Every finding on record at Mason City Area Nursing Home

Based on observation, interview and record review, the facility failed to promote and facilitate resident self-determination through support of a resident's choice of eating some meals in bed rather than in a wheelchair, affecting one resident (R2) in a sample of five residents. Findings include: On 7/21/2026 at 1:00 PM while speaking to R2, who was lying in bed with the tray table over her lap containing an unopened container of food, V8 (Registered Nurse) came into the room and stated R2 must get out of bed and into the wheelchair to eat the food on her tray table. R2 then stated, Here we go again. and that she doesn't like these rules. V8 stated that R2 is at risk for choking and that the facility does not want R2 eating in bed, even with the head of the bed elevated. On 7/21/2026 at 1:10 PM, R2, stated that facility staff do not allow her to eat meals in bed and that she must be sitting in the wheelchair for meals which makes R2 so mad. R2 states that her current medical conditions make sitting upright in a wheelchair for long periods of time physically uncomfortable. R2 stated that staff have told her she is at risk of aspiration pneumonia because of her history of pneumonia but feels she should still be able to eat in bed with the head of her bed raised to a safe position. On 7/22/2026 at 8:20 AM, V11 (Certified Nursing Assistant/CNA) stated she has always been told by nursing staff that R2 should be out of bed and sitting in a wheelchair for all meals until this morning (7/22/2026) when V11 states she was told by nursing staff she was to highly encourage R2 to eat all meals in a wheelchair but cannot force. On 7/21/2026 at 1:15 PM, V1 (Administrator) stated the facility does not have a dining policy or a policy that would explain why a resident must sit in a wheelchair rather than the bed while eating but states R2 has a history of aspiration pneumonia and chronic lung problems. V1 stated we encourage all residents to eat sitting up and in the dining room, but we cannot force them.On 7/22/2026 at 9:45 AM, V12 (Physical Therapist) stated R2 has not received, and has no orders for, speech therapy and is not aware of R2 having any swallowing difficulties. On 7/22/2026 at 9:45 AM, V13 (Occupational Therapist) stated R2 needs support while sitting but if the head of the bed was elevated it would provide the support needed. V13 stated R2 does not have limitations that would prohibit her from eating in bed if she had the support of the head of the bed being elevated behind her. On 7/22/2026 at 10:15 AM, V2 (DON) was unable to produce any resident assessments or physician orders to clarify why R2 would need to be in a wheelchair to eat rather than in bed. R2's Care Plan, dated 7/20/206, documents R2 is able to make her own meal choices and eats independently after plate set up. This care plan documents interventions which include ensure resident is in proper position and modify diet as appropriate according to Resident's food tolerances and preferences. The care plan does not mention R2 must remain in a wheelchair to eat, specify what the proper position is, document a risk of aspiration pneumonia or a risk for choking on food. The facilities Care Plan Process Policy dated 11/2017 documents the care plan shall meet the resident's preferences and goals, and address the resident's medical, physical, mental and psychosocial needs, while honoring resident rights to choice.

Based on observation, interview and record review the Facility failed to maintain Resident dignity and follow a personalized toileting plan of care to maintain urinary continence for a staff dependent mechanical lift for one of three Residents (R1) reviewed for toileting assistance in a sample of six. This failure resulted in R1 suffering severe mental anguish and emotional distress from being placed in incontinence briefs and not being offered toileting privileges.Findings include:The Facility Assessment, dated 4/7/26, documents the facility will provide bowel/bladder general care for bowel/bladder toileting programs, incontinence prevention and care, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity.The Certified Nursing Assistant Job Description, effective 9/14/18, documents: transfer resident utilizing appropriate assistive devices; assist residents in all activities of daily living; ensure Resident respect and dignity; provide maximum resident-care services to assure the well-being of resident to greatest degree; execute duties and responsibilities in conformance with established routine; assist with execution of resident assessment and plan of care; assure the mental well-being of Residents; assist with daily tasks such as toileting; and observe and report symptoms and changes in Residents.The Facility Resident Council Meeting Minutes, dated 5/18/26, document eleven Residents in attendance and Residents voiced concerns regarding response times after requesting assistance.The Facility Resident Council Meeting Minutes, dated 6/29/26, document 19 Residents in attendance and residents expressed concerns regarding timely response to call lights.The Facility Concern Form, dated 5/29/26 and signed by V1(Administrator) on 6/10/26, documents concerns that Residents state they have waited over an hour after pressing call light for assistance and an in-service began with Certified Nursing Assistants and Nurses on 6/1/26 and all departments.R1's current Care Plan documents: admitted to the facility on [DATE]; diagnoses including Right Side Cerebral Vascular Infarct; Radiculopathy Cervical Region, Adjustment Disorder, Biliary Tract disease, Left Artificial Knee Joint, Transient Ischemic Attack, Hemiplegia/Hemiparesis Right Dominant Side, Unsteadiness on Feet, Muscle Weakness, Abnormal Posture and Aphasia; toilet use requires maximum assistance of one staff member for participation to use toilet; occasionally incontinent of bladder; wears depends when going to outside appointments, when going to dining room and therapy; and prefers to not wear depends and prefers to wear personal underwear at times; provide consistency in care to promote comfort with Activity of Daily Living/ADL; maintain consistency in timing of ADLs, caregivers and routine, as much as possible; provide with opportunities for choice during care provision; allow to make decisions about treatment and regime to provide a sense of control; monitor/document bladder and bowel function; if incontinent monitor/document for appropriate bowel and bladder training program and implement; is here for short term Rehabilitation Therapy; plans to discharge to home when able with Home Health services if indicated; at risk for an ADL Self Care Performance Deficit related to recent joint replacement surgery and chronic obstructive pulmonary disease; risk for a decline in range of motion related to recent joint replacement surgery and chronic obstructive pulmonary disease as evidence by activity intolerance; at risk for a decline in bed mobility related to recent joint replacement surgery and chronic obstructive pulmonary disease as evidence by activity intolerance; requires moderate to maximum one person staff assistance with peri care and clothing management; Toileting schedule, staff is to assist and/or offer toileting assistance approximately every two hours to assist in having less than three episodes of incontinence during waking hours; transfer, utilizes a mechanical lift with sling and two member staff assistance with transfers; and monitor/record/report to Physician mood patterns and signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols.R1's Nursing Progress Note, dated 6/25/2026 3:50 pm, documents: Genitourinary: continent of bladder. Urine is clear yellow. Denies urinary complaints and alert and oriented (times three), communicated verbally, speech is clear and is able to understand and be understood when speaking.R1's Nursing Progress Note, dated 6/25/26 at 3:46 pm, documents a Braden evaluation: Moisture: Rarely moist; Activity: chairfast, is very limited; and makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. R1's Nursing Progress Note, dated 7/5/26 at 9:09 pm, documents: Genitourinary: urine clear yellow in color; no urinary complaints; incontinent of urine; uses adult briefs; new onset incontinence: No. Resident is occasionally incontinent (less than 7 episodes of incontinence); peri care provided.R1's Nursing Progress Note, dated 7/8/26 at 11:32 am, documents a Care Plan Meeting note: Interdisciplinary Team (IDT) met for Care Plan Meeting; V16 (R1's Power of Attorney) and (R1) invited to attend, (R1) present and (V16/R1's Power of Attorney) present via telephone. Nursing reviewed and discussed physician's orders; has a preference to not wear depends; prefers to wear no underwear or personal underwear and care plan updated; goals for short term care with therapy services and discharge home; encouraged to notify staff at any time with any questions or concerns; and staff to continue cares per Care Plan through next review.R1's Nursing Progress Note, dated 7/9/26 at 3:13 pm, documents R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation documents a Late Entry: Moisture: Occasionally moist; Activity: chairfast. Resident is slightly limited; makes frequent though slight changes in body or extremity position independent.R1's Nursing Progress Note, dated 7/9/26 at 11:20 pm documents: Genitourinary: urine clear yellow in color. No urinary complaints; is incontinent of urine; uses adult briefs; frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding); peri care provided; Skin: warm and dry, skin color within normal limits and turgor is normal; and no skin issues identified.On 7/18/26 at 10:43 am, R2 (R1's roommate/alert and oriented) stated, They always take forever to answer our calls lights. I have never seen them take (R1) to the bathroom, she always has to wear depends/diapersOn 7/18/26 at 10:48 am, R1 was sitting in a wheelchair in R1's room with a mechanical lift pad underneath R1. V17 (Certified Nursing Assistant/CNA) and V18 (CNA) entered R1's room and transferred R1 from the wheelchair to the bed, using a mechanical lift. When R1 was placed in bed, R1 was wearing a soiled incontinence brief. V17 and V18 removed the soiled incontinence brief. R1 stated, I have never worn diapers, ever before until I got here. I have had meetings with them and asked them not to put me in diapers because I have always used the bathroom. I had a stroke about 25 years ago and it left my right side weak. I am here for therapy because I just had left knee surgery and I plan on going back home to live with my partner again, he and I have been together for years. I always used the bathroom by myself when I was at home. They have to use a (mechanical lift) to transfer me. I have never been offered the bathroom, and they have put me in diapers since I have been here. I told them that when I go to a doctor's appointment or therapy, I would be fine with wearing one if it makes it easier. I have one on today, and I do not have therapy or a doctor's appointment. R1 was crying and stated, It makes me so upset and it makes me feel horrible and they only make me wear a diaper because they do not have enough staff or time to take me to the bathroom because I am a (full mechanical) lift, and it takes longer for me to go. Yesterday I sat in my wheelchair and was not taken to the bathroom from 11:00 am until 7:00 pm, so I just went to the bathroom in my diaper. Today, I have been in my diaper since I have been up, no one has offered to take me to the bathroom or offered to change me. I just now had to urinate in my diaper. Do you know how terrible that makes a person feel. I am in my sixties and should not have to go to the bathroom in a diaper. They never come in and ask me if I have to use the bathroom, I usually sit in a diaper for hours until I get changed, and if I ring my call light it takes them forever to come in and help, and a lot of times they just leave and say they are coming back and never come back for a long time. So basically, I just sit in my urine all day and now I am so red down there, it hurts so bad. When V17 (CNA) and V18 (CNA) were performing peri care, (R1) was screaming out in pain and crying. R1 was sobbing a large amount of tears, moaning/groaning and flinching throughout the peri care. R1's labia fold was bright red and had an open area on the left upper labia. After completion of R1's peri care, V17 and V18 attempted to apply a clean incontinence brief back on to R1.On 7/18/26 at 11:03 am, V17 (CNA) stated, I have only been here a few weeks, but I did not know that (R1) was able to use a bathroom. We just assume that they are a mechanical lift that they cannot use the bathroom. Maybe (R1) could use a bedside commode, we can check in to that, that is what we used to do at the last facility I worked at. V17 confirmed that R1 stated R1 was continent prior to admission.On 7/18/26 at 11:05 am, V18 (CNA) stated, I have never taken any Resident that is a mechanical lift into the bathroom since I have worked here, I do not think we can fit the lift into the bathrooms. We have always just offered a bedpan or put them in incontinent briefs. I guess we could use the shower room and wheel them down the hallway. I did not know that (R1) could use the bathroom, I guess, now that I look at it, it is wrong to put someone in a diaper when they are capable of using a toilet. V18 confirmed that R1 stated R1 was continent prior to admission.On 7/18/26 at 11:35 am, V2 (Director of Nursing) stated, (R1) should not be in an incontinence brief except to go a doctor or therapy appointment, and I am not sure, but I also think mealtimes. (R1) should be on a every two-hour toileting schedule also. The use of incontinence briefs for R1 does not follow the plan of care or R1's wishes. (R1's) admission nursing assessment does not document that (R1) was incontinent on admission.

Based on observation, interview and record review the Facility failed to maintain skin integrity after placing a continent Resident in incontinence briefs due to transfer status and not offering toileting services, leading to skin irritation, pain, redness and an open area on a peri area labia fold for one of three continent Residents (R1) reviewed for toileting assistance in a sample of six. Findings include:The Facility Assessment, dated 4/7/26, documents the facility will provide bowel/bladder general care for bowel/bladder toileting programs, incontinence prevention and care, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity. The Facility Assessment documents the facility will promote skin integrity, pressure ulcer prevention and care, skin care and wound care.The Facility Wound and Ulcer Policy and Procedure, revised 6/19/26, documents: the Facility will provide nursing standards for assessment, prevention and management of skin conditions and wounds; care will be provided to ensure residents do not develop pressure injuries unless avoidable and that Residents receive necessary care and services to promote healing and prevent new wounds in accordance with professional standards of practice and provider orders; comprehensive skin assessments will be completed with significant change in condition and ongoing based on identified risk and clinical condition; preventative interventions will be individualized based on assessed risk factors including mobility, moisture/incontinence, and comorbid conditions; and preventative measures include repositioning, pressure redistribution surfaces, moisture management and skin protection.The Certified Nursing Assistant Job Description, effective 9/14/18, documents: transfer resident utilizing appropriate assistive devices; assist residents in all activities of daily living; ensure Resident respect and dignity; provide maximum resident-care services to assure the well-being of resident to greatest degree; execute duties and responsibilities in conformance with established routine; assist with execution of resident assessment and plan of care; assure the mental well-being of Residents; assist with daily tasks such as toileting; and observe and report symptoms and changes in Residents.R1's current Care Plan documents: admitted to the facility on [DATE]; diagnoses including Right Side Cerebral Vascular Infarct; Radiculopathy Cervical Region, Adjustment Disorder, Biliary Tract disease, Left Artificial Knee Joint, Transient Ischemic Attack, Hemiplegia/Hemiparesis Right Dominant Side, Unsteadiness on Feet, Muscle Weakness, Abnormal Posture and Aphasia; toilet use requires maximum assistance of one staff member for participation to use toilet; occasionally incontinent of bladder; wears depends when going to outside appointments, when going to dining room and therapy; and prefers to not wear depends and prefers to wear personal underwear at times; provide consistency in care to promote comfort with Activity of Daily Living/ADL; maintain consistency in timing of ADLs, caregivers and routine, as much as possible; provide with opportunities for choice during care provision; allow to make decisions about treatment and regime to provide a sense of control; monitor/document bladder and bowel function; if incontinent monitor/document for appropriate bowel and bladder training program and implement; is here for short term Rehabilitation Therapy; plans to discharge to home when able with Home Health services if indicated; at risk for an ADL Self Care Performance Deficit related to recent joint replacement surgery and chronic obstructive pulmonary disease; risk for a decline in range of motion related to recent joint replacement surgery and chronic obstructive pulmonary disease as evidence by activity intolerance; at risk for a decline in bed mobility related to recent joint replacement surgery and chronic obstructive pulmonary disease as evidence by activity intolerance; requires moderate to maximum one person staff assistance with peri care and clothing management; Toileting schedule, staff is to assist and/or offer toileting assistance approximately every two hours to assist in having less than three episodes of incontinence during waking hours; transfer, utilizes a mechanical lift with sling and two member staff assistance with transfers; monitor/record/report to Physician mood patterns and signs/symptoms of depression, anxiety, sad mood as per facility behavior monitoring protocols; Braden Scale Assessments per schedule; daily skin assessment; moisturizer applied to skin; and use mild cleansers for peri-care and washing.R1's Nursing Progress Note, dated 6/25/2026 3:50 pm, documents: Genitourinary: continent of bladder. Urine is clear yellow. Denies urinary complaints and alert and oriented (times three), communicated verbally, speech is clear and is able to understand and be understood when speaking; Skin: warm & dry, skin color WNL (within normal limits) and turgor is normal. No skin issues identified. Skin note: slightly red groin and sacrum.R1's Nursing Progress Note, dated 6/25/26 at 3:46 pm, documents a Braden evaluation: Moisture: Rarely moist; Activity: chairfast, is very limited; and makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. R1's Nursing Progress Note, dated 7/5/26 at 9:09 pm, documents: Genitourinary: urine clear yellow in color; no urinary complaints; incontinent of urine; uses adult briefs; new onset incontinence: No. Resident is occasionally incontinent (less than 7 episodes of incontinence); peri care provided.R1's Nursing Progress Note, dated 7/8/26 at 11:32 am, documents a Care Plan Meeting note: Interdisciplinary Team (IDT) met for Care Plan Meeting; V16 (R1's Power of Attorney) and (R1) invited to attend, (R1) present and (V16/R1's Power of Attorney) present via telephone. Nursing reviewed and discussed physician's orders; has a preference to not wear depends; prefers to wear no underwear or personal underwear and care plan updated; goals for short term care with therapy services and discharge home; encouraged to notify staff at any time with any questions or concerns; and staff to continue cares per Care Plan through next review.R1's Nursing Progress Note, dated 7/9/26 at 11:20 pm documents: Genitourinary: urine clear yellow in color. No urinary complaints; is incontinent of urine; uses adult briefs; frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding); peri care provided; Skin: warm and dry, skin color within normal limits and turgor is normal; and no skin issues identified.R1's Nursing Progress Note, dated 7/9/26 at 3:13 pm, documents R1's Braden Scale for Predicting Pressure Ulcer Risk Evaluation documents a Late Entry: Moisture: Occasionally moist; Activity: chairfast. Resident is slightly limited; makes frequent though slight changes in body or extremity position independent; Friction and Shear: potential problem; and Braden score (17) for mild risk for skin breakdown.On 7/18/26 at 10:48 am, R1 was sitting in a wheelchair in R1's room with a mechanical lift pad underneath R1. V17 (Certified Nursing Assistant/CNA) and V18 (CNA) entered R1's room and transferred R1 from the wheelchair to the bed, using a mechanical lift. When R1 was placed in bed, R1 was wearing a soiled incontinence brief. R1 stated, I have never worn diapers, ever before until I got here. I have had meetings with them and asked them not to put me in diapers because I have always used the bathroom. They have to use a (full mechanical lift) to transfer me.I have never been offered the bathroom, and they have put me in diapers since I have been here. I told them that when I go to a doctor's appointment or therapy, I would be fine with wearing one. I have one on today, and I do not have therapy or a doctor's appointment. R1 was crying and stated, it makes me so upset and it makes me feel horrible and they only make me wear a diaper because they do not have enough staff or time to take me to the bathroom because I am a (full mechanical) lift, and it takes longer for me to go. Yesterday I sat in my wheelchair and was not taken to the bathroom from 11:00 am until 7:00 pm and had to go the bathroom in my diaper. Today, I have been in my diaper since I have been up, no one has offered to take me to the bathroom or offered to change me. I just now had to urinate in my diaper again. Now I am so irritated and hurting so bad down there (pointing at peri area). I think all the urine sitting on my private area has it so irritated, it burns and stings. So basically, I just sit in my urine all day and now I am so red down there, it hurts so bad. I have been telling them for days, that it burns when they change me and nothing has been done. When V17 (CNA) and V18 (CNA) were performing peri care, (R1) was screaming out in pain and crying. R1 was sobbing a large amount of tears, moaning/groaning and flinching throughout the peri care. R1's labia fold was bright red and had a quarter size open area on the left upper labia. On 7/18/26 at 11:03 am, V17 (CNA) stated, We have been here assigned to (R1) since 5:45 am, we did not notice the red area. We need to tell the nurse, it looks like her right upper inside labia is open, and it is really red. On 7/18/26 at 11:05 am, V18 (CNA) stated, I will tell the nurse (V13/Licensed Practical Nurse) to come look at it. It is definitely red and open. I had not noticed that area until now.On 7/18/26 at 11:09 am, V13 (V13/Licensed Practical Nurse) entered R1's room and evaluated R1's right labia fold open area and stated, I will call the doctor and get treatment orders, that area is definitely open. It looks like it irritated from urine.On 7/18/26 at 11:32 am, V3 (Assistant Director of Nursing) stated, I just heard about (R1's) open area. We are getting treatment orders.On 7/18/26 at 11:35 am, V2 (Director of Nursing) stated, (R1) should not be in an incontinence brief except to go a doctor or therapy appointment, and I am not sure, but I also think mealtimes. (R1) should be on a every two-hour toileting schedule so that we avoid skin breakdown. The use of incontinence briefs for R1 does not follow the plan of care or R1's wishes. (R1's) admission nursing assessment does not document that (R1) was incontinent or had any skin irritation to the peri area on admission.

