Every finding on record at Medina Nursing Center

Based on interview and record review the facility failed to protect residents from verbal abuse from staff. This applies to 2 of 4 residents (R1, R2) reviewed for abuse in the sample of 4. The findings include: R1's Physician's Order Sheet dated June 2026 shows that R1 has diagnoses including Alzheimer's Disease and Vascular Dementia. R2's Physician's Order Sheet dated June 2026 shows that R2 has diagnoses including Dementia and Encephalopathy. On 6/29/26 at 9:55AM R4 stated, (V4- CNA- Certified Nursing Assistant) was trying to provide care of some kind (to R2), I don't remember what and (R2) wouldn't listen. I heard (V4) say, You better roll over or I'm going to get the nurse to give you a shot and it is going to hurt. I thought that is not going to make her listen to you. (V4) was here a lot- she went on vacation for a week and then she was back so yes, she was regular staff here. She was not a very nice CNA. Not friendly at all. When she said that to (R2) I couldn't believe she was threatening her like that and I lost a lot of respect for her. I just thought she should be doing her job. I said something to another CNA about her but not about that exact thing. She has not been back since. At least that I have seen. Sometimes (R2) is difficult to work with but that does not excuse (V4's) behavior. She just needs to do her job. I have no issues with her as a roommate. On 6/29/26 at 10:55AM, R3 stated, One CNA was always abrupt. (R1) sometimes doesn't cooperate, she has Dementia. This CNA was kind of forceful- not in a physical manner but verbally. She always seemed kind of lazy to me. Never saw her work a lot. Liked to walk to hallways but really not doing much. Never called (R1) a name or anything. Got a little loud at times. (R1) is not hard of hearing. She is stubborn as hell- has been for 58 years. (R1) requires full assistance with everything. This CNA (V4) was always in a hurry. Get things done and get out of the room and get on her way. She never did or said anything to me. I am pretty easy going. That was just her way of working- her way of doing things. (R1) is a little heavier than (V4) so I imagine it is hard for her to turn her and take care of her. If I said she said Get your a** over here last week then that is what she said. I can't remember if it was a** or s**t. I have not seen (V4) lately and that is a good thing. On 6/29/26 at 10:15AM V5 (CNA) stated, I've heard from residents like (R4)- her roommate (R2) is sometimes with it and sometimes she can be difficult, and it is the tone that (V4- CNA) says things. I've been in the halls, and I've heard (V4) and it sounds like she is yelling at the residents- like she doesn't explain what she is doing- she just goes in there and starts doing it. I've heard complaints from residents and other CNAs have noticed it too. Other CNAs and Nurses have seen it. No verbal cussing or anything, just the tone and the yelling. Last Tuesday or Thursday, I went to (V2-DON-Director of Nursing) and then to (V6- Social Worker) and they were just like Thank you for reporting this and they went and got (V4) and sent her home. They went and talked to the residents (R3 and R4) and got more information from them. I never heard anything that the residents reported to them. (V4) has not worked here very long, less time than me. She wants everyone to help her, but she won't help anyone else. She has not been back since that day. On 6/29/26 at 11:35AM V6 stated, The CNA (V5) reported to the (V2- DON) that he had concerns with another CNA. (V5) stated that concerns had been brought to him from (R3) and (R4). He also voiced concerns that the (V4) was not friendly with staff and not working with the others on the floor- although that is not really relevant to this investigation. I went into (V1's -Administrator's) office and had the (V3- ADON) pull (V4) from the floor. We told (V4) she was under investigation but couldn't give her too much information as to why. I walked (V4) out of the building after taking her radio and her badge, so she had no way to access the building, and I made sure she got in her car. As she was leaving, she asked if she could work her shift on Friday and I told her it was pending my investigation. Then I went and spoke to (R3). He told he didn't think (V4) was the brightest of ladies. He said nothing physical had ever happened but then I asked him if (V4) had ever cussed at him or his wife and he said there was this one time when she said, Get your a** over here to (R1- R3's wife). I asked (R3) how that made him feel and he said it was whatever. He said, 'my wife can be difficult, I told my wife she needs to cooperate.' I told (R3) that does not give (V4) the right to talk to her like that. Then I went and spoke to (R4). She said (V4) is not a nice lady. She had had difficulty with (R2), her roommate. She would come in the room and say, How are we going to act today? and that just set the tone for a bad day. One time she came in, and (R2) was being resistant and (V4) told (R1) if she didn't behave, she was Going to get the nurse to give her a shot and it was going to hurt.That was a big alarm for me. Basically, she was saying if you don't do what I want you are going to get hurt. That is not how we treat residents here. (R4) said it made her feel bad for (R2) and she didn't like it when that CNA was around. She had a real issue with (V4's) approach. It was almost like (V4) got really agitated when the residents didn't cooperate. I called (V4) the next day and told her she was terminated and she said she was ok with that. I called (R2's) POA and explained the situation and she was satisfied with our actions. It is basically a he said she said but I don't know any situation where a person is actually going to admit to saying something like that. Do I think she was trying to be abusive, probably not but that is not how we speak to residents in our facility. The facility abuse investigation dated 6/24/26 states, Upon conclusion of my investigation, I find that the allegations of verbal abuse involving residents (R1) and (R2) are substantiated based upon the witness statements obtained during the investigation. In order to protect the health, safety. and well- being of the residents entrusted to our care, (V4) will no longer be permitted to work with residents or be present on (Facility) property. The facility policy entitled Abuse, Neglect and Exploitation Policy dated 5/2025 states, It is the policy of this facility to provide to provide protections to the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This same policy defines Verbal Abuse as, the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on observation, interview, and record review, the facility failed to ensure the Illinois Department of Public Health survey results were accessible to residents. This failure affects all residents residing in the facility. The findings include:The facility's census report dated 6/23/26 showed 47 residents currently residing in the facility. On 6/24/26 at 10:00AM, R4, R7, and R16 attended the resident council meeting. All 3 residents stated that the survey results are in someone's office, but they are unsure of who's office they are in. Surveyor toured the facility following the resident council meeting and was unable to find the survey results nor was there a sign indicating where survey results were available. On 6/25/26 at 7:55 AM, V1 (Administrator) stated, We do have the survey results binder, but it is in my office so it's locked when I am not here. we do not have a sign or anything anywhere telling residents or visitors where it is at. They would have to ask for it and if I'm not here there aren't any floor staff that would be able to get it for them. The facility was unable to provide a policy regarding where survey results should be located.

Based on observation, interview, and record review the facility failed to ensure the nurse daily staffing was posted on a daily basis. this applies to all residents in the facility. The findings include: On 6/25/2026 at 7:30 AM, the facility census and staffing information was not posted in the building. At 7:38 AM, V1 Administrator was asked if the daily staffing and census was posted and she stated to ask V2 Director of Nursing - DON because she was the one to do that. At 7:45 AM, V2 showed what she posts at the back nurses desk and on a clipboard it showed the nurses and certified nurses assignments for the day. V2 was asked where the census was and breakdown of nursing hours etc. she stated she did not know what that meant and that it was not being done. On 7:53 AM, the requirements for posting were gone over with V1 and V2 and it was confirmed that it was not being done. On 6/25/2026 at 11:15 AM, V2 stated she was pretty sure that since they were not posting the staffing that they did not have a policy. The Long term Care Facility Application for Medicare and Medicaid Form - 671 Form dated 6/23/26 showed the facility census as 47 residents.

Based on interview and record review, the facility failed to provide a bed hold policy and written notice of transfer to 4 of 4 residents (R1,R15,R35,R41) reviewed for hospitalizations in the sample of 23. The findings include:1) R1's facility assessment dated [DATE] showed R1 has no cognitive impairment. R1's nursing progress notes dated 2/12/26 showed R1 was sent to the local hospital for blood in his urine. On 6/25/26 at 10:07 AM, R1 stated, If you go to the hospital, they give you a folder with paperwork in it, but I don't know what is in it. That all goes to the hospital staff. R1's nursing progress notes showed no documentation that R1 was provide the facility bed hold policy or written notice of transfer. 2) R15's facility assessment dated [DATE] showed R15 has no cognitive impairment. R15's nursing progress notes showed R15 was sent to the local hospital on 4/12/26 and 5/14/26. No documentation was present in R15's progress notes showing that R15 was provided a bed hold policy or written notice of transfer. 3) R35's facility assessment dated [DATE] showed R35 has no cognitive impairment. R35's nursing progress notes dated 4/17/26 showed R35 was sent to a local hospital for abdominal distention and tenderness. R35's nursing progress notes for 4/17/26 showed no documentation present that R35 received the facility's bed hold policy & notice of transfer. On 6/25/26 at 9:44 AM, R35 stated, I don't recall getting any paperwork when I went to the hospital. They give you a folder but I don't know what's in it. I didn't know what all of the paperwork was. I would be upset and anxious if I didn't know if I could come back to the facility or not. 4) R41's facility assessment dated [DATE] showed R41 has moderate cognitive impairment. R41's nursing progress notes dated 2/16/26 showed R41 was transported to the local hospital for seizure like activity. R41's progress notes showed no documentation that R41 or her representative was given the bed hold policy or written notice of transfer. On 6/25/26 at 9:26 AM, V2 (Director of Nursing) stated, When a resident goes to the hospital, the paperwork sent with the resident does include bed hold and notice of transfer policy. It is all put in an envelope and sent to the hospital. I thought it was given to the resident, but I could be wrong. I guess if we are putting it all in the same envelope as all of the resident's paperwork, that is all just going to the hospital staff. They don't know to give the bed hold policy and notice of transfer to the resident or family. The facility's undated policy titled, Bed Hold Policy showed, When hospital transfers occur, the nurse will provide the resident and/or family member or legal representative with a copy of this policy and have the resident or legal representative sign the bed hold authorization form. In the event of an emergency transfer, a copy of the bed hold policy will be sent with other paper accompanying the resident and the copy for the resident's family member or legal representative will be mailed the next business day .

Based on observation, interview, and record review, the facility failed to apply oxygen as ordered by a physician for 2 resident (R19,R49), failed to maintain oxygen concentrator per manufacturer's recommendations for 1 resident (R49), failed to change oxygen tubing per facility policy for 1 resident (R43). These failures apply to 3 of 3 residents reviewed for oxygen therapy in the sample of 23. The findings include: 1) R19's electronic face sheet dated 6/25/26 showed R19 has diagnoses including but not limited to cerebral palsy, epilepsy, dementia without behaviors, Alzheimer's disease with late onset, dysphagia, and hypertension. R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment. R19's physician's orders dated 5/30/26 showed, Oxygen 2-3L (liters) per NC (nasal cannula) as needed for resident. R19's progress note dated 6/1/26 showed, Continue oxygen 3L. Her oxygen level goes down while in bed. R19's care plan showed no care plan was developed for R19 requiring oxygen use. On 6/23/26 at 9:58AM, R19 was lying in bed with her oxygen concentrator turned on at 3L. R19's nasal cannula was under her chin and not providing oxygen therapy to the resident. On 6/23/26 at 10:05 AM, V6 (Registered Nurse) stated, (R19) doesn't have a diagnosis or anything for her oxygen. Her oxygen saturations just drop when she is in bed. Sometimes when she is eating she will put it under her chin but for the most part she keeps it on. She does have a diagnosis of dementia but is usually pretty compliant with everything. On 6/23/26 at 11:37 AM, R19 was sitting up at the lunch table with her nasal cannula tucked under chin and her portable oxygen machine was on at 3L. On 6/24/26 at 10:10AM, R19 was lying in bed with her oxygen concentrator on at 3L and her nasal cannula tucked under her chin. On 6/24/26 at 10:41AM, R19 continued to lay in bed with her nasal cannula no longer able to be visualized while the oxygen concentrator was on at 3L, On 6/25/26 at 9:28 AM, V2 (Director of Nursing) stated, We should be reapplying the oxygen if a resident has an order for it and they are removing it. We cannot force them to wear it, but we should be encouraging them to wear it. If it is a constant issue, we would talk to the physician and family about discontinuing it. The facility's undated policy titled, Oxygen Administration showed, Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences .1. Oxygen is administered under orders of a physician . 2. On 6/23/2026 at 9:51 AM, R49 was in bed on his back with the prongs of the nasal canula in his mouth. R49 had oxygen on at 4 liters per nasal canula. The humidification bubbler on the concentrator was 1/4 of the way full. The oxygen tubing and bubbler were not dated. The oxygen concentrator was missing a filter on the back of the machine; the holder where the filter sits was empty. On 6/23/2026 at 10:30 AM, V11 Licensed Practical Nurse - LPN stated she doesn't know anything about the filters on the concentrators and doesn't know who cleans them or maintains them etc. On 6/24/2026 at 1:07 PM, V2 Director of Nursing - DON stated that the filters on the oxygen concentrators were taken care of by the maintenance department. Then hospice would take care of the hospice ones. A company comes out once a year to check their machines. V2 stated that nursing doesn't do anything with the concentrator filters and they never have. V2 did not have any information on routine cleaning/maintenance of the filters on the oxygen concentrators etc. The Face Sheet dated 6/24/26 for R49 showed diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, dementia, retention of urine, depression, hypertension, hypothyroidism, chronic kidney disease, atrial flutter, hyperkalemia, hypo-osmolality and hyponatremia. The June 2026 Treatment Administration Record - TAR for R49 did not show anything about cleaning the oxygen filters on the concentrator/maintenance of the concentrator. The Care Plan dated 4/30/26 for R49 showed R49 has end stage disease, 6 or fewer months to live related to lung cancer. He is currently receiving hospice care. R49's care plan did not show any interventions related to the oxygen concentrator. The facility's blank Oxygen Concentrator Service and Maintenance Log form showed cabin air filter - clean weekly. Preventative maintenance check - inspect filters and replace as necessary. 3. On 6/23/26 at 9:57 AM, R43 was observed sitting in his wheelchair with his nasal oxygen cannula sitting on his ear, and not in his nose. The long tubing had a piece of tape dated 6/2/26. On 6/23/26 at 10:10 AM, V5 CNA said R43 should have his oxygen all the time. V6 RN said the oxygen tubing is changed every 2 weeks. The order comes up on the treatment record. The whole system, including the bottle of water, is changed every month. V6 looked at the tubing and stated she was the nurse who changed it, and she had signed the 6/2/26 tubing. V6 said it should have been changed. On 6/25/26 at 8:40 AM, V2 stated the tubing should have been changed after 2 weeks. The facility's oxygen therapy policy states H. Change nasal cannula/and or mask every 14 days, extension tubing every 30 days.

