/25 at Chick-fil-A for $35.34 R1 said she cancelled her card on 2/11/25 or 2/12/25. She could not recall which date. R1 said she does not do online banking and has not received her monthly statement in the mail yet. R1 was asked what town(s) the fraudulent credit card charges were made in. R1 said she got the information regarding the fraudulent charges from the fraud department at her credit card company. They did not say what town(s) the card was used in. R1 said when her monthly statement comes in, she could provide additional information if needed. On 2/21/25, at 11:59 AM, V4 (Registered Nurse-RN) said she did not see R1's family come in on 2/8/25. V4 said she does not know R1's family. V4 said she is not aware of any envelope containing a credit card for R1. On 2/21/25 at 12:09 PM, V5 (Certified Nursing Assistant-CNA) said she does not remember any family member visiting R1 on 2/8/25. V5 said she did not recall seeing any envelope with R1's name and room number on it. At 1:40 PM, V8 (RN) said she is a floating nurse and was not aware of any credit card for R1 that was missing. At 1:47 PM, V9 (Licensed Practical Nurse-LPN) said she did not see anyone bring in an envelope for R1 while she was working. At 2:08 PM, V10 (CNA) said she did not recall seeing any of R1's family members come in on 2/8/25 or see any envelope with R1's name on it. On 2/21/25 at 11:51 AM, V1 (Administrator) said the facility's electronic log in system showed V7 punched into the system at 10:39 AM on 2/8/25 and left at 10:42 AM. The facility provided a copy of the electronic sign in document showing V7 electronically signed in on 2/8/25 at 10:39 AM and signed out at 10:42 AM. The facility's incident investigation was reviewed. The investigation showed on 2/14/25, V13 (another of R1's nieces) reported that R1's credit card was missing. the report showed V1 and V6 (Social Services) went to speak with R1 and V13. V1 and V6 were informed that V7 had a cold and did not want to get R1 sick, so she left the envelope with R1's name and room number on it with a nurse in bright colored clothing and a double-mask on. The note showed she was not able to identify anyone outside of that. The 2/14/25 interview with R1 and V13 showed that it was discussed with R1 and V13 that there are many visitors, vendors, etc. that come in and out of the facility and maybe it was dropped or thrown out for someone to find and use. The facility's policy and procedure titled Abuse and Neglect of a Resident, with a revision date of 6/16/2023, showed The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation . The policy defines misappropriation of Property as the deliberate misplacement, exploitation, or wrongful, temporary use of a resident's belongings or money without the resident's consent.

Based on interview and record review, the facility failed to notify the police when a resident's credit card was missing and could not be located for 1 of 3 residents (R1) reviewed for misappropriation of residents' funds in the sample of 9. The findings include: On 2/21/25 at 10:40 AM, V1 (Administrator) said R1 and her niece (V13) reported to the facility on [DATE] that V7 (another one of R1's niece's) claimed she dropped off a credit card for R1 on 2/8/24 at 10:45 AM. V1 said it was reported that the credit card was dropped off at the nurse's desk in a white hallmark envelope. V1 said she was going to call the police to report it, however, R1 did not want her to. V1 said V13 asked her to please hold off for now because all of the charges that were made on the card would be covered by the credit card company. V1 said she did not report R1's missing credit card to the local police. On 2/21/25 at 12:29 PM, R1 said she did say she did not want the police notified at that time because she wanted to give the facility time to investigate it. R1 said she also did not want police officers walking down the halls of the facility because she was worried it might scare other residents. At 5:19 PM, R1 returned a previous call from this surveyor. R1 said she spoke to the credit card companies' fraud department, and they identified seven charges that were made to R1's credit card that neither she (R1) or her family made. R1 said the combined total of the charges that went through were $346.87. R1 said there was a charge from Amazon that did not go through; it was refused payment because she had reported the credit card missing by then. The facility provided a printout of the electronic sign in system. The document showed V7 signed into the system on 2/8/25 at 10:39 AM and left the facility at 10:42 AM. The facility's policy titled Abuse and Neglect of a Resident, with a revision date of 6/16/2023, showed 7. Internal Reporting .Examples of situations that would likely be considered crimes would include but are not limited to .Theft/Robbery. The policy showed 9. External Reporting of Abuse Allegations .The facility will notify local police and (the) Department of Public Health within two hours after first suspecting that a crime has occurred if the suspected crime involves serious bodily injury to the individual, or within 24 hours if there is no serious bodily injury involved. Examples of crimes may include, but are not limited to: murder, assault and battery, theft, drug diversion/theft, fraud and forgery.

Based on observation, interview, and record review the facility failed to communicate and effectively treat a resident's pain; and failed to verify and obtain a resident's ordered pain medication in a timely manner for 1 of 1 resident (R425) reviewed for pain in the sample of 35. These failures resulted in R425 experiencing continued pain and emotional anguish. The findings include: On 11/19/24 at 11:46 AM, R425 was lying in bed, on his left side. R425 had a catheter drainage bag on each side of the bed frame. R425 said he's been sick since March and was in the hospital. R425 said the hospital found out that he had urine draining into his right upper leg area (fistula - an abnormal opening in the urinary tract). R425 said that caused him to develop an abscess in his right upper leg. R425 said they had to drain out the fluid from his leg and now he has a catheter in his penis to protect the fistula and a suprapubic catheter (directly through the abdominal wall, into the bladder) to empty most of his urine. R425 said his pain seemed to be getting worse. R425 said in the hospital he was getting 2 Norcos (opiate pain medication), but when he was transferred to the facility it was changed to 1 Norco. R425 started crying and plead, I'm just so miserable and I can't get anyone to listen to me. R425 shook his head then became irritable. R425 stated, I just don't feel like anyone communicates with each other. I'm tired of being in pain. I tell them and no one listens. This position (left side lying) is the only position that is even the slightest bit comfortable for me. Any movement of my right leg is excruciating. I can't do therapy because my right leg hurts so bad when it's moved. I'm so f****** frustrated! I'm sorry I'm cussing, but that's how I feel. (R425 began crying again). Most days I just lay here, grip the side rail and cry. This pain is awful, and no one is doing anything about it. V20 (R425's spouse) was seated in a chair at the bedside. V20 said the facility wasn't managing his pain, but they had a tele-visit with R425's pain doctor at 1:30 PM today. V20 reminded R425 of the appointment and attempted to reassure him. On 11/20/24 at 12:47 PM, R425 was sitting up in the wheelchair in his room. R425 and V20 (R425's spouse) were discussing nutritional supplements with V15 (RN - Registered Nurse). After V15 left the room, the surveyor asked R425 how he was feeling today. R425 reported, I'm miserable! (and began crying). R425 became agitated and said they had the tele-visit with V22 (Pain Nurse Practitioner) at 1:30 PM yesterday. R425 said about an hour later V22 called V20 (R425's spouse) to provide an order for Fentanyl patch 12 mcg. R425 said he was supposed to continue the Norco scheduled every 4 hours and start the Fentanyl patch. R425 said V22 (Pain NP) would follow-up with them in a few days to see if his pain was improving. R425 yelled, I still don't have the damn patch! I guess they don't have the order or something like that! How can that be, it's almost been 24 hours! See what I mean. The communication sucks! R425 was becoming agitated and crying. V20 (R425's spouse) rubbed his shoulders and tried to calm him. V20 said when V22 (Pain NP) called with the order for Fentanyl, she couldn't find the nurse. V20 said she went to the desk; the nurse wasn't there. V20 said the receptionist was there and said she would make sure the order was put in right away. V20 said she's not sure what the receptionist's credentials were, but she trusted that the information would be communicated. V20 said the receptionist provided the facility's pharmacy information to her. V20 said she provided the pharmacy information to V22 (Pain NP), and she said that she would send the Fentanyl patch prescription directly to the pharmacy. V20 said the nurse did not come in the room to discuss it with her later. V20 stated, I expected the pain patch to be delivered by this morning (at the latest), but it's still not here. They don't even have an order for it here. R425 stated, I'm so disgusted, miserable, and frustrated! They need to communicate and control my pain. R425 started crying and placed his face into his hands. At 12:55 PM, V16 (NP) entered the room. V16 asked R425 how are you? R425 replied, Don't even ask! R425 reported his frustrations to V16. V16 stated, This is my first time seeing you. I'll have to take a look at your notes. There is no Fentanyl order in the computer at this time. The surveyor walked to the nurses' station where V15 (RN) was on the phone with pharmacy. V15 said there was a prescription for a Fentanyl patch sent yesterday and the family is asking me about it. V15 said he reviewed the chart and R425 did not have an order for Fentanyl and there were no progress notes. V15 said the pharmacy said they received a prescription from V22 (Pain NP), but the prescription was for 30 patches, and they will not accept it. V15 stated, I don't know why the pharmacy didn't call [V22 - Pain NP] to verify the order. They are the ones that gave the phone number for [V22]. V16 (NP) walked up to V15 sand stated, I'll give you a one-time order (for Fentanyl patch) now, so the resident can get it right away. He's in pain. Then we can make follow-up appointments to get an order (for ongoing treatment). Don't even bother to call this office [V22]. I'll give the Fentanyl order and [V23 - Pain MD] will follow-up. V16 asked V15 to call the nursing supervisor and see if they can get the Fentanyl patch from the emergency box, so he (R425) doesn't have to wait any longer. V15 said R425's Fentanyl patch prescription was sent directly to the pharmacy, but they didn't call the doctor's office to get the quantity changed. V15 stated, They should have done that. They gave me the number. Why didn't they call? I'm putting the orders in now. Hopefully they can get the Fentanyl patch from the emergency box. This is the first time I've experienced Pharmacy not liking a quantity. They (Pharmacy) didn't call us to check. The previous nurse would have told me that. The pharmacy should have sent at least 1 Fentanyl patch to get the resident's pain controlled, then got the clarification. It's important to control the resident's pain. That's why I was surprised someone came to me and said he was asking for his pain medication. I didn't know anything about the Fentanyl. I checked the orders and progress notes and there wasn't anything. It's true that there was a communication break down and I'm sorry this happened to them. V15 said R425 has prostate cancer and had pain to his lower back and right hip area. V15 said R425 had therapy in the gym and that may have triggered more pain again. V15 said V23 (Pain MD) is at the facility 1-2 times per week and will see R425 tomorrow. On 11/20/24 at 1:23 PM, V17 (RN - Registered Nurse/Unit Manager) said she is not sure what happened with R425's Fentanyl. V17 said she called V18 (LPN - Licensed Practical Nurse) because she was R425's nurse yesterday (11/19/24). V17 said V18 didn't know anything about a Fentanyl order sent to the pharmacy. V17 states if an outside physician order's medication, then the facility needs to get approval from an in-house provider and enter an order. V17 said R425 did not have a Fentanyl order entered into the EMR (electronic medical record) yesterday. V17 said the emergency box does not contain Fentanyl patches. V17 said pharmacy was called and a STAT order was placed. V17 said the pain patch should be here in 2-4 hours. On 11/20/24 at 1:34 PM, V19 (Guest Services Associate) said she works at the reception desk on R425's floor. V19 said she works 8 AM to 4 PM. V19 said she answers the phones, assists with scheduling appointments, and orders equipment and supplies for the unit. V19 said she was working 11/19/24 and spoke with V20 (R425's spouse). V19 said the nurse was busy and V20 was asking what pharmacy we used and what their phone number was. V19 said she gave V20 the information because the nurses were busy. V19 said she didn't ask V20 why she needed the pharmacy number. On 11/21/24 at 9:08 AM, V18 (LPN) said she worked 11/19/24 and took care of R425. V18 said she was not aware that R425 had a tele-visit with a pain NP. V18 said V19 (Guest Services Associate) did tell me that V20 (R425's spouse) was asking for the pharmacy we use and for the number. The surveyor asked why V20 would be asking about the pharmacy information. V18 replied, I'm not sure why she would be asking for the pharmacy information. That's a good question. V18 said she didn't follow-up with R425 or V20 regarding their request for the pharmacy information. V18 said she worked until 7 PM on 11/19/24. V18 said they didn't mention they were waiting for a pain patch. V18 said if she knew, then she would have checked to see if there was an order in the EMR. V18 said if there wasn't an order, then she would call the facility provider to obtain an order, enter it into the EMR, and notify pharmacy. V18 said there should have been follow-up to V20's request for the pharmacy information. V18 said she didn't speak to the pharmacy about R425's Fentanyl patch because she didn't know anything about it. On 11/21/24 at 9:26 AM, V21 (Pharmacist) said an electronic order for Fentanyl patch 12 mcg was sent on 11/19/24 at 7:43 PM by V22 (Pain NP). V21 said it looks like there was a discrepancy on the quantity. I see documentation that the pharmacy attempted to contact the facility at 9:11 PM and was not get in contact with facility staff. There was a note in the system that the Fentanyl patch was pending clarification. V21 said there is no further documentation, and he is unsure if the pharmacist made contact with someone at the facility. V21 said on 11/20/24 at 1:13 PM, V16 (NP) entered an order for 1 Fentanyl patch for R425. V21 said the delivery left the pharmacy at 2 PM and arrived at the facility a few hours later. V21 said the pharmacy director will follow-up with more details on 11/22/24. On 11/21/24 at 9:59 AM, V24 and V25 (Restorative Aides) were donning gowns and gloves to provide R425 incontinence care and get him up to the wheelchair. R425 looked up and started crying and motioned for the surveyor to come talk. R425 stated, This is a f****** mess! The system is broken down. I tell every f****** person that comes in that I'm in pain. I lay here in unbearable pain. One time I laid here crying for what seemed like 5 hours, but only 1 f****** hour had passed. I don't feel like I'm moving forward with pain control. I had that tele-visit on Tuesday at 1:30 PM (11/19/24) with [V22 (Pain NP)]. [V22] called back within an hour to give an order. It took damn near 24 hours to get the pain patch (Fentanyl patch). When I finally got the patch, they started messing with my Norco. I don't like taking narcotics. It scares the s*** out of me, but I need them! I don't like it, but I NEED them. (R425 was lying on his back in bed, speaking loudly, cursing frequently, and his eyes welled up with tears.) I've never not been in pain. I can't even say if this pain patch is working because they quit giving my Norco last night. [V22 - Pain NP] knew I was on Norco every 4 hours and said it wasn't effective and added the Fentanyl patch. They were NOT supposed to stop my Norco! I got a couple doses of my scheduled Norco with the Fentanyl patch, but then the nurse last night said she I couldn't have them both together. I told her I was in pain and needed them. (R425 began crying). Why do they keep messing with stuff. I can hardly take this and their poor communication. See what I mean? They don't communicate! It's beyond frustrating and I'm still in pain. V24 and V25 came in the room to assist R425. They provided incontinence care and dressed R425, rolling him side to side. Each time R425 was rolled onto his right side, or his right leg was touched, he groaned in pain and grimaced. R425 told V24 and V25 that it hurt whenever his right leg was moved. They assisted R425 to roll up on his right side to sit up on the edge of bed. R425's right side was on the bed, and he started crying, It hurts, lying on this side hurts. I'm lying on my sore spot. V24 and V25 assisted off his right side and to a sitting position on the edge of the bed. On 11/21/24 at 11:17 AM, V20 (R425's Spouse) said the facility's pain doctor (V23) just left R425's room. V20 said they are going to allow him to take his scheduled Norco every 4 hours and the Fentanyl patch to see if it works. If that doesn't work, then they will come up with a different plan. V20 said R425 seemed to be in better spirits after the visit and he feels like they are finally starting to listen to him. V20 said R425 had been in so much pain every day, so they decided to call his pain doctor because he needed some relief. V20 said she told the receptionist (V19) why she needed the pharmacy number because the nurse wasn't around. V20 said she doesn't know what happened after that because she went back to R425's room. V20 stated, All I know is when I came back yesterday (11/20/24) he still didn't have his pain patch and he was very upset about it. It didn't come until around 4 PM. R425's Facesheet dated 11/20/24 showed he had diagnoses to include, but not limited to: urinary tract infection; sepsis; cutaneous abscess of right lower limb; diabetes; prostate cancer; obstructive and reflux uropathy; other injury of the ureter; chronic kidney disease; and benign prostatic hyperplasia with lower urinary tract symptoms. R425's Brief Interview for Mental Status (BIMS) Evaluation dated 11/17/24 showed he was cognitively intact. R425's Physician Order Sheet dated 11/20/24 showed Norco 5-325 mg - Give 1 tablet by mouth every 4 hours for pain was started on 11/15/24. On 11/20/24 an order for Fentanyl 12 mcg transdermally every 72 hours for pain was entered. (The facility did not have an order in the EMR prior to 11/20/24. V20 (R425's spouse) requested the facility's pharmacy information at approximately 2:30 PM. The nurse did not follow-up with V20 and R425 regarding their request for the pharmacy information). R425's November 2024 MAR (Medication Administration Record) showed he received the Fentanyl patch at 4:09 PM on 11/20/24. This document showed that R425's Norco tablet scheduled for midnight on 11/21/24 was held. The code 5 was documented. This form showed 5 means hold, see progress notes. R425's Progress Notes did not contain an entry explaining why this dose was held. R425's NP Progress Note dated 11/20/24 showed the patient is upset he has not received his Fentanyl patch. The wife relayed it was ordered by his pain MD. Spoke to RN and gave order for Fentanyl patch and V23 (Pain MD) to follow-up with patient for pain control. The patient is complaining of right thigh pain. R425's Nursing Note dated 11/20/24 at 12:50 PM showed, Resident and family asking about the order for Fentanyl patch as from pain MD office. As nurse writer verified today (11/20/24). Pharmacy received order/prescription directly from Pain MD office on 11/19/24 for Fentanyl 12 mcg every 72 hours; but it was not delivered due to questions regarding the prescription. [The pharmacy] did not call [the unit] for verification of order. Upon knowledge, nurse immediately contacted primary attending NP to inform resident circumstance of investigation and approved orders for Fentanyl by outside MD, with current med order on Norco given at 12 PM for pain 8/10 (rated at 8 on 1-10 scale, 10 being worst pain ever experienced) . 4 PM Resident comfortable in bed, left side lying; received from pharmacy and applied Fentanyl patch 12 mcg on right upper chest . 6 PM Resident comfortable in bed, with some relief of pain observed. On 11/21/24 at 11:29 AM, V3 (ADON - Assistant Director of Nursing) said if the pharmacy has questions regarding a medication order, then they usually call the floor nurse of the 24/7 supervisor. V3 said the staff receiving the call should address the clarifications as soon as possible. V3 said the pharmacy makes three scheduled deliveries per day and can make STAT deliveries in between. V3 said STAT deliveries usually arrive to the facility in 2 hours. V3 said if a resident is complaining of pain, then the staff should believe it. The nurse should perform a pain assessment and determine the level of pain. If the resident is already receiving pain medications, then the nurse will need to notify the physician of continued pain. V3 said the resident may need additional pain medications or a different approach to pain control. V3 said as soon a resident is complaining of pain, then the nurse should start working on obtaining orders for pain control. V3 said the R425, and his family shouldn't have felt they needed to call an outside pain clinic. V3 said V23 (Pain MD) rounds at the facility 1-2 times per week and is available for consults when residents complain of pain. V3 said she expects her staff to communicate a resident's complaints of pain to each other and continuity of care should be maintained. V3 said if R425's wife was asking for pharmacy information, then the staff should have followed-up with her. I don't know why the nurse didn't follow up. There isn't a progress note that showed the nurse was aware of the request for pharmacy information. V3 said pain control is important to a resident's healing, rehab, overall health, and resident comfort. V3 said she was not aware that R425 was unhappy and experiencing such pain. The surveyor asked why R425's scheduled Norco was held at midnight 11/21/24. V3 said she didn't know, but 5 stands for hold, see progress notes. The surveyor asked V3 to review R425's progress notes for an entry for the held 11/21/24 midnight dose of Norco. V3 reviewed R425's chart and said there isn't a note, but there should be one. V3 stated, I'm not sure everyone is aware that he is in pain. It's expected that we would do our best to control the resident's pain. We must listen to them. I can't say what happened because the nurse didn't chart anything to explain why the Norco was held. She should have. On 11/22/24 at 12 PM, V33 (Director of Pharmacy) said he followed up regarding my questions for R425's Fentanyl patch. V33 said the electronic order was received from pharmacy at 7:43 PM on 11/19/24. V33 said there were errors with the prescription regarding the quantity and duration. V33 said the order was not entered as a STAT, so the pharmacist reviewed the orders later in the evening. V33 said pharmacy sent an email to V34 and V35 (Supervisors) regarding the need for order clarifications. V33 said it's the facility's procedure to email V34 and V35. V33 said a new order was entered for Fentanyl on 11/20/24 by V16 (NP) and it was filled STAT. V33 said he would expect the facility staff to communicate effectively to address any pharmacy concerns or resident complaints with pain. The facility's Pain Assessment and Management Policy reviewed 11/27/24 showed, A comprehensive and effective pain management program is provided to residents who require such services to ensure comfort, facilitate independence, and preserve dignity. The purpose of this policy is to provide guidelines for the assessment and identification of the resident's pain with underlying causes, and the development of pain management interventions consistent with professional standards of practice, person-centered care plan, and the resident's goals and preferences. Guidelines: 1. The pain management program is based on professional standards of practice and the resident's preferences related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessments and recognition of pain. b. Identifying the underlying causes and characteristics of pain; c. Developing and implementing a treatment/pain management plan; d. Monitoring for effectiveness and modifying interventions; and 3. Documentation and reporting . Documentation and Reporting: 1. The following information shall be documented and reported to the physician/medical provider immediately: a. Significant changes in the level of the resident's pain . d. Prolonged, unrelieved pain despite care plan interventions.

Based on observation, interview, and record review the facility failed to ensure insulin was refrigerated or dated and failed to ensure controlled medications were double locked for 2 residents in the sample (R8, R172) and 4 residents outside of the sample (R367, R375, R41, R179). The findings include: 1. On 11/20/24 at 9:42 AM, the 2B unit medication cart was reviewed with V26 (RN-Registered Nurse) present. The top drawer of the cart contained an insulin pen labeled with R172's name. A multi-dose vial of insulin belonging to R375 was in the drawer. Both items were unopened and inside clear bags stating to keep refrigerated. The drawer had an opened insulin pen belonging to R367 and a multi-dose vial of insulin belonging to R41. Neither of the open insulin containers were labeled with any dates. V26 (RN) stated insulin needs to be refrigerated until it is opened. It maintains the usefulness. Any open insulin needs to be dated to know when it will expire. It needs to be discarded after 28 days. The insulin proteins can breakdown and not work effectively. 2. On 11/20/24 at 10:01 AM, the 2B unit medication room was reviewed with V26 (RN). The medication refrigerator was unlocked and contained two multi-dose vials of lorazepam (anti-anxiety medication). The vials were labeled with R8 and R179's names. V26 stated the lock is needed for safe keeping of the medications. V26 said the refrigerator is always kept unlocked and he was not even sure if he had keys to the lock. V26 did locate the key in his possession and stated the refrigerator is normally kept open from shift to shift. V26 and this surveyor exited the medication room with the refrigerator left unlocked. On 11/21/24 at 11:20 AM, V3 (Assistant Director of Nurses) stated insulin needs to be refrigerated until it is opened. Any open insulin should be dated with the day opened and day it will expire. It is necessary so staff know how long it is good for. There is the potential for less efficacy if it is not stored correctly or used after 28 days. V3 said controlled medications should always be under a two-lock system. It ensures it is in a safe place and prevents unauthorized people from taking the medication. The facility's Medication Storage policy dated 1/24 states under the procedures section: 2. Controlled substances stored in refrigerator should be secured such as a separately locked, permanently affixed compartment. 12. Insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used.