Based on observation, interview and record review the Facility failed to staff a Registered Nurse for eight consecutive hours a day and assigned the Director of Nursing as a direct Resident care floor nurse. This failure has the potential to affect all 79 Residents residing in the Facility.Findings include:The Facility Resident Listing Report (dated 7/16/26) and Long-Term Care Facility Application for Medicare and Medicaid (7/17/26) documents 79 Residents residing in the facility.The Facility Assessment, dated 4/7/26, documents V2 (Director of Nursing/DON) for eight hours a day. The Facility Assessment documents V2 (DON) will provide leadership, oversight and regulatory compliance monitoring for the Facility; and that nursing services (Registered Nurses, Licensed Practical Nurses, Certified Nursing Assistants, Minimum Data Set/MDS Coordinator and Wound Care Nurse) are responsible for medication administration, clinical assessments, monitoring changes in condition, wound care, infection control monitoring, chronic disease management and assistance with activities of daily living; the Facility determines staffing levels based on Resident acuity, census, clinical complexity and the types of services required to meet the Resident needs and staffing patterns are evaluated regularly using MDS, clinical categories, Resident Care Plans, incident reports and Payroll Based Journal reports; and the Facility utilizes the staffing ratio calculator to assist with determining the number of staff needed to meet the requirements. The Areas Facility Assessment Informed area staffing does not have requirements documented.The Facility Daily Nurse Staffing Sheets (dated 7/1/26 through 7/17/26) do not document a Registered Nurse on duty on 7/1/26, 7/2/26, 7/3/26, 7/6/26, 7/8/26, 7/9/26, 7/10/26, 7/15/26, 7/16/26 or 7/17/26.The Facility Daily Nurse Staffing Sheet, dated Monday, 7/13/26, documents a day shift call off for the nurse assigned to the Hall 2/Hall 4 assignment and documents a reassignment for V2 (DON).The Facility Daily Nurse Staffing Sheet, dated 7/17/26, documents V15 (Agency Licensed Practical Nurse/LPN) assigned to the T-Wing.On Friday, 7/17/26 at 8:49 am, V2 (Director of Nursing) was working as the floor nurse on the T-Wing and passing medications. V2 stated, Sorry it took me so long to come talk to you, I am passing medications and working on the floor right now because (V15/Agency Licensed Practical Nurse/LPN) called off for today.On 7/18/26 at 9:22 am, V4 (Registered Nurse/Infection Preventionist/Restorative Nurse) states, I had to end up relieving (V2/DON) from working on the floor yesterday (7/17/26) because we had a call-off. (V2/DON) took the early part of the shift. We had to cover the floor on Monday (7/13/26) because we also had a call-off.On 7/17/26 at 11:35 am, V11 (Social Service Director) was trying to locate (V2/DON) and stated, I cannot find (V2), she was working the floor and still may be down there.On 7/17/26, at 1:16 pm, V2 (Director of Nursing) stated, We have a difficult time finding nurses, so we use agency nurses. Sometimes management (V2, V3 and V4) must cover and work on the floor, especially if there is a call-off.

Based on interview and record review, the facility failed to ensure residents were free from abuse for two (R1 and R2) of three residents reviewed for abuse in a sample of three. Findings include:Facility Abuse and Neglect Prohibited policy, dated 1/29/26, documents All residents have the right to be free from verbal, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, and exploitation. Abuse is the willful infliction of injury. Willful means the individual must have acted deliberately.1. Facility initial report to state dated 4/26/26, and final dated 5/1/26, documents (R3) stated (R1) was getting ready to hit (V4) CNA and (R3) grabbed (R1's) arm to stop it.Facility interview with R3 documents R3 was in the dining room when she saw R1 attempt to hit V4 CNA and her reaction was to grab R1's arm and stop her.R3 told R1 You're not going to hit them and then let go of R1's arm. R3's MDS/Minimum Data Set, dated [DATE], documents R3 is cognitively intact.R1's nurses notes, dated 4/26/26 at 12;30PM by V7 LPN/Licensed Practical Nurse, documents Possible resident to resident altercation while waiting in dining room for meal. Other resident grabbed this resident by left arm and residents moved from each other. Head to toe done on this resident bruising dark purple times three noted.On 6/11/26 at 12:30PM, V4 CNA/Certified Nurse Aid stated I worked on 4/26/26, I was walking a resident into the dining room, I needed a chair by (R1), I told (R1) I needed to move her and she called me a bitch, then (R1) went to reach around to hit me, and (R3) grabbed (R1's) arm.On 6/11/26 at 11:30AM and 2:10PM, R3 was alert and oriented in the dining room and bingo for activities. R3 stated she grabbed R1's arm in response to her trying to hit staff.2. Facility initial report to state dated 4/30/26, and final report to state dated 5/5/26, documents (V4) CNA observed (R1 and R2) altercation outside of the dining room. (V4) reported (R1) struck (R2) after (R2) accidentally bumped into (R1) with her wheelchair. R1 was discharged from the facility on 5/23/26, and was unable to be interviewed. R1's MDS, dated [DATE], documents R1 is cognitively intact.On 6/11/26 at 10:38AM, R2 was alert but not able to be interviewed due to cognition. R2's MDS, dated [DATE], documents R2 is severely impaired cognitively. Facility staffing for 4/30/26 documents V4 CNA was assigned to the dining room, V7 LPN was assigned as R1's nurse, and were working day shift. R1 and R2's nurses notes, dated 4/30/2026 at 1:20pm by V2 DON/Director of Nursing, documents Resident to resident incident occurred. Residents separated immediately. Facility interview with R1 documents R1 stated R2 was grabbing her shoulder and poking at her outside of the dining room. R1 stated she yelled at R2 to stop it and then shoved R2's wheelchair. On 6/11/26 at 12:20PM, V7 LPN stated she was R1's nurse on 4/30/26, and did R1 and R2's assessment. V7 was not in the dining room when the incident took place between R1 and R2.On 6/11/26 at 12:30PM, V4 CNA stated she worked on 4/30/26. V4 stated R1 told R2 to Get off me bitch. R2 was behind R1 in the dining room lunch line and bumped into R1 with her wheelchair. (R2) is confused and did it accidentally, but (R1) began to swat at (R2). On 6/11/26 at 1:00PM, V5 SSD/Social Services Director stated she was working on 4/30/26. R1 and R2 were lined up for the dining room outside of her office area,and she heard staff say She hit her. V5 stated she did not see it happen but staff said it was R1 that hit R2.

Based on interview and record review, the facility failed to prevent abuse for one resident (R7) of three reviewed for abuse in a total sample of 14.Findings include:The facility's Resident Care Policy and Procedure Regarding Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media Policy dated 8/25/2025 document All residents have the right to be free of verbal, sexual, physical, mental abuse. Sexual Abuse is non-consensual sexual contact of any type which includes, but is not limited to, unwanted intimate touching of any kind especially of breasts or perineal area.The Final Facility Incident Report Form for 01/02/2026 documents a resident-to-resident interaction in which R8 was observed with R8's hand placed on R7's chest and R8 reported he had a moment of weakness and placed his hand on R7's breast over R7's clothes. Incident occurred in the TV lounge area.R8's Electronic Health Record documents R8 was admitted to the facility on [DATE] with diagnoses to include Displaced Right Acetabulum Fracture, Chronic Obstructive Pulmonary Disease, Heart Failure, Atrial Fibrillation, Peripheral Vascular Disease, and Hypertension.R8's Progress Note dated 12/15/25 documents R8 is alert and scored 15/15 on his BIMS (Brief Interview for Mental Status) which indicates R8 is cognitively intact and R8 is understood and understands.R8's Progress Note dated 1/23/26 at 4:03 PM documents, R8 noted to be wandering throughout the facility and noted to be observing others. Interdisciplinary Team implemented 15 minute check observations related to sexual tendencies.R8's Progress Noted dated 1/23/26 at 5:42 PM documents, Interdisciplinary Team implemented 1:1 observations related to history of sexual tendencies.R7's Electronic Health Record documents R7 was admitted to the facility on [DATE] with diagnoses to include Dementia, Depression, Hypertension, and Hyperlipidemia.R7's Progress Note dated 12/24/25 documents, R7 is severely cognitively impaired.R7's Physician's Order dated 9/12/25 documents, 15 minute observation checks due to wandering.R7's Progress Note dated 1/23/26 documents, CNA reported she visualized another resident made inappropriate contact with this resident.On 1/23/26 at 10:03 AM V1 (Administrator) reported that after the incident on 12/28/25 R8 was placed on 15 minute checks for 3 days and no concerns were identified so the 15 minute checks were discontinued for R8.On 1/24/26 at 8:20 AM V1 (Administrator) reported on 1/23/26 R8 was observed by staff touching the back of R7's head and R8 was placed on 1:1 supervision.On 1/24/26 at 9:14 AM R8 denied touching R7's breast and stated, It didn't mean anything.On 1/24/26 at 10:09 AM V21 (CNA) reports she has observed R8 pacing the hallways looking for R7.

