Every finding on record at Mclean County Nursing Home

Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions by failing to wear Personal Protective Equipment when emptying an internal urinary drainage device and failed to maintain urinary drainage bags off the floor, in a dignity bag, and away from potentially contaminated surfaces. This failure affects three of five residents (R9, R26, R48) reviewed for infection control on a sample list of 38. Findings include: The Urinary Catheter Policy and Procedure dated February 2025 documents that care shall be taken to avoid contact of the drainage tube with anything that could contaminate it. 1.On 8/12/25 at 10:00 AM, R9 was in R9's wheelchair propelling down the hall. R9's urinary drainage bag was dragging on the floor as R9 moved down the hall. On 8/12/2025 at 2:22 PM, R9 was in the dining room with other residents participating in an activity and R9's urinary drainage bag was beneath R9's wheelchair and resting on the ground. R9's Care Plan dated 6/27/25 documents R9 requires an internal urine drainage device due to obstructive uropathy. This Care Plan documents the approach to this problem is that staff are to avoid allowing tubing or any part of the drainage system to touch the floor. R9's Care Plan dated 7/21/25 documents R9 requires enhanced barrier precautions (EBP) related to internal urine drainage device. This Care Plan documents that R9 and staff will be taught the chain of infection, methods of transmission and principles of infection control. 2.R26's Care Plan dated 6/13/25 documents R26 requires an internal urine drainage device related to Flaccid Neuropathic Bladder. This Care Plan documents that staff are to avoid allowing tubing or any part of the drainage system to touch the floor. R26's Care Plan dated 8/5/25 documents R26's need for EBP related to internal urine drainage device. This Care Plan documents that EBP will be used to reduce the transmission of multidrug-resistant organisms. This Care Plan also documents that R26, and staff will be taught the chain of infection, methods of transmission and principles of infection control. On 8/12/2025 at 2:22 PM R26 was in the dining room with other residents participating in an activity and R26's urinary drainage bag was hanging beneath R26's wheelchair and resting on the ground. On 8/13/25 at 1:22 PM, V2 Director of Nursing (DON) stated urine drainage bags should never be resting on the ground. 3.R48's Minimum Data Set (MDS) dated [DATE] documents R48 is alert and oriented, R48 requires assistance with R48's indwelling urinary catheter with a diagnosis of long-term indwelling catheter and R48 is on Enhanced Barrier Precautions due to R48's indwelling catheter. On 8/11/2025 at 12:54 PM R48 was lying in bed with the urinary catheter bag hanging from the garbage can and the catheter bag was not in a dignity bag. V8 Certified Nursing Assistant was emptying R48's indwelling catheter drainage bag and was not wearing personal protective equipment. On 8/11/2025 at 12:55 PM V8 Certified Nursing Assistant stated R48 should have a dignity bag in place covering the drainage bag and the urinary drainage bag should not be hanging from the garbage can. V8 stated V8 should wear Personal Protective Equipment (PPE) when V8 empties R48's catheter bag. On 8/11/2025 at 12:56 PM V9 Licensed Practical Nurse stated V8 should have worn Personal Protective Equipment (PPE) when V8 emptied R48's catheter bag. On 8/13/2025 at 2:05PM V2 Director of Nursing stated Personal Protective Equipment (PPE) should always be worn when a resident is on Enhanced Barrier Precautions, and V8 should have worn Personal Protective Equipment (PPE) when V8 emptied R48's catheter bag. V2 confirmed that R48 is on Enhanced Barrier Precautions for R48's indwelling catheter.

Based on interview and record review, the facility failed to prevent misappropriation of resident property for one of three residents (R89) reviewed for misappropriation in the sample list of 38.Findings include:R89's Facility Census documents R89 was admitted to the facility on [DATE] at 12:08pm.R89's Minimum Data Set (MDS) dated [DATE] documents R89's Brief interview for Mental Status (BIMS) 14, cognitively intact.R89's Facility's Observation Detail List Report dated 5/23/25 at 11:55am completed by V17 Social Service Assistant documents inventory of R89's Personal Items as Wallet/Purse/Checkbook, describe, including contents. Yes-wallet, cards and cash. No duffle bag was inventoried.R89's Credit Card Statement documents the following charges 6/3/25 $41.00, 6/10/25 $48.14, 6/13/25 $41.00, 6/19/25 $51.03, and 6/25/25 $47.02 at a local gas station.R91's Facility Census documents R91 was admitted to the facility on [DATE] at 1:00pm.R91's Facility's Observation Detail List Report dated 5/21/25 at 4:20pm completed by V17 Social Service Assistant: Documents Inventory of R1's Personal Items: Wallet/Purse/Checkbook, describe, including contents. No. The Facility's Abuse Prevention Policy and Procedure regarding, Abuse and Neglect, Involuntary Seclusion, Misappropriation of Resident Property, Resident Altercations, Injuries of Unknown Origin and social media. Revised 1/2025 documents: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, volunteers, or staff or other agencies serving the resident, family members, legal guardians, visitors or other individuals. The Facility's Non-Clinical admission Procedure not dated documents: Nursing Home will maintain the capability of admitting residents 24 hours a day. Nursing Home will collaborate with referring entity to ensure the admission times are in the best interest of the residents, as much as practicable. Upon Arrival of admission: 4. Complete Personal Inventory Observation. On 8/12/25 at 10:59am R89 stated that on 5/23/25 R89 was admitted to the facility from the hospital. R89 stated that while being admitted by V17 Social Service Assistant, V17 asked to inventory R89's personal property. R89 stated that R89 had a blue duffle bag with some clothes in it, a clear plastic bag with toiletries and had R89's wallet and keys in R89's pants pocket. R89 stated that R89 gave V17, R89's wallet which was black with a hole in it. R89 stated that it contained $200.00 United States Currency, credit card, Illinois Driver's License, insurance card, Illinois Firearms Identification Card (FOID) and grocery store cards. R89 stated that R89 also gave V17 R89's house keys. R89 stated that on 6/29/25 R89's Son came to the facility and brought R89's credit card bill, and there were charges on 6/3/25 for $41.00, 6/10/25 for $48.14, 6/13/25 for $41.00, 6/19/25 for $51.03 and 6/25/25 for 47.02 at a local gas station. R89 stated R89 was a resident in the facility, and did not, and could not make these charges. R89 stated R89's credit card and money were supposed to be locked up in the social service office. R89 stated on 6/30/25 at 8:40am, R89 spoke to V18 Social Service Director, and asked to get R89's wallet to check to make sure R89's credit card was in R89's wallet. R89 stated V18 could not locate R89's wallet or keys in the Social Service Office. R89 stated V1 Administrator was notified, and an investigation was started, and the local police department was called.On 8/12/25 at 12:54 pm V17 Social Service Assistant stated on 5/23/25 V17 was assisting V18 Social Service Director with admitting R89 and R91. V17 stated R89 told V17 that R89 had a wallet. V17 stated that when completing R89's inventory sheet, V17 did document that R89 had a wallet, cards and cash. V17 stated that this was in error. V17 stated that V17 accidentally forgot to delete this entry after admitting the R91, who did have a wallet. V17 confirmed that R89's property inventory did document that R89 had a wallet, and that V17 typed that it contained cards and cash. V17 confirmed that R89's inventory sheet documents that R91 did not have a wallet. On 8/12/25 at 1:08pm V18 Social Service Director stated on 6/30/25 at around 8:40am V89 approached V18 and requested to see R89's wallet. V18 stated that R89 described it as black with a hole in it, and had about $200.00 cash in it, credit cards, and that R89 also had keys locked up. V18 stated R89 wanted to make sure R89's credit card was in R89's wallet. V18 stated that R89 informed V18 that R89 had some charges put on R89's credit card and doesn't know why. V18 stated that R89 wanted to make sure R89's credit card was in still in R89's wallet. V18 stated that V18 didn't recall R89 giving V18 a wallet and asked who R89 gave it to. R89 stated R89 gave it to V17 Social Service Assistant. V18 could not locate the wallet/keys in Social Service office. V18 looked in the safe in the front office and it was not there. V18 searched R89's room with R89 present and did not locate a wallet or keys. V18 stated V18 immediately notified V1 Administrator.On 8/13/25 at 11:50am V1 Administrator stated on 6/30/25 V18 Social Service Director informed V1 that V18 could not locate R89's wallet that R89 gave to V17 Social Service Assistant when R89 was admitted to the facility on [DATE]. V1 stated on 6/30/25 V1 Administrator interviewed R89 who said that the day before (6/29/25) V23, R89's Son, brought in R89's credit card statement, and R89 noticed that there were five charges on the credit card that were suspicious and were charged while R89 was in the nursing home. V1 stated R89 asked V18 if R89 could see R89's wallet to make sure R89's credit card was still present. V1 stated that V18 could not find R89's wallet or R89's keys. V1 stated R89 was understandably very anxious about the missing items. V1 stated that R89 called the bank and the bank informed R89 there were five charges in June totaling $227.19, and all charges were at a local gas station/convenience store. V1 stated on 7/2/25 V1 and V18 interviewed V17. V1 stated V17 said on 5/23/25, V17 was completing the admission process for R89 and that the inventory included wallet, cards, cash. V1 asked V17, if R89 didn't have a wallet with R89, why did you put it on the inventory. V1 stated that V17 said that V17 was doing two admissions that day (R89 and R91) and documented the wrong person. V1 said, the were no other residents admitted to the facility on (May 23rd). V1 confirmed that R89's admission inventory documents that R89 had a wallet with cash and cards in it, and that R91's admission Inventory documents that R91 did not have a wallet.

Based on observation, interview, and record review, the facility failed to ensure essential resident-care equipment (toilet safety frames) was maintained in safe operating condition for two of two (R4, R70) residents reviewed for environment on a sample list of 38. 1.) The Toilet Safety Frame Owner's Manual dated February 2024 documents that the toilet safety frame should be checked regularly to make sure that it is securely locked onto the toilet. This manual also documents that safety precautions should be taken by always making sure that the safety frame is correctly and securely locked in place before use. R70's Minimum Data Set (MDS) dated [DATE] documents R70's Brief Interview for Mental Status (BIMS) score as 15. This score indicates R70 has normal cognitive function.R70's Electronic Medical Record (EMR) documents R70 has a diagnosis of repeated falls.R70's Care Plan dated 7/7/25 documents R70 is at risk for falling and requires staff assistance when toileting.R70's Care Plan dated 2/03/25 documents R70 has urinary incontinence and requires staff assistance when toileting.R70's Occupational Therapy Evaluation and Treatment Plan dated 8/8/25 document that R70 will safely perform toileting tasks using grab bars with moderate assistance and 25% verbal cueing.On 08/10/2025 at 9:55 AM, R70 stated her bathroom handrails around the toilet are wobbly and that R70 fell off the toilet recently but had no injury but that it scared R70. During this interview these handrails that were attached to R70's toilet seat were observed to be unsecure and moved around easily when grabbed.On 8/13/25 at 9:09 AM, V24 Physical Therapist stated R70 had a recent fall on 8/9/25 near the bathroom with no injury. V24 stated that his recommendation was that R70 always have stand-by assist (SBA) with transfers and ambulation. V24 stated that R70 definitely needs safety handrails around her toilet for balance and to assist with getting off the toilet even with SBA present. V24 stated that an unsecure handrail creates the potential for a fall.On 8/13/25 at 11:31 AM, V25 Certified Occupational Therapy Assistant (COTA) stated that she is currently working with R70 and that R70 needs toilet stabilizer bars to assist with safe transfers and balance. V25 stated a loose stabilizer bar could contribute to a fall.2.) The Bariatric Commode Owner's Manual dated April 9, 2020, documents that periodic visual inspection of this commode is recommended to ensure that all parts and hardware are secure, that components are in good working order and not worn, torn, frayed, or loose, and that there are no obstructions or impediments to normal, safe operation. The manual also documents this commode should be checked for fit and tightness of all nuts, bolts and knobs WEEKLY to ensure the commode is stable and safe to use.On 08/10/2025 at 10:30 AM, R4 stated he is concerned about the assistive bars that are in the bathroom attached to his toilet seat. R4 stated he doesn't feel safe on the toilet because these bars move around too much. During this interview these handrails that were attached to R4's commode were observed to be unsecure and moved around easily when grabbed.R4's MDS dated [DATE] documents R4's BIMS as 15. This score indicates that R4 has normal cognitive function.R4's EMR documents a diagnosis of repeated falls and weakness.R4's Care Plan dated 7/17/25 documents that R4 has difficulty transferring independently related to history of falls, general muscle weakness and pain. This Care Plan also documents that R4 is at risk for falling due to impaired mobility, decreased safety awareness, easily fatigued and pain related to diagnoses of Cerebrovascular Accident (CVA) with left sided weakness and history of falls. Interventions documented for this problem are that staff are to provide toileting assistance as needed and provide verbal reminders to R4 that R4 is not to ambulate/transfer without assistance.R4's Occupational Therapy Discharge summary dated [DATE] documents R4 requires skilled treatment interventions as follows: use of adaptive equipment and use of assistive device(s) in order to increase to highest level of function. This summary also documents R4 will safely perform toileting tasks using raised toilet seat 3 in 1 commode with contact guard assistance for clothing management and for safety awareness with ability to right self to achieve/maintain balance. On 8/13/25 at 11:35 AM, V25 Certified Occupational Therapy Assistant (COTA) stated that due to R4's history of CVA and left sided weakness he most definitely needs toilet stabilizer bars to assist with transfers to and from the wheelchair. V25 stated that a loose stabilizer bar around R4's toilet has the potential to contribute to a fall.On 08/12/25 at 12:15 PM, V1 Administrator and V21 Maintenance Director stated that quarterly preventative maintenance is done on all resident bathrooms. V21 stated they have a checklist as a guideline but do not use it to document when these checks were completed and what was done. V21 stated that the evening shift Maintenance Mechanic (V22) is responsible for these quarterly checks and that he documents his work as chicken scratch. V1 and V21 provided a copy of the chicken scratch documentation from October but did not provide any further documentation that the toilet safety frames in R4's and R70's bathrooms had been routinely checked. On 8/12/25 at 2:55 PM, V22 Maintenance Mechanic stated that maybe he checked R4's and R70's toilet safety frames in June but V22 could not provide documentation that an inspection was done.

Based on observation, interview, and record review the facility failed to maintain a resident's personal hygiene by failing to ensure routine fingernail care was completed for one of three residents (R64) reviewed for Activities of Daily Living (ADL) on a sample list of 38. The facility's ADL policy dated February 2025 documents under Policy Explanation and Compliance Guidelines #3.) A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Grooming includes, but is not limited to hair care, shaving and or facial hair care. R64's Minimum Data Set (MDS) dated [DATE] documents R64 scored a ten on her Brief Interview for Mental Status (BIMS). A BIMS score of eight to twelve indicates moderate cognitive impairment with potential need for help with daily tasks.R64's care plan dated 6/17/25 documents R64 has limited ability with ADLs and requires assistance with ADLs due to impaired cognition, general weakness and pain related to diagnoses of Alzheimer's, Ulcerative Colitis, and Low Back Pain. This care plan documents that the staff will assist R64 with showering twice weekly and partial bathing twice a day. The care plan documents staff will also assist with face, upper and lower body, hair, lotion and nail care. On 8/10/2025 at 11:49AM, R64 was sitting in R64's wheelchair near the 300 hall nurses' station. R64's fingernails were jagged and untrimmed, with brown material beneath the nails.On 8/12/25 at 10:00 AM, R64 was sitting in her wheelchair near the 300 hall nurses' station and her fingernails remain untrimmed with brown material beneath her nail. On 8/12/25 at 10:05 AM, V16 Certified Nursing Assistant (CNA) stated that the shower aides are responsible for providing nail care with the residents' shower. V16 stated R64 had a shower on Saturday, August 10, 2025, and R64's nails should have been cleaned and trimmed then, and it doesn't look like it was done. R64's Care Plan documents R64 is dependent for care and received shower/bathing assistance on the following dates and times: 8/09/2025 at 2:39 PM, 8/10/2025 at 2:53 PM, and 08/11/2025 at 2:51PM. On 8/12/25 at 11:24 AM, V19 Certified Nursing Assistant stated that V19 did not give R64 a shower on 8/10/25 but does know that R64 got a shower because V19 did the documentation. V19 stated the shower aides are responsible for cleaning beneath the nails after the shower and as needed and that R64's nail care should have been done on 8/10/25. V19 stated that it is hard to keep R64's nails clean because R64 digs in her pants and scratches at R64's skin making it difficult to maintain clean nails.On 8/12/25 at 11:30 AM, V20 Certified Nursing Assistant/Shower Aide stated the expectation is that the shower aide will provide nail care which includes removing dirt/debris from beneath the nail with every shower and as needed and that R64 should have had that done on her last shower day.