Based on observation, interview, and record review the facility failed to provide feeding assistance in a dignified manner and failed to utilize a catheter dignity bag. This applies to 2 of 2 residents (R108, R425) reviewed for dignity in the sample of 35. The findings include: 1. R108's Admission Record (Face Sheet) showed he was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, lack of coordination, and need for assistance with personal care. R108's 10/2/24 Significant Change Minimum Data Set (MDS) showed he had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 0 out of 15. On 11/19/24 at 11:49 AM, V9 Certified Nursing Assistant (CNA) provided R108's feeding assistance. V9 stood over R108 during the entire noon meal while she provided feeding assistance. On 11/20/24 at 2:24 PM, V10 Memory Care Unit Manager/Registered Nurse stated staff can either sit or stand when providing feeding assistance. On 11/20/24 at 3:00 PM, V3 Assistant Director of Nursing (ADON) stated staff should be seated and making eye contact with residents while providing feeding assistance. V3 stated this is the dignified way to provide feeding assistance. The facility's Assistance with Meals policy (effective date 4/1/24) showed, Residents who require feeding assistance will receive appropriate assistance with meals in a safe, dignified manner. In implementing the policy, the following shall apply: .Resident who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over residents while assisting them with meals . 39537 2. On 11/19/24 at 11:46 AM R425 was lying in bed, on his left side. R425 had a catheter drainage bag, draining cloudy yellow urine, visible from the hallway. R425's catheter drainage back was not covered with a dignity bag. R425 said he'd prefer for everyone not to see his catheter bag. R425's Facesheet dated 11/20/24 showed he had diagnoses to include, but not limited to: urinary tract infection; sepsis; cutaneous abscess of right lower limb; diabetes; prostate cancer; obstructive and reflux uropathy; other injury of the ureter; chronic kidney disease; and benign prostatic hyperplasia with lower urinary tract symptoms. R425's Brief Interview for Mental Status (BIMS) Evaluation dated 11/17/24 showed he was cognitively intact. R425's Physician Order Sheet dated 11/20/24 showed he had orders for a indwelling urinary catheter and a suprapubic urinary catheter. R425's Indwelling Urinary Catheter care plan initiated 11/18/24 showed he had an indwelling urinary catheter and a suprapubic catheter due to prostate cancer with ureteral stricture and obstructive uropathy. The Interventions included, but were not limited to: Position the catheter bag and tubing below the level of the bladder and away from the entrance room door. On 11/20/24 at 1:23 PM, V17 (RN - Registered Nurse/Unit Manager) said R425's catheter bag should be covered with a dignity bag, especially if the drainage bag was facing the hallway door. V17 said these bags are used to cover the catheter drainage back for the resident's dignity. On 11/21/24 at 9:59 AM, V24 and V25 (Restorative Aides) provided incontinence care and assisted R425 with getting dressed. V24 and V25 placed each drainage back through R425's short openings and placed each bag in a dignity bag. They said the catheter drainage bags should always be covered in the dignity bags. On 11/21/24 at 11:29 AM, V3 (ADON - Assistant Director of Nursing) said R425's catheter bag should have been covered or facing away from the hallway. V3 said the purpose of doing this is so people passing by can't see what is draining and for the resident's privacy and dignity. The facility's Resident Rights Policy reviewed 12/10/24 showed, Employees shall treat resident with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence . t. privacy and confidentiality .

Based on interview and record review, the facility failed to obtain a Level I Preadmission Screening and Resident Review (PASSAR) for a resident who admitted with a serious mental health diagnosis for 1 of 1 residents (R77) reviewed for PASSAR in a sample size of 35. Findings include: R77's face sheet documented that resident last admitted to the facility on [DATE] and has a past medical history not limited to major depressive disorder, recurrent dated 07/25/2023. Review of R77's care plan showed the following: has known history of displaying inappropriate behavior and/or resisting care/services. Specific behavior exhibited: paranoia in the evenings, hallucinations. She has diagnosis of dementia, delusional disorder. Date Initiated: 08/19/2022. Revision on: 08/19/2022; is an elopement risk/wanderer related to impaired safety awareness. Resident wanders aimlessly. Date Initiated: 11/09/2022; uses psychotropic medications (antipsychotic and antidepressant medications) related to behavior management, depression. Date Initiated: 01/05/2023. Revision on: 10/18/2024. Review of R77's Minimum Data Set (MDS) quarterly resident care assessment screening dated 10/17/2024 documented in Section I for Active Diagnoses under Psychiatric/Mood Disorder, the diagnoses of Depression and Psychotic Disorder. On 11/21/24 at 09:21 AM, V4 (Social Services Director) said she attempted to complete a level I PASSAR screen upon R77's admission to the facility, but the system would not allow her to do so and showed an error message. V4 reviewed R77's medical diagnosis list with surveyor and indicated that R77 has a diagnosis of major depressive disorder dated 07/25/2023. At 09:58 AM, V4 (Social Services Director) said the hospital usually does the level I PASARR screening prior to admission, but if the screening is not completed by the hospital, then she is the person responsible to complete the screen. V7 then said that R77 was hospitalized in 2024 with covid so a screening should have been done upon her readmission. On 11/21/2024, requested PASSAR policy from the facility. Received Referral and Admission Process for Short-Term Skilled Nursing Admissions policy that did not include any information related to the PASSAR screening process.

Based on observation, interview, and record review, the facility failed to provide assistance with activities of daily living for a resident assessed to be dependent on staff for grooming and personal hygiene for 1 of 1 residents (R166) reviewed for activities of daily living in a sample size of 35. Findings include: R166's face sheet documented that resident last admitted to the facility on [DATE] and has a past medical history not limited to: cerebral infarction, dementia, need for assistance with personal care, problem related to care provider dependency, pain and anxiety disorder. Review of R166's functional abilities and goals assessment with effective date of 10/14/2024 documented that R166 is dependent on staff for shower/bathing and personal hygiene. Review of R166's Minimum Data Set (MDS) quarterly resident care assessment screening dated 10/15/2024 documented in section C for cognitive patterns, a brief interview for mental status (BIMS) score of 15/15 that indicated no cognitive impairment. Section GG for functional abilities documented that R166 is dependent on staff for shower/bathing self and requires partial/moderate assistance with personal hygiene that includes the ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene). On 11/19/24 at 10:55 AM, R166 was observed by surveyor lying in bed watching television. Resident was wearing a hospital gown and appeared disheveled with noted facial hair to her upper lip and chin that was long and coarse in appearance. Her fingernails extended approximately 0.5 centimeters (cm) in length beyond the tips of her fingers to both hands and were noted with debris under several fingernails to both hands. R166 said she was last given a bed bath on Sunday and has not received any type of bathing since then. On 11/20/24 at 10:08 AM, R166 was observed by surveyor with a visibly unkept appearance, her hair was uncombed and appeared disheveled and her fingernails remained long in length with noted debris under several fingernails to both hands. R166 voiced that she had not received any recent assistance with oral hygiene then stated that she was last given a bed bath on Sunday and has not received any type of bathing since then. On 11/20/2024, reviewed R166's care plan with last completion date of 10/30/2024 that documented resident has a behavior, prefers and want to stay in bed 24/7 with date initiated on 08/09/2023. No documentation was found indicating that resident is resistive to care. On 11/21/2024 at 09:33 AM, R166 was again observed by surveyor with a visibly unkept and disheveled appearance, her hair was uncombed, and her fingernails remained long in length with noted debris under several fingernails to both hands. R166 again voiced that she had not received any recent assistance with oral hygiene then stated that she was last given a bed bath on Sunday and has not received any type of bathing since then. Facial hair to upper lip and chin remains long and course in appearance. On 11/21/24 at 09:37 AM, V6 (Registered Nurse) said R166 receives a bed bath weekly on Sundays and as needed if we see that she needs it and she receives daily hygiene and grooming which includes shaving her facial hair and trimming her long fingernails. V6 added that R166 is also seen by podiatry monthly for nail trimming to her hands and feet, then said if R166's family complains or requests for her facial hair to be trimmed, then staff will do so. V6 (Registered Nurse) also said that staff should encourage residents daily to receive grooming, that R166 refuses care often and any refusals of care should be documented within the resident's progress notes. On 11/21/24 at 09:43 AM, V7 (Certified Nursing Assistant) said she is assigned to R166 and was just about to provide her with morning care. When surveyor asked what care will be provided, V7 said that she will change her gown, diaper and bed pad and will check her for any skin issues. When asked by surveyor if she will provide any other type of care, V7 (Certified Nursing Assistant) said see if her linens need to be changed and that's it. On 11/21/2024 at 10:07 AM, V5 (Clinical Educator) said residents receive either a shower or bed bath weekly and as needed. She then said residents should be provided with daily hygiene that includes face and hand washing, grooming and/or shaving, oral hygiene and hair combing. She added that female should not have long facial hair. On 11/21/2024 at 11:05 AM, V5 (Clinical Educator) provided care plan for R166 that documented the following revision that was not previously noted by surveyor, the resident is resistive to care (washing face, brushing teeth, washing and combing hair, shaving) related to anxiety with date initiated of 03/10/2023 and last revision date of 11/21/2024. Review of R166's podiatry notes for last three months showed care provided to bilateral feet only. Progress notes for last thirty days showed no documented refusals of care including daily bathing and/or grooming. Review of Activities of Daily Living Policy retrieved on 11/21/2024 indicated that residents will be provided with the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene. Requested bathing, grooming and/or personal hygiene policies from facility. None were provided.

Based on observation, interview, and record review the facility failed to ensure a wound vacuum was operational, failed to ensure physician orders were obtained, and failed to have care interventions in place for 1 of 3 residents (R371) reviewed for non-pressure wounds in the sample of 35. The findings include: R371's face sheet printed on 11/20/24 showed an admitted [DATE] and diagnoses including but not limited to aftercare following joint replacement, displaced fracture of the left femur, and the presence of left artificial hip joint. R371's brief interview of mental status report dated 11/15/24 showed cognitively intact. On 11/19/24 at 12:09 PM, R371 was seated in an upright recliner in her room and stated she had left hip surgery a week ago. R371 said she was wet underneath her left buttocks and the aide was on her way to get her cleaned up. R371 repeatedly said she was soaked and could not understand why her pants were all wet. A wound vacuum was lying on her bed and the tubing was running under her clothing, to the left side of her body. The vacuum fluid collection chamber appeared to be dry and empty. On 11/19/24 at 12:15 PM, V27 (RN-Registered Nurse) stated R371 came from the hospital with the wound vacuum following hip surgery. V27 said the surgical site orders are to change and empty the wound vacuum device as needed. V27 said there were no scheduled orders for the surgical site care. V27 said the only other order is for a follow up appointment with the orthopedic surgeon. V27 said there was nothing related to when or how to change the surgical dressings. On 11/19/24 at 12:21 PM, V28 (CNA-Certified Nurse Aide) entered the room and assisted R371 to stand to change her wet pants. V28 said R371 was at a therapy session earlier in the morning and she found the wound vacuum disconnected. V28 said she assumed R371's left side and buttocks were wet because the vacuum was not working. R371's left side and buttocks were observed. A large wound sponge was on the side of her left hip, a white dressing was top of her left hip, and a white dressing was near her left knee. The areas were covered with a clear, plastic dressing. The hip and buttock were wet with a clear fluid. V28 removed R371's brief which was clean and dry. V28 stated she was sure it was the surgical site draining onto R371's pants. V28 stated she was not sure how long the wound vacuum was not working but guessed quite a while since the clothing was thoroughly saturated. On 11/19/24 at 1:33 PM, V27(RN) examined R371's wound vacuum. V27 said it was not working. The device should have a light turned on to show it is suctioning fluid from the surgical wound. V27 examined the collection chamber and noted it was empty. V27 examined the surgical site and said fluid has been leaking out of the site. V29 (R371's family member) was seated on the edge of the bed. V29 said she was glad someone finally noticed the device. V29 said when R371 came into the facility last week, in the evening, none of the staff knew how to work it. It was acting weird and nobody could figure it out. R371's progress note dated 11/15/24 at 6:47 AM (morning following the prior evening admission) stated Resident's wound vac battery dead. No charger to charge the equipment. Endorsed to the oncoming nurse to contact the facility wound care nurse for possible solution to the situation. On 11/20/24 at 8:44 AM, R371 was seated in the upright chair in her room. R371 stated the wound vacuum was removed yesterday. She said she had no idea why it was removed or if it was going to be replaced. R371's November 2024 physician orders and care plan were reviewed by this surveyor. There was nothing related to the surgical site care, order to remove the wound vacuum, or interventions in place. There was an order start dated 11/14/24 to check wound vacuum placement and functioning. The treatment administration record was documented as being done twice per day, including 11/19 (day found by surveyor not operating). On 11/20/24 at 12:41 PM, V11 (Wound Care Nurse) stated she removed R371's wound vacuum just yesterday on the evening shift. V11 said the device light was flickering and the battery was close to dead. V11 said the floor nurse (V27) told her it was not working so she took it out. V11 said wound vacuums are important to suction the open skin area. Wound drainage can set in and cause the potential of a delay in healing. Skin maceration can be an issue if the drainage is allowed to sit on the skin too long. Infection is always an issue for surgical sites. V11 reviewed R371's electronic medical record and confirmed there were no treatment orders for the surgical wound site. V11 said there should be orders stating how often to change dressings, the type to use, and how to monitor the site. V11 confirmed there were no care plan interventions related to the surgical site or use of a wound vacuum. V11 said both are important to ensure wound healing, reduce the risk of infection and guide resident care. V11 said they should already be in place for a resident who has been here for a week. On 11/20/24 at 1:16 PM, V2 (Director of Nurses) stated physician care orders need to be in place within 24 hours of admission. They are important to give staff direction on how to care for residents. Orders are necessary to indicate when to start or stop medical intervention. Care plans do just as they say, direct care. A baseline care plan should be done within 48 hours of admission. On 11/21/24, R371's November 2024 Treatment Administration Record (TAR) showed orders start dated 11/20/24 (7 days after admission) to clean left hip surgical incision with normal saline and cover with dry dressing. Monitor daily for signs of infection. The TAR showed at second order start dated 11/20/24 to monitor surgical site of left hip daily for signs of infection, increased drainage, foul smell, redness. R371's care plan showed a focus area related to the potential/actual impairment to skin start dated 11/20/24. The goal and intervention sections were blank. The facility's Non-Sterile Dressing Change policy last revision dated 7/18/23 states under the procedure section: 1. Review the medical orders for wound care related to wound care.

Based on observation, interview, and record review the facility failed to ensure preventative measures were in place, correct treatment orders were in place, and air mattress settings were for a resident's weight for 3 of 3 residents (R197, R280, & R466) reviewed for pressure in the sample of 35. The findings include: 1. On 11/20/24 at 8:59 AM, R 197 was laying in bed on his back with his heels resting on the bed. R197 had a pillow under his calves that was flat and did not provide any offloading to his heels. R197 had a dressing to his right heel dated 11/20/24. The Face Sheet dated 11/20/24 for R197 showed diagnoses including right femur fracture, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, abnormalities of gait and mobility, muscle weakness, hyperlipidemia, benign prostatic hyperplasia, cardiomegaly, fall, and need for assistance with personal care. The Physician Orders for November 2024 for R197 showed, 10/3/24 - elevate heels. Apply boots on both heels. 11/5/24 - To Right heel, cleanse wound with normal saline, apply foam dressing, and offload heel when in bed. Apply boots on both heel every shift. Elevate heels every shift. The Wound Care Physician's Progress note dated 11/14/24 for R197 showed, stage 3 pressure wound of the right heel; wound size (L x W x D) 2.4 x 4.2 x 0.1 cm; moderate serous exudate. Treatment plan alginate calcium once daily with a gauze island dressing with border. The TAR (Treatment Administration Record) for November 2024 for R197 showed right heel - cleanse wound with normal saline, apply foam dressing, and offload heel when in bed with a start date of 11/5/24. The order was completed every Tuesday, Thursday, and Saturday on 11/5, 11/7, 11/9, 11/12, 11/14, 11/16, and 11/19/24. R197's pressure ulcer treatment was changed on 11/14/24 by the wound care physician and that change was not on the R197's TAR; he did not receive the correct wound care treatment. On 11/20/24 at 12:59 PM, V14 RN (Registered Nurse) stated, R197 has a dressing change daily and as needed. His dressing was changed this morning. V14 went into R197's orders and stated his heels are to be offloaded and on Tuesday, Thursday, Saturday the residents wound is cleaned with normal saline and a foam dressing applied. V14 stated the order was placed on 11/5/24. V14 stated the wound nurse does the wound orders. V14 stated the wound care nurse looks at the wound care doctor's note for treatment orders and puts those in as orders. V14 reviewed the 11/14/24 wound care physician note and stated the treatment order was for calcium alginate daily for 30 days with a secondary dressing of gauze island with border. On 11/20/24 at 1:15 PM, V 11 RN (Registered Nurse/Wound Care Nurse) stated, she looks at the physician orders for the treatment orders. The treatment orders for R197 pressure ulcer said to clean with saline and apply a foam dressing on Tuesday, Thursday, Saturday, and as needed. Those orders come from the wound care physicians progress notes when he see's the patient. V11 reviewed the Wound Care Physician Note dated 11/14/24 and stated the doctor changed the treatment to calcium alginate. V11 stated R197 has not been receiving the correct treatments. V11 stated R197's heels should be offloaded when he is in bed to take pressure off the wound. The Care Plan dated 10/3/24 for R197 showed, the resident has a right heel deep tissue injury. At risk for skin breakdown related to impaired mobility; right hip fracture - status post surgery. Administer treatments as ordered and monitor for effectiveness. Follow facility policies/protocols for the prevention/treatment of skin breakdown. The facility's Pressure Injury Prevention policy (1/10/24) showed a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The wound team will manage wound care, implement prevention interventions, and monitor compliance with documentation. Residents with pressure injury whether facility acquired or present on admission will have specialized mattress and wheelchair cushion appropriate to the resident's need. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc). 2. On 11/19/24 at 11:39 AM, V11 and V12 RN (Registered Nurse/Wound Care Nurse) changed the dressing on R280's coccyx/right buttock area. R280 had a round open area to his right inner buttock. V12 stated it was a stage 3 pressure ulcer. R280 had a flat pressure relief cushion between two towels on his wheelchair seat. After the dressing change was completed, V11 and V12 were asked to look at the pressure relieving device in R280's chair. V11 stated that sometimes the cushions get flattened out. The Face Sheet dated 11/21/24 for R280 showed diagnoses including benign neoplasm of pancreas, secondary malignant neoplasm, severe protein-calorie malnutrition, type 2 diabetes mellitus, gastrostomy, thalassemia, anxiety, hypertension, essential tremor, benign prostatic hyperplasia, sepsis, and acquired absence of pancreas. Physician Order dated 11/12//24 for R280 showed, apply calcium alginate and then foam on coccyx (buttock) pressure wound every night shift and as needed. The Wound Care Physician's Note dated 11/14/24 for R280 showed, Dressing Treatment Plan: Primary Dressing(s) Foam silicone border apply three times per week for 30 days The November 2024 TAR (Treatment Administration Record) for R280 showed starting on 11/12/24 the treatment provided was calcium alginate and then foam dressing daily every night to coccyx (buttock). This was being completed 11/12/24 - 11/18/24. The Physician Orders for R280 showed on 11/19/24 the wound care nurse changed the wound care treatment orders in the physician orders 5 days after the physicians treatment orders changed. The order entered on 11/19/24 for R280 showed, apply foam dressing on right medial buttock pressure ulcer wound every night shift every Tuesday, Thursday, Saturday for wound and as needed if dressing is soiled or loose. On 11/21/24 at 10:00 AM, V11 RN (Registered Nurse/Wound Care Nurse) reviewed R280's wound orders and stated the original order was for calcium alginate because he had drainage. V11 stated the orders from the wound care physician's visit on 11/14/24 should have been entered as the current treatment order for R280 and that was not done. V11 stated R280 had only one pressure ulcer that the facility said was on the coccyx and the wound care physician stated it was located in the right inner buttock. The Care Plan dated 11/1/24 for R280 showed, the resident has pressure ulcer to coccyx (buttock) and potential for pressure ulcer development related to history of ulcers and immobility. Follow facility policies/protocols for the prevention/treatment of skin breakdown. The resident is on Pressure relieving/reducing device) on bed/cushion in chair. The MDS (Minimum Data Set) dated 11/2/24 showed partial/moderate assist rolling in bed, moving from sitting to lying, sit to stand, chair/bed transfer, and toilet transfer. Walk 10 feet with supervision. The facility's Pressure Injury Prevention policy (1/10/24) showed a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. The wound team will manage wound care, implement prevention interventions, and monitor compliance with documentation. Residents with pressure injury whether facility acquired or present on admission will have specialized mattress and wheelchair cushion appropriate to the resident's need. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc). 39543 3. R466's Admission Record (Face Sheet) showed he was admitted on [DATE] with diagnoses to include but not limited to dementia, Parkinson's disease, and weakness. R466's 11/11/24 Admission Minimum Data Set (MDS) showed he had short-term and long-term memory problems. (Brief Interview for Mental Status was not able to be done.) R466's 11/14/24 Physician wound care note showed he had a stage 3 pressure wound to the sacrum which was identified on admission. R466's Order Summary Report (as of 11/20/24) showed he had an active order, started on 11/7/24, for a low air loss mattress (commonly referred to as an air mattress). The order showed the mattress should be verified every shift. R466's November 2024 Treatment Administration Record (TAR) showed a treatment for Low air loss mattress every shift (twice daily) with an 11/7/24 start date. The TAR showed the 11/19/24 day shift, night shift, and 11/20/24 day shift air mattress checks were documented as being completed. On 11/19/24 at 3:05 PM, R466 was laying on his back in bed. At the foot of his bed was an air mattress pump/control unit, which was running. The air mattress was set to the highest weight setting which was 400 pounds. R466 appeared thin, frail, malnourished, and weighing less than 150 pounds. The air mattress control unit showed an applied label stating, in capital letters, KEEP DIAL AT RESIDENT WEIGHT. On 11/20/24 at 9:00 AM, R466's air mattress was set at the maximum weight of 400 pounds. On 11/20/24 at 2:07 PM, R466's air mattress remained at the 400-pound setting. R466's Weights and Vitals Summary showed, on 11/11/24, he weighed 110. (Nearly 300 pounds less than the air mattress setting.) On 11/20/24 at 3:00 PM, V3 Assistant Director of Nursing stated the purpose of an air mattress, for a resident with pressure ulcers, is to promote healing and to prevent further skin breakdown. V3 stated the air mattress should be set to the resident's weight, which alters the pressure in the air mattress to match an optimal pressure for the resident. V3 stated low air loss entry in the TAR is when the nursing staff should be verifying the air mattress pressure.