Based on observation, interview, and record review the facility failed to implement individualized care planned interventions to prevent a resident (R1) from sustaining multiple burns, failed to identify a hot water/coffee dispenser used in the main room as a potential burn hazard, and failed to establish protocols and provide adequate monitoring to ensure hot water within a water/coffee dispenser located in the main dining room were kept below temperature levels to prevent burns. These failures resulted in R1, a resident with the diagnoses of Spastic Cerebral Palsy, Scoliosis, Dysphagia, and Muscle Spasms, spilling hot coffee on her left posterior thigh on two separate occasions on 11/14/24 and 1/25/25, sustaining a second degree burn on her left posterior thigh on both occasions, and having the failure to affect all 59 residents who receive coffee/hot water out of the dispenser located within the main dining room. These failures resulted in an Immediate Jeopardy that started on 11/14/24 when the facility failed to identify a hot water/coffee dispenser used in the main room as a potential burn hazard, and failed to establish protocols and provide adequate monitoring to ensure hot water within a water/coffee dispenser located in the main dining room were kept below temperature levels to prevent burns, resulting in R1 spilling hot coffee on herself and sustaining a second degree burn to her left posterior thigh. While the immediacy was removed on 3/10/25, the facility remains out of compliance at a severity Level II as additional time is needed to evaluate the implementation and effectiveness of their removal plan and Quality Assurance monitoring. Findings include: The facility's Midnight Census Report, dated 3/7/25, documents 59 residents currently reside within the facility. The facility's Hot Liquids policy, dated 3/7/25, documents Policy: It is the policy of this facility to maintain protocols to assist in preventing injuries related to hot liquid and develop and individualized plan of care to address resident risk. Procedure: 1. A Hot Beverage Use Assessment will be performed upon admission, quarterly and with a significant change in condition. 2. Residents with a yes response in section number one of the Hot Beverage Use Assessment will be referred to Occupational Therapy for a thorough assessment of physical abilities and recommended safety interventions. 4. Residents identified through the assessment process as a risk for injury related to exposure to hot liquids shall not be left unsupervised during meal service. The American Burn Association Scald Statistics and Data Resources, dated 8/13/2018, documents Infants/toddlers and elderly adults have thinner dermal layers compared to persons of other ages, leading to deeper burn injuries of lower temperatures or shorter exposure times. Hot water will burn skin at temperatures much lower than boiling point. It only takes three seconds of exposure to 140 degrees Fahrenheit water to cause a burn serious enough to require surgery. 85 to 90% (percent) of scald burns are related to cooking/drinking/serving hot liquids. R1's Admission Record, dated 3/7/25, documents R1 was admitted to the facility on [DATE] with the following, but not limited to, diagnoses: Spastic Diplegic Cerebral Palsy, Visual Hallucinations, Spasmodic Torticollis, Anxiety Disorder, Other forms of Scoliosis, Thoracic Region, Unspecified Osteoarthritis, Muscle Wasting and Atrophy, Muscle Weakness, Need for Assistance with Personal Care, Muscle Spasm of Back, Dysphagia, Spondylosis without Myelopathy or Radiculopathy, and Thoracic Region. R1's MDS (Minimum Data Set) Assessment, dated 12/6/24, documents R1 is cognitively intact, requires supervision or touching assistance with eating, and is dependent on staff with all other ADLs (Activities of Daily Living). This same MDS documents R1 had a second or third-degree burn. R1's Contracture Risk Evaluation, dated 9/6/24 and signed by V4/MDS Coordinator, documents R1 currently has contractures, is confused at times, needs staff to turn and reposition, and is noted to have contracting throughout R1's body. R1's OT (Occupation Therapy) and Plan of Treatment, dated 3/19/24, documents (R1's) RUE (Right Upper Extremity) ROM (Range of Motion) = impaired (Right should flexion actively to 60 degrees passively, right shoulder abduction to 65 degrees actively and 80 degrees passively. Right elbow flexion 60 to 130 degrees actively, right wrist 25 to 30 degrees flexion/extension). LUE (Left upper extremity) ROM= impaired. (Left should flexion actively to 60 degrees and passively to 85 degrees, left elbow flexion 35 to 100 degrees actively, left wrist assisted active ROM contracted hand which has elicited superficial palm indentation). Joints: Shoulder=impaired, Elbow/Forearm=impaired; Wrist=Impaired; Shoulder = impaired; Elbow/Forearm=Impaired; Wrist=impaired. R1's Progress Note, dated 11/14/24 and signed by V12/LPN (Licensed Practical Nurse), documents (R1) spilt coffee on left posterior thigh. Area red no blisters noted. R1's Progress Note, dated 11/14/24 and signed by V13/LPN, documents (R1) red area to left thigh now presents with blisters related to spilling coffee on self. R1's Wound Evaluation and Management Summary, dated 11/19/24 and signed by V9/Wound Physician, documents Burn wound of the left thigh partial thickness. Etiology: Burn. Further Etiology Detail: Hot liquid. Duration: Less than five days. Wound size 20cm (centimeters) x 9cm x 0.01cm. Peri-wound radius: Erythema. Exudate: Sero-sanguinous (pinkish-red drainage). Additional Wound Detail: Hot coffee spilled on area last Thursday. R1's Illinois Department of Public Health Final Report, dated 11/22/24, documents R1 was in her room drinking her coffee after breakfast, per R1's normal activities, when V6/Activity Director entered R1's room around 9:00 AM and noticed R1 had spilled her coffee on herself. V13/LPN completed a skin assessment which revealed a reddened area with blisters. Interventions: Requested order from V7/R1's Physician for OT to evaluate and treat, assist R1 with drinking hot liquids and eating, and R1 will drink out of a two handled cup with a straw with staff assist as needed. R1's Progress Note, dated 1/25/25 and signed by V14/LPN, documents (R1) was eating in the dining room when staff reported that (R1) spilled coffee on her left leg. Upon assessment (R1) has a 14cm (centimeter) x 20cm red raised area to her left thigh and around the back of her left thigh. R1's Wound Evaluation and Management Summary, dated 1/28/25 and signed by V9/Wound Physician, documents non-pressure wound of the left posterior thigh. Etiology: Trauma/Injury. Further Etiology Detail: Burn. Duration: Less than two days. Wound size: 6cm x 6cm, x not measurable cm. Exudate: None Blister: Fluid Filled. Additional Wound Detail: hot coffee spilled on leg. Area is blistered with surrounding pink skin. Blisters are intact. R1's Wound Evaluation and Management Summary, dated 2/4/25 and signed by V9/Wound Physician, documents non-pressure wound of the left posterior thigh. Etiology: Trauma/Injury. Further Etiology Detail: Burn. Duration less than nine days. Wound size: 5.5cm x 4 x 0.01cm. Additional Wound Detail: Blister opened. R1's Illinois Department of Public Health Final Report, dated 1/30/25, documents (R1) was in the dining room eating breakfast. When (R1) was taking a drink of the coffee, (R1) spilled coffee on her leg. (V8/Wound Nurse) assessed (R1's) left thigh area and noted that (R1) had a burn to the left thigh area. This same report documents IDT (Interdisciplinary Team) met to discuss the root cause of (R1's) incident of spilling coffee on herself and sustaining a burn. Root cause of the spill was determined to be from (R1) unable to handle cup with lid upright to prevent from spilling it on herself. R1's Clinical Medical Record does not include a hot liquid risk assessment. R1's Order Summary Report, dated 3/7/25, document R1 has a physician order as follows: Apply emollient cream to R1's left thigh burn/scar tissue every night shift for wound healing. This same Report documents a physician order to apply emollient cream to R1's left thigh every eight hours as needed for wound healing. R1's current Care Plan documents, (R1) is at risk for impaired skin integrity due to impaired physical mobility. Interventions- Date Initiated 11/18/24: Staff to assist (R1) with meals due to spilling coffee. (R1) agreed, having staff assistance with meals would be beneficial. (R1) encouraged to refrain from eating and drinking hot liquids in room without staff assistance. Intervention- Date Initiated 2/4/25: Staff to ensure waterproof clothing protector and lap blanket to be worn during all meals and during as needed fluid and food intake. (R1) has a history of spilling food and liquid when attempting to eat meals per self. (R1) is at risk for ADL self-care performance deficit related to cerebral palsy as evidence by weakness, muscle wasting and atrophy, dysphagia, and right-hand contracture. Interventions- Date Initiated 12/16/22: Eating: (R1) requires extensive to total assistance times one staff with meals. Therapy encouraged use of smaller utensils for an effective grip while eating meals. Utilizes two handed cups for liquids. The facility's Food Temperature Log for Meal Service dated the week of 11/10/24 documents Coffee/hot water temps for breakfast, lunch, and supper. During this week the coffee/hot water temperature ranged from 171 degrees Fahrenheit to 177 degrees Fahrenheit. The facility's Food Temperature Log for Meal Service dated the week of 1/19/25 documents Coffee/Hot water temps for breakfast, lunch, and supper. During this week the coffee/hot water temperatures ranged from 170 degrees Fahrenheit to 176 degrees Fahrenheit. On 3/7/25 at 9:35 AM R1 was in her room in her wheelchair. R1 was leaning left in her wheelchair, with a contracted posture and her head contracted towards the left lying on a pillow. R1's left hand was observed to be in a closed fist position. R1's right hand was observed in a closed fist position with R1's fingers pointed inward towards her palm. R1 had a green two handled cup sitting in her lap. R1 grabbed the green cup with water with her right hand and used her pointer finger and thumb to hold on to the cup. R1 was shaky while holding the cup and the cup was leaning to the left as R1 was attempting to take a drink. R1 did not have on a waterproof clothing protector or lap blanket during this time as identified in R1's care plan. R1 stated, The first time I spilled my coffee I was in my room. It spilled all down the left side of me. The staff came in and noticed I had spilled my coffee. The second time I spilled my coffee I was in the dining room and a staff member (I don't know her name) handed me my coffee. I went to take a drink and dropped the entire cup. It ended up burning me in the same spot and that time it was more painful. Staff has never assisted me with drinking until just recently. On 3/7/25 at 10:10 AM V11/LPN (Licensed Practical Nurse) was preparing to apply R1's wound treatment to R1's left posterior thigh. R1's posterior left thigh area had approximate 20cm x 9cm, red/blanchable area. On 3/7/25 at 11:55 AM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. The coffee pot was observed to have three nozzles that dispensed hot water, decaffeinated coffee, and regular coffee. On 3/7/25 at 2:30 PM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. The dining room door across from the medical record office was observed propped open. The dining room door across from the Social Service Office was shut but was unlocked and was able to be opened. During this time V1/Administrator verified the door was propped open and the other door was unlocked and stated, The doors are supposed to be locked in between meals so no resident can enter. I do not know why the door is propped open and the other door was left unlocked. On 3/8/25 at 8:13 AM an automatic dispensing coffee pot was observed sitting on a counter that would be able to be accessed by all residents in the main dining room where all residents eat. V3/Dietary Manager stated that all residents in house drink some sort of hot liquid like hot chocolate, hot tea, or coffee out of the automatic dispensing coffee pot. V3 then proceeded to calibrate a thermometer and then temped a cup of coffee after being poured directly from the automatic coffee dispenser in the main dining room. V3 temped the coffee at 163.2 degrees Fahrenheit. V5/CNA then came over to pour R1 a cup of coffee. Steam was rising from R1's cup of coffee. V3 temped R1's cup of coffee at 161 degrees Fahrenheit. On 3/7/25 at 1:15 PM V9/Wound Physician stated (R1's) burns that happened on the two different occurrences would be classified as second-degree burns. On 3/7/25 at 1:20 PM V16/Manufacturer Consultant stated, The automatic coffee pot dispenser setting is set at 185 degrees Fahrenheit for the hot water to brew the coffee. On 3/7/25 at 2:20 PM V3/Dietary Manager stated the hot water/coffee out of the coffee machine temperature ranges from 170 degrees Fahrenheit to 175 degrees Fahrenheit daily. On 3/8/25 at 8:20 AM V2/Director of Nursing stated they (the facility) has not done any hot liquid risk assessments on R1 or any other resident prior to them drinking hot liquid on their own. On 3/8/25 at 8:35 AM V10/Vice President of Culinary Services stated The coffee pot the facility currently has must brew the coffee at 175 degrees Fahrenheit or above for coffee sanitary purposes. You and I both know that to have no burns at the facility the coffee should be served at 120 degrees or less. V10 verified the only way to keep the residents from being burned is take the automatic coffee machine out of the dining room and install it in the kitchen with a machine that keeps the coffee and the hot water at a lower temperature. On 3/8/25 at 8:43 AM V5/CNA stated, On 1-25-25 I took (R1) to the dining room and got (R1) a cup of coffee that had two handles and a lid and gave it to her. I did not assist (R1) with the coffee. Five to ten minutes after giving (R1) her coffee, I realized (R1) spilled the coffee onto her lap. (R1's) cup was lying all the way to the left. I thought (R1) was able to drink the coffee by herself. I did not know there was a Kardex (Care plan) we could look at to see updates and I still don't know how to access a resident's Kardex. I did not know (R1) needed assistance with drinking hot liquids or eating her meals. On 3/8/25 at 9:38 AM V15/CNA stated the doors to the dining room are shut most of the time to the dining room in between meals, but sometimes the door is propped, or the doors are unlocked so we can get in that way to get coffee or a drink for the residents. On 3/8/25 at 10:50 AM V1/Administrator stated (the facility's) managing company just sent a Policy for Hot liquids yesterday. V1 stated We (the facility) did not have a Hot Liquids Policy in place prior to yesterday (3/7/25) and should have to try and prevent burns in the facility. V1 also stated After the first time (R1) was burned we put an intervention in place to have staff assist (R1) while drinking and eating, especially with hot liquids. The second time (R1) was burned by the spilled coffee, (V5/CNA) was newer to our building and did not know (R1) required assistance with hot liquids. (V5) just handed (R1) a two handled cup of hot coffee with a lid and did not assist her. (R1) ended up spilling the coffee again on her left side, sustaining another burn to her left posterior thigh. The immediate jeopardy started on 11/14/24 when the facility failed to identify a hot water/coffee dispenser used in the main room as a potential burn hazard, and failed to establish protocols and provide adequate monitoring to ensure hot water within a water/coffee dispenser located in the main dining room were kept below temperature levels to prevent burns, resulting in R1 spilling hot coffee on herself and sustaining a second degree burn to her left posterior thigh. V1/Administrator and V2/Director of Nursing were notified of the Immediate Jeopardy on 3/10/25 at 11:40 AM. On 3/11/25 the surveyor confirmed through interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 3/10/25 all residents were interviewed by V8/Wound Nurse, V22/Restorative Nurse, V23/Business Office Manager, and V24/Social Service Director for hot liquid spills with injury. 2. On 1/25/25 R1 was removed from the dining room, laid down, clothes were removed, and a head-to-toe skin assessment was completed. V7/R1's Physician and V25/R1's Family member was notified. On 1/25/25 a wound dressing was ordered, R1's care plan was updated to ensure staff assisted R1with a waterproof clothing protector and lap blanket to be worn during all meals and as needed for food and fluid intake and to continue Occupation therapy three times a week for twelve weeks. 3. On 3/8/25 a Hot Liquid Policy was developed and implemented. 4. On 3/8/25 a Hot Liquid Risk Assessment was developed and implemented. 5. On 3/8/25 V1/Administrator in-serviced Department Managers (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the facility's Hot Liquid Policy. The facility's Department Managers then carried out the same in-services on 3/8/25 for their respective employees. All employees of the facility have been in-serviced on these topics and policies. 6. On 3/8/25 all residents, including R1, were assed with the facility hot liquids assessment to determine if they are at risk of being injured 7. On 3/10/25 R1's care plan was updated to include interventions for hot liquid spills with injury and for Speech Therapy to Evaluation and Treat. 8. On 3/8/25 the facility implemented utilizing colored napkins to alert each member of the team that the resident is at high risk for burn injury. 9. On 3/8/25 all at risk residents for being injured due to hot liquids were identified on meal tray cards. 10. On 3/8/25 V4/MDS Coordinator updated all resident care plan with interventions that were identified as at risk for spilling hot liquids causing injuries. 11. On 3/8/25 the coffee machine in the main dining room was disconnected. 12. 3/10/25 the coffee machine was removed from the main dining room. Coffee and other hot liquids are being served from the kitchen and temped prior to being served. 13. On 3/8/25 a new coffee machine was ordered and will be dispensed at 150 degrees Fahrenheit. 14. On 3/10/25 waterproof adult clothing protectors and waterproof blankets were ordered for the residents identified at risk for injury from hot liquid. 15. On 3/10/25 a Food Temperature Log for Meal Services was implemented with coffee/hot water to be served at 150 degrees Fahrenheit or less. 16. On 3/8/25 V1 in-serviced each department manager (V2/Director of Nursing, V3/Dietary Manager, V4/MDS Coordinator, V6/Activity Director, V22/Restorative Nurse, V23/Business Office Manager, V24/Social Service Director, V26/Assistant Director of Nursing, and V27/Environmental Service Director) regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool we be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, and that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit. The facility's Department Managers then carried out the same in-services on 3/8/25 for their respective employees. All employees of the facility have been in-serviced on these topics and policies. 17. A system was put in place for an audit to be done by V2/Director of nursing, for five residents daily, five days a week, for six weeks to ensure compliance with interventions being put in place. On 3/10/25 V2/Director of Nursing is utilizing the audit tool to ensure care plan interventions are being followed. These are monitored/audited for compliance by V1/Administrator one time per week. 18. On 3/8/25 V4/MDS Coordinator reviewed and updated R1 and the residents identified to be at risk for injury from hot liquids care plans. 19. On 3/10/25 V1/Administrator provided all staff in-servicing regarding the use of red napkins at meals for the residents identified at risk for injury from hot liquids. 20. On 3/10/25 V1/Administrator in-serviced all Agency Staff regarding the appropriate temperature of hot liquids and utilizing the audit tool to confirm if resident received hot liquids at mealtime and what temperature it was serviced. Audit tool we be utilized for breakfast, lunch, dinner to ensure hot liquid temperatures are serviced at a minimum of 135 degrees Fahrenheit but not to exceed 150 degrees Fahrenheit, residents who were identified to be at risk for injury from hot liquids, following care plan interventions, that kitchen will be temping all hot coffee and water to ensure facility is serving 135 degrees Fahrenheit to 150 degrees Fahrenheit, and the use of red napkins at meals for the residents identified at risk for injury from hot liquids. 21. On 3/10/25 a copy of the facility's Hot Liquid Policy was added to the new orientation manual and the agency orientation manual. 22. A system was put in place for an audit to be done by V3/Dietary Manager, for five residents daily, five days a week, for six weeks to ensure compliance with temperatures of hot liquids prior to being served to ensure they are below the appropriate temperatures. V3/Dietary Manager is utilizing this audit form to ensure hot liquids are being served at appropriate temperatures. These are monitored/audited for compliance by V1/Administrator once time per week. Completion Date: 3/10/25.