Based on interview and record review the facility failed to report an allegation of abuse to the State Agency for one (R1) of three residents reviewed for abuse in the sample list of 11. Findings include: R1's Investigation of Occurrence dated 4/30/25 documents, (V7, Certified Nurse's Assistant) called (V1, Administrator) to report that (R1) had reported to (V7) that (R1) had a small nightgown, and the girl behind the desk took it from me .snatched it out of my hand and claimed the staff member (V3, Certified Nursing Assistant) bruised her right inner arm. On 5/12/25 at 1:45 PM, V7 stated on 4/30/25 at 7:15 PM, R1 told her that V3 took a gown away from her causing a scratch to her hand. V7 stated she saw a red spot on R1's forearm. V7 stated she called V1 to report the incident. On 5/12/25 at 1:10 PM, V1 (Administrator) stated he received a call from V7 (Certified Nursing aide) on 4/30/2025 at 7:15 PM. V1 stated V7 reported that R1 told her that V3 snatched a gown out of her hand and bruised her right inner arm. V1 stated he did not notify the state agency. R1's medical record does not document the state agency was notified of R1's allegation of abuse. The Facility's Abuse Prevention Policy dated 1/2025 documents upon receiving an allegation of abuse the facility will immediately notify the state agency.

Based on interview, and record review the facility failed to protect resident's (R2, R3) right to be free from abuse by another resident (R1). This failure affects three (R1, R2, R3) of four residents reviewed for abuse in the sample list of four. Findings include: The facility's Final Abuse Investigation Report dated 12/13/2024 documents the following: On 12/8/24 at approximately 6:15 AM in the Main Dining Room (MDR), R1 and R3 were seated at neighboring tables. Dietary staff heard raised voices in the main dining room and responded immediately. Residents told staff that R1 had struck R3 on the left side of the face. The facility's Final Abuse Investigation Report dated 12/13/2024 documents the following: On 12/8/24 following the approximately 6:15 AM incident that Facility increased supervision of R1 the rest of the day and night including staff encouraging R1 to eat in her room and to stay around the nursing unit to prevent further distressed behaviors from resident/environmental stimulation. The same final abuse investigation documents that R1 complied and no additional behaviors were noted. The facility's Final Abuse Investigation Report dated 12/13/2024 documents the following: On 12/8/24 at approximately 2:15 PM V5, RN, heard screaming in the main dining room (MDR), when entering the MDR R2 was crying and stated to V5 that R1 threw coffee on him. R2 was assisted to his room and skin was assessed. R2 right bicep was noted to be red in color. R2 abdomen was noted to have red splotches. R1's ongoing Diagnoses List includes Psychotic disorder with delusions due to known physiological condition, anxiety disorder due to known physiological condition. R1's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score of 12, the high end of moderate cognitive impairment, and R1 uses a wheelchair for mobility. R1's Care Plan dated 07/15/2024 documents R1 has potential for behavior(s) of verbal behaviors not directed at others and directed at others: aid/staff caring for her and refusing care form staff, yelling at staff, being argumentative with staff raising voice, putting all staff members down, calling staff inappropriate names. Hitting/swinging and kicking staff. The facility's Final Abuse Investigation Report dated 12/13/2024 documents the following: On 12/8/24 following the approximately 6:15 AM incident that V1 interviewed R1 who recalled the occurrence. R1 said that R3 would not stop singing and that it was so blasphemous and loud. R1 recalled striking R3 on the face because R3 would not stop. R1's Nursing Note dated 11/24/2024 at 07:15 AM documents R1 was observed throwing coffee at another resident. When asked about the altercation by staff resident stated she was spoken to offensively and felt her response was justified. R1's Nursing Note dated 11/25/2024 at 10:54 AM documents R1 had a confrontation between resident and another resident heard yelling at one another. Same progress note documents R1 kicked other resident in the legs. R2's ongoing Diagnoses List includes Cerebral palsy, unspecified acquired deformity of right lower leg, unspecified acquired deformity of left lower leg, Anxiety disorder and depression. R2's MDS dated [DATE] documents R2 has unclear speech due to slurred or mumbled words. R2's MDS documents R2 is dependent on staff for mobility/transfers, uses an electric wheelchair. R2 has a documented Brief Interview for Mental Status score of 15, meaning R2 is cognitively intact. On 12/18/24 at 09:30 AM R2 confirms R1 threw coffee on him and R2 confirms he did have redness to the right arm and right abdomen. On 12/18/24 at 11:21 AM V5 confirmed that R2 called the facility from his cell phone and was crying/upset. V5 states that R2 could be heard crying/screaming from the main dining room. V5 confirms that R2 stated R1 threw coffee on him and had reddened right arm and abdomen upon assessment. V5 confirms there were no staff present at the time of the incident. V5 states that a visitor in the dining room also witnessed R1 throwing coffee onto R2 after threatening to do so. R3 ongoing Diagnoses List includes Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Anxiety disorder. R3's MDS dated [DATE] documents R3 has a Brief Interview for Mental Status score of 08, Moderate cognitive Impairment. On 12/17/24 at 1:00 PM R3 confirms that R3 has no recollection of being hit by another resident. On 12/17/24 at 1:10 Pm V3 [NAME] confirms that V3 and V4 Dietary [NAME] heard screaming coming from main dining room (MDR) and upon V3/V4 entering the MDR R3 was holding the right side of her face. V3 stated that other residents in the area stated that R1 had hit R3 in the left side of the face. V3 confirms that R1 was removed from the area at that time. On 12/18/24 at 11:21 AM V4 confirms that V3 and V4 heard screaming coming from main dining room (MDR) and upon V3/V4 entering the MDR R3 was holding the right side of her face. V3 stated that other residents in the area stated that R1 had hit R3 in the right side of the face. V3 confirms that R1 was removed from the area at that time and taken back to R1's room. On 12/18/24 at 3:06 PM V2 Director of Nursing confirms that increased supervision meant that staff should be close enough to observe R1 as R1 self propels around the unit/nursing home. V2 confirms staff should keep an eye on when R1 is near. The facility Abuse Prohibition policy dated Rev. 06/2021 documents: FACILITY POLICY: (The facility) affirms the right of our residents to be free from abuse, neglect misappropriation of resident property, corporal punishment, and involuntary seclusion. The same policy defines PHYSICAL ABUSE as: Physical abuse means the infliction of injury on a resident that occurs other than by accidental means. Physical abuse may include, but is not limited to, hitting, slapping, pinching, etc.

Based on observation, interview, and record review the facility failed to maintain the juice dispenser in a clean sanitary manner and failed to date perishable refrigerated foods when opened. This failure has the potential to affect all 100 residents who reside at the facility. Findings Include: The facility's Long Term Care Application for Medicare and Medicaid dated 8/12/24 documents the facility census as 100 residents. On 8/12/24 during the walk through of the main kitchen the juice dispenser was noted to have dried juice on the surface of the nozzles and the surrounding flat surface. Some of these dried juices were covered by green fuzzy material. V8 cook verified the dispenser is used to pour drinks for all residents who reside in the facility. Opened containers of almond milk, juices, thickening agent, and ice cream toppings were in the refrigerator on the front wall of the kitchen. The containers were not dated as to when they were opened. V8 verified the containers should be labeled with the date when opened. On 8/13/24 at 10:00 AM the juice machine in the kitchen had not been cleaned. V9, Dietary Manager verified the juice machine should be cleaned daily. The facility's policy Cleaning Instructions states Coffee Makers, Urns, Juice machines, frozen yogurt and/or ice machines will be cleaned thoroughly.

Based on interview and record review the facility failed to identify/track resident specific behaviors to justify the use of an antipsychotic and failed to implement nonpharmacological interventions for one resident (R65) of five residents reviewed for unnecessary medication in a sample list of 35 residents. Findings Include: R65's medical record documents current physician's orders for the following psychotropic medications: 1. Fluoxetine (antidepressant) 10 mg (milligram) on Sundays Fluoxetine 20 mg on Monday, Tuesday, Wednesday, Thursday, Friday, Saturday. 2. Lorazepam (antianxiety) 2mg/ml (milliliter) 0.25ml every 2 hours PRN (as needed). 3. Quetiapine (antipsychotic) 37.5 mg at bedtime. R65's Treatment Administration Record (TAR) for August 2024 documents Acknowledgement of Behaviors: Episodes of self-isolating and refusal of care. There is no documentation of nonpharmacological interventions attempted. There is no specific behavior identified or tracked to justify the use of an antipsychotic medication. On 8/14/24 at 11:00AM V17, Registered Nurse (RN) Unit Manager stated The only behavior we have documented for (R72) is Self-Isolating and refusing care. V17 verified self-isolation and refusing care is not justification for an antipsychotic. The facility's Psychotropic Medication Policy reviewed February 2022 states An unnecessary medication is any medication used: 1. In an excessive dose, including duplicative therapy 2. For an excessive duration. 3. Without adequate monitoring. 4. without adequate indications of its use. 5. In the presence of adverse consequences that indicate the drug should be reduced or discontinued.

Based on observation, interview, and record review the facility failed to implement Dietician recommendations for significant weight loss for two of three residents (R39, R40) reviewed for weight loss in the sample list of 35. Findings include: The facility's Weight Management Protocol with a revised date of July/2020 documents, Monthly (or as ordered by MD {medical doctor}) weights for all residents will be obtained. A copy of accurate weights will be provided to dietary monthly. Any residents with a significant weight change will be referred to the consultant dietitian. The Dietitian and food management will assess the resident's condition and make recommendations as necessary. Physician will be made aware of recommendations and place orders as needed. 1.) R39's Care Plan dated 7/14/24 documents diagnoses including Femur Fracture, Rheumatoid Arthritis, Gastroesophageal Reflux Disease, Hypothyroidism and Type 2 Diabetes Mellitus. This Care Plan documents R39 is at nutritional risk and to monitor weights monthly. R39's Nutritional Assessment completed by V26 Registered Dietician dated 6/11/24 documents R39 received a regular diet with regular texture and documents her weight was 117 pounds. R39's weight log documents her weight on 5/29/24 was 117.2 pounds and her weight on 8/8/24 was 106 pounds which was a 9.56 % (percent) weight loss in three months. V26's Weight Review note dated 7/16/24 documents R39 had an 11.1% weight decrease in one month and recommended adding a house shake with lunch to encourage weight maintenance. R39's Physician's Order Sheet dated 8/1/24 through 8/31/24 does not document an order for a house shake at lunch. On 8/13/24 at 12:00 PM, R39 was feeding herself lunch and there was no house shake served to R39. R39's menu card does not document an order for a house shake at lunch. R39's Dietary Recommendations for Physician Approval is dated 7/16/24 and documents Dietary Recommendations of adding a house shake with lunch due to a significant weight decrease in one month. This recommendation is signed by V26. There is no Physician's signature on this recommendation. On 8/14.24 at 1:14 PM, V2 Director of Nursing stated that the Dietician emails her recommendations to them monthly and they give the recommendations to the Physician or Nurse Practitioner to approve. V2 stated after they have approved the recommendations, they enter the order into the computer. V2 stated typically it can take 24 to 48 hours for this to happen. V2 confirmed that this dietary recommendation was missed. V2 stated that V26 adds the weight loss onto the Care Plans herself. R39's Care Plan does not document the significant weight loss. 2.) R40's Care Plan dated 8/9/24 documents diagnoses including Acute Respiratory Failure with Hypoxia, Stage 4 Pressure Ulcer to the Coccyx and Vitamin D Deficiency. This Care Plan documents R40 is at nutritional risk and to monitor weight daily. R40's Nutritional Assessment completed by V26 dated 5/19/24 documents R40 received a regular diet with regular texture and documents her weight was 164.6 pounds. V26's note dated 7/16/24 documents R40's current weight as 149.2 pounds and is an 11.4% decrease in 6 months. V26 recommended added a house shake at lunch to encourage weight maintenance. R40's Physician's Order Sheet dated 8/1/24 through 8/31/24 does not document an order for a house shake at lunch. On 8/14/24 at 12:41 PM, R40 was in her room eating her lunch. She was feeding herself. R40 did not have a house shake served to her with her lunch and the house shake was not on her menu card. R40's Dietary Recommendations for Physician Approval is dated 7/16/24 and documents Dietary Recommendations of adding a house shake with lunch due to a significant weigh decrease. This recommendation is signed by V26 but is not signed by a physician. On 8/14/24 at 1:14 PM, V2 confirmed R40's dietary recommendation of the house shake was missed. V2 confirmed that the significant weight loss should have been added by the Dietician to R40's Care Plan.

Based on observation, interview, and record review the facility failed to administer medications in accordance with Physician's Orders and manufacturer's recommendations for two of five residents (R4, R25) reviewed for medication administration in the sample list of 35. The facility had 2 medication errors out of 30 opportunities resulting in a 6.67% (percent) medication error rate. Findings include: The facility's Medication Administration Policy with a reviewed date of February/2024 documents, Medications will be administered to residents as prescribed and by persons lawfully authorized to do so in a manner consistent with good infection control and standards of practice. The (insulin aspart) manufacturer's instructions dated [DATE] documents, Throw away all opened insulin aspart vials after 28 days even if they still have insulin left in them. 1.) R4's Medication Administration Record (MAR) dated [DATE] through [DATE] documents an order dated [DATE] for insulin aspart U-100 insulin solution 100 units/ml (milliliters) per sliding scale before meals for diagnosis of Diabetes Mellitus. On [DATE] at 11:40 AM, V4 Licensed Practical Nurse (LPN) checked R4's blood glucose level and R4's blood glucose level was 406 which indicated R4 needed 12 units of insulin aspart. V4 removed the vial from the medication cart, cleaned the plunger and withdrew 12 units of insulin aspart from the vial. The vial had an open dated of [DATE] written on the side. V4 continued to administer the insulin to R4 in R4's stomach. After administering the insulin aspart, V4 confirmed the open date on the vial of insulin aspart said [DATE] therefore is expired and should not have been used. V4 stated she misread the date. 2.) R25's Medication Administration Record dated [DATE] through [DATE] documents an order dated [DATE] for Vitamin C 500 mg (milligrams) two tablets for a diagnosis of Vitamin Deficiency. On [DATE] at 8:50 AM, V3 LPN prepared R25's medications at the medication cart outside of R25's room. V3 removed one 500 mg tablet of Vitamin C from the bottle and confirmed that she only removed one tablet. R25 took her medications whole with water. On [DATE] at 12:04 PM, V2 Director of Nursing confirmed R25 should have received two 500 mg tablets of Vitamin C.

Based on observation, record review, and interview the facility failed to label medication with date opened for two residents (R150, R151) of 25 residents reviewed for medication in a sample list of 35 residents Findings Include: 1.) R150's Medication Administration Record (MAR) includes a current physician's order for Refresh tears 0.5% (percent) two drops in each eye as needed every six hours. On 08/14/24 at 11:37 AM an opened bottle of Refresh eye drops with R150's name was observed on the 400 Hall medication cart not labeled with date opened. 2.) R151's Medication Administration Record (MAR) includes a current physician's order for Maxitrol (neomycin-polymyxin b-dexameth) 3.5mg(milligram)/g(gram)-10,000 unit/g-0.1 % ointment apply to right eye, ophthalmic (eye), At Bedtime. The insert for the Maxitrol eye ointment indicates it should be discarded 30 days after opening. On 08/14/24 at 11:36 AM an opened bottle of Maxitrol Eye drops with R151's name was observed on the 400 Hall medication cart not labeled with date opened. On 08/14/24 at 11:36 AM V25, Licensed Practical nurse stated we are supposed to label multidose medication containers with the time and date they are opened. I see the Maxitrol and the Refresh are not dated. I did not open either of them. The policy for medication administration provided by the facility does not address this issue.