Based on observation, interview, and record review the facility failed to supervise a resident with difficulty swallowing while eating for 1 of 6 residents (R8) reviewed for safety in the sample of 35. The findings include: R8's face sheet printed on 11/21/24 showed diagnoses including but not limited to multiple sclerosis, dementia, psychotic disturbance, bipolar disorder, and dysphagia (difficulty swallowing). R8's facility assessment dated [DATE] showed moderate cognitive impairment and staff assistance of setup for eating meals. R8's physician orders showed an order start dated 6/21/24 for: Regular diet, pureed texture, regular/thin consistency, please feed for Multiple Sclerosis, Dysphagia, Oropharyngeal Phase. R8's care plan showed an intervention initiated on 9/20/24 to assist/feed at mealtimes. On 11/19/24 at 12:35 PM, R8 was seated in a wheelchair in the unit dining room. R8's lunch was a pureed consistency and approximately 50% of the food had been consumed. Another resident was seated next to R8 and eating a regular texture meal. A third resident was across the room with her private caregiver who was talking on the phone. There was a dietary aide at the serving counter across the room and R8's back was facing her. There were no facility nursing staff present in the dining room supervising. On 11/20/24 at 8:57 AM, R8 was in his wheelchair in his room and alone. A pureed texture breakfast tray was in front of him. R8 was feeding himself and there were no staff present. At 12:36 PM, R8 was in his room eating his pureed lunch and alone. On 11/21/24 at 9:24 AM, R8 was in his wheelchair in his room and alone. A pureed texture breakfast was in front of him. On 11/21/24 at 9:30 AM, V31 (Licensed Practical Nurse) stated R8 has dysphagia due to his multiple sclerosis. He has trouble swallowing and has been on a puree texture diet since he was admitted . The texture helps him swallow more easily. On 11/21/24 at 9:36 AM, V32 (Diet Technician) stated R8 needs a pureed diet because of swallowing difficulties. He has the potential to choke if he isn't supervised while eating. He should be eating meals in the dining room so staff can supervise him. The nursing department would be the ones to determine if it is safe for him to eat alone in his room. On 11/21/24 at 9:51 AM, V3 (Assistant Director of Nurses) said R8 needs to eat meals in the dining room so that staff can supervise him. He has the potential to choke if he is eating alone. It is not safe for him to be eating alone in his room. The facility was unable to provide any policy related to the supervision of residents with dysphagia or difficulty swallowing.

Based on observation, Interview, and Record Review the facility failed to ensure a resident's indwelling urinary catheter bag was not on the floor or stepped on for 1 of 1 residents (R291) reviewed for catheters in the sample of 35. The findings include: On 11/20/24 at 9:32 AM, R291 was sitting on the toilet in her bathroom with the catheter drainage bag laying on the floor. V13 CNA (Certified Nursing Assistant) picked the drainage bag up from the floor, treaded it through R291's pants and put the drainage bag back on the floor. R291 scooted forward on the toilet and her right foot was stepping on the catheter drainage bag. V13 counted to three and had R291 stand and she cleaned R291's buttocks. V13 put an incontinence brief on the resident and pulled up her pants. R291 sat in her wheelchair and her drainage bag continued to lay on the floor. V13 moved the drainage bag over next to the outside of R291's leg, went to the back of her chair, grabbed the bag and placed it in the dignity bag under the wheelchair. V13 stated the catheter bag should be below the bladder so it can drain. V13 stated the drainage bag shouldn't be on floor because a lot of things can happen to the bag. On 11/20/24 at 12:59 PM, V14 RN (Registered Nurse) stated the catheter drainage bag should not be on the floor because it can cause an infection. On 11/20/24 at 2:20 PM, V5 RN (Registered Nurse/Nurse Educator) stated the catheter bag should not be on the floor for infection control. The floor is not the cleanest; we want to prevent an infection from happening. The Face Sheet dated 11/20/24 for R291 showed diagnoses including congestive heart failure, low back pain, neuropathy, pleural effusion, hypertension, generalized edema, muscle weakness, cellulitis of right lower limb, atrial fibrillation, hyperlipidemia, gastroesophageal reflux disease, venous insufficiency, retention of urine, and peripheral vascular disease. The Care Plan dated 11/5/24 for R291 showed resident requires enhanced barrier precautions related to indwelling catheter. Make sure PPE, including gown and gloves are available. Post clear sign on wall outside room indicating type of precautions and required PPE. The resident has and indwelling urinary catheter for urinary retention. The resident has 16 french indwelling catheter. Position catheter bag and tubing below the level of the bladder and away from entrance door. The facility's Catheter Care, Urinary policy (7/6/23) showed, Infection Control: b. Be sure the catheter and tubing are kept off the floor.

Based on observation, interview, and record review the facility failed to ensure enhanced barrier precautions were implemented for residents with surgical wounds (R371, R197) and failed to ensure personal protective equipment was worn during catheter care (R291) for 3 of 8 residents reviewed for infection control in the sample of 35. The findings include: 1. R371's face sheet printed on 11/20/24 showed an admitted [DATE] and diagnoses including but not limited to aftercare following joint replacement, displaced fracture of the left femur, and the presence of left artificial hip joint. R371's brief interview of mental status report dated 11/15/24 showed cognitively intact. On 11/19/24 at 12:09 PM, R371 was seated in an upright recliner in her room and stated she had left hip surgery a week ago. R371 said she was wet underneath her left buttocks and the aide was on her way to get her cleaned up. A wound vacuum was lying on her bed and the tubing was running under her clothing, to the left side of her body. R371 did not have any type of signage on her door and there was no PPE bin (personal protective equipment) outside the doorway. On 11/19/24 at 12:21 PM, V28 (CNA-Certified Nurse Aide) entered the room and assisted R371 to stand to change her wet pants. R371's left side and buttocks were observed. A large wound sponge was on the side of her left hip, a white dressing was on top of her left hip, and a white dressing was near her left knee. V28 removed R371's brief and provided pericare to the groin and buttock areas. V28 was only wearing gloves. At 1:33 PM, V27(Registered Nurse) examined R371's wound vacuum and said it was not working. V27 examined the surgical site and said fluid has been leaking out of the site. V27 wore only gloves. At 1:47 PM, V28 (CNA) transferred R371 from her recliner to the bed. V28 handled the wound vacuum and wore only gloves. On 11/20/24 at 1:03 PM, V30 (RN/Infection Control Preventionist) stated residents with any draining wound need to be on (EBP) enhanced barrier precautions. V30 said residents with wound vacuums indicate the wound is draining and need to be on EBP. Staff should be wearing gowns and gloves during all resident care. Face shields are needed if there is a chance of any splashing during care. The PPE needs to be worn during all high contact activities. V30 said there is the risk of spreading germs to other residents if it is not worn. EBP rooms should have signs posted on the door and PPE bins in the hall. The facility's Enhanced Barrier Precautions policy last revision dated 1/1/2024 states 2. EBPs employ targeted gown and glove use during high contact resident care activities . The policy listed examples of high contact care activities which require the use of gown and gloves. The list included dressing, providing hygiene, changing briefs, and wound care. The policy further stated: 9. Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 10. PPE is available outside of the resident room. 20042 2. On 11/20/24 at 9:32 AM, R291 was sitting on the toilet in her bathroom with the catheter drainage bag laying on the floor. V13 CNA (Certified Nursing Assistant) had gloves on but was not wearing a gown. V13 picked the drainage bag up from the floor, treaded it through R291's pants and put the drainage bag back on the floor. R291 scooted forward on the toilet and her right foot was stepping on the catheter drainage bag. V13 counted to three and had R291 stand and she cleaned R291's buttocks. V13 put and incontinence brief on the resident and pulled up her pants. V13 removed her gloves. R291 sat in her wheelchair and her drainage bag continued to lay on the floor. V13 moved the drainage bag over next to the outside of R291's leg without any gloves on. V13 stood up, put gloves on, went to the back of her chair, grabbed the bag and placed it in the dignity bag under the wheelchair. V13 was asked what EBP (Enhanced Barrier Precautions) was and she stated she believes gloves is the only PPE (Personal Protective Equiment) she should wear. R291 had an EBP sign outside the door that stated what staff should wear for PPE. On 11/20/24 at 2:20 PM, V5 RN (Registerd Nurse/Nurse Educator) stated EBP is for people with devices like catheters, picc (peripherally inserted central catheter), feeding tube, wounds, surgical wounds, stage 3 & 4 wounds, and tracheostomy; there is a long list. V5 stated when staff are providing direct care the PPE they should wear is gown and gloves because we dont want to introduce anything to the patient and put them more at risk. The Face Sheet dated 11/20/24 for R291 showed diagnoses including congestive heart failure, low back pain, neuropathy, pleural effusion, hypertension, generalized edema, muscle weakness, cellulitis of right lower limb, atrial fibrillation, hyperlipidemia, gastroesophageal reflux disease, venous insufficiency, retention of urine, and peripheral vascular disease. The Physician Orders for R291 showed an order dated 11/15/25, enhanced barrier precautions related to foley catheter every shift for urinary retention. The Care Plan dated 11/5/24 for R291 showed resident requires enhanced barrier precautions related to foley catheter. Make sure PPE, including gown and gloves are available. Post clear sign on wall outside room indicating type of precautions and required PPE. The Enhanced Barrier Precautions (1/11/24) showed, enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention control intervention to reduce the spread of MDROs to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene; .f. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc); and wound care (stage II skin opening requiring a dressing). Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required. 3. On 11/20/24 at 8:59 AM, R197 was laying in bed on his back with his heels resting on the bed. R197 had a pillow under his calves that was flat and did not provide any offloading to his heels. R197 had a dressing to his right heel dated 11/20/24. R197 stated his dressing to his right heel was changed this morning. R197 did not have EBP (Enhanced Barrier Precautions) sign posted on his doorway and/or next to his door. The Face Sheet dated 11/20/24 for R197 showed diagnoses including right femur fracture, type 2 diabetes mellitus, atrial fibrillation, congestive heart failure, hypertension, abnormalities of gait and mobility, muscle weakness, hyperlipidemia, benign prostatic hyperplasia, cardiomegaly, fall, and need for assistance with personal care. The Physician Orders for November 2024 for R197 did not show any orders for EBP (Enhanced Barrier Precautions). The Wound Care Physician's Progress note dated 11/14/24 for R197 showed, stage 3 pressure wound of the right heel; wound size (L x W x D) 2.4 x 4.2 x 0.1 cm; moderate serous exudate. Treatment plan alginate calcium once daily with a gauze island dressing with border. On 11/20/24 at 12:59 PM, V14 RN (Registered Nurse) stated R197 has a dressing change daily and as needed. V14 stated if a resident is on EBP then staff should wear a gown and gloves because they can come in contact with bodily fluids. EBP are put in place to protect the resident and yourself; to prevent any contamination. On 11/20/24 at 1:15 PM, V11 RN (Registered Nurse/Wound Care Nurse) stated, R197 should have EBP in place. V11 walked down to R197's room and confirmed there wasn't a sign up for R197 to show that he was on enhanced barrier precautions. The Care Plan dated 10/3/24 for R197 did not show a plan in place for EBP. The Enhanced Barrier Precautions (1/11/24) showed, enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) are used as an infection prevention control intervention to reduce the spread of MDROs to residents. 2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include: a. dressing; b. bathing/showering; c. providing hygiene; .f. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc); and wound care (stage II skin opening requiring a dressing). Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

Based on observation, interview, and record review, the facility failed to implement interventions to prevent pressure ulcers and failed to identify a pressure ulcer for 2 of 3 residents, R1 and R3, reviewed for pressure injuries in the sample of 3. These failures resulted in R1 developing a Stage 3 sacral pressure wound which later became an infected Stage 4 pressure ulcer and R3's pressure wound not receiving wound care treatment until it was an unstageable pressure injury. The findings include: On 11/6/24 at 10:42 AM, V4, Wound Care Nurse, V7, Registered Nurse, and V8, Certified Nursing Assistant transferred R1 from her chair to her bed to provide wound care. R1 had a half dollar coin sized wound to her sacrum. R1's Admission Record dated 11/7/24 shows R1 was admitted to the facility on [DATE]. R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation shows R1 was At Risk on 10/20/23, was a High Risk on 11/3/23, a Moderate Risk on 12/13/23 and 1/4/24, High Risk again on 1/15/24 and Moderate Risk on 4/18/24. R1's Care Plan initiated on 10/20/23 shows R1 has an ADL (activities of daily living) self-care performance and functional mobility deficit related to confusion, dementia, and impaired balance. On 11/1/23, R1's care plan identifies she is incontinent of bowel and bladder. R1's care plan does not identify that she is at risk to develop pressure injuries with corresponding prevention interventions. R1 is totally dependent on staff for toilet use. R1's Full Body Skin Assessment effective 10/20/23 shows R1 has no wounds. R1's Wound Evaluation dated 5/8/24 shows R1 has a new, facility acquired, Stage 2 pressure wound of her butt crack. R1's Wound Evaluated dated 5/9/24 which was completed by V4, shows R1 has a Stage 3 facility acquired pressure wound of her sacrum. R1's Wound Evaluation & Management Summary completed by the Wound Care Physician, V5, on 5/9/24, shows the visit is an initial evaluation of R1's sacral wound and confirms R1's sacral wound is a Stage 3 Pressure Wound. R1's Wound Evaluation & Management Summary dated 7/18/24 shows R1's Stage 3 sacral Pressure Wound merged with a non-pressure wound of her right upper medial buttock and became a Stage 4 sacral pressure wound with odor, heavy serosanguinous exudate, and 100 percent necrotic tissue. R1's sacral wound culture collected 7/25/24 shows the wound has become infected by Escherichia coli (E-coli), and Morganella morganii. R1's Order Recap Report dated 11/7/24 shows R1 was prescribed an antibiotic on 7/30/24 for eight days related to her wound culture. R3's Admission Record dated 11/7/24 shows he was admitted to the facility on [DATE]. R3's Braden Scale for Predicting Pressure Ulcer Risk Evaluation dated 4/11/24 shows he was a Very High Risk. R3's Skin/Wound Note dated 4/12/24 at 3:17 PM shows R3's sacrum is clear. R3's Skin/Wound Note dated 5/23/24 at 5:31 PM shows R3 has MASD (moisture associated skin damage) to sacrum/coccyx, dry healing, also present upon admission, but much improved, this is not a pressure injury. R3's Skin/Wound Note dated 6/21/24 at 3:17 PM shows R3 has an unstageable sacral wound with a 3 centimeter (cm) by 3 cm area of slough surrounded by a 10 cm by 7 cm area of redness. It does not note the etiology of the wound. R3's Initial Wound Evaluation & Management Summary dated 6/28/24 shows an unstageable (due to necrosis) sacral pressure wound measuring 11.6 cm by 10 cm by 0.2 cm with heavy sero sanguinous exudate and 70 percent necrotic tissue. On 11/6/24 at 3:18 PM, V5 ( Wound Care Doctor) said (wound) infection is never normal. V5 said he would expect a wound to be identified before it is the size R3's sacral pressure wound was when it was found. V5 said R3 had a pretty horrific (pressure) ulcer. On 11/7/24 at 9:45 AM, V4 (Wound Care Nurse) said R1 did not have any pressure wounds on admission, but R1 was at risk of developing a pressure ulcer. V4 said R1 was a 12 on the Braden scale which puts her at high risk of developing a pressure wound. V4 said they should develop a care plan to include pressure injury prevention measures such as frequent turning. V4 said R1's risk factors include limited mobility, need for assistance with ADLs (toileting and transferring), bowel and bladder incontinence, and dementia. V4 said R1 did develop a wound infection this past summer. Signs and symptoms of wound infection include increased redness, drainage, warm to touch, necrotic tissue, increased slough, purulent drainage, increased drainage, and odor. V4 said wound infections are not very common and should not occur as part of the normal wound healing process. V4 said they are still working on healing R1's sacral pressure wound. V4 said R3 was admitted to the facility on [DATE] with a history of pressure ulcers. V4 said R3 was at risk for developing pressure ulcers. V4 said R3's sacral pressure ulcer was first identified on 6/21/24 as an open, unstageable pressure ulcer with slough and V5 first saw R3 on 6/28/24 regarding the sacral pressure ulcer. V4 said she would expect to have been notified (about R3's pressure ulcer) when there was just redness, before it opened. V4 said she expects nursing to notify her about any change in skin, any alterations of the skin, especially in the pressure point areas such as the sacrum. V4 said it is obvious a wound would not start out at 10 centimeters, she should be notified long before it ever gets to a significant size so she can assess the wound, make sure there is wound treatment and get the wound care physician involved. The facility's Pressure Injury Prevention Policy (revised 1/10/24) shows the wound team will manage wound care, implement prevention interventions, and monitor compliance with documentation. If a wound is identified, a would assessment is done and should include the type of injury (pressure versus non-pressure related). Identified wounds are assessed and measured on a regular basis at least weekly and documented. Based on the Braden's Scale, any resident who is identified as high risk for developing pressure injuries will have interventions initiated to decrease risks. The IDT (interdisciplinary team) will review care plan ensuring that it includes measurable goals for prevention and management of pressure ulcers with appropriate interventions.

Based on observation, interview, and record review, the facility failed to safely transfer two of two residents (R1, R3) reviewed for safe transfers in the sample of three. This failure contributed to R1 falling forward out of her wheel chair which required a transfer to a local hospital where R1 was diagnosed with a brain hemorrhage. The findings include: 1. R1's Admission Record shows she was admitted to the facility on [DATE] with diagnoses including adult failure to thrive, traumatic subdural hemorrhage, palliative care, glaucoma, dementia, and macular degeneration. R1's Fall Scale dated September 20, 2024 shows she was at a moderate risk of falling. The facility's Incident Report shows on September 20, 2024, R1 had a fall from her wheel chair when she impulsively and abruptly put her feet down on the floor while being propelled by staff. She landed face down to the floor with right side of face touching the floor. A small cut was noted, the arm of her eyeglasses's was bent. R1 became more confused overnight, labs were ordered and the results were insignificant to R1's mental status change. The doctor was notified by staff regarding the increase in confusion and developing skin discoloration to the right side of her face, prompting an emergency department transfer .care plan updated to reflect use of high back wheelchair with footrests . R1's local emergency record shows on September 21, 2024 R1's brain cat scan showed There is subarachnoid hemorrhage overlying the right frontal and temporal lobes. There is a small amount of subarachnoid hemorrhage in the right occipital lobe. Within the left frontal lobe, there is a 1.7 x 1.4 cm intraparenchymal hematoma with a small amount overlying subdural hemorrhage. There is a small amount of hemorrhage within the left lateral ventricle. On October 1, 2024 at 9:37 AM, R1 was observed in a high back wheel chair with foot pedals on. R1 had some bruising to the right side of her forehead, eye, and cheek area. On October 1, 2024 at 9:42 AM, V4 RN (Registered Nurse) said she was passing medications when R1 had her fall. V4 said V5 CNA (Certified Nursing Assistant) was wheeling R1 to the bathroom via her wheel chair when R1 put her feet down. V4 said that R1 fell forward on her right side. There was a small cut to R1's right eye from her glasses. V4 said that R1 was able to follow commands and was talking after her fall. V4 said when she came in for her shift the next day, the night nurse (V8-LPN-Licensed Practical Nurse) reported that R1 was more confused than normal and she called the doctor. V8 said the doctor ordered labs to be done. V4 said after breakfast, she called R1's primary doctor and told him about R1's increase in confusion and R1's doctor said to send R1 to the local emergency room . V4 said that if staff are bringing residents off of the unit or staff take residents to the bathroom via their wheel chairs, then foot rests should be applied. On October 1, 2024 at 10:01 AM, V5 CNA said after R1 finished breakfast, he took R1 to the bathroom. V5 said that R1 is able to propel her wheel chair and did not want her foot pedals on the wheel chair. V5 said he was pushing R1's wheel chair and he told R1 to put her feet up. V5 said R1's feet were up. V5 said R1 then put both of her feet down while he was pushing R1's wheel chair and R1 fell forward on her right side. V5 said it all happened so fast. V5 said that when staff are pushing residents' wheel chairs, staff would normally have foot pedals on for residents' safety. V5 said that R1 kept taking her foot off of the foot pedal so V5 took that as a sign that R1 did not want her foot pedals on. V5 said that R1 could not verbally say she did not want her foot pedals on. V5 said that R1 had dementia and R1 would not know to follow V5 to the bathroom by self propelling. On October 1, 2024 at 12:26 PM, V8 LPN (Licensed Practical Nurse) said she was the night nurse taking care of R1 the night after her fall. V8 said she was making her rounds and noticed R1 not acting how she normally acts, so she called the on call doctor. V8 said the on call doctor ordered blood work to be done and to monitor the resident. On October 1, 2024 at 9:56 AM, V6 CNA said resident wheel chairs should have foot rests on when staff is pushing them because you don't want the residents to jump and fall. On October 1, 2024 at 9:58 AM, V7 CNA said when pushing resident's wheel chairs, the foot pedals should be on to help prevent the residents from tipping. V7 said the foot pedals also help the residents to not put their feet down on the ground while getting pushed. R1's Care Plan initiated April 16, 2024 shows R1 has impaired cognitive function/dementia or impaired thought processes related to dementia. Initiated January 20, 2024 and revised September 24, 2024 shows R1 is high risk for falls related to gait/balance problems, impulsive behaviors, and dementia. Make sure patient has a footrest on the wheelchair while ambulating her anytime and around the unit was initiated September 20, 2024. The facility's Wheelchair and Associated Attachments policy last revised January 11, 2024 shows, Resident requiring transport by wheelchair will have access to the equipment and associated detachable accessories (leg rests) at all times. Transport by wheelchair will be in accordance with safety guidelines for managing such transport equipment. Wheelchair leg rests are to be in position on the wheelchair in the following situation: The resident is propelled by staff, family members, volunteers, therapists, etc. General safety precautions when using wheelchair leg rests: Once the resident is seated in the wheelchair, make certain the foot rests are lowered and secured with the resident's feet in place before releasing the brakes and moving the wheel chair. 2. R3's Admission Record shows he was admitted to the facility on [DATE] with diagnoses including congestive heart failure, secondary malignant neoplasm of bone, malignant neoplasm of prostate, sciatica, low back pain, and osteoarthritis. R3's Care Plan revised on September 30, 2024 shows R3 is at high risk for falls related to confusion due to dementia, gait/balance problems, history of fall, and generalized weakness. On October 1, 2024 at 9:37 AM, V6 CNA pushed R3's wheel chair from the dining room to the activity room. R3 had gripper socks on and R3's feet were sliding against the floor. There were no leg rests to R3's wheelchair. At 9:46 AM, V5 CNA pushed R3's wheel chair to the middle of the hallway. R3's feet were sliding against the floor and R3 still did not have leg rests to his wheel chair. R3 was not self propelling his wheel chair.