Based on interview, record review and observation, the facility failed to ensure residents were free from unnecessary physical restraints(s), failed to identify the specific medical symptoms warranting the use of physical restraints, failed to obtain physician orders with medical justification for the placement of a physical restraint(s), and failed to obtain resident or responsible party consent for the use of a physical restraint for two (R1, R2) of 12 residents reviewed for restraint usage in the sample of 12. These failures resulted in R1 and R2 being physically restrained to their wheelchair with a gait belt placed around their torso and fastened behind their back with the inability to rise from their chair and suffering psychosocial harm of humiliation and embarrassment that any reasonable person would experience being improperly restrained. These failures resulted in an immediate Jeopardy. An Immediate Jeopardy situation was identified to have started on 01/01/25 at approximately 6:00pm when V3 LPN/Licensed Practical Nurse placed a gait belt around R1 and R2's torso and fastened the restraint behind the back of each resident's wheelchair, preventing R1 and R2 the ability to rise from their wheelchair or remove the restraint. While the immediacy was removed on 02/20/25, the facility remained out of compliance at a Severity Level 2 as additional time is needed to evaluate the implementation and effectiveness of the facility's removal plan and quality assurance monitoring. Findings include: The facility's final Report to Illinois Department of Public Health, dated 01/10/25 identified R1 and R2 as the subjects of the incident. This report documents the following: On 01/06/25 CNA (verified as V4) reported that (R2) was improperly restrained on evening shift but was unsure when it happened. This report further documented, Interviews with staff revealed that on the evening of 01/01/25, Resident (R2), BIMS/Brief Interview for Mental Status 0 (zero/severely cognitively impaired), was improperly restrained in her wheelchair. The report stated, Staff interviews reveal they observed the resident at the nurse's station improperly restrained. Staff said they observed a second resident, (R1), BIMS 01 (severely cognitively impaired), improperly restrained to his wheelchair at the nurse's station. Neither resident was able to provide any comment upon interview. The facility's Restraint Program Policy and Procedure, dated 11/10/2015, documents the following: Policy: It is the policy of this facility to provide appropriate care for residents in relation to restraint utilization. 3. If a restraint is necessary, physician and POA (Power of Attorney) are notified, and a Restraint Consent is completed. Specific risk factors are marked as appropriate for the individual resident. The facility's Nonemergency Use of Physical Restraints policy dated 3/1/11 documents the following: I. Physical restraints shall be used when required to treat the resident's medical symptom or as a therapeutic intervention, as ordered by a physician, and based on: A. the assessment of the resident's capabilities and an evaluation and trial of less restrictive alternatives that could prove effective; B. the assessment of a specific condition or medical treatment that requires the use of a physical restraints, and how the use of physical restraints will assist the resident in reaching his or her highest practicable, mental, physical, mental, or psychosocial wellbeing. II. A physical restraint will be used only with the informed consent of the resident, the resident's guardian, or other authorized representative This informed consent will include information about potential negative outcomes of physical restraint use, including incontinence, decreased range of motion, decreased ability to ambulate, symptoms of withdrawal or depression, or reduced social contact. VII. Physical restraints will not be used on a resident for the purpose of discipline or convenience. The facility's Emergency Use of Physical Restraints policy dated 7/1/02 documents: B. If a resident needs emergency care and other less restrictive interventions have proved ineffective, a physical restraint will be used briefly to permit treatment to proceed. The attending physician will be contacted immediately for orders. If the attending physician is not available, the facility's advisory physician or Medical Director will be contacted. 11. The emergency use of a physical restraint will be documented in the resident's record and include: 1. The behavior incident that prompted the use of the physical restraint; 2. The date and times the physical restraint was applied and released; 3. The name and title of the person responsible for the application and supervision of the physical restraint; 4. The action by the resident's physician upon notification of the physical restraint use; 5. The new or revised orders issued by the physician; 6. The effectiveness of the physical restrain in treating medical symptoms or as a therapeutic intervention and any negative impact on the resident; and 7. The date of the scheduled care planning conference or the reason the resident's emergency need for physical restraints. III. The facility's emergency use of the physical restraints will comply with our policy for non-emergency use of physical restraints section III, IV, V, and IX. The facility's Abuse Prohibition policy dated 3/15/18 documents the following: All residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of property, exploitation. This includes but is not limited to freedom from .physical or chemical restraints not required to treat the resident's symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative. R1's medical record documents R1 is [AGE] years old and was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia with Agitation; Alzheimer's Dementia; Impulsiveness and Generalized Muscle. Weakness. R1's current Care Plan documents R1 has significant cognitive impairment, is dependent on staff for ADLs/Activities of Daily Living, transferring and ambulation. R1's MDS/Minimum Data Set, dated dated dated [DATE], documents R1's BIMS/Brief Interview for Mental Status score was 01 of 15, indicating R1 is severely cognitively impaired; R1 uses a wheelchair, requires assistance with ambulation and ADLs. R2's medical record documents R2 is [AGE] years old and was admitted to the facility on [DATE] with diagnoses including: Dementia with other Behavioral Disturbance; Disorientation; Cognitive Communication Deficit; Weakness; Recurring Falls; Anxiety Disorder and Insomnia. R2's current Care Plan documents R2 is dependent upon staff for cares, including transferring, ambulation, and ADL's/Activities of Daily Living. R2's Care Plan documents R2 has significant cognitive impairment and is a fall risk. R2's Quarterly MDS Cognition Assessment documents R2 has severe cognitive impairment with a BIMS score of 0 (zero) of 15. There was no documentation, no physicians order, and no medical symptom listed justifying the use of this inappropriate restraint in R1's nor R2's medical records. The facility's January 2025 Nursing schedule documents V3 LPN/Licensed Practical Nurse worked the evening shift on 01/01/25 and 01/03/25. On 02/11/25 at 2:10pm, V6 CNA stated that on 01/06/25 she and another CNA were getting R2 ready to get out of bed, when she noted a gait belt fastened around R2's wheelchair. When V6 mentioned the gait belt, the other CNA told her that on 01/01/25, V3 LPN/Licensed Practical Nurse had used gait belts to keep (R2) in her wheelchair. V6 stated R2 was continent of bowel and bladder and able to let the staff know if she needed to use the bathroom and was able to ambulate with CNA assistance to the bathroom in her room, and a fall risk due to weakness. On 2/11/25 at 2:45pm V3 LPN/Licensed Practical Nurse stated that on 01/01/25 at approximately 6:00pm, she fastened a gait belt around R1 and R2 while they were sitting in their wheelchairs near the Nurses Station. V3 stated she fastened the gait belts behind the back of the chairs, out of the residents' reach, in order to prevent R1 and R2 from rising from their wheelchairs. V3 confirmed she was aware her actions constituted inappropriate use of physical restraints at the time. V3 stated R2 uses a cushioned lap restraint and removes it frequently and tries to stand up from her wheelchair. V3 stated it was a very busy and hectic time, after dinner, and no staff were available to keep watch on R1 and R2, as CNAs were transferring and toileting the residents and putting some residents to bed for the evening. V3 stated she felt R1 and R2 required 1:1 attention to prevent a fall when trying to stand up from their wheelchairs and there was not enough staff on duty to provide it. On 02/11/25 at 9:00am V6 CNA stated she was on duty on 01/01/25 on 2nd shift and, at approximately 6:00pm, V3 LPN was working and R1 was anxious and repeatedly asking for his wife at the Nurses Desk. V6 stated she saw V3 place a gait belt across (R1's) chest, under his arms and fastened it in the back of his wheelchair. V6 stated R1 has dementia and severe hearing deficit and does not always process what you're saying and does not follow commands. V6 stated R1 is ambulatory with assistance and is very unsteady. V6 stated she did not report the incident to the Abuse Coordinator/Administrator because she felt V3 LPN was not approachable as she seems rude. On 02/11/25 at 2:00pm V4 CNA/Certified Nursing Assistant stated that on 01/06/25, a CNA (unable to identify) she was working with told V4 that V3, LPN restrained R2 in her wheelchair with a gait belt to keep her in her wheelchair. V4 stated she immediately reported the incident to a supervising nurse and V1 Administrator/Abuse Coordinator. On 02/11/25 at 1:30pm V7 LPN stated she was on duty with V3 LPN on the evening shift of 1/1/25. V7 stated at approximately 6:00pm, she saw R1 was restrained in his wheelchair with a gait belt. V7 stated she was aware V3 had placed a gait belt around R1 and fastened it behind the back of his wheelchair. V7 stated R1 would not have been able to remove the gait belt and would not have been able to rise from the wheelchair. V7 verified she did not report the incident to anyone. V7 stated she knew this was improper restraining of a resident at the time of the incident and, even though she knew that the policy was to report incidents immediately to the Administrator/Abuse Coordinator, she did not report it. On 2/11/25 at 10:45am V2 DON/Director of Nursing stated V3 LPN inappropriately restrained R1 and R2 in their wheelchairs using gait belts fastened around them and clasped behind the back of their wheelchairs, out of reach of the residents. V2 confirmed V3 should not have restrained R1 and R2 in that manner and the action constituted inappropriate use of restraints. On 2/11/25 at 11:15am V2 DON stated there were interventions in place for R1 and R2, including redirection, implementing an activity with an Activity staff member with one on one assistance; television viewing and taking R1 and R2 for a walk around the facility with CNA assistance. On 2/13/15 at approximately 10:00am, V2 stated the fall preventions interventions in place for R2 were providing a low bed, and a mattress next to her bed when she is sleeping; a pressure bed alarm, a cushioned lap restraint when R2 is up in her wheelchair. Redirection interventions included taking a walk with CNA assistance, distraction with activities and television viewing. On 2/11/25 at 1:15pm, V1 Administrator stated she was notified of this incident on 01/06/25, after the incident occurred on 01/01/25, and began the investigation of the incident immediately, calling the evening shift staff for questioning. V1 stated she first called V3 LPN/Licensed Practical Nurse for information, who had worked the evening shift on 01/01/25 and was usually considered the charge nurse for the shift. V1 stated V3 readily admitted that she had placed gait belts around R1 and R2 in their wheelchairs and fastened them out of their reach, behind the backs of the wheelchairs in order to prevent them from standing. V1 verified V3 stated she was aware the incident constituted inappropriate physical restraints when she did it. V1 stated she suspended V3 immediately, pending the outcome of the facility's investigation. On 2/18/25 at 3:55pm, V1 stated she did not bring this incident to the attention of the IDT/Interdisciplinary Team or QA/Quality Assurance members. V1 stated the next QA meeting will be in April 2025. On 2/11/25 at 9:20am R1 was seated in his wheelchair at a table near the Nurses Station, working with building block materials with an activities aid. R1 was calm with no behaviors exhibited. No restraints were noted. R1 did not respond to this surveyor's greeting or question. On 2/11/25 at 11:20am, R1 was calm and quiet, self-propelling his wheelchair down the hallway toward his room. R1 did not respond to surveyor's greeting or question. No restraints noted. On 2/11/25 at 3:00pm R1 was in bed with his eyes closed. There were no restraints noted. On 2/13/25 at 9:45am, R1 was sitting in a wheelchair near the Nurses Station. R1 was alert, calm and quiet. R1 did not respond to this surveyor's greeting or question. On 2/11/25 at 9:20am R2 was sitting in a high-backed wheelchair with a lap cushion in place. On 2/11/25 at 10:05am, R2 was seated in a high-backed wheelchair near the Nurses Station. A lap cushion was in place, and R2 was counting out loud with her eyes closed. R2 did not respond to this surveyor's greetings or questions. On 2/11/25 at 3:05pm, R2 was lying in bed with her eyes closed. The pressure alarm on R2's bed was turned on. An Immediate Jeopardy situation was identified to have started on 01/01/25 at approximately 6:00pm when V3 LPN/Licensed Practical Nurse placed a gait belt around R1 and R2's torso and fastened the restraint behind the back of each resident's wheelchair, preventing R1 and R2 the ability to rise from their wheelchair or remove the restraint. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 02/20/25 at 9:47 AM. On 2/25/25, the abatement plan was confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 2/20/25 Department Managers (V2 DON; V13/Acting DON; V15/MDS/Care Plan Coordinator; V11/RN Restorative Nurse; V19/Business Office; V20/Social Services; V21/Activity Director; V22/CDM; V23/Environmental Services Director) were in-serviced by V1 Administrator on the facility's restraint policy, care of residents with restlessness and agitation, improper restraint usage, the need for alternative interventions, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure. The facility's Department Managers then carried out the same in-services for their respective employees. All employees of the facility have been in-serviced on these topics and policies. 2. On 2/20/25 all residents have been assessed to ensure that none are restrained improperly or unnecessarily. 3. On 2/20/25 Care Plans were reviewed by the Care Plan Coordinator and updated as needed for residents with restlessness or agitation. 3. On 2/20/25 a full physical assessments of R1 and R2 were conducted by for any signs of injury from restraint usage with no findings of injury. 5. All facility staff, contracted Therapy staff and Agency staff utilized by the facility were in-serviced on the following: care of the resident with restlessness and/or agitation; the facility's restraint policy, improper restraint usage, the need for alternative interventions, care of the resident with restlessness and/or agitation, appropriate diagnosis, physician's orders, care planning, the facility's abuse policy and reporting procedure on 02/20/25. 6. V15 verified R2 was care planned with interventions addressing potential for abuse and proper restraints related to her diagnoses. Restraint consents were present in R2's medical record for R2's cushioned lap restraint, mattress, and bed pressure alarm. V15 verified R1 was care planned for falls and restlessness, agitation with interventions. No restraints were in use for R1. 7. A system was put in place for an audit to be done by the V1 Administrator or designee three times weekly to ensure compliance with the interventions put in place. V2 DON conducted daily reviews of the 24-hour Report for any new or additional restraint usage. These are monitored/audited for compliance by V1 three times per week. The results of the audits will be discussed at the next Quality Assurance meeting in April 2025. 8. On 02/20/25 all residents were interviewed regarding history or existence of unnecessary restraint usage and abuse incidents. No incidents were reported by the residents. These interviews were conducted and documented by the V2 DON, V 1 Administrator, V15 MDS/Care Plan Coordinator, V13 ADON/Assistant Director of Nursing and Department Managers. 9. On 02/20/25 V15 Care Plan Coordinator reviewed and updated Care Plans for those residents with restraints, agitation, restlessness or exhibition of behaviors. R2 was the only resident identified with restraint utilization. 10. ON 2/20/25 Agency staff were inserviced and Resident Rights, improper restraint usage and the Abuse/Neglect policy to the Agency Orientation Binder. 11. The Interdisciplinary Team met on 2/20/25 and reviewed, discussed and approved the facility's Immediate Jeopardy Removal Plan. 10. V15 Care Plan Coordinator completed Care Plan audits for all residents and a system was put in place to audit five residents' Care Plans per week.

Based on record review and interview the facility failed to ensure a Registered Nurse (RN) worked at least eight hours daily. This failure has the potential to affect all 56 residents residing within the facility. Findings include: The facility's Staffing policy dated 01/16/2018 documents: There shall be at least one registered nurse on duty seven days per week, 8 consecutive hours in a skilled nursing facility. The facilities Resident Roster dated 2/11/25, provided by V2 Director of Nursing documents 56 residents currently reside within the facility. The facility's Nurse Schedules for January 1 through January 31, 2025, document the facility did not have the services of an RN at least eight hours a day on 01/01/25, 01,04/25, 01/05/25, 01/18/25 and 01/19/25. On 02/0/25 at 11:18am V2 Director of Nursing verified the nursing schedules were accurate and the facility did not have an RN working in the facility for at least eight hours on 01/01/25, 01/04/25, 01/05/25, 01/18/25 and 01/19/25.

