Every finding on record at Macomb Post Acute Care Center

Based on Observation, Interview and Record Review, the facility failed to ensure a resident with known bowel incontinence was provided dignified incontinence care for one of four residents (R1) reviewed for incontinence care assistance in the sample of seven. This failure resulted in R1 experiencing mental anguish and feeling embarrassed and ashamed of the lack of control of R1 bowels and the need for daily assistance with hygiene. Findings include:The facility's Dignity policy, dated 8/2019, documents Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. This same policy also documents Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to the resident's request for toileting assistance.The facility's Perineal/Incontinence Care policy, dated 9/11/2020, documents Purpose: To provide cleanliness and comfort to the resident, prevent infections and skin irritation, and observe the resident's skin conditions.The facility's Certified Nursing Assistant job description (undated), documents Job requirements: Be considerate, pleasant, and professional in the performance of his/her duties. Must have compassion, tolerance, and understanding for the residents of the facility. Main duties: Be sensitive to residents' families and respond in an appropriate professional way as the situation requires. Answer call lights promptly. Wash, clean, and dry all incontinent residents. Be responsible for well-being and nursing care of all residents assigned to his/her unit while on duty.R1's current Care Plan, dated 6/10/26, documents R1 was admitted to the facility on [DATE] and has diagnoses including Adult Failure to Thrive, Calculus of Gallbladder, Type two Diabetes Mellitus, and Generalized Anxiety Disorder.R1's Minimum Data Set assessment, dated 5/31/26, documents R1 has intact cognition, is continent of bladder function and is always incontinent of bowel function. This assessment also documents R1 requires substantial/maximal assistance with toileting and hygiene.R1's progress notes, dated 7/12/26 at 4:00 PM and completed by V20 (Registered Nurse), documents (R1) Refuses to get up and utilize toilet for bowel movements. Would rather be incontinent and have to have the CNA's (certified nursing assistants) clean him up after he has went in his (incontinence brief). Education given to resident that he has been cleared by therapy to get up into wheelchair and utilize toilet.On 7/23/26 at 2:15 PM, V15 (R1's family) stated R1 has been dealing with issues at the facility for awhile. V15 stated (R1) says they don't come change him and won't change him. (R1) cannot feel when he has to go to the bathroom. He told me that the CNAs (certified nursing assistants) are rough when cleaning him and that his testicle was bruised after cares and it was because the CNA squeezed and said she thought it was feces stuck on him. (R1) waits for hours just to get cleaned up so maybe there is stuck on feces.On 7/24/26 at 10:20 AM, R1 was sitting in his room, in bed. R1 stated he has to wait a long time for his call light to be answered. R1 stated I have sat in a soiled diaper for an hour. They (facility staff) get mad at me about it. I can tell when I have to urinate, but I cannot tell when I have to go number two and then staff get mad at me for that. When (V18, CNA) was cleaning me up she grabbed my testicle and was too rough, she squeezed until I was bruised from it. I was upset because it hurt. (V18) and another CNA (unknown) laughed about it after it happened. R1 stated he feels at fault for being incontinent and feels like the staff make him wait a long time on purpose. R1 stated I don't want this to happen (bowel incontinence) and I feel embarrassed, like I am inconveniencing them.On 7/24/26 at 1:30 PM, V1 (Administrator in Training) and V17 (Regional Administrator) confirmed that R1 has been noted to be incontinent of bowel since admission and that his status has not changed. Both V1 and V17 confirmed they were not aware of staff making R1 feel ashamed or at fault for being incontinent and stated it is not acceptable for staff to treat residents in that manor. V17 stated the expectation is that Residents should receive prompt care when they are incontinent, and nurses and nursing assistants should never make residents feel embarrassed or at fault for being incontinent.

Based on observation, interview and record review, the Facility failed to provide scheduled menu items, palatable food, personal preference food temperature and personal preference portion sizes for dining services. This failure has the potential to affect all 58 Residents residing in the Facility.Findings include:The Facility Resident Room Roster, undated, documents 58 Residents residing in the Facility.The Facility Resident Nutrition Status Policy, dated 12/30/2024, documents: each Resident shall receive the correct diet, with preferences accommodated as feasible; food services and/or nursing personnel will assure that Residents are served the correct food; and prior to serving the food, the dietary aide/nurse aide must check the tray card to assure that the correct food is being served to the Resident.The Facility Food Service Director Job Description, undated, documents: responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting and physical management of the dietary department's employees and equipment in a way that the dietary services of the facility shall be maintained in accordance with established policies; establish, in conjunction with the dietary consultant, dietary policies and procedures and maintain their currency with new state and federal regulations; communicate pertinent information to the dietary employees; ensure the standardized recipes are being followed; inspect and supervise food preparation and service to ensure that infection control and the highest sanitation standards in all aspects of the dietary department are followed; assure proper maintenance of all food service equipment in all kitchen areas; visit with residents upon admission to make an initial nutritional assessment to ascertain food preferences; make rounds at meal times to check resident's acceptance of foods served; provide meal substitution for residents when requested; participate in Care Plan, Quality Assurance and Performance Improvement meetings; and implement plan of correction as required by State and Federal surveys.The Dietary [NAME] Job Description, undated, documents: purpose is to prepare, serve and maintain food safety with current federal, state and local standards, guidelines, regulations and established policies and procedures to assure that ongoing program of food safety and to assist with resident food preferences; prepare food in a safe and palatable manner that meets appearance, taste and quality expectations of residents; and maintain a clean and safe environment.V11's Employee Discipline Form, dated 7/20/26, documents: V11's position as the Facility Cook; a verbal warning for quality concerns and not following directions; detailed information including did not follow the menu or make necessary substitutions needed to follow the Registered Dieticians approved menu for residents and should have clarified appropriate substitutions. V11 was educated, retrained, in-services and change of positions from Dietary [NAME] to Dietary Aide.The Facility Grievance Log, dated 5/8/26 through 7/22/26, documents eight separate dietary issues (6/8/26, 6/9/26, 6/10/26, 6/15/26, 7/7/26, 7/14/26 and 7/22/26).The Facility Suggestion/Complaint/Grievance Communication Form, dated 6/8/26, documents R2's concerns no longer receiving menu prior to meals, no substitution options, meals are cold when received, feels like rights are being violated. The Facility Suggestion/Complaint/Grievance Communication Form, dated 6/9/26, documents R2's concerns, breakfast, lunch and dinner, no menu's and action taken for (6/8/26 and 6/9/26) we are going to start passing menu's out on Second Shift, in-servicing all Dietary staff on doing this also, in-servicing Dietary staff on substitutions and steam table is now fixed.The Facility Suggestion/Complaint/Grievance Communication Form, dated 6/10/26, documents, the food it is not good, the cook sent out salad for a hot meal and the food served cold and I feel you need a new (cook) that can cook. The corrective action taken was that new cooks are in the process of being trained and we are on a new menu cycle so you will be seeing different menu items.The Facility Suggestion/Complaint/Grievance Communication Form, dated 6/15/26, documents, the new kitchen staff, we have not filled out any menu for three weeks now. I have not had a complete hot meal for the same amount of time. Does anyone in the kitchen know how to turn the steam table on at all? It is also my understanding that the truck has not been here for the kitchen in over three weeks. The corrective action taken was we are going to start passing out menus again. Steam table is fixed. The truck has been here every week.The Facility Suggestion/Complaint/Grievance Communication Form, dated 7/8/26, documents, meals are cold, all of the time, actual meals do not match menus and portions are very small. The corrective action taken was that in-services will be conducted on portion control, food temperatures and right menus. The Facility Suggestion/Complaint/Grievance Communication Form, dated 7/8/26, documents that on 7/14/26, (R2) states that food is still cold, would like at least one meal a day to be warm. Portions continue to be small and that (R2) does not receive food as described on the menu. (R2) gave example of ordering a fried egg sandwich and only receiving an egg. R2 request that further changes be made to address concerns fully as there is a lot of room for improvement. The Facility Suggestion/Complaint/Grievance Communication Form, dated 7/22/26, documents that, (R8) stated during a care plan meeting that (R8) did not receive protein for a recent meal. The corrective action taken was, in-serviced all dietary staff on how to read diet tickets, how to do equal substitutions, cook did not follow menu or made the necessary substitutions that needed to follow the Registered Dietitian's approved menu. The [NAME] (V11) was demoted to dietary aide, wrote up, retained and in-serviced.On 7/23/26, a corrective action taken documents, In-serviced all dietary staff on accuracy and portion control and did audit on scoop sizes. Dietary staff are using the right scoops. V2 (Director of Nursing) sent order over to doctor for double portion sizes for (R2).On 7/23/26 at 12:54 pm, R2 (alert and oriented) stated, I have been complaining about the food for weeks. The food is rotten, and it is slop. The portion size is very small and it is normally just luke warm by the time I get it. Yesterday (7/22/26) I got one bite of chicken and was told that it was the right portion size. I keep telling them that I would like more food. If I ask for more or complain, they give me snarky remarks, and I can hear them talking about me. I am sick of cold meal and everything tasting terrible.On 7/23/26 at 1:10 pm, R4/Resident Council President (alert and oriented) stated, We get a lot of complaints about food in our council meetings. They do not follow the menus, and we do not get enough food. We tell them our issues, and they do not really seem to listen or do better.On 7/23/26 at 12:45 pm, R7 (alert and oriented) stated, The food is sometimes way too hard and cold. My potatoes were too hard today. The food temperature is way off, it is mostly cold. If we ask for more food, they do not give it to us. I recently had a room tray and instead of my meal, I literally got lettuce. One day, they forgot my supper, and the kitchen was closed, so the nurse was nice enough to get me a fast-food sandwich.On 7/23/26 at 11:21 am, V6 (R2's and R6's Sister) stated, I come to visit (R2) and (R6) every day. I gag every time I see their food. There is never enough either. When they had macaroni and, supposedly hamburger bake, he got literally six pieces of macaroni. I bring food in for my brother (R6) and (V19/R2's Spouse) brings in food for (R2). Neither one of them like the food and they do not get enough. We have had multiple discussions with them about this, but it does not seem to get better.On 7/23/26 at 12:56 pm, V19 (R2's Spouse) stated, I am here every single day, and I bring (R2) food, because the food is so bad and (R2) does not get enough.On 7/23/26 at 2:06 pm, V11 (former Dietary Cook/Dietary Aide) stated, I just got written up for not following the menus. I was the [NAME] and now I am a Dietary Aide. Sometimes we have to serve an alternative. Just this week, we forgot to put the turkey out of the freezer for turkey sandwiches, and we had to substitute the meat. I am not sure how it gets told to the Residents when we must substitute. There have been occasions where we cannot find a meal ticket, they get lost, I think the CNA's accidentally leave them in the Resident rooms.On 7/24/26 at1:50 pm, V4 (Dietary Manager) stated, We have all new staff. (V11) was our former cook and I had to demote (V11) because (V11) was not following the menus and substituting recipes.On 7/24/26 at 2:00 pm, V1 (Administrator) stated, We are trying to make a lot of changes in the Dietary Department. We also try and address each individual dietary complaint as they happen.

Based on observation, interview and record review, the Facility failed to maintain clean kitchen floors, clean walk-in cooler, clean walk-in refrigerator units/coolers, clean inside/front/handles of the refrigerators and label/date opened food items in the refrigerator. This failure has the potential to affect all 58 residents residing in the Facility.Findings include:The Facility Resident Room Roster, undated, documents 58 Residents residing in the Facility.The Facility Food Service Director Job Description, undated, documents: responsible for planning, organizing, staffing, directing, coordinating, reporting, budgeting and physical management of the dietary department's employees and equipment in a way that the dietary services of the facility shall be maintained in accordance with established policies; establish, in conjunction with the dietary consultant, dietary policies and procedures and maintain their currency with new state and federal regulations; and inspect and supervise food preparation and service to ensure that infection control and the highest sanitation standards in all aspects of the dietary department are followed.The Dietary [NAME] Job Description, undated, documents: purpose is to prepare, serve and maintain food safety with current federal, state and local standards, guidelines, regulations and established policies and procedures to ensure that ongoing program of food safety; prepare food in a safe and palatable; and maintain a clean and safe environment.The Facility Grievance Log, dated 5/8/26 through 7/22/26, documents eight separate dietary issues (6/8/26, 6/9/26, 6/10/26, 6/15/26, 7/7/26, 7/14/26 and 7/22/26).On 7/23/26 at 10:10 am, the walk-in refrigerator and walk-in freezer door handles had a substantial amount of thick sticky substance with debris in the crevices of the handles, and the floors had a moderate amount of debris. The surface of the floors of the walk-in refrigerator, walk-in freezer and kitchen exhibited a heavy tactile resistance, causing the soles of the surveyor's shoes to stick and adhere to the floor.On 7/23/26 at 10:10 am, the stand-up food preparation refrigerator, located in the food preparation area, had a substantial amount of thick sticky substance with debris on the handles. The stand-up food preparation refrigerator had the following food items: open undated bottle of 16-ounce soda, with no name; a container of gravy, dated 7/13/26; coleslaw dated 7/17/26; no date, partially uncovered nine individual serving bowls of whipped fruit salad; and an open container of half-n-half dated 7/15/26.On 7/25/26 at 8:31 am, the walk-in refrigerator, walk-in freezer door handles and the stand-up food preparation refrigerator had a substantial amount of thick sticky substance with debris in the crevices of the handles.On 7/25/26 at 8:31 am, the stand-up food preparation refrigerator had two open undated bottles of 16-ounce soda, with no name and French salad dressing container, dated 2/8/26 and 6/9/26.On 7/23/26 at 10:10 am, V4 (Dietary Manager) stated, We usually mop the floors once a month. We just swept the floors but did not mop them. We clean the outside of the refrigerators and freezer handles about every week. V4 verified the sticky door handles with debris and the sticky floors.On 7/24/26 at 2:00 pm, V1 (Administrator) stated, We are trying to make a lot of changes in the Dietary Department. We also try and address each individual dietary complaint as they happen. I went into the kitchen, and I even noticed the floors really were sticky, so I had them clean the floors. We may need to look at the cleaning schedule and make sure it is being followed.

Based on interview and record review the Facility failed to respond to Resident call lights in a timely manner and comply with Resident requests for assistance, for five of seven Residents (R1, R2, R4, R6 and R7) reviewed for call light response in a sample of sevenFindings include:The Facility Resident Call Bells Policy, dated 11/5/25, documents: will be adequately equipped to allow Residents to call for staff assistance through a communication system which relays the call directly to a staff member or centralized staff work area from each Resident's bedside, toilet and bathing facilities; calls for assistance shall be answered timely; and any staff member that hears or sees an alert from a Resident from the communication system is responsible to answer within reasonable timeframe; non-clinical staff are to answer requests for assistance from the communication system.The Facility Concern/Grievance Form, dated 4/1/26, documents lights not answered in a timely manner and action taken was call light audits, showing longest call light on for three minutes.The Facility Resident Council Minutes, dated 5/5/26, document follow-up concerns with lights not being answered.The Facility Resident Council Minutes, dated 6/16/26, document Residents concerned about timely response to call lights.The Facility Concern/Grievance Form, dated 6/16/26, document Residents would like better customer service from Certified Nursing Assistants (CNA) and would like call lights to be answered in a timely manner and call light audits and CNA education reviewed, and action taken.The Facility Resident Council Minutes, dated 7/16/26, document Residents are concerned about their call lights not being answered in a timely manner on Second and Third Shift.On 7/24/26 at 10:01 am, R1 (alert and oriented) stated, My call light takes forever to get answered.On 7/23/26 at 12:54 pm, R2 (alert and oriented) stated, Call lights take a very long time, all the time, usually over an hour to get answered.On 7/23/26 at 1:10 pm, R4/Resident Council President (alert and oriented) stated, My call lights take about anywhere from a half-an-hour to an hour to get answered. I heard a lot of call light complaints in Resident Council meetings. We have been trying to work on that issue for quite some time.On 7/23/26 at 1:32 pm, R6 (alert and oriented) stated, We have issues with call lights, they take forever, usually way too long.On 7/23/26 at 12:45 pm, R7 (alert and oriented) stated, Oh yea, the call lights getting answered is random, always takes a long time. I am constantly having issues with them.On 7/23/26 at 11:21 am, V6 (R2's and R6's Sister) stated, I come to visit (R2) and (R6) every day. I am their sister. I have sat in their rooms and had the call light on for over an hour and no one check on them (R2 or R6). It just makes me worry for the people that do not have family, if they are taking that long when I am here, it makes me worry how long it is taking them to help the ones that do not have any family.On 7/23/26 at 12:56 pm, V19 (R2's Spouse) stated, I am here every single day, and they really do take a long time to answer the call lights, I am just glad that I am here to help (R2). Half the time, (R2) is lucky that they even have time to give (R2) water, sometimes (R2) goes without water. I just filled up the water pitcher because they still had not been in here yet.On 7/23/26 at 1:48 pm, V7 (Ombudsman) stated, I have been working on the call light issues at that Facility.On 7/24/26 at 2:00 pm, V1 (Administrator) stated, We have been doing call light audits. We know that we have an issue with the call lights, so we in-serviced the CNA's.

Based on Observation, Interview and Record Review, the facility failed to ensure allegations of resident abuse and neglect were reported to the facility's abuse coordinator and the state agency for three of seven residents (R1, R3, R5) reviewed for Abuse in the sample of seven.Findings include:The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy, dated 2026, documents The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy also documents In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported in the proper time frame pursuant to this policy. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with state law, including to the state agency within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.On 7/23/26 at 11:40 AM, V1 (Administrator in Training) stated she does not have any reported abuse allegations since starting as the Administrator. V1 stated she began her role on 3/9/26.1. R1's current Care Plan, dated 6/10/26, documents R1 was admitted to the facility on [DATE] and has diagnoses including Adult Failure to Thrive, Type two Diabetes Mellitus, and Generalized Anxiety Disorder.On 7/23/26 at 2:15 PM, V15 (R1's family) stated R1 has been dealing with issues at the facility for awhile. V15 stated (R1) says they don't come change him and won't change him. (R1) cannot feel when he has to go to the bathroom. He told me that the CNAs (certified nursing assistants) are rough when cleaning him and that his testicle was bruised after cares and it was because the CNA squeezed and said she thought it was feces stuck on him. (R1) waits for hours just to get cleaned up so maybe there is stuck on feces.On 7/24/26 at 10:20 AM, R1 was sitting in his room, in bed. R1 stated When (V18, CNA) was cleaning me up she grabbed my testicle and was too rough, she squeezed until I was bruised from it. I was upset because it hurt. (V18) and another CNA (unknown) laughed about it after it happened. R1 stated the nurses had the physician (V13, facility Physician Assistant) exam R1's genitals and V13 confirmed the presence of the bruise. R1 denied ever talking to V1 (Administrator in Training, AIT) about the incident and confirmed that V18 has continued to provide care for him since the incident.R1's Progress Note, dated 7/14/26 at 8:00 AM, documents R1 was seen by V13 and examined for a bruise to R1's testicle and acute onset of pain after cares were provided by facility staff.2. R3's current Care Plan, dated 5/1/26, documents R3 was admitted to the facility on [DATE] and has diagnoses including Generalized Anxiety and Morbid Obesity.R3's Minimum Data Set assessment, dated 5/26/26, documents R3 has intact cognition.R3's Suggestion/ Complaint/ Grievance Communication Form, dated 5/11/26, documents (R3's) verbal form with assistance of Administrator (V1, Administrator in Training). CNA (certified nursing assistant) needs to be more gentle with peri care. This form documents (R3) doesn't want CNA to care for her anymore.On 7/23/26 at 1:40 PM, R3 was sitting in her room in a recliner chair at her bedside. R3 confirmed that in May she had an incident with a CNA (V14, certified nursing assistant) that upset her very much. R3 stated (V14) was cleaning me up and hurt me. She was way too rough and entered places she shouldn't. (V14) did it three times and I told her after the first time that it hurt me. She just said, well I have to clean there and kept doing it. I was married for many years, and my husband didn't put his fingers there. There was another CNA (unknown) who heard me complaining and she must've told the administration. (V1) came and talked to me and the CNA no longer cares for me. I've seen her but she doesn't provide care for me. I can talk and report things like this, even though it's embarrassing and I didn't really want to, but I think about the residents who can't talk for themselves or speak up.3. R5's current Care Plan, dated 6/5/26, documents R5 was admitted to the facility on [DATE] and has diagnoses including Anxiety, Dementia, Hemiplegia, Hemiparesis and Major Depressive Disorder.R5's Suggestion/ Complaint/ Grievance Communication Form, dated 6/3/26, documents V16 (R5's family) completed the form on 6/3/26. V16 wrote I feel that my mother (R5) is not getting the proper care. She does not get a bath every week and it takes CNAs forever to change her. I also feel that (R5) has more bruises than she should. She does not eat well at meals, and no progress has been made. This form continues to include V16's concerns that R5 experiences long call light wait times and has back pain and cannot stand on her own, making her at the mercy of whoever can help her.On 7/24/26 at 11:24 AM, V1 (AIT) confirmed she is the facility's abuse coordinator and stated Any willful abuse should be reported to me. V1 verified that she was not made aware of R1 having bruising to his genital area and she would have expected that to be reported to her. V1 stated for R3's grievance, she reached out to her corporate team and was told it was a customer service concern and did not have to be reported as abuse. V1 stated she did not report the allegation to the state agency. V1 also stated she was made aware of the concerns for R5, after V16 (R5's family) filled out a complaint/grievance form and stated she did not report the allegations included in the complaint to the state agency.

