Every finding on record at Manor Court of Peru

Based on interview and record review, the facility failed to supervise a cognitively impaired resident resulting in R1 opening her bedroom window, removing the screen, climbing through the window, walking approximately 350 yards to the roadway where a bystander saw her, picked her up, and notified the police on [DATE]. This applies to 1 of 4 residents (R1) reviewed for safety and supervision in the sample of 5.The Immediate Jeopardy began on [DATE] when R1 eloped from the facility through the window. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 4:25PM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the window alarms and the in-service training. The findings include:R1's Progress Notes dated [DATE] at 12:30PM state, Activity Aide noted screen from the window outside on the ground. Missing resident procedure initiated. Resident noted to be within eyesight of the facility. Nurse completed skin assessment and neuro checks with all findings WNL (within normal limits) for resident. POA (Power of attorney) and MD (physician) notified of event.On [DATE] at 10:48 AM V3(RN-Registered Nurse) stated, I had just gotten her back to her room, she was on isolation for COVID and I left the door open because she is a fall risk. A few minutes later her door was shut and (V5- Memory Care Director) went and opened it again and (R1) was still upset but she was sitting in her chair. Then a few minutes later (V4-Resident Assistant) was leaving in the parking lot and he saw the screen was out of the window, so we started looking for (R1) in the building and outside. Then I saw her across the field- she was at the road already. I am pretty sure she had shoes on and I think she was wearing long sleeves. She had never tried to go out the window before. She had tried to exit seek but never out the window. I don't know if the alarms (on the windows) are new or not. I can't remember if her door was open when we found out she was missing or if she had closed it again. She did not use a walker or a cane. She could walk. She had a tendency to fall when she got tired or upset but otherwise, she walked pretty well. From the time I put her in her room to the time the screen was noticed to be missing was about 10-15 minutes. It was lunch time so about 12:00PM- 12:30PM. When I saw her across the field the police car was with her. I think the police called the facility and they also called her family. We called her family too. The police called an ambulance and brought her back here. (R1) knows her name and she had her purse with her, so I don't know if the police got her daughter's number from her purse or how they got it. The family came to the facility a few minutes after the ambulance brought her back here. (EMS- Paramedics) did their assessment and then we did ours. She did not have any injuries. I charted it late because I was not 100% sure how to chart it. I didn't want to miss anything. I did not talk to the police that day, but management might have.On [DATE] at 11:00AM V4 (Resident Assistant) stated, I pass water and help with flowers and decorating and little things that residents need help with. I was leaving so it was about 12:15PM. I noticed the screen was off one of the windows on the memory care unit. I drove around to the front, and I told (V6- Receptionist) and then I went back to the Memory care unit and notified (V5). She went with me right away to search outside, but I never found her or saw her. One of the staff saw her and then I knew she was found so I left. I don't believe there was snow on the ground because there would have been tracks.On [DATE] at 11:23AM V4(Memory Care Director) stated, We were all in COVID isolation on the memory care unit. It was lunch time, but it was a little later lunch for us than it normally is. It was about 12:00PM. I had just gone in R1's room because she kept closing the door and when I opened it she kind of mean mugged me. She was sitting in her chair with her table and her lunch in front of her. Then I went on to help the CNAs pass the trays to the other residents in their rooms. Then V4 came and told me the screen was off the window, and I ran to R1's room and pushed the door open and saw the window was open and R1 was gone. I yelled for the nurses and the CNAs and V3 and another nurse went out the back, and I went out the front to look for her. I looked across the field, and I could see her bright pink sweater and I said, 'there she is'. There was a black pick-up truck and a squad car. It was a Sunday and V3 wanted me to call V1 (Administrator), but I told her I thought V1 was out of town, so I called V2 (Director of Nursing). I ran back to the front because I was ready to go get her and V6 was trying to tell me something and a squad car pulled up and I ran outside and the police officer told me to calm down. He said, Are you missing something? I said yes, is she ok? He said 'yes, she is fine.' I told him I would go get her and he was talking to the other police officer, (on his radio) and they said the EMTs wanted to check her out. Then they brought her back in the squad car. They also called her family because they thought her family was going to come and get her. She had on her pink sweater, and she always wore like dress pants and slip on Sketchers (tennis shoes). She was carrying some pictures and she had her purse. When she got out of the car she thought she had just come back from vacation and she said, the boys will get my luggage. She had never tried to get out the window before, but she has a ton of behaviors. She is very [NAME] and would always question things you tell her. She would exit seek all the time. The alarms have been on the windows, but it did not sound. They have always been there. I don't know if she was smart enough to turn it off before she opened the window.On [DATE] at 12:30PM V7 (Maintenance Director) stated, The windows had older alarms on them, and they did work but we replaced them with new ones after this happened. I got the call on a Sunday, and I was fairly new to my position, so I came in and put the screen back on. The alarm on the Right window (that R1 got out of) was knocked off. They were pretty old. Surveyor and V7 assessed the location that R1 left the building and could see across the field to where she was found.V7 stated, I would say it is about 100-125 yards from here to that street- about the size of a football field- maybe a little further- like 2 city blocks but across a field.A Google Map search of the area shows the approximate distance from the building to the location that R1 was found (near the auto parts store) to be approximately 350 yards.An internet search on Weather Underground shows that temperature on [DATE] was around 32 degrees Fahrenheit from noon to 3:00PM. On [DATE] at 1:20PM V2 (Director of Nursing) stated, R1 has behaviors, always exit seeking. She has been seeing a psych specialist since admission in [DATE]. She is very nice, very sharp. She knows when you are playing her. She is usually compliant with her medications, but sometimes she takes some convincing. We have been gentle with her medication adjustments. Her daughter was living with her and then her husband died and that trauma set off her dementia. She was forgetful but a lot of this is very new to them. I got a call at home that R1 had kicked out the screen and had gotten out the window. I was on the phone with V5 and she was running- I could tell she was running then she said- 'I can see her pink sweater. The police have her. The EMT's just pulled up.' Then the next time she called me the police had brought R1 back and V5 said she was happy and R1 thought she had been on vacation. The nurse did a check and then we called the POA and I called the MD and the NP (Nurse Practitioner) that specializes in psych. We do not have a policy or plan about alarms, and I told V7 today that we need to have a system to check them monthly to make sure they are working. We did not have a system for checking the old alarms. We have never had this happen before. The alarms are there to alert the staff if someone opens the window. It is their right to open the window but then the CNAs (Certified Nursing Assistants) keep an eye on them if the window is open. There are no alarms on the windows outside the memory care unit. I have a timeline and I did an internal investigation but there is no incident report on the incident.On [DATE] at 2:30PM V6 (Receptionist) stated, The police called and said they found a woman by (Local) Auto Parts Store and wanted to know if we were missing a resident. At the same time V4 had told me that the window was open on the memory care unit. I told the police the staff were out looking for the resident. I don't know if the police knew R1's name or not or if she told them that she lived at the nursing home.The (R1's) Police Report dated [DATE] states, 12:17PM Caller advising that she has the female in a white Dodge Pickup truck, 12:21PM On Scene, 12:24PM I called (Local Assisted Living Facility) and was advised that R1 does not live there, 12:26PM I called (Facility) and spoke to an employee V6 who stated that R1 does reside there and that staff are outside trying to find R1. I asked how long they have been looking for R1, and the employee was not able to tell me. I advised her to have a supervisor call back when available. 12:26PM Arrived at (Facility), 12:50PM (City) ambulance checked on R1 and spoke to V8 (R1's daughter). V8 stated that R1 did not have to go to the hospital and could be transported back to (Facility). Officers transported R1 to (facility) and left her in medical staff care. The (R1's) (City) Volunteer Ambulance Service Report dated [DATE] states, (City) EMS was requested by (City) police to evaluate an elderly female patient who had been located following elopement from a nearby long-term care facility. The crew proceeded to the scene from quarters and upon arrival found the patient conscious and alert but confused sitting upright in a bystander's pick-up truck with no complaints. The patient was in the care of (City) police officers who reported that the patient was located by bystanders who found the patient wandering near the roadway in a confused state. The police officers reported that they had determined that the patient was a dementia patient who had eloped from a nearby long-term care facility, after which she was moving on foot for an unknown period of time. The police officers reported that they had made contact with the facility, and the staff reported that they had been actively searching for the patient for approximately 10 minutes. The patient was confirmed to have a history of advanced dementia. Upon assessment the patient denied any complaints and denied any injuries. The patient was in possession of various photos and personal belongings and reported she left the house to go and look for help for an unknown issue (Facility) was contacted via telephone and contact was made with the patient's nurse who requested that the patient be returned to the facility. The patient's nurse reported that the patient had eloped from the facility through a window and that she had been out of the facility for approximately 10-15 minutes .R1's Face Sheet shows she is an 83 female resident with diagnoses including Dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. R1's Care Plan date [DATE] states, R1 is at risk for elopement and is not able to make decisions regarding her safety due to diagnosis of unspecified dementia. Approaches include: Know where R1 is at all times, Offer to do one on one activity with R1 if she seems restless.The facility presented an abatement plan to remove the immediacy on [DATE] at 6:40PM. The surveyor reviewed the abatement plan and was unable to accept the plan. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE] at 9:56AM, the surveyor reviewed the abatement plan and was unable to accept the plan. The abatement plan was returned to the facility for revisions. The facility presented a revised abatement plan on [DATE] at 11:26 AM, the surveyor reviewed the abatement plan and accepted the abatement plan on [DATE] at 12:50PM.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: On [DATE] Maintenance was immediately called in to change the window locks to a lower position in order to prevent resident from opening window more than halfway.On [DATE] Administrator ordered all new window alarms. On [DATE] Memory Care Director/Designee initiated an all-staff in-service on missing resident policy and protocol, alternative call light/call system; to include the frequent monitoring of the residents, including cognitively impaired residents. In-servicing continued to ensure staff not working at that time were also in-serviced. On [DATE] New window alarms were installed on R1's window and all other resident windows in the Memory Care Unit. On [DATE] Maintenance to include checking window alarms during weekly door alarm checks. On [DATE] R1 is not in the facility. On [DATE] The facility Department Heads conducted a unit wide walk through of the Memory Care Unit to assure all window alarms are in place and functional.On [DATE] An audit tool was developed for maintenance to check weekly that window alarms are in place and functional. All information will be reported by Maintenance Director to the Quarterly QA Committee.On [DATE] The facility Department Heads verified all resident room doors are open and residents are visible. On [DATE] In-services scheduled for all staff. In-services to include:Missing Resident policy and protocolAlternate call system: the frequent monitoring of the residents and verifying the doors are open, including cognitively impaired residents. Also, when staff are checking residents, ensure the window alarms are in place and in the alarm position. Maintenance in serviced on the use of the audit tool to check weekly that window alarms are in place and functional. All staff present were in serviced by the facility Director of Nursing, Assistant Director of Nursing or Designee. Any staff not present on [DATE] will be in-serviced prior to their next scheduled shift.Starting on [DATE] All new hires during orientation will be in-serviced on missing resident policy and protocol, alternate call system, and checking window alarms when entering resident rooms in the Memory Care Unit. On [DATE] resident belongings were moved to a room in the memory care unit that is within an external gated areaOn [DATE] audits were developed on missing resident, alternative call and window alarm monitoring. Administrator, Director of Nursing, or designee will complete on going audits for ensuring compliance with missing resident, alternative call and window alarm monitoring 5 times a week on alternating shifts for 4 weeks then as needed thereafter. All information will be reported by the Administrator to the quarterly QA committee.On [DATE] Maintenance Director contacted the facility's electronic monitoring company to obtain information to install hard wired alarms to windows and external gate in the Memory Care Unit. Currently waiting on a response.