Based on observation, interview, and record review, the facility failed to provide a wheelchair to enable a resident to self-propel for 1 resident (R19), failed to provide foot pedals for a resident's (R19) wheelchair. These failures apply to 1 of 1 residents reviewed for accomodation of needs in the sample of 23. The findings include:R19's electronic face sheet dated 6/25/26 showed R19 has diagnoses including but not limited to epilepsy, hypertension, cerebral palsy, and dementia without behaviors. R19's facility assessment dated [DATE] showed R19 has severe cognitive impairment, utilizes a manual wheelchair, and requires partial/moderate assistance to wheel 50 feet with 2 turns. On 6/23/26 at 11:53 AM, R19 was sitting up in her wheelchair at the lunch table with her feet dangling from the wheelchair. R19 was unable to touch the floor with her feet while seated in the wheelchair. At 12:42 PM, staff wheeled R19 upstairs in the wheelchair with no foot pedals on the wheelchair and R19's feet still dangling from the wheelchair. On 6/24/26 at 11:18 AM, R19 was being pushed in her wheelchair to the dining room. R19's feet continued to dangle down from her wheelchair. R19's room was observed and no foot pedals were located in R19's room. On 6/25/26 at 11:55AM, V2 (Director of Nursing) stated, (R19) can self-propel in here wheelchair. I have not seen her with any foot pedals on her wheelchair before but if staff are pushing her in her wheelchair then her feet shouldn't be dangling down. She needs to have foot pedals and a wheelchair where she can touch the floor so that she can propel herself better and use her feet if she wants to. If a resident does not have foot pedals and they suddenly decide to put their feet down then that poses a risk for them to fall out of the wheelchair. Either way, her wheelchair is not appropriate for her. The facility was unable to provide a policy regarding safe use of a wheelchair.

Based on observation, interview, and record review the facility failed to attempt a reduction of a resident's restraint and release the restraint when supervised for 1 of 1 residents (R3) reviewed for restraints in the sample of 23. The findings include:On 6/23/2026 at 10:02 AM, V9 (R3's power of attorney) stated she did not think R3 needed the seat belt any longer; she did not feel it was necessary. V9 stated it would suit her fine if they got rid of the seatbelt. V9 stated R3 used to scoot in her padded wheelchair but she doesn't see her do that anymore. On 6/24/2026 at 11:19 AM, R3 was up in her padded wheelchair at the dining room table for lunch. R3 had her seatbelt in place and her protective helmet on. At 11:21 AM, R3's food was served. V13 Certified Nursing Assistant - CNA removed R3's protective helmet, put a clothing protector on her, and sat down to assist R3 with lunch. V13 stated they remove the helmet at lunch. The seatbelt remained in place during lunch. V13 stated she thinks R3's new padded wheelchair was helping her with her positioning. V13 stated R3 rarely scoots anymore; they only had to reposition her once earlier. The Face Sheet dated June 2026 for R3 showed medical diagnoses including epilepsy, acute kidney failure, intellectual disabilities, unspecified lump in breast, dysphagia, osteoporosis, profound intellectual disabilities. The Progress Notes for R3 dated 1/1/26 - 6/23/26 did not show any falls from the resident's padded reclining wheelchair. The Restraint Reduction assessment dated [DATE] for R3 showed dated of review as 10/7/25 and stated R3 uses a seatbelt while up in her wheelchair, she has poor trunk control, spastic, involuntary movements and seizures. She has intellectual disabilities and epilepsy; she continues to require the use of the lap belt when she is up in her wheelchair. She is laid down between meals for at least 10 minutes every day and it is released under direct supervision (ie. while cares are rendered). Her mother is highly involved in her care and does release her seatbelt when she is with her also. The Care Plan dated 5/1/26 for R3 showed R3 has a diagnosis of epilepsy. Potential for seizure activity. R3 needs a lap belt on when she is left unattended, while in her wheelchair. R3 has diagnoses of epilepsy and profound intellectual disabilities. R3 is unable to stand or sit unsupported, her last fall was 10/9/25; R3 does continue to have spastic, uncontrolled body movements at times. A lap belt and helmet are used when R3 is left unattended in her wheelchair R3 needs her lap belt and helmet in place when she is left unattended in her wheelchair. On 6/24/2026 at 1:07 PM, V2 Director of Nursing stated, R3 has been in a padded wheelchair for awhile and she just got a new one. V2 stated R3's seatbelt should be released at least every two hours. V2 stated the seatbelt is released when R3 is supervised. V2 reviewed the April 2026 Restraint Reduction Assessment and confirmed the date in the assessment was 10/7/25; she stated that she just copied and pasted the assessment. V2 stated R3's epilepsy diagnosis has not changed so they have not tried to reduce the restraint. V2 stated V9 wants the seatbelt in place. V2 stated R3's last seizure was sometime last year. V2 confirmed that R3 is not moving around like she used to and R3 is on hospice. The facility's Physical Restraint policy (no date) showed the need for a restraint will be re-evaluated at least quarterly to determine their continued need and efforts will be made to eliminate their continued use.

Based on observation, interview and record review, the facility failed to obtain weekly weights as ordered by the physician for 1 of 1 resident (R43) reviewed for quality of care in the sample of 23.The findings include:The findings include:R43s admission records show he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to chronic diastolic (congestive heart failure). R43s June medication review report shows an order for weekly weights on Monday, for fluid retention to begin on 5/25/26.The Weights and Vital summary dated 6/25/26 shows on 5/10/26 at 156 pounds, and the next weight was completed on 6/7/26 was 168.7 pounds, and 6/11/26 at 165.3 pounds.The June Medication Administration Record (MAR) and Treatment Administration Record (TAR) were reviewed, and the weekly weight order was not listed.On 6/25/26 at 8:46 AM, V2 Director of Nursing (DON) said when an order for weekly weights is received, the nurse should put the order on the MAR. V2 looked into the computer and said the order was put under standard other which will just put the order in the chart, and it was not put in correctly and did not trigger the nurses to complete the weight. The weights should have been done to ensure R43 was not in fluid overload with his congestive heart failure.On 6/23/26 at 2:15 PM, R43 was observed to be sitting up in his wheelchair, had oxygen per nasal cannula. He stated he wears oxygen all the time as he gets short of breath.The facility undated policy for weights documents they are to obtain and document resident's weight accurately upon admission and thereafter by following standard protocol and procedures. Systematically and accurately identify any significant weight changes and implement appropriate instructions in a timely manner.

Based on observation, interview, and record review, the facility failed to develop a restorative program tailored to a resident's needs for 1 of 2 residents reviewed for restorative therapy in the sample of 23. The findings include:R18's electronic face sheet dated 6/25/26 showed R18 has diagnoses including but not limited to frontotemporal neurocognitive disorder, dysphagia, repeated falls, and depression. R18's facility assessment dated [DATE] showed R18 has severe cognitive impairment and receives restorative therapy R18 had no care plan related to restorative therapy or his need for assistance with transfers/ambulation. R18's restorative task for June 2026 showed, Walk towards the elevator and back towards the room with gait belt, walker, and 2 assist, remind him to keep walker close to him. He does get tired. On 6/23/26 at 9:58 AM, V5 and V8 (Certified Nursing Assistants-CNA's) assisted R18 to the bathroom. Both V5 and V8 stated R18 might take a few steps here and there but nothing more. Both staff stated they do not do any other restorative therapy with R18 because it's not on their task list to do anything else with him. On 6/25/26 at 9:20 AM, V2 (Director of Nursing) stated, I am in charge of restorative and I am the Director of Nursing. I have been doing both positions for a year and a half. My restorative CNA is working the floor because of staffing so things are lacking. We are supposed to do a walk to dine program and the aides on the floor don't have time to get to everyone. I don't know that (R18) is on restorative programming that works for him. We attempt to walk, but he does not do it near as much as he was. His sister still wants us to attempt and we can usually get him a few steps. He does not receive passive range of motion or anything like that. He is one that should be on a program because he is getting increasingly stiff and we need to keep him moving as best as we can for as long as he is able to do it. The facility's undated policy titled, Restorative Programming showed, Objectives: to decrease or prevent contractures and/or atrophy, increase circulation, improve strength and movement, to ensure the resident can participate to the best of their ability in ADL's (Activities of Daily Living), providing holistic care by staff .

Based on observation, interview and record review the facility failed to ensure a resident was transferred using a gait belt and failed to ensure a resident was safely transported in a wheelchair for 2 of 6 resident (R43, R9) reviewed for safety in the sample of 23. The findings include: 1. R43s admission record shows he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to congestive heart failure, and mild protein-calorie malnutrition. The 3/17/26 care plan for R43 identifies him as a risk for falls. The interventions show he requires the assistance of one staff using a gait belt for transfers.On 6/23/26 at 2:00 PM, V5 Certified Nursing Assistant (CNA) pushed R43 towards the bathroom. Standing behind the wheelchair she leaned over and assisted R43 to stand up without placing a gait belt around his waist. He stood, turned and sat down on the toilet. When he was finished, V5 then placed a gait belt around his waist to assist him back to the wheelchair. She stated R43 required one assist but only with supervision and did not always need the gait belt. On 6/25/26 at 8:43 AM, V2 Director of Nursing (DON) said R43 transfers with the assistance of 1 staff with a gait belt. The gait belt will provide leverage should he begin to fall during the transfer. The facility's 5/22/25 policy for gait blet/1-assist transfers documents Gait belts are used as a safety measure for both staff and residents in any of the following situations: 1. Transfer (all phases) of a resident.2. On 06/23/26 at 12:23 PM, R9 was observed to be pushed down the hallway by V8 CNA. The wheelchair had no pedals in place, and R9 was holding his feet off the floor.R9s Resident Assessment and care screening of 4/29/26 shows he has severe cognitive impairment. The same assessment also shows he uses a wheelchair for mobility and requires partial/moderate assistance for transfers. The assessment documents he does have a history of falls.On 6/25/26 at 9:02 AM, V2 said normally R9 will propel himself with his feet. But while the staff are pushing him, if he were to put his feet down during the transport he would fall out of the chair. The facility's 5/2026 policy for falls documents HEAR ME fall prevention strategy: H- Hazards. Environmental hazards should be identified, addressed and corrected promptly. M- Materials and Equipment. Ensure all equipment and assistive devices are functioning properly and used appropriately.

Based on observation, interview, and record review the facility failed to ensure cathter bags were covered and not resting on the floor for 2 of 2 residents (R2 & R21) reviewed for catheters in the sample of 23. The findings include:1. On 6/23/2026 at 10:21 AM, R21 was in a low bed to the floor. R21 had a catheter drainage bag on the side of bed with no cover on the bag and the bag was laying on the floor. On 6/23/2026 10:25 AM, V10 certified nursing assistant - CNA went into R21's room and stated the drainage bag should not be on the floor for infection control. V10 stated there should be a dignity bag to keep out of site and off the floor, also for infection control. On 6/25/2026 at 8:30 AM, V2 director of Nursing - DON sated the bag/covers for the catheter bags are used for dignity and to keep the drainage bag off the floor for infection control. V2 stated drainage bags should not be on the floor or touching the floor for infection control. The Face Sheet dated 6/25/26 for R21 showed diagnoses including multiple sclerosis, retention of urine, ventricular tachycardia, atherosclerotic heart disease, hypertension, chronic kidney disease stage 3, type 2 diabetes mellitus, hyperlipidemia, and traumatic subarachnoid hemorrhage. The Physician Orders dated June 2026 for R21 showed catheter care every shift. The Care Plan dated 6/22/26 for R21 showed R21 has a catheter related to urine retention. The catheter is a 16 French with a 10 cc balloon. Do not allow tubing or any part of the drainage system to touch the floor. Store collection bag inside a protective dignity pouch. The facility's Catheter Care Policy (no date) showed keep the collection bag (port opening) and tubing off the floor. 2. On 6/23/2026 at 10:16 AM, R2 was in bed on her back and had an indwelling urinary catheter drainage bag hanging on the lower part of her bed facing the entrance/hallway to the room. There was darker yellow urine that is cloudy and sediment present. On 6/25/2026 at 8:30 AM, V2 director of Nursing - DON sated the bag/covers for the catheter bags are used for dignity and to keep the drainage bag off the floor for infection control. V2 stated drainage bags should not be on the floor or touching the floor for infection control. The Face Sheet dated 6/24/26 for R2 showed diagnoses including heart failure, vascular dementia, cerebrovascular disease, retention of urine, major depressive disorder, dyspnea, vertigo, hypertension, dizziness and giddiness, hyperlipidemia, stress incontinence, cardiac murmur, and anxiety disorder. The Physician Orders Dated June 2026 for R2 showed she has a 20 French catheter with a 10 cc balloon. Catheter care every shift. The Care Plan dated 5/19/26 for R2 showed she has a catheter related to urine retention. Store collection bag inside protective dignity pouch.