Based on Observation, Interview and Record Review, the facility failed to ensure allegations of resident abuse and neglect were investigated and residents were immediately protected to prevent further potential abuse for three of seven residents (R1, R3, R5) reviewed for Abuse in the sample of seven.Findings include:The facility's Residents Right to Freedom from Abuse, Neglect, and Exploitation policy, dated 2026, documents The facility's residents have the right to be free from abuse, neglect, misappropriation of their property, and exploitation as defined in this policy. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. This policy also documents The facility explicitly and expressly prohibits, and will take steps to prevent, any associates from engaging in any behaviors or actions that may result in the abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility will investigate any allegations made alleging abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility will ensure that any suspicion of resident abuse, neglect, misappropriation of property, and exploitation is coordinated with the facility's QAPI (Quality Assurance and Performance Improvement) program. In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility shall: Have evidence that all alleged violation are thoroughly investigated. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with state law, including to the state agency within five working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.On 7/23/26 at 11:40 AM, V1 (Administrator in Training) stated she does not have any abuse allegations or investigations since starting as the Administrator. V1 stated she began her role on 3/9/26.1. R1's current Care Plan, dated 6/10/26, documents R1 was admitted to the facility on [DATE] and has diagnoses including Adult Failure to Thrive, Type two Diabetes Mellitus, and Generalized Anxiety Disorder.On 7/23/26 at 2:15 PM, V15 (R1's family) stated R1 has been dealing with issues at the facility for awhile. V15 stated (R1) says they don't come change him and won't change him. (R1) cannot feel when he has to go to the bathroom. He told me that the CNAs (certified nursing assistants) are rough when cleaning him and that his testicle was bruised after cares and it was because the CNA squeezed and said she thought it was feces stuck on him. (R1) waits for hours just to get cleaned up so maybe there is stuck on feces.On 7/24/26 at 10:20 AM, R1 was sitting in his room, in bed. R1 stated When (V18, CNA) was cleaning me up she grabbed my testicle and was too rough, she squeezed until I was bruised from it. I was upset because it hurt. (V18) and another CNA (unknown) laughed about it after it happened. R1 stated the nurses had the physician (V13, facility Physician Assistant) exam R1's genitals and V13 confirmed the presence of the bruise. R1 denied ever talking to V2 (Director of Nursing) or V1 (Administrator in Training, AIT) about the incident and confirmed that V18 has continued to provide care for him since the incident.R1's Progress Note, dated 7/14/26 at 8:00 AM, documents R1 was seen by V13 and examined for a bruise to R1's testicle and acute onset of pain after cares were provided by facility staff.R1's electronic medical record does not document any detailed notes, skin assessments, incident narrative or investigation related to R1's bruising and pain to his genitals.On 7/24/26 at 10:45 AM, V2 (Director of Nursing) stated (R1) was seen by (V13, Physician Assistant) for the bruising to his scrotum. V2 stated this visit was because R1 complained that his testicles hurt. V2 denied having any further records, interviews or evaluation to determine the cause and details around R1's injury.2. R3's current Care Plan, dated 5/1/26, documents R3 was admitted to the facility on [DATE] and has diagnoses including Generalized Anxiety and Morbid Obesity.R3's Minimum Data Set assessment, dated 5/26/26, documents R3 has intact cognition.R3's Suggestion/ Complaint/ Grievance Communication Form, dated 5/11/26, documents (R3's) verbal form with assistance of Administrator (V1, Administrator in Training). CNA (certified nursing assistant) needs to be more gentle with peri care. This form documents (R3) doesn't want CNA to care for her anymore.On 7/23/26 at 1:40 PM, R3 was sitting in her room in a recliner chair at her bedside. R3 confirmed that in May she had an incident with a CNA (V14, certified nursing assistant) that upset her very much. R3 stated (V14) was cleaning me up and hurt me. She was way too rough and entered places she shouldn't. (V14) did it three times and I told her after the first time that it hurt me. She just said, well I have to clean there and kept doing it. I was married for many years, and my husband didn't put his fingers there. There was another CNA (unknown) who heard me complaining and she must've told the administration. (V1) came and talked to me and the CNA no longer cares for me. I've seen her but she doesn't provide care for me. I can talk and report things like this, even though it's embarrassing and I didn't really want to, but I think about the residents who can't talk for themselves or speak up.R3's electronic medical record does not document any investigation, interventions or incident details related to R3's grievance completed in May 2026.The facility's Interdisciplinary note, provided by V1 on 7/24/26 at 1:15 PM, documents a written statement was obtained from V14 on 5/11/26 that documents V14 assisted R3 with toilet hygiene on 5/6/26. V1 confirmed this is the only written staff interview or statement that she has and stated it is not a part of R3's medical record. V1 also confirmed she is unsure if V14 was suspended from working pending investigation.3. R5's current Care Plan, dated 6/5/26, documents R5 was admitted to the facility on [DATE] and has diagnoses including Anxiety, Dementia, Hemiplegia, Hemiparesis and Major Depressive Disorder.R5's Nursing Progress notes, dated 5/23/26 at 9:47 AM, documents (R5) has a bruise to the right side of her forehead that is very light in color. (R5) states that she does not know what happened. She denies pain. ADON (V8, former Assistant Director of Nursing) notified and looked at area. (V16, R5's family) aware.R5's Suggestion/ Complaint/ Grievance Communication Form, dated 6/3/26, documents V16 (R5's family) completed the form on 6/3/26. V16 wrote I feel that my mother (R5) is not getting the proper care. She does not get a bath every week and it takes CNAs forever to change her. I also feel that (R5) has more bruises than she should. She does not eat well at meals and no progress has been made. This form continues to include V16's concerns that R5 experiences long call light wait times and has back pain and cannot stand on her own, making her at the mercy of whoever can help her.On 7/24/26 at 11:24 AM, V1 (AIT) confirmed she is the facility's abuse coordinator and stated Any willful abuse should be reported to me. V1 denied having an investigation or statements from R1's incident and verified that she was not made aware of R1 having bruising to his genital area but confirmed that V2 (Director of Nursing) was aware. V1 stated for R3's grievance she does not have an abuse investigation, interviews with other residents or written statements from staff members, aside from the CNA (V14) involved. V1 stated the CNA (V14) can no longer care for R3 since the incident. V1 stated she was only made aware of the concerns for R5, after V16 (R5's family) filled out a complaint/grievance form and verified she did not record any statements or conduct interviews with other residents and staff or complete an investigation after learning of V16's allegations. V1 confirmed that there are no notes in R5's record that document the detailed allegations, cause or any investigation to address the concerns.

Based on interview, observation, and record review, the facility failed to provide adequate supervision and prevent a cognitively impaired resident with identified exit seeking behaviors and high risk for elopement from exiting the facility, through alarmed doors and failed to identify the resident's elopement. The resident exited the facility unsupervised and wandered approximately 0.4 miles down a main street which has continuous traffic to the hospital and multiple medical complexes. The police were notified by a community member and upon arrival at 6:43 PM the resident was standing on the corner waving down traffic for help. Due to the resident having an alarm device on her ankle, the police officer called the facility at 7:15 PM, 45 minutes after exiting the facility to confirm the residents' identity. The resident required an emergency room evaluation and was returned to the facility at approximately 8:00 PM. This occurred for one of three residents (R1) reviewed for accidents and supervision, in a sample of 4.The facility's failure to prevent a cognitively impaired high risk for elopement resident from exiting the facility unsupervised because a non-medical staff member silenced the alarm and identify and respond promptly to an elopement placed the resident in immediate danger of serious injury or death.Findings include:These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy started on 5/3/26 when R1 exited the facility, through alarmed exit doors after a non-medical staff member silenced the door alarm without staff knowledge.V1 (Administrator) was notified of the Immediate Jeopardy on 7/1/26 at 3:15 PM.The immediacy is not removed, and the facility remains out of compliance at a severity level J, substandard quality of care, as an acceptable abatement plan has not been provided by the facility. The Wandering and Elopement Assessment and Prevention policy revised 6/4/24 documents the facility uses a multi-faceted approach to prevent elopement such as alarmed doors, alarmed bracelets, signage, elopement prevention drills and missing person drills. Resident Elopement Risk Assessments will be conducted within 72 hours of admission, one month after admission, quarterly, annually, significant change in condition, after an attempted elopement. A score above 7.0 is considered high risk. Residents with Alzheimer's/Dementia that are independently ambulatory will be automatically considered at risk for elopement and an individualized care plan will be implemented. An elopement risk log will be maintained by the Social Services including a photograph and face sheet of the residents at high risk. Appropriate interventions per care plan include application of an alarm device, an Interdisciplinary review for wandering precaution interventions, schedule for observation of residents and diversional activities. In the event an alarm device is sounded, or a resident is reported missing all personnel hearing the alarm are to immediately respond to site. If initial investigation does not reveal the cause of the alarm, open door and search immediate perimeter, secure door if no one is found, report to Charge Nurse who will notify Supervisor and initiate a head count. The Code Butterfly-Elopement/Missing Resident policy dated 5/3/26 documents if an individual is identified as missing, notify supervisor announce Code Butterfly and page the missing resident overhead. All staff report to nurse's station. Search teams organized and search begins. If resident is not found, notify police and family until missing resident is found. Once the resident is located, cancel the Code Butterfly, assess resident, determine what intervention shall be immediately implemented to prevent elopement recurrence, seen by medical staff within 48 hours, document incident, investigate and gather witness statements. R1 was admitted on [DATE] with diagnoses of Unspecified Dementia, Conversion Disorder with Seizures, Anxiety Disorder, History of Falling and Transient Alteration of Awareness.R1's Minimum Data Set (MDS) dated [DATE] documents R1 has a Brief Interview for Mental Status score of 08, moderate cognitive impairment. R1's Wandering/Elopement Risk Assessments scores indicated R1 was at high risk on 4/25/26, 4/28/26 and 5/3/26.R1's Progress Notes dated 4/25/26 documents R1 was standing at the exit door attempting to leave by following a visitor out of facility and an alarm device was placed. On 5/3/26 at 7:15 PM the facility was notified by the local police department that a person was found wandering and lost and inquired as to if the person was a resident at the facility. The police department took R1 to the local hospital for evaluation. At 8:00 PM, R1 returned from the hospital without injury. R1's care plan documents on 4/26/26 an alarm device was initiated, safety will be monitored every shift, staff will be aware of R1's location every 2 hours and as needed, on 5/3/26 post elopement, every 15-minute checks will be conducted and on 5/4/26 R1 was moved to a room closer to nurse's station on hallway without door close.R1's Physician's Order/Treatment Administration Record dated 4/26/26 documents to check placement of the alarm device was to be conducted every shift for safety and to check the function of the alarm device weekly. Placements were not checked daily on each shift on 4/28/26, 4/30/26, 5/12/26, 5/16/26, 5/26/26, 5/27/26, 6/3/26, 6/4/26, 6/8/26, 6/14/26 and 6/23/26 and function checks were not conducted on 4/28/26, 5/12/26 and 5/26/26. The Certified Nurse Aide Task documentation dated 6/24/26 through 7/7/26 lacked documentation R1 was monitored every 15 minutes and/or visualized every 2 hours by the Certified Nurse Aides. The facility's investigation report included staff witness statements, the police report, hospital records and actions conducted post R1's elopement on 5/3/26. The investigation did not identify a root cause which led to R1's elopement. During interviews on 7/1/26, V7 (Registered Nurse), V10 (Certified Nurse Aide) and V11 (Certified Nurse Aide) stated R1 was last seen at 6:30 PM near the front nurse's station/front lobby area. On 6/30/26 at 11:00 AM, V2 (Director of Nursing) agreed the facility was unaware that R1 was not in the facility or identified as missing prior to police notification approximately 45 minutes later on 5/3/26 at 7:15 PM. V2 confirmed R1 had an alarm device on at the time of elopement and this is how the police were able to identify where R1 was from. On 7/1/26 at 9:40 AM, V1 (Administrator) stated the facility investigated and collected witness statements to determine the root cause of R1's elopement. V1 stated facility staff denied hearing the alarm when R1 exited the building and that R1 was presumed to follow a visitor out. Stated R1 would tell people she left her purse in the car and needed to go get it. Staff education on the Wandering and Elopement Assessment and Prevention policy and the Code Butterfly-Elopement/Missing Resident policy was conducted on 5/3/26 and 5/4/26, alarm devices and door alarms were checked for proper functioning on 5/3/26, elopement drills were conducted on 5/4/26, Wandering/Elopement Risk Assessments were conducted on all residents 5/3/26, care plans were updated on 5/3/26 and the exit door alarm code was changed and would be changed monthly thereafter. V1 stated on 5/8/26, staff were educated on verbal check-in process and the stop and scan method used by staff prior to someone exiting the facility. On 7/8/26 at 2:36 PM, V18 (Certified Nurse Aide, Date of Hire: 12/16/24), V19 (Nurse Aide, Date of Hire: 3/13/26) and V20 (Licensed Practical Nurse, Date of Hire: 9/22/25) stated the door code had not been changed since date of hire. V18, V19 and V20 stated they had not received education on door alarms nor the verbal check-in and stop and scan method. V20 stated I guess a verbal check would include asking the visitor who they were and who they were there to see but no education was given on how to do that. On 7/8/26 at 3:57 PM, V21 (Maintenance) stated he was instructed to change the exit door code today and had not changed the code in I don't recall. Probably 6 months or more. That's (change the exit door alarm code) not something I do very often. Generally, we don't have much of a problem unless maybe there is a disgruntled employee we don't want to have access to the building. On 7/8/26 at 2:40 PM, V16 (Regional Administrator) stated the facility had identified that V17 (Dietary staff) silenced the exit door alarms and let R1 exit the facility on 5/3/26, V16 stated this information was not disclosed during the survey because the facility did not want to place blame on V17. V16 agreed this information was not included in the investigation. 2. R3 was admitted on [DATE] with diagnoses of Metabolic Encephalopathy, History of Transient Ischemic Attack and Cerebral Infarction. R3's current care plan documents on 6/5/24 that R3 was at high risk for wandering/elopement, safety will be monitored every shift, staff will be aware of R1's location every 2 hours and as needed and will wear an alert bracelet.R3's Physician's Orders/Treatment Administration Records dated 5/16/24 documents to check the function of R1's alarm device every night shift and on 10/29/24 to check placement of the alarm device every shift. The function was not checked daily on 5/4/26, 5/12/26, 5/26/26, 5/27/26 6/4/26, 6/8/26 and 6/23/26 and placement was not checked every shift on 5/12/26, 5/18/26, 5/26/26, 5/27/26, 6/4/26, 6/8/26, 6/14/26 and 6/23/26.On 7/7/26 at 3:16 PM, V1 (Administrator) reviewed R1 and R3's Treatment Administration Records and CNA Task documentation and agreed the alarm device placement and functioning checks, 15 minute or 2 hours checks were conducted as ordered and should have been.Request for Reconsideration of Immediate Jeopardy Determination received on 7/2/26 at 9:59 AM, revision requested.Abatement Plan was received on 7/7/26 at 11:54 AM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/7/26 at 1:57 PM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/8/26 at 11:24 AM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/8/26 at 2:19 PM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/8/26 at 3:42 PM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/8/26 at 8:02 PM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/9/26 at 4:20 PM, from facility Administrator. After review, revision requested.Abatement Plan was received on 7/10/26 at 3:16 PM, from facility Administrator. No revision requested. Exit was already conducted on 7/10/26 at 12:15 PM.

Based on interview and record review the facility failed to have adequate processes in place for acquiring /receiving refill prescriptions for narcotic medications for one (R4) of three residents reviewed for pharmaceutical services in a sample of four. Findings include:The facility's policy, Medication Orders IB2: Controlled Substance Prescriptions, dated November 2021, documents not in it's entirety, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and recordkeeping requirements in the facility, in accordance with federal and state laws and regulations. Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication. The Director of Nursing and the contracted consultant pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. Only authorized, licensed nursing and pharmacy personnel have access to controlled medications.A verbal prescription for a schedule II medication may be called in to a pharmacist directly by the prescriber only, if: Immediate administration of the controlled substance is necessary for proper treatment of the intended ultimate user.The prescriber is contacted for direction when delivery of a medication will be delayed, or the medication is not, or will not be available.Refill Requests for CIII-CV, and Partial Fill Requests for CII: 1) Additional supplies of controlled drugs are ordered by the facility from the provider pharmacy. 2) Re-orders for controlled substances should be made allowing for appropriate time for the pharmacy to obtain the prescription and to assure an adequate supply is on hand. R4's admission Record documents R4's admitted to the facility on [DATE] and R4's diagnoses on admission include but are not limited to Encounter for Other Orthopedic Aftercare, Other Nonrheumatic Aortic Valve Disorders, Heart Failure, Type 2 Diabetes Mellitus without Complications, Opioid Dependence Uncomplicated, and Depression. R4's physician order dated 1/30/25 documents that R4 has an order for Fentanyl (Narcotic Pain Reliever) Patch 72 Hour 75 mcg (microgram)/HR (hour) apply every 72 hours for pain and remove per schedule. R4's Medication Administration Record for April 10, 26 shows R4 was due to have a Fentanyl (Narcotic Pain Reliever) Patch of 75mcg (microgram)/HR (hour) applied at 9:07am but lacks documentation that it was applied, area blank. R4's progress notes dated 4/10/26 at 15:55 documents, called pharmacy fentanyl patches will be delivered in tonight's shipment. unable to pull from backup. R4's progress notes dated 4/10/26 at 16:43 documents, wife brought in fentanyl patch and placed on left rear shoulder. On 5/6/26 at 2:30pm, V13/Registered Nurse stated that if Fentanyl (Narcotic Pain reliever) Patches are noted to be down to one or two patches remaining the nurse will contact the physician to receive a new prescription so the patches can be refilled before the resident runs out of the supply on hand. V13 also stated that they have had issues prior with obtaining R4's prescription for his Fentanyl Patches and have had to reach out to V10/R4's spouse to have her bring in one from home until they can get the physician to send in a new prescription by repeated calls to the office. On 5/6/26 at 2:40pm, V10/R4's spouse stated that since R4's admission to the facility in October of 2024 she has had to bring in a total of 11 Fentanyl (Narcotic Pain Reliever) Patches to the facility because of issues with getting his prescription filled. On 5/12/26 at 8:30am, V2/Director of Nursing stated that R4 has had only one issue this year with the facility getting his prescription filled for his Fentanyl (Narcotic Pain Reliever) Patches and verified that it is documented in the nurse's progress notes that one was obtained from R4's spouse, V10, on April 10th at 4:43pm and placed at that time with no documentation on R4's Medication Administration record that R4 received the dose. V2 stated that the facility has difficulty in getting prescriptions for controlled substances from V14/R4's Physician in a timely manner. V2 also stated that it is the expectation of the nursing staff to contact the doctor for a new prescription when a resident's Fentanyl patches have two remaining in hopes that the prescription will be to the pharmacy in time to refill so no missed doses occur. When asked if the prescription is not received and dose is due what does the facility do, V2 stated they keep calling the doctor's office and inform them they need a new prescription now. V2 also stated that the facility has never reached out to V15/Medical Director for assistance because they do not want to upset the community doctors they work with, they want to keep a good rapport.

Based on observation, interview, and record review, the facility failed to ensure a multidose tuberculin vial was dated when opened. This failure has the potential to affect all 60 residents residing in the facility. Findings include: The Facility's Storage, Labeling of OTC (over the counter) Medication, Destruction and Disposal of Medication policy, dated/revised November 9th, 2021, documents, Purpose: To ensure that medications and biological are stored in a safe, secure storage and safe handling. Medications requiring refrigeration should be stored in the refrigerator located in the drug room at the nurse's station. Medications should be stored separately from food and must be labeled. Please refer to package insert for specific temperature requirements of medication. On 4/16/25 at 9:30 AM V3 (LPN/Licensed Practical Nurse) opened the refrigerator located in the medication room. On the top shelf of the door in the refrigerator was one vial of Aplisol (Tuberculin) units/0.1 ml (milliliter). Vial was opened, one fourth of the way full, and was not dated when opened. V3 verified the vial was opened and not dated. V3 verified the vial of (Tuberculin) is used for all residents residing in the facility. On 4/15/25 at 9:40 AM V3 stated (Tuberculin) should be dated once opened and discarded after 30 days of opening. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility.

Based on observation, interview, and record review the facility failed to offer food substitutions of similar nutritive value. These failures have the potential to affect all 60 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Substitution policy dated 12/30/24, documents Food Substitutions will be made as appropriate or necessary. Policy Interpretation and Implementation 1. The food services manager, in conjunction with the clinical dietitian, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when unavoidable. 2. The food services manager will maintain an exchanged list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making substitutions. 3. Resident' likes and dislikes will be considered when making substitutions. 4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitutions. 6. The dietician will provide feedback on appropriate substitutions as necessary. The facility's Menus dated 4-13-25 through 4-19-25 document there is only one vegetable and one entree option daily for lunch and supper. The facility's Substitution Menu does not include a vegetable option. The Lunch/Dinner Substitute Menu only includes the option of applesauce, corn dog, hot dog, cottage cheese, or grilled cheese. On 4-14-25 at 12:01 PM V7 (Cook) was serving mixed vegetables and spaghetti with meat sauce to all residents. V7 stated, There are no substitutes offered in place of the mixed vegetables. We (facility) staff do not offer a substitution for vegetables. The only substitutes we offer every day for the main entrees are hot dogs, corn dogs, or grilled cheese. On 4-14-24 from 12:00 PM through 12:50 PM the lunch meal was observed in the main dining room. All residents were served mixed vegetables. On 4-14-25 at 12:05 PM R9 was served spaghetti and meat sauce, cake, mixed vegetables, and a bread stick. R9 pointed at the mixed vegetables and stated to V3 (LPN/Licensed Practical Nurse), I don't like those. V3 stated to R9, Let me turn your plate around so you don't have to look at them (mixed vegetables). On 4-14-25 at 12:35 PM R13, R27, R32, R36, R37, and R40 were in the dining room and ate everything on their plate except for the mixed vegetables. R13, R27, R32, R36, R37, and R40 all verified that they do not like mixed vegetables and are never offered a substitute for vegetables at meals. On 4-15-25 from 12:05 PM through 12:30 PM the lunch meal was observed in the main dining room. All residents were served steamed broccoli. R13, R32, R36, and R40 did not eat the broccoli and were not offered a substitute. R13, R32, R36, and R40 also verified they do not get substitutes offered for the main entree except for the same options of a corn dog, hot dog, or grilled cheese. On 4-15-25 at 1:40 PM during a resident group meeting, R1, R10, R13, R15, R17, R20 and R45 all stated they are given one choice for lunch and supper and then if they want something different, they can choose from a hot dog, corn dog, or grilled cheese. At this time all the residents confirmed there are not any vegetable substitutions or alternate choices. R45 stated he has watched residents just push their vegetables aside if they don't like them but there isn't ever a second option offered for vegetables. On 4-15-25 at 2:45 PM, R51 stated, (R51) does not feel like they have any options on the dietary menus. The institutional like food and canned vegetables are not enough. We are given one choice and if that is something you don't like they have a few options to choose from which is a corn dog, hot dog, or grilled cheese. I've had a corn dog a few times, you can only eat so much of that.