Based on interview and record the review, the facility failed to notify the resident physician and the resident representative of an accident for one of three residents (R64), reviewed for notification of change in a sample of 33.FINDINGS INCLUDE:The facility policy dated 12/02, Change in a Resident's Condition, directs staff to, Promptly notify the resident, and /or resident's representative, and his or her attending physician of changes in the resident's condition and /or status. a) The resident is involved in any accident or incident that results in an injury including injuries of an unknown source.1. R64's progress notes dated 7/20/25 at 10:21 a.m., V5 documents Entered R64's room this a.m. and R64's bottom lip noted to be macerated in center to outer/inner part of lip with patch of white slough. R64 kept repeating Soup, it happened with soup to this nurse and another nurse. Denies any pain. R64 able to take medications and ate 75-100% of breakfast. Hospice updated. Will monitor.2. R64's medication administration record dated 7/20/25-8/01/25 documents monitor bottom lip every shift. 07/20/2025 - 08/01/2025 (DC Date). On 08/27/2025 at 2:20 p.m., V5/Registered Nurse states, At approximately 6am on 7/20/25 I entered R64's room and noticed a burn like area on R64's bottom lip. The area was macerated and white. R64 denied any pain. R64 told V5 I burned it on soup. V5 notified R64's hospice provider via telephone and received verbal orders from hospice nurse to monitor area. V5 confirms she did not update R64's physician or R64's resident representative. On 8/28/25 at 9 a.m., V7/Medical Director confirms he was not notified of R64's burn to bottom lip and verifies that he would expect to be notified even if the patient is on hospice services.

Based on observation, interview and record review, the facility failed to offer a therapeutic diet for one of three residents (R107) reviewed for nutrition in a sample of 33FINDINGS INCLUDE: The facility policy dated 04/22 Supplementation directs staff To provide residents additional calories and/or protein to the Regular Diet in the form of supplements in order to improve caloric intake, promote weight gain or weight maintenance or improve wound healing. a) follow resident's prescribed diet. 1. R107's physicians order dated 1/25/24 documents High Calorie/High Protein Supplement with every meal. 2. R107's dietary ticket documents regular diet with regular texture, and thin liquids. Notes: Offer super cereal. Offer finger foods when available. 3. R107's most recent care plan Care plan dated 4/10/25. Problem Start Date: 03/20/2025 Category: Nutritional Status R107 has experienced weight loss due to poor intakes. Goal Target Date: 01/01/2026 R107 will not have a significant weight change through next review. Approach Start Date: 05/07/2025 Provide supplements: High calorie high protein supplement daily. Med Pass 2.0 supplement 90mL three times a day. Nursing Approach Start Date: 04/07/2025 Encourage finger foods. 4. R107's facility weight log dated 3/01/25-08/28/25 documents 3/24/35 weight 110 pounds, 04/02/25 weight 106 pounds, 05/05/25 weight 99 pounds, 6/05/25 weight 96 pounds, 07/02/25 weight 95 pounds, and 8/06/25 weight 98 pounds. On 8/27/25 at 830 a.m., R107 was observed in the dining room. R107's breakfast tray had scrambled eggs, and a bowl of peaches. R107 was picking up food with her fingers but kept dropping it before she could get it in her mouth. There were no finger foods available to R107, on her food tray. R107 also did not have her super cereal per her prescribed physician's diet.On 8/27/28 at 8:40 a.m., V14/ Certified Nursing Assistant verified that R107 isn't always served her super cereal by staff, because R107 will refuse it sometimes. V14 also confirmed that the super cereal was delivered to R107's dining room, but was still on the steam table because V14 figured R107 wouldn't eat it.On 8/28/25 at 9:00 a.m., V8/Certified Dietary Manager confirmed R107 is a significant weight loss, and R107 has orders for high calorie high protein supplements which includes super cereal. V8 also verified that R107 should be served finger foods, because R107 does better with them. V8 confirms her expectations are that staff serve the super cereal to R107, even if they think R107 will refuse it, and they should document the refusal in R107's intake record.

Based on observation, interview and record review, the facility failed to document a diagnosis and identify target behaviors to warrant the use of Seroquel (antipsychotic medication) and document a care plan to address behaviors and antipsychotic use for two of three residents (R6, R79) reviewed for antipsychotic medications in the sample of 46. Findings include: The facility's Psychopharmacologic Drug Usage Procedure policy, dated 10/18/17, documents A Psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety medications, and sedatives/hypnotics. Procedure: Use of psychopharmacological medications requires assessment by the attending physician, and specific orders must be written by the attending physician with supporting diagnosis. Psychopharmacological medication usage must also be addressed in the Care Plan, including goals, likely medication effect and potential adverse consequences. This same policy documents Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. 1. On 10/28/24 at 11:28 AM, R6 was sitting in the dining room in a wheelchair with a mechanical lift sling under him. Other residents were seated at the same table with R6. R6 was quiet and not exhibiting any behaviors. R6's current Physician Order sheet, dated 10/31/24, documents R6 has an order for Quetiapine (Seroquel, antipsychotic medication) 50 MG (milligrams), take 1 tablet by mouth two times a day. R6's current Care Plan, dated 5/30/24, documents R6 is [AGE] years old and has diagnoses including but not limited to; Dementia without behaviors, Abnormal weight loss, Depression and Mood Disorder. This same Care Plan documents (R6) has diagnoses of Depression, Anxiety, Insomnia, Attention-deficit hyperactivity disorder (ADHD) and Mood Disorder. Administer Quetiapine 50 MG twice a day as ordered related to Mood Disorder. Monitor for side effects, including boxed warnings. This Plan of Care does not list psychiatric behaviors or side effects to monitor for quetiapine use in elderly. R6's Behavior Analysis sheets, dated 4/29/24-10/29/24, document R6 has exhibited two physical behaviors and three verbal behaviors in the past six months. These behaviors list a date and time but no explanation as to what the behavior was. All five behaviors document staff was able to easily alter the resident's behavior with non-pharmacological interventions. On 10/29/24 at 2:00 PM, V9 (Certified Nursing Assistant) confirmed she has worked at the facility for a long time and works a shift from 3:00 AM until 2:00 PM. V9 stated (R6) hasn't been eating and needs assistance with meals. He is also more sleepy lately. No current behaviors that I can recall. He used to have behaviors but mostly it was if his roommate kept him up all night then he would be more moody, would cuss and had some falls. (R6) isn't harmful to other residents or himself. On 10/29/24 at 2:10 PM, V10 (Registered Nurse) stated (R6) has had no recent behaviors. He used to have some rejection of care, he would walk on his own and not ask for help or use a call light. He would then get upset when told to use it. (R6) is not harmful to other residents or himself. Maybe was harmful towards staff at one time. 2. On 10/28/24 at 11:50 AM, (R79) was sitting in her wheelchair in the dining room at table and was eating lunch independently. R79 was seated next to other residents and was not displaying any behaviors. R79's current Physician Order sheet, dated 10/30/24, documents R79 has an order for Quetiapine (Seroquel, antipsychotic medication) 25 MG (milligrams), take 1 tablet by mouth two times a day. R79's current Care Plan, dated 10/8/24, documents R79 is [AGE] years old and has diagnoses of Alzheimer's disease and Dementia. This Care Plan documents (R79) has Depression, Anxiety, Insomnia, and Mood Disorder. (R79) can be tearful at times. Administer Quetiapine 25 MG twice a day as ordered. Monitor for side effects, including boxed warnings. This Plan of Care does not list psychiatric behaviors or side effects to monitor for quetiapine use. R79's Psychotropic Medication consent, dated 9/17/24, documents R79 was prescribed Seroquel 25 MG two times a day for Mood Disorder. R79's Behavior Analysis sheets, dated 4/29/24-10/29/24, document R79 has exhibited two physical behaviors, two verbal behaviors, 17 behaviors of wandering and ten other behaviors in the past six months. These behaviors list a date and time but no explanation as to what the behavior entailed. R79's nursing progress notes for dates and times related to behavior sheets do not list details on what behaviors R79 has exhibited over the past six months. On 10/29/24 at 2:00 PM, V9 (Certified Nursing Assistant) stated (R79) has had no behaviors lately. Back in the day when she had them, (R79) would stand up and she broke her hip. (R79) has no other behaviors. She was in memory care (locked unit), but we moved out here after hip fracture. On 10/29/24 at 2:10 PM, V10 (Registered Nurse) stated (R79) usually in the evening time she has typical behaviors of sundowners (increased confusion in the evening). (R79) gets restless and has to be re-directed. (R79) is not harmful to herself or other residents though. On 10/30/24 at 11:13 AM, V2 (Director of Nursing) confirmed both R6 and R79 are taking Seroquel for Mood Disorder. V2 stated (R6) is verbal at times towards staff. Like if they are trying to help him with care or it is time to eat. He will direct profanity towards us. The physical behavior for him is usually if we're trying to help him, he will refuse because of the Dementia. He doesn't understand. Those physical behaviors are also towards staff. (R6) is not harmful towards other residents or himself. (R79) has some behaviors that are mostly agitation with staff. (R79) doesn't always like to be provided care that she needs. (R79) tries to stand unassisted and when we are trying to get her to sit back down, she will become agitated and strike out at us. (R79) is not harmful towards other residents or herself. V2 confirmed that both R6 and R79's care plans do not address the antipsychotic medication or behaviors adequately. V2 confirmed that both residents do not exhibit behaviors that are psychotic in nature or unrelated to dementia, to justify the use of Seroquel.