Based on observation, interview, and record review, the facility failed to perform glove changes during wound care for 1 resident (R7), and failed to wear personal protective equipment during wound care for 1 resident (R15). These failures apply to 2 of 5 residents reviewed for infection control in the sample of 23, The findings include: 1) R7's electronic face sheet dated 6/25/26 showed R7 has diagnoses including but not limited to heart failure, pressure ulcer stage 4, type 2 diabetes, cystostomy status, pressure ulcer stage 3, and colostomy status. R7's facility assessment dated [DATE] showed R7 has no cognitive impairment and has 2 pressure ulcers. R7's care plan dated 3/24/26 showed, (R7) is at high risk for skin breakdown. He has a foley catheter and a colostomy. (R7) is a 1-2 assist with transfers and uses a wheelchair for mobility. (R7) was admitted to this facility with a stage 4 pressure ulcer to his coccyx, breakdown to his left posterior thigh and excoriation to his perineum and groin. (R7) also has a stage 2 pressure ulcer to his right gluteal fold with treatment in place. On 6/24/26 at 10:19 AM, V7 (Registered Nurse) provided wound care to R7. V7 applied a gown and gloves, removed the soiled dressing from R7's coccyx wound, cleansed the wound with wound cleanser, sprinkled metronidazole inside the wound, packed the wound, and applied a new dressing without changing her gloves. V7 removed her gloves and applied a new pair of gloves with no hand hygiene in between glove changes. V7 removed the soiled dressing from R7's buttocks, cleansed the wound with wound cleanser, applied calcium alginate to wound bed and covered the wound with a dressing without changing her gloves between cleaning the wound and applying a clean dressing, V7 then changed her gloves without performing hand hygiene in between glove changes and applied a barrier cream to R7's scrotum. V7 stated, I didn't realize that I didn't change my gloves in between dirty and clean. I thought I just had to change them between the wounds.: On 6/24/26 at 11:55AM, V2 (Director of Nursing) stated, Glove changes should be performed in between dirty and clean tasks. If a nurse is performing a dressing change, they should be removing the old dressing, cleaning the wound, performing hand hygiene, applying new gloves, and then applying the clean dressing to ensure no cross contamination occurs. The facility's policy titled, Glove use dated 3/1/10 showed, E. Wash hands after removing gloves. Gloves do not replace hand washing. F. Disposable (single use) gloves should be replaced was soon as practical when contaminated . 2. On 6/24/26 at 7:58 AM, V12 Registered Nurse - RN was at R15's bedside for dressing changes to his bilateral lower extremities. There was an enhanced barrier precaution magnet on his door. V12 had gloves on but did not have a gown on. V12 removed the elastic bandage, and dressing from R15's right lower leg. V12 cleansed R15's right lower leg and right posterior thigh using a cleanser on 4 x 4's. V12 held R15's leg up at times next to her body in order to re-apply the dressings and elastic bandages to his right lower leg and thigh. V12 removed the elastic bandage and dressings from R15's left lower leg. V12 used a cleansing solution on 4 x 4's and cleaned the macerated skin on his left foot. V12 cleansed between his toes and under them. V12 applied gauze between his toes, applied and abdominal pad over the top of his left foot, and wrapped his foot and lower leg with kerlix. V12 stated R15's the skin on his left foot appeared to be macerated. On 6/25/2026 at 10:55 AM, V2 Director of Nursing - DON stated enhanced barrier precautions (EBP) is for anyone with an opening, catheter, tubes etc. Staff should wear gown and gloves with care. V2 stated there are magnets on the doors that are the same as the actual signage. V2 stated staff are to follow what the signage states if it is posted. The Face Sheet dated 6/25/26 for R15 showed diagnoses including cellulitis of left lower limb, congestive heart failure, bipolar disorder, hypertension, morbid obesity, peripheral vascular disease, restlessness and agitation, type 2 diabetes mellitus, venous insufficiency, carrier of carbapenem resistant acinetobacter baumannii, gastroesophageal reflux disease, benign prostatic hyperplasia, obstructive and reflux uropathy, and hyperlipidemia. The Physician Orders dated June 2026 for R15 showed cleanse right posterior thigh with wound cleanser, air dry, wrap with kerlix and ace wrap entire thigh. Left lower extremity and right lower extremity, cleanse with wound cleanser, air dry, wrap with kerlix followed by ace wrap twice a day (clean with hydrogen peroxide only if maggots are present). Enhanced barrier precautions due to wounds/extensively drug-resistant organism. The Care Plan dated 6/24/26 for R15 showed, R15 is at high risk for skin breakdown. R15 was admitted with wounds to his bilateral lower extremities due to peripheral vascular disease. There were no interventions on the care plan regarding enhanced barrier precautions. The Wound assessment dated [DATE] for R15 showed vascular wounds with the following description: left top of foot with some maceration noted The facility's Enhanced Barrier Precautions policy (February 2026) showed enhanced barrier precautions will be used for residents with indwelling medical devices, wounds, or those who are colonized or infected with multi-drug resistant organize. At a minimum gloves and gown must be worn during high contact tasks with affected residents.

Based on interview and record review the facility failed to identify a resident's new, non-pressure wounds. The facility failed to perform weekly wound assessments on a resident's wounds. These failures resulted in R2 being hospitalized for cellulitis (bacterial skin infection) of his left foot after maggots were found in R2's left foot wounds. These failures apply to 1 of 3 residents (R2) reviewed for wounds in the sample of 6.The findings include:R2's admission records dated 1/2/26 showed R2 was admitted to the facility with diagnoses including cellulitis of his bilateral lower legs, peripheral vascular disease, lymphedema, obesity, and congestive heart failure. R2's infection notes, and Treatment Administration Records (TAR) dated 4/15/26-5/13/26 showed R2 received daily dressing changes to his bilateral lower legs due to his diagnosis of cellulitis. The notes showed R2 had redness, swelling, open areas, and drainage to the wounds on his lower legs. These notes showed no wound measurements of the wounds on his lower legs. These notes showed no documentation of any wounds to R2's left foot or toes on his left foot. R2's April 2026 Medication Administration Record (MAR) showed R2 was administered antibiotics, from 4/13/23-4/23/26, for treatment of his lower leg cellulitis. These notes showed R2 was noncompliant, at times, with offloading his lower extremities in an attempt to reduce his lower leg swelling. R2's electronic medical records dated 4/15/26-5/13/26 showed only one weekly wound assessment was completed on R2's bilateral lower leg wounds during this time. R2's wound assessment, completed by V4 Registered Nurse (RN) on 5/1/26, showed R2 had wounds to his posterior and anterior bilateral lower legs. The assessment showed R2 also had wounds to his toes on both of his feet. The assessment does not show any measurements for the wounds on his legs or feet. The assessment does not show where the wounds on his toes were located, or which toes were involved. The note showed, Bilateral lower extremities with excoriated with sloughing skin, red, swollen, left worse than right. 2 small open areas to left anterior lower leg, from knee to toes ruddy, bilateral feet swollen/red.Left anterior foot skin sloughed off, draining serosanguinous drainage. The assessment showed no documentation that a physician or nurse practitioner were notified of R2's wounds. R2's progress notes dated 5/14/26 showed nursing staff found multiple maggots in new wounds noted between R2's toes on his left foot. R2 was transported to a local hospital for an evaluation of his wounds. R2's hospital records dated 5/14/26-5/21/26 showed R2 was admitted to the hospital for the diagnosis and treatment of cellulitis to his left foot. The records showed maggots were found in open wounds between the first and second toes of R2's left foot and between the third and fourth toes of his left foot. R2 was discharged back to the facility on 5/21/26. On 5/26/26 at 10:15 AM, R2 was seated in a wheelchair in his room. A gauze and elastic bandage was noted to R2's left leg; from his left knee down around his toes. R2 stated, My legs and feet are always swollen. I really don't have any problems with the wound care here. They changed my dressings (to his lower legs) every day. They just didn't always look between my toes. R2 stated he had no idea how long he'd had the wounds with maggots between the toes on his left foot but stated he'd had increased pain to his left foot for about a week prior to the facility finding his left foot wounds. R2 stated he could not feel the maggots in the wounds in his foot. R2 stated he'd had a history of refusing to offload his lower legs in the past. On 5/26/26 at 11:00 AM, V3 Assistant Director of Nursing (ADON) stated she had recently taken over as the facility's wound nurse. V3 stated the facility did not have a wound physician. V3 stated all resident wounds are treated by a resident's primary care physician and/or nurse practitioner. V3 stated staff are to assess residents' skin daily. Residents with wounds are to have a wound assessment done once a week. V3 stated all wound assessments are to include wound measurements and a description of each wound. V3 stated the bedside nurses are responsible for completing weekly wound assessments on residents. V3 stated any new swelling, redness, and/or wounds are to be assessed by nursing and reported to a physician immediately. V3 stated R2 had a history of chronic wounds to his lower legs due to lymphedema and peripheral vascular disease. V3 stated, prior to 5/14/26, she was aware that R2's feet and toes had been swollen, however R2 never had wounds to his feet that she was aware of. V3 stated the facility had completed only one wound assessment on R2 from 4/15/26-5/13/26. V3 stated, on 5/14/26, she assisted R2's bedside nurse, with changing the wound dressings to R2's lower legs. During the wound dressing change, R2 complained of increased pain to the toes on his left foot. V3 stated, His toes (on his left foot) were very swollen and red. When I spread his first and second toes apart, I saw the wound with maggots in it. We immediately called the doctor. I am not sure how long he had the wound or maggots. On 5/26/26 at 1:15 PM, V4 RN stated she completed the wound assessment on R2 on 5/1/26. V4 stated the toes to R2's left foot appeared red and swollen at that time. V4 stated R2 also had a wound to the top of his first (big) toe on his left foot but stated, I thought he always had that. I didn't think it was new. V4 stated she couldn't recall if she had assessed or looked in between R2's toes during her assessment. V4 stated she did not notify R2's physician or nurse practitioner of R2's wounds on 5/1/26. R2's TAR dated 5/12/26 and 5/13/26 showed V7 RN completed R2's daily wound dressing changes to his lower extremities. On 5/26/26 at 12:25 PM, V7 stated, on 5/12/26 and 5/13/26, R2 did complain of pain to his left foot and toes during his dressing changes. V7 stated, I did look between all his toes (on his left foot) as much as I could, but it was painful when I touched them. I didn't see any maggots. The skin between his toes was mushy and red but his skin always looked like this. V7 stated she did not notify a physician or nurse practitioner of R2's left foot pain. R2's progress note dated 5/10/26 showed R2 was seen and assessed by V5 Nurse Practitioner (NP). On 5/26/26 at 11:40 AM, V5 NP stated when she assessed R2 on 5/10/26, R2's left lower leg and foot were covered with a bandage. V5 stated she did not remove the bandage to assess R2's left leg or foot. V5 stated she was never notified that R2 was having left foot pain and/or that he had wounds to the toes on his left foot prior to 5/14/26. V5 stated, (R2's) toes and feet were usually swollen. He was noncompliant with offloading his feet and would refuse his meds. If (R2) was having increased pain to his foot, staff should have assessed his foot along with looking between his toes for a source. Any new findings should have been reported to me immediately. We had been actively treating the cellulitis to his lower legs, but I wasn't aware of any wounds on his feet. V5 NP stated, on 5/14/26, the facility notified her R2 had new wounds between his toes on his left foot with maggots noted in the wounds. V5 stated she had no idea how long R2 had the wounds between his toes.The facility's Wound Care policy dated April 2026 showed, This policy pertains to wounds where the skin is broken-for example, but not limited to-skin tears, lacerations, pressure injuries. When the nurse is aware of skin wound/breakdown, whether in-house or upon a resident's admission, area is assessed. If acquired in-house, the resident's PCP (primary care physician) is notified for further treatment orders. The nurse that identifies the skin issue will notify the facility wound care nurse. Documentation of open wound must occur upon identification and at least once a week. The physician and/or facility wound care nurse is to be notified if no improvement is noted after a reasonable period of time, and/or upon signs of deterioration.The facility's Prevention and Intervention of Skin Breakdown policy (undated) showed all resident wounds will be assessed and measured at least once a week.

