Every finding on record at Northbrook Health and Rehab

Based on observation, interview, and record review, the facility failed to ensure resident dignity while dining and needing assistance during eating. This deficiency affects 1 of 3 residents (R71) reviewed for meal assistance. Findings include: On 3/26/2024 at 12:30PM, observed V18 (Certified Nursing Assistant/CNA) standing over R71 during lunch while assisting R71 to eat. On 3/26/2024 at 12:45PM, V18 said she should sit down while assisting with feeding. On 3/27/2024 at 8:51AM, V2 (Director of Nursing) stated staff/CNA should be sitting down and within eye level when assisting resident with eating. R71's Admission Record indicated a diagnosis of Unspecified Dementia, Unspecified Severity, with other Behavioral Disturbance, Dysphagia, Oral Phase and Need Assistance with Personal Care. R71's Care Plan included: Initiated 12/17/2021, Revision 4/11/2023. Focus: The resident has an ADL (activities of daily living) self-care performance deficit r/t ADL needs and participation vary, confusion, dementia, fatigue, COPD, impaired balance, weakness. Interventions: Resident currently requires assistance with ADLs: Eating: limited X1. Policy and Procedure: Dignity Guidelines: The facility shall promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. The facility shall consider the resident's lifestyle and personal choices identified through the assessment processes to obtain a picture of his or her individual needs and preferences. Staff shall carry out activities in a manner which assists the resident to maintain and enhance his/her self-esteem and self-worth. Maintaining a resident's dignity should include but is not limited to the following: Promoting resident independence and dignity while dining, such as avoiding: Staff standing over residents while assisting them to eat.

Based on observation, interview, and record the facility failed to implement its policy on resident self-administration of medication. This deficiency affects 1 of 1 resident (R84) in the sample of 21 reviewed for Resident Self administration of medication. Findings include: On 3/26/24 at 12:21PM, observed a nasal spray bottle at bedside of R84. R84 said that she brought the medication from the hospital, and she has been taking it since she came to this facility. R84 said that she is taking it on daily basis every 4 to 6 hours. The medication is not labeled. Called V14 (Licensed Practical Nurse/LPN) who is the nurse assigned to R84 and showed observation made. V14 said that she is not aware that R84 has medication at bedside. V14 said that R84 did not have order for nasal spray. V14 added that R84 does not have order to have medication at bedside. V14 said that all resident's medication should be kept in medication cart and should be given by the nurse. V14 said that she will call the doctor. On 3/26/24 at 12:35PM, Review R84's active physician order sheet indicates no order for nasal spray. Progress notes and Care plan does not indicate that R84 preferred to take nasal spray at bedside. On 3/26/24 at 2:28PM, Informed V3 (Assistant Director of Nursing) of the above observation made. V3 said that no medication at resident's bedside unless ordered by primary care physician. All medications taken by a resident in the building should have a physician order. Requested the policy. On 3/26/24 at 5:02PM, Informed V1 (Administrator) and V2 (Director of Nursing) of above observation made. V2 gave surveyor the policy on Resident Self-administration of medication. On 3/27/24 at 9:30AM, observed R84's nasal spray at bedside table not in locked drawer. Review R84's physician order sheet indicates nasal spray nasal solution 1 spray in each nostril every 6 hours as needed for stuffy nose. Patient may keep at bedside and self-administer. No skill assessment tool was done to evaluate R84's competency for self-administration of medication. No IDT (Interdisciplinary Team) documentation of determining R84's ability to self-administration of medication. On 3/27/24 at 9:48AM, Review policy with V2 and informed her that they did not implement their policy for R84. They did not complete Assessment for Self-administer medications tool to determine R84's ability to self-administer. Medication is not kept in locked drawer in the resident room. The IDT did not formulate care plan intervention for R84's self-administration of medication. V2 said they don't have the assessment form indicated in the policy. V2 said V11 (Unit Manager) documented R84 demonstrated self-administration of nasal spray to her and called physician for medication to be administered at bedside. Surveyor informed V2 that R84's care plan has impaired cognitive function/dementia or impaired thought processes related to impaired decision making which needs IDT to determine R84's ability for self-administering of medication. On 3/27/24 at 1:50PM, V2 presented another policy for Resident Self-Administration. Review policy provided which still indicates that facility failed to implement its policy. On 3/28/24 at 10:05AM, Informed V2, V3, V21 (Nurse Consultant) and V23 (Vice President of Clinical Operations) of the above concerns. R84 was admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, anxiety disorder. R84 is alert and oriented. She can verbalize her needs to staff. Medication Administration Record (MAR) indicates: nasal spray nasal solution 1 spray in each nostril every 6 hours as needed for stuff nose. Patient may keep at bedside and self-administer dated 3/26/24. No documentation that R84 self-administered the medication. Facility's policy on Self Administration of Medication and Treatments indicates: General: Self-administration of medications and treatments are done to prepare a resident for discharge and to help the resident maintain their independence. The decision for self-administration is done by the interdisciplinary team. Policy: 1. Self-administration of medications and treatments are determined by physician order after determining that a resident is able to self-administer. 