Based on interview and record review, the facility failed to ensure a resident was transferred safely for one of three residents (R1) reviewed for safety in the sample of three. This failure resulted in R1 obtaining a right surgical neck fracture (Right shoulder area). This past non-compliance occurred from February 19, 2024-February 23, 2024. The findings include: R1's Admission Record dated February 28, 2024 shows she was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, quadriplegia, right and left hand contractures, heart disease, low back pain, and muscle spasms. R1's diagnoses were updated February 19 & 20, 2024 to reflect pain and fracture of upper end of right humerus. R1's Minimum Data Set (MDS) dated [DATE] shows she is cognitively intact and shows R1 is dependent on staff for showering, toileting, and transfers. R1's Fall Scale dated January 13, 2024 shows she was a moderate risk for falls. R1's Care Plan revised on June 23, 2023 shows R1 requires a mechanical lift with two staff and total assistance for transferring between surfaces. The facility incident report dated February 19, 2024 shows, On February 19, 2024 at approximately 11:00 AM, the resident reported pain in her right shoulder and lower extremity to the nurse. Family and physician notified with orders for x-ray. X-ray results received February 19, 2024 at approximately 4:30 PM noting right shoulder view: question subtle impacted fracture of surgical neck. R1's Radiology Results Report dated February 19, 2024 at 4:39 PM shows, Fracture of the surgical neck. No dislocation of the head. Joint space narrowing. Mild soft tissue swelling. On February 28, 2024 at 9:10 AM, R1 said V4 CNA (Certified Nursing Assistant) came into R1's room with the mechanical lift machine, but said V4 told R1 she wasn't going to use it. R1 said that V4 just picked her up by her hands and underneath her arms to put her in the shower chair. R1 said she kept telling V4 that she could not walk. R1 said she hasn't been able to use her legs for years. R1 said that V4 pushed the shower chair into the bathroom, gave her a shower, then transferred her back into bed in the same manner. R1 said she had a lot of pain. R1 said that V4 was by herself during the transfer. R1 said she felt like V4 was handling her like a rag doll. R1 said, This was the first time V4 took care of me. I've been here for almost seven years, and no one has hurt me before. All V4 said when she was done was if I needed a pain pill. I was crying, it really hurt. I kept telling her that I don't walk. I felt like I was being taken advantage of and she wasn't listening to me. I feel safe here as long as V4 does not come back. R1 had a black sling to her right arm and said the ortho doctor said she is not allowed to use her right arm. V4 was not in the facility during this investigation nor was V4 answering the phone calls made by this surveyor on February 28 & 29, 2024. On February 28, 2024 at 10:07 AM, V5 RN (Registered Nurse) said she gives the CNAs instructions every morning. V5 said she told V4 that R1 uses the full body sling with two staff members for transferring and to call V5 when she was ready to transfer R1. V5 said at about 10:30 AM, V4 came to her and said that R1 needed pain medications. V5 said that R1 was upset when she went into R1's room. V5 said that R1 told her that V4 did not use the lift to transfer R1. V5 said that R1 complained of pain to both of her shoulders, both knees, both hips, and both ankles. R1 told V5 that V4 pulled R1 by her arms and armpits to put her into the chair. V5 said she notified the manager on duty and notified the nurse practitioner which ordered stat x rays on all of R1's joints. V5 said the results showed that R1 had a right shoulder fracture. On February 28, 2024 at 12:35 PM, V7 Unit Manager said V5 called her and reported that R1 wanted to talk to her. R1 told V7 that V4 transferred R1 without using the mechanical lift and now R1 had pain. V7 said she went to talk to V4 and V4 told V7 that she transferred R1 without the lift. V7 said that V4 knew she was supposed to use the lift, but she said she was strong enough to do it without the lift. On February 28, 2024 at 1:14 PM, V6 Nurse Practitioner said she was notified by the nurse that R1 was experiencing pain. V6 said she saw R1 soon after the report. V6 said R1 is alert and oriented and that R1 told V6 that she was held up by her shoulders during a transfer that occurred in the morning. V6 said the x ray came back with a shoulder fracture. V6 said the fracture occurred during the transfer when staff was holding R1 by her shoulders. V6 said R1 should be transferred using a mechanical lift. R1's Nursing Notes dated February 20, 2024 shows, Resident came back from her ortho appointment with instruction to have the patient wear an arm sling to her right arm at all times. Ice the shoulder for 20 minutes twice per day. No lifting to right arm. V4 signed a Pledge for Transfer Safety document on February 23, 2023. This document shows, Policies and procedures are written for the safety of residents, patient and myself. I will follow policies and procedures. I understand that I increase the risk to the resident, patient and to myself if I do not follow policies and procedures. I understand that I must use the lifts according to the policy to protect residents, patients, and myself from harm. The facility's Mechanical Lift Policy revised April 27, 2023 shows, The purpose of this policy is to establish the general principles and procedure of safe lifting using mechanical lifting devices. Two team members are needed to safety move a resident with a mechanical lift with sling: one team member will operate the mechanical sling lift, while the second team member supports the resident. A full body sling mechanical lift is used for residents who are not able to bear any weight or provide support for the transfer. Prior to the survey date of February 28, 2024, the facility had taken the following actions to correct the non-compliance: 1. The facility identified that all residents who require assistance with lift transfers may be affected. 2. February 20, 2024-February 23, 2023 Nursing staff in-serviced on the mechanical lift policy with focus on ensuring that a mechanical lift be used for residents requiring this level of transfer or assist per care plan. 3. Starting February 22, 2023, The Director of Nursing and/or designee will conduct a minimum of ten QA audits on transfers of residents daily for two weeks, then weekly for four weeks, identifying any concerns/trends and address one on one with identified staff. 4. Audits will be reviewed at the QAPI meetings

Based on interview and record review the facility failed to ensure a gait belt was used to safely transfer a resident. This failure contributed to R1 falling and sustaining a right femur fracture requiring hospitalization and surgical intervention. This applies to 1 of 5 residents (R1) reviewed for safety/supervision in the sample of 5. The findings include: R1's face sheet shows she is a [AGE] year old female with diagnoses including: transient ischemic attack, restless leg syndrome, pain in right leg and atrial fibrillation. R1's 9/14/23 facility assessment shows her cognition is intact, and she requires extensive 1 staff assistance with transfers. R1's care plan shows she has an ADL (Activities of Daily Living) self- care deficit due to having a cerebral vascular accident (stroke) with right sided weakness. R1's 8/10/22 fall risk care plan shows she is at a moderate risk for falls related to having weakness and gait and balance problems. R1's 9/20/23 6:00 AM, nursing progress note completed by V5 (Licensed Practical Nurse/LPN) shows that R1 had a fall while being transferred by staff from her wheelchair to the toilet. The note says that R1 indicated to V5 that she felt her knees buckle and she fell forward landing on her knees. After the fall R1 was not able to move her right lower extremity and said she was having a lot of pain to her right knee. R1's 9/20/23 progress notes show after the fall R1 continued to complain of pain to her right leg and was sent to the local emergency room for evaluation and was admitted with a right femur fracture. R1's Nursing progress notes show she was readmitted to the facility on [DATE] and had a surgical incision and immobilizer on her right leg. R1's hospital records from a local community hospital show she was admitted to the hospital on 9/20/23 after falling at the facility and was found to have a a right peri-prosthetic distal femur fracture. R1 underwent surgery on 9/22/23 for a complex revision of the right total knee arthroplasty. A final IDPH (Illinois Department of Public Health) notification of serious incident report form completed by V3 (Assistant Director of Nursing/ADON) on 9/21/23 shows that R1 sustained a fall on 9/20/23 during a staff assisted transfer from wheelchair to the toilet. The report describes R1 as alert and oriented with some periods of forgetfulness. The report says that R1 should be transferred by one staff person and a gait belt. On 10/10/23 at 10:03 AM, R1 said I had a fall while being transferred to the toilet. The aide did not use a gait belt on me like they usually do, and she was rushing me and said come on let's go and next thing I knew I was on the floor. She did not ask me if I was ready to stand like the CNAs (Certified Nursing Assistants) usually do. She was standing beside me and used my pants and arm to try to grab me when my knees buckled and I went down. If she had put a belt on and let me go slow she could have assisted me to transfer and held on to me, because I have been doing really good. Once I hit the floor all I know is I was in a lot of pain on my right knee. On 10/10/23 at 10:15 AM, V4 (Registered Nurse/RN) said R1 is a stand and pivot transfer with 1-2 staff persons and a gait belt. V4 said she has heard that when R1 had the fall resulting in a fracture, the CNA did not use a gait belt to assist R1 to pivot and turn. On 10/10/23 at 10:23 AM, V6 (CNA) said gait belts are required to transfer all residents. V6 said with R1 you have to go slow, explain to her what you want her to do and let her get going slowly. On 10/10/23 at 11:02 AM, V5 (LPN) said she was notified by the CNA (V8) that R1 had fallen and was on the floor. V5 said she got into the bathroom and R1 was covered in urine and feces and on the floor crying out in pain. She said R1 had her legs out in front of her and complained of pain to her right knee. V5 said R1 did not have a gait belt on her when she arrived to the room and she asked V8 why she didn't use a gait belt to transfer R1 and V8 said something like she had forgotten. V5 said gait belts are required during all resident transfers and had V8 used one during R1's transfer she would have been able to use it to stabilize R1 when her knees buckled. On 10/10/23 at 11:07 AM, V8 (CNA) said she had taken R1 into the bathroom and had pulled her pants down to put her on the toilet. She was standing beside R1 and R1 used her walker to stand up and pivot and then it happened so fast her knees buckled and she was on the floor. V8 said she did not use a gait belt during R1's transfer and she was supposed to and usually does. V8 said she felt so bad after R1's fall happened, and she did tell the facility staff that she did not use a gait belt during the transfer and she received coaching from the facility about the incident. On 10/10/23 at 11:18 AM, V9 (Nurse Practitioner) said It is common sense for a resident of this age to be moved with a gait belt. I think it would have helped the CNA to have something to grab on to instead of the back of the resident's pants to prevent the fall. V9 said the facility should be following their gait belt protocol and this type of fall would be consistent with R1's femur fracture. On 10/10/23 at 11:26 AM, V3 (ADON) said gait belts are required for all resident transfers and V8 was given in-servicing and education after R1's fall occurred. A facility provided document titled Pledge for Transfer Safety was signed by V8 on 1/12/23 showing she understood that gait belts are required for all assisted transfers. A facility provided document titled Gait Belt use Acknowledgement signed by V8 on 1/12/23 shows it is an expectation of work performance to use a gait belt with proper technique with residents that require assistance with transfers or ambulation and failure to do so may result in disciplinary action. The facility provided Gait Belt/Transfers policy revised on 2/14/23 states, All staff members who assist resident to transfer will be required to use a gait belt.

Based on interview and record review, the facility failed to ensure a demented resident was free from sexual abuse by a staff member for 1 of 4 residents (R1) reviewed for sexual abuse in the sample of 17. This failure resulted in R1 being sexually assaulted. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 5/20/23 when V7 (Certified Nursing Assistant-CNA) found V8 (Housekeeper) in R1's room, forcing his penis into R1's mouth and was touching R1's exposed breast. V1 (Administrator) was notified of the Immediate Jeopardy on 5/23/23 at 3:15 PM. The surveyor confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 5/24/2023; however, noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: R1's electronic medical record accessed on 5/23/23 showed R1 is an 88 y/o female admitted to the facility on [DATE] with diagnoses that include severe dementia, fracture of left femur and respiratory failure. R1's facility admission assessment dated [DATE] show R1 has severe cognitive impairment. R1's Facility Reported Incident (FRI) dated 5/20/23 with Final report dated 5/22/23 show, On 5/20/23 at approximately 1PM, the CNA heard the resident yelling and entered the room. Upon entering the room, the CNA observed a male housekeeper with his penis pressed against the resident's mouth and his hand on her breast while she was laying in her bed. The housekeeper was startled by the interruption and stopped his actions, zipped up his pants and began pleading with the CNA not to report him. CNA confronted the housekeeper when she realized what was happening and started recording the interaction on her phone; she told him what he was doing was wrong and that she must report him. Conclusion: Investigation concluded that housekeeper engaged in a nonconsensual sexual act toward resident This conclusion is based on CNA witnessing the act, housekeeper reaction, and pleading not to be reported. R1's progress notes dated 5/20/23 by V3 (License Practical Nurse-LPN) shows, About 13:10pm, I walked down the hallway because I heard the CNA shouting, upon entering R1's room I saw the housekeeper begging the CNA not to report, she reported she saw the housekeeping forcing his penis into the resident mouth and touching her left breast. The CNA showed me what she recorded; I told her to write an incident report which I took to the supervisor. On 5/23/23 at 10:53 AM, V7 (Certified Nursing Assistant-CNA) said she was R1's CNA last Saturday, 5/20/23. At around 1PM, V7 (CNA) said she was walking by R1's room when she heard R1 yelling for help. R1's door was opened. When she entered R1's room, she observed V8 (Housekeeper-Hskp) standing by R1. V7 (CNA) said she went to the opposite side of R1's bed and clearly saw V8 (Hskp) forcing his penis into R1's mouth and was touching R1's exposed breast. V7 said she screamed at V8 and told him to leave R1's room at once then turned her phone on video to record what was happening. V7 said she was able to record V8 putting his penis back into his pants. V8 then pleaded to V7 not to report him, he was afraid losing his job. V8 said what he did was wrong, it was a mistake and that he won't do it again. At this time, the Nurse (V3-LPN) entered R1's room and asked what was going on. V7 said V8 was forcing his penis into R1's mouth and touching her exposed breast. V3 (LPN) told V7 to put what she witnessed in writing, then told V8 to leave R1's room now. V8 again begged that he is not reported. V7 on her way to the nurse's station to write her statement, V8 followed and repeatedly begged again not to be reported. V7 said she told V8 he will be reported, V8 then disappeared. V7 said 30-45 minutes after the incident happened, V8 was again in the resident's unit and begged V7 to not report him, he would be losing his job. V7 informed V8 that he had been reported and there was nothing to discuss further. V7 stated she did not know where V8 was during the 30-45 minutes he was unaccounted for in the building. On 5/23/23 at 10: 05 PM, V3 (LPN) said on 5/20/23, she was in the nurse's station when she heard voices talking loudly. V3 said she walked towards the hallway and found V7 (CNA) confronting V8 (Housekeeper) in R1's room. V7 was very angry and said, this man, (pointed to V8) was forcing his penis in R1's mouth and he was also touching R1's breast! Then showed the recorded video. V3 said she told V7 to give a written statement. V3 ordered V8 to leave R1's room, instead V8 said he was sorry of what he did, and it was wrong. V8 pleaded to not report him. V3 said she told V8 again to get out of the room and that he will be reported. V3 said she was so upset at the same time heartbroken of R1 being sexually abused. V3 said she assessed R1 who was in bed, her eyes were wide open with her oxygen via nasal cannula. V3 asked R1 are you ok, did anyone put anything in your mouth? R1 responded, I don't know. V3 said everything with R1 was either I don't know or no due to dementia, R1 is cognitively impaired. V3 said after completing R1's body check, she went to find the Nurse Supervisor. V3 said this was clearly sexual abuse. On 5/23/23 at 12:05 AM, V4 (Nurse House Supervisor-RN) said on 5/20/23 at around 2PM, V3 (LPN) handed her V7's written statement. V4 (RN) said after reading the statement stating V8 (Housekeeper) forced his penis into R1's mouth and touching R1's breast, she immediately notified V5 (Nurse Unit Manager). V4 (RN) said she did not know where V8 was and did not look for him. (An hour had gone by and V8's whereabouts were unknown.) V4 said she proceeded to R1's room to check R1's wellbeing after the sexual assault. On 5/24/23 at 9:13 AM, V5 (RN Unit Manager) said on 5/20/23 at around 2PM, he was in the facility and received a call from V4 (RN Supervisor) informing him of what happened to R1 being sexually abused, a housekeeper forcing his penis into R1's mouth and grabbing R1's breast. V5 said he called V1 (Administrator- Abuse Coordinator) to report the sexual abuse. V5 said he also went to security to report that no one knew where V8 was. V5 said, later he was told that V8 punched out at 2:55 PM on 5/20/23. (An hour and 55 minutes after the incident.) On 5/23/23 at 8:52 AM, V1 (Administrator) said on 5/20/23 at around 2:20 PM she received a call from V5 (RN Unit Manager) regarding V8 sexually abusing R1. V1 said she instructed V5 to call the police. V1 said on her way to the facility, she called R1's daughter to inform her of the incident. V1 said Police were already at the facility when she arrived. V1 said per family's request, R1 was transported to the hospital at around 3:30 PM. V1 said during all this time, no one knew where the perpetrator (V8) was. Video surveillance show V8 punched out at 2:55pm and used the back stairwell towards the Assisted Living exit. V1 said her investigation concluded that sexual abuse was substantiated. V1 said the Police informed her on 5/20/23 at around 5PM that V8, the perpetrator, was now in custody. R1's Hospital Records dated 5/20/23 timed at 3:58 PM show, an [AGE] year-old female with advanced dementia alert and oriented x1 came from a local nursing home for evaluation of sexual assault. Per EMS (Emergency Medical Services), a male Environmental Services worker touched patient's chest and placed his penis in patient's mouth. Patient does not recall the event. Patient's POA gave verbal permission for sexual assault kit and to treat for potential sexually transmitted disease. Adult protective services have been notified The facility Policy on Abuse and Neglect effective 5/21/23 show, Policy Statement. The resident has the right to be free form abuse, neglect, misappropriation of resident property and exploitation. This include but not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's symptoms. Definitions: Abuse: the willful infliction of injury unreasonable confinement intimidation or punishment resulting in physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Sexual abuse- is non-consensual sexual contact of any type with a resident, including but not limited, assault, rape, or sexual harassment. Examples are: exhibitionism by the service provider, forcing the individual receiving services to view pornographic material, intimate touching of the individual receiving services by the service provider during bathing, molesting the individual receiving services. -Criminal Sexual Abuse- serious bodily injury includes sexual intercourse with a resident by force or incapacitation or through threats of harm to the resident. Serious bodily injury also includes sexual intercourse with a resident who is incapable of declining to participate in the sexual act or lacks the ability to understand the nature of the sexual act. The Immediate Jeopardy that began on 5/20/23 was removed on 5/24/23 when the facility took the following actions to remove immediacy. 1. V8 had worked on the XX Unit, the facility assessed all residents on the XX Unit with skin checks and interviews. No evidence of abuse toward any other resident of XX Unit was found. Completed 5/24/23 2. The facility terminated V8's employment on 5/20/23. 3. The facility began in-service training to all facility staff about the facility's Abuse and Neglect of a Resident policy and procedure. The in-service training reviewed the whole Abuse and Neglect policy and also emphasized 1) to remove a resident from harm's way immediately; 2) to report the incident immediately to the Abuse Prevention Coordinator; and 3) to immediately secure the alleged perpetrator to ensure no interaction with other residents. The in-service started on 5/20/23 and extended to staff on all units, including non-clinical staff and was completed on 5/22/23. Individual staff who did not receive the in-service training on those three days will view the in-service before working a next shift at the facility. 4. The Unit manager or designee will conduct documented, daily surveillance rounds of the memory care units. The Executive Administrator or designee will audit the daily surveillance rounds and all reports pursuant to the Abuse and Neglect Policy for the next 4 weeks to confirm all allegations or suspicions of abuse, neglect, mistreatment, and injuries of unknown source are timely and correctly reported and investigated. 5. Audit results and any identified trends will be forwarded to the QAPI Committee for review and follow up until resolved. QAPI review will be completed weekly. 6. The Medical Director was notified of the incident on 5/20/2023 and approved the Removal Plan. Completed 5/24/23

Based on interview and record review, the facility neglected to ensure contracted staff reported a fall with a head injury for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in resident (R1) not being monitored for an hour and a half after the fall occurred. R1 was later sent to a local emergency room and admitted to the intensive care unit. The findings include: The facility's Initial IDPH (Illinois Department of Public Health) Notification of Serious Incident, dated 1/29/23, showed R1 was noted to have a laceration with purplish discoloration to forehead while in bed during nursing rounds at 7:56 PM on 1/27/23. The notification showed 911 was activated and R1 was transferred to a hospital. R1's Progress Notes, printed by the facility on 1/31/23, showed she had diagnoses including pneumonitis due to inhalation of food and vomit, altered mental status, moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), reduced mobility, weakness, and need for assistance with personal care. R1's Brief Interview For Mental Status Assessment (an assessment to determine cognitive status), dated 1/23/23, showed she was not able to complete the assessment due to Resident is rarely/never understood. The assessment also showed R1 had a short-term and long-term memory problem. R1's admission Baseline Care plan showed she needed one-person physical assist for eating, personal hygiene, and bed mobility. The care plan showed R1 required assistance of two staff persons for transfers. On 1/30/23 at 4:50 PM, V16 (R1's daughter) said the incident happened on 1/27/23. V16 said she was at the facility until 11:00-11:30 AM on 1/27/23. V16 said V3 (Licensed Practical Nurse-LPN) called her around 8:00 PM and said she found (R1) in the bed with an injury to her head. V16 said there is no way (R1) could have made that kind of injury on her head by herself. V16 said Something happened, either accidental or on purpose. V16 said there is no way (R1) could have fallen out of the bed and got herself back up on her own. V16 said something happened between 11:30 AM and 8:00 PM. V16 said when she went to the emergency room to be with R1, she had a laceration about the size of your hand on her head. V16 said R1 was wailing and sobbing and making noises like an animal would make. V16 said R1 was on the critical care unit and was moved to the hospice unit of the hospital on 1/30/23. On 1/31/23 at 9:02 AM, V1 (Administrator) said V5 (Registered Nurse-RN) started his shift at 7:00 PM on 1/27/23. V1 identified V3 (LPN-Agency) as R1's nurse from 7:00 AM-7:00 PM on 1/27/23. V1 said V18 (an RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) was in the facility and left around 6:00ish (PM). V1 said she spoke with V18, and he said he noticed a bump on R1's head when he was starting the intravenous (IV) line. V1 said she asked V18 if he reported it to the nurse, and he said no. V1 was told by V3 (LPN) that V18 seemed to be in a rush when he was leaving. V1 said V6 (Certified Nursing Assistant-CNA) told her (V1) that about 6:00 PM, she was sitting at a computer and heard R1 yell out. V1 said V6 ran to the doorway of R1's room where she saw a man trying to put both of R1's legs in the bed, like she had her legs off the side of the bed, and he was trying to put them back up on the bed. V1 said V6 asked the man what was going on and he got out of the room quick. V1 said around 7:00 PM, V6 noticed blood on the sheet by R1's arm. V5 (RN) went into R1's room to check her IV line and that is when the bump on her head was discovered. V1 said V18 came into the facility around 5:00 PM on 1/27/23 and was in R1's room for about 45 minutes to an hour. V1 said during that time, no one went into R1's room to check and see how it was going. On 1/31/23 at 11:38 AM, V5 (RN) said he worked on 1/27/23. V5 said his shift started at 7:00 PM and he got the shift report from V3. V5 said V3 (LPN) mentioned during report that R1 had a PICC line (a Peripherally Inserted Central Catheter that goes into a vein in the upper arm). V5 said after getting report, he started his medication pass and rounds. V5 said he went into R1's room to check her PICC line and saw bleeding near the PICC line. V5 said he did not notice the injury to R1's head at that time because her hair covered the area and R1 was looking the other way. V5 said he went out and got V20 (Nurse) to come in with him to check R1's PICC line and that is when V20 noticed the bump on R1's head. V5 said V20 asked V5 if he saw the injury on R1's head. V5 said it was probably a little smaller than a golf ball, with blood that was dried and crusted on it. V5 said it was not fresh blood. V5 said he went back out and asked V3 about it and V3 said she did not know anything about it. V5 said V3 told him it must have happened earlier and no one reported it to her. V5 said V3 took over for R1 after that. On 1/31/23 at 11:56 AM, V6 (CNA) said she worked on 1/27/23. V6 said she was not assigned to R1. V6 said about 6:00 PM, she was on the computer doing her charting and she heard R1 scream. She ran to R1's room to check on her, and she saw a guy bending down to put R1's legs back on the bed. V6 said she asked what happened and the guy said just bring a couple of sheets, maybe she's cold, then he went out of R1's room. She took a couple of sheets to R1 and covered her up. After the guy left R1's room, he went into the dining room and sat at a table for at least 10 minutes doing something on his computer, maybe charting. V6 said about 7:00 PM she went in to take R1's blood pressure and saw blood on R1's right arm and sheet. She ran to inform V5, and he (V5) came back to R1's room with her. V6 said she left R1's room at that time. She went back in to do R1's vitals a little later and that is when she saw the bump on R1's head. V6 said she heard V5 just outside of R1's room telling someone on the phone that she had a bump on her head. On 1/31/23 at 12:34 PM, V9 (RN/Unit Manager) said he worked on 1/27/23. V9 said he and V10 (Licensed Practical Nurse-LPN/IV Certified) went in to R1's room between 2:30 - 3:00 PM to try to start an IV. They were unsuccessful in trying to start the IV for R1, so they put R1's bed back down to the floor (low position) and placed the fall mat next to R1's bed. V9 said he did not see any injuries to R1 at that time. V9 said he and V10 went out and informed V3 that they were not able to start the IV and to call and get an order for someone from (the company that specializes in vascular access and is contracted with the facility's pharmacy) to come in and start the IV. On 1/31/23 at 12:43 PM, V7 (Certified Nursing Assistant/CNA) said she was assigned to R1 on 1/27/23. V7 said she did not see any bump, bruising or bleeding on R1 during her shift. V7 said after the residents had lunch, she took her break and then put R1 into her bed. V7 said she put R1's bed in the low position and placed the mat on the floor next to her bed. V7 said she was moved to another floor at 2:57 PM because someone had to leave. On 1//31/23 at 12:55 PM, V8 (Physician's Assistant) said she saw R1 around 11:30 AM on 1/27/23. V8 said R1 did not have any injuries to her face at that time. On 1/31/23 at 1:08 PM, V10 (LPN) said between 2:30-3:00 PM on 1/27/23 she went in with V9 to try to get a peripheral IV started on R1. V10 said they were not able to get the IV started. V10 said R1 was in bed with a sweater and pants on. V10 said R1 did not have any bumps, bruising or bleeding on her forehead when she and V9 were attempting to start the IV. V10 said they let V3 (LPN) know they were unsuccessful and V3 called to get an order for someone from (company that specializes in vascular access and is contracted with the facility's pharmacy) to come in and start the IV. V10 said she (V10) is the one that called the company to have them come in. On 1/31/23 at 1:18 PM, V1 (Administrator) said she spoke with V18 (RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) again and he told her that R1 had fallen out of bed while he was trying to start the IV. V1 said V18 panicked and thought it was something manageable. V1 said V18 told him he changed R1's clothes and placed a gown on her because there was blood on R1's clothes. V1 said V18 told her he did not tell the nurse about the fall, and he knew it was not the right thing to do. He panicked. On 1/31/23 at 1:29 PM, V3 (LPN) said she was R1's nurse on 1/27/23 from 7:00 AM-7:00 PM. V3 said between 5:00-6:00 PM she took the tech (RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) to R1's room. V3 said when V18 went to leave the area, he was in a hurry and was not going to provide her with paperwork about the procedure. She had to flag V18 down to get the paperwork from him. V18 handed her the paperwork, said here, and then left the area. V3 said R1 had been fully dressed when she took V18 to R1's room. V3 said after the injury was discovered, R1 had a gown on. She does not know who put the gown on R1. V3 said it was about 7:20 PM when V5 told her there was blood around R1's IV. V3 said she and V5 were in R1's room a few times tending to the IV and did not notice the injury to R1 because they were focusing on the IV. V3 said she went back out to chart and V5 came up to her asking about the injury to R1. She went back in to assess R1 and then called 911 because it was a bruise that she did not know where it came from and had not been there earlier. On 2/1/23 at 11:26 AM, V3 said she had walked by R1's room some time between 5:00-6:00 PM and R1's door was still closed. V3 said she told another nurse that it seemed to be taking a long time to start the IV. V3 said she did not go in to see what was taking so long. V3 said the injury was discovered some time between 7:30-8:00 PM. On 1/31/23 at 5:26 PM, V18 said on 1/27/23 he went to the facility to start three IVs. V18 said V3 took him to R1's room. V18 said he saw the mattress on the floor by R1's bed. He introduced himself to R1 and explained why he was there. V18 said he moved the mattress out of the way that was on the floor and raised R1's bed up about six to eight inches. V18 said he lifted R1's sleeve and prepared his kit. He applied a tourniquet to her arm and gave R1 lidocaine. V18 said R1 became squirrely at that time and was reaching over with her left arm to where he was working with her right arm. He wanted to get R1 more comfortable, so he turned to get more lidocaine from his cart. V18 said he heard a thud. V18 said he turned around and R1's torso and face were on the floor, and her feet were still on the bed. V18 said he panicked and lifted R1 back up into the bed. He did not notice any injury at that time. He asked R1 if she was okay and R1 did not respond. V18 said R1 had not responded when he introduced himself to her either. V18 said he gave R1 more lidocaine and inserted the mid-line. V18 said then he noticed blood on the right side of R1's head. He cleaned up the wound and applied pressure for about five minutes until the bleeding stopped. V18 said he noticed blood on R1's clothes and pillow case, so he removed her clothes and put a gown on her. V18 said he felt comfortable with R1's wound, that it was not bleeding. He was stressed out about what had happened, and he had other jobs to do. V18 said he moved onto the other residents in the facility. V18 said he panicked. He understands he should have reported it. It was a bad, bad, bad decision not to tell the nurse. When asked why he told V1 when she interviewed him the first time about the incident, V18 said he was scared to say what happened. V18 said he panicked. He was scared not only for her (R1), but for himself-the consequences. V18 said he is beside himself and feels horrible. He had been a nurse for [AGE] years and had emergency department experience. V18 said it is important to inform the nurse when a resident has a fall because they could have a head injury, a concussion, possible brain-bleed, or broken bones. R1's notes from a local hospital show R1 was sent to the emergency department on 1/27/23 and was diagnosed with acute localized area of extra-axial hematoma overlying the lateral left frontal lobe (intracranial hemorrhage). The hospital notes showed R1 was transferred from the emergency department to the ICU unit and a critical care physician was consulted. The facility's Abuse and Neglect of a Resident policy, with a revision date of 12/20/22, defined Neglect as Failure of the facility, it's associates or service providers to provide goods and services to a resident, necessary to avoid physical harm, pain, mental anguish, or emotional distress. Medical care, mental health treatment, psychiatric rehabilitation, personal care, or assistance with activities of daily living are necessary to avoid physical harm, mental anguish, or mental illness of a resident. Examples are but not limited to not acting on medical problems, prescribed treatment, or therapies, not calling a physician when necessary .