Based on observation, interview, and record review the facility failed to secure catheter tubing to prevent tension and failed to position catheter tubing so that the flow was not interrupted for two of four residents (R40, R72) reviewed for catheters in the sample list of 35. Findings include: The facility's Catheter Care policy with a reviewed date of 2/27/20 documents, 11. Secure catheter as needed. 1.) R40's Care Plan dated 8/9/24 documents diagnoses including Obstructive and Reflux Uropathy, Overactive Bladder and Urinary Tract Infection. This care plan documents R40 requires an indwelling urinary catheter related to diagnosis of Urinary Retention. The intervention dated 5/14/24 documents to manipulate the tubing as little as possible and to avoid obstructions in the drainage. On 8/14/24 at 9:56 AM, V21 and V22 Certified Nursing Assistants (CNA) prepared to complete urinary catheter care. V21 and V22 uncovered R40 and R40's urinary catheter drainage flow was being impeded by the pressure of R40's right thigh as the tubing was laying underneath the right thigh and over the side of the bed. There was no visible urine in the tubing. After completing care on R40's front side they rolled R40 onto her left side. There was a red imprint on the back of R40's right thigh where the catheter tubing had been compressed underneath R40's leg. V21 and V22 confirmed R40 did not have a securement device to anchor the tubing to her leg. On 8/14/24 at 10:44 AM, V23 Licensed Practical Nurse stated R40 had not had a securement device for a while for her catheter tubing. V23 stated that the tubing should not be placed under R40's leg either. On 8/14/24 at 12:04 PM, V2 Director of Nursing stated ideally the urinary catheter drainage tubing should not be placed underneath the resident's leg. 37813 2. R72's medical record includes a current physician's order for an indwelling urinary catheter and a diagnosis of Urinary Retention. On 8/14/24 at 9:30AM V20, Certified Nurse's Aide (CNA) and V19, Certified Nurse's Aide (CNA) rolled R72 in bed to complete catheter care. Upon rolling R72 the catheter tubing pulled causing visible tension at the insertion site. R72's Urinary meatus was red and slightly swollen. V19 stated R72 Should have the catheter anchored to his leg. R72 stated I broke my leg in a car accident and it's hard for me to turn and it pulls on the tubing when (the CNAs) turn me. On 8/14/24 at 1:00PM V2, Director of Nursing confirmed R72 should have an anchoring device to keep the catheter tubing from pulling.

Based on observation, interview, and record review the facility failed to maintain a mechanical wheelchair in a clean sanitary manner for one resident (R16) of five residents reviewed for wheelchair cleanliness in a sample list of 35 residents. Findings Include: R16's Care Plan reviewed 5/21/24 documents (R16) is under the care of Hospice Services related to diagnosis of severe protein malnutrition. A further decline in Cognitive and Physical Abilities is expected, all care is directed towards maintaining comfort through end of life. On 8/12/24 at 10:15AM R16 was in her room seated in a mechanical wheelchair. R16 stated I got this special chair from hospice. It's pretty comfortable but look it's dirty. The chair was caked around the padded seat with a chunky brown and white substance. R16 stated she doesn't like sitting in a dirty chair. On 8/13/24 at 2:00PM V2, Director of Nursing verified the night shift staff are responsible for cleaning wheelchairs and all staff should wipe off any visible debris as soon as they see it. The facility did not provide a policy specific to the cleaning of wheelchairs or other equipment.

Based on observation, interview, and record review the facility failed to timely report a resident change of condition to the resident's representative and physician for one (R1) of four residents reviewed for change in condition and injury of unknown origin in the sample list of four. Findings include: The Progress Note dated 05/31/2024 at 09:16 PM by V3, Nurse, states R1 noted to be complaining of pain during cares. The progress note states that R1 was saying ow over and over and when R1 was asked if she hurts R1 said yes. The Note documents R1's right knee was observed to be swollen and painful. The Note documents no redness or bruising was noted and alert charting to monitor for the next three days was started. The Note documents Management was made aware, and a pillow was placed under R1's knee for support and Tylenol was administered for pain. R1's Minimum Data Set completed on 5/16/2024 documents a Brief Interview for Mental Status (BIMS) score of 99. A score of 99 indicates R1 is severely cognitively impaired and unable to complete the interview. R1's Care Plan with revised date of 04/02/2024 states that for transfers: R1 requires a total body mechanical lift with the assist of two staff. The same care plan edited on 05/17/2024 states R1 is at risk for falling due to impaired mobility, impaired cognition, pain, easily fatigued and impaired safety awareness related to diagnosis of metabolic encephalopathy, dementia, chronic pain, and anemia. R1's Nursing Note dated 05/31/2024 at 9:16 PM documents nursing management was notified of the change of condition and new onset pain. The same medical record documents that the physician was not notified of the change of condition and new onset pain until 06/03/2024 at 2:13 PM. The Progress note dated 06/03/2024 at 2:13 PM states an x-ray was ordered for R1's right knee. R1's medical record progress note dated 06/04/2024 at 06:57 AM documents R1's x-ray results as right knee arthroplasty with acute periprosthetic fracture of the distal femur with posterior displacement of the major distal fracture fragment. On 6/7/24 at 11:00 AM R1 was laying in R1's bed covered, with a right knee immobilizer in place. On 6/7/24 at 1:41 PM V10, Primary Care Physician, stated the on-call practitioner should be notified any change of condition or new pain onset. On 6/7/24 at 2:45 PM V2 Director of Nursing confirmed the practitioner and power of attorney were not notified of the change of condition and new onset pain for R1 from 5/31/24 at 9:16 PM until 6/3/24 at 2:13 PM. The facility's Change in a Resident's Condition or Status Policy with review date of February 2024 documents The Unit Nurse will chart in PN (Progress Notes) and notify the resident's Attending Physician, POA (Power of Attorney), or On-Call Physician when there has been A significant change in the resident's physical/emotional/mental condition.

Based on interview and record review, the facility failed to have a certified dietary manager on staff. This failure has the potential to affect all 103 residents in the facility. Findings include: The facility resident census and condition report dated 8/29/23 documents 103 residents in the facility. On 8/28/23 at 9:20 AM, V5 Dietary Manager attempted to test the low temperature dishwasher with high temperature heat strip. When this did not change for heat, V5 Dietary Manager stated that he did not realize that he needed to test the machine with a chlorine strip, but that his staff know how to test the machine. On 8/29/23 at 11:40 AM, residents were observed being served lunch at the same tables, at different times, leaving some to wait and watch others eat for long periods of time. At 1:01 PM, V2 Director of Nursing said that serving times were all over the place, and that she would prefer for the residents to be served at the same time but sometimes, it's all over the place. On 8/29/23 at 11:55 AM, R97 was sitting in the dining room eating lunch and was given a lunch tray with the wrong ticket on the tray. R97's tray belonged to a different resident and did not have correct meat consistency on the tray. On 8/29/23 at 11:59 AM, V5 Dietary Manager said that residents should receive the correct ticket and diet as ordered. On 8/30/23 at 9:30AM, V5 Dietary Manager stated that serving is done as it is because it has always been done that way, but that it is chaotic. On 8/28/23 at 9:45AM, V5 Dietary Manager stated, I have been here for two years, and I don't have my certification as a dietary manager yet.

Based on interview and record review the facility failed to answer call lights in a timely manner for five of 21 residents (R23, R85, R28, R19, R79) reviewed for call lights in the sample list of 49. Findings include: The facility's Call Light Policy with a revised date of 11/17/19 documents, Objective: To respond to the residents' request and needs in a timely manner. Procedure: Answer the resident's call light as soon as possible. The Resident Council Meeting Minutes dated May 3, 2023, documents concerns that residents have (call) lights on and the CNA (Certified Nursing Assistant) come in and turn off the call light and tell the residents they will be right back and never show up again on all of the shifts, (call) lights are not answered in a decent time on all shifts. The Resident Council Meeting Minutes dated July 7, 2023, documents concerns that the CNAs don't answer the call lights on time, and they sit at the nurse's station and chat and don't answer the call lights. 1.) R23's Minimum Data Set (MDS) dated [DATE] documents R23 has a BIMS (Brief Interview for Mental Status) score of 12/15. 2.) R85's MDS dated [DATE] documents R85 has a BIMS score of 15/15. 3.) R28's MDS dated [DATE] documents R28 has a BIMS score of 15/15. 4.) R19's MDS dated [DATE] documents R19 has a BIMS score of 15/15. 5.) R79's MDS dated [DATE] documents R79 has a BIMS score of 13/15. On 8/29/23 at 8:47 AM, R23, R85, R28, R19 and R79 all stated that there are still issues with staff not answering call lights timely. R79 stated a lot of the time they will turn on the call light and have to wait a long time for it to get answered. R79 stated R79 does not think they have enough CNAs (Certified Nursing Assistants) here to answer the call lights. R85 stated they don't get the help that they need without waiting a long time. R85 stated that R85 has waited an hour to have the call light answered. R79 stated that R79 has waited at least 30 minutes to have the call light answered. On 8/30/23 at 10:05 AM, V2 Director of Nursing stated anyone can answer the call lights and ideally within five minutes. V2 stated that V2 has completed in servicing and audits regarding call lights but was not aware that the residents were having issues getting call lights answered timely again.

Based on observation, interview and record review, the facility failed to ensure Scheduled II medications were locked in a permanently affixed compartment, date insulin and liquid protein when opened, resident medications were properly labeled with a pharmacy label and dispose of discontinued medication for residents. This failure affects 10 of 49 (R89, R16, R23, R13, R40, R12, R81, R28, R14, and R26) residents reviewed for medication storage and labeling on the sample list of 49. Findings Include: The facility's Drug Labeling Policy dated December 2021 documents the label of each individual container shall clearly indicate the resident's full name, physician's name, prescription number, name and strength of drug, directions for administration, date of issue, the initials of the pharmacist filling the prescription, and the amount of medications contained in each individual prescription. In addition, the pharmacy's name, address, and telephone number shall be on all prescription labels. Medication containers having soiled, damaged, incomplete, illegible, or makeshift labels shall be returned to the issuing pharmacy for disposal. Medications having no labels should be destroyed in accordance with Federal and State Laws. The facility's Medication Destruction Policy dated February 2023 documents medication will be disposed of in accordance with Federal, State and Local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. The facility's Medication Room Policy dated February 2023 documents all medications for residents will be properly labeled and stored near the nurses' station in a locked medication room, locked mobile medication cart or may be kept in resident room per provider order. All Schedule II controlled substances should be stored with two separate locks, utilizing two different keys, to access these substances. This should include the medication refrigerators. 1.) On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) was in the dining room passing medications while the medication cart was in the hall/dining room entrance. Upon returning to the cart, V7 unlocked the cart and started preparing R89's ordered medications, which included Norco (Scheduled II Narcotic) 7.5/325 mg (milligrams) and liquid protein. V7 lifted the lid to the narcotic compartment with V7's fingernail. V7 confirmed the lid was not locked and should have been. Within the unlocked narcotic compartment, there were cards of controlled substances for the following residents: Norco 5/325 mg for R1, Norco 5/325 mg for R16, Fentanyl Patches (Scheduled II Narcotic) 12 mcg (microgram)/hour for R13, and Fentanyl Patches 75 mcg/hour for R23. The bottle of liquid protein was open, half full and did not have a date on it documenting when it was opened. The label documents the liquid protein only has a shelf life of 3 months once opened. 2.) On 8/30/23 from 9:15-9:30 AM the 300 Hall Medication Room and Team 1 Medication Cart was checked with V7 RN (Registered Nurse) present. The Medication Cart contained a Humalog KwikPen (Insulin) for R16 that had a faded pharmacy label on it and was not dated when it was opened. V7 confirmed the Humalog was an active order and stated, it's an older pen, it's almost all gone. V7 stated insulin pens are to be dated when they are opened. The medication cart also contained the same undated open bottle of liquid protein from 8/29/23. There was also a biohazard bag with R40's name handwritten on it that contained four individual doses of Ipratropium Bromide with Albuterol Inhaler Solution {Anticholinergic with Bronchodilator}. There was no pharmacy label on the bag or medication. At this time, V7 stated R40 doesn't even have an order for the solution anymore; normally medications are either sent back to the pharmacy when the order is discontinued. The Medication Room refrigerator drawer had seven loose/unlabeled Compro Suppositories {Antipsychotic and Antiemetic} in it. The undated Insulin Storage Graph documents Humalog expires 28 days after being opened. 3.) On 8/30/23 between 10:15-10:30 AM, the 400 Hall Medication Room and Medication Cart was checked with V21 LPN (Licensed Practical Nurse) present. There was an open/undated bottle of Liquid Protein. V21 stated R12, R81 and R28 all have orders for Liquid Protein and use out of this unopened bottle. The Medication Room refrigerator contained a bottle of Lorazepam {Benzodiaepine} 2 mg (milligrams)/ ml (Milliliter) without a pharmacy label or resident name on it. At this time, V21 stated, that is for R14. There were also two cups of loose/unlabeled Bisacodyl {Laxative}suppositories in the refrigerator. 4.) On 8/30/23 at 10:35 AM, Team 2 Medication Cart contained an open, undated bottle of liquid protein that was halfway full. V22 LPN (Licensed Practical Nurse) stated R26 is the only resident that uses the liquid protein and confirmed the bottle should have been dated when opened.

Based on observation, interview and record review, the facility failed to prevent significant medication errors by failing to administer hormone medication to ensure for proper absorption contributing to abnormal lab results for a resident and failing to administer medication for a resident on dialysis. This failure affects two of five residents (R89, R36) reviewed for significant medication errors on the sample list of 49. Findings Include: 1.) R89's ongoing Census documents R89 was admitted to the facility on [DATE]. R89's ongoing TSH laboratory results document, historically from 2017 - 2019, R89's TSH levels ranged between 0.872 - 2.289 (Normal Value is 0.3 - 5.0). This ongoing TSH results do not document any other results until 8/10/23, in which R89's TSH level is 25.271. R89's Progress Notes dated 8/14/23 documents new orders received to increase R89's Levothyroxine dose based on R89's TSH (Thyroid Stimulating Hormone) level. R89's August 2023 Physician Order Sheets document a diagnosis of Hypothyroidism (underactive thyroid) with orders for Levothyroxine {Thyroid Hormone} 200 mcg (Microgram) one tablet every morning, and Levothyroxine 25 mcg one tablet every morning to be taken with the 200 mcg for a total of 225 mcg every day, both to be given between 5:00 am - 10:00 am. On 8/29/23 at 8:25 AM, V7 RN (Registered Nurse) prepared all of R89's morning medications, including R89's ordered Levothyroxine, while R89 sat at the dining room table eating breakfast. There was no warning label on the Levothyroxine Card indicating that the medication needed to be given on an empty stomach. By the time, V7 had prepared R89's medications, R89 had completed breakfast and returned to the unit. V7 left the dining room and returned to the unit, then administered R89's medications. At 8:30 AM, V7 explained 89's morning medications are normally given in the dining room except when he is already finished and leaves like today. On 8/29/23 at 3:52 PM, V28 Pharmacist stated Thyroid medication should be given before meals, on an empty stomach due to absorption, that is the manufacturer's recommendation. V28 explained the pharmacy does not place warning labels on medication cards alerting staff of when to give the medication but staff can find that information through their computer system. Staff just needs to click on the medication being administered and it will pull up the package insert that tells them that information. The undated Levothyroxine computerized Clinical Drug Information Sheet documents to take on an empty stomach, at least 30 to 60 minutes before breakfast. On 8/30/23 at 1:54 PM, V2 DON (Director of Nursing) stated, the facility started doing a liberalized medication administration time of 5:00 am - 10:00 am earlier this year (for the last five months). On 8/30/23 at 3:00 PM, V27 Nurse Practitioner stated V27 is aware that the facility has liberalized medication pass times but Levothyroxine still should be given on an empty stomach. It is absorbed best on an empty stomach. 2.) On 8/28/23 at 10:00 AM, R36 was in R36's wheelchair and stated, on Sunday, 8/27/23, R36 did not get R36's morning or noon medications, including R36's dialysis medications. R36 explained, R36 goes out for church every Sunday and staff always send medications with R36 for when R36 is out of the facility however on 8/27/23, there was a substitute nurse at the facility and when R36 returned to the facility, the nurse stated it was too late to give them. R36's MDS (Minimum Data Set) dated 6/8/23 documents R36 is alert and oriented. R36's Progress Notes dated 8/28/23 by V10 RN (Registered Nurse)/Unit Manager documents when speaking to R36's POA (Power of Attorney) this morning, the POA mentioned that R36 had reported that R36 did not receive R36's medications yesterday. Reviewed medication administration & medications were signed out by V9 Agency RN that was here yesterday. Spoke with V9 who was here yesterday and V9 stated that R36 did receive morning medications after R36 returned from church yesterday. V9 stated that R36 did not tell V9 that R36 was leaving the facility to go to church. V9 stated that if R36 would have told V9, V9 would have given R36's the ordered medications before R36 left. V9 also stated that R36 received R36's afternoon medications around 1:30. On 8/28/23 at 3:37 PM, V9 Agency RN confirmed V9 was R36's nurse on 8/27/23. V9 stated R36 was not around during morning medication pass so R36 did not receive medications at that time. V9 explained, when asking staff where R36 was, the other staff informed V9 that R36 was at church and that was R36's weekly routine. V9 stated R36 did not report to V9 that R36 was leaving the facility, if R36 had, V9 would have given R36 the ordered medications before R36 left. V9 explained around 1:30 pm, (R36) approached (V9) wanting (R36's) medications. I (V9) explained that I (V9) could only give (R36) some of the medications because if (R36) was due for them again at 5:00 pm, it was too close, and I (V9) wasn't able to administer them. V9 explained R36 was really concerned about the binder but (R36) had already eaten. V9 also explained that V30 (R36's family) reported that R36 had been back to the facility for about an hour but that V9 didn't know that because R36 didn't tell V9. V9 explained, V9 don't normally work there so I (V9) don't know (R36's) routine. V9 stated V9 did give the binder late around 1:30 - 2:00 pm per (R36) and (V30's) request but (V9) explained to (R36) it should be taken with food so it would not have the same effects and work the way it should. V9 also stated, V9 does not recall which morning and noon medicines V9 administered after R36 returned to the facility but all I (V9) know is I (V9) didn't give (R36) anything that (R36) was going to be given at 5:00 pm, except the binder. On 8/29/23 at 9:02 AM, V2 DON (Director of Nursing) confirmed that R36 is alert and oriented. The medications that were not given on 8/27/23, per V9's statement of medication not given if ordered again at 5:00 pm, are the following, according to R36's August 2023 Physician Order Sheets. Acidophilus {Probiotic for digestive and abdominal health}, schedule between 5:00 am - 10:00 am. Calcium Acetate 667 mg (milligrams) {Phosphate Binder for End Stage Renal Disease} schedule with breakfast and again at lunch {which was given late, after R36 had already eaten}Carvedilol 6.25 mg {Beta-Adrenergic Blocking Agent for Hypertension}, Fish Oil 1,000 mg for Hyperlipidemia, Minoxidil 2.5 mg {Antihypertensive for Hypertension}, Renvela 800 mg {Phosphate Binder for End Stage Renal Disease} with breakfast and again at lunch {which was given late, after R36 had already eaten}, and Saline Mist {Sodium Chloride} 0.65% for Allergic Rhinitis. On 8/29/23 at 10:13 AM, V11 Dialysis RN stated Phosphate Binders should be taken at the start of the meal so it can absorb the phosphates in the food so the patient can excrete them. If (R36) was going out that day, the nurse should have sent the medications with (R36) so they could be taken with food. On 8/29/23 at 3:46 PM, V28 Pharmacist stated both Calcium Acetate and Renvela are Phosphate Binders and should be given with food. By not giving it or giving it after the resident is finished eating, it will not work as it should and residents' phosphate levels could increase causing muscle spasms, itchy skin, weakened bones due to the depletion of calcium levels. V28 stated, not giving these medications as ordered is a significant medication error.