Based on observation, interview, and record review the facility failed to implement fall interventions and update a residents care plan for a resident with a history of falls (R1). The facility also failed to investigate a resident's falls, update their care plan, and implement fall interventions (R3) for a resident with a history of falls. This applies to 2 of 3 residents reviewed for falls in the sample of 4. The findings include: 1. R1's admission Record (Face Sheet) showed an admission date of 8/28/25 with diagnoses to include but not limited to neurocognitive (brain) disorder, repeated falls, aphasia (impaired speech), and failure to thrive. R1's 2/25/26 Quarterly Minimum Data Set (MDS) showed Brief Interview for Mental Status could not be completed and he had both short and long-term memory issues. The MDS showed he used a walker and wheelchair; and he had range of motion limitations to both arms. The MDS showed he was dependent upon staff for all forms of transfer (bed, chair, and toilet) and he required substantial/maximal (staff do more than half the effort) assistance for walking 10 and 50 feet. R1's 2/4/26 Social Service note from 3:46 PM showed, Family meeting held with ADON (Assistant Director of Nursing) and [R1's] sister, whom is his POA (Power of Attorney). She expressed concerns of [R1] having a decline in his health and the changes that have come with it. For example, [R1] used to walk to and from his meals and now he is using the wheelchair to go to and from meals. POA would like [R1] to walk whenever he possibly can and use his wheelchair when it is appropriate. However, after such, POA would like for [R1] to be brought back from his room with guidance of CNA's (Certified Nursing Assistant) and helped back into his recliner to relax instead of waiting in his wheelchair in the lounge. The note continued, .Social services and nursing agreed that these plans and goals were obtainable and will help support family and his wishes. R'1s 3/30/26 Fall Documentation from 7:34 PM showed he had an unwitnessed fall in the lounge. The note showed, Found on floor in lounge in front of wheelchair. R1's 4/14/26 Fall Documentation from 5:45 PM showed another fall in the lounge. The note showed the only witness was R4. The note showed R4 stated the fall happened quickly. The fall note showed R1 had been placed in the lounge, after the evening meal, by V11 Transporter. The note showed R1 sustained superficial scratches to his left arm and a bump on his forehead. The note showed R1's POA declined Emergency Department (ED) evaluation. (Note authored by V8 Registered Nurse). On 4/30/26 at 3:22 PM, V8 stated R1's 4/14/26 fall was unwitnessed by staff. V8 stated R1 had been placed in the lounge, following the evening meal, and was not supervised. V8 stated herself, V11, and the other staff she spoke to on 4/14/26 were not aware R1 had instructions that he should not be left in the lounge unattended after meals. V8 stated I immediately called his sister after the fall and his sister said he was supposed to go immediately from dining room to his room and be put in his recliner. [V11] said he was not aware that was supposed to happen. so I typed up a sign and put a sign in the elevator and his room to inform all transporters the process for [R1]. I did not know that was the process for [R1] at that time. She [R1's POA/Sister] said she had spoken to the DON before, and this process was supposed to have been in his care plan. It was my understanding that intervention was to be in place for his fall prevention. She knew his history because she cared for him at home and he was not appropriate to be left alone in the lounge. On 5/1/26 at 10:55 AM, V2 DON stated the notes on R1's wall regarding being placed in his recliner after the meal are per the request of R1's POA. V2 said, [R1's POA] made it clear she does not want him (R1) left in the lounge unattended and activities was told to not leave him alone in the room if they would have to leave. Not being left unattended and put in the recliner, those were fall interventions. The POA did request those interventions and that information was disseminated to all the staff. The information was given to all the staff but on the night of the 14th that process wasn't followed. When [V11] was asked about it he said he didn't know he (R1) was not to be left alone. Typically, information like that is disseminated via text message to the staff that they need to check the [Electronic Health Record] dashboard, or the information will be given in the text message, or we tell them via word of mouth. I would expect that intervention to be in his care plan also. It was not entered into his care plan until the day after his fall on the 14th. It should have been put in his care plan prior to the fall. I do know [R1's POA] asked me about the interventions prior to his fall on 4/14. She asked if I was aware of the interventions. I think she worded it like it had been discussed in the care plan meeting or it was supposed to be in his care plan. I may have discussed it with her on 3/31 because he had a fall in the lounge the night before when he was in the lounge unattended. V2 said the purpose of the fall interventions is to prevent falls and prevent injury. R1's Care Plan showed, is at risk for falls due to Hx (history) of repeated falls prior to admission. The care plan showed, [R1] is not to be put in the lounge before or after meals. He is to be brought straight to his room and put in his recliner. This is for his safety. Date Initiated: 04/15/2026 (more than 2 months after the 2/4/26 Care Plan meeting) Created by: [V2 Director of Nursing, DON] R1's Fall Documentation showed a third fall on 4/18/26 at 6:55 AM. The note showed, Resident found on the floor next to his bed on his right side.CNA was preparing to get him washed up. Floor pad had been moved away from bed. Bed was in an elevated position. CNA was coming out of the bathroom with soap and water when she saw him roll out of the bed. She immediately called for assistance. On 4/30/26 at 1:35 PM, V7 Certified Nursing Assistant (CNA) stated she was the CNA with R1 on 4/18/26 when he fell from his bed. V7 said she was getting R1 up for the day, she had raised R1's bed, moved his fall mats away from his bed, then left R1 unattended when she went to R1's bathroom to gather additional cleaning supplies. V7 said during that time R1 rolled off his bed and onto the floor. V7 stated she should have lowered the bed, replaced the fall mats, then gone to the bathroom to gather additional cleaning supplies. On 4/30/26 at 3:22 PM, V8 stated she was working the morning of 4/18/26 when R1 fell from his bed. V8 stated V7 called her over the radio stating she needed assistance with R1. V8 said, I went there and said, oh what happened, she said she went to bathroom to get washcloths and water, and she came out and he rolled out on to the floor. She had already moved the fall mat, so he landed on the floor. The bed was high, it was at a working height, like countertop height and the mat was not underneath him. I asked why did you leave him when the bed was so high, and she said I just stepped away momentarily to get soap and water. She had not started cleaning him up, he was still fully dressed, there was no basin of water or wash clothes near him. She should have gathered all his supplies before going in. He has fallen so many times so she should be prepared. On 5/1/26 at 10:55 AM, V2 DON stated, regarding R1's fall on 4/18/26, My expectation is if they walk away, they have to lower the bed and put the fall mats in place. The purpose of lowering the bed and the fall mat is to prevent injury or minimize the severity of the injury of the fall. The facility's Fall Prevention and Management policy (Undated) showed, .Falls can also lead to severe complications including hip fractures, traumatic brain injury and premature death. As all falls cannot be prevented, [the facility] strives to minimize potential injury by identifying common fall risk factors and developing individualized care plan interventions that focus on maintaining a person's independence and mobility function to the best of their ability. [The facility] assesses all residents and evaluates fall situations as well as potential fall/injury situations in order to achieve this goal. 2. R3's face sheet showed he was admitted to the facility on [DATE] with diagnoses to include hypertensive heart and chronic kidney disease with heart failure, Type 2 Diabetes, dementia without behavioral disturbance, obstructive sleep apnea, peripheral vascular disease, and arthropathy. R3's facility assessment dated [DATE] showed he has severe cognitive impairment and requires substantial to maximum assist of staff for most cares. R3's medical record showed he experienced 10 falls between 1/10/26 and 4/26/26. R3's 4/26/26 Fall (Initial Documentation) Note showed, Time of fall: 1:40 PM. Witnessed. Son at bedside for the whole incident. Son states patient was moving around the room in wheelchair and started to slide out of his chair. At this time, son was able to assist patient gently on the floor avoiding any head trauma. R3's 4/22/26 Fall (Initial Documentation) Note showed, Time of fall: 6:15 PM. witnessed by another resident. laying on hallway floor. he was in his chair and slid out. skin tear to right elbow. R3's 4/4/26 Fall (Initial Documentation) Note showed, Time of fall: 7:50 PM. Unwitnessed. Resident says he was moving up and down the hallway in his wheelchair. Resident slid from his wheelchair to the floor as staff was walking up and down. R3's 3/22/26 Fall Follow Up Note showed, Nurse was called in room by CNA stating while walking past residents room chair alarm was going off and CNA saw resident slipping from wheelchair onto floor. Resident stated, I don't know, with a big smile on his face. Nurse assessed resident. Patient was on floor in sitting position with back against wheelchair. R3's 2/21/26 Fall (Initial Documentation) Note showed, Time of fall: 12:0 PM. unwitnessed. Resident attempting to use restroom. sitting on buttocks. Injuries: small 1.5 cm skin tear to left upper extremity. R3's 2/12/26 Fall (Initial Documentation) Note showed, Time of fall: 4:20 PM. Unwitnessed. Resident is alert and states that he did not hit his head while falling in his room. On the floor in doorway of his room on his back. Resident was going into his room and chair went out behind him. Two wounds noted on right arm. One at right elbow and another 2-4 inches from elbow. R3's 2/12/26 Fall (Initial Documentation) Note showed, Time of fall: 3:30 PM . witnessed. he slid out of his chair. Witnessed, resident was in another resident's room being aggressive. R3's 2/11/26 Fall (Initial Documentation) Note showed, Time of fall: 9:00 AM. unwitnessed. On floor in room laying on his back. R3's 1/23/26 Fall (Initial Documentation) Note showed, Time of fall: 11:35 PM. unwitnessed. he was walking unassisted by staff and fell. His alarm was not sounding. Back up against the room door, leaning on right elbow, legs stretched out in front of him. resident stated he was going to the bathroom. R3's 1/10/26 Fall (Initial Documentation) Note showed, Time of fall: 7:00 PM. unwitnessed. patient unable to provide details due to chronic baseline altered mental status. Patient assumed to have been attempting to use the toilet but there is not any evidence of toilet use, patient declined to use the toilet after fall assessment, and incontinent brief clean and dry. R3's Care Plan initiated 7/17/25 showed, [R3] is at risk for falls related to Dementia, CHF (congestive heart failure), Asthma, Type 2 Diabetes. This care plan shows no interventions added since the care plan was initiated 7/17/25. On 5/1/26 at 12:21 PM, V2 DON (Director of Nursing) said, We have talked about what we do for falls and how we do meetings. [V1] started a fall PIP (performance improvement plan). We talk about different things. We do a monthly meeting, and she has been trying to put new things in place and track more than we used to about falls. In the February meeting, we talked about bed and chair alarms, talked about [R] and his self-transferring, we talked about a new policy for making sure the alarms have new batteries and are tested. In our 3/11/26 meeting we had our Restorative CNA come down and talk about alarms. Different sounds and what you might hear if the battery is dying. We had our April quality assurance meeting, and we went over the falls and [V1] got more detailed in her tracking. For fall prevention we use alarms, different chairs depending on the person, with [R3] we tried multiple different chairs, got to the broda because of the way he sits in the chairs, we can do toileting programs, there are certain people that might need to be kept occupied in activities or hanging out at the nurses station. I come in every morning and look at notes, so that I can see when there is a fall. I will take that information, put it in my notebook, talk about it in morning meeting. We talk about interventions we can try and put in place. For [R1], Hospice is informed of any falls. with him they were very involved because his falls are so habitual. They were involved with trying the different chairs. He has behaviors when we try to sit him up straight in the chair. The care plan updates depend on where it is going to be at in the care plan. If the interventions have to do Restorative Nursing, I would be the one updating the care plan. If it goes on the fall care plan, that would be only me who would add. I think I am the only one who touches the fall care plan. My investigations would be looking at history. For R3, with him having multiple falls, we tried multiple chairs, added alarms, and talked to family and seen if there was something that would help with him. I like to add broda chairs to care plans, but I don't think I put his chair on his care plan. I don't have any formal fall investigations. The facility's undated policy and procedure showed, Fall Prevention and Management. [The facility] seeks to promote an active and healthy lifestyle with respect, dignity and security for reach resident as a whole. Falls are the leading cause of injury-related death for those 6 years of age and older. Falls can also lead to severe complications including hip fractures, traumatic brain injury, and premature death. As all falls cannot be prevented, [the facility] strives to minimize potential injury by identifying common fall risk factors and developing individualized care plan interventions that focus on maintaining a person's independence and mobility function to the best of their ability. [The facility] assesses all residents and evaluates fall situations as well as potential fall/injury situations in order to achieve this goal. Post Fall management: . E. Intervention to prevent a similar recurrence will be initiated by the licensed nurse on duty and will be indicated in the initial fall report to enable follow through and staff will be alerted of recent falls and/or interventions put into place. Fall Investigation. A). Falls are reviewed during the daily department meeting, interventions are discussed, approved or added to, depending on situations. B. Care plan coordinators review the care plan areas of the residents who have fallen in order to assure that interventions are adequately documented and communicated.