Based on observation, interview, and record review the facility failed to complete and record cool down temperatures for meat that was prepared ahead and stored in the facility's refrigerator for future use, ensure facial hair was appropriately restrained within a hair net while in the kitchen, ensure a gallon of milk's temperature was kept below 41 degrees Fahrenheit, and ensure the sanitation buckets had the appropriate amount of quaternary ammonium. These failures have the potential to affect all 60 residents residing within the facility. Findings include: The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 4-14-25 and signed by V1/Administrator documents 60 residents currently reside within the facility. The Food Temperature policy dated 12/30/24, documents Food will be stored in accordance with local, state, and federal guidelines. Policy Interpretation and Implementation 1. Food will be stored in accordance with local, state, and federal guidelines. 3. Food in refrigerators will be kept at 41-degrees F (Fahrenheit) or below. 6. Food items will be cooled from 135-70 degrees F within 2 (two) hours and from 70-41 degrees F or below within 4 (four) additional hours. 8. Food items being cooled will be checked and if food items do not meet the required cooling timeframe, will be heated to 135-degree F and the re-cooling process restarted. The Personnel Adherence to Sanitary Procedures policy dated 12/30/24, documents Food service personnel shall follow appropriate sanitary procedures. Policy Interpretation and Implementation 1. In addition to employee personnel policies, food services and dietary personnel will be required to adhere to the following sanitary standards: a. Hair nets or approved hats, covering all the hair, must be worn at all times while on duty. The Cleaning Dining Room Tables or Food Service Carts policy dated 3/23/24, documents To maintain sanitary dining room table and food surfaces. Policy Interpretation 3- Bucket Procedure 1. Prepare 3 (three) buckets: soapy water, plain water, and sanitizing solution. 2. Use a clean cloth in each bucket and keep cloth with the proper bucket. 3. After each meal, when dishes are removed, wipe table with soapy water, including edges. a. When cart is emptied, wipe with soapy water. 4. Rinse with plain water-if necessary, per manufacturer's guidelines. 5. Wipe with sanitizing solution diluted according to manufacturer's directions for food contact surfaces. 6. Permit to air dry. Cleaning of Dining Room Tables, Chairs, Food Surfaces, and Carts 1. Use detergent water and a clean cloth in each bucket and keep the cloth with the proper bucket. 2. Wipe tabletop, under side, top edges, and legs. 3. With another bucket, wipe chairs including seat, arm, and legs. 4. Rinse with plain water (if required per manufacture's guidelines) 5. Wipe with food safe sanitizing solution diluted according to manufacturer's directions for food contact surfaces for the appropriate amount of time. 6. Allow to air dry. The Manufacturer's instructions for Quat (Quaternary Ammonium Compounds) Sanitizer, (not dated) documents Direction for Use - Use Quat Sanitizer (200 ppm/parts per million active) for sanitizing and cleaning of equipment and utensils in food processing, dairy industry, bars, restaurants, institutional kitchens, meat and poultry processing plants. Prior to application, remove gross food particles and soil by a pre-wash, pre-scrape, or pre-flush, and when necessary, pre-soak. Thoroughly wash or flush equipment or utensils with a good detergent or compatible cleaner followed by a potable water rinse before applying sanitizer. Apply QUAT Sanitizer to pre-cleaned hard non-porous surfaces with cloth, mop sponges, or sprayer or by immersion. Surfaces must remain wet for 60 seconds. Drain thoroughly and allow to air dry before reuse. On 4-14-25 from 9:33 AM to 10:03 AM a tour was completed in the kitchen and dining room. During this tour, V5 (Dietary Aide) was washing all dining room tables with wash clothes that were submersed in a red sanitizing bucket of water. V5 tested the water within the sanitizing bucket for Quaternary Ammonium using a Quaternary Ammonia Strip. The strip read zero PPM of Quaternary Ammonium. The container holding the Quaternary Ammonia testing strips stated 200-400 PPM was the normal range of Quaternary Ammonia. V6 (Dietary Aide) was washing dishes and had a full beard that was not restrained with a hair net. On the top shelf of the three-drawer refrigerator there was a plastic bag dated 4-10-25 containing 12 cooked sausage patties, a plastic bag dated 4-13-25 containing 14 cooked chicken breasts, and a plastic bag dated 4-9-25 containing two cooked polish sausages. There were no cool-down logs located within the kitchen for the cooked sausage patties, cooked chicken breasts, or cooked polish sausages. On 4-14-25 at 9:45 AM (V5) stated, I did not fill the sanitizing bucket. (V6/Dietary Aide) filled the bucket. On 4-14-25 at 10:00 AM V6 stated, I did not add any sanitizer to the sanitizing bucket. I did not know I was supposed to. I did not know I have to wear a hair restraint over my beard. On 4-14-25 at 10:15 AM V4 (Dietary Manager) verified there are no cool-down logs for the cooked sausage, polish sausage, and chicken breasts located in the refrigerator. V4 stated, We (kitchen staff) do not do cool-down logs when storing leftovers. The health department gave me cool-down logs last week, but I have not started to do them yet. (V6) should be wearing a hair net over his beard while in the kitchen and the sanitizing bucket should have had sanitizer. On 4-14-25 at 12:13 PM V4 calibrated a thermometer and inserted the thermometer into a gallon of skim milk that was in a wash tub in the main dining room. The milk was sitting on top of ice. The temperature of the milk was 49 degrees Fahrenheit. V4 (Dietary manager) stated, Whoever put the milk out here should have put ice all the way up on the outside of the milk to keep the milk cool. The milk should have a temperature of 41 degrees (Fahrenheit) or below. On 4-15-25 at 2:10 PM V10 (Dietary Aide) was in the kitchen washing dishes and V11 (Dietary Aide) was prepping meals. Both V10 and V11 had full beards that were not restrained with hair nets.

Based on Observation, Interview and Record Review, the facility failed to ensure a resident with a Failure to Thrive diagnosis was provided with Physician ordered double meal portions for one of four residents (R52) reviewed for Nutrition in the sample of 38 Finding include: The facility's Therapeutic Diets policy, dated 12/30/24, documents Therapeutic diets shall be prescribed by the attending physician. The facility will strive for the fewest possible dietary restrictions. The food service manager will establish and use a tray identification system to ensure that each resident receives his or her diet as ordered. On 4/14/25 at 11:00 AM, R52 was in his room sitting up in bed. At this time R52 stated he has a note on all of his dietary meal slips that document Double portions and Cottage cheese with all meals. R52 stated I don't get this. I asked about it because I am not sure where that note came from. The dietary staff told me that when everyone is done being served, I can ask for a second portion. So, a lot of times I will wait and then ask and then there isn't any food left, so I don't get a second portion (double portion) of food most days. At this time R52's dietary slip was viewed and documents Cottage Cheese with lunch and supper four ounces, Double Portions and cottage cheese with Lunch and Supper. May have extra helping after the double portion if needed. R52's Physician Order Sheet, dated 4/15/25, documents a diet order, dated 2/15/25, for R52 to receive a Regular diet; may have double portions and seconds for double portions and cottage cheese with lunch and supper related to Adult Failure to Thrive. R52's current Care Plan dated, 2/21/25, documents R52 was admitted to the facility on [DATE] with diagnoses of Anorexia, Adult Failure to Thrive and Protein-Calorie Malnutrition. This same Care Plan documents (R52) is currently at nutritional risk related to Anorexia and Weight loss. On 4/14/25 at 11:52 AM, R52 was sitting at a table in the dining room and was served lunch. R52's plate contained a single portion of spaghetti, vegetables, bread, and cottage cheese. R52 consumed 100% of his meal. On 4/15/25 at 12:05 PM, R52 was sitting in the dining room eating lunch. R52's plate contained a single serving portion of the lemon pepper chicken and rice entree. After consuming 100% of his meal R52 reached over to a bowl of uneaten rice that was left from R22's tray and consumed all the contents. On 4/15/2025 at 2:00 PM, V7 (Cook) stated, We (dietary staff) do not give (R52) double portions with his meals. If (R52) asks for seconds, we would give them to him. I am not aware of (R52) having a physician's order to get double portions at meals. On 4/16/25 at 9:21 AM, V2 (Director of Nursing) confirmed R52's dietary order documents double portions with lunch and dinner meals and that those double portions should be served without R52 having to ask.

Based on observation, interview and record review the facility failed to assess, document and provide pain management for one resident (R2) of three residents reviewed for change in condition. This failure resulted in no pain management provided for 7 hours after R2 fell and sustained a left hip fracture Findings include: Facility Policy/Pain Management and assessment dated [DATE] documents: Evaluation and Assessment: Comprehensive pain assessment tool will be completed upon admission, transfer or onset of new pain which includes: Quality of pain (e.g. burning, aching, numbness) Pain intensity (numeric, visual analog scale, or nonverbal behavior, changes in function observation) Changes in mood state (e.g. depression, anxiety) Location and/or radiation of pain Factors that palliate or provoke pain Characteristics of pain (i. e., stable, progressive, crescendo) Facility Policy/Change in Condition Procedure dated 9/21/2022 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Full assessment by nursing staff including but not limited to: Full Vital signs (Temperature, Pulse, Respirations, Blood Pressure and Oxygen Saturation) Level of consciousness; Respiratory status including last bowel movement and urine properties Functional status, Pain Glucose test if diabetic or decrease in level of consciousness. Progress Note dated 9/27/24 at 11:59pm indicates (R2) on floor, sitting on his bottom. (R2) claims he was looking for his remote. Vital signs within normal limits, no injuries, moves all extremities within normal limits. Progress Note dated 9/28/24 at 7am indicates R2 complained of hip pain 10/10 after fall last evening. Note indicates (R2) fell at 11:59pm 9/27/24, now complaining of pain and left leg appears to be externally rotated. No other progress notes or documentation regarding R2 was found between 9/27/24 at 11:59pm and 9/28/24 at 7am. Hospital ED (Emergency Department) Final Report Note dated 9/28/24 at 11:14am presented to the ED with left hip pain-swelling, stating he fell last night with pain persisting this AM. Note indicates R2 has a past surgical history of right hip fracture. Risk Management Incident Report dated 9/27/24 at 11:51pm indicates Level of Pain (post fall): Alert; wheelchair bound. Report does not include any actual documentation of R2's pain post fall. On 10/22/24 at 11:40am V6, CNA stated that she was sitting at the nurse station and heard a loud thud. V6 stated she left the nurses station and followed the sound of the thud and saw R2 on the floor in front of the sink. V6 stated R2's room is almost right next to the nurse station, R2's television is above the sink and R2 said he was trying to turn the television on. V6 stated she called V3, LPN who came in and barely did an assessment of R2 and then helped her get R2 back into his wheelchair. V6 stated she was holding the top half of R2 and V3 was holding his bottom half. V6 stated R2 was complaining of pain while they were trying to get him into the chair. V6 stated that night R2 would complain of pain and yell Ow! every time they turned and changed him when he was in bed, especially when turned to the left side. V6 stated R2 really couldn't roll onto the left side. V6 further stated When I found (R2) on the floor, he was completely on his left hip/side. He must have hit hard because the sound I heard from the nurses station was loud. V6 stated she did notify V3 about R2's pain throughout the night. On 10/22/24 at 12:30pm V3, LPN stated that she went to R2's room when she heard he was found on the floor. V3 stated that she and V6, CNA manually picked R2 up and put him in his wheelchair. V3 stated (R2) had no complaints of pain. V3 stated I rely on the CNA's to tell me. It was a busy night, I didn't reassess him. I gave (R2) meds in the morning (not for pain), he took it ok. There is not a spot to document pain on the Neuro sheet. I should've put in a progress note about R2's pain assessment. On 10/18/24 at 11:30am V5, LPN (Licensed Practical Nurse) stated she was told in report in the morning of 9/28/24 that R2 had an unwitnessed fall during the night (of 9/27/24) and was on neuro(logical) checks. V5 stated a CNA came to tell her that while she was providing cares to R2, he was complaining of pain on his left side. V5 stated the night nurse (V3) didn't say anything to her in report about R2 being in pain during the night. V5 stated she had another nurse (V8) came into R2's room and they both agreed R2 needed to go to the hospital for evaluation. V5 stated R2 was in a great deal of pain especially with any movement. No documentation of R2's pain at time of fall or anytime between time of fall at 11:59pm through 7am the following morning (9/28/24) was found or presented. No assessment or interventions to relieve R2's pain from after he fell was found or presented until the morning of 9/28/24 at 7am. Medication Administration Record (MAR) dated September 2024 indicates no pain medication was administered during the night of 9/27/24 through 9/28/24. Current Care Plan has no focus/problem area identifying R2's pain or interventions for pain management. On 10/22/24 at 10am R2 was sitting in his room in his wheelchair with a distressed facial appearance. R2 stated his back hurt and he wanted to lay down. R2 became teary-eyed while speaking. R2 stated this latest hip fracture was much more painful than his previous (right) hip fracture. R2 was unable to recall anything else from the night he fell (on 9/27/24) other than he was trying to turn on the television. At that time V5, LPN came in to assess R2 and stated that R2 is easily emotional especially when in pain. On 10/23/24 at 4:30pm V11, Medical Director stated there can be severe pain associated with a hip fracture, especially with movement. V11 stated there should be a policy to assess for pain after a fall and the policy should be followed.

Based on observation, interview and record review the facility failed to provide treatment to a scalp laceration post fall and failed to provide post fall neurological monitoring for one resident (R1) of three residents reviewed for change of condition. Findings include: Facility Policy/Fall/Accident/Incident Protocol dated 8/1/22 documents: The following guidelines will be utilized as appropriate to each situation and change in condition: Nursing evaluation on all resident falls, witnessed and unwitnessed Complete set of vital signs (temperature, pulse, respirations, blood pressure and oxygen saturation) including pulse oximetry Neuro-checks to be initiated with every un-witnessed fall and witnessed fall with head injury Contact On-call Nurse Notify physician Notify family Document progress note (May complete in Risk Management) Complete Risk Management Obtain complete vital signs including pulse oximetry at a minimum of every shift for 72 hours Document in chart minimum of 72 hours post fall. Progress Note dated 9/27/24 at 11:17pm indicates R1was found on the floor on his bottom. Note indicates a head to toe assessment was done and a small amount of blood was found on the top of R1's head Looked like a scab that he picked. Note indicates (V3, LPN/Licensed Practical Nurse) used a (tissue) to clean the area with no active bleeding noted. Progress Note dated 9/28/24 at 6:25am indicates at 6:05am report received from night nurse that R1 was in bed with no new or ongoing concerns. Note indicates at 6:25am dayshift V4, CNA (Certified Nurse Assistant) notified V8, LPN/(Licensed Practical Nurse) that R1 had a bump on his head that was bleeding. Note indicates V4, CNA stated he received in report from V6, CNA that R1's head was bleeding all night. Note indicates V8, Nurse immediately entered R1's room and assessed R1. Note indicates a palm-size raised bruise was noted to the back of R1's head with a laceration noted to the center of the bump with blood dripping. Note indicates quarter-size drops of blood were noted to multiple areas of R1's pillowcase. Note indicates when asked, R1 stated he fell last night at 10:30pm with complaints of pain to the back of his head. Note indicates R1 was then transferred to the hospital for evaluation. Hospital Emergency Department (ED) Report dated 9/28/24 at 6:52am indicates R1 was found to have a bruise on the back of his head that had a small amount of blood. Note indicates R1 stated he may have had a seizure and fallen last night. Hospital Report indicates R1 was diagnosed with a Scalp Contusion. On 10/18/24 at 11am V8, LPN stated during report from V3, LPN on the morning of 9/28/24, V3 stated I don't have anything new to tell you (regarding R1). V8 stated she was never told R1 fell or had bleeding from his head. V8 stated she didn't find out until V4, CNA told her about R1. On 10/22/24 at 10:10am R1 was sitting in his room watching television. R1 was able to recall falling and hitting his head. At that time a linear approximately 4cm (centimeter) dark pink, slightly scabbed area to the posterior top part of R1's head was noted. On 10/22/24 at 11:46am V6, CNA stated On Friday night (9/27/24) I found (R1) sitting on the floor leaning against his bed. When (R1) laid down I noticed a small amount of blood on his head. I told the nurse (V3) and she did somewhat of an assessment and wiped the blood away with one of R1's tissues. She said he was Ok. She never started neuro checks or anything else. V6 stated R1's head continued to bleed all night The other CNA (V7) noticed it too. The nurse was aware. It was not right. I told my boss (V1, Administrator) exactly what happened. On 10/22/24 at 11:22am V4, CNA stated he came on shift and got a brief report and was told R1 had hit his head when he fell the night before, but it stopped bleeding. V4 stated he went to see R1 and noticed blood scatted on his pillow case. V4 stated he saw swelling and a knot on R1's head and It was still dribbling blood at that time. V4 stated he immediately went and told the V8,LPN who also had just received morning report. V3 stated that she had received no information about R1 in report and had no idea what happened to R1. V3 stated that V6, CNA (from night shift) stated that she told the V3 (night nurse) R1's head was still bleeding. On 10/22/24 at 12:30pm V3, LPN stated that V10, CNA told her that R1 (on 9/27/24) was on the floor. V3 stated she went to R1's room and R1 said he didn't fall. V3 stated R1 has behaviors of putting himself on the floor. V3 stated a short while later V6, CNA told her there was a small amount of blood on R1's head. V3 stated shehad already looked at R1's head and there was no swelling, and that she wiped the area with one of R1's tissues. V3 stated she didn't believe R1 fell and thought it was R1's behaviors so she didn't do neurological checks. V3 stated she didn't notify the physician and didn't notify R1's family. V3 stated R1's POA (Power of Attorney) said she doesn't want to hear about his Bullcrap so she didn't bother her. V3 stated R1 denied falling, but could not explain how he got on the floor. V3 stated she was aware of R1's seizure diagnosis but believed it was one of R1's behaviors. V3 stated she didn't hear from R1 or the CNA's for the rest of the night so she didn't check on R1 again during the night. On 10/22/24 at 12:50pm V7, CNA stated that she went to see R1 shortly after he fell . V7 stated that R1 told her he fell but he seemed ok. V7 stated there was blood on his pillow and it looked like he hit his head. V7 stated that she reported what she saw to the nurse (V3) and told her there was blood and (V3) said she already assessed R1. V7 stated I don't think she (V3) went back in to see him. On 10/22/24 at 2:15pm V1, Administrator stated staff should not disregard and not follow the fall protocol just because someone has behaviors. On 10/23/24 at 4:32pm V11, Medical Director stated there should be a policy and the staff should follow the policy for what to do when someone falls and when someone hits there head. V11 stated Staff should not minimize or disregard incidents because someone has behaviors, but should actually do more to make sure they are ok.