2. Medications and treatments that are self-administered are kept in a locked drawer in the resident room. 3. All medications and treatments that are self-administration are signed out in the EMAR (Electronic Medication Administration Record) and ETAR (Electronic Treatment Administration Record). Procedure: 1. If it determined by a member of the interdisciplinary team, or of the resident requests to self-administer, a self-administer assessments completed, it is documented in the resident's chart and the physician is called for an order to self-administer medications and keep the medications at the bedside. 2. Assessment of the ability to self-administer medications will be done by nursing using the tool Assessment for Self-Administer Medications. 6. A care plan is for resident who self-administer, and documentation should be present in the nursing notes of teaching related to self-administration of the medications or treatments. Facility's on Policies and Procedures- Pharmacy Services for Nursing Facilities Revised [DATE] IIA10: Self -Administration of Medications: Policy: In order to maintain the resident's high level of independence, residents who desire to self-medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedure: A. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team (IDT) of the resident's cognitive (including orientation to time), physical and visual ability to carry out this responsibility during the care planning process. C. For those residents who self-administer, the IDT verifies the president's ability to self-administer medications by means of a skill assessment conducted on a quarter basis or when there is a significant change in condition. 5. Similar reviews of administration technique is conducted for other dosage forms such as inhalers, sublingual tablets, eye drops, injections, etc. 6. The resident is asked to complete a bedside record indicating the administration of the medication (If bedside storage is to be used). D. The results of the IDT assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each authorized for self-administration, the label contains a notation that it may be self-administered. E. If the resident demonstrates the ability to safety self-administer medications, a further assessment of the safety of bedside medication storage is conducted.

Based on observation, interview, and record review the facility failed to ensure implementation of pressure ulcer prevention as ordered by the physician to a resident who is at high risk for developing skin impairment. This deficiency affects 1 of 3 residents (R48) in the sample of 21 reviewed for Pressure Ulcer Prevention Program. Findings include: On 3/26/24 at 12:01PM, observed R48 lying in bed with V13 (Licensed Practical Nurse/LPN). Bilateral heel protector/heel boots are at bedside chair. V13 said that R48 uses the bilateral heel protectors only at night. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus (DM), need for assistance with personal care, non-traumatic intracerebral hemorrhage. Active physician order sheet indicates: Offload bilateral heels with pillows when in bed. Monitor heels for significant changes every shift for protection. Care Plan indicates: R48 is at risk for skin impairment/pressure injury. Fragile thin skin, impaired/limited mobility, incontinence. Intervention: Bilateral heel lifts on all the time. R48 has impaired circulation related to Type 2 DM. R48 has an ADL (Activity of Daily Living) self-care performance deficit. Braden scale for predicting pressure sore risk dated 2/22/24 indicated that R48 is at moderate risk. On 3/26/24 at 2:28PM, V3 (Assistant Director of Nursing/ADON) said that she is also the Wound Care Nurse (WCN) while V10 is on training for WCN. V3 said that she has taken care of R48. Informed V3 of above observation. V3 said that R48 should have bilateral heel protector at all times. On 3/27/24 at 9:36AM, V2 (Director of Nursing/DON) and V21 (Nurse Consultant) said that they are expected to implement intervention for prevention of skin impairment as indicated in physician order and resident's care plan. On 3/28/24 at 9:38AM, observed R48 in her room with V3 (ADON). Observed R48's bilateral heels with blanchable redness. Facility's policy on Wound Prevention indicates: Purpose: Identify those residents that are high risk for developing pressure areas using Braden Plus form. Relieve or remove pressure. Stimulate circulation. Management of interventions: 1. Staff will care for residents as indicated in the resident's care plan, regarding individualized interventions.