Based on interview and record review, the facility failed to ensure the safety of a resident during care for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. This failure resulted in R1 falling out of bed, getting a head injury, being sent to a local hospital emergency room , and later to the intensive care unit of the hospital. The findings include: R1's Progress Notes, printed by the facility on 1/31/23 showed she had diagnoses including pneumonitis due to inhalation of food and vomit, altered mental status, moderate protein-calorie malnutrition, dysphagia (difficulty swallowing), reduced mobility, weakness and need for assistance with personal care. R1's Brief Interview for Mental Status assessment (an assessment to determine cognitive status) dated 1/23/23, showed she was not able to complete the assessment due to Resident is rarely/never understood. The assessment also showed R1 had a short-term and long-term memory problem. R1's admission Baseline Care plan showed she needed one-person physical assist for eating, personal hygiene and bed mobility. The care plan showed R1 required assistance of two staff persons for transfers. No observations were made of R1 as she is no longer a resident of the facility. R1 is now on the hospice unit of a local hospital. On 1/30/23 at 4:50 PM, V16 (R1's daughter) said she received a call from the facility informing her that R1 had been found in bed with an injury to her head. V16 said there is no way R1 could have caused that kind of injury to herself. V16 said if R1 had fallen out of the bed, there is no way she would be able to get up and get back in bed by herself. On 1/31/23 at 11:56 AM, V6 (Certified Nursing Assistant-CNA) said she worked on 1/27/23. V6 said about 6:00 PM, she was on the computer doing her charting and she heard R1 scream. V6 said she ran to R1's room to check on her, and she saw a guy bending down to put R1's legs back on the bed. V6 said she asked what happened and the guy said just bring a couple of sheets, maybe she's cold, then he went out of R1's room. V6 said she took a couple of sheets to R1 and covered her up. She did not notice any injury at that time because R1's hair was covering her forehead. V6 said about 7:00 PM she saw blood on R1's right arm and sheet. She informed V5(Registered Nurse/RN), and he went back to R1's room with her. V6 said she left R1's room at that time. V6 said she went back in to do R1's vitals a little later, and that is when she saw the bump on R1's head. V6 said she heard V5 just outside of R1's room telling someone on the phone that she had a bump on her head. On 1/31/23 at 1:29 PM, V3 (Licensed Practical Nurse/LPN) said she was R1's nurse on 1/27/23 from 7:00 AM-7:00 PM. V3 said between 5:00-6:00 PM she took the tech (V18- RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) to R1's room. V3 said when V18 went to leave the area he was in a hurry. V3 said she had to flag V18 down to get the paperwork from him. R1 had been fully dressed when she took V18 to R1's room. V3 said after the injury was discovered, R1 had a gown on. V3 said she was out charting and V5 (RN) came up to her asking about the injury to R1. No one had reported an injury regarding R1 to her. V3 said she went back in to assess R1 and then called 911 because it was a bruise that she did not know where it came from and had not been there earlier. On 1/31/23 at 5:26 PM, V18 (an RN that works for a company that specializes in vascular access and is contracted with the facility's pharmacy) said on 1/27/23 he went to the facility to start three IVs (Intravenous access). V18 said V3 (LPN) took him to R1's room. He saw the mattress on the floor by R1's bed. V18 said he moved the mattress out of the way that was on the floor and raised R1's bed up about six to eight inches. R1 became squirrely and was reaching over with her left arm to where he was working with her right arm. V18 said he turned to get more lidocaine from his cart, and he heard a thud. He turned around and R1's torso and face were on the floor, and her feet were still on the bed. V18 said he panicked and lifted R1 back up into the bed. He did not notice any injury at that time. V18 said he gave R1 more lidocaine and finished the procedure. Then he noticed blood on the right side of R1's head. V18 said he cleaned up the wound and applied pressure for about five minutes until the bleeding stopped. V18 said he noticed blood on R1's clothes and pillow case, so he removed her clothes and put a gown on her. V18 said he felt comfortable with R1's wound, that it was not bleeding. V18 said he was stressed out about what had happened, and he had other jobs to do. He moved onto the other residents in the facility. V18 said he panicked. V18 said he understands he should have reported it. It was a bad, bad, bad decision not to tell the nurse. V18 said it is important to inform the nurse when a resident has a fall because they could have a head injury, a concussion, possible brain-bleed or broken bones. R1's progress note dated 1/27/23 at 7:56 PM, showed Writer noted resident with discoloration/dry blood to right forehead and lethargic. Writer assessed. Called 911. The progress note dated 1/27/23 at 8:20 PM, showed Resident via stretcher transported to (local ER) . R1's notes from a local hospital show R1 was sent to the emergency department on 1/27/23 and was diagnosed with acute localized area of extra-axial hematoma overlying the lateral left frontal lobe (intracranial hemorrhage). The hospital notes showed R1 was transferred from the emergency department to the ICU unit and a critical care physician was consulted.

Based on observation interview and record review, the facility failed to ensure fall interventions were put in place after a resident (R11) at risk for falls fell . This failure resulted in R11 sustaining a right hip fracture requiring surgical intervention. The facility failed to ensure a cervical collar was applied during transfer, the facility failed to ensure a gait belt was used to transfer a resident safely, and the facility failed to ensure a resident received nectar-thick liquids as ordered. This applies to 4 of 35 residents (R11, R600, R188, R452) reviewed for falls and safety in the sample of 35. The findings include: 1. R11's Physician Order Sheet dated 8/22 show R11 has diagnoses that include seizure, hypothyroidism and bipolar disorder. R11's facility assessment dated [DATE] show R11 is moderately cognitively impaired and needs extensive assist of 2 person assist with all transfers. R11's Fall Risk assessment dated [DATE] show R11 was at risk for falls. A Facility Reported Incident (FRI) dated 12/13/22 sent to the state agency show as initial and final, 12/12/22 at 10:30 AM, resident called out and was attended to in the room. The resident was observed lying on the floor by the bed, with call light within easy not activated by resident. When asked by the nurse what happened, resident verbalized, I stood up trying to look for my mask and lost balance. Nurse immediately initiated assessment. Head to toe assessment performed, noted with skin tear to right elbow, resident denies hitting his head noted pain in right hip .MD notified of incident and resident c/o of pain, STAT X-ray of the right hip was ordered . Results came back with Acute displaced right femoral neck fracture. MD notified of results with order to send patient out to the hospital for evaluation and treatment . (R11) was transported to ER via 911. Resident admitted for right hip fracture. Surgery planned 12/14/22 .Injury acute displaced right femoral neck fracture. R11's Emergency notes (ER) dated 12/12/22, show 80 y/o sig (significant) for developmental delay, seizure disorder CAD s/p CABG bipolar hypothyroidism who presented to ED with complaints of mechanical fall unto his right side .He was in a wheelchair when he dropped his mask onto the floor. He bent down from the wheelchair to pick up his mask, lost his balance and fell on to his R side . R11's radiology report dated 12/12/22 show R11 sustained Fracture of the right femoral neck (Right hip fracture) R11's surgical consultation dated 12/13/22 show the patient presents with observed fall . living in nursing home .who has pain and dysfunction in his right hip region. He was seen in the ER .X-rays taken in the ER consistent with right femoral neck fracture .He has pain with movement of the right hip .the right hip is short and externally rotated. It was difficult to get the history, he has some developmental delay which have been life long. Plan: We will take the patient to the operating room where he was medically optimized. R11 underwent surgical procedure: hemiarthroplasty of right hip. On 1/23/23 at 1pm, R11 was sitting in his wheelchair in his room. When asked how he was doing, he said Ok. When asked about his recent fall, he said he did not remember falling. On 1/24/23 at 8:34 am, V12 (Registered Nurse/RN) said she was the nurse when R11 fell . V12 (RN) said on 12/12/22 she was at the nurses' station when she heard R11 screaming. V12 said she ran to R11's room and found R11 on the floor on his right side. V12 said R11 said he was reaching for his mask and fell . V12 said R11 had discomfort to his right hip. R11 was sent to the ER via 911. R11 fractured his right hip. V12 said R11 had surgery to fix R11's right hip. V12 said R11 has history of falling due to unassisted transfers. V12 said R11 tends to forget frequent reminders. R11 has poor safety awareness and does not ask for assistance. V12 said R11 needs frequent monitoring. V12 said R11's room is far from the nurses' station. On 1/24/23 at 8:38 AM, V13 (Certified Nursing Assistant/CNA) said he was one of the CNAs working on 12/12/22. V13 said he heard R11 yelling for help. V13 said he went to R11's room and saw R11 on the floor. R11 said he stood up and tried to reach for something on the floor and fell . V13 said R11 has history of getting up from wheelchair without asking for assistance. R11 does not remember reminders. V13 said staff tries to make sure R11 was not transferring himself without assistance. V13 said there was no device to alarm staff when R11 was attempting to transfer. On 1/24/23 at 8:47 am, V14 (Certified Nursing Assistant/CNA) said R11 fell trying to reach for his mask. R11 was sent to the hospital. V14 said R11 had done this in the past, trying to transfer himself without waiting for assistance. V14 said staff do their best to check and monitor R11, but staff gets busy. A fall incident dated 9/30/22 show per resident had a fall . his head and c/o of back pain. Resident description: I slid from the chair. A fall incident dated 8/7/22 show writer heard a call from resident's room, went to resident's room and noted resident lying on his left side on the floor. Resident description: Per resident he was trying to go to bed by himself lost balance and fell to the floor. R11's fall care plan did not show any fall interventions or necessary precautions after R11's previous falls of 9/30/22 and 8/7/22. R11's latest care plan with revision date of 12/28/22 (only updated after R11 already had the fall with injury.) show R11 has history of falls r/t poor balance, unsteady gait, recent fall with right hip fracture with intervention to include remind resident to call for help and not to get up unassisted. On 1/24/23 at 11:30 AM, V3 (Assistant Director of Nursing/ADON) said reminders do not work for R11 since R11 has developmental delay. V3 said R11 does not retain reminders. V3 (ADON) said R11 is a fall risk due to history of unassisted transfers. V3 said unfortunately R11's care plan did not show any new evaluation and new fall interventions after R11's repeated falls due to unassisted transfers. V3 said there should be interventions for each fall that works for R11. R11's room is not visible from the nurses' stations. V3 said R11 will be moved closer to the nurses' stations, and more effective intervention has to be put into place to prevent falls and falls with injury. R11's progress notes, dated 12/28/22, by V48 (R11's physician), confirms R11's diagnosis of having developmental delay. The facility policy entitled Fall Risk Assessment and Prevention with revised date of 10/11/22 shows, Purpose: to guide management of falls within (name of the facility) according to regulation and best practices for fall management to assist the IDT in reducing the risks of resident falls in the community as well as managing post fall interventions. 35541 2. R600's Progress Note dated September 28, 2022, showed R600 sustained a C2 (second cervical (neck) vertebrae (spine) fracture) with severe cervical stenosis and (spinal) cord edema after a fall. R600's Restorative Progress note dated January 23, 2023, showed R600 wears Aspen collar (cervical collar) on at all times except for eating and bathing time for spinal precautions . R600's physician order dated January 23, 2023, showed, Precautions: Fall Risk, cervical collar on at all times except eating and drinking: spinal precautions. On January 23, 2023, at 9:22 AM, R600 was lying in bed with no cervical collar around her neck. A cervical collar was noted on R600's bedside table. At 9:40 AM, V6 (Certified Nursing Assistant/CNA) and V7 (Certified Nursing Assistant/CNA) transferred R600, from her bed to a chair, without a cervical collar in place. At 12:20 PM, R600 was seated in her room with no cervical collar on. On January 24, 2023, at 9:24 AM, R600 was alone in her room with no cervical collar on. On January 23, 2023, at 10:15 AM, V6 (CNA) stated, I don't know why exactly she (R600) needs to wear that collar. I know she doesn't wear it when she eats. She is a new resident to us. She just got admitted last week. On January 25, 2023, at 9:10 AM, V3 (Assistant Director of Nursing/ADON) stated, R600 is to have her cervical collar on at all times except when eating or drinking. She needs it to keep her cervical spine fracture stable. She is at risk for falls. If she were to fall again, without the collar on, it could make her spine fracture worse or cause another spinal fracture. 3. R188's current care plan showed R188 was at high risk for falls due to her diagnosis of dementia and problems with her balance/gait. The care plan showed R188 required the assistance of one staff, with the use of a gait belt and walker, for all transfers. On January 23, 2023, at 9:10 AM, V7 (CNA) transferred R188 from a wheelchair to a recliner without the use of a gait belt. V7 placed her hand on the waistband of R188's pants to assist her with the transfer. On January 24, 2023, at 11:20 AM, V3 (ADON) stated, A gait belt should be used for all transfers. R188 had a fall about a month ago so a gait belt should be used when transferring her. The facility's Gait Belt/Transfers policy dated May 10, 2021, showed, Gait belt must be used with any assisted transfer or ambulating procedure. 34314 4. R452's electronic medical record (EMR) shows, she was admitted to the facility on [DATE]. On January 23, 2023, at 9:34 AM, R452 was lying in bed. Her breakfast tray was on her bedside table, pushed up against the wall. She was served a regular diet of french toast, breakfast sausage, oatmeal and regular thin orange juice. There were 4 cups of water on her bedside dresser. 2 of them were regular water and the other 2 were thickened water. She had not eaten breakfast yet. On January 23, 2023, at 10:56 AM, V49 (Occupational Therapist/OT) asked V29 (CNA) to please warm up R452's breakfast so she could eat breakfast. (lunch being served at 11:30 AM) On January 23, 2023, at 11:15, V33 (R452's sister) was at the facility visiting her. She stated, they served her a regular diet for breakfast that morning. She had a feeding tube until Thursday last week (January 19, 2023). She was on a special diet when she left the hospital on Friday (January 20, 2023). We told them that on Friday when she was admitted . She can't eat a regular diet. On January 23, 2023, at 11:50 AM, V29 (CNA) stated, she did not know what R452's diet order was. V29 did not have a meal ticket for R452. She had given her a regular diet this morning even though she didn't know what her diet was. She stated, she asked the nurse, but the nurse did not have time to look at R452's diet order. V29 felt she couldn't wait for the nurse to look so she served her a regular tray. On January 23, 2023, at 12:03 PM, V30 (Licensed Practical Nurse/LPN) stated, she didn't know what R452's dietary orders were because she didn't see anything in the computer. R452's order summary report provided on January 24, 2023 shows, no dietary orders were entered into the computer until Monday, January 23, 2023 (3 days after she was admitted to the facility). Regular diet, mechanical soft texture, nectar/mildly thick consistency, seen by ST (speech therapy). R452's ST daily treatment note provided on January 25, 2023, shows, Reason for referral: Dysphagia (difficulty swallowing), The patient (R452) is a [AGE] year old female who was admitted to the facility following hospitalization with diagnosis of CVA (cerebral vascular accident). During hospitalization , patient with increased lethargy and recommendations of NPO (nothing by mouth) with NG tube (nasogastric tube) for immediate nutrition. Increased levels of alertness noted, and video swallow study completed on 1/19/23 with diet recommendations of NTL (nectar thick liquids)/mechanical soft solids. Upon admission to the facility, no diet orders were placed in patient's chart, with staff requesting immediate SLP (speech language pathologist) evaluation to determine safest least restrictive diet . ST was not requested to see patient until January 23, 2023 (3 days after admission and no diet orders). On January 25, 2023, at 10:25 AM, V31 (Speech Therapist) stated that there were no orders from the hospital, but they should have still verified what her diet order was. She definitely is recommending nectar thick liquids because she is a silent aspirator (swallows liquids into her lungs) which was shown on the video swallow study. There were no orders for speech therapy either. If they would have entered orders for ST, we would have seen her over the weekend. R452's hospital admission paperwork dated January 20, 2023, shows, SLP recommendations: Compensatory swallowing strategies: Upright 90 degrees for all oral intake; remain upright for 10-30 minutes after meals; eat/feed slowly; small bites/sips; alternate solids and liquids. Recommended form of medications with puree. SLP skilled therapy needed at next level of care, YES. No ST orders were placed until January 23, 2023 (3 days after admission).