Based on observation, interview, and record review, the facility failed to ensure walk-in coolers in the kitchen maintained a temperature of less than 40 degrees Fahrenheit/F and that food in refrigerators were kept at a temperature of 41 degrees Fahrenheit or below. This failure has the potential to affect all 50 residents residing in the facility. Findings include: The facility's Policy and Procedure Refrigerators and Freezers revised 11/15/21 states, Policy Statement: The facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy Interpretation and Implementation: 1. Acceptable temperatures should be 35 degrees F to 40 degrees F for refrigerators and less than 0 degrees F for freezers. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and/or department contacted. The facility's Policy and Procedure Food Temperatures revised 11/5/21 states, Policy Statement: Food will be stored in accordance with local, state, and federal guidelines. Policy Interpretation and Implementation: 2. Food in refrigerators will be kept at 41 degrees F or below. An Electronic/E-mail Communication from V1 (Administrator) to V14 (Chief Operating Officer) on 5/9/24 at 3:30 PM states, Our walk-in cooler is running at 45 degrees (F), and we just received both of our trucks today. They put coolant in it twice in the last two weeks, 4 lbs. (pounds) the first time and then 10 days later 3.5 lbs. We don't want our food to go bad. What do we do? On 5/9/24 at 4:42 PM, V14 responded that V16 (Corporate Maintenance Director) is off the rest of the week, but that V16 is working on someone to work up a repair quote. An Electronic/E-mail Communication from V16 on 5/14/24 at 10:03 AM documents that a (Name of Electrical, Plumbing, and Heating Company) had been contacted to get the facility on their schedule to look at walk-in (cooler). An Electronic/E-mail Communication from V1 to V14, V15 (Purchasing), V16, and V4 (Dietary Manager) on 5/15/24 at 2:53 PM states, Just an update our walk-in is running at 43 degrees (F) today. An Electronic/E-mail Communication response from V16 to V1, V4, V14, and V15 on 5/15/24 at 1:56 PM states, Why are we still trying to use it? (Name of Electrical, Plumbing, and Heating Company) is going to get us on the schedule as soon as possible. On 5/15/24 at 2:56 PM, V1 (Administrator) responded, We have no other option. Everything won't fit in the reach in and somethings we can't freeze. On 5/15/24 at 1:58 PM, A second Electronic/E-mail Communication from V16 stated, We can't keep throwing money away on putting freon (in) it. We are trying to get it fixed as soon as we can. On 5/15/24 at 3:07 PM, V1 responded, I understand that. I just don't know what to do. An Electronic/E-mail Communication from V16 on 5/16/24 at 10:18 AM states, (Name of Electrical, Plumbing, and Heating Company) is working on a quote to repair walk-in should have it today. An Electronic/E-mail Communication from V17 (Employee at Name of Hired Electrical, Plumbing, and Heating Company) on 5/17/24 at 11:31 AM states, That's good enough for me to schedule someone to look at it. I will work it into our schedule to check out the problem and price repairs next week, as soon as someone can get to it, probably the middle of next week is the soonest we could. Did you say it was a walk-on cooler? A Price Quote from (Name of Electrical, Plumbing, and Heating Company) dated 5/23/24, states, We are pleased to offer the following work to be done: We will remove the old evaporator coiled and condensing unit. We will install the following new equipment with new copper line set: (Name Brand) Condensing Unit and Air ECM (Electronically Commutated Motor) with Intelligen Controller. The total cost for all parts material and labor will be $10, 218.00 (dollars). Everything is in stock with our supplier and takes 3-5 (three to five) days to receive. On 6/4/24 at 10:04 AM, a tour of the kitchen was conducted with V4 (Dietary Manager). V5 (Temporary Maintenance Director) was also present in the kitchen. At this time, the walk-in coolers digital temperature outside the door was reading 44 degrees F. At this time, V4 stated, We just got done cleaning breakfast, so that door has been opened, so it's reading higher than normal. At this time, V4 and V5 were asked if there have been any known issues with any of the refrigerators or freezers not working as they should. V4, quietly responded, Oh, yeah. and V5, pointing to the walk-in cooler that was reading 47 degrees, stated, That one right there. V4 and V5 both stated the walk-in cooler has not been working correctly for at least a month and a half. V5 stated, They tried dumping freon in it over and over, but that was an easy fix and it's not working anymore. V4 stated, The walk-in freezer is on the other side of the walk-in cooler, so I keep the freezer door opened to keep the walk-in cooler at temperature. V4 stated, Once the door stays closed for a period of time, it will cool down. V5 stated, It (walk-in cooler) needs a new condenser. It's not working. At this time, a prepared cup of milk on a drink cart was observed. V4 checked the temperature of the milk and it read 44.1 degrees F. On 6/4/24 at 11:01 AM, a follow-up visit was made to the kitchen with V4. At this time, the walk-in cooler digital temperature read 47 degrees F. On 6/4/24 at 11:10 AM, V9 (Dietary Aide/Cook) toured the walk-in cooler with this writer. At this time, the walk-in cooler contained the following items: 55-four ounce/oz. containers of fruit yogurt; 123 eggs; A cardboard box of sliced cheese; Four-One Gallon containers of Mayonnaise; Six individual containers of pear fruit cups; One-Five Pound Vacuum sealed portion of Diced Beef; A metal pan containing leftover Tuna Noodle Casserole dated 5/31/24; One container of Thickened Dairy Supplement; One vacuum sealed 15 pound package of Corned Beef Brisket; a metal pan of gelatin dessert; one chocolate cream pie; four gallons of milk; a variety of drink pitchers labeled: Apple Juice, Lemonade; Cranberry Juice, and Tea; and two unopened boxes of ham. On 6/4/24 at 11:20 AM, V9 removed one yogurt cup, the pan of tuna noodle casserole, and poured a glass of milk into a plastic cup and set it on a counter in the kitchen. With a digital thermometer, V9 checked the temperature of the three items: The fruit yogurt cup read: 41.9 degrees F; The tuna noodle casserole read 42.6 degrees F; and the glass of milk read 41 degrees F. V9 stated, I am going to have to tell (V4) these temperatures are too high, we can't serve this. It has to be 41 degrees F or less, and it's not. On 6/4/24 at 11:26 AM, the walk-in cooler continued to read 47 degrees F. On 6/4/24 at 11:32 AM, the drink cart container one gallon of milk and the variety of fruit juices was removed from the walk-in cooler and brought out to the main dining room to be served. On 6/4/24 at 11:36 AM, V18 (Resident Aide/RA) poured three glasses of milk and gave them to R2. On 6/4/24 at 11:40 AM, R2 took a drink out of one of the milk glasses that were given to her. At this time, R2 stated, It is actually colder than it usually is. Months ago, I was given chocolate milk that was spoiled. On 6/4/24 at 11:52 AM, the digital temperature gage outside the walk-in cooler was reading 46 degrees F. At this time, V9 was observed disposing of the tuna noodle casserole into the trash and the yogurt cups had been disposed of as well. V9 stated, We have to get rid of this. We can't use that cooler anymore. We are taking everything out of there. On 6/4/24 at 1:29 PM, R1 stated, Oh, the food is disgusting. They serve warm milk. It's bad. On 6/5/24 at 9:22 AM, a tour of the kitchen was conducted. V4 (Dietary Managaer) stated, We have shut it down (walk-in cooler). It's not working. Everything is out of there. We shut it down last night. The digital thermometer outside the walk-in cooler read 51 degrees F. At this time, V4 was observed removing the vacuum sealed package of corned beef brisket from the walk-in cooler and placing it into the freezer. V4 stated, I still had this (corned beef brisket) in there (walk-in cooler). I just put it in the freezer to keep it cool until I can make room in the stand-up fridge. At this time, V4 stated V4 refused to check the internal temperature of the corned beef brisket due to its vacuum seal. V4 stated, I don't know when I am serving this. If I open the seal, I will have to serve it. I know the temperature is fine because I keep that freezer open, and I keep the meat in the back of the walk-in cooler. When asked why V4 was continuing to use a walk-in cooler that was not operating correctly, V4 stated, What do you want me to do? I don't have anywhere else to put all of this food. There is no room in the other refrigerators. No other food items were observed in the walk-in cooler. On 6/5/24 at 12:00 PM, V1 (Administrator) stated the Corned Beef Brisket was disposed of into the trash and would not be served to any residents. V1 stated the walk-in cooler will not be used until it is repaired. The Resident Room Roster dated 6/4/24 documents 50 residents currently reside in the facility.

Based upon observation, interview, and record review, the facility failed to remove soiled gloves and perform hand hygiene before cleansing a wound, failed to wear gloves while touching wound dressing materials, and failed to wash hands before touching clean items after performing wound care for one of one resident (R1) reviewed for wound care in the sample of seven. Findings include: The facility's Clean Dressing Change Policy undated states, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. 9. Loosen the tape and remove the existing dressing .10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound. (i.e., clean outward from the center of the wound). Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. R1's Admission Record documents R1 admitted to the facility on [DATE] with diagnoses to include but not limited to: Osteomyelitis; Type 2 Diabetes Mellitus with Foot Ulcer; Arthritis due to other Bacteria, Left Ankle and Foot; and Necrotizing Fasciitis. R1's current Care Plan documents the following: R1 has an alteration to R1's Integumentary System due to surgical incision related to Necrotizing Fasciitis, Osteomyelitis; R1 currently has an infection due to Necrotizing Fasciitis, Osteomyelitis with an intervention of Emphasize good hand washing techniques to all direct care staff. R1's current Physician Order Sheet documents orders for Weekly Wound Documentation for R1's Left Foot Wound and Daily Dressing Change with Calcium Alginate (to the left foot wound). R1's Progress Note signed and dated by V13 (Advanced Nurse Practitioner) on 6/4/24 at 1:37 PM documents R1 is currently receiving intravenous antibiotics for treatment for recent diagnoses of Gangrene, Osteomyelitis, and Necrotizing Fasciitis to R1's left foot. On 6/4/24 at 1:53 PM, V8 (Registered Nurse) entered R1's bedroom to change R1's left foot wound dressing. Two foam border dressings were noted to the posterior portion of R1's left foot. Dark brown drainage was noted to have soaked through the center of both of R1's dressings. With gloved hands, V8 removed the soiled dressing from the bottom of R1's left foot. V8 removed the soiled glove from V8's right hand and disposed of the soiled dressing. V8 kept the same soiled glove on V8's left hand. V8 then proceeded to cleanse R1's left foot wound with wound cleanser and gauze wearing the same left hand soiled glove and an ungloved right hand. V8 then removed the left-hand glove and performed hand washing. Without donning gloves, V8 began to cut a piece of Calcium Alginate to fit the center of R1's open wound, touching the wound covering with V8's bare hands. V8 then placed a glove to V8's left hand, exited R1's room wearing the glove to V8's left hand, returned wearing the same glove to V8's left hand and then placed a glove on V8's right hand. No handwashing or glove changes occurred upon V8's return to R1's bedroom. V8 then proceeded to place the Calcium Alginate to R1's left foot wound and dress the wound. V8 then removed V8's soiled gloves and without handwashing, V8 adjusted R1's left foot, handed R1 R1's sock, and placed items in the trash. V8 exited R1's bedroom carrying the bottle of wound cleanser, walked up the hallway to the nursing station where V8 then performed hand hygiene. On 6/4/24 at 2:05 PM, V8 verified V8 did not change gloves or perform hand hygiene after removing R1's soiled left foot dressing and before cleaning R1's left foot wound. V8 stated, I don't think I should have because I was still touching a dirty wound. At this time, V8 verified V8 should not have touched R1's Calcium Alginate with V8's bare hands. V8 stated, I was trying to barely touch it, but I should have worn gloves. V8 verified V8 did not immediately wash V8's hands after performing wound care and before touching clean items in R1's room and should have. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview, V1 and V2 both stated V8 should have immediately removed V8's soiled gloves and washed V8's hands before cleansing R1's wound. V1 and V2 stated V8 should not have touched R1's Calcium Alginate with V8's bare hands.

Based upon observation, interview, and record review, the facility failed to ensure a resident had physician orders and a diagnosis for use of an indwelling urinary catheter and failed to ensure a resident's indwelling urinary catheter did not come in direct contact with the ground for one of two residents (R4) reviewed for indwelling urinary catheters in the sample of seven. Findings include: The facility's Policy and Procedure: Indwelling Catheter dated 12/29/23 documents the physician's order for indwelling urinary catheters will note the size French and bulb inflation (milliliters). R4's Hospital Records Discharge Orders document R4 discharged from the hospital on 5/23/24 after management of a femur fracture with repair. These same Hospital Records do not document an order for R4 to admit to the skilled nursing facility with an indwelling urinary catheter. R4's Admission Record documents R1 admitted to the facility on [DATE]. R4's current Physician Orders do not document an order for R4's indwelling urinary catheter, size French, or bulb inflation. R4's current Care Plan documents R4 with the presence of an indwelling urinary catheter and that R4 is currently on antibiotic therapy related to urinary tract infection. R4's Nursing Progress Note dated 5/29/24 states, Urine obtained and sent to lab. (R4) has been yelling out, attempting to hit staff, throwing items. R4's Urine Culture Result dated 5/31/24 documents an abnormal result of greater than 100,000 colony-forming unit per milliliter Escherichia coli. This same laboratory results documents an order for R4 to start Macrobid 100 milligrams twice a day for ten days. On 6/4/24 at 12:30 PM, R4 was sitting up in wheelchair in the front lobby of the skilled nursing facility. R4's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R4's wheelchair. The tubing of R4's indwelling urinary catheter was noted to be resting directly on the ground. Dark amber colored urine was noted in the tubing with thick brown sediment. On 6/4/24 at 12:46 PM, V6 (Certified Nursing Assistant) pushed R4 in R4's wheelchair out of the facility and across the parking lot to a nearby office for a scheduled appointment. R4's indwelling urinary catheter tubing remained directly touching the ground and was dragging across the pavement of the parking lot and the road. On 6/5/24 at 9:10 AM, R4 was lying in R4's bed in R4's room. R4's indwelling urinary catheter bag and tubing was resting directly on the floor to the left side of R4's bed. R4's urine remained a dark amber color. No dignity bag covering was in place on R4's catheter bag at this time. On 6/5/24 at 9:13 AM, V10 (Certified Nursing Assistant/CNA) entered R4's bedroom. V10 noted R4's indwelling urinary catheter bag and tubing resting directly on the floor. At this time, V10 picked R4's indwelling urinary catheter bag off the floor and hung it to the side of R4's bed and using a plastic clip that was located around the tubing of R1's catheter, clipped the tubing to the fitted sheet on R4's bed, so the tubing was not directly touching the ground. At this time, V10 stated R4's indwelling urinary catheter bag and tubing should not have any direct contact with the ground. V10 stated R4 does not like having the catheter and that R4 frequently attempts to pull it out. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview, both stated R4's indwelling urinary catheter bag and tubing should never come into direct contact with the ground. V1 and V2 also stated they were looking into the reasoning for R4's indwelling urinary catheter. V1 verified R4 did not come to the facility with orders for an indwelling urinary catheter and R4 did not have a diagnosis to justify the use of an indwelling urinary catheter. V1 stated R4 is always attempting to pull her catheter out, so V1 is looking into getting it discontinued. V1 and V2 verified R4 is currently receiving antibiotic treatment for a urinary tract infection.

Based upon observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions for residents with open wounds, indwelling urinary catheters, and peripherally inserted central catheters/PICC for three of six residents (R1, R4 and R6) reviewed for Enhanced Barrier Precautions in the sample of seven. Findings include: The facility's Policy and Procedure Enhanced Barrier Precautions dated 3/27/24 states, Policy: It is the policy of this facility that Enhanced Barrier Precautions (EBP) are used to prevent transmission of infectious organisms spread by direct or indirect contact with the patient or the patient's environment. They are a strategy in nursing homes to decrease transmission of CDC (Centers for Disease Control and Prevention) targeted and epidemiologically important MDROs (Multidrug-Resistant Organisms) when contact precautions do not apply. EBP is used during high-contact care activities for residents with chronic wounds or indwelling medical device, regardless of MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply. The website https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html states, What is the definition of indwelling medical device? An indwelling medical device provides a direct pathway for pathogens in the environment to enter the body and cause infection. Examples of indwelling medical devices include, but are not limited to, central vascular catheters (including hemodialysis catheters, peripherally-inserted central catheters/PICCs), indwelling urinary catheters, feeding tubes, and tracheostomy tubes. The guidance advises using Enhanced Barrier Precautions for the care and use of indwelling medical devices. How is 'care and use' defined? The presence of an indwelling device is a major risk factor for being colonized with or acquiring a MDRO. Therefore, the safest practice would be to wear a gown and gloves for any care (e.g., dressing changes) or use (e.g., injecting or infusing medications or tube feeds) of the indwelling medical device. The CDC's (Centers for Disease Control and Prevention) Enhanced Barrier Precautions door signage states, STOP. Everyone must: Clean their hands including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities: Device care of use of: central line, urinary catheter, feeding tube, tracheostomy; Wound Care: any skin opening requiring a dressing. On 6/4/24 at 9:15 AM, V1 (Administrator) stated that the facility only has one resident (R7) currently in the facility with Enhanced Barrier Precautions implemented. R1's Progress Note signed and dated by V13 (Advanced Nurse Practitioner) on 6/4/24 at 1:37 PM documents R1 is currently receiving intravenous (IV) antibiotics through a PICC Line for treatment of recent diagnoses of Gangrene, Osteomyelitis, and Necrotizing Fasciitis to R1's left foot. This same note documents R1 receives daily wound care to R1's left foot. R1's current Care Plan states, I (R1) have a PICC line and am at risk for opportunistic infection to enter my body and intervention of Educate resident on reason for Enhanced Barrier Precautions. R4's current Care Plan documents R4 with the presence of an indwelling urinary catheter and that R4 is currently on antibiotic therapy related to urinary tract infection. R6's Baseline Care Plan dated 5/25/24 documents R6 with the presence of an indwelling urinary catheter. On 6/4/24 at 12:30 PM, R4 was sitting up in wheelchair in the front lobby of the skilled nursing facility. R4's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R4's wheelchair. On 6/5/24 at 10:00 AM, R6 was observed coming inside from the smoking patio. R6's indwelling urinary catheter drainage bag was noted in a dignity bag covering hanging from the underside of R6's wheelchair. On 6/4/24 at 12:36 PM, R1, R4, and R6's bedrooms were observed. R1 and R6's rooms were next door to each other and R4's bedroom was directly across the hall from R1 and R6. At this time, R1, R4, and R6's bedroom doors did not contain the CDC's Enhanced Barrier Precautions door signage. No bins containing personal protective equipment were located outside R1, R4, or R6's bedroom. On 6/4/24 at 1:41 PM, R1 was sitting up in a chair in R1's room. R1 stated R1 has a Peripherally Inserted Central Catheter (PICC Line) that R1 is receiving IV (intravenous) antibiotics through for a wound infection to R1's left foot. At this time, R1 was receiving a dose of antibiotics through R1's right upper arm PICC line. R1 stated the staff has never worn a gown while performing treatments to R1's PICC Line or R1's left foot wound. On 6/4/24 at 1:48 PM, V7 (Registered Nurse) entered R1's room to respond to a beeping alarm coming from R1's IV pump. At this time, V7 disconnected R1's IV tubing from R1's PICC line and then proceeded to flush R1's PICC line with a Normal Saline 10 milliliter flush. V7 did not wear a gown during the care of R1's PICC line. On 6/4/24 at 1:53 PM, V8 (Registered Nurse) entered R1's bedroom to change R1's left foot wound dressing. V8 removed R1's soiled dressing. Dark brown drainage was noted to have soaked through the center of R1's dressing. A dime-sized open area was noted to the posterior lateral side of R1's left foot. V8 cleansed R1's wound with a spray cleanser and proceeded to place Calcium Alginate in R1's wound bed. V8 did not wear a gown during R1's entire wound care treatment. On 6/4/24 at 2:05 PM, V8 verified did not maintain Enhanced Barrier Precautions/EBP during R1's wound care. V8 stated R1 did not have enhanced barrier precautions ordered. V8 stated V8 did not know if R1 should have EBP implemented. On 6/5/24 at 9:13 AM, V10 (Certified Nursing Assistant/CNA) entered R4's bedroom. V10 noted R4's indwelling urinary catheter bag and tubing resting directly on the floor. At this time, V10 picked R4's indwelling urinary catheter bag off the floor and hung it to the side of R4's bed and using a plastic clip that was located around the tubing of R1's catheter, clipped the tubing to the fitted sheet on R4's bed. V10 stated R4 did not have Enhanced Barrier Precautions implemented and stated, The nurses order that. On 6/4/24 at 2:09 PM, V3 (Infection Preventionist) stated that R7 was the only resident in the facility with EBP implemented. V3(Assistant DON/Infection Preventionist) verified R1 currently had a PICC line and a wound to R1's foot. V3 stated V3 did not think R1's wound was open, and R1's PICC line alone wasn't a reason to implement EBP. At this time, V3 also verified R4 and R6 had indwelling urinary catheters but did not have EBP implemented because they did not have more than one reason for EBP to be implemented. V3 stated V3 did not think an indwelling urinary catheter alone was a reason to implement EBP. V3 stated you would know if a resident had EBP implemented by the sign posted on their door and the bin of personal protective equipment/PPE outside of their door. On 6/5/24 at 9:10 AM, R1, R4, and R6's bedroom doors remained without the CDC's Enhanced Barrier Precautions door signage and no bins containing personal protective equipment were located outside of their bedrooms. On 6/5/24 at 2:04 PM, V1 (Administrator/Registered Nurse) and V2 (Director of Nursing) in a joint interview verified R1, R4, and R6 did not have EBP implemented. V2 stated, Gowning every time they need catheter care or do wound dressings? I would have to talk to (V3) about that.

Based on interview and record review the Facility failed to develop a Resident centered Care Plan for three Residents (R6, R9, R17) of 33 reviewed for Care Plans in a sample of 33. Findings include: Facility Comprehensive Care Plan Policy and Procedure, revised 6/25/20, documents: an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the Resident's medical, nursing, mental and psychological needs is developed for each Resident; the Facility's Care Planning/Interdisciplinary Team (IDT), in coordination with the Resident/Family/Representative, develops and maintains a Comprehensive Care Plan for each Resident that identified the highest level of functioning for the Resident to be expected to attain; the IDT documents in the clinical record the Resident's status in triggered areas; each Resident's Comprehensive Care Plan has been designed to incorporate identified problem areas, risk factors, treatment goals, objectives, aid in preventing/reducing declines in functional status/levels and enhance optimal functioning; and Care Plans are revised as changes in Resident's condition dictate. The Facility's Psychotropic Medication Management policy dated 12/4/19, states 12. A plan of care will be developed to include precipitating factors, non-pharmacologic interventions and potential side effects. 1. R6's Physician Order's document R6 takes Risperdal (Antipsychotic medication) 0.25 mg (milligrams) by mouth two times a day and Abilify (Antipsychotic medication) 5 mg one time a day for a diagnosis of Bipolar Disorder. R6's Care Plan dated 11/29/22, documents R6 is on an Antipsychotic therapy (Ability and Risperdal) for Bipolar Disorder. This same Care Plan does not document R6's precipitating factors and target behaviors/symptoms to justify the use of antipsychotic medications or non-pharmacological interventions. 2. R17's Physician Order Sheet document R17 takes Risperdal (antipsychotic medication) 1 mg daily for the diagnosis of Major Depression without Psychotic Features. R17's Care Plan last updated on 2/16/24, does not document R17's use of an antipsychotic medication, precipitating factor and target behaviors for the use of antipsychotic medication or the target behaviors/symptoms to justify the use of antipsychotic medication or non-pharmacological interventions. On 2/22/24 at 11:50 a.m., V2 (Director of Nursing) stated the care plan content for psychotropic medications should follow the facility policy. 33975 3. R9's Physician Order Sheet/POS, dated 2/21/24, documents a Physician Order for Compression Stockings (TED Hose) on in the morning and off in the evening (on in AM and off in PM) every day and night shift for Prophylaxis. R9's current Care Plan does not document R9's order for Compression Stockings (TED Hose). On 2/22/24 at 11:05 am, V2 (DON) stated, I do the Care Plans and I do not remember why these (antipsychotics and Compression Stockings) are not on their (R6, R9, R17) Care Plans. I have got too much going on and too much on my plate.