Based on interview and record review the facility failed to ensure personal alarms were working for a resident at risk for falls for 1 of 3 residents (R2) reviewed for falls and safety in the sample of five.The findings include:The Fall Initial Documentation dated 1/10/26 at 7:10 PM for R2 showed he had an unwitnessed fall. R2 was observed on the bathroom floor in a supine position. R2 was unable to state what had happened and his alarm was noted not to be working. R2 was assumed to have been attempting to use the toilet, but there was not any evidence of toilet use.R2's Care Plan dated 12/8/25 showed R2 is at risk for falls related to dementia, congestive heart failure, asthma, type 2 diabetes mellitus, and dysthymic disorder. Other diagnoses include chronic kidney disease, arthropathy, benign prostatic hyperplasia, hypercholesterolemia, gastroesophageal reflux disease, obstructive sleep apnea, hyperparathyroidism, peripheral vascular disease, and hypertension. R2 has a sensor pad alarm that is to be in place when he is left unattended in his bed, chair or wheelchair. R2's care plan was not reviewed and/or revised after his fall on 1/10/26.On 2/4/26 at 11:59 AM, V8 Certified Nursing Assistant - CNA stated R2 has the alarm when he is in his chair and when he is in bed. The alarm is the same one and it gets moved back and forth. R2 always has an alarm to alert staff when he tries to get up. V8 stated R2 likes to try and get up on his own and falls. V8 stated R2 has a sensor pad that alarms when he tries to get up. R2 has it for his safety.On 2/4/26 at 12:47 PM, V6 Registered Nurse - RN stated on 1/10/26 R2's alarm was not working when he fell. V6 stated she asked the CNAs when he was last toileted and was last seen. V6 said that her and the CNA replaced the batteries and messed with the wire on R2's alarm and it started working. V6 stated the wire was kind of worn out on the alarm.The Fall Initial Documentation dated 1/23/26 at 11:35 PM for R2 showed he was found on the floor with his back up against the room door. R2 was leaning on his right elbow with his legs stretched out in front of him. R2's alarm did not sound. R2 stated he was going to the bathroom.On 2/4/26 at 2:29 PM, V11 CNA stated she was working on 1/23/26 when R2 fell and his alarm was not working. V11 stated the nurse called her for help because the nurse (V5 Licensed Practical Nurse - LPN) found R2 on the floor in the doorway of his room. V5 stated R2's alarm was not working; it wasn't going off. It worked after the batteries were replaced. V11 stated that staff can tell when the battery is going low because some of them will start beeping real fast and some make a humming noise. V11 stated when this happens the batteries need to be replaced. V11 stated if staff keep resetting the alarm when this happens then the batteries will be dead and staff will not be aware of it.On 2/4/26 at 12:25 PM, V3 Assistant Director of Nursing - ADON stated she was not aware that R2 had two falls in which it was documented that his alarm was not working. V3 stated his alarm should be working; he has it as an intervention for falls. V2 stated the alarm is in place to help alert staff that he is up so a fall can be prevented.R2's Care Plan, dated 12/8/25 showed R2 is at risk for falls. R2's care plan was not reviewed and/or revised to show that he had two actual falls in January 2026 or any changes made for the prevention of falls.The facility's Fall Policy (no date) showed the facility seeks to promote an active and healthy lifestyle with respect, dignity and security for each resident as a whole. Falls are the leading cause of injury-related death for those [AGE] years of age and older. Falls can also lead to severe complications including hip fractures, traumatic brain injury and premature death. As all falls cannot be prevented, the facility strives to minimize potential injury by identifying common fall risk factors and developing individualized care plan interventions that focus on maintaining a person's independence and mobility function to the best of their ability. The facility assesses all residents and evaluates fall situations as well as potential fall/injury situations in order to achieve this goal.

Based on observation, interview, and record review the facility failed ensure the safety of a dependent resident by not preventing a burn for 1 of 3 residents (R1) reviewed for safety in the sample of 3. This failure resulted in R1 sustaining a 2nd degree burn to his left knee. The findings include:R1's face sheet showed he was admitted to the facility 8/15/25 with diagnoses to include dementia, metabolic encephalopathy, atherosclerotic heart disease, ischemic cardiomyopathy, chronic congestive heart failure, chronic obstructive pulmonary disease, benign prostatic hyperplasia with urinary tract symptoms. R1's facility assessment dated [DATE] showed he has severe cognitive impairment and is dependent on staff for all cares.R1's care plan initiated 9/15/25 showed, [R1] is at moderate risk for skin breakdown.R1's 12/5/25 Skin/Wound/Bruise Note entered at 11:10 AM showed, . burn. 6.0 cm x 2.5 cm. Drainage: serosanguinous light. when resident was lying in bed, knee was hovering over heater next to the bed. Prevention; what actions taken to prevent from happening again: possible room rearrange to move away from heater. R1's Wound assessment dated [DATE] showed, . Left Knee (front) burn. 6.0 cm x 2.5 cm.R1's Order Summary for December 2025 showed, . Measure/Chart. left knee burn.On 12/6/25 at 8:49 AM, V4 RN (Registered Nurse) said, I had gotten called in to [R1's] room at approximately 10:45 AM because of a new skin issue on his left knee. Upon assessment, I realized it was a burn and that is when [V6 CNA (Certified Nursing Assistant] and [V7 CNA] informed me that when they went in to [R1's] room, his knee was on the heater. [R1] uses a low bed that goes all the way to the floor. I provided the medical treatment, measured it, dressed it, and I called for a manager. The wound was warm and red, at that point there was no drainage, just redness but there was skin that looked like there was a blister that had popped. [R1] didn't report any pain to that area. when palpating the area, he does flinch. He doesn't usually stay in bed for breakfast, but they said he was sleeping really good and he has been more tired than usual. V4's said the hospice company was notified of the new wound and there were no recommendations for needing treatment outside of the facility. V4 said R1 did not require treatment from an acute care setting. On 12/6/25 at 10:51 AM, V4 and this surveyor went to R1's room. R1's bed was positioned parallel to the room's heating unit under the window. There was a grated radiator heating unit down the length of the wall under the window. V4 said the mat that was on the floor now was not there previously and R1's bed was usually pushed close to the heating unit. V4 said there would usually be only a small amount of space between the heating unit and R1's bed so that the CNA could squeeze in between the bed and the heater. V4 said R1's bed is usually in the lowest position when he is in it. V4 put R1's bed into the lowest position which showed R1's knee would have been at approximately the same height as the heating grate. On 12/6/25 at 8:57 AM, V2 DON (Director of Nursing) said, . They came into my meeting and said they needed me to come and look at something. When I went into the room to access the injury, [V4 RN] had already assessed it and dressed it. I pulled his pant leg up; it was on his left knee. I removed the dressing and saw there was some hanging skin that looked like a popped blister. He showed slight discomfort when I was manipulating it. I trimmed off the excess skin that was hanging there and redressed it. He was happy and smiling afterward. On 12/6/25 at 12:45 PM, V6 CNA (Certified Nursing Assistant) said, . I think it was around 10 AM, I had assistance from another person to help me get him up. That is when I saw the burn. When I went in there, he was laying on his left side like he always does. but his leg was on the heater, so I moved him and went to go get the nurse. he didn't seem to be hurting. When I lifted his leg up off the heater, it was pink and red, the part that was on the heater. He can move around in bed himself. We position him and he will turn himself back and lay himself on that side. He grabs the bar and scoots himself either up or down. His bed is usually pretty close to the heater. They told me to move the bed after this happened.On 12/6/25 at 1:01 PM, V7 CNA said, It was probably a little bit after 10:30 AM when V6 asked her to help with [R1]. When we went in there his leg was hanging off the bed, it was kind of tucked into the bed and kind of onto the heater. That is how close the bed is to the heater. When I moved the bed, to get in between the bed and the window, she called the nurse because there was blood dripping onto the floor. I didn't know if he tore the skin or if it got burnt from the heater. He was not complaining of pain. He didn't seem to notice it was burned. His feet were tucked in the bed and his knees were pointed out to the heater. The bed was so close to the heater that I had to move the bed to squeeze in to help [V6] get him ready. He moves his legs himself sometimes.On 12/6/25 at 11:57 AM, V5 (Personal Care Helper) said, I took water into [R1] yesterday but that was between 9:45 AM to 10:00 AM. He was laying on his side facing the window when I went in there. I didn't want to wake him, so I just dropped the water off, we didn't speak. He appeared to be sleeping. He wasn't moving and didn't make any sound.On 12/6/25 at 11:15 AM, V9 (Owner/Maintenance) said, . When it gets colder in the winter we use the boiler system, hot water radiator heat to heat the building. The boiler is controlled by outside temperature, as it gets colder the water temperature goes up. At 12:03 PM, V9 and this surveyor went into R1's room to record the surface temperature of the metal grates on the heating unit near where R1's knee would have been touching it on 12/5/25. The surface temperature of the heating unit grates was recorded at 126 degrees Fahrenheit.On 12/6/25 at 3:20 PM, V1 Administrator said, We moved [R1's] bed and we went through the whole facility to make sure no other resident beds were that close to the heating unit.The facility's undated policy and procedure showed, Safety and Health Policy. [the facility] is aimed at minimizing the exposure to our employees, residents, families and other visitors to health or safety risks. To accomplish this objective, all employees are expected to work diligently to maintain safe and healthful working conditions and to adhere to proper operating practices and procedures designed to prevent injuries and illness. The responsibilities of all employees to [the facility] in the regard include: 1. Exercising maximum care and good judgement at all times to prevent accidents and injuries. 3. Reporting unsafe conditions, equipment, or practices to supervisory staff.