Based on interview, and record review, the facility failed to monitor, provide treatment, and evaluate a resident's acute episode of [CONDITION(S)]. This failure resulted in R1 being found unresponsive with a blood glucose level of 33mg/dl. R1 expired as a result of [CONDITION(S)]. This applies to 1 of 3 residents (R1) reviewed for quality of care in the sample of 3. The Immediate Jeopardy began of [DATE] when a resident had an acute episode of [CONDITION(S)] and expired as a result of [CONDITION(S)]. The Immediate Jeopardy was identified on [DATE]. V2 (DON) and V12 (Assistant Administrator) was informed of the Immediate Jeopardy on [DATE]. The surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on [DATE] however, noncompliance remains at a Level Two because time is needed to evaluate: The Findings include: R1's Medical Certification of Death dated [DATE] documents the immediate cause of death is [CONDITION(S)]. The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The nurse's note dated [DATE], V5 (RN) documents R1 was transferred to his room at 2:00 PM. V5 documents he is unable to perform a neuro check on R1, he is refusing to be cooperative with the assessment. R1 is refusing evening medications, refusing to have his blood sugar checked, and refusing to eat. Supervisor was made aware. The nurse's note dated [DATE], V4 (RN) documents at 7:30 PM, R1 is alert, and verbally responsive to staff. Blood glucose check was 58mg/dl. V5 offered juice but R1 pushed it away refusing anything offered to him, V8 (Physician) was notified with new orders received. V5 notified V10 (R1's son) and a virtual visit was connected. V9 encouraged R1 to drink fluids because of his low blood sugar. R1 was able to consume 25% (percent) of the juice and took his medications in applesauce. The nurse's note dated [DATE] at 10:30 PM, V4 (RN) documents R1 was awake in his bed screaming and yelling. R1's blood glucose check was 90mg/dl. (3 hours later). V5 offered R1 a drink of juice but R1 refused. The nurse's note dated [DATE] at 4:00 AM, V4 documents R1's incontinent pad is on the floor and his bed linens are wet. R1 is uncooperative during care. The nurse's note dated [DATE] at 6:00 AM, V4 documents at 6:00 AM, R1 is not responding to verbal calling, absence of breathing, and no pulse. R1's blood glucose check is 33mg/dl. [MEDICATION(S)] 1mg given paramedics called and CPR (Cardio Pulmonary Resuscitation) given until paramedics arrived. The Emergency Medical Response report dated [DATE] shows they were called to the scene for a person not conscious, not breathing. Unknown last time seen normal. CPR was discontinued at 6:59 AM, and R1 was pronounced expired. R1's intake report dated [DATE] shows he had 0% intake for breakfast, 0% intake for lunch, and 25% or less for dinner. R1's electronic medical records do not show any further blood glucose monitoring was recorded from 10:30 PM to 6:00 AM when he was found unresponsive with a blood glucose level at 33mg/dl. R1's Vitals report dated [DATE] shows the last set of vitals was recorded at 6:15 AM. (There was no vitals recorded after R1's acute episode of [CONDITION(S)]). On [DATE] at 11:51 AM, V5 (RN) said R1 was transferred to his floor at 2:00 PM. V5 said R1 was agitated and it was reported he had refused lunch earlier that day. V5 said R1 ate minimal during the dinner meal. V5 said R1 was combative and refused medications, and his blood sugar check during the evening. V5 said if a resident's blood sugar is below 60 we notify the physician and give the resident some juice, and recheck the blood sugar 15 minutes later to make sure it was effective. On [DATE] at 2:09 PM, V4 (RN) said she was R1's nurse the night of [DATE]. V4 said she received report that R1 had behaviors and was refusing medications, care, and had poor intake for the dinner meal. V4 said at 7:30 PM, R1's blood sugar was 58mg/dl. V4 said she notified V8 (Physician) and received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . V4 said she notified V10 (R1's son) and with his encouragement via face time he was able to encourage R1 to take his medications with applesauce. V4 said R1 drank not much of the cranberry juice offered and then she offered him orange juice. R1 drank not a lot of the orange juice. V4 said I'm worried do I send (R1) out the care we are doing is not working. V4 said she checked R1's blood sugar at 10:30 PM (3 hours later) and it was 90mg/dl. V4 said she did not recheck R1's blood sugar until she found him unrepsonsive and not breathing at 6:00 AM. His blood sugar check was 33mg/dl. V4 said she then administered the [MEDICATION(S)] and started CPR immediately until the paramedics arrived. V4 stated, It was my assumption. R1 had enough juice (25 % of a cup) enough to have his blood sugar go up. V4 said she was not familiar with the facility's policy regarding [CONDITION(S)], but said my practice is to recheck a residents blood sugar after 30 minutes of treatment to ensure the treatment was effective. On [DATE] at 2:24 PM, V10 (R1's son) said he got a call from V4 (RN) the evening on [DATE] and said R1's blood sugar was 58. V10 said we connected via face time and he encouraged his dad to drink some juice. V10 said his dad took one sip of cranberry juice and 2 sips of orange juice and he was worried that it wasn't enough for his low blood sugar. On [DATE] at 12:00 PM, V11 (Physician) said staff should have administered [MEDICATION(S)] for a residents blood sugar below 60mg/dl and provided frequent monitoring of the blood glucose level every 30 minutes until consistently above 100. V11 said if the [MEDICATION(S)] was not effective they should administer a second dose and continue to monitor. V11 said I don't know if the facility has a standard protocol for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 2:25 PM V8 (Physician) said he does not recall the details with R1. V8 staff should do everything possible to encourage a resident to drink or eat something for a diabetic resident with a low blood sugar, and administer [MEDICATION(S)] if possible. I would expect the staff to monitor the resident, check the vitals, and monitor the blood glucose level. On [DATE] at 12:10 PM, V3 (Night Shift Supervisor) said she worked the evening on [DATE]. She said V4 reported to her R1's blood sugar level was 58mg/dl at 7:30 PM. V3 said V4 notified the physician and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:07 AM, V7 (RN) said she was working the night of [DATE]. V7 said she heard the V4 (RN) screaming for help in the morning. V7 said R1 was unresponsive, and not breathing. V7 said if a resident is hypoglycemic she would administer juice, notify the physician, and monitor resident's blood glucose 30 minutes later to ensure the effectiveness of the treatment. V7 said if a resident was unable to drink fluids she would notify the physician and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 12:28 PM, V2 (DON) said they have no protocol or policy in place for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . That's why the staff notify the physician. The facility's Gluocose Testing Policy revised on [DATE], states, A. Obtain order from physician or perform PRN glucose testing based on nursing judgement to assess and evaluate a resident's clinical status or response to diabetic therapy. The facility's [MEDICATION(S)] Administration Policy last revised [DATE] states, [MEDICATION(S)] is available for administration in case of hypoglycemic episodes when the resident exhibits unconsciousness, unresponsiveness, or inability to safely eat or drink , evaluate effectiveness which may include blood glucose monitoring. The Immediate Jeopardy that began on [DATE] was removed and the deficient practice was corrected on [DATE] when the facility took the immediate actions to remove immediacy and correct the non-compliance. To remove the immediacy the facility has initiated the following interventions: 1. A policy for managing [CONDITION(S)] was put in place, which includes a protocol for nursing interventions after a blood sugar level of less than or equal to 70mg/dl is detected. (Attachment A). 2. Education on the policy was initiated immediately to all nurses working, and will continue at the start of each shift so that all nurses on all shifts, and any newly hired nurses will be aware of the steps to take if a blood sugar level of less than equal to 70mg/dl is identified. 3.The Director of Nursing and/or designee will conduct audits weekly for four weeks, then monthly for one year to determine if (i) if nurses are able to verbalize understanding of the [CONDITION(S)] policy; and (ii) whether the policy is being followed based on review if blood glucose readings of 5 selected diabetic residents (Attachment B). Audits will be reviewed by the Quality Assurance Committee until substantial compliance has been achieved as determined by the committee.

Based on interview, and record review, the facility failed to ensure a resident was free from sexual abuse which resulted in a staff member making sexually inappropriate comments to a resident (R1) for 1 of 3 residents reviewed for abuse in the sample of 4. The findings include: A facility incident report dated February 26, 2021 showed, A culinary employee reported that he overheard a CNA (Certified Nursing Assistant) say to (R1), If you wash your hands, you can touch my chingadara. In this situation, chingadara was a slang word which referenced male genitalia. The report showed the referenced CNA (V7) was interviewed and admitted to telling R1, If you follow me then you can touch me. The report showed the allegation of sexual abuse was substantiated involving R1 and V7 CNA. R1's Care Plan dated October 11, 2020 showed R1 was severely cognitively impaired due to his diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On March 8, 2021 at 11:05 AM, two attempts were made to interview R1 in regards to the February 26, 2021 incident. The attempts to interview R1 were unsuccessful as R1's verbal response to questions was babbling, and incoherent speech. On March 8, 2021 at 11:45 AM, V7 CNA stated on February 26, 2021, I was trying to get (R1) to wash his hands. (R1) can have behaviors and refuse to do things. We were out in the main dining room by the sink. He kept trying to touch my penis and offer me oral sex. I ignored him. I know it was wrong but I then told him that if he washed his hands, I would let him touch my chingadara. Chingadara is Spanish for penis or male parts. On March 8, 2021 at 12:52 PM, V11 Dietary Aide stated, On that morning (2/26/21), I was cleaning up dishes in the dining room on the dementia unit. (V7 CNA) was at the sink in the dining room with (R1). I overhead (V7 CNA) tell (R1), I know you want to touch my chingadara. Wash your hands and I will give you the banana. On March 8, 2021 at 11:30 AM, V10 CNA stated on February 26, 2021, he overheard V7 CNA tell R1, Come and wash your hands before you touch me or my chingadara. On March 8, 2021 at 9:50 AM, V3 Assistant Director of Nursing (ADON) stated on February 26, 2021, V7 CNA told her, One of the culinary people overheard me tell (R1) that if he washed his hands, I would let (R1) touch me. The facility's Abuse and Neglect of Resident policy dated November 26, 2019 showed, The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .Sexual abuse is nonconsensual sexual contact of any type with a resident, including, but not limited to, assault, rape, or sexual harassment .

This resulted in two deficient practice statements: 1. Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control and Prevention (CDC), observation, interview and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to: 1) follow appropriate protective personal equipment (PPE) guidelines in the observation rooms for COVID-19 residents on contact and droplet precautions; 2) properly disinfect shared medical equipment after each use and; 3) adhere to social distancing. This had the potential to affect all 17 residents in MyRehab1, 17 residents in 2EFG and 27 residents in 3HJ units. This failure had a high likelihood of causing serious harm or death to the residents given their congregate nature, age, and underlying medical conditions. At the time of the survey, the facility had 21 residents who tested positive for COVID-19 and 41 residents who were on observation units (MyRehab1, MyRehab2 and 1E). There were 22 staff who tested positive for COVID-19. The facility was in a county which had sustained community transmission, especially in the nursing home setting. The Immediate Jeopardy began on 5/21/20 when the facility failed to: 1) follow appropriate protective personal equipment (PPE) guidelines when entering and exiting R2 and R3's room (both residents in the COVID-19 Observation Unit) 2) properly disinfect shared medical equipment after each use in the Observation unit using an EPA-approved disinfectant under List N and; 3) follow social distancing among five (R4, R5, R6, R7, and R8) residents in the common activity area on the 2EFG unit and among 17 (R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, and R25) residents in the dining room on the 3HJ unit. Staff were present during observation on both units. The Administrator and Director of Nursing were informed of the Immediate Jeopardy on 5/22/20 at 3:11pm. The Immediacy was removed when the removal plan was accepted on 5/27/20 at 2:51pm and was verified as implemented on May 29, 2020 at 3:44pm. Findings include: Review of the CDC's Responding to Coronavirus (COVID-19) in Nursing Homes revised on 4/30/20 under Considerations for the Public Health Response to COVID-19 in Nursing Homes revealed, .Resident Cohorting .Assign dedicated resident care equipment (e.g. vitals machine) to the cohort unit. Cleaning and disinfection of shared equipment should be performed between residents and the equipment should not leave the cohort unit. Further review of the same document under Considerations for new admissions and readmissions revealed, .Create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Options include placement in a single room or in a separate observation area so the resident can be monitored for evidence of COVID-19. All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of a N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown .However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Testing should not be required prior to transfer of a resident from an acute-care facility to a nursing home. Retrieved on 05/26/20 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes- responding.html A. During the entrance interview on 5/21/20 at approximately 11:00am, the Administrator and the Director of Nursing (DON) were asked if the facility had any confirmed cases of residents with COVID-19 or persons under observation. The Administrator stated they had residents who tested positive for COVID-19 on isolation in their COVID unit. The DON added the facility also had observation units namely: the MyRehab1 (MR1), MyRehab2 and unit 1E. The DON explained the residents on MR1 were new admissions, readmissions and under observation for 10 days. Both were asked about the 10-day observation period in lieu of the 14 day-observation period per the CDC Guidelines. The DON stated they took into consideration the number of days the residents were under observation in the hospital hence the decision to put them on a ten-day observation. Both were informed to review the CDC guidelines rigorously to ensure the facility followed the appropriate number of days for the observation period. During an observation on 5/21/20 at approximately 2:30pm, in the MyRehab1 (COVID-19 Observation unit), Nurse Aide (NA) 1 was observed to exit R2's room with the Mobile Vital Signs Machine (MVSM) in tow. NA1 had his gloves on. NA1 immediately entered R3's room without removing his used gloves, without donning an isolation gown and without disinfecting the MVSM. Since NA1 did not close the door of R3's room and the bathroom door was wide open, NA1 was observed inside the room to take R3's vital signs. NA1 then went to the bathroom to empty R3's urinal. Afterwards, NA1 exited the bathroom without performing hand hygiene, and still wearing the same gloves, went back to R3's room, took the MVSM, and exited R3's room. NA1 was observed to only remove his gloves when he was outside R3's room. NA1 was about to enter the next room when he was stopped by the surveyor and was asked about the above-mentioned observations. NA1 stated, I know, I know. I should have used the gown. When asked about the lack of hand hygiene and what the facility's process was in disinfecting the MVSM in between resident's use, NA1 did not provide an answer. The unit manager (UM) who was nearby was asked about cleaning and disinfecting the MVSM. The UM stated, We used the bleach wipes. The UM asked NA1 to retrieve the disinfecting wipes that staff used to disinfect the shared MVSM. NA1 took a tub of hand sanitizing wipes from the basket attached to the roll stand of the MVSM that he had used earlier. After checking the tub, the UM verbalized the wipes were not the correct disinfecting wipes. NA1 refuted the DON's statement and said, This is what we've been using. The UM later found a tub of bleach wipes and confirmed they were the appropriate disinfecting wipes. When asked what the dwell time was for the said wipes to reach its full efficacy, the UM responded, I am not aware if there's one. The UM was asked to check the label affixed on the tub. After reading the label the UM stated, It's for one minute. The UM was also asked about NA1's lack of hand hygiene. The UM explained that NA1 should have removed his gloves and performed hand hygiene before he exited R2's room. When asked about the use of an isolation gown. The UM explained that staff members in the observation unit were expected to don isolation gowns prior to entering and providing care to residents. The UM described the process as follows: A. Staff members were issued one gown prior to the start of their shift. Staff wrote their names on their gown. B. Don the gown prior to entering and providing care to residents. C. Remove the gown in the Clean Room (a room where staff could hang the gowns when not in use) and reuse the same gown as needed for the entire shift unless it was visibly soiled. The UM was asked about MR1's staffing considerations during this time. The UM explained MR1 was staffed accordingly with two nurses and three nursing assistants on a regular day. The UM further explained that although staff had specific room/resident assignments they were expected to help other residents regardless of assignments. Review of the MR1's daily census for 5/21/20 revealed there were 17 residents residing on the unit during the survey. Review of the 17 residents' demographics revealed their age ranged from 65 to [AGE] years old. Further review of the 17 residents' hospital discharge summaries indicated presence of underlying chronic medical conditions such as hypertension, [DIAGNOSES REDACTED], [MEDICAL CONDITION], asthma, different types [MEDICAL CONDITION] and heart failure, to name a few. According to the CDC, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19 and other pathogens, including [MEDICAL CONDITION] (e.g., Carbapenemase-producing organisms, [MEDICAL CONDITION]) Review of R2's electronic health record (EHR) revealed R2 ([AGE] years old) was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. Further review of the same EHR under nursing progress notes dated 5/11/20 signed by (name of nurse) 11:11am, indicated, Went out with transport in stable condition for Orthopedic appointment. Review of R3's EHR revealed R3 ([AGE] years old) was admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. On 5/21/20 at approximately 3:45pm, the DON was notified of the observation in the MR1 unit. The DON stated she expected staff to follow proper PPE use especially in the observation unit and echoed the earlier explanation provided by the MR1 UM. In addition, the DON explained that staff should have disinfected the MVSM in between resident's use for infection control purposes. The DON was queried about the extended length of time R2 had stayed in the observation unit. The DON replied, She went out for an outside appointment. That's why she's still under observation. The DON further explained that every time a resident went out for an outside appointment the 10-day observation period automatically restarted. The DON indicated the facility did not accept residents who tested positive for COVID-19. When asked whether R2 was re-tested for COVID-19 after her outside appointment on 5/11/20. The DON stated, I do not think so but I can give you her test results from the hospital. Review of the said COVID-19 test report provided by the DON indicated R2 tested negative for COVID-19. The said test was performed on 4/20/20 in the hospital and four days prior to her admission to the facility. It was reiterated to the DON that a single negative test did not negate the fact that the resident could still be exposed or would not become infected in the future, and this was precisely why the CDC emphasized the use of all PPE and strict adherence to the 14-day observation period in the observation unit. During a follow up interview on 5/29/20 at 1:45pm, the DON was asked what she considered were high-contact patient care activities. The DON stated that she considered showering, providing hygiene and transferring (residents) as high-contact care activities. When asked about the emptying of R3's urinal in the toilet, the DON confirmed, That too is a high-contact care since there's a possibility of splashing. Review of the facility's Coronavirus, Screening, Prevention and Care policy revised on 5/14/20 under III Policy Implementation indicated .2. Reinforcement of preventive measures with HCPs such as: a) Standard Precautions b) Use of PPE c) Hand hygiene d) Respiratory hygiene and cough etiquette e) Proper handling and cleaning of the environment, linens and resident care equipment .4. New admissions and readmissions will be placed on Contact-Droplet Precautions and monitored for symptoms for a minimum of 10 days . Review of the facility's Infection Prevention and Control Plan revised on 5/2/20 under Hand Hygiene: General Statement Good hand hygiene is a requirement of Standard Precautions. Hand hygiene is performed before and after each care contact for which hand hygiene is indicated by acceptable professional practice, utilizing designated time frames and products. Alcohol based hand rub (ABHR) is the preferred method, however, hands should be washed with soap and water when they are visibly soiled, before or after eating or handling food, after using the restroom and after caring for a resident with known or suspected [MEDICAL CONDITION] or norovirus infection .under Gloves indicated, .Gloves should be removed promptly after use and hands should be washed or sanitized to avoid transfer of microorganisms to other individuals or the environment . Further review of the same document under Resident/Client Care Equipment: General Statement revealed, .Ensure that reusable equipment is not used for the care of another resident until it has been appropriately cleaned. Manufacturer's recommendations for cleaning and disinfection are followed . Review of the Edan (manufacturer of the facility's MVSM) Monitor User Manual under Chapter 8 Maintenance and Cleaning dated 4/12 indicated, Regular cleaning of the monitor shell and the screen is strongly recommended. Use only non-caustic detergents such as soap and warm water (+40 /+104) monitor shell. Do not use strong solvents such as [MEDICATION NAME] or trichloroethylene. Take extra care when cleaning the screen of the monitor because it is more sensitive to rough cleaning methods than the housing. Do not permit any liquid to enter the monitor case and avoid pouring it on the monitor while cleaning. Do not allow water or cleaning solutions to enter the measurement connectors. Wipe around, except connector sockets .3. This company has no responsibility for the effectiveness of controlling infectious diseases using these chemical agents. Please contact infectious disease experts in your hospital for details. 4. Please disinfect timely to prevent the cross infection between patients . Review of a CDC article titled Coronavirus Disease 2019 (COVID-19) dated April 30, 2020 under Older Adults revealed, Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Under Older Adults are at Higher Risk revealed, 8 out of 10 deaths in the U.S. have been in adults [AGE] years old and older. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html 2. On 5/21/20 at 11:33am, seven residents were observed in the common activity area of the 2EFG unit. R4, R5, R6, R7, and R8 were next to each other while sitting in their wheelchairs. There was approximately two feet distance in between these residents. R4, R5, R6, R7, and R8 were not wearing any cloth face covering or face masks. None of the residents had tissue paper with them that could be used to cover their nose and mouth if they sneezed or coughed. Registered Nurse2 (RN2), Certified Nursing Assistants (CNA2 and CNA3) were present in the area but failed to assist residents to practice social distancing. At 12:40pm, when CNA2 was asked if there was at least six feet distance between R4, R5, R6, R7, and R8, CNA2 stated, No. R4 tested positive for COVID-19 on 5/26/20. A. Review of R4's medical record revealed R4 was [AGE] years old. R4's [DIAGNOSES REDACTED]. Review of R4's Nursing Follow-up note dated 5/22/20 at 1:11pm revealed, .Resident confused wandering around the unit by herself, up on wheelchair. Review of R4's Nursing Follow-up note dated 5/23/20 at 2:05pm revealed, Resident confused, wandering around the unit by herself, up on wheelchair. Assisted to washroom and bed. Wander guard LLE (left lower extremity). Safety/fall risk precautions . Review of R4's [MEDICAL CONDITION] Note dated 5/26/20 at 3:23pm revealed, Review of Symptoms: occasional cough .Transferred to 2C .Assessment and Plan: Covid 19 + Asymptomatic .Plan: Isolation .Respiratory toilet [MEDICATION NAME] . Review of R4's Nursing Follow-up note dated 5/27/20 at 10:12am revealed, .Resident confused, wandering around all over the unit by herself, up on wheelchair. Assisted to washroom and bed .4:10pm Per DON (Director of Nursing) and ADON (Assistant Director of Nursing), resident tested COVID-19 positive, and transferred back to room [ROOM NUMBER] 4B unit. MD informed. Endorsed to 4A unit staff. Review of R4's lab result revealed nasal swab was collected on 5/22/20. R4's result dated 5/26/20 revealed, Positive [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2 - the [MEDICAL CONDITION] that can cause COVID-19) B. Review of R5's medical record revealed R5 was [AGE] years old. R5's [DIAGNOSES REDACTED]. C. Review of R6's medical record revealed R6 was [AGE] years old. R6's [DIAGNOSES REDACTED]. D. Review of R7's medical record revealed R7 was [AGE] years old. R7's [DIAGNOSES REDACTED]. R7's MD Progress Note dated 5/14/20 revealed [DIAGNOSES REDACTED]. E. Review of R8's medical record revealed R8 was [AGE] years old. R8's [DIAGNOSES REDACTED]. 3. On 5/21/20 at 11:58am, 19 residents were observed in the dining room of 3HJ unit. There were seven tables in the dining room. The 17 residents at six different tables were seated close to each other. This was verified by Registered Nurse3 (RN3). There were other staff present in the dining area but the staff failed to remind these residents on social distancing: R9, R10 and R11 were sitting at the first table. They were approximately two to three feet away from each other at the time of observation. R12, R13 and R14 were sitting at the second table. They were approximately two to three feet away from each other at the time of observation. R15, R16 and R17 were sitting at the third table. They were approximately two to three feet away from each other at the time of observation. R18, R19 and R20 were sitting at the fourth table. They were approximately two to three feet away from each other at the time of observation. R21, R22 and R23 were sitting at the fifth table. They were approximately two to three feet away from each other at the time of observation. R21, R22 and R23 were sitting at the fifth table. They were approximately two to three feet away from each other at the time of observation. R24 and R25 were sitting at the sixth table. They were approximately two to three feet away from each other at the time of observation. A. Review of R9's medical record revealed R9 was [AGE] years old. R9's [DIAGNOSES REDACTED]. B. Review of R10's medical record revealed R10 was [AGE] years old. R10's [DIAGNOSES REDACTED]. C. Review of R11's medical record revealed R11 was [AGE] years old. R11's [DIAGNOSES REDACTED]. D. Review of R12's medical record revealed R12 was [AGE] years old. R12's [DIAGNOSES REDACTED]. E. Review of R13's medical record revealed R13 was [AGE] years old. R13's [DIAGNOSES REDACTED]. F. Review of R14's medical record revealed R14 was [AGE] years old. G. Review of R15's medical record revealed R15 was [AGE] years old. R15's [DIAGNOSES REDACTED]. H. Review of R16's medical record revealed R16 was [AGE] years old. R16's [DIAGNOSES REDACTED]. I. Review of R17's medical record revealed R17 was [AGE] years old. R17's MD progress note dated 5/21/20 revealed [DIAGNOSES REDACTED]. J. Review of R18's medical record revealed R18 was [AGE] years old. R18's [DIAGNOSES REDACTED]. K. Review of R19's medical record revealed R19 was [AGE] years old. L. Review of R20's medical record revealed R20 was [AGE] years old. R20's MD Discharge note dated 5/26/20 revealed [DIAGNOSES REDACTED]. M. Review of R21's medical record revealed R21 was [AGE] years old. R21's [DIAGNOSES REDACTED]. N. Review of R22's medical record revealed R22 was [AGE] years old. R22's [DIAGNOSES REDACTED]. O. Review of R23's medical record revealed R23 was [AGE] years old. R23's [DIAGNOSES REDACTED]. P. Review of R24's medical record revealed R24 was [AGE] years old. R24's [DIAGNOSES REDACTED]. R24's MD progress note dated 5/21/20 revealed [DIAGNOSES REDACTED]. Q. Review of R25's medical record revealed R25 was [AGE] years old. R25's [DIAGNOSES REDACTED]. During interview with the DON on 5/29/20 at 1:42pm, when asked about her expectation from staff on social distancing especially during meals and activities, the DON stated, We did the education on social distancing and how it is up to staff to intervene when they (residents) are not following social distancing and redirect them. We applied the x mark on the floor as guide for the staff. When asked about additional measures being implemented to other residents that may have had contact with R4, the DON stated So our 2F unit is like an observation unit, everybody (staff) is using PPE. They're all dementia and Alzheimers. (Staff) Checking on residents every 8 hours including spO2 (oxygen saturation in the blood) and retest them (residents) on Tuesday. We did just retest them again yesterday morning 5/28 and are waiting for the result. Review of facility's policy titled Coronavirus, Screening, Prevention and Care dated 5/14/2020 under III. Policy Implementation revealed, 3. Following the direction of CDC, CMS, and state and local authorities regarding .b) Restrictions of: 5) Group activities, including communal dining. According to QSO-20-14-NH Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised) dated March 13, 2020, under Guidance for Limiting the Transmission of COVID-19 for Nursing Homes revealed, Additional guidance: 1. Cancel communal dining and all group activities, such as internal and external group activities .3. Remind residents to practice social distancing and perform frequent hand hygiene . In a CDC article titled Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs) dated May 21, 2020 under #3. Prevent spread of COVID-19 revealed, Actions to take now: Cancel all group activities and communal dining. Enforce social distancing among residents. Ensure all residents wear a cloth face covering for source control whenever they leave their room or are around others, including whenever they leave the facility for essential medical appointments. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html In a CDC article titled Social Distancing dated May 6, 2020, revealed, Limiting face-to-face with others is the best way to reduce the spread of coronavirus disease 2019 (COVID-19) .Social distancing, also called physical distancing, means keeping space between yourself and other people outside of your home. To practice social or physical distancin .Stay at least 6 feet (about 2 arms' length) from other people, do not gather in groups .In addition to everyday steps to prevent COVID-19, keeping space between you and others is one of the best tools we have to avoid being exposed to this virus and slowing its spread locally and across the country and world. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html 2. Based on observation, interview and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure on: social distancing; proper storage of clean linens; and proper doffing of personal protective equipment. This had the potential to affect all 214 residents who had not yet tested positive for COVID-19 in the facility. Findings include: 1. On 5/21/20 at 11:52am, Registered Nurse3 (RN3) was observed sitting in front of the computer in 3HJ nurses' station wearing a face mask. Group Therapy Staff (E5) was observed in a squat-kneel position wearing a face mask, next to RN3. There was approximately one to one and a half feet distance between RN3 and E5. Review of facility's policy titled Coronavirus, Screening, Prevention and Care dated 5/13/20 under IV. Procedure revealed, The primary goal is to prevent COVID-19 from being introduced within the campus. Prevention efforts include 1. Providing training and communication for associates, residents, resident representatives and other campus visitors on COVID-19 which may include: .d) Maintaining social distancing, when possible, of 6 feet or greater. In a CDC article titled Preparing for COVID-19 in Nursing Homes dated May 19, 2020, under Implement Social Distancing Measures revealed, Implement aggressive social distancing measures (remaining at least 6 feet apart from others): Remind HCP (healthcare personnel) to practice social distancing and wear a face mask (for source control) when in break rooms or common areas. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html 2. A. On 5/21/20 at 12:48pm, a clean linen cart was observed inside the laundry room. There were four folded flat sheets exposed and a folded black leather jacket on top of the clean linen cart. There was no barrier or covering on the black leather jacket and was laying on top of one of the flat sheets. The Director of Facilities/EVS (E1) and Laundry Staff (E6) were present during the observation. E6 stated that the black leather jacket belonged to another laundry staff. When asked if any item could be placed on top of the clean linen cart, both E1 and E6 stated, No. B. On 5/21/20 at 12:57pm, a tall clean linen cart was observed along the hallway of My Rehab 1 which was an Observation Unit. There were three clean cloth underpads laying on top of the clean linen cart. On the opposite end of the unit, another clean linen cart was observed with several linen exposed, on top of the linen cart. During interview with the DON on 5/29/20 at 1:42pm, when asked if other supplies including personal items could be placed on top of the clean linen cart, the DON stated, No. Review of facility's policy titled Infection Prevention and Control Plan dated 5/6/20 under Linen, revealed, Clean linen must be covered until it is used and stored on carts with a solid bottom. In a CDC article titled Appendix D - Linen and laundry management dated March 27, 2020 under Best practices for management of clean linen revealed, Sort, package, transport, and store clean linens in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html 3. A. Observations on 5/21/20 at 1:06pm on My Rehab 1 Unit revealed Registered Nurse4 (RN4) was coming out of R1's room wearing personal protective equipment (PPE): mask, face shield, gown and gloves. RN4 proceeded to walk the hallway to the end of the unit. R1 was in a contact and droplet precautions room. A printed PPE guide with pictures was observed on top of the isolation set-up outside of R1's room. Review of the facility's printed PPE guide revealed, PPE required for COVID contact-droplet precaution .Before exiting remove in this order. Gloves, goggles, gown, mask, hand sanitizer B. Observations on 5/21/20 at 1:22pm on My Rehab 1 Unit revealed Housekeeping Staff (E4) was cleaning inside room [ROOM NUMBER]. E4 was wearing PPE: mask, face shield, gown and gloves. room [ROOM NUMBER] was a contact and droplet precautions and a recently emptied room. A PPE guide was observed on top of the isolation set-up outside of the room. With gloves on, E4 was observed to be talking on her mobile phone while cleaning inside room [ROOM NUMBER]. E4 stated she was cleaning the room because the resident moved. When asked if she could be cleaning and be on the phone at the same time, E4 stated she was talking to a relative. Still with PPE on, E4 stepped out of the room approximately one to two feet away from the door. E4 stepped back into the room after the surveyor called her attention. During interview with the DON on 5/29/20 at 1:42pm, when asked what PPE she expected the staff to keep on upon leaving an observation room, the DON stated that staff could keep their eye shield and mask and added, Because the facility was in a crisis capacity, this is the expectation. Hand hygiene would be an expectation. It is a good practice to do hand hygiene. The eye protection, the (TRUNCATED)