Based on observation, interview, and record review the facility failed to ensure a urinary collection bag was in a privacy cover and kept off the floor for one of three residents (R22) reviewed for catheters in a sample of 46. Findings include: The facility's Catheterization (Drainage Bag) policy, revised 01/04, documents that to attach the drainage bag to the frame, below the level of the resident's bladder, not touching the floor. On 10/28/24 at 10:00am, R22's urinary drainage catheter bag was hanging on the lower aspect of her reclining chair. R22's urinary drainage bag was uncovered and draining cloudy yellow urine. On 10/28/24 at 12:00pm, R22 was in the dining room in her reclining chair. R22's urinary drainage bag was hanging, uncovered, on the outer aspect of her reclining chair. V6, Certified Nursing Assistant, verified that R22's urinary drainage bag was not covered. On 10/29/24 at 8:45am, R22 was in the main dining area in her reclining chair. R22's urinary drainage bag was hanging, uncovered, under the reclining chair. At 12:30pm, R22 was in her room, with the urinary drainage bag, uncovered, under her reclining chair. During observations made on 10/29/24 R22's urinary drainage spout was unhooked from the collection bag and touching the floor. On 10/29/24 at 1:45pm, V2, Director of Nursing, stated that she did see R22's urinary drainage bag uncovered. V2 stated that it is the policy of the facility to cover all the urinary drainage bags with a privacy cover. V2 also verified that the urinary drainage bag is not to be touching the floor.

Based on observation, interview, and record review, the facility failed to implement new fall prevention interventions after repeated falls for one of four residents (R60) reviewed for falls in the sample of 46. Findings include: R60's current medical record documents R60's diagnoses to include: Alzheimer's Disease; Repeated Falls; Muscle Weakness (generalized); and Other Abnormalities of Gait and Mobility. R60's Fall Risk Assessment (dated 10/14/24) documents a score of 25, indicating R60 is a high risk for falls. On 10/28/24 at 09:55 AM, R60 was reclined in a recliner in the day room near the television covered with a blanket. R60's eyes were closed at this time. V13 (Certified Nursing Assistant) stated R60 has declined some recently. I think there was talk about Hospice, but her husband is waiting to see if she'll bounce back any. V13 stated R60 has lost weight, has developed a pressure ulcer on her bottom and has a history frequent of falls. R60's Minimum Data Set Assessment (dated 07/30/24), Section C, documents a Brief Interview for Mental Status score of 0, indicating severely impaired cognition. This same assessment documents in Section GG, R60 requires supervision or touching assistance to walk 10 feet (Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space); Walk 50 feet with two turns (Once standing, the ability to walk at least 50 feet and make two turns); and Walk 150 feet (Once standing, the ability to walk at least 150 feet in a room, corridor, or similar space). The facility's Fall Log documents that R60 has fallen 13 times at the facility on the following dates: 07/04/24, 07/05/24, 07/07/24, 08/01/24, 08/14/24, 08/18/24, 09/01/24, 09/07/24, 09/29/24, 10/03/24, 10/08/24, 10/12/24, and 10/17/24. R60's Fall Investigation (dated 08/01/24) documents R60 was found on the floor after ambulating unassisted in her room. This same investigation documents, Care plan reviewed and updated. R60's current care plan has no mention of R60's 08/01/24 fall, or a new intervention implemented following this same fall. R60's IDT (Interdisciplinary Team) Evaluation Note (dated 08/01/24) documents, (R60) had a fall with no complaints of pain or injuries sustained. She was ambulating unassisted in her room. (R60) continues to be impulsive, transfer and ambulate unassisted, and has repeated falls related to severe Alzheimer's Disease. She enjoys spending time in her room which already addressed in the problem and will frequently shut her door. Care Plan reviewed and remains appropriate, continue with plan of care. On 10/31/24 at 10:30 AM, V12 (Care Plan Coordinator) stated R60's care plan was reviewed after her 08/01/24 fall, however, no increase in supervision or additional fall prevention intervention was implemented at that time. R60's Fall Investigation (dated 08/14/24) documents R60, attempted to get out of bed unassisted when she lost her balance and fell . R60's current care plan has no mention of R60's 08/14/24 fall, or a new intervention implemented following this same fall. R60's IDT Evaluation Note (dated 08/14/24) documents, Care Plan reviewed and appropriate, continue with plan of care. On 10/31/24 at 10:35 AM, V12 stated R60's care plan was reviewed after her 08/14/24 fall, however, no increase in supervision or additional fall prevention intervention was implemented at that time. As of 10/31/24, R60's medical record did not contain documentation that new fall prevention interventions were implemented after R60's 8/1/24 or 8/14/24 fall.

Based on interview and record review, the facility failed to ensure a resident with a new diagnosis of mental illness was referred to the state agency for a level II PASARR (Preadmission Screening and Resident Review) evaluation for one of one resident (R3) reviewed for PASARR screening in the sample of 46. Findings include: R3's current electronic medical record profile and Face Sheet, documents R3 was admitted to the facility on [DATE] and diagnosed with Schizophrenia on 2/19/24. R3's most recent Level I PASARR evaluation, dated 3/17/22, documents at the time of evaluation R3 had mental health diagnoses of: Major Depression, Paranoid personality, and Anxiety. R3's medical record does not document that R3 has had any further PASARR screening or evaluation since R3's new diagnosis of Schizophrenia in February 2024. On 10/30/24 at 11:42 AM, V8 (Social Service Director) stated We switched over to a new system of PASARR screenings in 2022. (R3) had an onsite evaluation in March of 2022. At that time (R3) did not have the diagnosis of Schizophrenia. That diagnosis was added in February of 2024. I am not sure when I am supposed to redo her PASARR screen. I am going to have to call them and find out. I am thinking it should have been re-done in February with the new Schizophrenia diagnosis.

Based on observation, interview, and record review the facility failed to ensure a call light was within reach for two of 32 residents (R8 and R20) reviewed for call lights in a sample of 46. Findings include: The facility's Call Light policy, revised 01/04, documents to be sure call light is within reach before leaving the room. 1. On 10/28/24 at 11:30am, R20's call light was on the floor at the head of the bed. R20 was on the other side of the bed attempting to stand up. R20 stated that she wanted to go to bed but did not know where her call light was. 2. On 10/28/24 at 11:35am, R8 was in a reclining chair by the door to the room. R8's call light was hooked to the sheets, under the blanket, on the opposite side of her bed. R8 was unable to find her call light. On 10/28/24 at 11:35, V6, Certified Nursing Assistant, was stopped when walking down the hall and asked to assist R20. V6 verified that R20's call light was on the floor and should be within R20's reach. V6 also verified that R8's call light was not within her reach. On 10/29/24 at 1:45pm, V2, Director of Nursing, stated that it is the facility's expectation that the call light be within reach, prior to staff leaving the room.

Based on observation, interview and record review the Facility failed to provide supervision for one of three Physical Disability/Intellectual Disability Residents (R1) reviewed for assistance to Doctor's appointments. Findings include: Facility Notice of Privacy Practices Policy, dated 10/23/17, documents: we will use your health information for regular operations; members of the medical staff, risk/quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case; the information will then be in an effort to continually improve the quality and effectiveness of the health care and services we provide. Residents' Rights for People in Long-Term Care Facilities, revised 10/2014, documents: the Facility must provide services to keep your physical and mental health, and sense of satisfaction; and your Facility must make reasonable arrangements to meet your needs and choices. R1's Physician Order Sheet/POS, dated 4/12/24, documents that R1 admitted to the facility on [DATE]. R1's diagnoses include: Cerebral Infarction, Contusion of the Left Lower Leg, Hemiplegia and Hemiparesis, Cognitive Communication Deficit, Dysphagia, Muscle Weakness, Intellectual Disabilities, Pacemaker, Lack of Coordination and Abnormal Posture. R1's POS also documents Physician Orders for an Indwelling Suprapubic Urinary Catheter, Mechanical Soft/Thin Liquid diet and an Orthopedic office visit scheduled for 3/25/24 at 3:15 pm, with a local vehicle transport company to transport and pick up R1 from the Facility on 3/25/14 at 2:30 pm. R1's Minimum Data Set/MDS, dated [DATE], documents: Section B, R1 always needs assistance with reading instructions or written material; Section C, Brief Interview for Mental Illness/BIMS score documents R1 is Severely Cognitively Impaired (BIMS score is 0/15); Section F, R1 is rarely/never understood; Section GG, R1 unable to perform Activities of Daily Living, walk/step up or down stairs, unable to transfer in and out of a car on a passenger side. R1's current Care Plan, documents: R1 is at risk for pain related to recent Left Thigh Hematoma and staff to monitor for non-verbal signs and symptoms of pain,; Anxiety and Mild Depression; Risk for falling related to Intellectual Disability, Development Disorder of Speech and Language, Incontinence, Poor Mobility with Right Sided Weakness post Cerebral Infarct/Stroke; and has an indwelling suprapubic catheter that increases the risk for tripping; and is nonverbal except for occasional yes or no questions. R1's Nursing Notes, dated 3/25/24 at 1:02 pm, document a telephone conversation with V7 (R1's Nephew/Guardian). V7 stated V7 was unable to accompany R1 to appointment (on 3/25/24) and that R1's appointment needed to be rescheduled. R1's Nursing Note, dated 3/25/24 at 1:13 pm, documents a telephone conversation with R1's Orthopedic Doctor's Office, and the Doctor's Office still want to keep today's appointment, aware of (transportation service) set up. R1's Nursing Note, dated 3/25/24 at 6:01 pm, documents R1's return from the Doctor appointment back to the Facility. R1's letter from the Orthopedic Doctor office, dated 3/5/24, documents an appointment reminder for 3/25/24 at 3:15 pm. R1's General Physician Order, dated 3/5/24, documents an Orthopedic Doctor appointment scheduled for 3/25/24 at 3:15 pm, and a 2:30 pm transport pick up time. On 4/12/24 at 11:05 am, R1 was supine in bed and unable to follow commands and was non-verbal. On 4/12/24, at 10:01 am, V7 (R1's Guardian/Nephew) stated, I spoke with the Facility on 3/25/24 and told them that I was unable to go to my Uncle's appointment with him that day. I work swing shifts and my schedule conflicts with some of these appointments. I called them and told them that they were making appointments and not asking me when I was available to go with him. On 4/12/24 at 9:18 am, V4 (Orthopedic Doctor's Registered Nurse) stated, (R1) was sent to our office for a 3:15 pm appointment and was transported by a local transport company. The local transport companies just wheel the patient's in and leave them. (R1) was sitting in the waiting room and was non-verbal and unable to do anything for himself. We noticed (R1) trying to propel (R1's) legs in the wheelchair, and was kicking (R1's) legs off of the floor, and we thought (R1) was going to fall out of the wheelchair. So we had someone sit with him. (R1) also had a catheter bag, that was uncovered and dragging the floor. We did not know if (R1) was thirsty or needed bathroom assistance either. (R1) came for a follow-up appointment for an abscess on (R1's) left leg. (R1) did not have any paperwork on (R1) and when we called out for (R1's) name, (R1) could not respond or even help get himself in for the exam. Then, around 5:00 pm, the transport company called and told us that they were going to be late picking (R1) up, and at this point everyone had left the office and no one was in the building, so I had to stay with (R1) until they came to pick (R1) up. (R1) would have sat in our office for a couple hours with no supervision, had I not been there to help. I was worried something bad was going to happen to him. On 4/12/24 at 9:08 am, V6 (Registered Nurse) stated, (V7) forgets appointments a lot of times and when (V7) could not go to the 3/25/24 appointment with (R1), I called the Doctor's office and they told us to still send (R1). We did not even think about having someone go with (R1). On 4/12/24 at 8:50 am, V3 (Assistant Director of Nursing) stated, (R1) had an Orthopedic Doctor's appointment on 3/25/24 and (V7/R1's Nephew/Guardian) had told us that he was unable to go with (R1) to that appointment. So we called the Doctor's office and they told us to send (R1) anyway. Looking back we probably should have not sent (R1) alone. We normally send a Shift Coordinator or another staff member to Doctor appointments with Resident's that need assistance, that do not have a family member available to go with them. On 4/12/24 at 9:58 am, V1 (Administrator) stated, Once we found out (V7/R1's Nephew/Guardian) was not able to go that appointment, we should have probably sent one of our staff members to go with (R1). We normally will send staff to Doctor's appointments for the Residents that need supervision for safety, that are like (R1) that are non-verbal and cannot perform Activities of Daily Living (ADL's). I have plenty of staff available to go on appointments, especially knowing that (V7) missed a lot of (R1's) other appointments, we should have made different plans to have someone go with (R1).