Based on observation, interview and record review the Facility failed to follow physician orders for compression stockings for one of 33 Residents (R9) reviewed for quality of care in a sample of 33. Findings include: Facility Physician Orders Policy and Procedure, revised 2/14/23, documents: to provide guidance to ensure physician orders are transcribed and implemented in accordance with professional standards; physician orders must be documented clearly in the medical record including the components of a complete order; clear and complete orders will be transcribed to the appropriate administration record; monthly review of physician orders will be completed to assure appropriateness, accuracy and completeness; adherence to Physician Orders will be reviewed quarterly by the Quality Assurance Committee for recommendations for sustaining professional standards; and the licensed nurse is required to record the order on the Physician Order Sheet and on the appropriate administration record and also do a progress noted. R9's Physician Order Sheet/POS, dated 2/21/24, documents R9's diagnoses including Hypertension, Atherosclerotic Heart Disease, Need for Assistance with Personal Care, Lack of Coordination, Unspecified Abnormalities of Gait and Mobility, Unsteadiness on Feet, Difficulty Walking and Acute Kidney Failure. R9's POS also documents a Physician Order for Compression Stockings (TED Hose) on in the morning and off in the evening (on in AM and off in PM) every day and night shift for Prophylaxis. On 2/20/24 at 10:10 am, 2/20/24 at 1:49 pm, 2/21/24 at 10:40 am and on 2/22/24 at 8:45 am, R9's was sitting in a wheelchair and R9's compression stockings were not on R9's lower extremities. R9's bilateral lower extremities were swollen/edematous and purple. On 2/20/24 at 10:10 am, R9 stated, I do not have any stockings on my legs and I do not know why, I do not know why they do not put them on. On 2/20/24, V2 (Director of Nursing/DON) stated, I am not sure why (R9) does not have on his compression stockings. I will check in to it. On 2/22/24 at 11:05 am, V2 (DON) stated, (R9) does not have TED Hose (Compression Stockings) on. (R9's) legs are swollen and discolored. I checked why (R9) does not have them on and they (Staff) told me that (R9) does not like to wear them, but nothing is documented anywhere and they have not notified (R9's) Doctor.

Based on observation, interview and record review the facility failed to establish appropriate fall interventions for one cognitively impaired resident (R2) and failed to prevent falls with injury for two of three residents (R1 and R2) reviewed for fall with injuries in a sample of three. These failures resulted in R1 requiring hospitalization , sustaining scalp lacerations and a cervical fracture, and subsequently resulting in R1's death, and R2 requiring hospitalization and sustaining a scalp laceration. Findings include: Facility Fall Policy, dated [DATE], documents: it is the policy of the Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; the Facility recognizes each situation is unique and must be handled in the manner is most appropriate at the time and for the nature of the change in the condition; guidelines will be utilized as appropriate to each situation and change in condition. Facility Resident Rights Policy, dated [DATE], documents: It is the policy of the Facility to respect the rights of the resident by providing comprehensive care with an approach aimed at maintaining dignity while respecting the core rights of patients and residents as outlined by the State of Illinois, Illinois Department of Public Health, Centers for Medicare and Medicaid/CMS; recognizing society is dynamic and the rights of residents are continually evolving; and strive to improve the quality of care through a multi-disciplinary approach recognizing each resident is an individual with unique needs; and the Facility develops policies and procedures to assist in the support of patient's rights. Facility Assessment, dated [DATE], documents: Nursing Services, the Facility much have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the Facility's Resident population in accordance with the Facility Assessment required; the purpose of the Assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies and is used to make decisions and determine capabilities to provide services to residents in the Facility, to ensure each resident is provided care allows the resident to attain or maintain the highest practicable physical and mental well-being Facility Musculoskeletal System diseases/conditions of Muscle Weakness, Difficulty Walking, History of Falling and Fractures and Rheumatoid Arthritis, Compression Fractures and Joint Replacement (Hip and Knee); Specific Care or Practices with Mobility and Fall with Injury prevention with transfers, ambulation assistance ad Restorative Nursing; dealing with resident's Mental Health and Behavior by managing the medical condition and medication and identifying/implement interventions to help support individuals with issues such as dealing with Anxiety; assessment of medical conditions, early identification of complications and management of medical and psychiatric symptoms; provide support emotional and mental well-being; and identify hazards and risks for residents. Facility Registered Nurse/RN Job Description, undated, documents: direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations and guidelines govern the long-term care facility; ensure all nursing personnel assigned to you comply with the written policies and procedures established by the Facility; responsible for complying with Facility policies and procedures and making recommendations for revisions; complete accident/incident reports and document appropriately; provide direct resident care as needed; implement and maintain established nursing objectives and standards; makes periodic rounds to observe and evaluate the resident's physical and emotional status to ensure continuing quality resident care; assures resident care delivery in accordance with Facility policies and procedures; responsible for competent administration of care; answers call lights promptly; ensures a safe environment; and reports incident's to the Director of Nursing/DON or Designee immediately. Facility Certified Nursing Assistant/CNA Job Description, undated, documents the purpose of this position is to assist the Nurses in providing of resident care primarily in the area of the daily living routine; knowledge of Department of Public Health (IDPH) regulations as related to duties; answer call lights promptly; check on all new resident and re-admissions; responsible for well-being and nursing care of all residents assigned to the his/her unit while on duty; and detect and report situations have a high probability of causing accidents or injuries to residents. 1. R1's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 9:34 am, documents R1's fall with physical harm or injury. The report documents R1 was transported and admitted to the local hospital Emergency Department with a Grade Three Odontoid Fracture/Laceration. The report states R1 stood up from R1's recliner and reached for R1's walker and fell forward hitting R1's head on the bedside table. R1 was noted to have two lacerations to the scalp ad R1 complained of neck pain and right hip pain. R1 was sent to the local hospital for treatment and was noted to have a seven centimeter/cm laceration to R1's lateral scalp, a three cm laceration vertical in between eyebrows and a Grade Three Odontoid Fracture requiring sutures to the lacerations and a cervical fusion of the Cervical (C,d+[DATE]). The report documents R1's Care Plan and interventions were updated. R1's Physician Order Sheet/POS, dated [DATE], documents R1 admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Unspecified Trochanteric Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing and Rheumatoid Arthritis. The POS also documents a Physician Order for Anxiety Medication (Alprazolam oral tablet 0.25 milligram/mg every eight hours for anxiety) and Anti-depressant Medication (Mirtazapine one tablet 7.5 mg at bedtime) and to monitor for side effects of falls, orthostatic hypotension, motor changes and behavior and mood changes. The POS also documents a Physician Order for Physical Therapy, Occupational Therapy and Speech Therapy. R1's Physical Therapy/PT Evaluation and Plan of Care, dated [DATE] through [DATE], document R1 was receiving PT Therapy for a Trochanteric Fracture of the Right Femur and was discharged on [DATE] with recommendations for independent transfers using an assistive device (walker) or requires supervision and/or cueing to complete the task without an assistive device. R1's current Care Plan does not document R1's Fall Interventions/Fall Risk, Activities of Daily Living level of assistance, therapy recommendation, assistive devices, R1's diagnoses, medications or R1's cognition. R1's Care Plan documents two areas of care (Do Not Resuscitation Code Status and Activity preference). R1's Minimum Data Set/MDS, Section GG, dated [DATE] and [DATE], documents R1's functional ability requires supervision/touching assistance (verbal cues and/or touching/steadying and/or contact guard assistance) for sit to stand position, chair/bed transfer and walking ten feet. R1's Fall Risk Assessment, dated [DATE], documents R1 is a High Fall Risk (11). The Fall Risk Assessment documents R1 has had no falls in the last three months, requires assistive devices, takes three/four high fall risk medications, and has three or more predisposing conditions increase R1's fall risk. R1's Nursing Note, dated [DATE] at 9:14 am, documents R1's medication administration of Alprazolam Oral Tablet 0.25 milligram/mg, one tablet by mouth, due to R1 being anxious and nervous about spouses' condition (spouse death). Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], were reviewed. The Fall Tracking Forms document a fall with injury for R1, in R1's room, on [DATE] at 9:34 am. R1 was admitted to the local Hospital. R1 had sustained a bone fracture (Cervical/C1 fracture) and laceration. The Tracking Form also documents R1 has a history of falls. No intervention was documented. R1's Nursing Note, dated [DATE] at 5:55 am, documents, (R1) was tearful this morning. Attentive listening provided with one on ones. States does not wish for anxiety medication at this time. R1's Nursing Notes, dated [DATE] at 10:08 am, document, Staff heard (R1) yelling for help. Upon entering room, noted (R1) lying semi-prone on right side on floor over the top of (R1's) bedside table. Moderate amount of bright red blood noted on head and on floor under (R1). Pressure held to lacerations (twice) on forehead. Repositioned to back and table removed from area. R1 complained of pain in neck and right hip. Emergency (911) called. Daughter called and informed of fall and transport to hospital. (V1/Administrator) notified of fall. R1's Nursing Note, dated [DATE] at 12:27 pm, documents, Family came into facility and stated (R1) has cervical fractures (C1 and C3) and is being transferred to (hospital) via air-evacuation. R1's Nursing Note, dated [DATE] at 12:47 pm, documents the local hospital was called and stated, (R1) was airlifted to hospital with Cervical (C1) fracture. R1's Hospital Record, dated [DATE], documents R1 presented to the Trauma Center with a Chief Complaint of Category Three Trauma and fall. admitted with Diagnoses including Odontoid Fracture, Fall, Closed Odontoid Fracture, Scalp Laceration and Facial Laceration. R1 required surgery (closed reduction of C1-C2 Dislocation). The record documents R1 was sitting in recliner and when standing up, R1 reached for walker and fell forward hitting a nearby table to R1's scalp/face. R1 presented to local hospital where imaging showed a Grade Three Odontoid Fracture. R1 was subsequently transferred to a higher level of care. The record documents a seven centimeter/cm scalp laceration was cauterized to reach metastasis and a three cm veridical laceration in between eyebrows, and multiple bruises to extremities. The record documents R1 had recent Right Hip surgery. The hospital timeline documents R1 admitted to Intensive Care on [DATE], transferred out of Intensive Care on [DATE] and then back to Intensive Care on [DATE] at midnight. On [DATE] at 6:58 pm, R1 was transferred out of Intensive Care and then expired on [DATE] at 3:21 am. R1's Certificate of Death, dated [DATE], documents R1's cause of death as Pneumonia, Odontoid Fracture and Ground Level Fall. On [DATE] at 9:15 am, V2 (Director of Nursing/DON) stated, (R1's) Care Plan is not completed and should document R1's Fall Risk status. (R1's) Fall Risk Assessment does document (R1) was identified as a High Risk for falls. V2 verified R1's Care Plan was incomplete and only had two areas of concerns, Activity and Code Status. On [DATE] at 9:15 am, V1 (Administrator/ADM) stated, (R1's) spouse died on [DATE], just two days before (R1) fell out of chair. Staff heard (R1) fall and went in to (R1's) room. (R1) was laying over the bedside table with lacerations to (R1's) head and was complaining of neck and hip pain. We sent (R1) to (local hospital) and then they life flighted (R1) to a hospital in [NAME]. R1 was independent and able to get up and move around (R1's) room by herself and without any assistance. (R1) was alert and oriented after the Cervical surgery and then all of the sudden (R1) ended up in Intensive Care and ended up dying days later, on [DATE]. On [DATE], at 2:00 pm, V1 (Administrator) stated, It makes sense how you should not just educate someone with memory problems for a fall intervention. R1's Care Plan does not document any level of assistance or care needs R1 requires. V1 verified R1 admitted to the facility on [DATE] with a Right Femur Fracture, Rheumatoid Arthritis and receiving medication for anxiety disorder. V1 verified R1 was receiving Physical and Occupational Therapy for the Right Femur Fracture and R1's current Care Plan did not have the required documentation to care for R1 and R1's medical record had conflicting documentation on R1's level of Cognition and Activities of Daily Living assistance needs. 2. R2's Serious Injury Incident and Communicable Disease Report, dated [DATE] at 10:00 am, documents R2's fall with physical harm or injury. The Report documents R2 was transported and admitted to the local hospital for a fall in R2's room. R2 fell and hit R2's head on roommates' bed and was found to have a scalp laceration. R2 leaned forward to grab something and fell out of R2's wheelchair hitting R2's head on roommate's bed. R2 was found to be laying on the floor beside roommate's bed and R2's wheelchair was sitting in the hallway. R2 received five staples to the laceration and admitted for observation of seizure activity, then readmitted to facility on [DATE]. R2's Hospital Record, dated [DATE], documents R2's Chief Complaint as an unwitnessed fall from a wheelchair with head injury (struck head on floor), unknown loss of consciousness, staff states mental status is altered and R2 sustained a Right Posterior Scalp Laceration. The record documents R2 was alert upon arrival, does not answer questions appropriately and is confused at baseline. The record documents the Nursing Home staff stated R2 has frequent falls, is ambulatory minimally with staff assistance only and spends most of time in wheelchair. The record documents R2's Medical Diagnoses including Bipolar Disorder, Left Eye Blindness, Borderline Personality Disorder, Cerebral Vascular Accident/CVA, Pseudo seizures and Vascular Dementia. R2 received a Comminuted Tomography/CT scan showed evidence of scalp trauma in the Right Occipital Region. R2's current Care Plan documents R2 has blindness in the Left Eye, had a Right Humerus Fracture, orders for medication administration of an Anti-depressant and Anti-psychotic, alteration in ability to care for self and needs assistance, requires extensive one to two staff assistance with transfers and requires an assistive device. The Care Plan also documents R2 is a high risk for Falls. R2's Care Plan documents an intervention for R2's falls on [DATE] and [DATE] as Education; [DATE] and [DATE] falls as continue current Care Plan; and [DATE] fall as putting a sign on the mirror to remind R2 to stay seated when washing hands. R2's MDS, Section GG (Functional Abilities and Goals) documents R2 requires partial/moderate assistance with sit to stand, chair/bed-to chair transfer and walking ten feet. R2's Fall Risk Assessment, dated [DATE] and [DATE], documents R2 is disoriented to person, place and time, has had three or more falls in past three months, is chairbound and requires assistance, poor eyesight, balance problems, requires assistive devices, takes three/four high risk medications and has one/two predisposing Diagnosis and a Fall Risk Score of 20 (High Risk). R2's Fall Risk Assessment, dated [DATE], documents R2 has a Fall Risk Score of 22 (High Risk). Facility Monthly Fall Tracking Forms, dated [DATE] through [DATE], document falls for R2: in R2's room on [DATE] at 1:40 pm, no injury and the intervention was education resident ; in R2's room on [DATE] at 1:15 pm, no injury and the intervention was to continue current care plan; [DATE] at 2:15 pm in R2's bathroom, with no injury and the intervention was to keep R2 in areas of visualization unless in bed; [DATE] at 3:55 pm in 'other' location, no injury and the intervention was Occupational Therapy to evaluate and treat; [DATE] at 5:34 pm in hallway and R2 sustained a scratch to R2's face and the intervention was for staff to close R2's door when R2 leaves room; [DATE] at 4:45 pm in R2's room with no injury and the intervention was to put a sign on the mirror to remind resident to stay seated when washing hands; [DATE] at 10:55 pm in R2's bathroom with no injury and the intervention was to frequently toilet R2; [DATE] at 10:00 am in R1's room, R2 was admitted to the local Hospital and sustained a laceration and required five staples to the scalp and the intervention was to move closer to the nurses station; [DATE] at 6:26 pm in R2's room and R2 sustained remained in the Facility and sustained an abrasion to the scalp and the intervention was to educate R2 on asking for help; [DATE] at 3:00 pm in R2's room, with no injury and the intervention was to continue plan of care; and on [DATE] at 2:45 pm in R2's room, does not document any injury or fall intervention. On [DATE] at 11:20 am, R4 (R2's roommate) stated, (R2) falls a lot. She just fell a little while ago and bumped her 'noggin' and had to go to the hospital. They tell (R2) to sit down but she has a head injury from a long time ago and does not have good memory, she just does not understand all the time. On [DATE] at 11:29 am, R2, was sitting in wheelchair in dining room, with anti-tippers on wheelchair and stated, I have bad eyesight. Every time I fall, they tell me to put my call light on, but I do not always remember and honestly, they take too long to answer my call light. I get impatient, and they take too long to get to me, and I just get up and do it myself, and is usually when I fall. On [DATE], at 2:00 pm, V1 (Administrator) stated, I do not think some of the interventions, such as education, are appropriate for (R2's) falls, because she does have memory issues. (R2) has definitely had a lot of falls, but we are not always sure what are the best interventions. V1 verified R2's [DATE] fall resulted in a scratch to R2's face and on [DATE], R2's fall required emergent hospital care for five staples to a scalp laceration and R2's [DATE] fall resulted in an abrasion to R2's scalp.

Based on observation, record review and interview the facility failed to implement appropriate person centered fall interventions. This failure resulted in multiple falls with injuries for two residents (R1, R2) reviewed for falls in a sample of three. This failure resulted R2 requiring medical attention for head lacerations and hematomas at the local hospital on multiple occasions. Findings include: Facility Fall Policy, revised 8/1/22, documents: It is the policy of this Facility to provide guidelines for the appropriate handling of a resident's fall, accident or incident; and each situation must be handled in the manner that is most appropriate at the time and for the nature of the change in condition. Facility Fall Monthly Tracking Logs, dated 1/1/23 through 1/31/23, were reviewed. The Fall Log documents that R1 had falls two falls on 1/14/23, and one fall on 1/17/23 and 1/28/23. The Fall Log documents that R2 had two falls on 1/9/23, and one fall on 1/11/23, 1/12/23, 1/14/23 and 1/30/23. 1. R2's current Care Plan documents that R2 has diagnoses including Osteoarthritis, Chronic Obstructive Pulmonary Disease, Unspecified Abnormalities of Gait and Mobility. R2's Minimum Data Set/MDS dated [DATE], documents R2 has a Brief Intermittent Mental Status/BIMS (score of 13/15) showing that R2 has minimal cognitive impairment. R2's MDS also documents that R2 requires extensive staff assistance of two persons for bed mobility and transferring and extensive staff assistance of one person for toileting. R2's Fall Report, dated 1/7/23 at 2:45 pm, documents that R1 had an unwitnessed fall while self ambulating with a wheeled walker in R2's room. R2 stated, I caught the edge of the bed and I fell over. R2 sustained two skin tears, one on each leg, and the skin tears were cleansed and bandaged. R2's Medication Administration and Treatment Administration Record does not document Physician Orders for treatment or monitoring of R2's skin tears. R2's current Care Plan documents an intervention of ensure the call light is in reach. R2's Fall Report documents that R2 had an unwitnessed fall on 1/9/23 at 12:15 pm. R2 was found on the floor with buttocks with back against her bed, overhead table was over resident, and resident's legs were over the bottom bar of the overhead table. The intervention was educated on the need for calling for assistance. R2's Fall Report documents that R2 had an unwitnessed fall on 1/9/23 at 8:45 pm. R2 was taking self to bathroom and fell backwards in room. R2 was found lying on back with walker at bedside and bleeding noted under R2's head. R2 sustained a one centimeter/cm laceration to the posterior left side of the head with a golf ball size hematoma. R2 stated, I was going to the bathroom and fell backwards. R2 denied dizziness and R2's blood pressure was 150/86. The intervention was for orthostatic blood pressure checks for three days. R2 was sent to the local hospital for evaluation and treatment and returned to the facility with four staples to the laceration. The Facility Local Health Department Serious Incident Report, dated 1/10/23, documents that R2 sustained a fall on 1/9/23 at 8:45 pm. R2 was discovered on the floor of her room with her walker lying to her side and had a laceration to the back of her head. R2 was returning from the bathroom and fell backwards striking her head on the floor. R2 was sent out to the local Hospital's Emergency Department for evaluation and returned to the facility with four staples to the laceration to the back of R2's head. The Report documents that R2 has a secondary diagnosis including abnormalities of gait and mobility. R2's Hospital Emergency Department Discharge Instructions, dated 1/9/23, documents that R2 was evaluated for a head laceration due to a fall. R2 received staples to the head laceration. Orders were received that R2 should have the staples removed in seven to ten days and should be evaluated in one to two days for redness or drainage. R2's Fall Report, dated 1/11/23 at 6:30 am, documents that R2 sustained an unwitnessed fall while self transferring to the bathroom. R2 was noted to be laying on the left side with legs wrapped around the legs of R2's walker. R2 was wearing non-slip socks and R2's call light was not activated. No injuries were noted and R2's current Care Plan documents that R2 was moved closer to the nurses station for monitoring. R2's Fall Report, dated 1/11/23 at 3:15 pm, documents that R2 sustained a staff assisted lowering to the floor fall. R2 was ambulating with staff to the smoking break with a wheeled walker. R2 stated, My leg got weak and I could not make it any further. No injuries were noted and R2's current Care Plan documents an intervention of R2 using a wheelchair to go outside to smoke. R2's Fall Report, dated 1/14/23 at 11:10 pm, documents that R2 sustained an unwitnessed fall. A loud crash was heard and R2 was noted to be laying on the floor by the bathroom door. R2 was noted to have a laceration on the back of R2's head with a moderate amount of bleeding. R2 was sent to the local hospital for evaluation and treatment. R2 returned to the Facility with a treatment (Dermabond) to the laceration. A CT was performed and all results were negative. R2's current Care Plan documents an intervention of Call Don't Fall signs to be placed in R2's room. R2's Physician Order Sheet, Medication Administration and Treatment Administration Sheets and Nursing Notes do not document Physician Orders for treatment or monitoring of R2's laceration. The Facility Local Health Department Serious Incident Report, dated 1/15/23, documents that R2 sustained a fall on 1/14/23. R2 was noted to be on the floor by the bathroom. R2's walker was on the floor next to her and no other trip hazards were identified. (R2) was assessed and noted to have a small laceration to the upper posterior aspect of her head which was bleeding. R2 was sent to the local Hospital's Emergency Department for evaluation and treatment. R2's laceration was glued (Dermabond) and R2 returned to the facility. R2 had slipper socks on and R2's call light was not activated at the time of the incident. R2's Hospital Computed Tomography/CT Report, dated 1/15/23, documents that R2 had a CT and the impression was that R2 had a left posterior parietal scalp hematoma. R2's Hospital Emergency Department Discharge Instructions, dated 1/15/23, documents that R2 was evaluated for a ground level fall and a laceration of the occipital region of the scalp. R2's Fall Report, dated 1/30/23 at 10:35 am, documents that R2 sustained an unwitnessed fall. R2 was found sitting on buttock next to R2's bed. R2 stated, I was trying to get my phone charger. R2 stated that R2 hit head. R2 was sent to the local hospital for evaluation and treatment. A CT of the head was performed with no findings and returned to the Facility. R2's current Care Plan documents an intervention to make sure that items are within reach of resident. R2's Hospital Emergency Department Discharge Instructions, dated 1/30/23, documents that R2 was evaluated for a closed head injury due to a fall sustained on 1/30/23. The Commuted Tomography (CT) results show a scalp hematoma. On 1/31/23, at 12:05 pm, R2 had a laceration to the back of the head with dark brown appearance and matted uncombed hair. R2 stated, I have tripped over my walker and stuff before and had a few falls that sent me to the hospital. The last time I went I had to get another gash 'glued.' On 1/31/23, at 11:01 am, V5 (Assistant Director of Nursing/DON) stated, For (R2's) first fall on 1/7/23, the intervention was to make sure that the call light was in reach. Then (R2) had two falls on 1/9/23, and the intervention for the fall at 1/9/23 at 12:15 pm, we educated on the need for calling for assistance. Then for the 1/9/23 at 8:45 pm fall, we thought maybe (R2's) blood pressure was dropping when (R2) stood up, so the intervention was for orthostatic blood pressure's for three days. Obviously, the first two interventions did not work because (R2) was not asking for help or activating the call light. (R2's) legs would give out and that is why (R2) fell on [DATE]. I am not sure why (R2) was not asking for help or putting on her call light. I am not sure if some of these interventions were right for her, because she kept falling. It is hard to do the right intervention. On 2/1/23 at 11:30 am, V5 (Assistant Director of Nursing/DON) stated, Some of the interventions were probably not the best but it is difficult to find the right intervention sometimes. I understand that you should not use things like education and stuff when finding an intervention for a confused person, that is probably not the best intervention. 2. R1's current Care Plan documents that R1 has diagnoses including Hemiplegia and Hemiparesis, unspecified Cerebrovascular Disease affecting Left Non-Dominant side; History of Falling, other Symptoms and Signs involving the Musculoskeletal System, other Symptoms and Signs involving Cognitive Functions and Awareness and Dementia. R1's Minimum Data Set/MDS dated [DATE], documents that R1 has a Brief Intermittent Mental Status/BIMS (score of 0/15) showing that R1 is rarely or never understood and has moderately impaired cognitive skills for daily decision making. The MDS also documents that R1 requires staff assistance of one person for bed mobility, transferring and toileting. R1's Fall Report, dated 1/14/23 at 3:15 pm, documents that R1 had an unwitnessed fall while transferring self to the bathroom and was noted sitting on her bathroom floor. R1's current Care Plan documents that the intervention was frequent checks. R1's Fall Report, dated 1/14/23 at 6:45 pm, documents that R1 had an unwitnessed fall while self transferring to bed. R1 was noted on the floor in front of wheelchair in between the bed and window. R1 was unable to recall the events. R1's Care Plan documents that Gripper strips were placed on the side of the bed on the door side. R1's Fall Report, dated 1/17/23 at 8:00 pm, documents that R1 had a witnessed fall. R1 was laying on left side with head on bedside table leg with bleeding noted above the left eye. R1 had support stockings on and R1's slipper socks were on the floor. Noted that R1's call light was not activated but within reach. R1's Nursing Note documents that on 1/18/23, at 2:46 pm, V7 (R1's Physician) was notified of R1 not extending the right lower extremity and grabbing right thigh in pain. Requesting an order for an X-Ray. V7 stated, It is okay to do an X-ray but X-rays usually do not show fractures. If the X-ray comes back okay and (R1) is still having pain, get a Commuted Tomography (CT) without contrast. R1's Nursing Notes and Medication Administration Records, dated 1/17/23 through 1/27/23 document R1 receiving pain medication. R1's Medical Record does not document an order for a CT or CT results. R1's Fall Report, dated 1/28/23 at 11:08 am, documents that R1 had an unwitnessed fall out of bed. R1 was noted to be on the floor next to R1's bed on the right side. R1's current Care Plan documents that R1 to be positioned in the center of the bed. On 2/1/23, at 11:44 am, V8 (Registered Nurse) stated, When a resident falls, we should try and put the right intervention in to place, sometimes it is hard, especially when someone falls a lot. We fax the Doctor and do a Risk Management Form that gets reviewed by the Department Heads for appropriate interventions. Sometimes we do not hear right back from the Doctor. On 2/1/23, at 10:26 am, V7 (Medical Director) stated, Sometimes I do not get notification of falls until many days later, we are trying to work on this. so that Residents can be treated and monitored adequately. Sometimes I do not get notification of a fall until days later. The Facility should be making the appropriate interventions on an individualized case by case. We are trying to work together to find the right cause of the falls, I have really been looking at the Gradual Dose Reductions of Medications that the Facilities keep wanting to put people on too.