Based on observation, interview and record review the facility failed to accurately code the Resident Assessment Instrument (Minimum Data Set) for two of 32 residents (R61, R89) reviewed for Minimum Data Set assessments in the sample list of 49. Findings include: The facility's Minimum Data Set (MDS) policy with a reviewed date of February 2023 documents, A Minimum Data Set will be completed for facility resident as outlined in the Resident Assessment Instrument (RAI) Manual. The facility will conduct admission and scheduled assessments for all facility residents. The assessment process includes direct observation, as well as communication with the resident and direct care staff. The MDS should reflect the resident's status and identify resident need and enhance resident-focused care planning. 1.) R61's Physician Order Report dated 8/29/23 documents diagnoses including Coronary Artery Disease and Hypertension. On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a CPAP (Continues Positive Airway Pressure) machine with tubing and mask attached and were laying on the cluttered bedside stand. On 8/29/23 at 3:12 PM, R61 was in R61's room with staff getting R61 ready to lay down in bed. R61 had the CPAP machine on the bedside stand with the mask and tubing attached. V29 Licensed Practical Nurse confirmed R61 wears the CPAP at night. R61's MDS dated [DATE] does not document the use of the CPAP machine. On 8/29/23 at 3:18 PM, V26 MDS Coordinator confirmed R61's MDS is not coded for the use of a CPAP machine. V26 stated the CPAP is not on the orders so V26 was not aware of the CPAP machine. 34201 2. R89's August 2023 POS (Physician Order Sheet) documents an order dated 5/10/23 for Eliquis {Anticoagulant} 2.5 mg (milligrams) - one tablet BID (twice a day). R89's MDS dated [DATE] does not document that R89 received the ordered Anticoagulant during the look back time. R89's June 2023 MAR (Medication Administration Record) documents R89 received the ordered Eliquis during the look back time for the MDS. On 8/28/23 at 3:24 PM, V26 MDS Coordinator stated Anticoagulants are to be coded on the MDS. V26 reviewed R89's POS and (Treatment Administration Record) TAR and confirmed R89 did indeed receive the ordered anticoagulant. V26 confirmed the anticoagulant is not coded on the MDS. The facility Minimum Data Set Policy dated February 2023 documents the MDS should reflect the resident's status and identify resident need and enhance resident-focused care planning.

Based on observation, interview, and record review the facility failed to assess and obtain physician's order for self-administration of medication for two of two (R90, R61) residents reviewed for self-administration of medication in a sample list of 49. Finding Include: The facility's Medication Administration policy with a reviewed date of February 2023 documents, Self-Administration: Residents with appropriate cognitive status will be able to self-administer medication. The facility will complete a self-medication administration assessment to determine if resident is able to give their own medications appropriately. 1. R90's Physician's Order Summary includes a physician's order which was initiated 5/9/23 for albuterol sulfate HFA aerosol inhaler; 90 mcg/actuation; amt: 2 puffs; inhalation Special Instructions: rinse mouth after each use every 6 hours. There is no self-medication assessment documented and no physician's order to self-administer albuterol. On 08/28/23 at 12:34 PM, R90 stated he's Miserable from a respiratory infection. R90 was experiencing frequent wet sounding coughs. R90 was not covering his cough. R90 stated I've got a puffer, but it fell on the floor. A red inhaler was laying under R90's bed. R90 stated I just take it whenever I need it. On 08/28/23 at 12:40 AM V20, CNA entered the room. The lid was off the inhaler. V20 picked up the inhaler and handed it to R90. V20 nor R90 cleaned the inhaler. R90 took two puffs on the inhaler without waiting between puffs. V20 verified the inhaler was labeled Albuterol. On 8/29/23 at 10:00 AM V2, Director of Nurses (DON) verified that an assessment/physician's order for R90 to have the Albuterol inhaler at bedside for self-administration was not completed until 8/28/23 at 5:18PM. 32853 2.) On 8/28/23 at 9:38 AM, R61 was not in R61's room, there was a tube of topical analgesic on the counter in in R61's room. On 8/29/23 at 3:12 PM, the tube of topical analgesic is still sitting on the counter in R61's room. R61's Physician Order Report dated 8/29/23 documents diagnoses including Muscle Wasting and Atrophy, Bilateral Primary Osteoarthritis of Hip, Pain in Right Hip, Pain in Left Hip and Pain Unspecified. This Physician Order Report does not document an order for the topical analgesic or an order to self-administer the topical analgesic. R61's Minimum Data Sheet (MDS) dated [DATE] documents R61 is cognitively intact and documents no impairment in range of motion in the upper and lower extremities. R61's Medical Record does not contain an assessment to self-administer the topical analgesic. On 8/29/23 at 3:03 PM, V2 Director of Nursing stated that residents can have medicine in their room if they have an assessment completed, V2 stated there should be a Physician's Order to self-administer the medication and an order for the medication. V2 confirmed there is no order for R61 to self-administer the topical analgesic and there is no current order for the topical analgesic.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview and record review, the facility failed to complete a safe transfer from the wheelchair to the recliner by ensuring proper foot placement during the transfer for one of three residents (R1) reviewed for falls on the sample list of three. This failure resulted in R1's foot getting caught on an unidentified object during the transfer and sustaining a spiral fracture of the left tibia. B. Based on observation, interview and record review, the facility failed to complete a fall investigation/root cause analysis, implement new post fall interventions, and complete fall risk assessments per facility policy for two of three residents (R2, R3) reviewed for falls on the sample list of three. Findings Include: a.) On 1/3/23 at 10:52 am, R1 was sitting up in R1's wheelchair across from nurses' station with a cast to the left foot/lower leg. R1 stated R1 had an accident about six weeks ago when two unidentified staff, one male and one female, transferred R1 from the wheelchair to the recliner. R1 explained, we must have turned the wrong way though because my shoe got caught up on the recliner, my other foot or something, twisting it and I immediately had pain in my left heel. R1's MDS (Minimum Data Set) dated 10/6/22 documents R1 is alert and oriented. R1's Progress Notes dated 11/16/22 by V6 LPN (Licensed Practical Nurse) documents R1 is complaining of severe pain to the left ankle and foot and states it hurts when leg is moved or lifted. R1 states (R1's) foot was twisted when transferred yesterday. R1 has been crying and yells out in pain. Swelling and tenderness noted. V11 Physician notified and x-ray requested. R1's left ankle x-ray dated 11/16/22 documents an oblique lucency is partially visible involving the distal third of the tibia. This may represent a nondisplaced oblique fracture. A dedicated tibia and fibular study may be helpful. R1's left tibia and fibula x-ray dated 11/17/22 documents a spiral fracture of the distal third of the tibia is identified. Minimal displacement noted. A distal fibular fracture cannot be excluded. R1's Progress Notes dated 11/23/22 document R1 was seen by V10 Orthopedic Physician and returned to the facility with a cast to the left lower extremity due to a distal third tibia fracture with orders to be non-weight bearing and to elevate for swelling. On 1/3/22 at 2:18 pm, V9 Restorative CNA (Certified Nursing Assistant) stated prior to R1's fracture, R1 required a partial weight bearing mechanical lift and when assessing R1's transfer status, (R1) needed help getting I think (R1's) left leg up on the platform and placed correctly. V9 stated, if (R1's) feet were on the {lift} platform correctly, they couldn't' have gotten caught on anything. Staff must not have made sure (R1's) feet were not planted correctly on the platform. V9 stated since R1's fracture and non-weight bearing status to the left lower extremity, R1 now uses a full weight bearing mechanical lift for transfers. On 1/4/23 at 9:20 am, V14 (V10's Nurse) stated R1 is being seen by V10 for a non-displaced spiral fracture of the left tibia shaft. When first seen on 11/23/22, R1 presented with ankle pain and swelling. R1 reported to V10 that the injury was caused by R1's foot twisting during a transfer with a lift on 11/15/22, when R1's foot got caught on something. This type of injury is seen with a twisting injury, so it aligns with R1's story. Staff should have been more careful and aware of R1's foot placement. This definitely could have been prevented. On 1/4/23 at 10:38 am, V4 CNA (Certified Nursing Assistant) stated V4 was assigned to R1 on 11/15/22, the day R1 claims R1's foot was twisted during the transfer. V4 stated V4 has provided cares to R1 for years and has never had a problem with R1. V4 stated R1 did not complain of any foot, ankle or leg pain at the time of transfer and that V4 isn't aware of R1's foot getting caught on anything. V4 explained that R1 doesn't bear weight good on the mechanical lift so V4 is always having to fix (R1's) feet because they are never on the {partial weight bearing mechanical lift} correct explaining R1's feet will stick out over the edge, dangling, or get a little twisted. b.)1) The facility Fall Prevention Policy and Procedure dated 2/28/2019 documents after a fall occurs, the QA (Quality Assurance) Team will conduct a case-by-case review of all falls to ensure that medications are reviewed and prevention measures are recommended, provide assistance to the front-line staff in recommending prevention strategies for residents and assist in the development of fall prevention intervention strategies and help with the implementation. An incident investigation form will be completed as part of the QA process. The form will be used by Nursing Administration and QA team members to ensure that each incident is properly analyzed. The incident investigation will allow the QA team to identify and assess the causes of the incident and the subsequent responses and/or actions that should be taken. This will be part of the facilities ongoing QA process. R2's Fall Risk assessment dated [DATE] documents R2 is at high risk for falls. R2's MDS (Minimum Data Set) dated 11/3/22 documents R2 has severe cognitive impairments and requires extensive assistance of one staff for bed mobility, transfers, and locomotion on the unit. R2's Event Report dated 11/10/22 documents R2 sustained an unwitnessed fall and was observed scooting on the floor in the bathroom. The root cause of the fall is documented as at risk for falls related to general weakness and history of repeated falls. Recommendations/Post Fall Interventions document: continue current measures. R2's Nursing Progress Notes document the following: 1/3/23 - R2 fell at 5:20 am. The CNA (Certified Nursing Assistant) heard someone call for help which the CNA followed to reveal R2 on the floor. R2 continued to scoot around until the nurse came out of medication room. Upon assessment R2 is able to move all extremities with equal strength and ROM (Range of Motion). R2 complained of mild pain in leg or foot. R2 was assisted by the nurse and CNA into R2's wheelchair where R2 was then taken and toileted and dressed for the day. R2's Care Plan last updated on 1/3/23 documents R2 is at risk for falling due to impaired cognition, pain, easily fatigues, and general weakness with interventions of keep call light in reach, complete fall risk assessment quarterly, ensure appropriate footwear and that R2 is wearing glasses, encourage to stand slowly, increase toileting frequency, and observe frequently/place in supervised areas when out of bed as R2 allows. This care plan has an intervention dated 11/14/22, {after the 11/10/22 fall} to continue current measures but no new post fall interventions were implemented. This care plan also has a new intervention dated 1/3/22 {after the 1/3/22 fall} that documents room move. On 1/3/23 from 9:30 am - 4 pm, and 1/4/22 from 8:30 am - 11:00 am, R2 was observed sitting either in a wheelchair or a recliner on hallway XXX. On 1/4/23 at 10:30 am, V2 DON (Director of Nursing) stated V1 Administrator has IDT (Interdisciplinary Team) Notes from where the IDT discusses resident falls that would have the root cause of the fall documented on due to the Event Report not having it documented for the 11/10/22 fall. On 1/4/23 at 10:48 am, V2 stated V1 did not have an IDT Note for R2's 11/10/22 fall showing that R2's fall was investigated. V2 also confirmed that no new interventions were implemented after R2's 11/10/22 fall. At this time, V2 stated the facility has already determined an intervention based on R2's fall on 1/3/22, and it's already been care planned. V2 explained R2 is to be moving from XXX hall into a different room on the YYY hall, where we {facility} feel (R2) is more appropriate for but haven't done it yet {more than 29 hours after the incident}. 2) R3's ongoing Census Sheet documents R3 was admitted to the facility on [DATE]. R3's Medical Record contained one Fall Risk Assessment completed on 12/23/22, after R3 fell and sustained a head laceration. On 1/4/22 at 2:21 pm, V2 DON (Director of Nursing) stated Fall Risk Assessments are to be completed upon admission, quarterly and annually. V2 checked R2's medical record and stated, V2 unfortunately don't see where (R3) had a fall risk assessment completed upon admission. The facility Fall Prevention Policy and Procedure dated 2/28/2019 documents a staff nurse is responsible for completing a fall risk assessment on a resident upon admission to the facility, then further assessments will be completed upon changes in condition, quarterly and annually.