Based on observation, interview and record review the facility failed to prevent abuse facilitated through social media for three of three residents (R1, R2, R3) reviewed for abuse. Findings include: Facility Policy/Abuse Prohibition and Reporting dated/revised 11/28/19 documents: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of physical or chemical restraints. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mental abuse also includes, but is not limited to, abuse that is facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident(s). Facility Policy/Social Media Policy dated 10/20/21 documents: Examples of information that should not be disclosed on social media include: Photographs. Incident Investigation timeline indicates on 5/17/23 at 11AM, an email was sent to the facility's Marketing Director regarding a social media post of three current facility residents. Timeline indicates the Marketing Director immediately notified V1, Administrator and V2, DON (Director of Nursing) of the email. Email dated 5/17/23 at 10:05 AM indicates videos were seen on a social media site of V4, Resident Aide taking videos of himself arguing with residents, making fun of their appearance and winding up as if to punch them. The email had the videos attached to the email. On 5/25/23 at 12:45 AM, social media video's posted by V4 showed pictures of R1 and R2 sitting at a table in a facility dining room and another video of V4 wearing a facility designated name tag and shirt with the caption [NAME], I'm high as F**K, arguing with theses Niggers. Another video shows V4 pretending to punch R3 in the face but does not actually make contact. R3 does not appear to be aware of V4's actions. Signed Statement (undated) indicates V4 stated he posted the videos as a joke and only believes it would be considered abuse if he actually struck (R3). V4 stated that he was only Joking that he was high and was talking to the residents like his friends. Statement includes I was joking with no ill intent. I know this is very serious. I was not trying to humiliate them - I was sending it to my friends as a joke. I see how it was seen that way. I understand that this was inappropriate. I heard last night the videos were going around. On 5/25/23 at 1:30pm V1, Administrator stated that V4 was interviewed by the police and then terminated from employment. V1 stated that R1, R2 and R3 all had diagnosis of Dementia and were unaware of the social media posts or comments by V4.

Based on observation, interview, and record review, the facility failed to ensure stored food was labeled and dated. This failure has the potential to affect all 89 residents at the facility. Findings include: The facility's Food Storage and Labeling Procedure Policy (Revised 9/2022), documents The label should include: 1. Product name: Even if you can see the product/leftover through the plastic wrap or lid, you must label the container or re-sealable bag with the product name; 2. Date: Document the date that the product is placed in the refrigerator; 4. Staff initials: Every label must include the initials of the staff member preparing the item/leftover to be refrigerated; and Nonperishable items removed from the original container should be placed in a covered container and marked with the name of the product and date opened. On 9/27/22 at 9:30am, a clear plastic bag half filled with egg noodles in the facility's Dry Storage Room was not labeled or dated. V7 Certified Dietary Manager (CDM) stated that the egg noodles should have been labeled and dated when the product was first opened and was not sure when the bag was opened and left in the Dry Storage Room. On 9/27/22 at 9:30am, there were five serving bowls containing chopped peach fruit in the Walk-In Cooler, which did not have labels or dates. V7 CDM stated, These should have been labeled and dated. V7 stated that she did not know when the fruit bowls were placed in the Cooler. The Resident Census and Conditions of Residents (Centers for Medicare and Medicaid Services/CMS 672) form, dated 9/27/22, documents 89 residents reside in the facility.

Based on observation, interview, and record review the facility failed to identify targeted behaviors for one (R1) of eight residents reviewed for [CONDITION(S)] medication usage in the sample of 33. Findings include: The facility's Psychopharmacologic Drug Usage Procedure, revised 10/18/17, documents A Psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety meds (medications), and sedatives/hypnotics. Documentation of behaviors and conditions requiring the use of these medications must be done on a routine basis, as well as medication response and adverse consequences. The Physician Order Report for R1, dated 09/01/2022 - 09/30/2022, documents R1 has the following diagnoses: Delusional Disorders, Major Depressive Disorder, and Generalized Anxiety Disorder. This same report documents the following dated physician orders for R1: [MEDICATION(S)] 50 mg (milligrams) one tablet by mouth once an evening for Delusional Disorders; [MEDICATION(S)] 1 mg (milligram) by mouth at bedtime for Generalized Anxiety Disorder; and [MEDICATION(S)] 40 mg (milligrams) one tablet by mouth daily for recurrent Major Depressive Disorder. The Behavior Committee Recommendation form, revised 6/27/19, documents Review Date for R1 as 8/30/22. This form documents R1 started [MEDICATION(S)] 25 mg, [MEDICATION(S)] 1 mg, and [MEDICATION(S)] 40 mg on R1's admitted [DATE] and R1's [MEDICATION(S)] was increased on 6/14/22 to 50 mg daily. This form also documents NONE for Behavioral Symptoms, Mood Symptoms, and Other indications. The Behavior Analysis Report for R1, dated 5/21/22 - 9/28/22 does not list any targeted behaviors for staff to be monitoring R1 for. This same Report does not document R1 having any behaviors between 5/21/22 - 9/28/22. On 9/27/22, 9/28/22, and 9/29/22, from 8:30 am through 4:00 pm, there were no exhibited behaviors observed and none reported for R1. On 9/28/22 at 8:30 am R1 stated that she takes the same medications that she took when she was at home and has taken these for a long time. R1 stated she has not had any problems. On 9/30/22 at 10:30 am, V2 DON (Director of Nursing) stated that R1 was admitted to the facility on [DATE] with physician orders for [MEDICATION(S)], [MEDICATION(S)] and [MEDICATION(S)]. V2 stated R1's [MEDICATION(S)] was increased after admission because (R1) said she took a higher dose at home. V2 DON stated she does not know what target behaviors R1 exhibited prior to admission and would have to check R1's hospital record to see if there was anything documented. V2 confirmed R1's Behavior Analysis Report does not document any targeted behaviors for staff to be monitoring for R1. On 9/30/22 at 11:00 am, V2 DON stated the facility's Electronic Health Record system was not set to include resident targeted behaviors for any of the residents. V2 DON stated that she does not have any other documentation to provide that shows targeted behaviors to be monitored for R1.