Based on observation, interview, and record review the facility neglected to assess a resident after a fall. This failure resulted in R1 experiencing prolonged pain for seventeen hours and a delay in treatment. This applies to 1 of 3 residents (R1) reviewed for neglect in the sample of 3. The findings include: R1's Minimum Data Set (MDS) dated (MONTH) 25, 2019 showed R1 had moderate cognitive impairment; required the assistance of two or more staff members for transfers and toilet use; and had functional limitations in the Range of Motion (ROM) on one side, in both the upper and lower extremities. The facility's Incident Tracking Report dated (MONTH) 15, 2019 - (MONTH) 15, 2019 showed R1 had a Fall - Joint Injury on (MONTH) 12, 2019 at 5:30 AM. R1's Nursing Note dated (MONTH) 12, 2019 at 3:42 PM showed, At 7:20 AM resident was screaming/crying d/t (due to) pain to her lower legs. Administered Tylenol . At 9:30 AM resident starts to cry and moan . At 9:45 AM came back wheeled by lady volunteer moaning, [MEDICATION NAME] administered . At 1430 (2:30 PM) starts crying/moaning. Pointing to her legs and right arm. Instructed CFP (CNA) that we will put her to bed for body assessment. It took 3 person assist to transfer her to bed manually using gait belt. Skin check done, swollen right joint shoulder, two size of the dime discoloration to inner arms. Right lower extremities swollen with redness to right shin area. also resident pointing to right groin area . Notified (V9 - R1's physician) and ordered X-ray of right side . Resident continued crying and moaning . R1's physician progress notes [REDACTED]. She also told me that she had a fall this morning. My response was to send her to the emergency room immediately. Of note I was called approximately 4 hours earlier and told that the patient had right shoulder pain and right hip pain that was getting worse all day and there was some swelling and there was no history of trauma or a fall even though I twice tried to elicit that history from the nurse I was speaking to who was caring for the patient . This behavior is reprehensible and should never be tolerated in a professional setting. R1's X-ray report dated (MONTH) 12, 2019 showed, Markedly displaced and overriding impaction [MEDICAL CONDITION] distal femoral shaft in respect to the distal femur and condyles (broken right leg). There is associated swelling. The report also showed, There is an acute impaction fracture through the right humeral neck (broken right arm). There is associated soft tissue swelling. The facility's Initial IDPH Notification of Serious Incident form dated (MONTH) 13, 2019 showed R1 was transferred with a sit-to-stand lift to the toilet on (MONTH) 12, 2019 at 5:30 AM; R1 became weak, her knees buckled, and R1 started slipping down. This document showed V5 (Certified Nursing Assistant - CNA), attempted to get resident onto the toilet, but it was too high so R1 was lowered to the ground by V5. This document showed, At 7:20 AM resident complaining of pain and medicated with Tylenol, but pain worsening throughout the morning. Physician notified with orders for X-ray of R (right) side. Results received at 10:15 PM with R Humerus and R femur fx (fracture). Patient transferred and admitted to local hospital for further treatment. This document showed R1 was transferred from the facility on (MONTH) 13, 2019 at 12:15 AM (17 hours after the resident's fall). R1's Investigation/Follow-up by V2 (DON) dated (MONTH) 13,2019 at 5:02 PM showed, Nurse who responded to fall did not do a complete assessment and failed to notice that resident had injured her R arm and leg, as this resident tends to complain of pain in those areas on and off. Since the resident was lowered to the floor the nurse did not recognize this to be a fall and did not complete a full incident report at the time of the assisted fall., nor contact the physician or family. Both staff put on administrative leave during the investigation and RN (Registered Nurse) termed after investigation completed. CFP (CNA) placed on 3 day suspension/final warning with retraining on safe lifting to be completed on her return to the floor. R1's hospital Inpatient Discharge Summary dated (MONTH) 14, 2019 showed R1 was admitted on (MONTH) 13, 2019 for a right femur fracture and right proximal humerus fracture. This document showed, RUE (Right upper extremity) in sling, bruising noted to right upper arm . RLE (right lower extremity) shortened, internally rotated, swelling noted to thigh . On (MONTH) 14, 2019 at 10:20 AM, V9 (R1's physician) said on (MONTH) 12, 2019 around 3:00 PM he was called by V3 (day shift LPN) regarding a sudden onset of severe pain in R1's right upper extremity and right hip. V9 said V3 reported R1 had received Tylenol and [MEDICATION NAME], but continued to complain of pain. V9 said he asked V3 twice if R1 had fallen or experienced a change in plane, but V3 assured him R1 had not fallen. V9 stated, Because (V3) assured me there was no trauma, I considered the possibility of an [MEDICAL CONDITION] process. V9 said I ordered X-rays and labs at this time. V9 said later that night, V4 (night shift RN) called and reported R1's pain was worsening and R1 had a fall at 5:30 AM. V9 stated, I'm not aware; nobody told me she fell . V9 stated, I insisted (R1) be transferred to the hospital; she had been suffering all day and needed to go now. V9 stated, I found out V4 (night shift RN) failed to report the fall to V3 (day shift LPN). V9 stated, I'm absolutely appalled by this situation; I feel the whole situation is neglectful and abusive to the resident. On (MONTH) 15, 2019 at 10:28 AM, V4 (RN) said V5 (CNA) approached her during the morning medication pass on (MONTH) 12, 2019 and said that R1 was on the floor. V4 said R1 was lying on her back, on the floor, next to her bed. V4 said she asked V5 what happened and V5 reported R1 was slipping in the sit-to-stand lift during a transfer and V5 assisted R1 to the floor. V4 said R1 complained of pain when assisted back to bed, but V4 thought it was just R1's usual pain. V4 stated, I don't know why I didn't report this as a fall at the time; I just had a lot going on. V4 said that night she returned for work and during report V3 discussed R1's pain and the ordered X-rays. V4 stated, I said, 'oh my God!'; at that time I realized I didn't tell V3 about R1 being lowered to the floor that morning. V4 stated, I called V9 (R1's physician) right away and told him about the fall; he was so mad at me. V4 stated, I called directly at report because I knew I made a mistake. V4 said she did not identify what happened to R1 as a fall, the morning of (MONTH) 12, 2019, so she didn't initiate the facility's Fall Procedure, document an assessment after the fall, notify the oncoming nurse, notify the physician, or notify the resident's POA (Power of Attorney). On (MONTH) 15, 2019 at 10:49 AM, V5 (CNA) said on (MONTH) 15, 2019 after 5:00 AM, she was getting R1 up for the day. V5 said R1 told her she needed to use the toilet, so she went to find V6 (CNA) and asked for help. V5 said V6 was helping another resident and R1 insisted on getting up to the toilet, so V5 used the sit-to-stand lift to transfer R1 from the bed to the toilet by herself. V5 said R1's knees bent and R1 started slipping down in the sit-to-stand lift. V5 said R1 was slipping, her knees were bending, and her arms were up in the air. V5 said the toilet was too high and the bed was too high, so she had to assist R1 to the floor. V5 said she reported to V4 (RN) that she had lowered R1 to the floor. V5 said V4 and V6 helped her get R1 off the floor to the side of the bed. V5 said V6 assisted her with transferring R1 to the wheelchair using the sit-to-stand lift; R1 did complain of pain when transferred to the wheelchair. On (MONTH) 15, 2019 at 11:43 AM, V3 (Licensed Practical Nurse - LPN) said when she arrived for dayshift (MONTH) 12, 2019, R1 had her alarm on for pain. V3 said R1 always has pain, so I gave her some Tylenol and she went to breakfast. V3 said R1 went to the church service after breakfast, but left early because she was in a lot of pain. V3 said R1 always does the prayers before and after the prayer meeting; It's unusual for her to leave the prayer meeting early. V3 stated, I gave her a [MEDICATION NAME] because I could tell she was in pain. V3 said R1 then went to lunch and seemed okay, but after lunch R1 was crying and moaning. V3 stated, This was when I started getting concerned. V3 said R1 was transferred back to bed and her clothes were removed, so she could complete a head-to-toe assessment on the resident. V3 said she noticed R1's right leg was a little bigger than her left and R1's right shoulder was swollen. V3 stated, I called the doctor right away and got orders for X-rays. V3 stated, (V9 -R1's physician) asked if she fell and I told him no because I didn't know about what happened. V3 stated, If I had known she fell , I wouldn't have waited that long to call the physician. On (MONTH) 15, 2019 at 12:09 PM, V6 (CNA) said she went to R1's room, V4 (RN) and V5 (CNA) were there and R1 was lying on the floor, near the bed. R1 was saying,oh my shoulder, my shoulder. V6 said she assisted with transferring R1 back to bed, then to the wheelchair. On (MONTH) 15, 2019 at 1:09 PM, R1 was lying on her left side in bed with a sling to her right arm. R1 stated, I fell , but I really don't remember how it happened. R1's Medication Administration Record (MAR) printed (MONTH) 15, 2019 at 1:27 PM showed R1's pain scale every shift had ratings of 0 on a 1-10 scale (MONTH) 1, 2019 - (MONTH) 12, 2019. On (MONTH) 12, 2019 (the day R1 fell ) a pain rating of 5 is documented on the MAR. This MAR showed R1 had an order for [REDACTED]. This MAR showed R1 had an order for [REDACTED]. On (MONTH) 15, 2019 at 1:32 PM, V2 (Director of Nursing - DON) said according to the facility guidelines this incident with R1 was considered a fall. V2 said after a resident falls, the nurse should complete an assessment to determine if the resident can be safely moved or should be transferred to the hospital; document assessment and vital signs; complete an incident report; complete all fall documentation; notify the resident's physician, a supervisor, and the resident's representative; and update the care plan with any new interventions. V2 said V4 (night shift RN) should have told V3 (day shift LPN) about R1's fall during report. V2 stated, If (V3) knew R1 had fallen, she would have called the physician immediately. R1's Facesheet dated (MONTH) 15, 2019 showed [DIAGNOSES REDACTED]. The facility's Fall Reduction Protocol (rev. 11/28/17) showed, Fall refers to unintentionally coming to reset on the ground, floor or other lower level . 2. Procedure following fall, outlined in Incident Reports policy, includes completion of: A. Incident Report B. Documentation in nurse's notes C. Initiate 72 hour monitoring D. Documentation on 24 hour report E. Fall Risk Evaluation Tool F. Incident Management Investigation Tool G. Review and Update Plan of Care. The facility's Abuse and Neglect of a Resident Policy (rev. 12/4/17) showed the resident has the right to be free of neglect. This document also showed, Neglect - failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress . Examples are but not limited to: not taking action on medical problems . Not calling a physician when necessary .

Based on observation, interview, and record review the facility failed to safely transfer a resident using a mechanical lift. This failure resulted in R1 sustaining multiple fractures. This applies to 1 of 3 (R1) residents reviewed for falls in the sample of 3. The findings include: R1's Minimum Data Set (MDS) dated (MONTH) 25, 2019 showed R1 had moderate cognitive impairment; required the assistance of two or more staff members for transfers and toilet use; and had functional limitations in the Range of Motion (ROM) on one side, in both the upper and lower extremities. R1's X-ray report dated (MONTH) 12, 2019 showed, Markedly displaced and overriding impaction [MEDICAL CONDITION] distal femoral shaft in respect to the distal femur and condyles (broken right leg). There is associated swelling. The report also showed, There is an acute impaction fracture through the right humeral neck (broken right arm). There is associated soft tissue swelling. R1's Interdisciplinary (ID) Note entered (MONTH) 13, 2019 at 1:11 AM showed, late entry, 5/12/19, 530am - CNA reported that she lowered the resident to the floor from a (sit-to-stand lift). R1's ADL Function Rehab care plan dated (MONTH) 14, 2019 showed R1's physical mobility is impaired due to a stroke with right [MEDICAL CONDITION] (weakness) and [MEDICAL CONDITION] (dizziness), as evidenced by R1's need for extensive assistance with bed mobility, transfers, and Activities of Daily Living (ADLs). This care plan showed, R1 experienced a fall on (MONTH) 12 and sustained a right humerus and right femur fracture. R1's Continence care plan initiated (MONTH) 14, 2019 showed R1 required extensive assistance of two staff members for toilet transfers using standing mechanical lift. R1's Facesheet dated (MONTH) 15, 2019 showed [DIAGNOSES REDACTED]. On (MONTH) 15, 2019 at 10:28 AM, V4 (night shift Registered Nurse - RN) said on (MONTH) 15, 2019 at 5:30 AM, V5 (Certified Nursing Assistant - CNA) came to her during med pass and said she put R1 on the floor during a transfer with the sit-to-stand lift. V4 said R1 was lying on the floor, on her back, next to the bed. V4 said V5 reported she had asked V6 (CNA) to help with R1's sit-to-stand lift transfer, but V6 was busy helping another resident. V4 said R1 should have two staff members assisting her with the sit-to-stand lift due to her contracted right arm. On (MONTH) 15, 2019 at 10:49 AM, V5 (CNA) said on (MONTH) 15, 2019 after 5:00 AM she was getting R1 up for the day. V5 said R1 told her she needed to use the toilet, so she went to find V6 (CNA) and asked for help. V5 said V6 was helping another resident and R1 insisted on getting up to the toilet, so she used the sit-to-stand lift to transfer R1 from the bed to the toilet by herself. V5 said R1's knees bent and R1 started slipping down in the sit-to-stand lift. V5 said R1 was slipping, her knees were bending, and her arms were up in the air. V5 said the toilet was too high and the bed was too high, so she had to assist R1 to the floor. V5 stated, I'm not supposed to use the lift myself, she (R1) is a two assist. V5 said V4 and V6 helped her get R1 off the floor to the side of the bed. V5 said V6 assisted her with transferring R1 to the wheelchair using the sit-to-stand lift; R1 did complain of pain when transferred to the wheelchair. On (MONTH) 15, 2019 at 12:09 PM, V6 (CNA) said V5 had asked for help transferring R1 into the bathroom, but V6 was assisting another resident at the time. V6 said when she finished assisting the other resident she went to R1's room, V4 (RN) and V5 (CNA) were there and R1 was lying on the floor, near the bed. R1 was saying,oh my shoulder, my shoulder. V6 said she assisted with transferring R1 back to bed, then to the wheelchair. V6 stated, It's hard to use the stand lift in her (R1's) case because she can't rely on her right arm. V6 stated, I've never seen anything like this; This is the first time I've seen anyone slip from a sit-to-stand lift. On (MONTH) 15, 2019 at 1:09 PM, R1 was lying on her left side in bed with a sling to her right arm. R1 stated, I fell , but I really don't remember how it happened. On (MONTH) 15, 2019 at 1:32 PM, V2 (Director of Nursing - DON) said V5 went looking for help because she knew she needed two for the transfer with the sit-to-stand lift. V2 stated, She (V5) made a mistake, she transferred her (R1) alone. The Operator's Instructions for the sit-to-stand lift (rev 8/8/18) showed, Patients should be able to bear some weight, have upper body strength, and be able to follow simple commands. The facility's Fall Reduction Protocol policy (rev 11/28/17) showed, The intent of the requirement is to ensure the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. Fall refers to unintentionally coming to rest on the ground, floor or other lower level .