Based on observation, interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R3) reviewed for abuse in the sample of 3.The findings include:The findings include:The 11/23/25 resident abuse report form completed by V6 Social Services documents an incident of verbal abuse by V7 Certified Nursing Assistant towards R3. The report states while V7 was assisting R3 with getting ready for breakfast, V7 came into the room and had earphones in her ears and talking to someone in a loud manner and using vulgar language.The 11/14/25 quarterly resident assessment and care screening for R3 documents her to be cognitively intact. She has no behaviors or delusions.On 12/2/25 at 1:25 PM, R3 was sitting in her wheelchair wrapped in a blanket. She was alert and very pleasant. She reached her hand out for a handshake to introduce herself. She recalled the events of 11/23/25. R3 said that day was the first day I had any encounter with (V7). She was helping me go to the bathroom. She had ear buds in and talking to the person on the phone, at first, I thought she was talking to me. Well, whoever she was talking to she started cussing a blue streak, she was using God Damn a lot and I find that offensive. She also was using the F word and Jesus Christ; those words were personally offensive. She was helping me and talking to them, it was very confusing. R3 said her tone of voice was very angry, and it was intimidating. and loud. R3 said she reported it to staff but did not recall which staff member. R3 said V7 made her feel scared if she were to come back, like she would be vindictive, and reported it because she does not want her to do the same thing to anyone else.On 12/2/25 at 2:37 PM, V9 Certified Nursing Aide said R3 reported the aide (V7) was on her phone using lots of foul language. She said the incident was immediately reported to the nurse on duty. V9 said after the incident R3 did seem upset, but not scared, but she definitely was not happy.On 12/2/25 at 2:30 PM, V8 Registered Nurse said an aide had approached her and reported the incident. She called V6 to report the allegation, and V7 was removed from the building. V8 said when she spoke to R3, she appeared very upset about the situation.On 12/2/25 at 1:45 PM, V6 said he received a text message with an allegation of verbal abuse. He then reported to the building to conduct his investigation. V6 said she spoke with the staff on duty, including V7. He said R3 reported to him, V7 was using foul and offensive language while on the phone. She described the language as GD, MF, and JC. V6 said R3 was upset and reported feeling threatened and feared retaliation. V6 said he reviewed the camera footage from outside of R3s room and could see V7 on her phone but was unable to hear anything. When confronted, V7 said she was on the phone but denied using any foul language. V6 said he did believe the incident did occur as R3 reported and is was substantiated as verbal abuse. V7 was not giving the resident the attention she needed. And R3 was shook up after the incident.The facility's undated policy for Abuse, Neglect and Exploitation Policy documents It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Verbal abuse: the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on observation, interview, and record review the facility failed to ensure the safety of a dependent resident who was left outside in the sun for two hours without water or a way to call for help. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6. This failure resulted in R1 being transferred to an acute care hospital for treatment of heat exhaustion, sun burn, hypoxia, and altered mental status. The Immediate Jeopardy began on 9/14/25 when R1 was assisted outside in her reclining wheelchair and placed directly in the sun without staff supervision and monitoring in place for two hours. V2 (Assistant Administrator) was notified of the Immediate Jeopardy on 9/19/25 at 11:25 AM. The surveyor confirmed by observation, interview, and review that the Immediate Jeopardy was removed on 9/19/25, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include:R1's face sheet showed she was admitted to the facility 11/3/2009 with diagnoses to include rheumatoid arthritis, reflex neuropathic bladder, major depressive disorder, scoliosis, encephalopathy, acute kidney failure, hyperkalemia, muscle spasm, anxiety disorder, peripheral vascular disease, and venous insufficiency. R1's facility assessment dated [DATE] showed she has no cognitive impairment and is dependent on staff for all cares. R1's care plan initiated 4/15/2010 showed, [R1] has a diagnosis of rheumatoid arthritis, which has caused her to have limitations in her ROM (range of motion), she is also obese, which has limited her mobility. [R1] requires total to extensive assist with ADL's (activities of daily living) and mobility.R1's care plan initiated 11/2/2017 showed, [R1] requires total care with all ADL (activities of daily living) tasks. R1's care plan did not include anything regarding R1 going outside or a plan for time limits.On 9/18/25 at 1:16 PM, R1 was observed at the local hospital. R1 was lying in bed with IV access to her right arm. R1's face, neck, and chest were visibly red. R1 said, I came here because I got too much sun, that is what happened. I don't remember going out and I don't remember coming back in.R1's 9/14/25 nursing note entered at 3:46 PM showed, The resident was observed outside, unresponsive by a CNA. This nurse obtained vitals, sternum (sternal rub) the resident and she did respond. The resident's oxygen dropped, and oxygen was administered, and oxygen jumped back up to 91%. This nurse gave the resident water, and she was drinking that with no issues, cold compress was applied to face, both arms and legs and was effective. The resident has been sent to [acute care hospital] .R1's Acute Care Hospital documents dated 9/14/25 showed, Chief Complaint. Altered Mental Status. HPI (History of Present Illness) Patient presents by EMS (Emergency Medical Services) from [Long Term Care Facility]. They called for Altered Mental Status. Per EMS she was apparently outside for 2 hours today. She was then apparently not acting like herself. EMS reports she would answer some questions, but other times would just stare at them. Patient doing the same upon arrival here. Patient appears sunburned. She has no specific complaints at this time. EMS reports she was hypoxic to 88% on room air. Physical Exam. Contractures to both hands/arms. Skin: . Sunburn to her face, shoulders, and upper chest areas that were exposed with the shirt she is currently wearing. ED Course as of 9/14/2025. Patient presents with above complaint. Was apparently left outside for 2 hours today in the sun. Has sunburn to her face and upper body. I called and spoke with the nursing home. Reports that she was out there for 2 hours. Per the notes, the patient was initially unresponsive. She still seemingly somewhat confused here but is much more alert than arrival. She was hypoxic upon arrival, which has also improved. CMP with an elevated creatinine. Due to the hypoxia D-dimer was obtained which was elevated. Diagnosis: After the evaluation in the Emergency Department, my clinical impression is 1. Acute cystitis without hematuria, 2. Heat exhaustion, initial encounter, 3. Sunburn, 4. Hypoxia, 5. Altered Mental Status.R1's Acute Care Hospital documented dated 9/15/25 showed, Assessment and Plan: . [AGE] year-old female brought in from [nursing home] . for being left out in the sun too long. She was found to be confused, sun burned, and have signs of UTI/dehydration. We will admit. Vitals on arrival show soft/normal BP (blood pressure) 110s, low grade temp 99, slightly hypoxic to 88. Exam shows patient to be dry, sunburnt.On 9/17/25 at 10:02 AM, V6 CNA (Certified Nursing Assistant) said, [R1] asked me to push her outside after lunch. Then I asked her the time limit because it is usually 10-20 minutes. It wasn't all that hot right then. She asked for 20 minutes to be outside. I used the walkie (handheld communication device) and said [R1] was outside and wanted 20 minutes. When I went inside, I told the girls at the desk too. I honestly don't remember who was at the desk, I just know there were 2-3 people there. I told them she wanted 20 minutes. I worked that day from 4:00 AM -1:30 PM but I think I left at about 1:45 that day. [R1] was the last one to come up from lunch so it could have been anywhere from 1:15-1:30 PM that I took her outside. She usually sits right at the end by the entrance, I usually put her at the end, past the building, and face her toward the sun so she is still in eye view of the door. I don't know if I was just a hair off with where I put her, but I don't remember. She has a 10-20-minute time limit to be outside. She goes out for 10 minutes and when you check on her, she will sometimes ask for 10 minutes more. Usually someone sets a timer for that. I don't know if they set the timer that day or not. They usually have a timer on someone's phone in their pocket. She goes outside all the time, and it is common for staff to be watching for her.On 9/17/25 at11:03 AM, V11 CNA said, I heard [V6] on the walkie say she took [R1] out and for a timer to be set. I just don't remember if there was a response. If there is no response for me when I take [R1] out, I go to the CNA in person, otherwise, you set the timer yourself because you are the one that took her out. She always sits in the same general place outside. She never takes water out with her. She doesn't take a phone or anything out with her. She will tell us either 10 minutes or 20 minutes, but no longer than 20 minutes. We set that limit, especially if it is really hot outside. She can't call us if she wants to come in. The limit is set because of the weather, you can't be in the sun that long. On 9/17/25 at 11:11 AM, V12 CNA said, I wasn't really part of it. I heard [V6] get on the walkie and say she put her outside. Usually whoever puts her outside sets the timer and brings her back in. I'm pretty sure I heard a response on the walkie when [V6] said [R1] was outside, but I don't know who responded. I left at 3:30 PM so I wasn't there when they found her. She has 10-20 minutes is the usual. If it is really hot, we check on her at the 10 minutes. She is able to tell us if she is too hot. Then we give her another 10 minutes. If it is hot, 20 minutes is the maximum. When [R1] is outside, she wouldn't be able to let us know if she wanted to come in. That is probably why we do the 10-minute check in. She doesn't take drinks out with her because she can't hold them. On 9/17/25 at 11:30 AM, V9 CNA said, I worked Sunday (9/14/25), I heard [V6] say to put on a 10-minute timer. I was mid-conversation with a coworker so I can't 100% say if I heard a response. [R1's] CNA was sitting at the nursing station. I was here until 2:00 PM that day. Everyone here has a 'walkie' and would hear that. It is a normal thing to hear. I will tell you what I do, if I take her outside, I put the timer on my own phone because I don't want someone to forget, and it be me that put her out there. If it rings (the timer) while I am in with another resident, I will 'walkie' to someone to go get her or I will go out as soon as I'm done. If it is hot, we limit the time because of issues like this. She doesn't have water out there so we would go and bring her in, give her water, give her time to cool down. It is limited so these situations don't happen. There is no way for her to let anyone know she needs to come in, that is why she is checked on in 10-minute increments. Either someone forgot to set the timer or didn't hear their timer. There should be a better system, so these things don't happen.On 9/17/25 at 10:50 AM V10 CNA (Certified Nursing Assistant) said she worked 5:30 AM - 5:30 PM on 9/14/25. V10 said, [R1] doesn't eat breakfast, so she got up for lunch. After lunch, I was not aware that someone put her outside. Someone wheeled her out there, I was not told she was out there. We had our shift change and one of the other CNA that had come in at 2:30 PM saw [R1] out there. We gave her water and we put cool, wet, towels on her. She was able to drink water. I told her to try and keep her eyes open. At first, she was really hard to get to respond but later she started to be more responsive. We got cold towels on her. We took her vitals. I don't remember what they were, the nurse should have the vitals somewhere. I was there immediately when she was brought in, she was red, warm, her eyes were closed, and we were shaking her to try and wake her up. She was in and out of consciousness until we started with the cold towels and water. After we started that, she started to be more responsive. We asked her if she had a headache, she said yes, really quickly and shut her eyes again. It took about 1-2 minutes before she started responding. There is no call light out there, we usually put a timer on our phone, and we go out and get her. I don't know who let her out or if there was a timer. No one reported to me she was outside. She doesn't take anything out to call us when she is ready. Usually whoever lets her out puts the timer on and will tell the person that has her assignment. Usually, it is whoever puts the timer on that is the one that goes back and gets her. I have never seen her take water out with her. I don't think she had any. She has trouble grabbing things so I don't know if she could even hold it. You maybe could see her when she is out there if you were looking out the window. It would depend on where you are at. For sure the cold towels and water helped. She was very thirsty, so we gave her a good amount of water. She was drinking water from the little plastic cups. She drank a few of those little cups. She kept drinking the water, so we kept giving her more. She was getting more conscious as she was leaving with the ambulance.On 9/17/25 10:10 AM, V5 CNA said, I found [R1] outside. No one had any idea that she was out there. No one mentioned in report when I came in that she was out there. Usually, whoever takes her outside, they are supposed to set a 20-minute timer. I came in at 2:30 and no one had any idea she was out there. I was taking another resident outside and I saw her. I didn't think anything of it at first, but I said 'hi' to her and she didn't respond. Her eyes were rolled back, and she was twitching. She was unresponsive for quite some time until she got sent out. Everything was normal that day until that point. I don't know who took her outside. It was hot outside, probably about 85 degrees and she was in the direct sun. She wasn't in view of the door or anything either. I didn't see her until I fully walked outside, and she was off to the left side. It was 3:30 PM when I found her because I was telling the resident that I was taking outside that I had a specific amount of time before I had to be getting people up for dinner. I went outside with my other resident and when I found [R1] I immediately brought her in. The nurse and a couple of the other CNAs were putting cold wet towels on her, getting her vitals, and things like that. I didn't watch the full process. She was kind of going in and out of responsiveness when I came back in. She would open her eyes and kind of look at you, but she wasn't verbal other than to say 'what'. I have never seen her unresponsive before. She was red, not like super sun burned or anything but she was a little red on her face and chest area. Her legs looked normal to me, but her face and chest were pretty red.On 9/17/25 at 2:40 PM, V7 CNA said, I was only involved after they brought [R1] back inside. She was left outside by [V6], apparently, she said to set a timer and she left. I guess no one must have set a timer. [V5] saw her outside and she was unresponsive.Myself, a nurse, and another CNA did vitals. Her temperature was done initially when she came in, but I don't remember what it was. After cold compresses and water her temperature was 97 something. She drank those little cups of water, probably 3 of them. We had a fan on her too. From what I know she came inside, and the nurse was rubbing her chest, and she would wake up and then fading in and out. Usually she does go out, there was a rule, no more than 10 minutes and they set a timer. Recently, it has been more lenient with the time restriction. She regularly does go out though for short periods of time. She has no button or anything to push. She does not propel her own wheelchair.On 9/17/25 at 9:38 AM, V8 LPN (Licensed Practical Nurse) said she worked Sunday. One of the CNAs had taken one of the residents outside. She came back in and said [R1] was unresponsive. They brought her back in. I put cold compresses on her and got vitals. She was very warm to touch. Red, hot. I know they had taken her out sometime after lunch. She was coming back up from lunch and then brought her back outside. They came and got me a little after 3:00 PM, I believe. The Restorative CNA had taken her out I believe. I have never had her be unresponsive before. She can't move her own wheelchair.On 9/18/25 on 3:42 PM, V13 (R1's Physician at the Acute Care Hospital) said, [R1] came in for burn, dehydration, heat exhaustion, and the UTI was caught in the work up. She was very burned. I saw her the second day and her face and neck were very red. I could see her neck was exposed and sunburned. After the first day of IV fluid, she was much improved. She was more alert and more awake. We found the UTI during the workup and started antibiotics but her improvement within the first day tells me her symptoms on admission were from the heat and sun. Treating the UTI with antibiotics would take a couple of days for an improvement. [R1] did a couple days of IV fluid. She is doing okay now. That first day after fluids really helped.The facility's undated policy and procedure showed, Resident Outside Policy; Policy Statement: At times residents who do not wander request to be taken outside to enjoy the sun and fresh air. Some residents are in wheelchairs and cannot return to the building themselves, this requires a [NAME] eye on the resident. Procedure: 1. Resident taken outside must be checked on every 15 minutes. 2. CNA who takes resident out is responsible for every 15-minute check. 3. If CNA is not able to check on resident outside, CNA must find another CNA to check on resident. a. Verbally assigning this to another CNA b. Announce over walkie. 4. If the resident appears to be in distress, the resident is immediately brought back inside and assessed by the nurse. The Immediate Jeopardy that began on 9/14/25 was removed and the deficient practice corrected on 9/19/25 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. An assessment form was created and immediately implemented to assess the residents' ability to safely be outside unattended. All residents have a completed assessment for going outside unattended. Newly admitted residents will have a completed assessment for going outside unattended. This assessment will be reviewed quarterly and if there is any change in condition. Audits will be completed quarterly by DON or designee. Completed 9/19/2025 2. Current policy reviewed. Input from Certified Nursing Assistants (CNAs) was collected via Survey Monkey. Policy updated with feedback from managers and CNAs. In addition to identifying safety measures and resident assessment, the policy includes timely checks on the resident and documentation on a log. A timer is placed at the door entry (Door 4) where residents go outside. The log book is stationed at Team B nurses' station, next to Door 4. The log includes documenting time going outside, 15-minute checks, notes regarding resident, hydration offered, time coming in, and staff signature. Completed 9/19/2025 3. All managers were educated on the new policy/procedure. Managers then educated their staff. This ensured that staff were educated on the policy and procedure prior to their next shift worked. Agency: New policy & Procedure has been sent to agency organizations who will in turn disseminated to their staff. Agency staff will be educated on arrival by DON or designee. Completed 9/19/2025 4. Policy states that whoever takes the resident outside is the one responsible to ensure 15-minute check is conducted. A timer is set for 15 minutes to alert for checking on the resident outside. If the CNA is unable to check on resident, CNA must find another CNA to check on the resident. CNA must confirm with other CNA that the 15-minute check is being conducted, either verbally or over the walkie/talkie. If the CNA is unable to find another individual to do the 15-minute check, the resident is brought back in to the facility. Completed 9/19/2025 5. Weekly audits will be conducted by DON or designee. Completed 9/19/2025 6. Removal of Immediacy completion date: 9/19/2025