Based on observation, interview, and record review the facility failed to provide necessary foot care and treatment for diabetic resident. This deficiency affects 1 of 3 residents (R48) in the sample of 21 reviewed for Foot Care Management. Findings include: On 3/26/24 at 12:01PM, observed R48 lying in bed with V13 (Licensed Practical Nurse/LPN). Observed bilateral heel protectors/heel boots were in the bedside chair. Surveyor requested V13 to check for R48's feet. V13 lifted the top sheet covering the feet of R48. Observed bilateral long thick yellowish brown colored toenails, with dry scaly skin and swollen feet. V13 said that podiatrist comes every Thursday to the facility. The Wound care nurse is the one scheduling resident to be seen by podiatrist. V13 added that R48 is diabetic. On 3/26/24 at 2:28PM, V3 (Assistant Director of Nursing/ADON) said that she is helping V10 (Wound Care Nurse/WCN) while he is on training. V13 said that the WCN is responsible for referring resident to be seen by podiatrist. Informed V3 of above observation made. V13 said that she has taken care of R48 but didn't notice of her long toenails. V3 said that the podiatrist comes every Thursday and will refer R48. Surveyor requested foot care management. R48 is admitted on [DATE] with diagnosis listed in part but not limited to Type 2 Diabetes Mellitus (DM), Need for assistance with Personal care, non-traumatic intracerebral hemorrhage. Active Care Plan indicates: R48 has an ADL (Activity of Daily Living) self-care performance deficit. R48 has impaired circulation related to Type 2 DM. Intervention: Podiatry consult PRN (as needed). R48 has potential for hyper/hypoglycemia related to DM. Intervention: Refer to podiatrist as needed. Take care when providing foot care to monitor for changes in condition and report PRN. R48's last podiatrist consultation was on 5/4/23 indicated: R48 seen for assessment and medically necessary debridement of painful long thickened nails several years duration gradually worsening over the last several weeks. On 3/27/24 at 2:00PM, V2 (Director of Nursing/DON) and V1 (Administrator) said that they don't have policy and procedure for Diabetic Foot Care Management. On 3/28/24 at 9:38AM, observed R48 in her room with V3 (ADON). Observed R48's bilateral heels with blanchable redness. Redness on right side on the great long toenails. R48 still with long thick yellowish brown colored toenails on both feet. Facility unable to provide policy on Diabetic foot care management. Facility's policy on Foot Care revision date 10/18/22 indicates: Policy: Foot care is given to promote cleanliness, prevention infection, control odor, provide comfort, monitor for skin breakdown, promote healing, and includes treatment to prevent complications from a variety of conditions that affects optimal foot health. Procedure: 8. Resident requiring foot care who have complicating disease processes must be referred to qualified professionals (i.e., podiatrist, a Doctor of Medicine (MD) and a doctor of osteopathy) who can treat foot problems/disorders. 9. Facility staff will also assist the resident, if necessary, in making appointments to visits a qualified person as well as help with arranging transportation to and from such outside appointments.