Based on observation , interview and record review the facility failed to supervise and implement interventions to prevent one resident ( R1 ) from falling from a 3rd floor window out of three residents reviewed for wandering behavior and supervision. This failure resulted in R1 entering the 3rd floor Dementia unit unlocked/unattended oxygen room and exiting the 3rd floor window. R1 was found face down on the concrete pavement . R1 was pronounced dead at the hospital. This resulted in an Immediate Jeopardy. On [DATE] at 11:35AM an Immediate Jeopardy was identified to have begun on [DATE] at 7:45AM when R1 was found face down on the concrete pavement outside the facility. The facility was aware of R1s wandering behavior and failed to implement 1 to 1 supervision to monitor his location on the 3rd floor locked Dementia unit. E1 ( Administrator) , E2 ( Director of Nursing ) and E9 ( Assistant Director of Nursing ) were made aware of the Immediate Jeopardy on [DATE] at 11:35AM. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at severity level 2 as the facility has not yet developed a 1:1 resident supervision policy. The facility has not trained its staff on 1:1 resident supervision. The facility has not included its 1:1 resident supervision policy in its Quality Assurance Program. Finding include: Document review reveals R1 is an [AGE] year old male with a [DIAGNOSES REDACTED]. R1 was admitted to the facility [DATE]. R1 was housed on the 3rd floor in the locked dementia care unit. ( The nurse station Pathways unit ) . R1 used a wheelchair but could walk with unsteady gait. Nurse Note ,[DATE]/, R1 expressed that he wanted a taxi to go home. Physician order [REDACTED]. Medicare Daily Documentation (undated) R1 "wanders on or off unit." Pre-Admission Clinical Assessment [DATE] documents "increased confusion at sundown." Nurse Note [DATE] "had sitter watching resident all night." Time Card for private sitter company documents R1 had a sitter for 3 nights in a row, [DATE] through [DATE]. Nurse Note [DATE] 6:30pm, R1 "wants to go home, wants to call for a taxi." Nurse Note [DATE], R1 "attempted to wander around the unit. Kept redirected by staff." Nurse Note [DATE] 5am, R1's wife notifies E10(Nurse) that she is going home, "watch the resident." 5:15am, E10 called Z1(Physician) for a sedative due to "extreme agitation." R1 threw a remote control at E10, and twisted another nurse's arm. Local Fire Department Report [DATE] documents "Arrived to find (R1) lying in the courtyard below an open window...found (R1) on the ground in the courtyard outside their office approximately 7:43am." Emergency Department Records [DATE] document "(R1) presents after jumping from 3rd story at nursing home. Patient last seen at 7am, found down by nursing home at 7:43am. Patient pronounced dead in emergency department at 8:30am." Interim Care Plan [DATE] documents the use of a departure alert system. No Minimum Data Set available due to R1 only residing at the facility for 4 days prior to death. Initial investigation report states on [DATE] at approximately 7:35AM R1 was found outside on the ground near the building in the supine position . A third floor window above the resident was open. Cardiopulmonary Resuscitation was initiated by staff. 911 was called. R1 expired after arrival at the hospital. Final Investigation Report [DATE] documents "The allegation of neglect was substantiated for (E10) for not making (E3) aware of (R1)'s change in condition and need for constant 1:1 care." R1s clinical record review revealed the following observations. R1s Occupational Therapy assessment dated [DATE] documents Suicidal Ideation. R1s Physical Therapy assessment dated [DATE] documents "Suicidal Ideation ( was on a psychiatric unit)." The facility was entered on [DATE]. The 3rd floor was toured with E9 ( Alzheimer Unit Director). The 3rd floor is a locked unit ( Pathway Unit). A keypad code is required to exit the doors from the floor. The "Oxygen/Crash Cart" room was observed next to the nurse station. At time of observation a small slide lock was temporarily installed on the door approximately 5 feet from the floor. The door was missing the lock latch assembly. Signs posted on the exterior side show "Crash Cart , CPR mask , Oxygen Room , Please keep this door closed". The inside of the room has a window. This window is three feet from the floor. The window has two glass panels approximately two by four feet in size. One panel swings outward by use of a crank handle. The crank handle and mechanism to open the window were missing. A small metal bracket was installed on the window with two screws preventing it from opening. Two locking levers to the opening glass panel were secured. There is an employee bathroom with a separate door in this room. The O2/Crash cart room was also used as a locker room for employees. E9 ( Alzheimer Unit Director) [DATE] 10AM stated the police removed the window latch mechanism after the incident. The small slide lock was installed on the room door after the incident. The room was normally open and there was no lock latch assembly on the door. The door could not be locked. The following staff that had direct contact with R1 , before the incident , were interviewed during the investigation. E10 ( Registered Nurse ) 1:15 PM [DATE] stated she works from 7 PM to 7AM. I received report from E4 ( Registered Nurse) at the beginning of my shift ( [DATE]) that R1 needs 1:1 supervision because he doesn't sleep at night and gets out of bed. R1 was wearing a departure alert system because he was a high risk for elopement and did not want to stay at the facility. R1s wife will be staying with him for the night. R1 was on sleeping pills and psychotropic medication. At 8PM I gave R1 his medications , his wife was sitting there. At 2AM wife got me and stated R1 would not sleep and he needed more sleep medication. I gave R1 Halcion .25 by mouth. At 4:30AM I saw R1 in his room with wife. She was putting on his socks.She told me he slept for two hours. At 5 AM R1s wife told E11 ( Certified Nurses Aid) she was going home and to watch the resident. After she left R1 was already standing up. I tried to get him to sit down but he threw the recliner chair remote control at me. He kept standing up and resisting. I called E11 for assistance. We put him in the wheelchair and wheeled him to the nurses station. I asked E12 ( Certified Nurse Aid) and E13 ( Certified Nurse Aid ) to watch R1. I called E14 ( Nurse Night shift supervisor) and told him we have a situation on the unit . R1 was agitated. At 5:15AM E14 told me to call the doctor. I called Z1 ( Physician) . Z1 ordered Haldol 2 Milligram intramuscularly to be given for severe agitation. During this time R1 twisted E14's arm. He refused to sit down and continued hitting staff. I called R1s wife and told her R1 was a danger to himself. I told her R1 needed 1:1 supervision immediately. R1s wife said her son would be there at 6:30AM to watch R1. R1 was at the nurses station from 5AM to 6:45AM. The son never showed up. At 6:45AM E11 took R1 back to his room . At 7AM I saw E3 ( Certified Nurse Aid ) walking R1 towards the nursing station. At 7:35AM I gave a report to E4 ( Nurse) on R1. At 7:35AM E5( Certified Nurse Aid) came to the nurses station panicking and stated someone was on the ground. I thought a resident fell on the floor. E4( Nurse) , E12( Certified Nurse Aid) , E15( Nurse) and myself were in the nurses station giving shift change reports. The overhead pager sounded code blue. E5 pointed to the window in the 'O2 " room next to the nurses station. We looked in the room. The window was open more that halfway. Normally the window is closed. The handcrank that opens the window was not there. There was someone on the ground outside. E3 ( Certified Nurse Aid) 2:35PM [DATE] stated the following. This was the first time I was R1s caregiver. In the morning [DATE] at 7AM I saw E11( Certified Nurse Aid) . He was trying to put R1 in bed. E11 assigned me to care for R1 at this time. I took R1 for a walk . We walked to the nurses station . There was 4 to 5 nurses in the nurse station behind the glass and closed door having a meeting. One nurse ( unidentified by interviewee ) told me to take R1 to his room so he could get a blood draw. Z2 ( Outside service nurse phlebotomist) and I took R1 to his room and sat him in his chair. I left R1 with Z2. I went to the next room to get the resident ready for breakfast. I assumed Z2 would get me when she was finished. When I was in room I saw R1 in the hallway by himself. I put R1 back in his room on the recliner chair and told him to wait until I was finished, and I left R1 alone in the room. I proceeded to take the resident to the dining room. I then heard E6 ( Certified Nurse Aid) scream a resident fell out the window. The O2 / Crash cart room is always open and unlocked. We use the bathroom in this room. It is also a locker room for staff belongings. Z2 ( outside service phlebotomist ) 2:45PM [DATE] stated the following. On [DATE] at 7 AM I arrived at the facility on the 3rd floor to draw blood from two residents. At this time R1 was standing at the nurses station . There were other staff (unidentified by Z2) at the nurses station. E3( Certified Nurse Aid) and I took R1 to his room ( 310) . E3 left the room. I had to ask R1 several times to sit down in his chair while I drew blood from his right arm. I left his room approximately 7AM after drawing his blood . He was standing and rearranging pillows on his wheelchair. I thought he would be ok so I went to draw blood in a different room. E3 was already in room with that resident. When I was finished I saw R1 in another residents room across the corridor. I told E3 that was next to me that R1 was across the hall. The certified nurse aid went to get R1 and escorted him back to his room. E3 was in room with R1 when I left the area. E5 ( Certified Nurse Aid) 2:05PM [DATE] stated the following. I was walking in the hallway ( time not identified by E5) when I noticed an empty wheelchair at the O2/Crashcart room doorway. I opened the door and saw the window was wide open. The wind was blowing in the room. The window screen was on the floor . E6s ( Certified Nurse Aid) lunch bag was scattered on the floor. E6 came into the room with me. We looked out the window. We saw a resident on the ground. Staff were standing around the resident. E6 ( Certified Nurse Aid) 1:45PM [DATE] stated it was almost time for breakfast . There was a wheelchair in the nurses station. E5 ( Certified Nurse Aid ) went to the O2 /Crashcart room . She told me my lunchbox and its contents was on the floor. I went into the room and started to pick up my lunch. The window screen was on top of the contents of my lunchbox. The window was open. There was a crank on the window . I looked out the window and saw staff around a resident on the ground. On [DATE] at 9:45am, E1(Administrator) stated that the facility does not have a policy on how to conduct 1:1 supervision. Z1 (Physician) 3PM [DATE] stated the following. The facility is expected to provide 1:1 supervision if the resident is able to get off of the floor. He was not supervised since he was found outside the building. 1:1 supervision means supervision 100 percent of the time. The facility made the decision for 1:1 supervision since they provided R1 with a sitter for three nights before the incident. R1 clearly needed 1:1 supervision. R1s situation fell through the cracks and had a bad outcome. E9 ( Nurse/Director of the Alzheimer's unit ) 9:25AM [DATE] stated the facility staff have no formal training in 1:1 supervision. We know we have to provide 1:1 supervision if there is harmful behavior or wandering. R1 was considered a wanderer since he was looking for a taxi to go home. E2 ( Director Of Nursing ) 3:45PM [DATE] stated if we know in advance that we need 1:1 supervision we have an outside provider send a sitter to be with the resident. R1 had a private sitter for three days (,[DATE],3,4th). The family wanted to give the 1:1 supervision . If the family leaves the resident we will either get the outside provider or have staff fill in for the 1:1 supervision. Wanderguard Process Policy "The decision to utilize a (departure alert device) for a particular resident will be based on, but not limited to the following: the specific exit seeking behavior of the resident and/or verbalized intent to leave the unit or facility. Devices may be utilized in one of two ways: a secondary security to the delayed egress system of the unit or to address exit seeking behavior." The facility does not have a policy for instructing staff on how to perform 1:1 supervision of a resident. The Lutheran Home Abatement Plan: Immediate Jeopardy Abated [DATE] Environmental After the incident occurring Saturday, [DATE]th and subsequent police investigation, the following remedial actions have taken place to abate the jeopardy. 1. The window involved in the occurrence (crash cart room adjacent to the 3A Nurse Station was secured shut on [DATE]th, after the police investigation, with hardware (metal plate and screws) to prevent opening. 2. The door to the above room was made secure on [DATE]th and subsequently, on [DATE]th, a keypad hardware mechanism was installed with pass code to ensure a locked space. Additionally, on [DATE]th, a door closer was installed to ensure self-closing operation. 3. The rooms with similar purpose on the 2nd and 1st floors of the Healthcare Pavilion were modified as well, including window secured and door keypad locking mechanism and door closer installation on [DATE]th and 8th. 4. All windows that are designed to open on the 3rd floor of the Healthcare Pavilion were secured on [DATE]th with a similar hardware technique to prevent opening. 1:1 Supervision 1. No new One-to-One assignments have been made since [DATE]th. No new assignments will be made until successful completion of training. Only successfully- trained personnel will be assigned 1:1. 2. A training plan has been developed and will be completed by [DATE]. 3. Unmanageable resident behavior will be treated as an emergency (911) and sent to an appropriate care setting immediately. 4. One-to-One Caregiver training (1:1 Caregiver Responsibilities) occurred on [DATE]-7 to all care staff. 5. Behavior mapping for all residents receiving One-to-One care was initiated on October 6. 6. A Behavior Risk Assessment will be completed today, [DATE]th, on all current residents of the 3rd floor. 7. A Behavior Risk Assessment will be completed upon pre-admission, within 24 hours of admission, quarterly, annually, and after any incident pertaining to unmanageable behavior. 8. A policy was written on [DATE] titled " Providing 1:1 Care " 9. An emergency QA meeting was held today, [DATE] to review the 1:1 policy. 10. The medical director has approved the policy. 11. Safety/maintenance oversight procedures have been reviewed at the emergency QA meeting.

Based on observation, interview and record review the facility failed to supervise and implement interventions for 1 of 3 residents ( R1 ) reviewed for wandering behavior and supervision. This failure resulted in R1 wandering unsupervised into an unlocked room and exiting the building from the 3rd floor window. R1 was found face down on the concrete pavement and was pronounced dead at the hospital. Finding include: Clinical record documents R1 is an [AGE] year old male with [DIAGNOSES REDACTED]. R1 was admitted to the facility [DATE]. R1 was housed on the 3rd floor in the locked dementia care unit. R1 used a wheelchair but could walk with unsteady gait. Nurse Note ,[DATE]/, R1 expressed that he wanted a taxi to go home. Physician order [REDACTED]. Medicare Daily Documentation (undated) R1 "wanders on or off unit." Pre-Admission Clinical Assessment [DATE] documents "increased confusion at sundown." Nurse Note [DATE] "had sitter watching resident all night." Time Card for private sitter company documents R1 had a sitter for 3 nights in a row, [DATE] through [DATE]. Nurse Note [DATE] 6:30pm, R1 "wants to go home, wants to call for a taxi." Nurse Note [DATE], R1 "attempted to wander around the unit. Kept redirected by staff." Nurse Note [DATE] 5am, R1's wife notifies E10(Nurse) that she is going home, "watch the resident." 5:15am, E10 called Z1(Physician) for a sedative due to "extreme agitation." R1 threw a remote control at E10, and twisted another nurse's arm. Local Fire Department Report [DATE] documents "Arrived to find (R1) lying in the courtyard below an open window...found (R1) on the ground in the courtyard outside their office approximately 7:43am." Emergency Department Records [DATE] document "(R1) presents after jumping from 3rd story at nursing home. Patient last seen at 7am, found down by nursing home at 7:43am. Patient pronounced dead in emergency department at 8:30am." Interim Care Plan [DATE] documents the use of a departure alert system. No Minimum Data Set available due to R1 only residing at the facility for 4 days prior to death. Initial investigation report [DATE] documents R1 was found outside on the ground near the building in the supine position at approximately 7:35am. A third floor window above the resident was open. Cardiopulmonary Resuscitation was initiated by staff. 911 was called. R1 expired after arrival at the hospital. Final Investigation Report [DATE] documents "The allegation of neglect was substantiated for (E10) for not making (E3) aware of (R1)'s change in condition and need for constant 1:1 care." Statement by E3(Nurse Aide) documents that E3 was not instructed to stay with R1 continuously for 1:1 supervision. Lab Results [DATE] documents that blood was collected at 7am [DATE]. On [DATE] a tour of the 3rd floor was conducted with E9(Alzheimer Unit Director). The 3rd floor is a locked unit ( Pathway Unit). A keypad code is required to exit the doors from the floor. The "Oxygen/Crash Cart" room was observed next to the nurse station. At time of observation a small slide lock was temporarily installed on the door approximately 5 feet from the floor. The door was missing the lock latch assembly. Signs posted on the exterior side show "Crash Cart , CPR mask , Oxygen Room , Please keep this door closed". The inside of the room has a window. This window is three feet from the floor. The window has two glass panels approximately two by four feet in size. One panel swings outward by use of a crank handle. The crank handle and mechanism to open the window were missing. A small metal bracket was installed on the window with two screws preventing it from opening. Two locking levers to the opening glass panel were secured. There is an employee bathroom with a separate door in this room. The O2/Crash cart room was also used as a locker room for employees. E9 (Alzheimer Unit Director) [DATE] 10AM stated the police removed the window latch mechanism after the incident. The small slide lock was installed on the room door after the incident. The room was normally open and there was no lock latch assembly on the door. The door could not be locked. The following staff that had direct contact with R1 , before the incident , were interviewed during the investigation. E10 ( Registered Nurse ) 1:15 PM [DATE] stated she received report from E4 ( Registered Nurse) at 7pm [DATE] that R1 needs 1:1 supervision because he doesn't sleep at night and gets out of bed. R1 was wearing a departure alert system because he was a high risk for elopement and did not want to stay at the facility. R1s wife will be staying with him for the night. At 5AM R1s wife told E11 (Nurse Aide) she was going home and to watch the resident. After she left, R1 was more agitated and restless, he threw a remote control at E10. R1 kept standing up and resisting help from staff. R1 was placed in a wheelchair and brought to the nurse's station. E12 (Nurse Aide) and E13 (Nurse Aide) were asked to watch R1. E14 (Nurse Night shift supervisor) was informed of the increased agitation of R1. At 5:15AM, Z1 (Physician) was called and [MEDICATION NAME] 2 milligrams intramuscularly was ordered to be given for R1's "extreme agitation." During this time R1 twisted E14's arm. He refused to sit down and continued hitting staff. R1s wife was called and told that R1 was a danger to himself and others, and R1 needed 1:1 supervision immediately. R1s wife said her son would be there at 6:30AM to watch R1. R1 was at the nurses station from 5AM to 6:45AM. The son never showed up. At 6:45AM, E11 took R1 back to his room. At 7AM, E3 ( Nurse Aide ) walked R1 towards the nurses station and then back to his room for a blood draw. At 7:35AM, E10 gave E4 (Nurse) report on R1. At 7:35AM E5(Nurse Aide) came to the nurses station panicking and stated someone was on the ground. Code Blue was announced over the public address system. E5 pointed to the window in the "oxygen room" next to the nurses station, the window was open more than halfway when normally the window is closed. The handcrank that opens the window was not there. There was someone on the ground outside. E3 (Nurse Aide) 2:35PM [DATE] stated this was the first time she cared for R1. " I was not told to stay with R1 all the time." On [DATE] at 7AM, E3 took R1 for a walk to the nurses station and then back to the room to get blood drawn. Z2 (phlebotomist) and E3 took R1 to his room and sat him in his chair. E3 left R1 with Z2 and went to the room next door to get the resident ready for breakfast. E3 expected Z2 to notify her when she was finished. E3 saw R1 in the hallway by himself. E3 put R1 back in his room in the recliner chair and told him to wait for her. E3 left R1 alone in the room. E3 took another resident to the dining room, and then heard E6 (Nurse Aide) scream a resident fell out the window. E3 stated the O2 / Crash cart room is always open and doesn't lock, there is a staff bathroom in this room, and it is also a locker room for staff belongings. Z2 (phlebotomist ) 2:45PM [DATE] stated the following. On [DATE] at 7 AM I arrived at the facility on the 3rd floor to draw blood from R1. E3(Nurse Aide) and I took R1 to his room. E3 left the room. Z2 left the room approximately 7AM after drawing R1'sblood . "I thought he would be ok so I went into another room to draw blood." \When finished, Z2 saw R1 in another residents' room across the corridor. Z2 told E3 that R1 was across the hall. E3 went to get R1 and escorted him back to his room. E3 was in the room with R1 when Z2 left the area. E5 (Nurse Aide) 2:05PM [DATE] E5 stated she was walking in the hallway ( time not identified by E5) when an empty wheelchair was noted at the O2/Crashcart room doorway. The door was opened and the window was wide open, and the screen was on the floor . E6s ( Certified Nurse Aid) lunch bag was scattered on the floor. E6 came into the room and looked out the window. E5 and E6 saw a resident on the ground with staff standing around the resident. E6 (Nurse Aide) 1:45PM [DATE] stated before breakfast time, there was a wheelchair in the nurses station. E5 (Nurse Aide ) went to the O2 /Crashcart room and told E6 that his lunchbox and its contents were on the floor. E6 went into the room and noted that the window screen was on the floor. The window was open. E6 looked out the window and saw staff around a resident on the ground. On [DATE] at 9:45am, E1(Administrator) stated that the facility does not have a policy on how to conduct 1:1 supervision. Z1 (Physician) 3PM [DATE] stated the following. The facility is expected to provide 1:1 supervision if the resident is able to get off of the floor. He was not supervised since he was found outside the building. 1:1 supervision means supervision 100 percent of the time. The facility made the decision for 1:1 supervision since they provided R1 with a sitter for three nights before the incident. R1 clearly needed 1:1 supervision. R1's situation fell through the cracks and had a bad outcome. E9 ( Nurse/Director of the Alzheimer's unit ) 9:25AM [DATE] stated the facility staff have no formal training in 1:1 supervision. We know we have to provide 1:1 supervision if there is harmful behavior or wandering. R1 was considered a wanderer since he was looking for a taxi to go home. E2 ( Director Of Nursing ) 3:45PM [DATE] stated if we know in advance that we need 1:1 supervision we have an outside provider send a sitter to be with the resident. R1 had a private sitter for three days (,[DATE],3,4th). The family wanted to give the 1:1 supervision . If the family leaves the resident we will either get the outside provider or have staff fill in for the 1:1 supervision. Wanderguard Process Policy "The decision to utilize a (departure alert device) for a particular resident will be based on, but not limited to the following: the specific exit seeking behavior of the resident and/or verbalized intent to leave the unit or facility. Devices may be utilized in one of two ways: a secondary security to the delayed egress system of the unit or to address exit seeking behavior." The facility does not have a policy for instructing staff on how to perform 1:1 supervision of a resident.

Based on interview and record review facility failed to follow their gait belt policy for transferring one resident (R1) out of three residents reviewed for falls. This failure resulted in R1 going to the hospital for evaluation of a laceration that required three staples to the back of his head. Findings Include: Record review of R1's incident report dated 5-17-13 denotes R1 was being transferred to wheelchair on 5-17-13 at 6:40 AM when R1 went down and hit head on bed. Uncertain if Aide used gait belt during transfer. R1 sent to hospital for laceration with three staples. Record review of R1's nurses' note dated 5-17-13 denotes E2 (CNA- Certified Nurse Aide) called for assistance. Observed R1 on the floor with bleeding on the back of his head. Doctor called and ordered R1 sent to emergency room . Review of R1's hospital discharge instructions dated 5-17-13 denotes R1 had 2.5 centimeter laceration to the posterior scalp that required three staples to be kept clean and dry. Interviewed R1 on 5-30-13 at 9:30 AM states on the day he fell E2 (CNA) was getting him up out of the bed. R1 states he stood up then all of sudden was on the floor. R1 states he did not recall R1 placing a belt around his waist before trying to get him up. Record review of facility's policy and procedure for gait belt/transfers denotes all staff members who assist resident to transfer or ambulate will be required to use a gait belt during these procedures. In order to promote safety and provide a safe environment for both residents and staff: Gait belt must be used with any assisted transfer or ambulating procedure. Interviewed E1 (Social Director/Abuse Coordinator) on 5-30-13 at 10:30 AM, states that they did an investigation to the fall for R1 and it was substantiated thru another CNA that assisted R1 from the floor after the fall on 5-17-13, observed that R1 did not have on a gait belt. E1 states E2 (Certified Nurse Aide) admitted to not using a gait belt for transfer. Record review of E2's employee file denotes a corrective action document signed by E2 on 5-23-13. Type of corrective action three day suspension for violation of gait belt policy: not using a gait belt for transfer resulted in injury to the resident (R1). Record review of R1's minimum (MDS) data set [DATE] denotes R1 required for transfer limited assistance with one person physical assist.

Based on record review and interview the facility failed to have a physician order [REDACTED]. R29 sustained second degree burns as a result of staff placing the compress on the residents abdomen. The facility also failed to ensure a medication cart was locked and secured while not attended. Findings include: 1. December 26, 2011 at 5:00 p.m E19 (LPN-Licensed Practical Nurse) stated in the Nursing Care Notes that she received a call from the daughter of R29, requesting to place a warm compress on the resident's left lower abdomen. Nursing notes indicate (E19) applied the compress at 5:25 p.m. At 5:30 p.m R29 was up in the hallway complaining of pain to the abdomen. E19 stated on the nursing notes that some redness was noted to be at the site where the warm compress was placed. E19 documented she applied a cold compress to the abdomen, and after 5 minutes R29 was still complaining of pain to the area and 2 blisters measuring 1 cm. x 0.5 cm were observed. The nursing notes did not indicate that E19 called the physician to obtain an order prior to applying the warm compress to R29's abdomen. December 26, 2011 at 5:30 p.m. the incident report indicates that (R29) did sustain two blisters and pinkish discoloration to the abdomen site after application of a warm compress by E19. December 26, 2011 at 5:20 p.m. the Corrective Action Form from the Final Investigation indicates, that E19 stated she told the daughter of R29 that she can not apply the warm compress without a physician order. E19 stated that the daughter kept begging her to apply the compress. March 8, 2012 at 1:20 p.m, E2 was asked if the nurses can apply compresses to residents she stated "No". E2 stated the nurses need to obtain an order from the physician if the Physical Therapy (PT) team is not on site. E2 stated that the PT is the only team assigned to assess and apply diathermy or warm compresses to the residents. 2. On 3/6/12 at 11:12am, E16 (Registered Nurse) entered room 332A to administer medications. E16 left the medication cart unlocked upon entering the resident's room. There were several residents in seated in their wheel chairs in the near vicinity of the medication cart.