Based on observation, interview, and record review the facility failed to inform a supervisor prior to transporting a resident in the facility van; failed to educate staff members on safely securing a resident in the facility van and procedure to follow in case of a fall/emergency while in the facility van; failed to secure a resident with a lap belt during transport in the facility van; failed to ensure a resident was assessed by a licensed nurse prior to moving resident; and failed to perform regular maintenance checks of the wheelchair securement system. These failures resulted in V4 (CNA-Certified Nursing Assistant) improperly utilizing facility van to transport R1 to the local parade on 10/22/22. Upon return, V4 hit a bump that caused R1 to 'fly' up in her wheelchair. As R1 came down, she fell onto the floor of the van. R1 was sent to the emergency room for evaluation where she was admitted with a left intertrochanteric hip fracture with excessive displacement, and a comminuted right distal tibia shaft fracture with associated fibular fracture. These failures apply to 1 resident (R1) reviewed for transport safety. These failures resulted in an Immediate Jeopardy. Findings include: While the immediacy was removed on 11/10/22, the facility remained out of compliance at a Severity Level 2. The facility is ensuring all staff are educated on the facility's policies and procedures regarding transporting residents; who is authorized to give permission for transports; who is eligible to drive residents in the facility van; and resident transportation schedule. The facility is also ensuring all authorized drivers are educated on the procedure of loading/unloading and securing a resident in the facility van. The drivers are being in-serviced on procedure if an emergency occurs while using the van. The facility is also developing tools to audit driver access, transportation logs, and safety inspections. The facility's Transportation of Residents policy dated 11/1/19, documents, Residents being transported from the facility to appointments must be done in a safe and efficient manner. An employee must obtain prior approval from his/her department director before the employee drives a vehicle for facility business purposes. An employee who drives any car for facility business purposes must exercise due diligence in so doing. The employee must comply with all traffic laws. Employee and their passengers who are driving/riding in a car on facility business purposes must wear seat belts at all times in which the car is being operated. The facility's Wheelchair Securement System Installation Manual, dated 2020, documents, The wheelchair securement system plus compliant shoulder and pelvic belt (Occupant restraint) make a complete wheelchair securement system. Complaint shoulder and pelvic belt restraint must go across occupant's shoulder and pelvis (lap), and not be worn twisted or held away from the occupant's body by wheelchair components. We recommend using both a pelvic and shoulder belt together and not individually since it will compromise the performance of the system. The wheelchair securement system and its components MUST be regularly inspected, cleaned, and maintained-reference the Maintenance and Care section in this manual. The wheelchair securement system should not be operated by anyone who does not have full comprehensive knowledge of how the system works or if the system is not working properly. The manual also documents, Maintenance and Care: The following items should be inspected and serviced by an experienced and trained technician during the scheduled maintenance of the wheelchair securement system. The facility's Transportation Job Description, no date available, documents, Main duties: Operates the vehicle per training. The facility's Fall/Accident/Incident Protocol, dated 2/25/21, documents, Nursing Evaluation on all resident falls, witnessed and unwitnessed. R1's Nursing Progress note, dated 10/22/22 at 11:45 a.m., documents, R1 was coming back to facility via facility van and staff (V4). Was reported that R1 slid out of wheelchair onto the floor of the van. R1 was brought back to facility and noted to have abrasions to bilateral lower extremities. R1 complains of right ankle pain and left leg pain 10/10 (Pain scale of 0-10). Alert and oriented. Right ankle swollen. 911 initiated. R1's Incident Investigation, dated 10/22/22, documents, Incident occurred on transport from parade. Interview of R1: I had the upper seat belt on, but not the one going across my lap. (V4) was not speeding, but we hit a really big bump, and the cushion that I was sitting on slid forward and then I slid out under the shoulder belt and fell to the floor. (V4) got me back in my chair and brought me back to the facility. My left leg was hurting above my knee and I had a couple of scrapes on my leg from the fall. Interview with V4: When asked about the lap belt she simply stated that she did not put it on, because she could not find it. The investigation also documents, No permission to go on outing had been given by any manager. Incident occurred on transport from parade. Interview with V4: When asked who gave her permission to take R1 to the parade, V4 stated that V8 (Transport) did. V4's written statement, dated 10/22/22 at 11:45 a.m., documents, I took (R1) to the local homecoming parade. On the way back there was a bumpy patch on the road and she slid forward out of her chair. I checked her then put her back in the chair. I noticed a skin tear on the bottom upper part of her left foot. One on top of her right foot and her right ankle looked swollen. She says her left leg hurts above the knee. I was going 25 mph. R1's Hospital Consultation, dated 10/22/22, documents, Chief Complaint: Left hip pain. History of Present Illness/consult note: (R1) who was being transported in a van at approximately 11:30 a.m. today, 10/22/22, when the van hit a bump and (R1) came out of her wheelchair injuring her right lower leg and left hip area. The van was apparently going 25 mph and the bump caused (R1) to fall out of a pillow padded wheelchair with one safety belt, which apparently was not enough to stop her from sliding. (R1) noted significant pain to her right lower leg and left hip immediately. Radiology: X-rays of the left leg show a left intertrochanteric hip fracture with excessive displacement. X-rays of the right lower leg show a comminuted right distal tibia shaft fracture with associated fibular fracture with mild displacement. R1's Hospital Physician Dictation, dated 10/22/22, documents, Patient's Chief Complaint is left hip pain. History of Present Illness: R1 presented to the hospital due to injury sustained after falling out of a wheelchair in a vehicle earlier today. R1 states that she is wheelchair bound and had been in a van traveling to a parade. She states that she had 1 restraint on her wheelchair, but it was not enough to keep her in place. She states that the van hit a big bump, causing R1 to fall forward out of the wheelchair. She sustained injury to both of her legs. She presented to local emergency room, where she was found to have a hip fracture on the left side as well as a tibia-fibula fracture on the right side. Assessment and Plan: Left intertrochanteric fracture: Orthopedics has been consulted for surgical evaluation, plan to undergo surgical repair tomorrow. Right sided tibia-fibula fracture: Per orthopedics, will likely continue to monitor this fracture, and brace as appropriate. The facility's Serious Injury Report, dated 10/24/22, documents, R1 traveling back in facility van from personal outing with V4 operating vehicle. V4 states that the vehicle was moving at approximately 25 mph (miles per hour) in a posted 30 mph when the van encountered a bump in the road enabling R1 to slide under applied safety harness. R1's statement concurs. R1 was evaluated by V6 (RN). Due to complaint of leg pain above the left knee and swelling to right ankle, R1 sent to ED for evaluation. Findings: Left femur fracture and right tibia/fibula fracture. Surgical repair of left hip performed on 10/23/22. Right leg cast placed on 10/23/22. V4's Personnel Disciplinary Notice, dated 10/24/22, documents, Incident/Issue Detail: 10/22/22 Took van with (R1) on outing without permission to do so. Did not fully secure resident in van during transport. Detail Action Taken: Immediate termination. On 11/7/22 at 9:00 a.m. V1 (Administrator) stated, this was a single person incident. (V4) acted alone. She didn't have permission to drive the van. Normally, we don't even do trips for individuals. We only do appointments and hospital transports. There was one other time that (V4) drove the van with (R1). (R1) wanted to go to a mural dedication ceremony that she had donated to, and I allowed it just the one time. I told (V4) I would not allow another personal trip like that for (R1) or any other residents. At the time (V4) transported (R1), the van keys were locked in the office. The nurse on duty has a key to get into the office to get those keys if needed. (V4) convinced (V5 RN) to give her keys. (V4) took (R1) to the parade, and on the way back hit a bump that caused (R1) to fall out of her wheelchair because (V4) put (R1's) shoulder harness on but not lap belt. (V4) picked (R1) up after she fell putting her back into her wheelchair, and then drove her back to the facility. (V6 RN) assessed (R1) and called 911 for her to be evaluated in the emergency room. (V4) was terminated because of this incident and for driving the facility van without permission. On 11/7/22 at 11:35 a.m., V1 stated, (V4's) date of hire was 4/26/22. V1 confirmed there was no documentation of V4 receiving training on the van prior to the incident. On 11/7/22 at 10:35 a.m., V4 (CNA) stated, Everyone knew (R1) wanted to go to the parade. I set it up to drive her to the local parade. That morning, (V5) gave me the van key that was locked in the main office. I made sure the wheelchair itself was secure, but I didn't use the lap belt. I had her arm through the shoulder belt only. When I came back from the parade, I hit some bumps and she fell out of the wheel chair. I pulled over and put (R1) back in her wheel chair. The chair was secured, but she did not have the lap belt on so she slid out from underneath of it. I thought that her right ankle looked messed up. (R1) said she was hurting. So as soon as I got her in the chair, I called the facility and told them to meet me at back door. The nurse (V5) met me at the door and said to just bring her in. I told (V5) she looked like she was in pain. We put (R1) in bed. (R1) told us her left leg hurt when we put her in bed. If a resident was to fall at the facility you get the nurse to assess the resident before getting them up. However, I was never trained on what to do if a resident falls in the van. I knew I had to call the facility as soon as I got her in the wheel chair, and I told them I thought she was hurt. The nurse told me to get her back to the facility. V4 also stated, I've drove (R1) before. We went to a mural dedication that she had donated to, and (V1) asked me to drive her to it. I think this was in June. The facility did not provide training on secure the wheel chair and what seatbelts to use. Both times I didn't use the lap belt when I transported (R1). On 11/7/22 at 11:00 a.m., R1 was alert sitting up in her wheelchair with her legs elevated on pillows. R1 had a cast on her right leg that started from her thigh down to her foot. R1 stated, We were on our way back from the parade. I didn't have the belt that went across my lap on. I don't know what road she went down but it was bumpy. All of a sudden, we hit something hard. I came up out of my wheelchair, and when I came down, I fell out of my wheelchair. When I hit the ground, I knew something was wrong. My whole body hurt all over. It wasn't a good pain. (V4) pulled over, got in the back, and lifted me up into my wheelchair. I was hurting pretty bad. She (V4) probably should have called an ambulance, but we went back to the facility. She (V4) got me back to the facility, and they put me in bed. Not long afterwards the ambulance came, and now this, pointing at her cast. R1 stated, (V4) drove me to the mural dedication that I was invited to back in June, pointing at an invitation that was taped to her wall that stated the ceremony was on 6/16/22. On 11/7/22 at 1:55 p.m., V9 (CNA) stated, When, (R1) came back I helped (V4) transfer her back into her bed, but I didn't know she had fallen. When we transferred her into bed she kept saying, 'Oh' and she said it was her hip hurting. On 11/7/22 at 2:50 p.m., V3 (Maintenance Director) demonstrated the use of the van and securing a wheelchair. Once the wheelchair is in the van, the wheelchair is tethered down at four different points. Then, the lap belt is latched. The shoulder belt then comes across the resident and hooks to the lap belt. V4 confirmed that if R1's lap belt wasn't latched then the shoulder belt would not have been utilized in a safe manner either. On 11/9/22 at 9:00 a.m., V3 stated, I'm not aware of the van needing any scheduled maintenance checks. On 11/9/22 at 11:20 a.m., V6 (RN) stated, In the middle of my medication pass, I got a phone call from (V4), and she was in a panic. At that point, (V4) had already gotten (R1) up into her wheelchair. I didn't know the extent of what had happened. If I was (V4) I would have called 911 and asked for assistance. When she returned (V5) and (V9) assisted (R1) back into the facility. On initial inspection just looking at her when she came in the building, (R1) had a small skin tear on her foot. She was escorted to her room and assisted to bed. I noticed she was having extreme amounts of pain in her right foot. She was displaying physical manifestations of extreme pain. (R1's) demeanor was just overall different she wasn't herself, she was wincing with movement, and we couldn't lift either of her legs without her crying out. At that time, I initiated 911 and contacted her on-call physician. Going 25 mph, not properly restrained, and an incident like this one occurs is going to cause someone significant injuries. V6 also stated, I have done resident transports for this facility. I have never received any type of training regarding the facility van. On 11/9/22 at 11:40 a.m., V2 (Director of Nursing) stated, (V4) shouldn't have been driving the van in the first place because she didn't have permission from any supervisors including myself. When (R1) fell (V4) should have immediately called 911 for assistance. She should not have gotten (R1) up into her wheelchair and then drove her to the facility. On 11/10/22 at 2:10 p.m., V8 stated that all the residents in the facility are able to be transported by the facility van. The facility's Midnight Census Report, dated 11/7/22, documents that 46 residents reside in the facility. On 11/10/22 at 9:05 a.m., V1 (Administrator) and V7 (Assistant Director of Nursing) were notified of the Immediate Jeopardy and substandard quality of care. On 11/10/22, the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. All staff were in-serviced on 10/23/22 and 11/4/22 by V1 and V3 on the facility Transportation Policy including where residents are transported and who is authorized to give permission for transports. 2. All staff were in-serviced on R1's incident on 10/23/22 and 11/4/22 by V1. 3. All facility drivers were in-serviced on 11/10/22 by V3 on what to do in case of an accident while in the facility van. 4. All staff were notified on 10/23/22 and 11/4/22 by V1 that only authorized drivers, with training, may transport residents. 5. All facility drivers were retrained, including return demonstrations, on van safety including pre-inspection and properly securing passengers before transporting residents on 10/24/22 by V3. 6. A facility audit tool to ensure safety inspections are being performed per manufacturer's recommendations was created by V1 on 11/10/22. 7. All staff in-serviced on 10/23/22 and 11/4/22 by V1 and V3 on the resident transportation schedule and those staff that are authorized to use the facility vehicle to transport residents. 8. A facility audit tool to monitor facility driver access and the facility transportation log was created by V1 on 11/10/22. 9. All staff were in-serviced on 10/23/22 and 11/4/22 by V1 and V3 on access of the facility van keys being limited to authorized personnel and whom may have access to them.

Based on observation, interview, and record review the facility failed to implement a fall intervention (mattress with raised sides) for one of three residents (R1) reviewed for falls with injuries in the sample of three. This failure resulted in R1 rolling out of bed onto the floor sustaining a painful baseball sized hematoma (collection of blood outside of the blood vessels/injury to the wall of a blood vessel) to the upper left breast, skin tears to the left elbow and left knee, and extensive bruising to the left side of the head, left side of the chin, area below the breasts, and both upper legs which required hospitalization . Findings include: The facility's Fall Reduction Policy dated 11-5-19 documents, Purpose: To provide an environment that remains as free of accident hazards as possible. To identify residents who are at risk for falling and to develop appropriate interventions to provide supervision and assistive devices to prevent or minimize fall related injuries. To promote a systematic approach and monitoring process for the care of residents who have fallen and/or those who are determined to be at risk. The care plan should be reviewed after every fall and updated with a new intervention when applicable. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is moderately cognitively impaired and requires extensive assistance of two staff for bed mobility, transfers, and toileting. R1's Fall Incident Report dated 4-4-22 at 12:05 AM and signed by V6 (Licensed Practical Nurse/LPN) documents, (R1) found on the floor beside bed on (R1's) stomach. (R1) was yelling, 'Get me up. I am hurt.' Sent to emergency room for evaluation. Neurological checks initiated. (R1's) description: I fell out of bed headfirst and hit my head. 4-7-22 Notes: Fall investigated. (R1) got tangled in her blankets and fell out of bed head first. Skin tear noted to arm and leg, and bruising noted to face. (R1) sent to the emergency room . No fractures noted. Care plan updated with perimeter mattress (mattress with raised sides). R1's Fall Care Plan dated 9-15-21 documents, Interventions/Task: Date initiated 4-4-22 Perimeter mattress to define boarders. R1's Hospice Equipment Orders document R1 was delivered an air mattress system without raised sides on 4-13-22. R1's Fall Incident Report dated 4-14-22 at 5:00 AM and signed by V5 (LPN) documents, (R1) noted lying on the floor on left side. Assessed and turned to supine position. Noted large full thickness skin tear tot he left elbow and patella. Bruising noted on left side of chin. Increased bruising to left temple area. Large bruise above left breast with very hard elevated area. Range of motion with minimal pain. Residents Description: I rolled out of bed and hit my head. Notes 4-15-22: Fall investigation. Hospice had replaced scoop mattress (mattress with raised sides) with air mattress. (R1) fell out of bed due to air mattress. (R1) obtained skin tears to left elbow and right patella, bruising to left temple, large raised bruised hardened area to left breast. Skin tears were treated and dressed. Air mattress was immediately removed from resident's bed and a scoop mattress was applied. Bruising to left breast became three times larger with increased pain, swelling, and a fluid filled blister. (R1) sent to the emergency room and was admitted to (the hospital) with diagnosis of [CONDITION(S)]. R1's Hospital History and Physical dated 4-15-22 documents, (R1) presented to the hospital following a fall at the nursing home. It is my understanding that (R1) slipped out of a low-lying bed and fell striking her head as well as her left side on the ground. This apparently happened early in the morning, but as the day progressed, she developed increasing swelling of the left chest wall/breast and ultimately presented to the hospital with a hematoma. (R1) had pain but did not complain of shortness of breath. As the day progressed (R1) developed worsening swelling and ultimately presented to the emergency room . Skin: (R1) has multiple areas of bruising. (R1) does have significant ulceration and bruising in her left elbow covered in steri-strips (strips of adhesive). Most significant area of bruising is noted on the left chest wall with swelling and tenderness thought to be hematoma with surrounding ecchymosis (discoloration of the skin from bleeding underneath). There is also bruising noted on the left side of her neck and on both lower extremities and arms. Assessment/Plan: 1. Hematoma of the left breast. 2. Acute blood loss [CONDITION(S)]. This is probably secondary to number 1. (Hematoma of the left breast). 9. Skin tear of the left upper extremity. On 5-1-22 at 8:30 AM R1 was lying in bed on her back. R1 had purple bruising the left side of her head and chin, and purplish/red bruising extending from the area under her right breast to the area below her left breast and down to her belly button. R1 also had a baseball sized hematoma to the area above the left breast, with a quarter sized opened reddened area in the center of the hematoma. R1 had skin tears to the left elbow and left knee that were closed with steri-strips and surrounded with purple bruising. R1's bilateral upper legs were covered with purple bruising. R1 stated, I rolled out of bed and got hurt. I feel like I have been beat up. I hurt everywhere. On 5-1-22 at 10:10 AM V5 (LPN) stated, I was (R1's) nurse when (R1) fell out of bed around 5:00 AM. I found (R1) on the floor laying on her left side with the blanket underneath her. (R1) had skin tears to her left knee and elbow and a very large hematoma to her left breast. (R1) also had multiple bruises to her breasts and legs. (R1's) hematoma to the left breast started getting larger throughout the day and (R1) was having increased pain, so I decided to send her to the emergency room for an evaluation. (R1) had an air mattress that did not have raised sides on it when she rolled out of bed. (R1) was supposed to have a mattress with raised sides which kept (R1) in the center of the bed and helped (R1) to know her perimeters. On 5-1-22 at 10:00 AM V1 (Administrator) stated, Hospice brought in the wrong mattress and none of us (facility staff) were aware. It was me and (R1's family's) understanding that hospice was going to bring in an air mattress with raised sides to keep (R1) from rolling out of the bed. On 5-1-22 at 10:20 AM V2 (Director of Nursing) stated, (R1) needs a mattress with raised sides so (R1) knows her perimeters and it keeps (R1) from rolling out of bed. (R1) was admitted to hospice and it was my understanding and (R1's family's) understanding that hospice was going to bring in an air mattress with raised sides. Hospice brought in an air mattress that did not have raised sides. I was not aware that the wrong mattress was brought in until after (R1) rolled out of bed. I do not believe anyone assessed the air mattress without raised sides for (R1's) safety. Hospice should have brought in an air mattress with raised sides.