Based on observation, interview, and record review, the facility failed to ensure a resident's room was set up for ease of moving around the room, getting in and out of the bathroom, and for finding frequently used items for one resident (R9) of 18 reviewed for environment in a sample of 33. Findings include: The facility's Residents' Rights for People in Long-term Care Facilities, undated, states You have the right to .participate in your own care .Your facility must make reasonable arrangements to meet your needs and choices. R9's current Care plan includes the following: R9 is blind, has a suprapubic catheter, bilateral nephrostomy tubes, bowel incontinence (wears brief), and staff are to ensure items are to be within R9's reach . On 9-28-22, at 10:07am, R9 sat in a wheelchair in R9's room. R9's bathroom door is currently held open by the wall light switch. A high-back reclining wheelchair is parked at the foot of the other (empty) bed in the room by the window. R9 stated I am totally blind and can't see light from dark. I have been blind since age six. On 9-28-22, between 10:15am and 10:45am, R9 stated the following: I wish my bathroom door would stay open. The light switch is what keeps it open. I've asked different people to get a door stop and nothing happens. I talked to maintenance yesterday and he said he'd look into it. I use the bathroom to put my teeth in, wash up. I've gotten caught with the door going in and it makes it difficult to get out and I have to fight the door. It is frustrating. R9 confirmed that R9 does not need the bathroom for toileting so privacy is not needed. I would prefer the door to stay open. R9 continued to state I wish they would get that other wheelchair out of here (my room). It is usually kept in my bathroom and in my way. It gets moved .I've gotten tangled up in the chair moving over there to get to the call light on the other side of my bed. On 9-28-22, at 2:05pm, V9 Certified Nursing Assistant/CNA confirmed that R9's high-back wheelchair was in R9's room over by the window and stated It is supposed to be placed neatly in (R9's) room. At times it is in (R9's) bathroom; (R9) will use the bathroom to put his dentures in or take them out and to wash his hands. On 9-29-22, at 8:50am, V5 Maintenance Director stated the following: (V5) is unaware of (R9) wanting (R9's) door kept open and (R9) did not speak to (V5) about that. All of the bathroom doors are on spring hinges and automatically close. They don't stay open unless blocked open, but then it is a privacy issue .I could just take the pin out of the hinge and would gladly remove it. At this time V5 looked for and didn't find any work orders. V5 verified that R9's door was currently propped open using the light switch. On 9-29-22, at 9:05am, V8 CNA stated We set (R9) up to clean his dentures and (R9) uses the bathroom to wash (R9's) hands. (R9) needs it (the bathroom door) open. We use the light switch to hold it open. I have told maintenance and so has (R9) .I did not put a work order in. On 9-29-22, at 9:30am, V4 Social Service Director/SSD stated that (R9) has not mentioned wanting (R9's) bathroom door always open, but that makes sense. (R9) likes to brush his teeth and is very independent. On 9-30-22, at 09:05am, R9 was self-propelling R9's wheelchair from the dining room to R9's room using the wall railing with R9's left hand to guide him. R9 came to a stop when R9 bumped into a mechanical lift that was parked along the same side of the hall where R9's room is located. V10 CNA called out for R9 to stop. V10 CNA stated that R9 usually will self-propel to R9's room .the (mechanical lift) is supposed to be on the other side of the hall. On 9-30-22, at 9:15am, R9 self-propelled over to the large garbage can by R9's door to the hall and emptied R9's razor out. Then R9 self-propelled to the far side of R9's bed and turned on the call light. R9 bumped into, then picked up a small waste can sitting in front of R9's bedside table, dragged it over to the other side of (R9's) bed, bumping into the foot of (R9's) bed several times while trying to maneuver around it. V10 CNA entered R9's room, asked what R9 needed, and asked R9 why he moved R9's waste can. R9 told V10 that R9 wanted to get in bed. R9 stated R9 didn't know why the waste can got moved over by the dresser and that it is supposed to be over here. On 9-30-22, at 9:30am, after putting R9 to bed, V10 CNA turned out (R9's) lights (per R9's request,) closed the bathroom door and left the room. V10 stated that when (R9) is out of bed they will open the door back up. V10 stated that R9 will go in and out of the bathroom to wash his hands and face so the bathroom door should be open. On 9-30-22, at 9:40am, R9 stated that R9 uses the small waste can to empty his razor in. I found it (the waste can) over by the dresser when I was looking for something else. When they move things in my room then it is lost to me. On 9-30-22, at 10:07am, V2 Director of Nursing/DON stated the following: (R9) can self-propel from the dining room to (R9's) room. (R9) may have to have help if (R9) gets too tired. We have to assist (R9) with knowing where things are. We don't like to move things so (R9) knows where they're at. V2 agrees that R9 wants to be more independent. Normally the hall is clear. The mechanical lift should not be on (R9's) side, it should be on the opposite side of the hall. (R9's) wheelchair is usually kept in the shower in (R9's) bathroom and out of (R9's) way. I'm not sure why it is at the end of the other bed. (R9) uses (R9's) bathroom; staff set (R9) up. (R9) doesn't need privacy since (R9's) not toileted. V2 agreed that R9 needs easier access to getting in/out of R9's bathroom and that it is not currently a good set up. We are looking into it.

Based on observation, interview and record review, the facility failed to post the current licensed staffing information with actual nursing staff working. This has the potential to affect all 89 residents residing in the facility. Findings include: On 9-28-22, at 11:00am, the facility's Daily Staffing sheet was posted on a bulletin board near the nurse's station and dated 9-28-22. On 9-29-22, at 1:00pm, V3 Assistant Director of Nursing/ADON stated that V3 does the CNA (Certified Nursing Assistant) schedule, but it is not V3 who makes the changes to the Daily Staffing sheet. V3 believes it is (V6 Human Resource/HR Director) who does. On 9-29-22, at 1:10pm, V6 HR Director produced 18 months of the Daily Staffing sheets in a binder. V6 confirmed at this time that the Daily Staffing sheets do not show any indication of staffing changes. V6 stated that V6 creates each Daily Staffing sheet from the current schedule and does not make changes to it. On 9-29-22, at 1:12pm, V3 ADON stated that there were call offs on 9-28-22 that are not reflected on the Daily Staffing sheet dated 9-28-22. V3 confirmed that there are other dates with changes to the schedule also. On 9-29-22, at 1:15pm, V2 Director of Nursing/DON, V3 ADON, and V6 HR Director all confirmed that none of the Daily Staffing sheets reflect the actual staff working. V3 stated it does not reflect any call-offs or agency. V2 stated that V2 does not update it on a daily basis to reflect changes. The facility's Resident Census and Conditions of Residents Centers for Medicare and Medicaid Services (CMS) dated 9-27-22, documents 89 residents currently reside in the facility.

Based on interview and record review, the facility failed to implement new fall interventions following a fall subsequently resulting in further falls for three of three residents (R1, R2 and R3) reviewed for falls in a sample of three. Findings include: The Facility's Resident Accident and Incident Reports log was reviewed dated February 2021 through April 2021. This log documents R1 did not endure any falls, R2 endured seven falls and R3 endured thirteen falls. The Facility's Matrix for Providers documents the following regarding R1's Fall status: FMI, (Fall Major injury). The Facility's Serious Injury Incident Report dated 4/27/2021 documented the following: Fall with physical harm. 1. R1's Safety Event-Falls form dated 5/5/2021 at 7:48 pm documents the following: Sitting on floor in room. R1's Safety Events-Falls form dated 5/6/2021 documents the following: Witnessed fall. R1's current Care Plan documents the following: Problem start date: 4/19/2021 (R1) is at risk for falling. This care plan documents fall goals and approaches and does not document an approach for the alleged fall that occurred on 4/27/2021. On 5/10/2021 V2, DON. (Director of Nursing) stated (R1) came from assisted living, and he had falls there and would get himself up. Due to (R1) having a history of falls, I concluded there was a fall that led to his [CONDITION(S)] on 4/27/2021. V2, DON stated, I did my own investigation and did not not complete a fall event form in the computer for 4/27/2021. V2 stated there were no interventions put in place after 4/27/2021 and no new interventions were implemented until 5/5/2021. 2. R2's Safety Events-Falls forms document that R2 had an unwitnessed fall in her room on the following dates: 2/27/2021, 3/12/2021 at 9:57 am and 6:20 pm, 3/16/2021, 3/23/2021, 3/25/2021, 4/2/2021, and 5/4/2021. R2's Safety Event-Falls form dated 3/16/2021 documents R2 was trying to find her cats. This same form documents the following Interventions for this fall: rest, increased toileting. On 5/10/2021 at 1:57 pm V2, DON, (Director of Nursing) stated the following: The intervention of 'rest and increased toileting' for the fall on 3/16/2021 'made no sense considering the resident was looking for her cats'. V2 also confirmed the same interventions were used for falls on the following dates: increased toileting was used on the falls that occurred on 3/16/2021, 3/25/2021 and 4/2/2021; fall mats were used on the falls that occurred on both falls on 3/12/2021, 3/25/2021 and 4/2/2021; and low bed was used for both falls on 3/12/2021, 3/25/2021 and 4/2/2021. 3. R3's Safety Events-Falls forms document R3 had unwitnessed falls on the following dates and times: 2/6/2021 at 6:15 pm, 2/7/2021 at 4:00 pm with an intervention to use a non slip seat cushion, 2/11/2021 at 12:53 pm with an intervention of a low bed, 2/15/2021 at 7:30am, 2/17/2021 at 1:20 pm, 3/5/2021 at 1:46 am, 3/19/2021 at 12:58 pm with an intervention of a low bed, 4/3/2021 at 7:50 pm, 4/8/2021 at 7:53 pm with an intervention of a low bed, 4/13/2021, 4/17/2021 with an intervention of a non slip seat cushion, 4/25/2021 with an intervention of a low bed and 4/29/2021. R3's current care plan documents the following: Fall problem start date 8/24/2021. On 3/10/2021 at 1:57 pm V2, DON (Director of Nursing) verified new fall interventions were not implemented following R3's falls.

Based on interview and record review, the facility failed to ensure an injury of unknown origin was immediately reported to the State Agency for one of three residents (R1) reviewed for falls in the sample of three. Findings include: The Facility's Abuse policy dated 11/28/19 documents the following: The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat residents' symptoms. Investigation-interviews with all parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have information related to the incident. This same policy documents the following: F. Injuries of Unknown Sources-Suspicious injuries of unknown source, including, but not limited to, significant bruises, fractures, dislocations, lacerations, abrasions, contusions, lumps and/or swelling shall be reported immediately to the shift nurse, the Director of Nursing (DON) and the Administrator. The shift nurse shall document the nature of the injury in the resident's medical record and assure the Director of Nursing and Administrator is informed of the injury. The Director of Nursing or designee shall complete the Resident Accident & Incident Tracking log including all information listed. The shift nurse shall inform the resident's attending Physician of the injury. The Administrator or designee shall assure that (State agency) is notified of serious injury of unknown source. The Administrator or designee shall investigate all serious injuries of unknown origin. R1's MDS (Minimum Data Set Assessment) dated 4/27/2021, Section C, Cognitive status documents R1 has a memory problem and has modified independence in daily decision making. R1's current progress notes document the following on 4/19/2021 at 11:00 a.m. by V8, RN, (Registered Nurse) Admission Note/ (R1) was admitted to the long term care facility from Assisted Living/Memory Care via staff with wheelchair. (R1) was alert with some confusion noted but able to make his needs/wants known. R1's current progress note on the same date at 11:54 am documents the following by V8, RN: (R1) awake, alert and oriented to self. Ambulates self, gait steady. (R1) denies any discomfort. R1's progress note dated 4/27/2021 at 9:47 am documents the following: (R1) denies any pain or discomfort when asked, but during ROM (Range of Motion) (and) transfers (R1) noted to grimace (and) moan. (R1) able to point out pain to right knee during ROM (and) WB (weight bearing), but unable to verbalize area of pain at rest. PRN (as needed) Tylenol administered with some effectiveness noted. (R1) resting in recliner with feet elevated at this time. Will continue to monitor. R1's progress note dated 4/27/2021 at 4:27 pm documents the following: Received RT (right) hip & pelvis Xray results: Findings highly suspicious for a right femoral neck fracture as discussed above. Call placed to (R1's Physician) office and notified of results, received order to send to ER (emergency room ) for evaluation and treatment. Requested Xray be sent to office, results sent per request. An undated, untitled form provided by the DON (Director of Nursing) documented the following regarding R1: admitted [DATE]. 4/21/2021 (R1) noted to have signs of occasional discomfort to right knee. DON was notified and assessed resident with no signs of discomfort at time of assessment. MD (Medical Doctor) and POA (Power of Attorney) notified of discomfort. When interviewing staff, no known falls were noted. Resident is independent with all cares and ADLs (Activity of Daily Living). No redness, swelling or bruising noted to (R1). When interviewing (R1), (R1) was unable to state any potential injury due to advanced Dementia. Resident has a fall hx (history) prior to admission. 4/23/2021 (R1) continues with discomfort. MD updated. Order received for Xray of right knee, lower leg and foot due to discomfort. Results returned no acute fractures and [CONDITION(S)] changes noted. 4/27/2021 (R1) upon continued assessment no discomfort was noted when asking resident. Staff noted facial grimacing. Update called to MD with order for Xray of right hip and pelvis. (Local X-ray service) stated suspicion for right hip fracture with resident transferred to ER (emergency room ) for more in depth follow up. The facility's Serious Injury and Incident Report documents the following: Report Type: Initial and Final, Incident date: 4/27/2021, report date 4/29/2021 On 5/11/2021 at 11:18am V4, LPN, (Licensed Practical Nurse) stated the following: On 4/27/2021 we did ROM (Range of Motion) on (R1) and when we did abduction, he moaned so I called the doctor to give an update and we obtained orders for x ray. Results came back possible femur fracture so we got ready to send to ER (emergency room ). (V4, LPN) stated that V4 was not aware of any falls here. (V4) stated that V4's speculation was that R1 possibly fell and got himself up. He was independent and not standby assistance. On 5/12/21, V2 (Director of Nursing) verified that R1's suspected fracture was discovered on 4/27/21 following an x-ray of the right hip and pelvis. V2 verified that V2 did not report R1's fracture and possible fall to the State agency until 4/29/21