Based on interview and record review the facility failed to immediately report inappropriate use of a physical restraint to the facility's Abuse Coordinator for two of 12 residents (R1, R2) reviewed for restraint usage in the sample of 12. Findings include: The facility's Abuse Prohibition policy, dated 03/15/2018, documents the following: Reporting - Allegations Of Abuse And Neglect: 1. A facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. The Abuse Prohibition policy continues, documenting: Abuse and Neglect Prohibition: 1. All resident have the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation. This includes seclusion and physical or chemical restraints not required to treat the resident's symptoms. On 2/11/25 at 2:45pm V3 LPN/Licensed Practical Nurse stated that on 01/01/25 at approximately 6:00pm, she fastened a gait belt around R1 and R2 while they were sitting in their wheelchairs and fastened the gait belt behind the back of the chair, out of the residents' reach, in order to keep R1 and R2 in their wheelchairs. V3 confirmed she was aware her actions constituted inappropriate physical restraints. On 02/11/25 at 1:30pm V7 LPN stated she was on duty with V3 LPN on 1/1/25. V7 stated she saw that V3 had placed a gait belt around R1 and fastened it behind the back of his wheelchair. V7 stated she knew this was wrong but did not report the incident to a supervisor or the Administrator/Abuse Coordinator. On 2/11/25 at 9:20am V6 CNA/Certified Nursing Assistant stated, I saw V3 place a gait belt across (R1's) chest, under his arms and fastened it in the back of his wheelchair. R1 would have been unable to release the gait belt. V6 stated she did not report the incident to a supervisor or the Abuse Coordinator/Administrator. On 2/11/25 at 1:30pm, V4 CNA stated that on 01/06/25 another CAN (unable to identify) told her that V3 had restrained R2 in her wheelchair with a gait belt. V4 stated she immediately reported this to a supervising nurse and the Administrator who is the facility's Abuse Coordinator. On 2/11/25 at 2:30pm, V2 DON verified the physical restraining of R1 and R2 by V3 LPN should have been immediately reported to the Abuse Coordinator/Administrator and was not reported to her until 01/06/25.

Based on interview and record review, the facility failed to have a Registered Nurse for eight consecutive hours in a 24-hour period on four of 30 days per the Facility's November Nursing Schedule, and on four of 31 days per the Facility's October Nursing Schedule. This has the potential to affect all 52 residents living in the facility. Findings: The document, Nursing, dated 1/16/18, states, There shall be at least one registered nurse on duty seven days per week eight consecutive hours, in a skilled nursing facility. The Facility's October Nursing Schedule shows that on four weekend days, 10/12/24,10/13/24 and 10/26/24,10/27/24, there was not eight hours coverage by a Registered Nurse in a 24-hour period. The Facility's November Nursing Schedule shows that on four weekend days, 11/9/24,11/10/24 and 11/23/24,11/24/24, there was not eight hours coverage by a Registered Nurse in a 24-hour period. On 12/02/24 at 11:00 AM, V1, Administrator, stated, I know that we have not had a registered nurse on several weekends in the past months. I have been trying to hire a Registered Nurse for the weekend schedule, but it's been difficult. The facility's Long-Term Care Facility Application for Medicare and Medicaid Form CMS (Centers for Medicare and Medicaid Services) 671 dated 12/01/24, signed by V1, Administrator, documents 52 residents currently reside within the facility.

Based on observation, interview and record review, the facility failed to document a diagnosis, identify behaviors, and monitor for identified targeted behaviors to warrant the use of psychotropic medications and attempt a gradual dose reduction of an antipsychotic medication for five of five residents (R5, R6, R34, R36, R39) reviewed for psychotropic medications in the sample of 33. Findings include: 1. On 12/03/24 at 9:17 AM, R6 was sitting in her room in a wheelchair. R6 stated she is happy with her care in the facility and was pleasantly confused with conversation. R6 was not exhibiting any behaviors. R6's current Physician Order sheet, dated 12/4/24 documents R6 has an order for Seroquel 25 milligrams (antipsychotic), Give 0.5 tablet (12.5 milligrams) by mouth in the evening related to Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R6's current Care Plan, dated 4/17/23, documents R6 is [AGE] years old and has diagnoses including but not limited to Anxiety, Alzheimer's Disease, Disorientation, Dementia without Behavioral Disturbance and Major Depressive Disorder. R6's care plan also documents I (R6) use antipsychotic/hypnotic medications related to Dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety. R6's Psychoactive Medication Quarterly Evaluation, dated 10/18/24, documents R6 is taking the antipsychotic medication Seroquel for a medical diagnosis/indication of Dementia without behavioral disturbance. R6's Behavior Monitoring and Intervention report, dated 6/1/24-12/3/24, documents R6 has had two days with behaviors of frustration/anger, screaming at others, agitated, sad/tearful and screaming not at others. Both occasions occurred in August of 2024. On 12/3/24 at 2:15 PM, V1 (Administrator) confirmed the provided behavior monitoring report shows (R6's) documented behaviors in last six months. V1 stated (R6's) family declines her GDR's all of the time. They never want her medications reduced. R6's Social Service Note, dated 4/22/2024 at 11:07 AM, documents (Depression Score assessment) conducted with (R6) on 4/19/2024. (R6) noted to have no concerns or issues with her mood. (R6) has diagnosis of Dementia and is receiving Seroquel per Physician orders, diagnosis of Alzheimer's. (R6) has had no behaviors in her 14 day look back period. R6's Pharmacy recommendation, dated 5/3/24, documents a recommendation to decrease R6's Seroquel to 12.5 milligrams six evenings a week and omit Sunday. This GDR was denied by V14 (R6's Physician) for the reason: Family noticed worsening mood symptoms after previous reduction in the medication. R6's Pharmacy recommendation, dated 11/1/24, documents a recommendation to decrease R6's Seroquel to 12.5 milligrams six evenings a week and omit Sunday. This GDR was denied by V14 (R6's Physician) for the reason: Has a lot of anxiety symptoms and family refuses decrease usually. On 12/4/24 at 10:00 AM, V8 (Certified Nursing Assistant, CNA) and V9 (CNA) both stated R6 has behaviors of crying & being emotional. V8 stated Sometimes it's bad dreams and (R6) knows it's not true and was a dream but she says they stick with her and upset her. (R6) isn't a harm to herself or other residents. (R6's) behaviors are not psychotic or uncontrolled in nature. On 12/4/24 at 10:09 AM, V7 (Licensed Practical Nurse) stated (R6's) behaviors are anxiousness, crying and frustration. (R6) isn't a threat or harmful to other residents or herself. On 12/4/24 at 12:30 PM, V10 (Registered Nurse/ Minimum Data Set coordinator) stated (R6's) behaviors are sadness, anxiousness, and tearfulness. (R6) admitted in 4/2023 with Seroquel and her family said she had been on it forever. (R6's) behaviors are not present when family is here, they are in the morning or after her family leaves. At this time V10 confirmed, R6 does not display behaviors that are psychotic in nature, does not have a diagnosis to support her antipsychotic medication, is not at risk for harming herself or other residents and has not had a GDR (gradual dose reduction) of her Seroquel in the last year. 2. On 12/2/24 at 11:10 AM, R36 was observed being wheeled out of his room and taken to the dining room. R36 interacted with staff while in the common areas and the dining room and was not displaying any behaviors. R36's Physician Order Sheet, dated 12/4/24 documents R36 has an order for Seroquel 25 milligrams (antipsychotic), Give one tablet by mouth at bedtime related to unspecified Dementia, moderate, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. R36's current Care Plan, dated 3/18/24, documents R36 is [AGE] years old and has diagnoses including but not limited to Dementia without Behavioral Disturbance and Major Depressive Disorder. R36's care plan also documents I (R36) use antipsychotic/hypnotic medications related to Dementia without behaviors. (R36) has the diagnoses of Dementia, Parkinson's and Depression and is receiving medications per Physicians orders. (R36) also has history of Traumatic Brain Injury and Seizures. (R36) gets very obsessive over his medications and wants them at certain times. (R36) has Meniere's Disease which can cause communication issues. (R36) is noted to be agitated with staff at times. R36's Behavior Monitoring and Intervention report, dated 6/1/24-12/3/24, documents R36 has had one day with a behavior of Public Sexual Acts which occurred on 10/3/24 and was improved with redirection from staff. No other behaviors are documented on this monitoring report for the previous six months. On 12/4/24 at 10:00 AM, V8 (CNA) and V9 (CNA) both stated R36 does not have any behaviors. V8 stated (R36) does pretty good. He used to try to get up a lot on his own but not really anymore. (R36) is not harmful to other residents or himself and doesn't have any behaviors of psychosis. On 12/4/24 at 10:09 AM, V7 (Licensed Practical Nurse) stated R36 does not have any behaviors and is not a threat to himself or other residents. On 12/4/24 at 12:30 PM, V10 (Registered Nurse/ Minimum Data Set coordinator) stated (R36) has behaviors of inappropriate comments towards staff and refusals of care. He's very particular about the timing of his medications for Parkinson's disease. V10 confirmed R36 is not at risk to harm other residents or himself and does not have behaviors or a diagnosis that is Psychotic in nature to warrant the use of his Seroquel. 31283 3. R34's current Physician's Orders document the following medication orders: Seroquel (antipsychotic) 25 milligrams by mouth every Monday, Tuesday, Wednesday, Thursday, Friday and Saturday for Dementia with Behavioral Disturbance; Venlafaxine (antidepressant) 150 milligrams by mouth in the morning related to Depression; Xanax (benzodiazepine/anti-anxiety) 0.25 milligrams by mouth every 8 hours as needed for Anxiety (date of order 11/11/24); and Xanax 0.25 milligrams by mouth twice daily for Anxiety Disorder. R34's current care plan documents the following focuses: (R34) has diagnosis for Depression and has a potential for a decline in her mood. Mood interview conducted as needed; I (R34) use anti-anxiety medications related to Anxiety Disorder; I (R34) use antidepressant medication related to Depression. (R34) prefers to stay in room and not participate with Activities or go to Main Dining Room for meals; and (R34) noted to be very tearful and anxious. (R34) noted to have visual hallucinations with delusional comments at times. (R34) also noted to be accusing, cursing, express frustration, and screaming at others. Noted to being agitated, panic, and screaming not at others. R34's current medical record does not contain documentation of behavior monitoring specific to the above-mentioned identified target behaviors. On 12/02/24 at 10:45 AM, R34 was sitting in her wheelchair near the fish tank in the front lobby visiting with her husband. R34 was dressed, groomed, and wearing glasses. R34 was alert and answering questions appropriately. R34 stated things are going well at the facility and denied having issues or concerns. R34 then stated, I would like to do more therapy. I did it a while back and I have been taken off. R34 was cooperative did not display any adverse behaviors at this time. On 12/04/24 at 11:20 AM, V10 (Registered Nurse/Care Plan/Minimum Data Set Coordinator) stated she is the individual at the facility responsible for overseeing psychotropic medication use. V10 stated R34 is not a harm to herself or others. V10 stated she could not provide documentation of behavior monitoring for R34's identified target behaviors. V10 confirmed R34 has the following PRN (as needed) order in place since 11/11/24: Xanax 0.25mg by mouth every 8 hours as needed for Anxiety. V10 stated R34's PRN Xanax is in place for, family preference. 4. R5's current Physician's Orders document the following medication orders: Seroquel (antipsychotic) 50 milligrams by mouth at bedtime Monday, Tuesday, Thursday, Friday, Saturday related to visual hallucinations; and Bupropion (antidepressant) 100 milligrams by mouth daily related to Depression. On 12/02/24 at 10:30 AM, R5 was propelling in a high-back chair near the nurses' station. R5 was dressed, groomed, and appeared pleasantly confused. R5 could answer basic questions, stated things are going well, and denied having any current issues or concerns. No adverse behaviors were displayed by R5 at this time. R5's current care plan documents the following focus: (R5) is currently receiving medications per physician orders for diagnoses of Vascular Dementia, Anxiety, Depression, and Visual Hallucinations. Visual Hallucinations noted with delusional comments. For diagnoses for Alzheimer's, she has no medicinal interventions in place at this time. There are times that (R5) will yell and scream and be combative with staff due to her Dementia. With her Depression diagnosis, she has the potential for a decline in her mood. (R5) noted to instigate a joking manner amongst staff, other residents, visitors. R5's current medical record does not contain documentation of behavior monitoring specific to the above-mentioned identified target behaviors. On 12/04/24 at 11:30 AM, V10 (Registered Nurse/Care Plan/Minimum Data Set Coordinator) stated R5 is not a harm to herself or others. V10 stated she could not provide documentation of behavior monitoring for R5's identified target behaviors. 50627 5. R39's current Physician's Orders document the following medication orders: Seroquel (antipsychotic medication) 75 milligrams by mouth at bedtime for visual hallucinations. R39's current care plan documents the following focus: (R39) has antipsychotic/hypnotic medications r/t (related to) Depression e.g. (example) visual hallucinations. R39 follows up with Psychiatry. R39's current medical record does not contain documentation of behavior monitoring specific to the above-mentioned identified target behaviors. On 12/01/24 at 10:30 AM, R39 was lying in bed waiting for staff to assist her with changing her adult brief. R39 was alert, oriented, and answering questions appropriately. R39 did not display any adverse behaviors at this time. R39's Minimum Data Set Assessment (dated 09/06/24) documents a BIMS (Brief Interview for Mental Status) score of 14, indicating R39 is cognitively intact. On 12/04/2024 at 1:30 PM, R39 stated that she takes Seroquel due to her Anxiety. R39 stated, Sometimes at night I get anxious, and the medicine is supposed to help me with feeling anxious. On 12/04/24 at 12:40 PM, V10 (Registered Nurse/Care Plan/Minimum Data Set Coordinator) stated that she could not provide documentation of R39's identified targeted behaviors. The facility's Psychotropic Medication policy (revised 11/28/17) documents the following: Intent: Residents are free from unnecessary psychotropic medication use. A psychotropic medication is any drug that affects brain activity associated with mental processes and behavior. These medications include but are not limited to: Antianxiety, Antidepressant, Antipsychotic, and Hypnotic. These medications are to be given to treat a specific condition/medical symptom that is diagnosed and documented in the clinical record. Specific condition/medical symptoms alone are not enough to justify pharmacological use. An evaluation must be done to determine other possible physical, mental, behavioral, psychological needs. This same policy documents, Residents should receive the lowest effective dose of psychotropic medication for the resident's physical, mental, and psychosocial well-being. GDR (Gradual Dose Reduction) is to be attempted within the first year in two separate quarters (with at least one month between attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated. This policy also documents the following: A psychotropic medication that is used on a PRN (as needed) basis: Classification of medication including antianxiety, hypnotic, antidepressant medication. Initial PRN order of above listed medication should not exceed 14 days, unless the attending physician or prescribing practitioner believes that to extend beyond 14 days and has documented the rationale and indicated the duration. +

Based on observation, interview and record review, the facility failed to follow Enhanced Barrier Precautions while performing wound care, perineal care, and hand hygiene for one of three residents (R39) reviewed for wound care in a sample of 33. Findings include: On 12/01/2024, at 10:45 AM, V12 (CNA/Certified Nursing Assistant) and V13 (CNA/Certified Nursing Assistant) were in R39's room changing R39's adult incontinent brief. V12 and V13 were not wearing a gown. V13 had only one glove on her right hand and was taking R39's adult incontinence brief off with the assistance of V12. V13 left the room briefly, and once V13 re-entered R39's room, she did not apply a gown, and only applied a glove to her right hand. After cares were completed, V12 and V13 removed their gloves, washed their hands, and proceeded to place R39 into a mechanical lift and assisted her to transfer into her wheelchair. V12 and V13 did not apply a gown or gloves prior to transferring R39. On 12/01/2024, at 11:00 AM, V13 stated that R39 was currently on Enhanced Barrier Precautions, due to a burn on her thigh. At this same time, V12 and V13 both stated that they should have been wearing a gown throughout R39's cares. V13 then stated she should have been wearing both of her gloves while providing cares to R39. On 12/04/24 at 08:58 AM, V11 (Licensed Practical Nurse) entered R39's room to provide a dressing change and wound care to R39's left thigh wound. V11 washed her hands, and donned gloves, but did not apply a gown before performing R39's wound care and dressing change. On 12/04/2024 at 09:15 AM, V11 confirmed that R39 was currently on Enhanced Barrier Precautions. V11 verified she did not wear a gown during R39's wound care and stated she should have. On 12/04/2024 at 12:40 PM, V2 (Director of Nursing) stated that staff should be wearing the required PPE (personal protective equipment) when providing care to residents in Enhanced Barrier Precautions. V2 then stated, There is no excuse, they should have been wearing gloves and a gown. The Facility's Enhanced Barrier Precautions Protocol Policy, revised 4/8/24, documents, Enhanced Barrier Precautions expands the use of Personal Protective Equipment (PPE) beyond situations in which exposure to blood and body fluids is anticipated, refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of Multi-Drug-Resistant Organisms (MDROs) to staff hands and clothing. If Enhanced Barrier Precautions are required, a sign should be placed outside the resident's room to assist in educating staff, residents, and visitors on appropriate personal protection. When required, Enhanced Barrier Precautions apply to everyone caring for the resident. This same policy documents, Personal Protective Equipment, PPE (e.g., gloves and gowns) should be used during high-contact resident care activities. Examples of high-contact resident care activities requiring gowns and glove use include Wound care: any skin opening a dressing. This policy also documents, Enhance Barrier Precautions may be indicated for residents with any of the following: Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or tears covered with an adhesive bandage (e.g., Band Aid) or similar dressing.