Based on interview and record review the facility failed to ensure an allegation of abuse was reported immediately for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. The findings include:R1's face sheet showed he was admitted to the facility 8/11/25 with diagnoses to include malignant neoplasm of prostate, acute posthemorrhagic anemia, severe protein calorie malnutrition, depression, hypertension, mild cognitive impairment of uncertain or unknown etiology, muscle wasting and atrophy, and dysphagia. R1's 8/21/25 facility assessment showed R1 is severely cognitively impaired and is dependent upon staff for cares.On 9/10/25 at 12:06 PM, V6 CNA (Certified Nursing Assistant) said, It was my first day there. I was working with V5 (CNA) at first and was washing people up and assisting to their wheelchairs. V4 CNA asked for help with a transfer, so I went with her. When we went into [R1's] room, [V4] walked up to the bed and said, 'This is [NAME], he is a f*%king asshole who thinks because he is a veteran he can treat people like shit.' [R1] looked right at me and said, 'Help me, they don't treat me well here.' . I watched videos for orientation before starting work there and it was clear what was considered abuse. It talked about using foul language in the presence of residents and she was using many cuss words. I notified staff of my concerns the same day when I left there. I talked to [V7 ADON (Assistant Director of Nursing)].The facility's Resident Abuse Report Form showed an incident reported regarding R1 on 9/4/25 at approximately 6:40 AM. This same document showed the allegation was reported at approximately 2:00 PM. The facility's Abuse Investigation Report showed, On September 4, 2025, at approximately 12:56 PM, [V6 CNA (Certified Nursing Assistant)] reported to ADON (Assistant Director of Nursing) via text . [V6] describes an encounter between [R1] and [V4 CNA], that she felt was abusive towards the resident. [V6] describes [V4] yelling at [R1] and cussing at him while applying cares. The encounter caused [V6] to feel extremely uncomfortable and resulted in her leaving the building before her shift had ended. An investigation was launched shortly after when Social Services was alerted of the circumstances. there is sufficient evidence demonstrating that verbal abuse has occurred. Camera surveillance matches the details expressed from [V6] following the text message conversation she had with V7. All abuse had taken place within the resident's room and in his presence. Due to the extreme findings of this case; [V4] has been terminated of her duties with [the facility] . On 9/10/25 at 1:10 PM, V7 ADON said the investigation was initiated because [V6] the CNA that was training that morning just left the facility in the middle of her shift without telling anyone. V7 said later that day, around 1:00 PM, she texted V6 to see if she would respond and find out why she left. V7 said it was at during that text conversation that V6 reported that she left because she wasn't comfortable with the way another CNA was talking to a resident and we just kind of continued the conversation from there. V7 said V6 should have reported it right away to the floor nurse, social service director, or she could have reported to [V7] or the DON (Director of Nursing). V7 said, It was her very first shift too so she should have known, after going through orientation, that she was supposed to let someone know right away.The facility's Termination Documentation Form signed 9/5/25 showed V4's employment was terminated due to improper conduct/carelessness, safety violation, and a policy and procedure violation. The same document showed, Founded verbal abuse against a resident witnessed on camera.The facility's policy and procedure with revision date of 5-2025 showed, Abuse, Neglect, and Exploitation Policy; Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implanting written policies and procedures that prohibit and prevent abuse. Verbal Abuse the use of oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability. g. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents, and grievances without fear of retribution and provide [NAME] regarding the concerns expressed. The reporting process is as follows; iii. Report the allegations to the Administrator and Social Services immediately after reporting to nursing. By doing so, the investigation will begin and all other necessary agencies, etc will be notified via the Administrator or Social Services.

Based on interview and record review the facility failed to ensure a resident was free from verbal abuse for 1 of 3 residents (R1) reviewed for abuse in the sample of 7. The findings include:R1's face sheet showed he was admitted to the facility 8/11/25 with diagnoses to include malignant neoplasm of prostate, acute posthemorrhagic anemia, severe protein calorie malnutrition, depression, hypertension, mild cognitive impairment of uncertain or unknown etiology, muscle wasting and atrophy, and dysphagia. R1's 8/21/25 facility assessment showed R1 is severely cognitively impaired and is dependent upon staff for cares.On 9/10/25 at 12:06 PM, V6 CNA (Certified Nursing Assistant) said, It was my first day there. I was working with V5 (CNA) at first and was washing people up and assisting to their wheelchairs. V4 CNA asked for help with a transfer, so I went with her. When we went into [R1's] room, [V4] walked up to the bed and said, 'This is [NAME], he is a f*%ing asshole who thinks because he is a veteran he can treat people like shit.' [R1] looked right at me and said, 'Help me, they don't treat me well here.' . I watched videos for orientation before starting work there and it was clear what was considered abuse. It talked about using foul language in the presence of residents and she was using many cuss words. I notified staff of my concerns the same day when I left there. I talked to [V7 ADON (Assistant Director of Nursing)].The facility's Resident Abuse Report Form showed an incident reported regarding R1 on 9/4/25 at approximately 6:40 AM. The facility's Abuse Investigation Report showed, On September 4, 2025, at approximately 12:56 PM, [V6 CNA (Certified Nursing Assistant)] reported to ADON (Assistant Director of Nursing) via text. [V6] describes an encounter between [R1] and [V4 CNA], that she felt was abusive towards the resident. [V6] describes [V4] yelling at [R1] and cussing at him while applying cares. The encounter caused [V6] to feel extremely uncomfortable and resulted in her leaving the building before her shift had ended. An investigation was launched shortly after when Social Services was alerted of the circumstances. there is sufficient evidence demonstrating that verbal abuse has occurred. Camera surveillance matches the details expressed from [V6] following the text message conversation she had with V7. All abuse had taken place within the resident's room and in his presence. Due to the extreme findings of this case; [V4] has been terminated of her duties with [the facility] . On 9/10/25 at 1:10 PM, V7 ADON said the investigation was initiated because [V6] CNA was scheduled to train that morning and she just left in the middle of her shift and didn't tell anyone. V7 said around 1:00 PM that day she texted V6 to see if she could find out why she left the facility without telling anyone. V7 said, That is when she told me she wasn't comfortable and didn't like the way the CNA was talking to the resident. We just kind of continued the conversation from there. V7 said they hadn't had any concerns about V4 so they were surprised by this incident. V7 said the facility has a camera right outside of R1's room and R1's door was open, so they could hear what went on. V7 said V6's description turned out to be accurate.The facility's Termination Documentation Form signed 9/5/25 showed V4's employment was terminated due to improper conduct/carelessness, safety violation, and a policy and procedure violation. The same document showed, Founded verbal abuse against a resident witnessed on camera.The facility's policy and procedure with revision date of 5-2025 showed, Abuse, Neglect, and Exploitation Policy; Policy Statement: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implanting written policies and procedures that prohibit and prevent abuse. Verbal Abuse the use of oral, written, or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families or within their hearing distance regardless of their age, ability to comprehend, or disability.

Based on interview and record review, the facility failed to perform a safe mechanical lift transfer for 1 of 3 residents (R12) reviewed for safety/supervison in the sample of 15 . This failure resulted in R12 experiencing a fall from the mechanical lift and sustaining a hematoma. The findings include: R12's electronic face sheet printed on 3/13/24 showed R12 has diagnoses including but not limited to Alzheimer's disease, dementia with behaviors, congestive heart failure, acute respiratory failure with hypoxia, acute pulmonary edema, major depressive disorder, and repeated falls. R12's facility assessment dated [DATE] showed R12 has severe cognitive impairment and is dependent on staff for all transfers. On 3/12/24 at 9:58AM, R12 was laying in her bed with a yellow, purple, black hematoma to her right forehead and eye. R12's progress notes dated 3/7/24 showed, Witnessed fall at 1400. Resident found on right side, legs over (mechanical lift) sling, (mechanical lift) sling with one strap not correctly fastened CNA's (Certified Nursing Assistants) state that resident slid out while trying to rotate (mechanical lift) towards bed, resident slid out of sling. CNA's stated that it was so fast they are not sure if she hit but they did try to grab her and slow the fall .hematoma developing to right front forehead. R12's care plan dated 9/26/23 showed, (R12) is at risk for falls, she no longer ambulates and has started using a (reclining wheelchair) for proper positioning. Her diagnoses includes: anxiety, depression, dementia with behaviors, Alzheimer's disease, and osteoarthritis. (R12) has a low bed which is left in the lowest position when she is left unattended while in bed, floor mat while in bed, and (mechanical lift) with assist of 2 with all transfers. On 3/14/24 at 8:27AM, V6 (Certified Nursing Assistant) stated, (V4-Certified Nursing Assistant) and I were transferring (R12) with the (mechanical lift) and we pushed the button to lift her up and she just fell out. I don't know exactly what happened because I hooked my side of the lift so (V4) must not have done her side. They have never done any previous competencies for me to watch me use the lifts. On 3/14/24 at 9:40AM, V4 (Certified Nursing Assistant) stated, The incident with (R12) happened very fast. We were transferring her from the reclining wheelchair to her bed and I remember there was a lump in her bed from the mattress. I hooked up the left top hook and I thought (V6) hooked up the other 3. When I was over at her bed I wasn't looking and was fixing her bed and (V6) started lifting her. It was both of our faults for not checking to ensure all of the straps were hooked. I had my back turned to (R12) and when I turned around she was falling out of the sling and landed on top of the base of the lift on her side. (V10-Restorative Nurse) told me she wanted to watch me do a (mechanical lift) transfer but she hasn't done that yet. I don't know when she is going to do my training. On 3/14/24 at 10:31AM, V10 (Restorative Nurse) stated, (R12) has been a (mechanical lift) transfer since I started here in January. There have never been any issues. I don't recall any competencies being done with staff for mechanical lift transfers that I know of. I reacted right away with the investigation. I checked (mechanical lift) policies and made sure everyone was re-educated on our policy. I looked at the (mechanical lift) checkoff and made sure I started training staff on the 8th (one day after it happened). Every day I go around and make sure I am getting the staff trained right away. I posted the (mechanical lift) policy at each nurse's station and have asked the staff that next time they do a (mechanical lift) transfer to let me know so that I can see the transfer. Once the resident's bottom comes off the surface, the transfer should be paused to make sure it's going to be a safe transfer. All I can do is try to re-educate them. I am trying to remind them that the black straps on the slings are not for using, they are for safety. I didn't know that so I learned that as well. They are there and should be hooked up as well so that if the colored straps fail, the black straps catch the sling. Both staff members should have their eyes on the resident so one can run the lift and the other one can ensure safety. I don't know if I even did (V4's) training yet. I haven't been doing anyone since you guys have been here since we have been busy. I still have to catch her to do it. On 3/14/24 at 10:47AM, V2 (Director of Nursing) stated, I would expect all straps on the (mechanical lift) to be hooked for safety. I would expect that both staff have eyes on the resident when doing a transfer to ensure the transfer occurs in a safe manner. Occasionally they may turn their back to fix something quick but they should know what's going on. (V10) has been re-educating CNA's and observing transfers to ensure the aides know how to perform the transfers. Both staff should have been trained immediately to prevent this from happening to anyone else. I'm not sure why they haven't been. Employee in-service records from 2/204-3/14/24 showed no documentation of in-services on fall prevention/safe mechanical lift transfers. Competencies for V4 and V6 were requested and not received. The facilities nursing schedule for March 2024 showed V4 (CNA) worked 3/9/24 and 3/11/24 and V6 (CNA) worked 3/7/24, 3/8/24, 3/10/24, and 3/12/24 without receiving any training on safe mechanical lift transfers. The facility's policy titled, Mechanical Lift Policy/Procedure dated 3/8/2024 showed, (Mechanical lifts) are used to enable staff to safely transfer a resident from once surface to another. A minimum of two appropriate staff members is required .Attach the straps of the (mechanical lift) sling to the swivel bar, and check for proper placement prior to lifting the resident up off the bed as one staff member manages the (mechanical lift) to raise the resident up, the second staff member provides support to the resident as needed, guiding legs to avoid injury, and guiding the resident to/from the bed to over the wheelchair, all while observing the resident for safety .

Based on interview and record review the facility failed to ensure a resident was supervised and assisted as needed by staff while ambulating which contributed to R1 falling in the facility and sustaining a right hip fracture. This failure applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 6. The findings include: The facility's Fall-Initial Documentation note dated 1/7/24 showed R1 fell while walking, by herself, in the dining room of the facility. The note showed R1's fall was witnessed by V7 Dietary Aide and V8 Nurse Manager. The note showed R1 was walking with a walker when she was trying to move her legs but legs would not move. Resident then lost her balance and fell on her right side. Upon examination, R1's right leg appeared shortened and rotated. R1 complained of pain to her right hip. 911 was called. R1 was sent emergently by ambulance to a local hospital. R1's hospital records dated 1/7/24-1/11/24 were reviewed. The records showed R1 was admitted to the hospital, on 1/7/24, with a diagnosis of an intertrochanteric fracture of her right hip. R1 had surgery on 1/8/24 to fix/treat her right hip fracture. R1 was discharged from the hospital, back to to the facility, on 1/11/24. R1's Fall Risk assessment dated [DATE] showed R1 was at risk for falls due to her history of previous falls, diagnoses of dementia, Alzheimer's disease, psychotic disturbance, and her impaired cognition. R1's electronic medical records showed R1 had sustained previous falls in the facility on 11/15/23, 3/1/23, and 2/7/22. The records showed R1 fractured her right ankle as a result of her fall on 2/7/22. R1's care plan dated 10/2/23 showed R1 was at risk for falls due to her unsteady gait and impaired balance. The care plan showed R1 will participate in a Walk N' Dine program by walking to and from the bathroom and from her room to the elevator prior to meals with the use of her front wheeled walker, stand by assist of one (staff) and wheelchair to follow by her . On 1/16/24 at 9:15 AM, this surveyor attempted to interview R1 about her fall on 1/7/24 but was unable to complete the interview due to R1's impaired cognition. On 1/16/24, two attempts to contact V7 Dietary Aide for an interview related to R1's fall were unsuccessful. On 1/16/24 at 12:10 PM, V8 Nurse Manager stated, Stand by assist with a wheelchair means staff are to stand next to the resident, with a wheelchair, when the resident is walking, in case the resident needs help or needs to sit down. I didn't realize (R1's) care plan showed that (R1) needed that assistance when walking. No one was walking with (R1) when she fell (on 1/7/24). She was in the dining room when she fell . I was right outside the dining room, passing medications to another resident, when it happened. I heard (V7 Dietary Aide) yell, 'She's going to fall.' I turned around and saw (R1). Her legs were twitching, she stopped walking, and she went down. I couldn't get to her in time. (R1) was using her walker when she fell . The only staff around when (R1) fell was me and (V7) . On 1/16/24 at 12:47 PM, V9 Nurse Practitioner stated, (R1) has had previous falls in the facility. In fact, I know she broke her ankle one time due to a fall. I really have never seen her walk. When I see her, she is always in her wheelchair. I know she requires staff assistance with transfers. Her care plan should be followed. For her safety, if her care plan says she should walk with staff walking by her with a wheelchair, then that's what staff should be doing.