Based on observation, interview, and record review, the facility failed to ensure maintenance staff removed contaminated Personal Protective Equipment (PPE) upon exiting a resident's room and the COVID-19 unit, and failed to ensure housekeeping staff wore an N95 respirator while cleaning a resident's room for two of four residents (R1, R4) reviewed for infection control in the sample of four. Findings include: The facility's Infection Control policy and procedure (revised 12/17/19)/Transmission-based Precautions documents Gowns are to be worn by all personal when they enter a strict isolation room, They are worn only once and then discarded in appropriate containers before leaving contaminated areas. 1. R1's laboratory report dated 12/11/20 documents she is positive for COVID-19 infection, and R1's physician orders [REDACTED]. On 10/15/20 at 9:50am V5, Maintenance staff, exited R1's room on the COVID-19 unit wearing contaminated PPE, and while still wearing the same contaminated gown, N95 respirator, goggles, and without performing hand hygiene, walked out of the COVID-19 unit and through the recovery COVID-19 unit. At this time, the zippered plastic wall housed a sign instructing staff to remove their contaminated N95 respirators when exiting the COVID-19 unit. On 10/15/20 at 11:50am, V5 stated he was in R1's resident room checking the heater. V5 stated he wore an N95 respirator, goggles, face shield, and gown. V5 stated I forgot to take off the gown, shield, and switch the N95 mask to a clean one. V5 stated he removed his PPE in the prep room outside the recovery COVID-19 unit and washed his hands at the sink at the nurse's station. On 10/16/20 at 2:28pm, V3, Maintenance Director, stated V5 was supposed to remove his PPE when he left R1's resident room and the COVID-19 unit. V3 stated V5 has been trained on how the PPE is supposed to be used. Inservices and sign in sheets provided by V1, Administrator, on 12/16/20 documented V5 received training on the proper use of PPE and hand washing on 12/3/20, and removing and replacing the N95 respirator when leaving a COVID-19 positive or symptomatic unit on 12/15/20. 2, On 12/15/20 at 8:30am, V2, Director of Nursing and Infection Preventionist, stated it is the facility's policy that all staff are to wear N95 respirators in all resident areas. On 12/15/20 at 8:50am, R4 laid in his bed in his resident room on the dementia care unit while V6, housekeeper, cleaned his room. V6 wore a surgical mask, goggles, and gloves. At this time, V6 stated she had trouble breathing through the N95 respirator so she switched to the surgical mask. V6 stated she thought the policy had recently changed so that wearing a surgical mask while cleaning a resident room was acceptable. On 12/16/20 at 2:41pm, V4, Housekeeping and Laundry Supervisor, stated housekeepers are to wear N95 respirators in all resident areas, and that the policy had not changed. V4 stated she had reminded V6 to wear an N95 respirator in all resident areas earlier that morning (12/15/20) or the afternoon before (12/14/20). Inservices and sign in sheets provided by V1, Administrator, on 12/16/20 documented V6 received training on wearing an N95 respirator in all general care areas on 12/3/20.

Based on observation, interview and record review, the facility failed to attempt alternatives prior to the initiation of bed rails. This failure has the potential to affect 11 of 20 residents (R3, R35, R36, R43, R44, R48, R63, R72, R80, R91 and R150) reviewed for bed rails in the sample of 35. FINDINGS INCLUDE: The facility policy, Side Rails, dated 11/28/17 documents, It is the policy of the facility to ensure that side rails are not used unless an assessment to determine risk has been completed and it is determined that the side rails do not pose a danger to the resident. The facility will use appropriate alternatives prior to installing a side or bed rail. R3, R35, R36, R43, R44, R48, R63, R72, R80, R91 and R150's current Physician order [REDACTED]. R3, R35, R36, R43, R44, R48, R63, R72, R80, R91 and R150's current Restraint/Adaptive Equipment (Side Rail/Device Assessment/Consent) 2019 documents under, Are there alternatives to using side rails for this resident - No. On 08/27/19 at 09:20 AM R72 was lying in bed with bilateral half side rails in the up right position. On 08/27/19 at 09:54 AM R150 was lying in bed with the right side rail in the upright position. On 8/27/19 at 10:00 AM and 8/28/19 10:00 AM, R3 was lying in R3's bed with bilateral bed rails on R3's bed. On 8/26/19 at 11:25 AM and 8/28/19 at 1:40 PM, R80's bed was observed with bilateral bed rails in the upright position. On 8/27/19 at 1:00 PM and 8/28/19 at 10:00 AM, R91's bed was observed with bilateral bed rails in place. On 08/27/19 at 11:59 P.M., V2 (Director of Nursing/DON) stated, I don't know what alternatives were attempted prior to the use of (R48's) bed rails. I have no documentation of alternatives attempted prior to installing bed rails for any resident in the facility.

Based on observation, interview and record review, the facility failed to ensure the application of a splint for a resident with functional limitations for one of two residents (R48) reviewed for limited range of motion in the sample of 35 . FINDINGS INCLUDE: R48's facility Face Sheet documents that R48 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R48's current Physician order [REDACTED]. R48's Occupational Therapy Plan of Care, dated 6/27/19 documents, (R48) has been living at this SNF (Skilled Nursing Facility) and was independent in splint wearing and tolerance without pain. (R48) now presents with a decline in functional ROM of left wrist and fingers due to hypertonicity and weakness. (R48) started noticing a decrease in ROM (Range of Motion) approximately a month ago, which has since resulted in (R48) now requiring significantly more assistance for donning and doffing of left hand-wrist orthosis and wearing tolerance. Due to history [MEDICAL CONDITION] combined with type II DM (Diabetes Mellitus) that has previously been an issue with splint tolerance and skin integrity issues, (R48) will require skilled OT (Occupational Therapy) to adjust splint or obtain more appropriate splint and improve muscle tone and range of motion in order to reduce pain with wearing and donning/doffing. R48's Occupational Therapy Therapist Progress and Discharge Summary, dated 7/24/19 documents, Skilled services provided (to R48) since start of care included therapeutic exercises focusing on low load progressive stretching and passive range of motion and caregiver education for passive range of motion to the LUE, manual therapy focusing on joint mobilizations, grade I and grade II, orthotic (splint) management and training focusing on adjustment and fitting of new splint to support left wrist and fingers in optimal position to prevent further joint contracture, electrical simulation and ultrasound focusing on use of modalities for improving circulation and increasing tissue extensibility allowing for (R48) to achieve this improved level of ADLs. discharged to SNF. (R48) and (facility staff) instructed in FMP (Functional Maintenance Program). R48's current Care Plan dated 7/1/2011 documents, PROBLEM: (R48) has ADL (Activities of Daily Living) and mobility limitations r/t (related to) [MEDICAL CONDITION] with left sided [MEDICAL CONDITION]. (R48) has left hand contracture and has need to maintain RUE (bilateral upper extremity) and BLE (bilateral lower extremity) strength. Requires extensive assist of one with transfers and with bed mobility utilizing upper rails/enablers. APPROACH: PROM (Passive Range of Motion) Program, Splint/Brace: 1. Explain to (R48) what you are going to do. 2. Perform ROM (Range of Motion) to left hand and wrist. 3. Monitor for any signs of pain/discomfort (i.e. facial grimacing, guarding of extremity, withdraw of extremity, etc.), if signs of pain stop performing PROM and notify the nurse. 4. Apply resting dorsal splint to left hand. 5. Monitor skin for redness/skin breakdown around brace upon applying and removing, as well as, with cares. On 08/26/19 at 10:50 [NAME]M., R48 was seated in a wheel chair in R48's room. A contracture was present to (R48's) left wrist, hand and fingers. (R48's) fingers on the left hand were pinched together and (R48's) wrist was hyperflexed. (R48) was able to pry her wrist open a few degrees. At that time, (R48) stated, I am supposed to wear my splint at all times, but I have not worn it since Saturday. I even had to ask the girls to put it on then. They always forget to put it on. It hurts when they put it on, but it helps me. On 8/26/19 at 1:50 P.M., V6 (Certified Nursing Assistant/CNA) verified R48's splint was not applied as ordered by the physician. Additional observations of R48 on 8/27/19, 8/28/19 at 8:55 [NAME]M. and 12:44 P.M. showed no splint in place to R48's left hand.