Based on interview and record review the facility failed to ensure mail was delivered on Saturdays. This failure has the potential to affect all 57 residents who reside in the facility. Findings include: The Residents' Rights for People in Long-Term Care Facilities Pamphlet documents the facility must promptly deliver and send residents' mail. On 1/17/2024 during a group meeting held with R3, R13, R19, R42, and R45 all residents agreed that they do not receive mail in the facility on Saturdays. On 1/17/24 at 10:55 AM, V1 (Administrator) verified mail is not delivered to residents in the facility on Saturdays. V1 stated the facility has a P.O. (Post Office) Box and V8 (Front Desk Receptionist) has the key and gets the residents' mail from the post office Monday through Friday and then delivers it to the residents. V1 stated that V8 does not work on Saturdays, therefore Saturday mail is not delivered to the residents. V1 stated no other staff members are responsible for getting mail from the facility's P.O. Box on Saturdays other than V8. CMS/Centers for Medicare & Medicaid Services Form-671 (Long-Term Care Facility Application for Medicare and Medicaid) signed and dated by V1 (Administrator) on 1/16/24 documents 57 residents currently reside in the facility.

Based on interview and record review, the facility failed to provide the services of a registered nurse eight hours a day, seven days a week. This failure has the potential to affect all 57 residents residing in the facility. Findings include: The facility's Direct Care Staffing Requirements Policy and Procedure, revised 1/16/ 2018, documents the facility will meet the staffing needs of the resident population. This same policy documents 1. There shall be at least one registered nurse on duty seven days per week, eight consecutive hours, in a skilled nursing facility. The facility's Daily Staffing Report Sheets document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 12/25/23; 12/31/23; 1/13/24; or 1/14/24. The facility's Nurse Schedules for December 2023 and January 2024 document the facility did not have eight consecutive hours of registered nurse (RN) coverage in the building to provide services on the following dates: 12/25/23; 12/31/23; 1/13/24; or 1/14/24. On 1/16/24 at 12:47 PM, V1 (Administrator) stated, We only have one RN who works weekends and it's every other weekend, so we have some weekends with no RN coverage. V1 stated RN management will take call on the weekends, but stated they don't usually come to the facility unless needed. On 1/18/24 at 2:10 PM, V1 verified the facility was without eight consecutive hours of RN coverage on 12/25/23; 12/31/23; 1/13/24; and 1/14/24. CMS/Centers for Medicare & Medicaid Services Form-671 (Long-Term Care Facility Application for Medicare and Medicaid) signed and dated by V1 (Administrator) on 1/16/24 documents 57 residents currently reside in the facility.

Based on interview and record review, the Facility failed to ensure a resident's allegation of staff abuse was reported to the Abuse Coordinator for one (R22) of 14 Residents reviewed for Abuse in a sample of 29. Findings include: Facility Abuse and Neglect, Involuntary Seclusion, Exploitation, Misappropriation of Resident Property, Injuries of Unknown Origin and Social Media Policy, revised 3/15/18, documents: the Facility, for protection of the Resident; screening, training, reporting incidents, investigations and facility response to the result of the result of the investigation, identification of possible incidents or allegations which need investigation, investigation of incidents or allegations, protection of Residents during investigations and prevention policies and procedures; all Residents have the right to be free from verbal, sexual, physical, mental abuse, corporal seclusion, neglect, misappropriation of property and exploitation; Abuse is defined as the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish, abuse includes deprivation by an individual; and Abuse may be verbal, sexual, physical or mental; a Facility employee or agent or covered individual who becomes aware of alleged abuse or neglect of a Resident shall immediately report the matter to the Facility Administrator; and the Facility Administrator who becomes aware of the alleged abuse or neglect of a Resident shall immediately report to the Local Health Department. Facility Electronic Mail correspondence, dated 1/17/24 at 1:12 pm, documents the Facility notification of R22's alleged Abuse investigation, that occurred on 1/3/24, to the local Health Department. R22's Admission Record Face Sheet, dated 1/17/23, documents diagnoses including Parkinson, Osteoporosis, Left Foot Drop, Overactive Bladder, History of Falling, Unsteadiness on Feet, Difficulty Walking and Muscle Weakness. R22's Nursing Progress Note, dated 1/4/24, documents that, (R22) had an involuntary stool, which is abnormal for (R22). (R22) shared with (V7/Certified Nursing Assistant/CNA) that an incident had occurred last night (1/3/24), with an unknown CNA. (R22) had been assisted into recliner but was not given (R22's) call light. (R22) waited on CNA to return to assist (R22) to bed but CNA (she) did not return so R22 put self to bed. (R22) could not lift legs into bed and pushed call light for assistance. A CNA came in and scolded R22 and proceeded to tell R22 that R22 should have been in bed already. The CNA said that she came in early to help out and it was not (her) job to put R22 to bed when 'second shifters' were standing around at desk. On 1/17/23 at 1:35 pm, R22 (alert and oriented) stated, On that night, a little after supper time, an Aide (CNA) came in to my room and helped me into my chair but did not leave me my call light, so after waiting a long time, I tried putting myself to bed, but I could not lift my legs in to the bed, but I was able to put on my call light, and a tall and slender Aide (CNA), came in and was not very nice at all to me. The Aide (CNA) was throwing stuff around and complaining to me about why I should have already been in bed. The Aide was very mean and kept scolding me. The next night, I told another Aide (V7/CNA) about it, but I have not heard anything from anyone about it, I do not know that they even did anything. On 1/17/24 at 2:34 pm, V4 (CNA) stated, I work a lot of overtime, by coming in early, because we are short all the time. I went in to (R22's) room on the night of 1/3/24. All the other 'CNAs' were just sitting around and not answering call lights, which was annoying to me, so I went in and (R22) had, had a small bowel movement, so I helped get her cleaned up and back into bed. I do not feel that I was mean to (R22). I was annoyed by the other staff sitting around though. On 1/17/24 at 2:10 pm, V6 (Licensed Practical Nurse/LPN) stated, I was (R22's) nurse on 1/4/24, and (V7/CNA) came to me and told me that (R22) had complained about a possible abuse from a 'CNA,' from the night before. I am not sure who the 'CNA' is but, (R22) told (V7) that a 'CNA' was scolding (R22), but we are not sure which 'CNA' it was. I did put in a nursing note, but I may be forgot to tell (V1/Administrator/Abuse Coordinator) or any other boss. I normally would put in my nursing note that I notified (V1), but I must have, for some reason, not told anyone, I was probably busy that night. I should have told (V1) so they could investigate it and report it. On 01/18/24 at 8:52 am, V1 stated, I have been the Administrator for about six months now, and I am the Abuse Coordinator. I have in-serviced the staff at least three times on the Abuse Policy since I have been here in that position and they should have reported that incident (of 1/3/24) to me, they are all aware of what should be done. (V6) should know better. So, I just now reported it and started an investigation to the Department of Public Health last night (1/17/24). We should have been told about this incident at the time, so we could have thoroughly investigated it and reported it if we determined if it was abuse.

Based on interview and record review, the facility failed to provide transfer/discharge notification, to the Ombudsman, for one (R11) of one resident reviewed for transfer/discharges in a sample of 29. Findings include: R11's medical record documents R11 was an active resident on 10/17/23, discharged to the hospital on 10/24/23, readmitted to the nursing home on 10/30/23, discharged back to the hospital on 10/30/23, and readmitted to the nursing home on 11/9/23. R11's nurses notes document 10/24/23 at 6:23 PM informed (family) of (R11's) fall and sending (R11) to the hospital. R11's nurses notes document 10/30/23 at 3:35 PM Resident returned from hospital. R11's nurses notes document 10/30/23 at 4:13 PM 911 called at this time to transport (R11) to the emergency room . R11's nurses notes documents on 11/9/23 at 4:30 PM R11 is up in the dining room for her meal. R11's medical record has no documentation the Long-Term Care Ombudsman was notified of the transfer or discharge in writing. On 1/17/24 at 12:23 PM, V1 Administrator stated, Social Services is responsible for notifying the ombudsman of discharges/transfers and it is not being done.

Based on interview and record review, the facility failed to notify R11 or R11's representative of the facilities bed-hold in writing for one (R11) of one resident reviewed for transfer/discharges in a sample of 29. Findings include: Facility Bed-Hold Notification form, undated, documents When a resident is transferred to a hospital, they have the right to request that their bed be held until their return. R11's medical record documents R11 was an active resident on 10/17/23, discharged to the hospital on 10/24/23, readmitted to the nursing home on 10/30/23, discharged back to the hospital on 10/30/23, and readmitted to the nursing home on 11/9/23. R11's nurses notes document 10/24/23 at 6:23 PM informed (family) of (R11's) fall and sending (R11) to the hospital. R11's nurses notes document 10/30/23 at 3:35 PM Resident returned from hospital. R11's nurses notes document 10/30/23 at 4:13 PM 911 called at this time to transport (R11) to the emergency room . R11's nurses notes documents on 11/9/23 at 4:30 PM R11 is up in the dining room for her meal. R11's medical record has no documentation R1 or R1's representative was notified of the facilities bed-hold in writing. On 1/17/24 at 12:23 PM, V1 Administrator stated, I cannot find (R11's) bed-hold notifications, I found bed-hold notifications on other residents, but I am not sure where (R11's) are. On 1/18/23 at 3:30 PM, V1 Administrator stated, I cannot find (R11's) bed-hold notifications.

Based on observation, interview, and record review, the facility failed to have physician's orders, for adaptive equipment, for one resident (R1) of 29 residents reviewed for physician's orders in a sample of 29. Findings include: On 1/16/24 at 11:38 AM, In R1's room, there was a right arm splint on the bedside table, and a right arm walker in the room. R1 had a left AFO/Ankle-foot Orthosis on her foot. R1's current Care Plan documents May wear left AFO/Ankle-foot Orthosis for foot drop with a date initiated on 3/11/16. Apply right hand splint at bedtime with a date initiated on 4/21/22. R1's electronic medical record has no orders for R1's right arm splint or left AFO. On 1/16/24 at 2:38 PM, V1 Administrator and V2 Director of Nursing stated (R1) has a right arm splint and AFO she wears. I will check into her orders. On 1/17/24 at 1:36 PM, V1 Administrator stated We don't have any orders for (R1's) splints. Sometimes when residents go out to the hospital the orders fall off and don't get re-ordered. There are no orders.

Based on interview and record review, the facility failed to implement appropriate interventions to prevent two falls out of bed for one (R46) of six residents reviewed for falls in a sample of 29. Findings include: Facility Fall Assessment and Management Policy, revised 4/2019, documents: it is the policy of the Facility to assess each Resident's fall risk on admission, quarterly and with each fall; this will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk; that factors related to the risk will be addressed and care planned; the interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the Resident; and interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall. The Facility Fall Log, undated, documents that R46 sustained a fall to the ground on 10/18/23 at 3:45 pm, and a fall on the floor on 11/16/23 at 2:15 pm. R46's current Care Plan, undated, documents that R46 is a fall risk and that R46 has a history of falls. R46's Minimum Data Set/MDS, Section C/Cognitive Patterns, dated 12/23/23, documents that R46 is never/rarely understood and cognitively is severely impaired. R46's Minimum Data Set/MDS, Section GG, dated 12/23/24, documents that R46 requires maximal assistance of staff with chair/bed transfers and rolling in bed. R46's Fall Details Report, dated 10/18/23 at 3:45 pm, documents: R46's fall on the floor in Resident (R46's) room; R46's cognition (oriented to person); R46's root cause of fall was determined that R46 was too close to the edge of the bed and R46 wiggled out onto the floor; the intervention was to educate the staff to make sure that R46 was laying in the center of the bed to prevent R46 from rolling on to the floor. R46's Fall Details Report, dated 11/16/23 at 2:15 pm, documents: R46's fall on the floor in Resident (R46's) room; R46's cognition (oriented to person); R46 was noted to be lying on the floor next to R46's bed; R46 requires two person staff assistance with transfers; an investigation and interviews determined that R46 rolled out of bed and sustained a head trauma/goose egg mid forehead to the center side of forehead; the intervention was to order a fall matt to be placed next to R46's bed and R46 was moved to a different room. On 1/28/24 at 2:15 pm, V2 (Director of Nursing/DON) stated, Our intervention on the first fall was to make sure that (R46) was placed in the center of R46's bed, then R46 fell again out of bed. We probably should have re-evaluated that intervention, because on the second fall R46 fell out of bed also and the only intervention was to place R46 in the center of the bed. R46 had a history of falls from the bed, and at one point we even had (R46) in a low bed but (R46) quit falling, so we discontinued that intervention.