Based on observation, interview, and record review the facility failed to protect all residents from potentially being abused from two of 13 residents (R5,R16) reviewed for abuse in the sample of 15 and one resident (R18) on the supplemental sample. R16 and R18 ambulate throughout the facility into the rooms of other residents and become verbally and physically aggressive with them. R5 propels in a wheelchair throughout the dining room and hallways and becomes physically aggressive with other residents. This failure has the potential to affect all 67 residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/10/13 at 6:10 p.m., the facility remains out of compliance at a severity level two as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Findings include: The Immediate Jeopardy situation was identified on 9/10/13 at 1:30 PM. The Immediate Jeopardy was determined to have begun on 6/16/13 when the facility failed to recognize and report abuse for R16. E1/Administrator was informed of the Immediate Jeopardy on 9/10/13 at 3:00 p.m. On 9/09/13 at 2:00 p.m., a group meeting was held with R2, R15, R21, R22, R23, and R24. R18 was present in the meeting area but unable to participate due to cognitive deficits. R18 randomly called out loud answers to questions asked of the group members but the answers R18 called out were rambling, incomplete, phrases unrelated to the questions asked of the group. R2 indicated discretely the group could not speak freely with R18 present. At that time, R18 got up from the table and wandered to the door of the room. R18 opened the door but did not exit the room and returned to the table and sat down. E15 (Activity Aide) was summoned to distract R18 and escort R18 from the area to provide privacy for R2, R15, R21, R22, R23, and R24 to speak freely. After R18 left the meeting area the residents present for the group meeting reported there are two residents who repeatedly wander in and out of their rooms, R16 and R18. R2, R15, R21, R22, R23, and R24 all agreed R18 wanders into their rooms and becomes argumentative when they ask (R18) to leave. R2 reported R18 has wandered into (R2's) room and picked up (R2's) belongings and left the room with R2's belongings. R2, R15, and R22 reported R16 enters their rooms and becomes argumentative, refuses to leave, and they are afraid R16 will become physically abusive towards them before they can summon staff to intervene. R2, R15, R21, R22, R23, and R24 reported wandering residents have been an on going problem. R2, R15, R21, R22, R23, and R24 indicated staff are aware of the behaviors of R5, R16, and R18 because residents called staff to intervene at the time of the incidents. 1. On 9/11/13 at 9:25 a.m., R22 stated, " ... I was sound asleep and (R16) came in with (R16's) walker and rammed my bed with (R16's) walker. I was sound asleep and it scared the heck out of me. The stop sign was up but that don't stop (R16). (R16) just comes on in anyway. It happened just the first of this week. (R16) informed me (R16) would leave when (R16) got ready. (R16) did finally leave. I didn't call staff. (R16) is always into something all the time. A year or so ago (R16) rammed into me with (R16's) walker intentionally, but I didn't get hurt. It's happened at least four to five times or more that (R16's) comes in here like that ... " R22 stated R16 and R18 go all over the building wandering into rooms. On 9-11-13 at 8:30 a.m., R36 stated the following: "(R16) always enters my room and I don't like it." R16 will enter R36's room and yell at R36. About a month ago, R16 approached R36, while in the hallway, and started shoving R36 with a walker. On 9-10-13 at 3:45 p.m., E12 (Certified Nursing Aide) stated the following: R16 ambulates to all the hallways and into all of the resident rooms within the facility. R16 uses the walker as a weapon and attacks other residents with it. R16 attacks R22 with the walker frequently using R16's body and walker to shove R22, nearly causing R22 to fall. R16 will antagonize the other residents until the other residents get mad, and then R16 will say, "Well my work is done here. You are mad." On 9-10-13 at 3:45 p.m., E12 stated R16 attacked R36 with a walker while in the hallway on 6-16-13. E12 stated R16 shoved R36 with a walker at least three times before E5 (Registered Nurse) intervened. E12 stated the stop signs that are on the resident doors do not mean a thing to R16, as R16 just removes them and enters the residents' rooms anyway. On 9-10-13 at 4:45 p.m., E5 (Registered Nurse) stated R16 is a wanderer and other residents will yell for staff to come and remove R16 from their rooms. E5 stated R22 does not like R16 and will get very "verbal" with R16. 2. On 9-8-13 at 9:30 a.m., R5 was propelling self, in a wheelchair, down the hallway. R5's Physician order [REDACTED]. R5's Mood/Behavior notes dated 2-7-13 at 1:48 p.m., document R5 grabbed a visitor by the wrist and hand, squeezing, and attempted to hit the visitor. The notes document E9 (Registered Nurse) attempted to reorient and calm R5, which was unsuccessful. R5's Mood/Behavior notes dated 2-21-13 at 2:18 p.m., document R5 refused morning and noon medications, threatened to throw milk on staff, pinched, and kicked. R5's Mood/Behavior notes dated 3-7-13 at 6:16 p.m., document R5 was found in another resident's room. When E7 (Activity Director) tried to remove R5 from the room, R5 grabbed and hit E7. The notes document R5 was "angry" and "wanted to hurt everyone" and R5 continued to hit, pinch, bite, and pull E7's hair. R5's General Progress notes, signed by E5 (Registered Nurse) and dated 8-14-13 at 10:13 p.m., document R5 started hitting and grabbing other residents and the residents were separated. On 9-9-13 at 11:15 a.m., E5 stated on 8-14-13 R5 grabbed, scratched, and kicked R16. E5 stated R5 is always grabbing and scratching other residents and the staff just try to re-direct E5. On 9-9-13 at 12:00 p.m., E5 stated the incident on 8-14-13 might have been between R5 and R2. E5 stated R5 grabbed and pinched R2 on the arm, and the staff had to separate R5 and R2. On 9-9-13 at 11:25 a.m., E6 (Certified Nursing Aide/CNA), stated R5 is always pinching, kicking, and biting the staff and residents. E6 stated R5 always bickers with R5's roommate. E6 reports R5 can propel self, in the wheelchair, down the hallway and in the dining room. On 9-10-13 at 3:45 p.m., E12 (CNA) stated, "a few weeks ago, (R5) grabbed (R2)'s right wrist and would not let go." E12 stated it took E12 and E5 to get R5 to let go of R2's wrist. On 9-9-13 at 1:30 p.m., R2 stated that about two weeks ago R2 got too close to R5 in the dining room and R5 grabbed R2's right arm and would not let go. R2 states, "I think (R5) has a streak of meanness." On 9-9-13 at 1:00 p.m., E1 (Administrator) stated, "all resident to resident altercations are considered abuse, regardless of the residents having dementia." The Resident Census and conditions of residents dated 9-8-13 and signed by E2 (Director of Nursing/DON), documents 67 residents currently reside in the facility. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R16 was placed on direct visual one to one supervision as soon as the Immediate Jeopardy was identified on 9/10/13. R16 was transferred from the facility on 9/10/13. 2. All staff scheduled to work on 9/10/13 were trained on the abuse policy prior to working their shift. The training included education on behavior identification and reporting to supervisors. 3. The facility performed updated behavior assessments for R5, R16, and R18, as well as all other residents with behaviors. Appropriate referrals were made by 9/11/13. 4. R18 was discharged from the facility due to behaviors. 5. R5 was placed on 1 to 1 supervision on 9-10-13. 6. R5 ' s care plan was updated to reflect all current interventions. 7. A review of R5 ' s medication regimen was conducted by Hospice at the request of the facility, and medications were adjusted accordingly. 8. Behavior monitoring of R5 was implemented and is ongoing. When R5 ' s aggressive behaviors diminish, the 1 to 1 supervision will be discontinued and other appropriate interventions will be put into place, based on R5 ' s behavior.

Based on observation, interview, and record review, the facility failed to report suspected physical/verbal abuse to the Administrator and the State Agency for two of 13 residents (R5,R16) reviewed for abuse in the sample of 15 and one resident (R18) on the supplemental sample. R16 and R18 continue to ambulate throughout the facility into other residents rooms and become verbally and physically aggressive with other residents, R5 propels in a wheelchair throughout the dining room and hallways and becomes physically aggressive with other residents. This failure to report and investigate has allowed the above residents (R5, R16, R18) to continue wandering throughout the facility putting other residents at risk. This failure has the potential to affect all 67 residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/10/13 at 6:10 PM, the facility remains out of compliance at a severity level two as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Findings include: The Immediate Jeopardy situation was identified on 9/10/13 at 1:30 PM. The Immediate Jeopardy was determined to have begun on 6/16/13 when the facility failed to recognize and report abuse by R16. The facility did not investigate the incidents and did not implement interventions to protect the residents from R16. Subsequent incidents of resident to resident physical aggression by R5 and R18 occurred. Those incidents were not reported, nor were they investigated. In addition, no interventions were put in place to protect residents from R5 and R18. E1, Administrator was informed of the Immediate Jeopardy on 9/10/13 at 3:00 p.m. On 9/09/13 at 2:00 p.m., a group meeting was held with R2, R15, R21, R22, R23, and R24. R18 was present in the meeting area but unable to participate due to cognitive deficits. R18 randomly called out loud answers to questions asked of the group members but the answers R18 called out were rambling, incomplete, phrases unrelated to the questions asked of the group. R2 indicated discretely the group could not speak freely with R18 present. At that time, R18 got up from the table and wandered to the door of the room. R18 opened the door but did not exit the room and returned to the table and sat down. E15 (Activity Aide) was summoned to distract R18 and escort R18 from the area to provide privacy for R2, R15, R21, R22, R23, and R24 to speak freely. After R18 left the meeting area the residents present for the group meeting reported there are two residents who repeatedly wander in and out of their rooms, R16 and R18. R2, R15, R21, R22, R23, and R24 all agreed R18 wanders into their rooms and becomes argumentative when they ask (R18) to leave. R2 reported R18 has wandered into (R2's) room and picked up (R2's) belongings and left the room with R2's belongings. R2, R15, and R22 reported R16 enters their rooms and becomes argumentative, refuses to leave, and they are afraid R16 will become physically abusive towards them before they can summon staff to intervene. R2, R15, R21, R22, R23, and R24 reported wandering residents have been an on going problem. R2, R15, R21, R22, R23, and R24 indicate staff are aware of the behaviors of R5, R16 and R18 because residents called staff to intervene at the time of the incidents. On 9-9-13 at 1:00 p.m., E1 (Administrator) stated, "all resident to resident altercations are considered abuse, regardless of the residents having dementia." The Resident Census and conditions of residents dated 9-8-13 and signed by E2 (Director of Nursing/DON), documents 67 residents currently reside in the facility. 1. On 9/11/13 at 9:25 a.m., R22 stated, " ... I was sound asleep and (R16) came in with (R16's) walker and rammed my bed with (R16 ' s) walker. I was sound asleep and it scared the heck out of me. The stop sign was up but that don ' t stop (R16). (R16) just comes on in anyway. It happened just the first of this week. (R16) informed me (R16) would leave when (R16) got ready. (R16) did finally leave. I didn ' t call staff. (R16) is always into something all the time. A year or so ago (R16) rammed into me with (R16 ' s) walker. Intentionally, but I didn ' t get hurt. It's happened at least four to five times or more that (R16's) comes in here like that ... " . R22 verified R16 and R18 go all over the building wandering into rooms. On 9-11-13 at 8:30 a.m., R36 stated the following: "(R16) always enters my room and I don't like it." R16 enters R36's room and yell at R36. About a month ago, R16 approached R36, while in the hallway, and started shoving R36 with a walker. On 9-10-13 at 3:45 p.m., E12 (Certified Nursing Assistant) stated the following: R16 ambulates to all the hallways and into all of the resident rooms within the facility. R16 uses the walker as a weapon and attacks other residents with it. R16 attacks R22 with the walker frequently, using R16's body and walker to shove R22, nearly causing R22 to fall. R16 will antagonize the other residents until the other residents get mad, and then R16 will say, "Well my work is done here. You are mad." E12 stated, "I have not reported (R16) attacking other residents to anyone, because I am just use to (R16) being like this all of the time." On 9-10-13 at 3:45 p.m., E12 stated on 6-16-13, R16 attacked R36 with a walker, while in the hallway. E12 stated R16 shoved R36 with a walker at least three times before E5 (Registered Nurse) intervened. E12 stated the stop signs that are on the resident doors do not mean a thing to R16, as R16 just removes them and enters the residents' rooms anyway. E12 stated, "I did not report this incident between R16 and R36, because I thought the nurse was aware." On 9-10-13 at 4:45 p.m., E5 (Registered Nurse) stated R16 is a wanderer and other residents will yell for staff to come and remove R16 from their rooms. E5 stated R22 does not like R16 and will get very "verbal" with R16. R16's most recent quarterly MDS (Minimum Data Set) dated 7/13/13 documents under section E Behavior, Wandering occurred daily but did not intrude on the privacy of others. R16's most recent full annual MDS dated [DATE] documented R16 did not have behaviors but wandered daily and the wandering significantly intruded on the privacy or activities of others. R16's progress notes dated 10/25/12 through 9/5/13 document multiple occurrences of wandering and aggression. On 11/4/2012 R16's Progress Notes documented "increased wandering this shift, redirection unsuccessful, becomes increasingly agitated with staff." On 11/4/12 a Mood Behavior Progress note documented R16 showed symptoms of anxiety and demonstrated behaviors "such as wandering." The note documented R16 "interferes with other residents care at times." On 12/7/12 R16's Mood/Behavior Progress notes documented "increased agitation and verbal abuse with staff." On 1/11/13 R16's Mood Behavior note documented "up wandering in halls. Went into another resident's room, when asked to leave told other resident R16 did not have to, then left and went into another residents room and had to be escorted out by staff." On 1/25/13 R16's General Progress note documented "up wandering in halls. went into another residents room, when asked to leave the room R16 was easily upset and verbally abused staff. Then left room and went into another residents room and had to be escorted out by staff." On 5/29/13 R16's Mood/Behavior note documented "increased agitation and yelling at other residents." On 6/16/13 R16's General Progress note documented "R16 very agitated and hitting other residents and refusing to leave and leave them alone. R16 also hitting staff members with walker." On 7/12/13 R16's Social Service Progress note documented "more confusion and short tempered, can become agitated and try to be aggressive with others. Redirection does not always work." On 8/7/13 R16's Mood/Behavior Progress note documented "wandered into room [ROOM NUMBER], resident in 103 asked R16 nicely to leave", staff attempted to redirect R16 to R16's room. The note documented R16 "became agitated and began scratching, hitting, cussing and spitting on staff." On 9/10/13 at 11:00 a.m. R16 was barefooted walking around a parked wheelchair in the front hallway by the main entrance of the facility. R16 appeared confused but responded verbally to staff with abrupt answers to their questions. R16 was argumentative but did eventually sit in the wheelchair at staff's repeated request. R16 was able to transfer self. On 9/11/13 at 11:30 a.m. E17 CNA (Certified Nursing Assistant) stated R16 wanders throughout the entire building in the afternoon and evenings. E17 stated R16 ambulates into other resident rooms and may yell at them. On 9/10/13 at 11:50 a.m. E5 RN (Registered Nurse) stated R16 usually shoves R16's walker at the staff at hits at mostly staff and some residents. E5 stated R16 irritates other residents and wanders into their rooms. On 9/10/13 at 10:45 AM. E2 DON (Director of Nursing) stated R16 ambulates independently throughout the facility with a walker and enters other residents rooms. E2 stated the stop signs on the doors of other residents' rooms are to prevent R16 from entering those rooms. E2 stated R16 is not verbally appropriate and gets very agitated. R16 stated neither physical nor verbal abuse has been reported to E2 regarding R16. E2 denied being informed of the alleged resident to resident abuse that occurred between R16 and R36 on 6/16/13. On 9/10/13 at 12:40 p.m. R20 and R30 stated the red stop sign is on their door to prevent R16 from entering. R20 and R30 stated R16 is "not a very nice person." On 9/10/13 at 12:55 PM. R25 stated the stop sign is on R25's door due to R16 coming into R25's room and taking things. 2. On 9-8-13 at 9:30 a.m., R5 was propelling self, in a wheelchair, down the hallway. R5's Physician order [REDACTED]. R5's Mood/Behavior notes dated 2-7-13 at 1:48 p.m., document R5 grabbed a visitor by the wrist and hand, squeezing, and attempted to hit the visitor. The notes document E9 (Registered Nurse) attempted to reorient and calm R5, which was unsuccessful. R5's Mood/Behavior notes dated 2-21-13 at 2:18 p.m., document R5 refused morning. and noon medications, threatened to throw milk on staff, pinched, and kicked. R5's Mood/Behavior notes dated 3-7-13 at 6:16 p.m., document R5 was found in another resident's room. When E7 (Activity Director) tried to remove R5 from the room, R5 grabbed and hit E7. The notes document R5 was "angry" and "wanted to hurt everyone" and R5 continued to hit, pinch, bite, and pull E7's hair. R5's General Progress notes signed by E5 (Registered Nurse) and dated 8-14-13 at 10:13 p.m., document R5 started hitting and grabbing other residents and the residents were separated. On 9-9-13 at 11:15 a.m., E5 stated on 8-14-13 R5 grabbed, scratched, and kicked R16. E5 stated R5 is always grabbing and scratching other residents and the staff just try to re-direct R5. E5 stated E5 did not report the incident on 8-14-13, between R5 and R16, to E1 (Administrator) or anyone. E5 stated, "I only notify (E1) or the Director of Nursing if there is injuries." On 9-9-13 at 12:00 p.m., E5 stated the incident on 8-14-13 might have been between R5 and R2. E5 stated R5 grabbed and pinched R2 on the arm, and the staff had to separate R5 and R2. On 9-9-13 at 11:25 a.m., E6 (Certified Nursing Aide) stated R5 is always pinching, kicking, and biting the staff and residents. E6 stated R5 always bickers with R5's roommate. E6 reports R5 can propel self, in the wheelchair, down the hallway and in the dining room. On 9-10-13 at 3:45 p.m., E12 (CNA) stated, "a few weeks ago, (R5) grabbed (R2)'s right wrist and would not let go." E12 stated it took E12 and E5 to get R5 to let go of R2's wrist. E12 stated E12 did not report this incident to anyone because E5 was aware. On 9-9-13 at 11:20 a.m., E1 (Administrator) stated all resident to resident altercations should be reported immediately to E1, E2 (Director of Nursing), the resident's family, and the resident's Physician. On 9-9-13 at 12:45 p.m., E1 verified E1 has not been notified of any resident to resident altercations involving R5 and therefore, an investigation has not been done and the state agency has not been notified. 3. On 9/10/13 at 1:30 p.m., R10 stated R18 hit R10 in the face in 3/13. R10 stated she reported the incident to a Nurse but cannot recall the Nurses name. R10 stated the Nurse told R10 to ignore R18 because "she has Alzheimer's." R10 stated " (R18) has the mentality of a five year old but could really hurt someone." R10 stated "I'll double up my fist and hit (R18) three times before she hits me one more time and I'm going to be talking to the Sheriff." A Minimum (MDS) data set [DATE], documents R10 scored 15/15 on the Brief Interview for Mental Status. R10's and R18's Nurses Notes were reviewed from 12/12 through 9/10/13 with no documentation of R18 hitting R10. On 9/10/13 at 2:30 p.m., E2 (Director of Nursing) denied any knowledge of any allegations of resident to resident abuse involving R18. On 9/10/13 at 3:05 p.m., E3 (Director of Care Delivering) denied any knowledge of R10 reporting R18 hit R10. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R16 was placed on direct visual one to one supervision as soon as the Immediate Jeopardy was identified on 9/10/13. R16 was transferred from the facility on 9/10/13. 2. All staff scheduled to work on 9/10/13 were trained on the abuse policy prior to working their shift. The training included education on behavior identification and reporting to supervisors. 3. The facility performed updated behavior assessments for R5, R16, and R18, as well as all other residents with behaviors. Appropriate referrals were made by 9/11/13. 4. R18 was discharged from the facility due to behaviors. 5. R5 was placed on 1 to 1 supervision on 9-10-13. 6. R5 ' s care plan was updated to reflect all current interventions. 7. A review of R5 ' s medication regimen was conducted by Hospice at the request of the facility, and medications were adjusted accordingly. 8. Behavior monitoring of R5 was implemented and is ongoing. When R5 ' s aggressive behaviors diminish, the 1 to 1 supervision will be discontinued and other appropriate interventions will be put into place, based on R5 ' s behavior.