Based on observation, interview, and record review the facility failed to ensure a warm pack was not too hot for a residents skin. This resulted in a resident receiving a second degree burn to his left upper back. This applies to 1 of 3 residents (R1) reviewed for safety. The findings include: On 3/24/23 at 9:30 AM, R1 was fully dressed, laying in bed on his right side. R1 had several blankets, and 3 shirts on. R1 had a dressing on his left upper back that had writing on it indicating the dressing was done on 3/23/23. No drainage was visible through the dressing. The dressing order is for the dressing to be changed every 3 days. On 3/24/23 at 9:30 AM, R1 said he doesn't remember who applied the warm pack that caused the blister, and he doesn't remembering it hurting when it was applied, but it hurt when the blisters broke and it's still tender if it gets bumped. R1's Care Plan shows his diagnoses to include: Hemiplegia and Hemiparesis following a CVA (cerebral vascular accident) affecting the left side, dysphagia (difficulty swallowing food or liquids), weakness, history of falling and lower back pain. On 3/24/23 at 10:00 AM, V4 RN (Registered Nurse) said R1 likes warm packs on him because he is cold all the time. V4 said sometime between the night of 11/8/22 and the early morning of 11/9/22, her assumption was that V3 Agency CNA (Certified Nursing Assistant) put a warm pack on R1's back that was too warm and it caused a blister. V4 said the day shift CNA found the blister when she removed the old warm pack and told V4 right away. V4 said it was several different blisters (not one big blister) within the size of the warm pack. V4 said R1 did not complain of pain. V4 said she told V12 (the previous Director of Nursing), the POA (Power of Attorney) and V5 NP (Nurse Practitioner) to get a treatment order for R1's blister. V4 said V12 no longer works at the facility. On 3/24/23 at 9:40 AM, V8 (CNA) said R1 was V3's resident at the time of the incident. V8 said V3 warms the cloth for the warm pack in the microwave and it was too hot and left a blister on R1. On 3/24/23 at 9:45 AM, V9 (CNA) said R1 was V3's resident at the time of the incident. V9 said V3 warms the cloth for the warm pack in the microwave and it was too hot and left a blister on R1. On 3/24/23 at 1:30 PM, V5 NP (Nurse Practitioner) said a blister caused by a warm pack is a second degree burn caused by the warm pack being too hot and on the skin for a prolonged amount of time. An attempt to contact V3 was not successful. V5 no longer is employed at the facility. The 11/9/22 wound assessment shows the initial blistered area measured 15.0 x 9.0 x 0.0 cm (centimeters) and 9.0 x 9.0 x 0.0 cm. R1's 11/9/22 Progress Notes shows R1 received a burn to the left side of his back going down to center of his back. The burn was 2 blisters, the upper left back measured 15.0 x 7.0 cm (centimeters) and the one closer to the middle of R1's back was 7.0 x 7.0 cm. The same Progress Note shows the treatment order is for Silvadene twice daily until resolved, the warm packs for R1 are to be discontinued and staff is to be re-educated on the correct usage of warm packs. The root cause analysis for R1 burn is from the hot packs. R1's MDS (Minimum Data Sheet) shows R1 is cognitively intact, and requires extensive assistance with all of his ADL's (activities of daily living). The Facility Bulletin Board for V1 (Administrator) shows on 11/9/22 NO WARM PACKS TO (R1)-If doing warm packs on other residents in the future, only do from faucet temp, no microwaves.

I. Based on interview and record review the facility failed to ensure that 2 staff were used to safely transfer a resident with a mechanical lift and failed to ensure that a resident was safely positioned to avoid injury while giving care. These failures resulted in R17 sustaining a fractured rib on 3/12/12 and R10 sustaining a fractured left humerus on 5/12/12. This applies to 1 of 5 residents (R10) reviewed for falls/fractures in a sample of 15 and 1 resident in the supplemental sample(R17). The findings include: 1. The Minimum Data Set of 5/7/12 shows that R17 is totally dependent on 2 or more staff for transfers from one surface to another. The Incident Report dated 3/13/12 states, "CNA noted dark purple bruise on left side , under arm pit and on left breast. Xray report states "possible fracture left 8th rib. No pneumothorax." Written interview from E1(administrator) with E18 (CNA) dated 3/20/12 states, " I informed (E18) that the cameras did not show anyone else entering or leaving (R17's) room from the time she took the (mechanical) lift in the room until the time she walked out with the sling, so she must have transferred her by herself. (E18) made no comments." On 6/27/12 at 10:45 AM, E11 (CNA- Staff Coordinator) stated, "(E18-CNA) claimed she never saw the bruise. When interviewed she was trying not to admit she did it wrong. (E18) was crying, she was very upset." The undated facility policy entitled Hoyer Lift states, "(Mechanical) lift are used to enable staff to lift and move a resident safely. A minimum of 2 staff members is recommended." 2. The Current [DIAGNOSES REDACTED]. The History & Physical dated 3/31/11 showed R10 is confined to a wheelchair and has right-sided paralysis secondary to Cerebrovascular Accident (CVA). The Minimum Data Set (MDS) assessment reference date of 4/5/12 assessed R10 as having moderate cognitive impairment. R10 required extensive assistance of 2 staff for transferring, bed mobility, hygiene, bathing and toilet-use. R10 was assessed as having impairment in range of motion in her upper extremity on one side. The facility's incident report for R10 dated 5/12/12 at 7:30pm documented, "While repositioning resident in bed, resident's right arm was under her and when E19 (CNA- Certified Nursing Assistant) rolled her over; heard a popping noise. CNA informed nurse who assessed (R10) who complained of pain with ROM (Range of Motion) and right shoulder appeared different from the left. Since R10 was not displaying any discomfort of the right shoulder except when transferring, the family and Physician agreed to monitor and wait until 5/14 to obtain an x-ray of the arm due to how it upsets R10 to go to the hospital." The x-ray report dated 5/14/12 showed R10 sustained a non-displaced oblique fracture of the right humerus. The x-ray showed no signs of osteoporosis. On 6/27/12 at 3:20pm E11(CNA) said, "E19 (CNA) was in the room turning the resident (R10). R10 was rolling in the bed and her bad arm was caught underneath (her body). He (E19) heard a "pop" and went right away to get the nurse. She had a stroke. He didn't pull the arm out which was underneath her. She was a 2 person transfer when she is in bed. She has good days and bad days and sometimes R10 could help with transferring, but usually not at night, she was tired. E19 should have had help (to reposition R10)." II. Based on observation, interview and record review the facility failed to ensure an exit door was not blocked by hazards. The facility failed to ensure that portable oxygen tanks were secured to minimize danger to residents and labeled to indicate if they were full or empty. This has the potential to affect all 65 residents in the facility. The findings include: The CMS Census and Condition of Residents (form 672), completed during the survey, shows there are 65 residents in the facility On 6/25 and 6/26/12 during the breakfast and noon meals, the designated exit door adjacent to the Main Lounge was blocked by a soiled linen hamper, 2 dish carts, a popcorn machine and a wheeled walker. The items blocked the access to exit the door and blocked the fire doors going to the exit. On 6/26/12 at 9:15am, E14 (Maintenance) said "I think we could quickly move the stuff out of the way." During the environmental tour at 9:25am, 2 small portable oxygen cylinders were observed unsecured. E14 thought the portable tanks were broken and empty but he was not certain. There were 7 oxygen tanks without signs to indicate whether they were empty or full. E14 said, "The CNA's come down and fill the portable tanks." The facility's undated oxygen safety policy documented, "1. Oxygen cylinders must be stored in racks with chains, sturdy carts or approved stands. 2. All oxygen cylinders must tagged or properly labeled, to indicate the contents of the cylinder... 7. Store securely empty portable tanks. 8. Label portable tanks in need of repair."

Based on interview and record review the facility failed to ensure that a resident at risk for falls had a floor mat next to her bed to prevent injuries from falls. This failure resulted in R15 falling out of bed and sustaining a fractured C4 and C5 (Cervical Spine 4/5) on 3/12/11. The facility also failed to ensure that a resident requiring 2 assist for transfer had 2 staff present during a transfer. This failure resulted in R9 sustaining a right 3rd toe injury requiring sutures on 1/31/11. R9's toe wound subsequently became infected and required debridement on 2/24/11. This applies to 1 of 4 residents reviewed with falls in a sample of 16 and one resident in the supplemental sample. (R9, R15) The findings include: 1. The Minimum Data Set of 1/24/11 shows that R15 has [DIAGNOSES REDACTED]. The incident report of 3/12/11 states, "(R15) found on left side on floor, was laying in bed, had a large lump on the side of head, pupils reactive to light but resident not able to respond to commands as previously could not, due to fall and bump called ambulance to take to ER to be eval and treated. Did not move until ambulance arrived and transferred to stretch on board. Resident was lifting head even when instructed not to." The Conclusion on the same incident report states, "(R15) scoots around in her bed and has fallen on the floor. Normally has a bed mat on floor. Bed mat was not beside bed. (R15) fell on to floor on left side. Hospital reports non-displaced stable fracture @C4-5. " R15's care plan dated 2/25/11 states, "(R15) is at risk for fall due to hx of falls and being on an antidepressant medication. One of the interventions listed states, "Make sure (R15) has a floor mat in place at her bedside when she is left unattended when in bed." On 5/11/11 at 2:45 PM, E2 (Director of Nursing) stated, "(R15) had a habit of swinging her knees out of bed and then she would fall out of it. The mat was not there. They had set it up against the back wall and then the CNAs put it at the roommate's bed instead of hers. " 2. 2. The physician's orders [REDACTED]. R9's nurse's note documented on 1/31/11 at 7:54pm, "R9 caught her 3rd toe on the bottom of her commode leg and it was cut deep enough to most likely get stitches." The facility's occurence report dated 1/31/11 showed R9 sustained a laceration to the right 3rd toe which required 5 stitches. E6 (CNA) is listed as a witness to the occurence but there is no further documentation as to how the injury occurred. The Minimum Data Set (MDS) reference date of 12/20/10 assessed R9 as being severely impaired in decision making skills with long and short term memory problems. The assessment showed R9 required extensive assistance of two staff for bed mobility, transfer, walking in the room, dressing, toilet-use and personal hygiene. The assessment documented R9 had a history of [REDACTED]. The Physical Therapy assessment dated [DATE] showed, prior to increase in altered mental status, patient (R9) was ambulatory and transferred with assist of 1. The same document showed that R9's current level of functioning at the time of this assessment as: requiring 2 assist for safe transfers and to transition from sit to stand. The care plan dated 11/11/10-2/14/11 showed R9 was continent of bowel and bladder but was unable to transfer herself to the toliet. The care plan was not updated to show R9's altered mental status change (1/13/11), and that R9 required 2 assist of staff for ambulation, transfer and toilet-use. The nurse's notes dated 2/9/11 at 3:11pm showed R9's sutures to right toe removed. The nurse's note of 2/10/11 at 3:30pm showed purulent drainage from right toes onto sock. The nurse's note of 2/12/11 at 10:09am documented, "Dressing changed to right foot 3rd toe as had moderate amount of serosanguneous drainage." R9 remains on antibiotic for right foot 3rd toe. The nurse's note dated 2/24/11 showed R9's right toe was debrided by the podiatrist. physician's orders [REDACTED]." On 5/11/11 at 1:40pm E7 (LPN) stated, "She was on the commode and when the aides were pulling her pants up, she (R9) picked up the handles and sat the commode down on her toe." On 5/11/11 at 3:00pm, E2 (Director of Nursing-DON ) said she was unaware of the circumstances of the incident. At 3:20pm, E6 was called and said, "She was walking by R9's room and saw her trying to transfer herself. E6 rushed in and swung R9 onto the commode and it tipped and came back down on R9's toe." E2 said she did not do an investigation of the incident.