Based on observation, interview and record review the facility failed to provide necessary equipment or devices for pressure relief for residents at risk for developing pressure ulcers or who required extensive or total assistance from staff for positioning, placing those residents at increased risk for the development of pressure ulcers or the worsening of existing wounds which affected two of two residents (R37, R49) reviewed for pressure ulcers in a sample of 20. This failure resulted in R37 developing multiple pressure ulcers including a right buttocks stage two pressure ulcer which deteriorated to a stage 4 pressure ulcer; and R49 developing an abrasion to the right iliac crest which deteriorated to a stage 3 pressure ulcer. Findings include: A Wound and Ulcer Policy and Procedure policy dated 1/10/18 states, It is the policy of this facility to provide nursing standards for assessment, prevention, treatment, and protocols to manage residents at any level of risk for skin breakdown and for wound management, This policy also states, Residents with existing pressure ulcers will be deemed as high risk for impaired skin integrity despite the Braden Risk Assessment score, and Specialty mattress (low air loss, alternating pressure, etc.) with enhanced pressure reducing/relieving properties may be placed on the resident's bed and chair as indicated. In addition, this policy states, Skin contact surfaces may be padded to protect bony prominences. This same policy documents, A pressure ulcer is 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 states that a stage 2 pressure ulcer is defined as, Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed (without bruising or slough). This policy states that a stage 3 pressure ulcer is defined as, Full thickness tissue loss involving damage of necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia (a thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place). Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough (dead tissue) may be present but does not obscure the depth of tissue loss. This policy documents that a stage 4 pressure ulcer is described as, Full thickness loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. In addition, this policy describes an unstageable pressure ulcer as, Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/ or eschar (dead or devitalized tissue that is tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, cannot be determined. This policy describes a Deep Tissue Injury as, Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. This policy documents that equipment to be included in pressure ulcer prevention and treatment should include, Positioning aids; special mattress and/or chair cushion (low air loss, alternating pressure, etc.) with pressure reducing/relieving properties. A Facility mattress manufacturers information sheet, marked by the facility to indicate the model used by R37 and R49, states this mattress is recommended, For the prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. R37's Minimum Data Set (MDS) assessment dated [DATE] documents R37 required extensive assistance of one person for bed mobility, transfers, dressing, toilet use, and personal hygiene. R37's 3/17/22 MDS documents during that assessment R37 required extensive assistance of two people for bed mobility, and extensive assistance of one person for transfers, dressing, toilet use, and personal hygiene. R37's MDS dated [DATE] documents during that assessment R37 required extensive assistance of two people for bed mobility, transfers and toilet use. R37's MDS dated [DATE] documents R37 requires extensive assistance of two people for bed mobility, transfers, toilet use and is totally dependent on staff for personal hygiene. R37's Braden Scale for Predicting Pressure Ulcer Risk dated 12/9/21 documents R37 was at risk for developing pressure ulcers. At the bottom of this same assessment is a list with boxes to be checked as clinical suggestions to prevent R37 from developing pressure ulcers, however, none of the boxes are checked. R37's medical record indicates R37 had 13 more Braden Scales for Predicting Pressure Ulcer Risk between 1/9/22 and 10/9/22, all document R37 is at risk or high risk of developing pressure ulcers, none of which have the clinical suggestion boxes marked. R37's Ulcer/ Wound documentation dated 12/27/21 as an initial assessment document that R37 had developed a facility acquired stage 2 pressure ulcer to R37's right buttock measuring 5.5 cm (centimeters) long x 2 cm wide. R37's Ulcer/ Wound documentation dated 1/18/22 documents that on that date R37 still had a stage 2 pressure ulcer to the right buttock and, additionally had developed a stage 2 pressure ulcer to R37's coccyx measuring 0.8 cm long x 0.4 cm wide x 0.1 cm deep in which the wound bed contained yellow or white slough tissue that was adhering to the ulcer bed in strings or in thick clumps or was mucinous. R37's Ulcer/ Wound documentation dated 2/8/22 documents R37's right buttock wound had deteriorated to an unstageable pressure ulcer measuring 2.2 cm long x 2.5 cm wide x 0.1 cm deep in which the wound bed contained black necrotic tissue. R37's Ulcer/ Wound documentation dated 2/22/22 documents R37's right buttock wound was still an unstageable wound but had deteriorated in size and was now measuring 3.7cm long x 3.2 cm wide x 0.3cm deep. This note also documents R37's wound was draining a serosanguineous (bloody) drainage during this assessment. R37's Ulcer/ Wound documentation dated 3/1/22 documents R37's right buttock wound was still unstageable and measured 3.7 cm long x 3 cm wide x 0.4 cm deep and was draining copious amounts of serosanguineous drainage. R37's Ulcer/ Wound documentation dated 3/22/22 documents R37's wound had deteriorated to a stage 3 pressure ulcer measuring 5 cm long x 3.5 cm wide x 2 cm deep. R37's Ulcer/ Wound documentation dated 4/18/22 documents R37's pressure ulcer to the right buttock had deteriorated to a stage 4 pressure ulcer measuring 6.5 cm long x 3.8 cm wide x 2 cm deep. R37's Ulcer/ Wound documentation dated 10/5/22 documents R37 still had a stage 4 pressure ulcer to the right buttocks but had also developed a new facility acquired Deep Tissue Injury to R37's left heel which measured 2.0 cm long x 2.8 cm wide. R37's Ulcer/ Wound documentation dated 10/25/22 documents that R37 had also developed a Deep Tissue Injury to R37's left elbow as of 10/5/22, although there is no ulcer/wound assessment for this wound on 10/5/22. R37's current care plan documents that since 12/10/20 R37 has had a plan of care for R37's risk for impaired skin and pressure injury (related to) age, sedentary behavior, decreased bed mobility, cognitive impairment, frequent incontinence of (bowel and bladder), and [CONDITION(S)] in (bilateral lower extremities.) This same care plan does not document any pressure relieving measures were implemented once R37's right buttocks stage 2 pressure ulcer developed on 12/27/22, or when R37 continued to have a stage 2 pressure ulcer during R37's Ulcer/Wound documentation on 1/18/22 when R37 was also assessed to have a new stage 2 pressure ulcer with slough on R37's coccyx; or when R37's right buttock wound deteriorated to an unstageable on 2/8/22, or when R37 had worsening depth to his right buttocks wound on 3/1/22. This care plan documented a pressure relieving cushion was provided for R37's wheelchair on 3/9/22 after R37's right buttock wound had deteriorated to an unstageable pressure ulcer, but no changes were made to R37's bed mattress. R37's care plan does not indicate R37's mattress was changed to a specialty mattress as per the facility's policy or any additional pressure relieving measures were implemented when R37's right buttocks wound deteriorated to a stage 3 pressure ulcer on 3/22/22 or when R37's wound deteriorated to a stage 4 pressure ulcer on 4/18/22. R37's care plan documents that R37 was provided with pressure relieving boots after R37 developed an unstageable pressure ulcer to the left heel on 10/5/22. R37's care plan does not document that R37 is on a turning and repositioning program. On 11/1/22 at 11:15a.m. R37 was lying on a regular facility mattress turned slightly to the right with a blanket under R37's left hip. V6 (Wound Nurse) and V7 (Restorative Nurse) entered R37's room and were preparing to change R37's right buttocks wound dressing. V6 and V7 removed the blanket from under R37 then using total assistance, turned R37 to his right side. V6 removed R37's dressing then measured R37's wound. R37's right buttock wound was a large round open area measuring 5 cm long x 4 cm wide x 1.5 cm deep with tunneling at the 9:00 o'clock position measuring 2 cm deep. R37's wound bed was a pale pink with some white/yellow areas visible deep within the wound. On 11/2/22 at 9:38a.m. V6 stated she is also the care plan/MDS coordinator but assesses wounds every Tuesday. V6 stated that R37 had been noncompliant with lying down to take pressure off R37's buttocks prior to developing his right buttock wound 12/27/21. V6 stated that R37 prefers to sit up in his wheelchair during the day but that R37 will sleep in his bed at night. V6 stated that despite R37's preference to sit up in his wheelchair all day, the facility did not provide R37 with a pressure relieving cushion for his wheelchair until 3/9/22 after R37 had developed an unstageable pressure ulcer to his right buttock. V6 stated that R37 has a regular facility mattress on his bed. V6 stated the facility thought if R37 had a specialized pressure relieving mattress it would interfere with how R37 transfers from the bed using a standing mechanical lift. V6 verified that no new pressure relieving measures were implemented after R37 developed a stage 2 pressure ulcer to the right buttocks on 12/27/22, after R37 developed a stage 2 pressure ulcer to the coccyx on 1/18/22, after R37's right buttocks wound deteriorated to an unstageable wound on 2/18/22, or when it deteriorated in depth on 2/22/22 and 3/1/22. V6 stated the facility implemented R37's pressure relieving cushion for his wheelchair on 3/9/22 after R37's right buttock wound was already an unstageable pressure ulcer. V6 stated that even after R37's right buttock pressure ulcer deteriorated to a stage 3 on 3/22/22, and then deteriorated again to a stage 4 on 4/18/22, the facility did not provide R37 with a specialized air mattress as indicated in the facility's pressure ulcer policy. V6 stated the facility did not implement a defined every two hour turn and reposition schedule for R37 until 7/22/22 after R37's pressure ulcer had deteriorated to a stage 4. V6 verified that R37 did not have any pressure relieving boots to protect his feet until R37 developed an unstageable pressure ulcer to his left heel on 10/5/22. V6 stated that when R37's stage 4 pressure ulcer to the right buttock did not appear to be healing, R37's family transitioned R37 to hospice services on 6/14/22. 2. R49's Ulcer/Wound documentation dated 8/10/2022, documents Right Iliac crest (rear) Length 0.5 x 0.5 x 0 depth. Stage N/A (non-applicable). Granulation tissue pink, no drainage, round/oval crater like with regular firm edges, no tunneling, no necrosis. Date ulcer/wound was initially identified 8/10/2022. R49's Ulcer/Wound documentation dated 8/16/2022, documents Right Iliac crest (rear) Length 1.8 x 1.8 x 0 depth. Stage N/A. Peri wound intact. No warmth, swelling or redness noted. Granulation tissue pink. No drainage, round/oval crater like with regular firm edges, no tunneling, no necrosis. R49's Ulcer/Wound documentation dated 8/23/2022, documents Right Iliac crest (rear) Length 2.3 x 1.8 x 0 depth. Stage N/A. Peri wound intact. No warmth, no swelling, or redness noted. Granulation pink. No drainage, round/oval crater like with regular firm edges, no tunneling. Necrosis tissue present 90% (percent). R49's Ulcer/Wound documentation, dated 8/30/2022, documents Right Iliac crest (rear) Length 3.4 x 2.9 x 0 depth. Stage: is unstageable. Wound Bed Tissue Type, Necrotic tissue (Eschar) - Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges, may be softer or harder than surrounding skin. Peri wound skin, 90% necrotic tissue with 10% yellow/slough tissue. Peri wound intact. No warmth or swelling. Redness noted to peri wound. R49's Ulcer/Wound documentation, dated 9/6/2022, documents Right Iliac crest (rear) Length 4.7 x 4.2 x 0 depth. Stage: is unstageable. Wound Bed Tissue Type : Necrotic tissue (Eschar). Peri wound is 50% necrotic tissue with 50% yellow/slough tissue. redness around peri wound. R49's Nurses Notes dated 9/9/2022, documents (R49) is being transferred and admitted to the local hospital for wound infection. R49's Nurses Notes dated 9/20/2022, documents R49 returned from the hospital on that dated and was assessed to have, Right posterior thigh, pressure ulcer Length (CM) Centimeters 8.1 x 5.6 x 0. Wound bed necrotic, stage 3, wound exudate: serosanguinous-thin, watery, pale/pink drainage. Moderate drainage 26-75%. Obscured full thickness skin and tissue loss. R49's Ulcer/Wound documentation dated 9/27/2022, documents Right Iliac crest (rear) Type: Pressure. Length 8 x 5 x 0.5 depth Stage 3. Slough- yellow white tissue that adheres to the ulcer bed. Noted to the center off the wound. Moderate drainage with firm edge. R49's Ulcer/Wound documentation dated 10/4/2022 documents, Right Iliac crest (rear) Type: Pressure. Length 7.5 x 5.8 x depth 0.5, Stage 3. Slough- yellow- white tissue that adheres to the ulcer bed. Noted to the center of the center of wound bed. moderate drainage. R49's Ulcer/Wound documentation dated 10/11/2022, documents, Right Iliac crest (rear) Type; Pressure, Length 7.5 x 5.3 x 0.5 depth, Stage 3. Yellow slough and necrotic tissue noted in the center of wound. Edges are sloped. R49's Nurses Notes dated 10/18/2022, documents (R49) Stage 3 pressure ulcer to right posterior iliac crest, 7.5 CM (Centimeters) x 4.8 CM x 0.5 CM. Yellow slough and 50% necrotic tissue noted to center of wound. Pink granulation tissue noted to outer wound bed. Edges noted to be sloped. No warmth, swelling or redness noted to peri wound. Moderate serosanguineous drainage noted. R49's Nurse notes dated 10/25/2022, documents (R49) Stage 3 pressure ulcer to right iliac crest, 6CM x 5.5CM x 0.5 CM depth. Yellow slough noted to the center of the wound. Cleansed area and applied an antiseptic solution with gauze and covered wound with Silicon foam dressing. R49's Ulcer/Wound documentation dated 11/1/2022, documents Right Iliac crest (rear), Type: Pressure. Slough 7.2 x 4.6 x 0.5 Stage 3. Yellow slough noted in the middle of the wound. R49's Care plan, dated 10/31/2022, documents Unstageable Pressure Ulcer to Posterior Right Iliac crest, Pressure relief mattress (also concave properties) to maintain skin integrity. The facilities mattress manufacturer guideline sheet documents that, It is recommended for prevention and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] R49's Braden Scale for Predicting Pressure Ulcer Risk, dated 9/27/2022, documents, Sensory Perception: Completely Limited. Moisture: Occasionally moist, Activity: Chair fast, Mobility: Slightly limited, Nutrition: Probably inadequate. Result: Moderate risk for skin breakdown. On 11/1/2022 at 2:55PM, R49's wound care treatment was observed to right iliac crest. Wound measured 7.2 x 4.7 x 0.5 with yellow slough in the center of wound. Edges were sloped. Moderate drainage noted on old dressing. Wound bed was odorous. R49 did not have a specialized mattress on the bed, and had two mattresses on floor. On 11/1/2022 at 3:00PM, V6/Wound Nurse stated The mattress (R49) has on the bed right now is the mattress that is used by all residents in the facility. This one has concave edges to help (R49) from rolling out of bed. I suppose (R49) should have a special pressure relieving mattress for (R49) wound. (R49) was admitted to hospice services on 9/20/2022, and they should provide (R49) with one. On 11/2/2022 at 9:00 AM, V2/DON (Director of Nurses) stated On 11/1/2022, I requested a special relieving mattress for (R49) to help with (R49's) pressure ulcer. Hospice should provide this mattress. On 11/2/2022 at 10:00AM, V6/Wound Nurse stated We did not order a special pressure relieving mattress until now. (R49) has that mattress that prevents (R49) from falling out of bed. We felt (R49) needed that one more. On 11/2/2022 at 9:30AM, V9/LPN (Licensed Practical Nurse) stated I requested a special air loss mattress for (R49) today. Hopefully it will show up, today. On 11/2/2022 at 1:30PM, V8/Physician stated (R49's) mental capacity isn't good. I would of like to see this type of (air) mattress on (R49's) bed. I don't know why they didn't provide (R49) one, but can you take an order over the phone for a special mattress for (R49's) bed?