Based on observation, interview and record review, the facility failed to implement ordered pressure reducing interventions for one of two residents (R3) reviewed for pressure ulcers in the sample of 35. Findings include: The facility's Pressure Injury Prevention and Treatment Protocol (7/2016) documents the following: To ensure that measures are taken to prevent skin breakdown and provide guidelines for treatment of [REDACTED]. A pressure injury is defined as a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. All high and moderate risk residents may have the following, and if so, they will be addressed on the Care Plan: Elbow/Heel protectors/Bridging of heels. Staff will be trained on pressure injury prevention and safety measures to be taken, including identifying redness that remains when pressure is relieved and proper positioning procedures. For those residents that cannot reposition themselves, transfer self out of bed or cannot turn and position themselves in bed, staff will be responsible for. Special devices will be used to relieve pressure. R3's Physician order [REDACTED]. These orders also document an order to ensure R3's heel are offloaded with two pillows at all times (heels not touching surfaces). R3's current electronic Care Plan documents R3 has a left heel pressure ulcer that developed on 4/2019. This care plan also documents that R3 is to have bilateral heel lift boots on at all times and that R3 should have pressure relieving devices on bed and chair as needed and as ordered. R3's Braden Scale for Predicting Pressure Sores (8/20/19) documents a score of 12 indicating R3 is high risk for skin breakdown. R3's weekly left heel pressure ulcer measurements (4/2019- 8/2019) were reviewed and document R3's left heel pressure ulcer improves and deteriorates intermittently. On 8/28/19 at 11:40 AM, V7 (Registered Nurse) performed R3's left heel pressure ulcer treatment. V7 removed R3's current dressing which revealed a large, half dollar, circular sized area on R3's left heel. This area was reddened around the edges with a pink/red center and small amount of clear and bloody drainage. The area was approximately 4 centimeters (cm) by 3 cm. On the following dates and times, R3 was observed in R3's high back wheelchair or R3's bed without R3's heels offloaded or R3's heel boots in place: 8/27/19 at 11:45 AM, R3 was sitting in R3's high back wheelchair with R3's heels touching the foot rest and not being offloaded and no heel boots on R3's feet; 8/27/19 at 2:00 PM and 3:00 PM and 8/28/19 at 10:00 AM, R3 was lying in bed with R3's heels not being offloaded and R3's heel boots not on R3's feet; and on 8/28/19 at 11:00 AM, R3 was sitting in R3's high back wheelchair with R3's heels not being offloaded and no heel boots on R3's feet. On 8/28/19 at 11:00 AM, V2 (Director of Nursing) verified that R3's heels were touching the high back wheelchair's foot rest and that R3's heels were not being offloaded as ordered. V2 also verified that R3's heel boots were not on R3's feet. V2 verified that R3's heel boots should be on at all times and R3's heels should be offloaded and not coming in contact with the foot rest.

Based on interview, record review and observation the facility failed to provide a safe transfer from the dining room to a resident's room by not using wheelchair pedals during a transport causing a fall with a fracture for one of three residents (R1) reviewed for accidents in a sample of three. This failure resulted in R1 sustaining a fracture of the third finger on the right hand and a hematoma on R1's forehead head. Findings include: On 4/2/2017 at 6:49PM, E4 Registered Nurse (RN) documented in R1's Progress Notes, Staff propelling res (resident) in w/c (wheelchair) from dining room when res' feet dropped to the floor. Res then fell out of w/c. Res fell head first onto the floor outside of dining room. Noted to land on R (right) head then R arm then R body. Moderate amount of blood on floor under head, lacerations noted on bridge of nose and R forehead. Res complained of pain to face. Unable to move head . Pupils equal and reactive. Res was not moved. Res sent to (hospital emergency room ). On 4/27/2017 at 12:30PM, E4 RN stated , I was in the dining room. I heard commotion and turned to see (R1) falling out of the wheelchair and E5, Certified Nurse Aide (CNA), standing behind (R1). (R1) had propelled herself to the dining room for supper and then (E5) started to push (R1) back to her room after supper. (R1) did not have foot pedals on her wheelchair. It is common practice here, if the residents propel themselves, they do not need foot pedals. If they need assist to be transported then they are to have foot pedals on. We cannot expect (the residents) to hold up their heavy legs for a long period of time without pedals. E5 knew this. On 4/27/2017 at 11:50AM, E6 CNA, who clarified she knew R1 well, stated, (R1) propels her wheelchair so when she does that (R1's) pedals are taken off. When we are transporting her, even short distances, we need to put on the pedals. That has been our policy for a long time. (R1) is capable of picking up her feet but not for a long period of time. On 4/27/2017 at 11:55AM, E3 Assistant Director of Nursing (ADON) stated, It is common practice that residents should have foot pedals on their wheelchair when staff are pushing them down the hall, even short distances. (E5) CNA who was pushing (R1) at the time of the fall was not a new CNA. She had been employed here for about six years. (E5) was aware this is a common practice. (E5) told me that she knew she was wrong but she did not think about it and started pushing (R1) without the foot pedals on. R1's current Care Plan documents R1 as having a [DIAGNOSES REDACTED]. On 4/27/2017 R1 has fading bruises over bilateral cheek bones and a splint on the right hand, third finger. R1 was not able to state what happened to cause these outward signs of a change in condition/injury. The emergency room reports dated 4/2/2017 document R1 had an acute fracture of the third finger on the right hand and a right frontal scalp hematoma.

Based on record review and interview the facility failed to maintain safety measures during a transfer for one resident (R1) of three residents reviewed for falls in a sample of three. This failure resulted in R1 sustaining a fracture of the distal right 11th rib. Findings Include: The Facility Policy titled Gait Belts dated 12/02, documents, It is the policy of the facility that all direct care staff shall use a gait belt when transferring or ambulating residents. All direct care staff will have a gait belt available for use with transfers. No staff will transfer or ambulate a resident by his/ herself if the transfer takes the assist of two. R1's MDS (Minimum Data Set) dated 11/8/2016 (R1's look back period), documents a BIMS (Brief Interview for Mental Status) of 15, R1 is alert and oriented and capable of answering questions appropriately. R1's MDS (Minimum Data Set) dated 11/8/2016 documents, R1 is extensive assistance of two physical assist to transfer. R1's Care Plan dated 11/2/2016 documents, (R1) is at risk for falls. The approach is to transfer and ambulate with assist of two at this time. On 11/6/2016 at 11:56 A.M., E3/ Registered Nurse documents in R1's Progress Notes, Noted to have a fall during transferring to W/C (Wheelchair) with staff, sat poorly on w/c, then fell to floor landing on right buttock and right elbow. Did not hit head and denies. AROM ( Active Range of Motion) performed with eases and equally. Denies any pain with ROM (Range of Motion). Assisted to wheelchair with full body lift. No injury noted at this time. Believes he (R1) fell due to wheelchair moved when sitting down. (R1) states is having pain to right buttock and left rib cage. Request to have an X-ray (Electromagnetic radiation).Call made to emergency contact and PCP (Primary Care Physician) for orders. On 11/6/2016 at 12:08 P.M., E 3/Registered Nurse documents in R1's Progress Notes, Z1/Primary Physician, return call to have X-ray (Electromagnetic radiation) done to right hip and left rib cage. Have them come out tomorrow to do them. As long as (R1's) vitals are stable, they can be done tomorrow. R1's Patient Report dated 11/7/2016 documents findings of X-ray (Electromagnetic Radiation). Acute Fracture of Distal Right 11th Rib with mild angulations On 11/7/2016 at 4:06 P.M., E5/LPN (Licensed Practical Nurse) documents in R1's Progress Notes, Received order from R1's MD/ Medical Doctor due to noted fracture 11th right rib, continue to monitor there is nothing else we are able to do. On 12/12/2016 at 12:00 P.M., E4/CNA (Certified Nursing Assistant) stated, I feel I got screwed over from this deal. I was dismissed because I had no gait belt. It was just me (E4) transferring him (R1) and he (R1) had a poofy pillow on his (R1) wheelchair seat. When (R1) went to sit down (R1) slipped out of the wheelchair and landed on the floor. I understand (R1) fell and fractured a rib because I (E4) was not using the gait belt.It wasn't my fault, the pillow slipped from the wheelchair causing (R1) to fall to the floor. On 12/12/2016 at 12:37 P.M., E2/ADON (Assistant Director of Nurses) stated, I interviewed the CNA/ Certified Nursing Assistant that was involved with this incident on 11/6/2016. CNA was not using a gait belt, and did not have any other staff member to assist with resident's (R1) transfer from the toilet to the wheelchair. R1's wheelchair brakes, the left side was locked and the right brake was not fully engaged causing the wheelchair to move, and causing the resident to fall on the floor landing on his (R1) right side, leaning against shower bench. He (R1) sustained a fracture of the right rib. On 12/12/2016 at 12:33P.M., E1/DON (Director of Nurses) stated, I expect the CNA's (Certified Nursing Assistant) to use a gait belt when transferring resident's and use two CNA'S when needed for transfer at all times. On 12/13/2016 at 11:08 A.M., Z1/Primary Physician stated, I think it is entirely possible that falling out of the wheelchair and landing on the floor, on right side, would cause him (R1) to sustain a fracture of the right rib. I am going to say Yes (R1's) fall caused R1 to fracture R1's rib.