Based on observation, interview, and record review the facility failed to implement fall prevention interventions as outlined in residents' plans of care. This failure affects two residents (R1 and R3) of three reviewed for fall prevention in the sample of three. This failure resulted in R1 experiencing a fall with pubic bone fractures and R3 experiencing a fall with a laceration requiring sutures in the forehead. Findings include: 1.) R1's Face Sheet dated 1/25/22 documents R1 was admitted to the facility 12/15/21 with medical diagnoses including [CONDITION(S)], Convulsions/ Seizures, Dementia with Behavior Disturbance, Repeated Falls, [CONDITION(S)], and Urge Incontinence. R1's Fall Risk assessment dated [DATE] documents R1 received a score of 15 points, rating R1 as a high risk for falls. R1's Care Plan initiated 12/15/21 documents a fall prevention intervention, which includes for staff to ensure non-slip socks are on resident. R1's Nurses Notes dated 12/26/21 document a fall experienced by R1 at 10:42 am, incurring a hematoma to the right side of R1's head. The facility's recommendation as documented on R1's Event Report for this fall was to repeat the same intervention ensure non-slip socks are on resident. R1's Care Plan did not document any new fall prevention intervention in response to this fall on 12/26/21. R1's Nurses Notes and Incident Report dated 1/5/22 document R1 experienced a fall on 1/5/22 at 3:21 am. According to a documented interview with V5 Certified Nursing Assistant, R1 was wearing regular socks when this fall occurred. R1's Computed Tomography scan report dated 1/6/22 documents R1 experienced fractures of the right inferior pubic ramus (lower pubic bone), right acetabulum (hip bone socket), and right pubic symphysis (joint between the two upper pubic bones). On 1/25/22 at 10:50 am, V8, Licensed Practical Nurse, stated, (R1) usually wore shoes when out of bed. (R1) maybe could put his own shoes on, but someone would need to tell (R1) to do it. (R1) wasn't wearing (non-slip) socks when he fell at 3 in the morning because second shift put him in bed without the (non-slip) socks. On 1/25/22 at 11:40 am, V2, Director of Nursing, confirmed R1 was not wearing non-slip socks at the time of the fall experienced on 1/5/21 stating R1 had a preference to not wear them because R1 did not like the feeling of the non-slip socks inside of his shoes. On 1/25/22 at 3:15 pm, V15, Registered Nurse/ Unit Director, stated, (R1) probably could put on his own shoes if they were the slip-on type, but (R1) wasn't cognitively aware of safety needs and would need someone to tell him to put them on. On 1/26/22 at 2:47 pm, V1, Administrator, confirmed there was not an intervention placed on R1's Care Plan for the fall on 12/26/21. R1's Occupational Therapy Notes dated 12/30/21 document R1 required partial to moderate assistance to put on or take off footwear. Partial to moderate assistance is defined in these notes as Helper does less than half the effort, lifts/ holds/ supports trunk or limbs. These notes document an anticipated goal for R1 to achieve a level of function requiring only supervision or touch assistance to put on or take off footwear. R1's Occupational Therapy Discharge Note documents R1 was discharged from Occupational Therapy 12/30/21 with Goal Not Met. 2.) R3's Face Sheet dated 1/25/22 documents R3 was admitted to the facility 1/5/22 with medical diagnoses including Cognitive Functional Impairments, Repeated Falls, and Urinary Tract Infection. R3's Fall Risk assessment dated [DATE] documents R3 received a score of 15 points, rating R3 as a high risk for falls. R3's Care Plan initiated 1/5/22 documents fall prevention interventions including observe frequently and place in supervised area when out of bed. This Care Plan documents another fall prevention intervention for staff to keep personal items within reach. R3's Nursing Notes and Event Report dated 1/17/22 document R3 experienced a fall on 1/17/22 while (by herself) in her own room eating lunch. The 1/17/22 at 5:25 pm nurses note for R3 documents, Resident was yelling out, 'help, I fell .' This writer and CNA went to residents' room and observed her lying on the floor on her right side with a puddle of blood near her head. This Nursing Note documents R3 experienced a laceration over the right eyebrow requiring a visit to the hospital emergency room and sutures. R3's Emergency Report dated 1/17/21 documents R3 received 5 sutures for the repair of a 3 centimeter forehead laceration. R3's Nurses Notes and Event Report dated 1/23/22 document R3 experienced a fall on 1/23/22 in front of her recliner while in her own room. The facility's intervention in response to this fall was to repeat the same intervention have resident in supervised area as able. On 1/25/22 and 1/26/22, R3 was seated in her own room at all observations including 1/25/22 at 10:50 am and 3:30 pm, and 1/26/22 at 10:40 am. On 1/26/22 at 10:40 am, R3's wheelchair and walker were approximately 8 feet and 6 feet away from R3's chair, respectively. On 1/25/22 at 10:50 am, V8, Licensed Practical Nurse, stated, (R3) is able to use the call light, otherwise we would have her out to be supervised by the nurse's station with all the other frequent fallers. On 1/25/22 at 3:30 pm, R3 was seated in her own room calling out repeatedly, Can you help, me? Can you bring me some food in Jesus' name? R3 did not respond to suggestions to utilize the nurse call system in order to gain staff attention, simply kept repeating the statements, Can you help me? Can you bring me some food in Jesus' name?

Based on interview and record review the facility failed to implement infection control procedures to prevent the spread of a highly contagious disease to a resident. The facility failed to isolate a symptomatic resident (R2) who subsequently tested positive for COVID-19 away from an asymptomatic resident (R3). This failure affected one of three residents (R3) reviewed for infectious disease on the sample list of three. This facility failure resulted in R3 contracting COVID-19 and requiring hospice care for [MEDICAL CONDITION]. These failures resulted in an immediate jeopardy, while the immediate jeopardy was removed on 12/12/20. The facility remains out of compliance at a severity level 2 while the facility is in the process of implementing re-education components and training related to infection control and prevention of COVID-19 exposure. Findings include: The facility's Emerging Infectious Diseases policy dated 6/2019 documents under the heading Suspected Infectious Case that, 1. A resident who exhibits symptoms of the infectious disease (EID) should be placed in an isolation room and local public health authorities should be notified. R2's nursing notes dated 11/27/2020 at 4:29 PM written by V2 Director of Nursing (DON) documents R2 has a 104.1 temperature and R2 has wheezing in upper lobes and diminished lung sounds in lower lobes. R2's nursing notes dated 11/27/2020 at 8:13 PM documents R2 was tested for COVID 19. On 12/08/20 at 10:55 AM, V2 stated R2 started having symptoms of COVID-19 on 11/27/20. V2 stated R2 was tested that day due to the facility doing their weekly testing. V2 stated V2 put R2 into isolation and left R2's roommate (R3) in the (same) room with R2. V2 stated R3 was not having symptoms only R2. R2's COVID-19 laboratory form dated 11/27/20 documents R2 was positive for COVID-19. R3's COVID-19 laboratory form dated 11/27/20 documents R3 was negative for COVID-19. R3's nursing notes dated 11/30/20 at 4:54 PM documents R3 has a wheezy cough and that scattered audible wheezes were noted on auscultation. On 12/08/20 at 10:55 AM, V2 stated R3 began to have a cough with abnormal lung sounds on 11/30/20. R3's COVID-19 laboratory form dated 12/1/120 documents R3 was positive for COVID-19. On 12/10/20 at 9:33 AM, V19 Health Department's Public Health Nurse stated the facility should not have left a symptomatic resident and an asymptomatic residents in the same room together. V19 stated this puts the asymptomatic resident at risk for exposure to COVID-19. R3's physician order [REDACTED]. The Immediate Jeopardy situation was identified on 12/11/20. The Immediate Jeopardy was determined to have begun on 11/27/20 when R2 began to have symptoms (high fever and abnormal lung sounds) of a highly contagious disease (COVID-19) and was not isolated. R3 who was asymptomatic continued to share a room with R2 who was symptomatic. R2 subsequently tested positive for COVID-19. V1 Administrator was notified of the Immediate Jeopardy on 12/11/20 at 9:00 AM. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the immediate jeopardy. 1. All staff were educated on the facility's infection control policy. 2. The facility ensured there was no cohorting of symptomatic/asymptomatic residents. 3. All nursing staff were educated on symptoms of COVID-19 and to isolate residents with these symptoms. 4. The Director of Nursing or Designee will log all employee tests by date and ensure test results are obtained. 5. All staff were re-educated on the facility's infection control policy.

Based on record review and interview the facility failed to develop and implement interventions to prevent an injury for one of three residents (R1) reviewed for falls with injuries and failed to complete quarterly and as needed fall assessments for two of three residents (R1, R2) reviewed for falls in the sample list of 12. This failure resulted in R1 rising from R1's wheelchair unassisted and falling to the floor which resulted in a left [MEDICAL CONDITION] requiring surgical repair. Findings include: The facility's Fall Prevention policy with a revised date of 2/28/19 documents, A fall will be defined as unintentionally coming to rest on the ground, floor or other lower level, not intentionally from an overwhelming external force or other purposeful action. Residents will be assessed for their fall risk: The facility nurse will be responsible for completing the Fall Risk Assessment on admission. The MDS (Minimum Data Set) Coordinator or designee will update following any significant change of status and as needed. On regular intervals which includes quarterly/annually MDS 3.0 Assessments. At any time necessary as assessed by the nursing administration. The Nurse Managers are responsible for: completing the fall-risk assessment at the appropriate intervals, Updating resident care plans appropriately and to ensure proper interventions are in place. Nursing staff including RNs (Registered Nurses), LPNs (Licensed Practical Nurses), and CNAs (Certified Nursing Assistants) are responsible for: Helping Nursing Administration with input to complete fall risk assessments upon admission and following a fall or change in condition of a low risk resident. To ensure procedures for high risk fall patients are in use. 1.) R1's Face Sheet dated 7/21/20 documents [DIAGNOSES REDACTED]. R1's Minimum Data Set ((MDS) dated [DATE] documents R1 has moderately impaired cognition. This MDS documents R1 required limited assistance of one person for transfers and for walking. R1 required extensive assistance of one person for toileting. This MDS documents R1 was not steady moving from a seating to a standing position and required staff assistance to stabilize self. This MDS also documented R1's Range of Motion was impaired on both lower extremities. R1's medical record documents fall events on 3/22/20, 5/22/20 and 7/17/20. R1's medical record documents an annual Fall Risk assessment dated [DATE] which documents a moderate fall risk. The next fall risk assessment in R1's medical records is a Quarterly assessment dated [DATE], almost six months later, and documents R1 is a high risk for falls with altered awareness of immediate physical environment. R1's medical record does not document fall risk assessments following the 3/22/20 fall or the 5/22/20 fall and R1's medical record does not document a quarterly fall risk assessment between the 12/19/19 assessment and the 6/11/20 assessment. R1's Restorative Note dated 3/5/20 completed by V26 Registered Nurse (RN), documents R1 requires one person assist for a stand pivot transfer. R1's Restorative Note dated 6/9/20 completed by V27 RN documents the same requirement for R1 to have one person assistance for a stand pivot transfer. R1's Care Plan with a start date of 12/25/17 and updated 7/23/20 documents R1 is at risk for falls with interventions dated 5/28/20 to keep gait belt in reach, 3/23/20 to remind resident to use the call light for assistance when wanting to get up, 5/3/18 resident reoriented and re-educated to use call light and encourage to use it, 12/25/17 fall risk assessments quarterly and prn (as needed). On 8/31/20 at 2:43 PM, V2 confirmed that there were no quarterly fall assessments completed nor were there fall assessments completed with the falls for R1. On 8/31/20 at 4:00 PM, V2 Director of Nursing provided a portion of R1's Care Plan that was not available in the electronic record which documents a problem date of 3/8/20 and documents R1 has the inability to ambulate independently due to unsteady gait and general weakness. R1's Nurses Progress notes dated 7/17/20 at 7:51 PM, by V13, RN documents staff heard resident yelling Hey, hey and as they started walking towards the yelling, the resident was yelling help, help, I've fallen. Staff ran to find resident (R1) laying on R1's left side next to R1's wheelchair, R1 stated that R1 was standing up, lost R1's balance and fell . Upon attempting assessment R1 verbalized severe pain to the left hip and lower back. Left lower extremity was noted to be abnormally rotated outward. R1 was unable to wiggle toes or move. R1 stated that R1's back hurt. Staff was instructed to not move resident and writer (V13) called 911. Ambulance arrived and R1 was taken to the hospital. SBAR (Situation, Background, Assessment and Recommendation) and bed hold were faxed to the hospital and POA (Power of Attorney) and PCP (Primary Care Physician) were notified. R1's Fall Investigation dated 7/17/20 documents R1 was last seen at 6:45 PM, however none of the witness statements document visualizing R1 at 6:45 PM. V28 Certified Nursing Assistant's (CNA) witness statement documents that V28 saw R1 last at 5:00 PM when V28 took R1 to the toilet before supper. On 9/1/120 at 8:34 AM, V28 confirmed that was the last time V28 saw R1 before R1 had fallen. V29's witness statement documents that V29 did not start V29's shift until after R1 had already fallen. On 9/1/20 at 9:00 AM, V13 Registered Nurse (RN) stated V13 was the one that saw R1 at 6:45 PM on 7/17/20. V13 stated R1 was in R1's room in R1's wheelchair at the end of R1's roommates bed reading a newspaper at 6:45 PM. V13 stated a little after 7:00 PM V13 heard a resident yelling for help so V13 went running and found R1 on the floor in R1's room. V13 stated R1 was non complaint with waiting for assistance to stand and transfer. V13 stated often times they would find R1 already on the toilet in the bathroom because R1 had taken R1's self to the toilet or they would find R1 in the doorway of R1's room with the depends at R1's knees because R1 took R1's self to the bathroom but could not pull up the depends afterwards. R1's hospital emergency room History and Physical dated 7/17/20 documents the chief complaint as fall from bed at nursing home. Hospital's assessment and plan document, R1 was unable to move R1's leg. Hospital Assessment/Plan documents a [AGE] year old female with known history of Dementia was sent to the hospital with noted unwitnessed fall, patient (R1) has been unable to move (R1's) left leg and is unable to give any history. Upon presentation to ED (Emergency Department) noted to a have left [MEDICAL CONDITION]. Will admit for possible operation tomorrow morning. R1's Radiology Report dated 7/17/20 at 9:03 PM, documents acute comminuted and displaced intertrochanter femoral fracture. R1's Surgical Case Record dated 7/18/20 documents actual procedure as left long intramedullary nail. R1's Nurses Progress Note dated 7/21/20 at 5:17 PM, documents R1 returned to the facility by ambulance. R1 was slightly confused. R1 had two incisions on left hip from the hospital stay. There were 16 staples in the top incision and six staples in the bottom incision. On 7/21/20 at 6:49 PM, R1's Nurse's note documents R1 was unable to take R1's medications whole as R1 did previously. This Nurse's note documents the medication had to be crushed and administered to R1. On 8/31/20 at 2:43 PM, V2 confirmed that the facility was aware that R1 frequently stood up without assistance and there is not anything documented prior to the 7/17/20 fall that the facility was doing to prevent the fall with injury. V2 stated that they could have done 15 minute checks, rounding every hour or kept R1 in a more supervised area. On 9/1/20 at 8:34 AM, V28 Certified Nursing Assistant (CNA) confirmed V28 last saw R1 at 5:00 PM on 7/17/20 when V28 took R1 to the toilet and V28 left the facility at 6:00 PM. V28 also stated that R1 stood up a lot without assistance. 2.) R2's face sheet printed 9/1/20 documents [DIAGNOSES REDACTED]. R2's medical record documents R2 had falls on 8/01/2020 at 4:25 PM, 7/30/20 at 2:27 AM, 7/26/2020 at 9:44 AM, 7/23/2020 at 12:44 AM, 7/22/2020 at 9:13 PM, 6/26/2020 at 8:21 PM, 6/18/2020 at 4:30 PM, and 5/03/2020 at 11:29 PM. R2's Care Plan dated 3/03/2020 documents R2 is at risk for falls related to Confusion, Forgetfulness, Poor Sleeping Habits, Lack of Personal Safety Awareness, Intermittent Impaired Balance and the use of medication known to increase the risk of falling. This Care Plan documents interventions for falls as placing safety mats next to the bed, medication review, make sure R2 has warm clothing on and Fall Assessments to be completed quarterly and prn (as needed), R2's Transfer assessment dated [DATE] documents R2 transfers independently. R2's Fall Risk assessment dated [DATE] documents R2 transfers independently. R1's next fall assessment is dated 6/4/20 which documents R2 is now a high risk for falls. R2's medical record does not document fall risk assessments being completed with each fall. R2's medical record documents the quarterly fall assessment completed on 6/4/20 was due in May, 2020. On 8/31/20 at 2:43 PM, V2 confirmed that fall assessments were not completed with the falls for R2 and quarterly assessments were not completed on time. V2 stated that R2 had a significant decline from March to June when R2's family could no longer visit on a daily basis due to COVID-19 like they had previously.