Based on interview and record review the facility failed to implement safe mechanical lift transfer measures, based on resident assessments, by ensuring two staff were present during the mechanical lift transfer for a resident with poor balance and severe limitation in range of motion, which affected one of three residents (R1) reviewed for falls in a sample of four. These failures resulted in R1 losing balance while sitting on the edge of the bed, following a mechanical lift transfer by one staff member, and falling to the ground sustaining an Intraparenchymal Hemorrhage. Findings include: A Food and Drug Administration (FDA) Patient Lifts Safety Guide (undated) documents safety measures to employ while using a mechanical lift. This guide states, A floor-based, full-body sling lift is featured throughout this guide; however, the information applies to all patient lifts, and Most lifts require two or more caregivers to safely operate lift and handle patient. This guide uses visual aides to demonstrate lift safety and shows two care givers involved in patient transfers, one to operate the machine and a second person to assist the patient. A Safe Resident Handling Program policy dated [DATE] states, Initial screening will be performed on all residents to assess transfer & ambulating status. Resident transfer status will be reviewed via care-plan time frame and on an as needed basis. If therapy recommends a change in transfer status the recommendations will be reviewed by a nurse manager prior to changing the status in the care plan. R1's Admission Record of diagnoses includes Dementia without Behavioral Disturbances, Cerebral Infarction, Heart Failure, Chronic Pain, [CONDITION(S)], Arthropathy, Dysphagia, Cognitive Communication Deficit, Feeding Difficulties, [CONDITION(S)]. R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is severely cognitively impaired, requires extensive assistance for bed mobility, transfers, does not walk, and requires extensive assistance for locomotion in a wheelchair. This same MDS documents R1 is not steady and only able to stabilize with staff assistance during surface-to-surface transfers meaning transfers between bed and chair or wheelchair and has a functional limitation in range of motion to both R1's upper extremities and one lower extremity. In addition, R1's MDS section GG Functional Abilities and Goals documents that during a lying to sitting on side of bed or chair/bed to chair transfer, R1 requires substantial/maximal assistance where the helper does more than half the effort and the helper lifts or holds R1's trunk or limbs and provides more than half the effort. R1's Morse Fall Scale assessment dated [DATE] documents R1 is at high risk for falling because R1 has a history of falls, is non-ambulatory with a mental status which indicates R1 overestimates or forgets the limits of R1's abilities to ambulate safely. R1's Physical Therapy (PT) Discharge Summary dated as signed [DATE] documents upon initiation of therapy, R1 had a therapy goal to improve R1's ability to move from a lying to sitting position and a sitting to lying position. This summary documents that at the time of discharge R1's ability to perform this task remained unchanged from baseline. This same PT discharge summary documents that, at baseline, R1 leaned 30 degrees to the right from a neutral alignment with a 40-degree lateral flexion to the left and with a 30-degree rotation of R1's upper body to the right and with R1's body flexed forward at an angle of 30 degrees. R1's PT goal for leaning to the left with rotation to the right and leaning forward was to improve R1's cervical spine side bending to only 15 degrees from a neutral alignment. This summary documents that R1 was able to meet this goal of leaning only 15% on [DATE]. R1's PT discharge summary also documents R1's sitting balance was considered fair - with the goal of improving R1's sitting balance to fair + in order to improve R1's participation in using the sit/stand mechanical lift transfer device. At the time of discharge from physical therapy, R1 was unable to meet R1's sitting balance goal and remained unchanged from her baseline. R1's PT goal of improvement in dynamic sitting balance to Fair in order to improve R1's stability during Activities of Daily Living (ADL) and sit/stand mechanical lift transfers was unmet with R1's ability remaining unchanged from baseline. At the time of R1's discharge from PT, R1's sitting balance was fair for static sitting balance and poor for dynamic balance. On [DATE] at 10:40a.m. V7 (Therapy Manager) stated that R1 was receiving physical and occupational therapy from [DATE] to [DATE]. V7 stated that R1 was discharged after less than a month because she had reached her maximum potential. V7 stated that R1's maximum potential was the same as her baseline from the start of therapy. V7 stated at the time of therapy discharge R1 required a total staff assistance with the use of a standing mechanical lift. V7 stated R1 was not expected to make any additional improvements. V7 stated the Therapy Department did not perform any additional evaluations to R1 after R1's discharge from therapy [DATE]. R1's current care plan documents that as of [DATE] R1 was at risk for falls related to R1's age, use of medications that may cause dizziness, weakness and history of a fall. R1's fall risk care plan goal was to minimize R1's risk of injury related to falls. R1's care plan fall prevention interventions included: the use of a Mechanical stander for all transfers on an as needed basis (PRN) which was initiated on [DATE] and discontinued [DATE]. On [DATE] the intervention of Mechanical sling lift with 2 (two) assist for all transfers, PRN was added to the care plan as a new fall prevention measure. R1's care plan for ADL Self Care Performance Deficit dated [DATE] documents R1's ADL self-care deficit is related to R1's weakness, confusion, low back pain, sedentary behavior, incontinence, limited range of motion to bilateral upper extremities and left lower extremity. This ADL care plan documents as interventions dated [DATE], May use mechanical sling lift with 2 assist with increased difficulty bearing weight, and (R1) to transfer with (standing mechanical lift) x 1 (one) assist, also dated [DATE]. This ADL care plan does not show R1's ADL interventions were updated on [DATE] when R1's fall risk care plan interventions were reviewed and updated. R1's progress note dated [DATE] at 12:54p.m. and entered by V3 (Registered Nurse) documents that on that date, Staff assisting resident to bed via mechanical stander x 1 staff. When removing mechanical stander away from resident/bed, resident fell to floor. Resident hit her head when falling to floor. Laceration noted to (right) temporal portion of head. Applied pressure with towels. Unable to stop bleeding from area. Further, this nursing progress note documents R1 was sent emergently to the hospital for evaluation and treatment. R1's progress note dated [DATE] at 5:34p.m. states, IDT (Interdisciplinary Team) Fall Team meeting held to discuss resident's recent fall. Root cause of fall: Decline in (R1's) functional ability and was unable to maintain sitting position on edge of bed. Intervention: (R1) was sent to ER (emergency room ) for eval and treat. Ongoing intervention: Transfer (R1) with mechanical stander and 2 assist. R1's progress note entered at 6:45p.m. documents R1 returned to the facility with sutures in place. R1's progress note entered at 7:30p.m. documents, Resident is confused. Doesn't know where she is, writer attempted to reorient resident, it didn't help. Resident unable to follow writer's fingers, grasping at things that aren't there. At (7:33p.m.) writer called MD (physician), gave orders to send to hospital. R1's progress note dated [DATE] at 10:32a.m. documents that nursing staff called the hospital for an update on R1's condition and were informed R1 had sustained a right side hemorrhage. On [DATE] at 2:23p.m. V3 stated she was R1's nurse on the day she fell [DATE]. V3 verified that there was only one staff member in the room during R1's transfer. V3 stated that after R1 fell , V4 told her that after V4 had transferred R1 to the bed using the standing mechanical lift, V4 was pulling the mechanical lift away from the bed when R1 fell on to the floor. V3 stated that the CNAs have transfer instructions that say R1 could be transferred using the standing mechanical lift using only one CNA but that they could choose to use the full mechanical lift with two CNAs if they thought R1 was having difficulty bearing weight. V3 stated it was up to the CNA to decide what kind of transfer R1 needed stating, It was their choice. V3 stated she does not know why R1's care plan was changed on [DATE] to include using a mechanical lift with two staff for all transfers PRN. V3 stated that R1 was not able to sit up on the side of her bed independently and R1 also had a specialized mattress with a motor which fills the mattress with air and is used as a pressure ulcer prevention. V3 stated she thought R1 was steady while sitting up on the side of the bed but that, No one should be left unattended on the side of the bed. R1's fall investigation dated [DATE] to [DATE] documents V4 (Certified Nurse Aide/CNA) was the staff member present when R1 fell on [DATE]. This investigation documents that during V4's interview V4 stated that she used the standing mechanical lift to transfer R1 to a seated position on the side of R1's air mattress and when V4 released the mechanical lift straps from around R1, R1 was unable to remain in a sitting position and slid off the bed and onto the floor, striking R1's head. This same investigation documents R1's roommate, R4, was a witness to R1's fall. R4 stated that V4 transferred R1 to the bed using the standing mechanical lift. R4 stated that when V4 released the straps, R1 fell on to the floor and hit her head. On [DATE] at 12:52p.m. V2 (Director of Nurses) stated she investigated R1's fall from the side of the bed on [DATE]. V2 stated that when she interviewed V4, V4 stated that after she had transferred R1 to the bed using the standing mechanical lift, R1 was unable to sit up straight which caused R1 to fall. V2 stated that R1's roommate, R4, was interviewed and she confirmed that after R1 was transferred to the side of the bed by V4, R1 could not sit up straight and fell off the bed. V2 stated, I don't think they (staff) knew (R1) was unable to maintain an upright position at that time. R1's hospital records dated [DATE] to [DATE] document R1 was transferred to the hospital following a fall at the facility on [DATE] where she initially had a negative Computed Tomography Scan (CT) but returned to the hospital a second time on [DATE] with acute mental status changes at which time another CT was performed which showed R1 had sustained Right Superior Temporal Intraparenchymal Hemorrhages. This hospital record documents R1 was not a surgical candidate but remained in the hospital for 16 days during which time R1's condition deteriorated. R1's hospital discharge summary documents R1 was referred to Hospice for comfort measures at the time of discharge. R1's Radiology report dated [DATE] documents R1 received a CT scan for Worsening confusion after a fall today. This CT scan documents R1 had sustained a 4.3cm (centimeter) x 3cm right superior temporal intraparenchymal hemorrhage with surrounding [CONDITION(S)] and additional small focus of cortical hyperintensity within the lateral right frontal lobe which could reflect additional hemorrhage. R1's Death Certificate dated [DATE] documents R1 died at the facility on that date with a cause of death due to Intracranial Hemorrhage.

Based on interview and record review, the facility failed to use a gait belt during a resident transfer for one of four residents (R1) reviewed for accidents in the sample of four. This failure resulted in R1 falling, fracturing her left hip, experiencing severe pain, undergoing surgical repair of the left hip fracture, and a 3-night hospital stay. Findings include: The Facility's Safe Resident Handling Policy dated 3/18/18, documents, Gait belt usage is mandatory for all resident handling with the exception of mechanical lift use, bed mobility, and medical contraindications. R1's Minimum Data Set assessment dated [DATE], documents R1 has moderately impaired cognition, requires assistance of one staff for transfers, is unable to ambulate, and is not steady going from sitting to standing without staff assistance. R1's Fall Investigation dated 4/3/22, documents the following: On 4/3/22 at 7:30 a.m., R1 was being transferred from her(R1) bed to the wheelchair, by V5 (Certified Nurse Aide). During this transfer, R1 crossed R1's legs and stumbled forward and V5 was unable to hold onto R1 causing both R1 and V5 to fall to the floor. R1 complained of left leg pain, the Physician was notified and an order for R1 to be sent to the hospital for evaluation and treatment was obtained. R1's hospital diagnosis indicated R1 had a left intertrochanteric femur fracture (hip fracture). On 4/3/22, R1 had a closed reduction with intramedullary fixation of the left intertrochanteric femur fracture (surgical repair of left hip fracture). R1's X-Ray report dated 4/3/22 at 10:33 a.m., states, (R1) complains of severe left hip pain and limited range of motion after a ground level fall today. Findings: Acute impacted mildly angulated left intertrochanteric femur fracture (hip fracture). R1's Operative Report dated 4/3/22, documents R1 was having a closed reduction with intramedullary fixation of a left intertrochanteric femur fracture after a ground level fall and diagnosed with a left hip fracture. R1's computerized Census Report documents R1 was admitted to the hospital on 4/3/22 and readmitted to the facility on [DATE]. On 4/10/22 at 3:20 p.m., V5 (Certified Nurse Aide) stated that on 4/3/22 V5 was transferring R1 from her (R1) bed to the wheelchair. V5 stated mid transfer R1's legs crossed wrong instead of pivoting causing R1 to lose R1 balance. V5 stated, I went to save both of us but we both went down. I did not use a gait belt on R1 that day because I could not find (R1's) and someone stole mine. I was grabbing the back of R1 pants for support and when I stepped back to try to save us, we both went down to the floor. (R1) was immediately in severe pain. (R1) was grasping R1 left leg and saying 'ouch' really loud. On 4/9/22 at 8:50 a.m., V4 (Licensed Practical Nurse) stated that V4 was R1's nurse on 4/3/22 when R1 fell during a transfer with V5. V4 stated V5 yelled for V4's assistance due to R1 falling and V4 found R1 on the floor in her room, lying on R1 left side, holding R1 left thigh, and screaming in pain. V4 stated R1's Physician was notified, and orders were received to transfer R1 to the hospital. On 4/9/21 at 9:25 a.m., V2 (Director of Nursing) stated R1 did have a fall with fracture on 4/3/22 during a one assist transfer performed by V5. V2 stated R1's fall with injury was investigated and found that V5 was transferring R1 from the bed to R1 wheelchair without using a gait belt. V2 stated R1 crossed her legs rather than pivoting, lost R1 balance and V5 was unable to hang on to R1 to help keep R1 balance or from falling. V2 stated all one or two assist transfers require the use of a gait belt. V2 stated R1's fall on 4/3/22 resulted in a left hip fracture, severe pain, surgical repair, and hospitalization .

Based on observation, interview and record review the facility failed to perform a fall assessment after falls, ensure fall prevention interventions were in place and failed to provide supervision to prevent falls with injury for one (R1) of three residents reviewed for falls in the sample of three. These failures resulted in R1 obtaining two humerus fractures, a subdural hematoma, and a [CONDITION(S)]. Findings include: The Resident Occurrence Reports for R1, document R1 had nine unwitnessed falls in her room in the last seven months on 10/18/20, 11/23/20, 12/4/20, 12/5/20, 1/15/21, 3/21/21, 5/5/21, and 5/9/21, and had one unwitnessed fall in a common area on 4/20/21. The State Agency Reports document the following falls with injuries to R1 on the following dates: 10/18/20 obtained a right humeral head fracture; 1/15/21 obtained a right humeral shaft fracture with moderate displacement of fracture fragments; 5/5/21 obtained a subdural hematoma; and 5/9/21 obtained a left femoral intertrochanteric displaced and comminuted fracture. The facility's Fall Assessment and Management Policy, Revised 4/2019, documents It is the policy of this facility to assess each resident's fall risk on admission, quarterly, and with each fall. This will help facilitate an interdisciplinary approach for care planning to appropriately monitor, assess and ultimately reduce injury risk .The potential for falls will be care planned when appropriate, based on the results of the Fall Risk Assessment. The interdisciplinary care plan will be person centered to reflect the specific needs and risk factors of the resident .Interventions will be based on the fall risk assessment and the circumstances surrounding the risk for injury or actual injury or fall .A licensed nurse will consult with the resident's care givers and other interdisciplinary team members in regards to future intervention, and resident specific risk factors. R1's Medical Records contains the following Fall Risk Assessments and Fall Risk scores for R1: 9/29/20 scored 80 and documents R1 is High Risk for Falling and 12/27/20, 3/29/21, and 5/16/21 scored 75 and document R1 High Risk for Falling. There are no Fall Risk Assessments completed after R1's falls on 10/18/20, 11/23/20, 12/4/20, 12/5/20, 1/15/21, 3/21/21, 4/20/21, 5/5/21, and 5/9/21. R1's Current Fall Care Plan includes the following interventions: Make sure my call light is always within my reach .Staff to increase visual checks and to ask resident if she needs to toilet frequently .Staff to provide assistance with ADL's (Activities of Daily Living) d/t (due to) right shoulder fracture .Toilet (R1) before and after every meal. 1. On 5/21/21 at 11:50 am, R1's room is in the middle of the 200 hall; yellow zone hallway. R1's doorway entrance to her room was covered with a semi clear plastic zippered barrier with signage on the wall documenting R1 is in a Droplet Isolation precautions room. There is a bin filled with PPE (Personal Protective Equipment) next to the entrance to R1's room. R1 is sitting up in a low seated reclining wheelchair with lunch tray in front of her. There are no staff in or near R1's room. On 5/21/21 at 1:30 pm and 5/25/21 at 12:35 pm and 2:00 pm, R1 was lying in bed and there were no staff in or near R1's room. On 5/26/21 at 9:25 am, R1 was sitting up in her low reclining wheelchair with breakfast meal in front of her. There were no staff in R1's room. R1's call light was rolled up her bed blankets on top of R1's bed, out of R1's reach. On 5/26/21 at 9:27 am, when R1 was asked if she can use her call light, R1 stated, I can't find it now. I don't know where it is. R1 began looking around her room. On 5/26/21 at 8:50 am, V6 (Certified Nursing Assistant/CNA) stated R1 can and will use her call light if she needs something. On this same date at 9:32 am, V6 confirmed R1's call light was on R1's bed and was not within R1's reach when R1 was sitting in her wheelchair. V6 stated generally the call light is on R1's chair when she is sitting up. 2. The Resident Occurrence Reports for R1, dated 10/18/20 at 1:20 am, 12/4/21 at 7:20 pm, 1/15/21 at 1:00 pm, and 5/5/21 at 3:00 pm document R1's unwitnessed falls in her room and were related to R1 attempting to get self into or out of her bathroom, with no staff present. R1's hospital reports document R1 was diagnosed with a right impacted humeral neck fracture after her 10/18/20 fall, an acute fracture of humeral shaft with moderate displacement of fracture fragments after her 1/15/21 fall, and a subdural hematoma after her 5/5/21 fall. The Resident Occurrence Report for R1, dated 5/9/21, documents another unwitnessed fall in R1's room with unknown activity documented prior to the fall with hospital diagnosis of left intertrochanteric femur fracture with surgical repair. The Resident Occurrence Reports for R1, dated 11/23/20, 12/5/20, 3/21/21, and 4/20/21 are also documented as unwitnessed falls and occurred in R1's room with no staff present and without injuries. On 5/25/21 at 1:30 pm, V2 (Director of Nursing) stated R1 is cognitively impaired and the root cause to (R1's) falls is that she has poor safety awareness related to her dementia. V2 stated staff repeatedly remind R1 to use her call light and ask for assistance prior to getting up but R1 does not always remember. V2 stated it has been more difficult to visualize and get to R1 with her being in a quarantine room and the plastic barrier was harder to see through. V2 stated R1 did fall on 5/9/21 while in the isolation room which was when the facility changed R1's plastic barrier to a semi clear plastic for better visualization. V2 also stated, We have plenty of staff and have hired more recently .We don't have the staff to assign someone to sit with her or at her door while she is in quarantine .Residents have the right to fall. When asked about frequency of resident checks, V2 stated, We don't use specific times, staff are to just check more frequently. V2 stated the facility does not do Fall Risk Assessments after every fall, they are done with Admission, Quarterly, and Significant Change Assessments only. On 5/25/21 at 3:17 pm, V1 (Administrator) stated the plastic barrier to R1's doorway entrance was changed to a semi clear plastic barrier after R1's 5/9/21 fall to enable better visualization of R1.