Based on observation, record review and interview the facility failed to follow fall prevention interventions for one of nine residents (R2) reviewed for falls in the sample of 18. This failure resulted in R2 sustaining a fall with a femur fracture and subsequent above the knee amputation. Findings include: R2's current electronic facesheet documents the following Diagnoses: [REDACTED]. The facility's Emergencies policy (revised 5/2014) documents the following: Falls: Check the resident immediately for ability to move extremities; check for bruised areas and/or cuts . Check resident's ability to explain what happened; evaluate resident's condition before the fall . Check if, or with anyone who witnessed the accident. Determine, if possible, where, how, and when the accident occurred . Check for any apparent discoloration or possible fracture . The facility's Care Plan Policy and Procedure (revised 11/2013) documents the following: The care plan meeting provides a framework for providing good resident care and sets direction for meeting the needs of the individual resident . Secondly, it provides a valuable communication tool for staff to ensure that individual plan of care is carried out . Care plans are available to clinical staff online in the (Electronic Health Record). All non-clinical staff members are to contact the nurse for access to the care plan as needed. R2's care plan (dated 10/15/2015) documents the following: Problem start date: 3/26/2015. (R2) is at risk for falls related to dementia and osteoporosis, as well as, history of falls and hearing impairment . Approach start date: 4/28/15. Assist R2 with toileting needs, upon rising, before and after meals, and at bedtime to reduce incident of falls associated with toileting needs . Approach start date: 3/26/15. Alternate call system . Approach start date: 3/26/15. Floor mats at bedside when in bed. R2's Event Report (dated 7/2/15) documents the following: Description: Fall . Location of Fall: Resident bathroom . What was resident doing just prior to fall: propelling self in wheelchair . Why does resident think they fell : 'I (R2) was trying to clean my butt' . Was fall witnessed: No . Does resident exhibit or complain of pain related to the fall: Yes (location)- right knee/leg . Positioning of extremities: rotation/deformity/shortening of right lower extremity. R2's Investigation Report (dated 7/3/2015) documents the following: Interview with (E14, Certified Nursing Assistant). I (E14) had gotten (R2) up about 2:45 PM. I (E14) think it was about that time. (R2) was trying to get out of bed when we went by the room so I (E14) washed (R2) up and got (R2) up to (R2)'s wheelchair, I (E14) brought (R2) out of (R2)'s room and (R2) was propelling around the halls after that, I (E14) couldn't leave (R2) in (R2)'s room, (R2) is a fall risk . I (E14) did not toilet (R2) when I (E14) got (R2) up, (R2) goes right before supper, usually (R2) will tell you when (R2) does not want to go. I (E14) do not know if (R2)'s bathroom door was open or shut, but I (E14) have seen (R2) open it. R2's Investigation Report (dated 7/3/15) documents the following: Interview with (E21, Registered Nurse, previously employed by facility during occurrence). I (E21) think (R2) could've opened the bathroom door, I (E21) don't know if it was propped open or not. I (E21) think (E14) had just gotten (R2) up shortly before it happened and (R2) was propelling around the halls . When I (E21) got to the bathroom, (R2) was laying on (R2)'s back, head towards the shower, the toilet riser frame was in place and (R2) was lying supine with (R2)'s left foot and leg extended and (R2)'s right leg flexed, (R2)'s right foot was between the toilet riser frame and the toilet, (R2)'s leg was externally rotated . R2's Investigation Report (dated 7/2/15) completed by E2 (Director of Nursing) documents the following: Writer (E2) summoned to (R2)'s bathroom per (E21) for evaluation of (R2). (R2) was lying on back with head towards west (shower) and feet alongside of inner toilet at wall side, left leg extended and right leg flexed. (R2) complaining of right knee pain and unable to straighten, maintained flexed with pillow support . (R2)'s wheelchair was noted to be nearby, toilet riser had been removed before writer (E2) summoned to room. (E21) stated (R2)'s right foot was between toilet and riser. (R2)'s clothing was in place and (R2) was not able to be moved due to immediate complaints of pain when right knee indicated or questioned about, knee appeared swollen and discolored. (R2) unable to state purpose, intent, details of event at this time. Recommended (Emergency Medical Services) transfer to (emergency room ) per (R2)'s complaints of pain and swollen appearance of (R2)'s right knee. R2's local emergency room report (dated 7/2/15) written by Z1 (Emergency Department Physician) documents the following: Course Progress: X-ray of the knee shows what appears to be a supracondylar fracture just at the level of the proximal portion of the knee prosthesis with dislocation of the prosthesis . R2's Consultation report from a local hospital (dated 7/3/15) written by Z2 (Orthopedic Surgeon) documents the following: Reason for consultation: Right knee supracondylar periprosthetic femur fracture . (R2) apparently fell at the nursing home and was brought to the emergency room and found to have a distal femur fracture below a (prior) femoral revision stem and above a cemented total knee arthroplasty . I (Z2) had a lengthy discussion with (Z3, R2's family member) who is the power of attorney about (R2)'s condition. The options would be to treat this in a cast or knee immobilizer versus an open reduction internal fixation versus a conversion of the total knee arthroplasty to a cemented hinged knee type of arthroplasty. The pros and cons were discussed with (Z3). The cast and immobilizer would most likely be very painful to (R2) and it would make it very hard to care for (R2) as far as sitting (R2) up and getting (R2) into a chair. The option of trying to perform an open reduction internal fixation would be very difficult given the extent of (R2)'s osteoporosis and difficult to do a hinged total knee arthroplasty. The last option would be to perform an above the knee amputation. This would allow good patient care and hygiene. (R2) would have a lower chance of developing complications from not being able to mobilize (R2) such as decubitus ulcers and pulmonary conditions such as pneumonia. (Z3) did appear to understand. (Z3) discussed it with family and opted to go with an above the knee amputation. (Z2) will plan to do this. On 10/19/15 at 12:15 PM, R2 was sitting in R2's wheelchair with R2's right above the knee amputation stump resting on R2's wheelchair seat. On 10/20/15 at 12:00 PM, E8 (Certified Nursing Assistant) and E9 (Certified Nursing Assistant) used a mechanical lift to transfer R2 from R2's bed to R2's wheelchair. E8 provided support to R2's right above the knee amputation during R2's transfer. On 10/21/15 at 2:35 PM, E14 (Certified Nursing Aide) stated that on 7/2/15, E14 got R2 up from bed at 2:45 PM and performed perineal care. E14 verified that E14 did not toilet R2 at the time E14 got R2 up from bed. E14 stated that E14 then took R2 to the facility's day room because R2 was not supposed to be left unattended. E14 stated that R2 self-propelled back to R2's room and attempted to toilet independently. R2 then sustained a fall. On 10/21/15 at 11:30 AM, E2 (Director of Nursing) verified that R2's care plan at the time of R2's fall indicated that facility staff were supposed to toilet R2 upon rising from bed and before and after meals. E2 stated that E14 did not toilet R2 upon R2 getting up from bed at on 7/2/15 at 2:45 PM and if R2 had refused to be toileted, E2 would expect that E14 would have offered to toilet R2 again. On 10/22/15 at 12:35 PM, E24 (R2's Physician/Medical Director) stated that R2 sustained a right femur fracture as a result of R2's fall on 7/2/15. E24 stated that R2 had a prior right knee surgery and right prior hip surgery, and this femur fracture was located just above R2's previous right knee surgical hardware. E24 stated that due to the site of the right femur fracture sustained on 7/2/15, it was difficult to surgically repair and therefore it was decided that R2 would have a right above the knee amputation. E24 also stated that if R2 would not have fallen and sustained this right femur fracture, R2 would not have required a right above the knee amputation.

Based on interview and record review, the facility failed to serve food in a form to meet the resident's needs and the resident's Physician order [REDACTED]. This failure resulted in R2 choking on a piece of cut up chicken nugget and having to be transported to the local area hospital and admitted with foreign body airway obstruction. Findings include: The facility's incident notification to the State Agency, dated 5/2/15, documents on 5/1/15, R2 had a choking episode during the evening meal. This same notification documents that R2 started to have increased respiratory distress at 4:00 AM requiring transportation to the local area hospital and admitted related to a foreign body airway obstruction. R2's Nursing Progress Note, dated 5/2/15 at 4:25 AM, states, Resident in bed with head of bed elevated to approximately 45 degrees. Calls for 'Nurse, nurse' with labored respirations of 40. Barking quality noted. Vital Signs: 98.4, 100, 40, 160/90. Assistance provided to sit up at bedside. Oxygen titrated to four liters (L) with little effect on saturation with peripheral capillary oxygen saturation: 85% on 4 L oxygen. 911 called at this time to transport to emergency room . Resident on 6 L oxygen with non rebreather attempted but will not tolerate. The local area hospital history and physical examination [REDACTED]. In the emergency room it was noted that the patient actually had a chicken nugget which was taken out by forceps. The patient saturation was in the low 80's at the time of admission. The local area hospital Discharge Summary, dated 5/7/15 states, (This patient) was admitted with upper airway obstruction. (R2) had a chicken nugget removed by forceps in the emergency room by the emergency room physician. (R2's) white blood cell count on admission was 27,000. Upon discharge normal at 10,000 (patient was started on Levequin, [MEDICATION NAME], and Intravenous [MEDICATION NAME] antibiotics for post-obstructive pneumonia. R2's Physician order [REDACTED]. The facility's Diet Spreadsheet provided by E5 (Dietary Manager), undated, documents the facility supper meal for 5/1/15 for the mechanical soft diet order was ground chicken nuggets with sauce. The facility's Diet Manual, undated, documents that for the Mechanical Soft Diet, meat should be ground and served with gravy or sauce. The facility's witness investigation statement, dated 5/4/15, from E8 (Certified Nurse Assistant/CNA), who was involved with meal assistance for R2 on 5/1/15, states, (E8) knows (R2) has a mechanical soft diet order. (E8) was cutting up the chicken nuggets when the alarm on another resident was sounding. (E8) stopped cutting up the chicken and went to attend to the other resident. The facility's witness investigation statement, dated 5/4/15, from E7 (CNA), also involved with meal preparation for R2, states, (E7) knows that (R2) is a mechanical soft diet.(E7) served the meal and the kitchen was not notified of the lack of mechanical soft foods. On 5/12/15 at 2:03 PM, E7 (CNA) stated, (R2) is (on) a mechanical soft diet. When (R2) didn't like the tuna sandwich, (E8) told me to get (R2) chicken nuggets. I usually feed (R2) and (R2's) meat is usually grounded up. I thought that if it was cut small enough, it would count as mechanical soft. On 5/12/15 at 11:55 am, E5 (Dietary Manager) stated, On 5/1/15, the chicken nugget was the entree and tuna salad sandwiches were the substitution meal. Usually the residents with a mechanical soft diet order prefer the tuna because the ground chicken nuggets are dry, so my cook didn't mechanically alter any chicken nuggets for this unit. Since (R2) refused the tuna salad sandwich, (R2) was given chicken nuggets. (R2's) chicken nuggets for that meal were not mechanically altered, just cut by the Certified Nursing Assistant (CNA). For the Mechanical Soft Diet Order, the chicken nuggets should've been ground/mechanically altered and served with sauce because they are dry. On 5/13/15 at 1:25 PM, Z1 (R2's Physician) stated, I would've expected the chicken nuggets to be grounded/mechanically altered. Yes, the hospital discharge summary of post-obstructive pneumonia could be related to the choking incident. On 5/13/15 at 12:08 PM, Z2 (Registered Dietitian/RD) stated, It is this facility's policy that mechanical soft diet orders will be served ground meat with sauce and/or gravy. Meat cannot just be cut into small pieces. On 5/12/15 at 3:00 PM, E11 (Speech Language Pathologist/SLP) stated, In this facility, mechanical soft diet orders are ground meat with sauce and/or gravy. (R2) needs a mechanical soft diet order because of choking risk. Technically, (R2's) meat should not have been cut/chopped. It's no different than regular consistency if it's just cut.