Based on observation, interview and record review the facility failed to initiate a treatment for [REDACTED]. These failures resulted in R52 developing a stage four pressure injury to R52's right heel and a stage three pressure injury to R52's left heel. Findings include: The undated Wound and Ulcer Guidelines policy states The following prevention measures may be initiated to address pressure, moisture, friction, and/or shearing: Pressure reduction surface on bed/chair when indicated Turn and reposition at least every two hours Avoid positioning on an area of [DIAGNOSES REDACTED] or breakdown whenever possible Support heels on pillows or in splints and Limit time out of bed if needed. The (seat cushion) Operations Manual dated (MONTH) 2007 states Precautions This product is designed to be used as a cushioning device to conform to a user's seated shape to protect skin tissue and aid in the preventions of tissue breakdown and Obstructions: DOT NOT place any obstructions between the user and the cushion because it will reduce product effectiveness. The Mechanical Lift policy dated 5/1/19 states after transferring the resident Remove the lifter. The Wound and Ulcer Policy and Procedure policy dated 7/22/15 states When a resident is found to have a wound or ulcer, either on admission of during their stay, the following will be completed by a licensed nurse Initiate the treatment protocol appropriate for the stage of ulcer or for the wound assessed and Notification of the physician, documenting, and initiating written and/or verbal orders of the physician. 1. The Physician order [REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] documents R52 is at risk for skin breakdown and that R52 has no pressure sores. The Admission MDS also documents R52 requires extensive assistance from staff for transfers and bed mobility. The Care Area assessment dated [DATE] documents (R52) requires staff assistance to move sufficiently to relieve pressure over any one site (R52) Confined to a bed or chair all or most of the time and (R52) Requires regular schedule of turning. R52's Care Plan updated 7/11/19 does not include a turning plan for R52. The Progress Note dated 5/2/19 documents R52 has blisters to bilateral heels. The Physician order [REDACTED]. The 4/18/19 through 7/16/19 POS documents an order for [REDACTED]. (R52) may wear slipper socks and (pressure relieving) boots until blisters resolve on feet. V27's (Wound Doctor) Progress Notes dated 5/9/19 documents Suspect (R52) is getting pressure to heels when in bed and when in recliner so (R52) is going to use (pressure reducing boots) in both settings. V27's Progress Notes dated 5/23/19, 5/30/19, 6/6/19 and 6/13/19 document (pressure reducing boots) boots to BLE when in bed. No closed heel shoes. V27's Progress Note dated 6/20/19 documents R52's right heel wound is a stage four pressure injury and R52's left heel wound is a stage three pressure injury. The readmission Body Diagram dated 7/5/19 documents R52 was readmitted to the facility on [DATE] with an open areas to R52's medial buttocks measuring seven cm (centimeters) by two cm and six cm by two cm. The Treatment Administration Record dated 7/1/19 through 7/16/19 documents a treatment was not initiated for the wounds on R52's medial buttocks until 7/8/19. V27's Progress Note dated 7/11/19 documents R52's medial buttocks wound is a stage three pressure injury. On 07/15/19 at 10:21 AM R52 was seated in the recliner chair with R52's feet on the foot rest and R52 was wearing closed back shoes. On 07/16/19 at 08:47 AM, 10:56 AM, 11:40 AM R52 was seated in the wheelchair with the mechanical lift sling between R52 and the pressure relieving cushion and R52 was wearing closed back shoes. On 7/16/19 at 11:40 V30 and V31 Certified Nurses Aides (CNA) used the mechanical lift to transfer R52 from the wheelchair to the bed. V30 and V31 removed R52's brief and completed perineal care. At that time R52's right hip and buttocks were red. After completing perineal care V30 and V31 left the room without placing R52's pressure relieving boots on R52's feet, with R52's heels resting on the bed. On 7/16/19 11:50 am V30 CNA stated V30 and V25 CNA got R52 up in the wheelchair between 7:15 AM and 7:25 AM and R52 has been in the wheel chair since that time until R52 was transferred to the bed (11:40 am). V25 stated R52 had been in activities and therapy. On 7/16/19 at 1:55 PM R52 was seated in the wheelchair with the mechanical lift sling between R52 and the pressure reliving cushion and R52 was wearing closed back shoes. On 7/17/19 at 11:45 am V25 stated when R52 was admitted to the facility R52 wore pressure relieving boots. V25 stated V25 does not know why R52 stopped wearing the boots. V25 stated most days V25 puts shoes on R52. V25 stated V25 was not told R52 should not wear shoes. On 7/17/19 at 1:00 PM V30 CNA stated V30 did not know R52 was not suppose to wear shoes. ON 7/17/19 at 12:10 PM V2 Director of Nurses stated V2 would expect staff to follow the manufacturers guidelines for R52's seat cushion and would expect staff to have a plan in place to ensure R52 is repositioned every two hours around therapy and activities. V2 also stated V2 would have expected staff to contact the doctor for a treatment order for R52's medial buttocks wound when R52 returned from the hospital (7/5/19). On 7/18/19 at 10:00 am V 22 Wound Nurse confirmed R52 was identified as at risk for skin breakdown when R52 was admitted to the facility (4/18/19). V22 stated V22 could not provide documentation that R52 had been on a repositioning program since R52 was admitted to the facility (on 4/18/19). V22 stated V22 usually adds a repositioning program to the care plan and then triggers the task to appear in the point of care (P[NAME]) computer system for the CNA staff so they know what to do and can sign off the tasks. V22 stated V22 missed adding the repositioning program program to R52's Care Plan. V22 stated V22 did not trigger the tasks of repositioning, pressure relieving boots and instructions that R52 should not wear shoes on the P[NAME] computer system so the tasks did not appear in P[NAME] for the CNA staff to complete. On 7/17/19 at 12:30 PM V27 Wound Doctor stated that if the facility had carried out a plan to prevent R52's pressure sores when R52 was identified to be at risk for skin breakdown and R52 still developed the sores you could say they were unavoidable. If the plan was not carried out then they failed to prevent the development of the wounds or maybe the (right heel) wound would not have been as severe if the plan had been implemented. V27 stated that if interventions had been in place at the time R52 was identified as at risk for skin breakdown the wounds could possibly have been avoided. V27 stated the source of the right heel wound was pressure from the bed. V27 stated the outside of the heel is a common pressure area if residents are flat on their back. V27 also stated R52 should not be wearing closed back shoes. 2. R16's physician's orders [REDACTED]. R16's Care Plans dated 6/26/19 document R16 is at risk for impaired skin integrity and is to use a pressure relieving cushion to the wheelchair and an air mattress on R16's bed. On 07/15/19 at 10:22 AM R16 was up in the wheelchair with R16's mechanical lift sling under R16 over top of R16's pressure relieving cushion in R16's wheelchair. On 07/15/19 at 12:08 PM R16 was sitting up in R16's wheelchair in the dining room with the mechanical lift sling under R16 over top of the pressure relieving cushion. On 07/16/19 at 12:00 PM R16 was sitting up in the wheelchair with the mechanical lift sling under R16 on top of the pressure relieving cushion. On 07/16/19 at 02:57 PM R16 was laying in bed with a thick fabric incontinence pad under R16 over top of R16's air mattress. On 7/17/19 at 01:00 PM V32, Licensed Practical Nurse (LPN) performed cares for R16. R16 was in bed in R16's room with a fabric incontinence pad under R16 over top of R16's pressure relieving alternating air mattress as well as on top of R16's bedding. V32 did not remove any of the extra bedding/linen after providing cares. 3. R40's Minimum Data Set ((MDS) dated [DATE] documents R40 is at risk of developing pressure ulcers. R40's Care Plans document R40 is at risk for impaired skin integrity due to incontinence, limited mobility and [DIAGNOSES REDACTED]. On 07/15/19 at 09:06 AM there was a sign in R40's room, documenting R40 is to have pressure reducing boots to bilateral lower extremities at all times located on the wall across from R40's bed. At this time, R40 was sitting at the nurses station with the mechanical lift sling under R40 over top of the pressure relieving cushion. R40 did not have boots on at this time. On 07/15/19 at 09:38 AM R40 was in bed and did not have pressure reducing boots in place. On 07/15/19 at 11:37 AM No pressure reducing boots to R40's bilateral lower feet. On 07/15/19 at 12:15 PM R40 was up in the hall in R40's wheelchair with the mechanical lift sling under R40 over top of the pressure relieving cushion in the seat of R40's wheelchair. R40 did not have pressure reducing boots in place. On 07/16/19 at 11:03 AM R40 was in bed and did not have pressure reducing boots on. On 07/16/19 at 11:40 AM R40 was up in the wheelchair in the hall without R40's pressure relieving boots on R40's feet. R40's mechanical lift sling was under R40 on top of R40's pressure relieving cushion. On 07/17/19 11:00 AM R40 in bed, pressure relieving boots are on at this time. Per V29, Certified Nursing Assistant (CNA), R40 requires these boots for pressure ulcer prevention. 4. R59's Minimum Data Set ((MDS) dated [DATE] documents R59 is at risk for pressure ulcers and uses a pressure reducing device for R59's chair and bed. On 7/17/19 at 10:27am, R59 was in bed with a thick fabric incontinence pad under R59's buttocks over R59's pressure reducing air mattress. V36, Registered Nurse (RN) turned R59 to R59's side to observe R59's coccyx/buttocks area per request. V36 stated R59's coccyx area was reddened at this time and R59's coccyx was observed to be reddened at this time. 5. R63's physician's orders [REDACTED]. R63's Resident Face Sheet printed 7/17/19 documents R63 was admitted to the facility 2/6/19. R63's Braden Scale dated 3/7/19 scored R63 as at risk R63's Skin Wound Report dated 2/17/19 by V22, Wound Nurse documents R63 had a deep tissue pressure injury to Left upper buttock/lower back. The wound is documented as measuring 1.0 centimeters by 1.0 centimeters by 0.1 centimeters. Interventions documented on R63's wound report include pressure reducing device for chair, pressure reducing device for bed, reposition every 2 hours and as needed, and moisture barrier. R3's Care Plan documents an entry dated 2/8/19 (R3) has a stage IV pressure ulcer to left lower back related to limited mobility, weakness, and pain. Use gel/foam pad in wheel chair for pressure reduction, comfort, and positioning. Roho cushion. V27, Wound Physician's wound evaluation documents Stage IV pressure wound of greater than 135 days duration on R63's Left lower back measuring 0.8 centimeters by 0.5 centimeters by 1.7 centimeters with 2.5 centimeters of undermining and moderate serous exudate (drainage). V27 recommends a Roho cushion. On 7/15/19 at 9:30AM R63 is in room sitting in wheelchair. There is a Roho cushion in the wheelchair, but it is almost completely deflated. on 7/18/19 at 9:18AM R63 was transferred from wheel chair to bed. The roho cushion was in the wheel chair but was almost completely deflated. The manufacturer's Precautions provided by the facility for the Roho cushion state Check your product every day and frequently while using. Under-inflation Do not use an under-inflated cushion. Using a cushion that is under-inflated reduces or eliminates the cushion's benefits increasing risk to skin and soft tissue. On 7/18/19 at 10:00 V22 Wound Nurse states I check the Roho cushions every few days for inflation. I just do it when I get a chance. There isn't a schedule of documentation, I just do it when I get a chance. (R63's) cushion wasn't completely flat. 6. R83's face sheet printed 7/17/19 includes the following Diagnoses: [REDACTED]. R83's Care Plan dated 2/20/29 documents (R83) is at risk for impaired skin integrity related to limited mobility, incontinence, and pain. R83's care plan entry dated 7/17/19 documents Bilateral left extremity heel protectors on at all times except during cares. On 7/15/19 at 9:45AM R83 is sitting in room in wheel chair alone. Heel protectors are lying on the unused bed in R83's room. There was a mechanical lift sling left between R83 and the cushion in R83's chair. On 7/16/19 at 4:00 PM V13, Licensed Practical Nurse (LPN) checked R83's heels. There was a callous approximately one inch in diameter. R83's left heel had a calloused area with a pin point black spot to the center. V13 stated The black spot is new. R83's heel protectors were in a chair in R83's room. On 7/16/19 at 4:10 PM V2, Director of Nursing stated There is a small dark area on R83's heel. We are getting an order to start skin prep. On 7/16/19 at 4:15PM V22, Wound Nurse stated I think the area on (R83's) left heel is just a callous.

Based on observation, interview, and record review the facility failed to provide established interventions to prevent burns for two residents (R1 and R2) of two residents reviewed for burns in the sample of five. This failure resulted in R1 and R2 sustaining third degree burns. Findings include: 1.R2's Progress Note dated 3/11/16 documents R2 as having a [DIAGNOSES REDACTED]. R2's care plan documents an intervention dated 3/22/16 to serve hot drinks in sippy cups. R2's nurse's notes dated 5/3/16 at 4:45 PM documents, Resident in (dining room) tonight was given a cup of coffee from aide. Resident dropped coffee cup and coffee landed on top of right foot. Resident has a 2 cm (centimeter) by 2.5 cm reddened area . On 5/18/16 at 3:20 PM, E21 Volunteer Coordinator stated on 5/3/16 R2 asked for a cup of coffee. E21 stated E21 gave R2 a cup of coffee in a regular cup without a lid. E21 stated E21 did not put ice in the coffee. E21 stated E21 sat with R2 for a couple minutes then left. On 5/19/16 at 10:50 AM, R2's right foot had a wound (burned area) that measured 7.5 by 3.2 centimeters. The wound had a red perimeter with yellow exudate that covered sixty percent of the wound bed. The wound had light clear drainage. On 5/19/16 at 11:10 AM, Z3 Wound Physician stated R2's burn is at least a third degree burn. R2's wound notes documented by Z3 dated 5/19/16 documents, Wound involves the lateral dorsal foot, extending onto the dorsal 4th and 5th toes. At least a 3rd degree burn but could be a 4th degree. On 5/19/16 E1 Administrator stated on 5/3/16 a R2's coffee should have been provided in a sippy cup because that is what R2's care plan says to do. 2. R1's Physician's Progress Note dated 10/9/15 documents R1 as having a [DIAGNOSES REDACTED]. R1's care plan documents an intervention dated 2/14/16 for, Hot liquids only in coffee cups with lids. R1's Nursing Notes dated 2/24/16 at 5:40 PM documents, Heard resident yelling while sitting in the dining room . Yelled my coffee spilled on me. Immediately removed afghan and lifted pants away from resident's right upper leg where resident stated coffee spilled on . R1's Nurse's Notes dated 2/24/16 at 5:45 PM documents, Area (burn area) measured 7 centimeters (cm) by 10 cm. On 5/19/16 at 9:20 AM, E22 Wound Nurse stated on 2/24/16 R1's coffee cup did not have a lid on it. On 5/19/16 at 12:35 PM, R1's wound (burned area) to the left thigh was red with a light amount of clear drainage. The wound area was a one centimeter circular area surrounded by a healed pink area that measured ten centimeters. At that time, E22 stated the burn to R1's thigh was a third degree burn. R1 stated the burn to R1's thigh causes R1 quite a bit of pain. R1 stated R1 remembers that a staff member sat a cup of coffee on R1's table. R1 stated R1 reached for it and spilt it on R1's thigh. R1 stated the coffee cup did not have a lid and it was hot. On 5/19/16 at 10:10 AM, E1 Administrator stated E1 would have expected R1's coffee cup to have a lid on it on 2/24/16 because that was an intervention on the care plan (for R1). On 5/19/16 at 9:00 AM, Z3 (R1's Physician) stated R1's burn that occurred on 2/24/16 was a result of R1 spilling coffee on R1. Z3 stated the facility should not have given R1 hot coffee and needs to be more careful with giving R1 coffee.