Based on observation, interview, and record review the facility failed to recognize and report multiple incidents of abuse by two of 13 residents (R5,R16) reviewed for abuse in the sample of 15 and one resident (R18) on the supplemental sample. R16 and R18 ambulate throughout the facility into other residents rooms and become verbally and physically aggressive with other residents. R5 propels in a wheelchair throughout the dining room and hallways and becomes physically aggressive with other residents. This failure allows these residents (R5, R16, R18) to continue to ambulate throughout the facility and has the potential to affect all 67 residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 9/10/13, the facility remains out of compliance at a severity level two as the facility is still educating management and staff on the importance of reporting allegations of abuse immediately and investigating all allegations thoroughly. Findings include: The Immediate Jeopardy situation was identified on 9/10/13 at 1:30 PM. The Immediate Jeopardy was determined to have begun on 6/16/13 when the facility failed to recognize and report abuse for R16. E1, Administrator was informed of the Immediate Jeopardy on 9/10/13 at 3:00 p.m. Findings include: The Facility ' s Patient Protection Practice guide dated 11/2011 documented "when investigating whether abuse has occurred, the center identifies and considers events such as behavioral changes, bruising of patients, and suspicious patient patterns, unexplained injuries, communication or social interaction changes and other trends may signify abuse. Any allegation requires investigation. Any allegation of abuse must be immediately reported to the supervisor and abuse prevention coordinator. The center must ensure that all alleged violations involving mistreatment, neglect or abuse are reported immediately to the administrator and other officials in accordance with state law through established procedures (including to the state survey and certification agency)." On 9-9-13 at 1:00 p.m., E1 (Administrator) stated, "all resident to resident altercations are considered abuse, regardless of the residents having dementia." The Resident Census and conditions of residents dated 9-8-13 and signed by E2 (Director of Nursing/DON), documents 67 residents currently reside in the facility. 1. On 9/11/13 at 9:25 a.m., R22 stated, " ... I was sound asleep and (R16) came in with (R16's) walker and rammed my bed with (R16 ' s) walker. I was sound asleep and it scared the heck out of me. The stop sign was up but that don't stop (R16). (R16) just comes on in anyway. It happened just the first of this week. (R16) informed me (R16) would leave when (R16) got ready. (R16) did finally leave. I didn't call staff. (R16) is always into something all the time. A year or so ago (R16) rammed into me with (R16's) walker. Intentionally, but I didn't get hurt. It's happened at least four to five times or more that (R16's) comes in here like that ... " . R22 verified R16 and R18 go all over the building wandering into rooms. On 9-11-13 at 8:30 a.m., R36 stated the following: "(R16) always enters my room and I don't like it." R16 enters R36's room and yells at R36. About a month ago, R16 approached R36, while in the hallway, and started shoving R36 with a walker. On 9-10-13 at 3:45 p.m., E12 (Certified Nursing Assistant) stated the following: R16 ambulates to all the hallways and into all of the resident rooms within the facility. R16 uses the walker as a weapon and attacks other residents with it. R16 attacks R22 with the walker frequently, using R16's body and walker to shove R22, nearly causing R22 to fall. R16 will antagonize the other residents until the other residents get mad, and then R16 will say, "Well my work is done here. You are mad." E12 stated, "I have not reported (R16) attacking other residents to anyone, because I am just used to (R16) being like this all of the time." On 9-10-13 at 3:45 p.m., E12 stated R16 attacked R36 with a walker, while in the hallway on 6-16-13. E12 stated R16 shoved R36 with a walker at least three times before E5 (Registered Nurse) intervened. E12 stated the stop signs that are on the resident doors do not mean a thing to R16, as R16 just removes them and enters the residents' rooms anyway. E12 stated, "I did not report this incident between R16 and R36, because I thought the nurse was aware." R16's progress notes dated 10/25/12 through 9/5/13 document multiple occurrences of wandering and aggression. On 11/4/2012 R16's Progress Notes documented "increased wandering this shift, redirection unsuccessful, becomes increasingly agitated with staff." On 11/4/12 a Mood Behavior Progress note documented R16 showed symptoms of anxiety and demonstrated behaviors "such as wandering." The note documented R16 "interferes with other residents care at times." On 5/29/13 R16's Mood/Behavior note documented "increased agitation and yelling at other residents." On 6/16/13 R16's General Progress note documented "R16 very agitated and hitting other residents and refusing to leave and leave them alone. R16 also hitting staff members with walker." On 9/11/13 at 11:30 a.m. E17 CNA (Certified Nursing Assistant) stated R16 wanders throughout the entire building in the afternoon and evenings. E17 stated R16 ambulates into other resident rooms and may yell at them. On 9/10/13 at 11:50 a.m. E5 RN (Registered Nurse) stated R16 usually shoves R16's walker at the staff and hits at mostly staff and some residents. E5 stated R16 irritates other residents and wanders into their rooms. On 9/10/13 at 10:45 AM. E2 DON (Director of Nursing) stated R16 ambulates independently throughout the facility with a walker and enters other residents rooms. E2 stated the stop signs on the doors of other residents' rooms are to prevent R16 from entering those rooms. E2 stated R16 is not verbally appropriate and gets very agitated. R16 stated neither physical nor verbal abuse perpetrated by R16 has been reported to E2 . E2 denied being informed of the alleged resident to resident abuse that occurred between R16 and R36 on 6/16/13. On 9/10/13 at 12:55 PM. R25 stated the stop sign is on R25's door due to R16 coming into R25's room and taking things. 2. R5's General Progress notes signed by E5 (Registered Nurse) and dated 8-14-13 at 10:13 p.m., document R5 started hitting and grabbing other residents and the residents were separated. On 9-9-13 at 11:15 a.m. E5 stated previously on 8-14-13 R5 grabbed, scratched, and kicked R16. E5 stated R5 is always grabbing and scratching other residents and the staff just try to re-direct R5. E5 stated E5 did not report the incident on 8-14-13 between R5 and R16, to E1 (Administrator) or anyone. E5 stated, "I only notify (E1) or the Director of Nursing if there is injuries." On 9-9-13 at 12:00 p.m., E5 stated the incident on 8-14-13 might have been between R5 and R2. E5 stated R5 grabbed and pinched R2 on the arm, and the staff had to separate R5 and R2. On 9-9-13 at 11:25 a.m., E6 (Certified Nursing Aide) stated R5 is always pinching, kicking, and biting the staff and residents. E6 stated R5 always bickers with R5's roommate. E6 reports R5 can propel self, in the wheelchair, down the hallway and in the dining room. On 9-10-13 at 3:45 p.m., E12 (CNA) stated,"a few weeks ago, (R5) grabbed (R2)'s right wrist and would not let go." E12 stated it took E12 and E5 to get R5 to let go of R2's wrist. E12 stated E12 did not report this incident to anyone because E5 was aware. On 9-9-13 at 11:20 a.m., E1 (Administrator) stated all resident to resident altercations should be reported immediately to E1, E2 (Director of Nursing), the resident's family, and the resident's Physician. On 9-9-13 at 12:45 p.m., E1 verified E1 has not been notified of any resident to resident altercations involving R5 and therefore, an investigation has not been done and the state agency has not been notified. 3. On 9/10/13 at 1:30 p.m., R10 stated R18 hit R10 in the face in 3/13. R10 stated she reported the incident to a Nurse but cannot recall the Nurses name. R10 stated the Nurse told R10 to ignore R18 because "she has Alzheimer's." R10 stated " (R18) has the mentality of a five year old but could really hurt someone." R10 stated "I'll double up my fist and hit (R18) three times before she hits me one more time and I'm going to be talking to the Sheriff." A Minimum (MDS) data set [DATE], documents R10 scored 15/15 on the Brief Interview for Mental Status. On 9/10/13 at 2:30 p.m., E2 (Director of Nursing) denied any knowledge of any allegations of resident to resident abuse involving R18. On 9/10/13 at 3:05 p.m., E3 (Director of Care Delivering) denied any knowledge of R10 reporting R18 hit R10. The surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. R16 was placed on direct visual one to one supervision as soon as the Immediate Jeopardy was identified on 9/10/13. R16 was transferred from the facility on 9/10/13. 2. All staff scheduled to work on 9/10/13 were trained on the abuse policy prior to working their shift. The training included education on behavior identification and reporting to supervisors. 3. The facility performed updated behavior assessments for R5, R16, and R18, as well as all other residents with behaviors. Appropriate referrals were made by 9/11/13. 4. R18 was discharged from the facility due to behaviors. 5. R5 was placed on 1 to 1 supervision on 9-10-13. 6. R5 ' s care plan was updated to reflect all current interventions. 7. A review of R5 ' s medication regimen was conducted by Hospice at the request of the facility, and medications were adjusted accordingly. 8. Behavior monitoring of R5 was implemented and is ongoing. When R5 ' s aggressive behaviors diminish, the 1 to 1 supervision will be discontinued and other appropriate interventions will be put into place, based on R5 ' s behavior. 9. The doctor and family were notified of R16 ' s occurrence on 9/10/13. The occurrence was reported to IDPH on 9/10/13. 10. Licensed staff will be educated on incident report completion and physician and family notification of allegations of abuse.

Based on interview, record review and observation the facility failed to remove an employee from duty for verbal abuse for one of three residents (R1) reviewed for abuse. Facility staff wittnessed E6 (Registered Nurse/RN) verbally abuse R1 and continue to agitate and threaten to "slap" R1. Findings include: R1's current Physician order [REDACTED]. According to an incident report dated 6-24-13 at 7:45 p.m., R1 exited the facility with four staff members, who were trying to calm R1 down and get R1 to return inside the facility. R1 pushed E6 RN (Registered Nurse/RN) against a building and threw water on E6. E6 then began cursing at R1. R1 was then brought back into the facility by another staff, E5 (RN). The 6-24-13 incident report documents R1 drew back R1's arm at E6 and E6 yelled, "I will backhand you (R1) if you slap me. No one hits me." R1 then acted like R1 would spit on E6 and E6 yelled, "Don't spit in my face or I am going to slap you (R1)." R1's 6-24-13 incident report documents E2 (Director of Nursing/DON) was notified by E3 (Certified Nursing Aide/CNA), later on the shift, about the behavior of E6 towards R1. On 7-15-13 at 2:17 p.m., E3 (CAN/Certified Nursing Assistant) stated the following events occurred on 6-24-13 around 7:45 p.m.: E3, E6 (RN/Registered Nurse), and E7 (CNA) was outside trying to get R1 to return inside the facility when R1 started throwing ice water on E6. E6 then yelled at R1, "You (R1) need to knock your sh-t off." Someone got E5 (RN) to help calm down R1. E3 told E6, "Just walk away and let (E5) handle the situation." E6 would not walk away and agitated R1 even more. E5 got R1 back in the building and E6 followed R1. E6 tried to give R1 medications and R1 stated to E6, "I am going to spit them if you give them to me." E6 then stated to R1, "I will slap you if you spit." E6 worked with E6 ' s assigned residents the rest of the shift, until about 11:00 p.m. Following the incident between R1 and E6, E3 told E5 (RN) to call E2 (Director of Nursing/ DON/Abuse Coordinator) and report E6 for abuse. E5 called E2 approximately 15 minutes later to report E6 for abuse. E3 verified that E1 (Administrator) was not notified. On 7-15-13 at 2:20 p.m., E4 (CNA) stated the following events occurred on 6-24-13 around 7:30 p.m.: E4 followed R1 outside and R1 refused to come back inside the facility as requested by staff. E4 called for help from E3, E6, and E7. E3, E6, and E7 could not get R1 back in the building, so E5 (RN) came to help and assisted R1 back into the building. Once R1 returned inside building, R1 drew back R1's arm in attempt to hit E6. E6 told R1, "If you hit me I am going to back hand you." E4 reported the incident right away to E5. E4 also stated E2 (DON) did not interview E4 the night of the incident on 6-24-13. On 7-15-13 at 3:00 p.m., E5 (RN) stated the following events occurred on 6-24-13: E5 helped get R1 back into the facility on at approximately7:45 p.m. Around 8:00 p.m., three CNA ' s (E3, E4, and E7) reported to E5 that E6 was verbally abusive towards R1 while attempting to get R1 to return to the building. E5 did not hear the verbal abuse from E6 towards R1 because E5 had just helped get R1 back into the building, and then returned to E5's nursing station. E5 notified E2/DON of E6's alleged verbal abuse towards R1approximately 15 minutes later, E2 told E5 to collect statements about the incident from the staff. E2 came to the building shortly after, but did not talk to or get any statements from E5. E5 states, "I know (E6) can be short at times." E5 stated that E1 (Administrator) was not notified. On 7-15-13 at 11:30 a.m., E2 (DON) stated on 6-24-13 around 8:00 p.m., E3 (CNA) called E2 at home and reported E6 told R1 that E6 was going to slap and was cursing at R1. E2 stated E2 came in immediately on 6-24-13 around 8:15 p.m. and started taking statements from the staff and investigating. E2 stated E6 was not suspended immediately because at that point only one Certified Nursing Assistant (E3) had heard E6 threatening R1. E2 stated E6 denied the accusations that E6 had threatened and cursed at R1. E2 states, "I felt like it was (E6's) word against (E3's) word." E2 stated if E6 would have touched R1, E2 would have suspended E6 immediately. E2 (DON) confirmed E6 was allowed to work with other residents (R1, R4-R25) while E2 investigated, and E6 finished the shift on 6-24-13 till around 11:00 p.m. E2 stated E6 was terminated on 6-25-13, after E2 received more statements from the staff about the incident on 6-24-13 between R1 and E6. E2 states, "I just felt like it was not a good situation." On 7-16-13 at 9:23 a.m., E1 (Administrator) stated E2 (DON) should have suspended E6 on 6-24-13, immediately after the incident with R1, instead of waiting until 6-25-13. E2 stated E6 should not have been allowed to work with other residents on 6-24-13, until the investigation was complete. E2 also stated the staff should have taken E6 away from the situation to keep R1 calm. E1 stated, "I do not know why (E6) did not remove one's self from the situation and away from (R1), instead of following (R1) to the nurses' desk." On 7/15/13 at 1:10 p.m., R1 was sitting in a chair in R1's room and stated, "My stay is good here. I don't recall staff being mean or ever yelling at me." The facility's group assignment dated 6-24-13 documents E6 was the nurse caring for R1 and R4-R25 and E2 verified this assignment on 7-15-13 at 11:00 a.m. E6's time card documents E6 worked on 6-24-13 from 2:54 p.m. to 1:45 a.m. According to an employee warning notice dated 6-26-13, E6 (RN) was terminated from the facility for verbally threatening a dementia patient, for not conducting self in a professional manner, and for making a threat to strike a dementia patient.

Based on observation, record review, and interview, the facility failed to use a gait belt during ambulation according to facility policy and failed to ensure resident was not left unattended at bedside for two of three residents (R1, R3) reviewed for falls in the sample of three. R1 sustained fractured ribs. Findings include: 1. R1 was admitted to the facility on [DATE] at 12:00 noon from another nursing home with the following admission note: " alert to three spheres, ...noted two person assist with cares and transfers. No pain or discomfort noted-tolerable level 6 (out of a linear scale from 1-10. Ten being the highest level of pain) Resident is legally blind... Noted scab to right knee from a fall." An unsigned and undated form (LIPS Manual Attachment 4) found in the resident's record under admissions discusses the resident's level of function. "Patient Transfer Screening Analysis" score of "3" has the following information collection- #14. Patient is a two person stand pivot transfer, #15. Patient ambulates less than 15 feet per day, and #18. Patient requires stand by contact guard (constant assistance). The incident report of 10/10/11 at 10:00 p.m. states "Resident was ambulating with the walker to the bathroom with the certified nurse assistant (CNA) staggered and fell back onto the floor scraped back on wheelchair wheels, 2 (two) red areas on the back on the upper back and 3 by 4 (inch) abrasion on the left side of the back." The area of "Medical Device" is blank only saying "No" for the question "Was a medical device involved?" Interview with E1 (Administrator) on October 25, 2011 at 10:45 a.m. stated that she was aware that R1 was "transferred from bed, and ambulated to the bathroom without the required gait belt." E1, stated that an in-service was conducted to make staff aware of the use of the gait belt when ambulating residents who require constant hands-on supervision with ambulation and transfers. The facility's Gait belt policy dated 12/2009 states "the purpose is to safely and effectively transfer or ambulate a patient." Procedure #13 states "Ambulate by maintaining hold of the belt." E9 (Certified Nurse Assistant) who was present during the incident with R1 on 10/10/11 at 10:00 pm. documented that "when taking the resident (R1) to the bathroom, resident staggered with walker and leaned back and sat down. She bumped her back on the wheel chair and I did not have the gait belt on the resident." E9 commented on page 2 of 2 of the statement form "I was coached on proper gait belt usage by (E12) Licensed Practical Nurse. The resident started panicking right away as as she leaned back. I would recommend transfer with wheelchair at night because she wasn't as steady as during the daytime. " E10, (Registered Physical Therapist), on 10/25/11 at 3:00 pm reviewed the Physical Therapy Evaluation of 10/11/11 to verify that the resident requires stand by assistance with transfers and locomotion. The following "comments" were found on this report, "Pt (R1) ambulates with decreased cadence, decreased step length, and decreased floor clearance and requires verbal and tactile cueing with walker stance and maneuvering secondary to poor vision." Precautions were identified for risk of falls, safety and poor vision. R1's functional mobility identified on the 10/11/11 physical therapy evaluation states that the "Patient requires verbal and tactile cuing with proper hand placement 50% of the time due to poor vision." Occupational Therapy evaluation of 10/11/11 after the fall of 10/10/11, noted R1 to have left post trunk abrasion and presents with dizziness upon initially sitting. The resident's functional activity tolerance was described as "poor with limitations by fatigue and pain." X-rays dated 10/10/11 of left uniribs with /PA Chest (Front view of Chest) noted "a small left apical pneumothorax.... Fracture of the posterior left eighth rib." The Attending Physician on 10/26/11 at 1:00 p.m. stated that he "leaves the ambulation status up to the therapy department to evaluate." He commented that he kept the family well informed of the status of R1 and ordered another x-ray to follow up on the condition of the pneumothorax and selected to transfer the resident to the hospital since the condition had worsened after talking with the family and the facility on 10/12/11. History and Physical Exam Impressions from the emergency roiagnom on [DATE] states "(R1) is an [AGE] year old woman who presents with left sided pneumothorax and left rib fracture, status [REDACTED]. Her pain is well controlled with oral analgesic medication." Current careplan dated 10/26/11, reviewed with E7 (RN) on 10/26/11 at 12:30 pm verified that the careplan does not specify how to transfer/ambulate the resident under the focus area "ADL Self care deficit as evidenced by extensive assist related to physical limitations of pelvic fracture, and weakness." Under the focus area " Activity of Daily Living self care deficit as evidenced by extensive assist related to weakness, confusion. Hospice Care has one of the interventions as "Use gait belt to facilitate safe transfer and ambulation." 2. R3 was asleep in his room on 10/25/11, 11:45 a.m., resting on his low bed near to the floor with a mat on the right side. His oxygen condenser and wheelchair on the left side of the bed. The call light was attached to the side of the bed. At 12:45 p.m. on 10/25/11, E3 ( Certified Nurse Assistant) CNA confirmed that R3's bed was in a high position and was to be positioned to the lowest level when resident is in the bed. E3, CNA, attached the call light to the blanket that she placed over R3. R3's incident report dated 10/13/11 at 5:00 am states, "Resident fell face forward off the side of the bed and landed on nose, has a 1.4 cm laceration to nose, and a 3.2 by 2 cm skin tear to right elbow. The section on medical device is blank other than answering no to the question "Was a medical device involved?" Summary of the investigation report generated on 10/13/11 under the "summary of critical information obtained during the investigation" states "patient is a [AGE] year old male, who is hospice patient with prostrate cancer et (and) metastases to the bones. He has weakness and periods of confusion, extensive assistance with transfers and Activities of Daily Living. He has a tabs alarm in the wheelchair and bed. When sitting up patient has episodes of dizziness and history of seizures. (R3) was not wearing gait belt." Conclusion states, "Certified Nurse Assistant moved away from the resident. Resident then fell first onto the floor." The resident's careplan dated 09/26/11 for the focus area "At risk for falls due to pain" includes interventions of: "Ensure that the tab alarm is in place when in wheel chair and bed, Low bed with matts, and Do not allow resident to sit unattended at side of bed." Handwritten statement of E13, (Certified Nurse Assistant), 10/13/11 who was present at the time of the incident, states "comments made by the witness- I had the resident sitting on the side of the bed. I had brought him over in a wheelchair. Brakes on the wheel chair were locked and as I turned to unlock the brakes and move the wheel chair back , the resident fell forward."