Based on observation, record review and interview, the facility failed to safely transfer and transport to prevent injury for two of 16 residents (R19, R21) reviewed for falls and transfers from a sample of 24. These failures resulted in R19 receiving hospitalization for laceration repair, Subarachnoid bleed and Hematoma to the scalp, and R21 receiving hospital treatment and staples for a head laceration. Findings include: 1. According to the current physician's orders [REDACTED]. The Minimum Data Sets dated 2/5/15 and 4/30/15 assess R21 with severe cognitive impairment, and requiring total assistance for transfers and all activities of daily living. The careplan last reviewed on 5/1/15 states that R21 is transferred by mechanical lift with two to three staff. R21's Nurses Notes dated 2/13/15 at 2:30pm state, . CNAs (Certified Nurses Aide) reported the {mechanical lift} tipped and frame hit resident in the back of head. Deep laceration to back of head. The Physician was called and R21 went to the hospital. R21's Nurses Notes state that R21 returned to the facility on [DATE] at 5:50pm with three staples to the occipital area. The incident investigation included a demonstration/reenactment after the incident by E11 and E12 (CNAs) at 3:20pm on 2/13/15. This demonstration showed that while E12 was guiding R21 into the wheelchair, the lift became unsteady and the wheel came up off the floor, due to the legs to the lift were not out, as they were under the resident's wheelchair. E11 and E12 could not verify exactly what caused the laceration, but the investigation determined it was presumably from the strap hooks over {R21's} head. The Root Cause Analysis sheet states that the frame of the lift hit the back of R21's head. Hospital Emergency Department records dated 2/13/15 describes a four centimeter scalp laceration, requiring three staples for skin closure. R21's Medication Administration Record for 2/2015 shows that Tylenol (analgesic) was given on four occasions from 2/13/15 to 2/15/15 for discomfort from laceration.grimacing. {signs/symptoms} of pain. On 7/7/15 at 12:00pm, E11 stated that at the time of the incident, the legs of the lift were partially open but not all the way, and the lift lost balance, hitting R21 in the head. E11 stated that he did not recall being specifically trained on the lift prior to the incident, but that E11 and all other staff were inserviced following the incident to always have the base legs open during the transfer. E11stated that prior to the incident, the manufacturer's instructions were not on the lift during use, but they were placed on each lift after the incident. On 7/8/15 at 8:15am, E1 (Administrator) and E2 (Director of Nursing) confirmed that R21's incident of 2/13/15 was due to the legs of the mechanical lift not being open apart during the transfer. E2 stated that E11 and E12 had been educated prior to the incident in the correct procedure for use of the mechanical lift, and that E11, E12 and all staff were inserviced following the incident. The undated manufacter's instructions for the mechanical lift states and diagrams the following: Lifting and Moving the resident with the base open for balance and support. Lock the wheelchair and approach from the front of the wheelchair with the base legs open. The facility policy for Mechanical Lift dated 5/18/2105 states to to use the mechanical lift, refer to the manufacturer's manual for instructions. 2. R19's Physician order [REDACTED]. Minimum Data Sheet ((MDS) dated [DATE] and 2/12/15 document that R19 was totally dependent on staff for transfers and needed two plus persons physical assistance for transfers. R19's Care Plan with a start date of 9/26/13 documents, use foot pedals at all times when up in w/c. On 7/6/15 at 1:52PM E15 and E16 CNAs (Certified Nursing Assistant) used a gait belt to transfer R19 from the wheelchair to the bed. R19's arms are contracted and her legs are contracted. R19 did not bear weight during the transfer. The Incident Accident Report for R19 dated 8/29/14 documents, CNA (Certified Nursing Assistant) pushing resident in a high back w/c (wheelchair) in the hallway. Resident tipped forward out of the w/c and landed on her (R19) right side of her (R19) body on the floor. 1 cm (centimeter) laceration noted to the left frontal scalp with a large amount of bright red blood. Resident (R19) was taken by ambulance to the Hospital emergency room for evaluation and treatment. The physician's orders [REDACTED]. Diagnosis: [REDACTED]. The emergency room Report for R19 documents, Patient was at the Nursing Home per Emergency Medical Services, tumbled out of wheelchair while being pushed by an aide.Patient sustained a large hematoma and small laceration to forehead.plan for a ct (computer tomography) scan of head, laceration repair.spoke to neurosurgery resident, will plan for admission. Primary Impression: Subarachnoid bleed, Hematoma of scalp.Disposition: admitted as inpatient. The Hospital Radiology Report for R19 dated 8/29/14 for the Head CT without contrast documents, Impression: 1. Minor 2mm (millimeter) acute subdural hemorrhage along the right frontal lobe convexity. 2. Small amount of acute subarachnoid hemorrhage in the right frontal region. The Hospital Discharge Summary for R19 documents, Discharge Diagnosis 1. Subdural hematomas 2. S/P (status [REDACTED]. R19's Nurses Notes dated 8/30/15 at 12:45PM documents, .Body assessment revealed bruising to the right elbow, left elbow, left shoulder and right hand. Bruise noted to right calf mild scaring 3cm x 2cm wide. Area to right buttock is dark purple, mild scarring 3cm diameter and draining small amount of bloody fluid. Bumps noted to top of head, left temporal area, back of head and left forehead. 1cm laceration noted to left temporal area and left scalp. Right forehead has a 3cm diameter bump with bruising. On 7/8/15 at 10:34AM, E2 Director of Nursing stated, Regarding the fall for (R19), they had everything in place. The CNA just did not put the foot pedals on the wheelchair like she was suppose to. I counseled her (E10 CNA) and wrote up a statement and we both signed the statement. It was operator error. 3. On 7/6/15 at 1:52PM E15 and E16 CNAs prepared to transfer R19 and applied the gait belt very loosely. There was at least 5 inches between the gait belt and R19. Both E15 and E16 put their arms under R19's arms and grabbed the gait belt and lifted R19. The gait belt slid up R19's back during the transfer. R19's legs are contracted and did not bear any weight. After R19 was in her bed, E16 stated, (R19) should be a {mechanical lift} transfer. R19's Care Plan with a start date of 9/26/13 documents, .Staff assist of 1 to 2 for ADLS (Activities of Daily Living), may need 3 assist for transfers, and for toileting prn (as needed). R19's MDS (Minimum Data Set) dated 5/7/15 documents that R19 is totally dependent on staff for transfers, and needs two plus persons physical assist. There are no previous transfer assessments in the record. The MDS dated [DATE] documents that R19 was totally dependent on staff for transfers with 2 plus persons physical assist. On 7/8/15 the facility provided a Transfer Assessment for R19 with that date documenting that R19 is now a mechanical lift. On 7/8/15 at 4:00PM E6 confirmed that this was the only transfer assessment they have. The facility's undated Transfer policy documents, .Standing Pivot Transfer (Active Transfer) This transfer is used when a patient can bear all or some of his weight when standing. On 7/8/15 at 10:17AM, E2 Director of Nursing stated that R19 is not a mechanical lift transfer but if she needs to be they can make her one. She stated that it is Restorative's responsibility to evaluate the transfers. The facility's undated Gait Belt Policy & Procedure documents, .Tighten the gait belt just prior to transfer, and release the belt as soon as the transfer is complete. The belt should be snug to avoid jerking or shearing force to the resident. 2. R19's Physician order [REDACTED]. Minimum Data Sheet ((MDS) dated [DATE] and 2/12/15 document that R19 was totally dependent on staff for transfers and needed two plus persons physical assistance for transfers. R19's Care Plan with a start date of 9/26/13 documents, use foot pedals at all times when up in w/c. On 7/6/15 at 1:52PM E15 and E16 CNAs (Certified Nursing Assistant) used a gait belt to transfer R19 from the wheelchair to the bed. R19's arms are contracted and her legs are contracted. R19 did not bear weight during the transfer. The Incident Accident Report for R19 dated 8/29/14 documents, CNA (Certified Nursing Assistant) pushing resident in a high back w/c (wheelchair) in the hallway. Resident tipped forward out of the w/c and landed on her (R19) right side of her (R19) body on the floor. 1 cm (centimeter) laceration noted to the left frontal scalp with a large amount of bright red blood. Resident (R19) was taken by ambulance to the Hospital emergency room for evaluation and treatment. The physician's orders [REDACTED]. Diagnosis: [REDACTED]. The emergency room Report for R19 documents, Patient was at the Nursing Home per Emergency Medical Services, tumbled out of wheelchair while being pushed by an aide.Patient sustained a large hematoma and small laceration to forehead.plan for a ct (computer tomography) scan of head, laceration repair.spoke to neurosurgery resident, will plan for admission. Primary Impression: Subarachnoid bleed, Hematoma of scalp.Disposition: admitted as inpatient. The Hospital Radiology Report for R19 dated 8/29/14 for the Head CT without contrast documents, Impression: 1. Minor 2mm (millimeter) acute subdural hemorrhage along the right frontal lobe convexity. 2. Small amount of acute subarachnoid hemorrhage in the right frontal region. The Hospital Discharge Summary for R19 documents, Discharge Diagnosis 1. Subdural hematomas 2. S/P (status [REDACTED]. R19's Nurses Notes dated 8/30/15 at 12:45PM documents, .Body assessment revealed bruising to the right elbow, left elbow, left shoulder and right hand. Bruise noted to right calf mild scaring 3cm x 2cm wide. Area to right buttock is dark purple, mild scarring 3cm diameter and draining small amount of bloody fluid. Bumps noted to top of head, left temporal area, back of head and left forehead. 1cm laceration noted to left temporal area and left scalp. Right forehead has a 3cm diameter bump with bruising. On 7/8/15 at 10:34AM, E2 Director of Nursing stated, Regarding the fall for (R19), they had everything in place. The CNA just did not put the foot pedals on the wheelchair like she was suppose to. I counseled her (E10 CNA) and wrote up a statement and we both signed the statement. It was operator error. 3. On 7/6/15 at 1:52PM E15 and E16 CNAs prepared to transfer R19 and applied the gait belt very loosely. There was at least 5 inches between the gait belt and R19. Both E15 and E16 put their arms under R19's arms and grabbed the gait belt and lifted R19. The gait belt slid up R19's back during the transfer. R19's legs are contracted and did not bear any weight. After R19 was in her bed, E16 stated, (R19) should be a {mechanical lift} transfer. R19's Care Plan with a start date of 9/26/13 documents, .Staff assist of 1 to 2 for ADLS (Activities of Daily Living), may need 3 assist for transfers, and for toileting prn (as needed). R19's MDS (Minimum Data Set) dated 5/7/15 documents that R19 is totally dependent on staff for transfers, and needs two plus persons physical assist. There are no previous transfer assessments in the record. The MDS dated [DATE] documents that R19 was totally dependent on staff for transfers with 2 plus persons physical assist. On 7/8/15 the facility provided a Transfer Assessment for R19 with that date documenting that R19 is now a mechanical lift. On 7/8/15 at 4:00PM E6 confirmed that this was the only transfer assessment they have. The facility's undated Transfer policy documents, .Standing Pivot Transfer (Active Transfer) This transfer is used when a patient can bear all or some of his weight when standing. On 7/8/15 at 10:17AM, E2 Director of Nursing stated that R19 is not a mechanical lift transfer but if she needs to be they can make her one. She stated that it is Restorative's responsibility to evaluate the transfers. The facility's undated Gait Belt Policy & Procedure documents, .Tighten the gait belt just prior to transfer, and release the belt as soon as the transfer is complete. The belt should be snug to avoid jerking or shearing force to the resident.

Based on observation, record review and interview, the facility failed to ensure safety and provide supervision by failing to monitor and implement post-fall interventions to prevent falls, failing to ensure safe equipment, and failing to ensure safe mechanical and manual transfers. These failures affect six of 16 residents (R1, R10, R13, R14, R23, R25) reviewed for falls in a sample of 24. These failures contributed to additional falls for R10 resulting in a subdural hematoma, and a fall from the toilet for R13 resulting in a hip fracture. The findings include: 1. Physician order [REDACTED]. The Nursing assessment dated [DATE] states, "(R10) is legally blind". The Minimum Data Set ((MDS) dated [DATE] indicates that R10 is cognitively impaired and requires limited assist of one with transfers and ambulation. The Fall Risk Assessments dated 1/9/14 and 4/3/14 score R10 at high risk for falls. The Incident/Accident Report dated 2/10/14 documents, "(R10) got up and took personal alarm off and fell going to the bathroom." The Root Cause Analysis dated the same states, "(R10) might benefit from a bed alarm." This intervention was not added to the careplan or implemented. An intervention of, "may use a personal alarm to his bed to alert staff to attempted independent mobility" was added, however this is not a new intervention. The Incident/Accident Report dated 2/22/14 documents, "Found sitting on floor in front of toilet in bathroom, had removed personal alarm." The Root Cause Analysis dated the same suggests, "changing him to a low bed so he may not be able to stand by self." This intervention of a low bed was added to the careplan but not implemented, according to E14, Restorative aide, on 7/7/14 at 3:05. E14 keeps a log of when personal alarms, bed alarms, low beds, etc. gets assigned to residents. E14 stated, "(R10) was in a regular bed with a personal alarm while in bed and in wheelchair until he returned from the hospital {4/18/14}, that is when we put him in a low bed with bolsters, and added the bed alarm...he still uses the personal alarm when in bed and up in wheelchair also." The intervention that E14 stated is on the careplan dated 4/18/14. The Incident/Accident Report dated 3/26/14 documents, "(R10) observed sitting on buttocks on floor between bed and wheelchair." The Root Cause Analysis dated the same lists interventions of : reinforce call light use, toilet every two hours, and bed alarm ordered. Reinforcement of call light use and toileting every two hours were already listed as interventions on the careplan dated 10/17/13. The Incident/Accident Report dated 4/3/14 documents, " (R10) had blood to right posterior arm...(R10's) roommate stated he saw R10 on the floor near door of room earlier...(R10) agreed that he did fall." The Root Cause Analysis dated the same states, "the best intervention would be moving resident closer to the nurses station", however this intervention was not on the careplan, and there was no evidence in the record that R10 was moved. The Incident/Accident Report dated 4/5/14 documents, "heard bed alarm go off, (R10) already sitting on the floor bedside the bed." The Root Cause Analysis dated the same states, "Needs to be closer to the nurses station." On 4/5/14 the careplan was updated with intervention of, "Nursing will work with Social Service in an attempt to move (R10) to a room closer to the nurses station." The Incident/Accident Report dated 4/13/14 documents, "heard bed alarm going off and found resident sitting on the floor." The Root Cause Analysis dated the same states, "(R10) continues to forget to call for assistance....will continue to place call light where it can easily be seen and used." No new interventions were implemented on careplan. The Incident/Accident Report dated 4/14/14 documents, "aide was alerted by the bed alarm....(R10) was sitting next to his bed...had a scalp laceration." The Root Cause Analysis dated the same suggests, "have (R10's) bed moved up closer to nurses station to provide closer supervision." Nurses notes for 4/14/14 state R10 was sent to the hospital. The Hospital History and Physical dated 4/14/14 states, "repeat Computerized Tomography (CT) of the head reveals a new Subdural Hematoma." R 10 was admitted to the hospital on that date and returned to the facility on [DATE]. On 7/7/14 at 2:55 PM E16, Social Service Assistant, stated, "(R10) returned to his regular room on 4/17/14, it was not until 4/18/14 that he was moved to his new room, closer to the nurses station". On 7/7/14 at 3:30 PM E15, Social Service Director, stated, "(R10's) son had been requesting he be moved closer to the nurses station due to his falls....we moved him as soon as we could...it was after he returned from his hospitalization ". On 7/8/14 at 11:05 am, E3, Director of Nursing (DON) stated, "the nurses on the floor fill out the Root Cause Analysis, what they put on there is only a recommendation, it doesn't mean interventions will be implemented...we decide what will be implemented as a team...if it isn't on the careplan, then it wasn't put into place." On 7/8/14 at 11:20 am E20, Assistant Director of Nursing/MDS/Careplan Coordinator, confirmed E3's statement. 2. An Incident/Accident report dated 1/24/14 documents that R13 floor from the toilet seat to the floor onto her left side. A Disciplinary Warning Record dated 1/24/14 documents that E23 Certified Nursing Assistant (CNA) took R13 to the bathroom, removed the pelvic restraint and personal alarm, and transferred R13 to the toilet. E23 then went to the hallway to get something and left R13 alone on the toilet. When E23 returned to the bathroom R13 was on the floor. R13's Careplan dated 2/28/14 documents that R13 had a fall on 1/24/14 which resulted in a hip fracture that was surgically repaired. The Radiology Report dated 1/30/14 documents that R13 had a fracture of the subcapital aspect of the left femoral neck. On 7/9/14 E3 Director of Nursing (DON) stated that the CNA left R13 alone on the toilet and was not supposed to. E3 stated E23 was terminated. E3 stated that R13 had previous falls and interventions of a pelvic restraint and the alarm were in place before this fall. Resident had the soft waist restraint in place on 7/7/14 at 12:06 PM, 12:42 PM, 2:35 PM, 3:00 PM and on 7/10/14 at 3:00 PM. 3. The Minimum Data Set Assessment ((MDS) dated [DATE], documents that R25 has no cognitive impairment and requires the total assistance of two staff members for transfers. The Accident/Incident Report dated 7/06/14, documents R25 was being transferred from the wheelchair utilizing a mechanical lift, when the "straps broke" and R25 slid out of the sling onto the floor. Nursing notes dated 7/06/14, indicate R25 was sent to the emergency room due to right hand and wrist swelling, and returned to the facility the same day. A Root Cause Analysis report dated 7/06/14, documents the "sling (used to transfer R25) was not good condition." On 7/09/14 at 11:40am, E2 (Interim Administrator) stated that after the 7/06/14 incident, staff were instructed to closely observed mechanical lift slings for fraying or disrepair prior to their use. E2 stated the facility does not have a system in place for the routine inspection of slings. On 7/09/14 at 12:20 p.m., R25 stated one CNA, identified as E13, was present when R25 fell from the mechanical lift on 7/06/14. R25 stated two staff members are usually present when they transfer R25 with the mechanical lift, but sometimes only one staff member does the transfer. R25 stated that as E13 was raising (R25) up out of the wheelchair with the mechanical lift, the straps to the sling "just broke" and E13 "couldn't stop me from falling." R25's right hand and arm were visibly bruised and swollen, on 7/09/14. On 7/10/14 at 9:05am, E2 confirmed that they did not obtain a statement from R25 as a component of their investigation into the 7/06/14 fall. E2 indicated that R25 is fully alert and oriented, and the facility should interview all those who have witnessed a fall in order to fully investigate the incident. E2 was unaware only one staff member was attempting to transfer R25 with a mechanical lift on 7/06/14. The undated policy for Using a Portable Lifting Machine documents "If using a (mechanical) lift, two nursing assistants must perform the procedure." The Fall Prevention Policy and Procedure revised 4/10/14 instructs staff to conduct an Initial post-fall assessment, which includes obtaining the "resident's objective description of the fall (if possible)." 4. The Minimum (MDS) data set [DATE], documents R1 required the extensive assistance of two staff to transfer at that time. R1's current Plan of Care, documents R1 was identified as a fall risk on 6/06/13. The Incident/Accident Report dated 8/08/13, documents R1 was "standing" with a CNA when R1 "lost balance" and fell . The Incident/Accident Report indicates R1 "moved quickly" and the "CNA was unable to stop (R1), need to use a gait belt." On 7/08/14 at 3:02 p.m., E3 (Director of Nursing) indicated a gait belt had not been used when R1 was transferred on 8/08/13 and that staff should always use a gait belt when transferring a resident. The undated policy for Transfers indicates when doing a "Standing Pivot Transfer" staff are to "apply the gait belt to ensure safety and to get a better position to lift from." 5. The physician's orders [REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documents that R23 requires total assistance of one person for transfers to/from the toilet. Physician's Telephone Order dated 6/20/15 documents that R23 "May use sit-to-stand." The Care Plan dated 5/15/14 documents that R23 is at "HIGH RISK for falls." On 7/9/14 at 10:35 am E19, Certified Nursing Assistant attached the sit-to stand mechanical lift belt loosely to R23's waist. E19 made two attempts to raise R23 from the toilet using the mechanical lift and each time the belt slipped up R23's back and under R23's arms causing her elbows to raise up. On the third attempt E19 transferred R23 with the mechanical lift to her wheelchair with the belt slipping up R23's back and under her arms causing R23 to extend her elbows upward and losing the grasp with her left hand. R23 stated, "I'm going to fall." On 7/9/14 at 10:50 PM E19 stated "the strap should have been a little tighter, it was slipping on her (R23)." The sit-to-stand manufacturer's specifications document that the belt "MUST be snug otherwise the patient can slide out of the sling during transfer, possible causing injury." On 7/9/14 at 4:10 PM E21, Therapy Manager stated that if a resident is "falling out" of the sit-to-stand lift belt that is when a full body mechanical lift is needed. 6. The Incident/Accident Report dated 4/4/14 at 2:05PM, states R14 fell from his bed to the floor. Root Cause Analysis completed by E4 (Licensed Practical Nurse) at the time of the fall recommended use of a personal alarm for bed and wheelchair and a pad on the floor next to his bed. The Incident/Accident Report dated 4/12/14 at 6:30PM, stated R14 was observed laying on the floor of his room and had slid out of the wheelchair. Root Cause Analysis completed at the time of the fall included a recommendation for use of a personal alarm when up in chair. On 7/10/14 at 1:55 PM, E25 (Assistant Director of Nurses/ADON) stated use of a personal alarm in bed was implemented for R14 on 4/4/14. E25 stated the use of a personal alarm in the chair was not implemented for R14 until after his fall on 4/12/14. R14's care plan for falls with a start date of 8/1/13, stated use of a personal alarm in wheelchair was started on 4/14/14. There was no approach start date for use of a personal alarm in bed in R14's care plan. The facility's Fall Prevention Policy and Procedure revised 4/10/14, states the Nurse Managers are responsible for enforcing the responsibilities of the staff nurses to comply with fall interventions, updating resident care plans, and ensure proper interventions are in place. Nursing staff are responsible for ensuring compliance of fall and fall-related injury interventions and implementing fall prevention measures as indicated.

Based on observation, interview, and record review, the facility failed to conduct complete investigations, root cause analysis and identify/ implement interventions to prevent falls for 4 of 11 residents(R13,R20,R15,R9) reviewed for falls, in the sample of 24. The facility failed to provide supervision during toileting to prevent falls for two residents(R13,R20) resulting in a fracture for R13 and a laceration with sutures for R20. Findings include: 1. R13's physician's orders [REDACTED]. The Care Plan dated 3/23/12 also lists a right humeral head fracture and a fracture to the radial head which occurred on 5/22/12. R13's quarterly Minimum (MDS) data set [DATE] identified R13 had severe cognitive impairment, requiring supervision of one for transfers. The Nurse's Notes dated 5/11/12, 7:30 am document R13 was being toileted at 4:55 am and as the Certified Nurse Aide (CNA) turned her back R13 stood, lost her balance, fell backwards and landed on her back with her head hitting the floor. R13 received a scrape to knee. CNA E8 stated on 6/06/12 at 10:30 am that she had R13 on the toilet (on 5/11/12). E8 stated R13 can be very "antsy". E8 said she was by the sink in the bathroom getting a piece of clothing off the towel rack, with her back to R13. E8 stated "I didn't see it, cause my back was turned, I think she stood up, started falling and grabbed on the the wheelchair that was in front of her." E8 stated R13 and the wheelchair tipped over. The Incident/Accident report dated 5/11/12 lists the root cause analysis as "Residents dementia keeps her from being able to move safely in her surroundings." There was no documented intervention suggested on the report to prevent a future falls during care. Nurse's Notes dated 5/24/12 at 1:55 pm document CNAs had taken R13 to her room to take her to the bathroom. After the lap cushion was removed R13 stood up, got her feet tangled, lost her balance and fell to the floor landing on her right hip and shoulder. The Nurses Notes document R13 could move all extremities as usual except would not move her right arm and shoulder. R13 was taken by ambulance to the emergency room and returned to the facility with her arm in an immobilizer and orders for pain medicine. The Care Plan dated 6/1/12 states R13 had a fall on 5/24/12 resulting in a Fractured Right Humerus. CNA E16 stated on 6/04/12 at 3:20 pm that she was assisting R13 when R13 fell and broke her arm on 5/24/12. E16 stated she and E20 were working in the room with R13 and her roommate. E20 was with the roommate in the bathroom. E16 was helping undress R13, who was seated in the wheelchair with the lap cushion removed and the personal alarm turned off. E16 stated she was standing in front of R13 and turned around to get some clothing off a table when R13 stood up quickly and tipped over. Nurse E19 stated on 6/05/12 at 10:20 am that she had been working on 5/24/12 when R13 fell and fractured her arm. E19 stated she spoke with the CNAs E16 and E20. E19 stated staff were getting ready to change R13, R13 was seated in the wheelchair with her pants down, and when E16 went to get an incontinent brief R13 stood up and fell and they couldn't catch her. E19 stated that R13's movements are quick. The facility Incident/Accident report dated 5/24/12 documented by Nurse E19 stated the personal alarm had been removed to give care and a gait belt was on. The report listed two CNAs as witnesses (E16, E20). The facility Investigation-Response Report dated 5/24/12 listed the Root Cause Analysis as "Due to decreased cognitive level and resident trying to get up independently despite lap buddy being used in wc (wheelchair). CNAs were by her but couldn't catch her before she fell . There were no recommendations for interventions to prevent future falls on the report. The Care Plan dated 6/1/12 documented the fall with fracture however there were no interventions added to the care plan to address R13's need for close supervision with care when she does not have the lap cushion in place because she will impulsively stand up. The care plan also had not been updated to address R13's previous falls in May 2012. This included another fall while being assisted by staff on 5/11/12. On 6/05/12 at 2:40 pm Director of Nurse's E2 stated that she had talked to both of the CNAs about the 5/24/12 incident but had not documented anything. E2 stated we don't take statements unless there is important information. The root cause analysis had not identified any supervision issues related to R14's falls or any recommendations of any new interventions to prevent falls during care. 2. R20's quarterly MDS dated [DATE] identifies R20 as cognitively alert, requiring limited assistance of one for ambulation, having unsteady balance requiring physical assistance to steady. On 6/05/12 at 12:15 pm R20 was noted to have two fading black eyes,a bruise to her jaw, and a very bloodshot right eye. R20 was seated in a wheelchair with a personal body alarm. R20 stated she fell when she stood up to get off the toilet. R20 stated she thought she could do it herself and she fell . The Nurse's Notes dated 5/13/12 at 3:00 am document the nursing staff heard a loud crash and moan and found resident lying half on her abdomen and half on her left side laying on top of her walker. R20 left forehead had swelling and bruising with an open area that was bleeding. The swelling measured 7.5 centimeters (cm) long by 4 cm wide. R20 was sent to the emergency room and returned to the facility with 6-7 stitches to her forehead. Director of Nurse's E2 stated on 6/06/12 at 11:55 am that E2 was told that E8 stepped from the bathroom out to grab a towel and the resident fell . The facility Incident/Accident report dated 5/13/12 documented that there was no actual witness to the incident. The assigned care giver was Certified Nurse Aid (CNA) E8. The "Investigation-Response" report dated 5/13/12 documents the resident was on the toilet, got up with out help with walker and fell outside of the bathroom, face down with the walker under the resident. The Root Cause Analysis documented "Should not have been left unattended on the toilet. Resident has personal alarm on bed and wheelchair." On 6/06/12 at 12:30 pm. CNA E8 stated that she had walked R20 to the bathroom and had left her seated on the toilet while she left the bathroom to get an incontinent brief out of the drawer in the bedroom and also went out into the hall to retrieve towels from the hall linen cart. E20 stated there were other call lights going off and she went into the hallway to take a peek at what other lights were on, grabbed the towels and when she came back into the room R20 had already gotten up and had fallen. When asked why she left R20 alone on the toilet, E20 responded that usually she takes what supplies she needs with her into the toilet room and R20 usually stays seated on the toilet. R20's Care Plan dated 3/28/12 stated "At Risk for falls, injury D/T (due to) weakness of her legs which causes unsteadiness. The approaches include assist with one or two persons for stand pivot transfer, remind not to stand with out wheeled walker, encourage not to rush when she is transferring, personal alarm to bed and wc (wheelchair) prn to alert staff to mobility. The Care Plan did not address R20's 5/13/12 fall, nor any intervention for supervision for toileting. 3. R15's physician's orders [REDACTED]. The POS documents the medical symptoms for use of the soft waist restraint as "poor balance and anterior listing." R15's Minimum Data Set ((MDS) dated [DATE] documents that R15 is severely cognitively impaired and requires the extensive assistance of one person for transferring and ambulating in her room. R15's Fall Risk assessment dated [DATE] shows R15 is at high risk for falls. On 06/05/12 at 8:40am, R15 slid off of her wheelchair and was held in the wheelchair (while buttocks and thighs were off of the wheelchair seat) by a soft waist restraint. The soft waist restraint (which was secured to the bars on the lower back of the wheelchair) had slipped up under R15's right and left axilla and across her upper chest, forcing R15's bent arms upward to shoulder height. E5, Licensed Practical Nurse (LPN), E6, Certified Nursing Assistant (CNA), and E7, CNA, picked up R15 and placed her back in the wheelchair, replaced the soft waist restraint, and secured the restraint to the bars on the lower back of the wheelchair. R15 then sat in the wheelchair in the hall near the nurse's station. On 06/05/12 at 8:45am E5, E6, and E7, stated that R15 had previous occurrences of sliding down in her wheelchair with the soft waist restraint in place. On 06/06/12 at 10:10am, E11, LPN, stated that R15 had previous occurrences of sliding down in her wheelchair with the soft waist restraint in place. On 06/06/12 at 10:15am, E12, CNA, stated that R15 had previous occurrences of sliding down in her wheelchair with the soft waist restraint in place. On 06/06/12 at 9:15am, 9:55am, 11:18am, 1:00pm, and 4:00pm, R15 was sitting in her wheelchair with the soft waist restraint in place. On 06/07/12 at 11:00am, E18, Registered Nurse (RN) and Care Plan Coordinator, stated that an Incident/Accident Report was not completed for the 06/05/12 incident. E18 also stated that an investigation determining root cause analysis for the 06/05/12 incident was not completed, and no interventions or other action was taken. E18 also stated that there was no documentation in the Nurse's Notes regarding the 06/05/12 incident of R15 sliding down in the wheelchair with the soft waist restraint in place. R15's Care Plan dated 04/26/12 and 05/02/12 directs staff to "Assess (R15) for safety alternative" and "Lap (cushion) on wheelchair." There was no direction to use a soft waist restraint. E18's Care Plan contained no interventions for the 06/05/12 incident. On 06/06/12 at 11:15am, E13, Certified Occupational Therapy Assistant (COTA), stated that he has not evaluated R15 for positioning and restraint use. The Facility's Fall Prevention Policy and Procedure (revised 04/21/11) defined a fall as unintentionally coming to rest on the ground, floor, or other lower level" and "an episode that occurs...when a resident would have fallen, if not for staff intervention, is also considered a fall." The Policy directs staff to complete an Incident Investigation Report, analyze each incident, determine a root cause analysis, and determine the response or action that should be taken. The Policy directs Physical and Occupational Therapists to "Conduct assessments for fall-risk patient referrals", and "(Help) develop an intervention program...to reduce fall risk." The Policy also directs staff to "Update resident care plans appropriately to ensure proper interventions are in place." 4. R9's POS dated June 2012 documents the following Diagnoses: [REDACTED]. R9's POS also documents [REDACTED]." R9's Fall Risk Assessment score dated 12/08/11 and 3/09/12 assess R9 at high risk for falls. R9's MDS dated [DATE] and 03/08/12 document that R9 is severely cognitively impaired and requires limited assistance with one staff person for bed mobility, transferring, and ambulation. R9's MDS documents that R9's balance is not steady, but that he is able to stabilize without human assistance. On 06/04/12 at 12:10pm R9 sat in the hall in his wheelchair with a soft waist belt on. The soft waist belt was secured to the bars on the lower back of the wheelchair. On 06/05/12 at 8:45am, 10:15am, 11:45am, 12:20pm, and 3:45pm, R9 sat in the hall in his wheelchair with a soft waist belt in place and secured to the bars on the lower back of the wheelchair. The wheelchair did not have anti-tip bars in place. On O6/06/12 at 9:00am, 1:00pm, and 4:00pm, R9 sat in the hall in his wheelchair with a soft waist belt on. The waist belt was secured to the bars on the lower back of the wheelchair. The wheelchair did not have anti-tip bars in place. The Facility's Incident and Accident Report dated 02/02/12 at 8:00pm documents that R9 was found lying on the floor of his room on his left side while still in the wheelchair with the soft waist restraint still in place and secured to the bars on the lower back side of the wheelchair. R9's personal alarm was still attached to the resident's clothing and did not alarm. The Facility's Incident and Accident Report dated 02/08/12 at 7:30pm documents that R9 was found sitting on the floor of his room next to his bed with his back against the dresser, with his lower legs caught inside the wheelchair and inside the soft waist restraint. The Facility's Incident and Accident Report dated 02/09/12 at 5:30pm documents that R9 was found on his hands and knees on the floor of his room with the wheelchair strapped to his back by the soft waist restraint which remained secured to the bars on the lower back side of the wheelchair.