Based on observation, interview, and record review the facility failed to elevate the head of bed at least 30-degree angle and check for Gastrostomy Tube (GT) placement prior to water flush, administering feeding and medication to GT site. This deficiency affects 1 of 3 residents (R157) in the sample of 21 reviewed for Tube feeding Management. Findings include: On 2/26/24 at 3:04pm observed V16 (Agency Registered Nurse) preparing for R157's GT (Gastrostomy tube) feeding and reading instructions of GT tubing connector. On 3/26/24 at 3:30PM, observed V16 hang and connect the feeding bottle of (brand name of tube feeding) 1.2 liter to the GT feeding pump. R157 lying in bed with head of the bed less than 30-degree angle elevation. On 3/26/24 at 3:47PM, observed V16 use the graduated cylinder to get 200ml of water from the bathroom faucet. V16 flushed the 200ml water using 60ml syringe without checking for placement. Surveyor asked V16 what angle of degree R157's head is positioned? V16 said that R157 is on 10-degree angle head elevation. Then V16 connected the feeding tube to R157 GT site and turned on the feeding pump. V16 elevated R157's head. On 3/26/24 at 3:52PM, R157's feeding pump machine alarming sound. V16 Agency Nurse turned off the feeding machine and V16 prepared medication for R157. After preparing for R157's medication (Valproic Acid 10ml placed in medicine cup). V16 aspirated the medication in the medication cup using 60ml syringe and flushed the GT site without checking for placement. After administered the medication she turned on the feeding pump machine. On 3/26/23 at 4:03PM, R157's feeding pump machine keeps on alarming sound. V16 called V15 (Registered Nurse/RN) to help her with trouble shooting R157's feeding pump. V15 checked the feeding pump and informed V16 the reason for the feeding pump's malfunction/alarming because V16 did not reset the volume to be infused. On 3/26/24 at 4:09PM, asked both V15 and V16 what was the GT feeding administration procedure. V15 said that they have to check the GT placement via auscultation using stethoscope prior to start of feeding, flushing or medication administration. V15 added that resident should be positioning at least 30-degree angle or higher. Informed both of observation made with V16 that she did not check GT placement before flushing with 200 water to start R157's GT feeding. R157 was position at 10-degree angle (less than 30 degree) when V16 administered water and feeding via GT. On 3/26/24 at 4:30PM, Informed V19 (Unit Manager) of above observation made and requested for Policy on Tube Feeding Management. On 3/26/24 at 5:02PM, Informed V1 (Administrator) and V2 (Director of Nursing/DON) of above observation made and requested for policy. On 3/27/24 at 9:38AM, V2 (DON) presented policy on Gastrostomy Tube feeding and Care. On 3/28/24 at 10:02AM, V3 (Assistant Director of Nursing/ADON) said that they verify/check GT the placement via auscultation using stethoscope. V3 said that she listens to the air as she instills into the GT. On 3/28/24 at 10:05AM, V2 said that they check GT placement via auscultation. On 3/28/24 at 10:08AM, Informed V2 (DON), V3 (ADON), V21 (Nurse Consultant) and V23 (Vice President of Clinical Operation) that the facility is not following its policy on checking for tube placement. They are using auscultation instead of aspiration as indicated in their policy. Surveyor requested for Nursing competency skills for Gastrostomy tube feeding and care since the last survey. V2 DON said that they do not have any. R157 is readmitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, Dysphagia, gastrostomy status. Active physician order sheet indicates: Enteral feed order every shift (brand name of tube feeding) 1.2 at 65ml/hr x 17 hours total of 1100ml infused. Flush G-tube with 200ml of water every 4 hours. Flush feeding tube with 20ml water before and after medication every shift. Care plan indicates R157 requires tube feeding related to poor appetite and weight loss. Intervention: Check tube placement as needed. Keep head on bed elevated while tube feeding is infusing. Facility's policy on Gastrostomy Tube-Feeding and Care effective date: 5/17/22 indicates: Purpose: To provide nutrients, fluids, and medications as per physician orders to residents requiring feeding through an artificial opening into the stomach. Procedure: 5. Position resident on his/her back with head elevated to minimal 30 degree and preferable 45 degrees. 7. Observe for tube feeding placement before: a) Starting feeding b) Water flushes and hydration and c) Medication administration. Checking for tube placement: a. Aspirate to visually verify stomach contents. Gastric fluid normal appears clear or yellow with mucus or may appear milky if residual remains from previous feeding. Aspirated contents must be returned to the stomach to maintain pH, fluid, and electrolyte balance. Facility's policy on General guidelines for administering medication via enteral tube Revised [DATE] indicates: Policy: The facility assures the safe and effective administration of enteral formulas and medications via enteral tubes. Procedures: B. Inservice training on bacteriological safely, administration and monitoring of enteral solutions and medication via the enteral tube is provided by the facility to nursing personnel.

Based on observation, interview, and record review the facility failed to ensure that no medication is kept at bedside and safely stored and locked in medication cart. This deficiency affects 1 of 3 (R84) residents in the sample of 21 reviewed for Medication storage and safety. Findings include: On 3/26/24 at 12:21PM, observed a nasal spray bottle at bedside of R84. R84 said that she brought the medication from the hospital, and she has been taking it since she came to this facility. The medication is not labeled. Called V14 (Licensed Practical Nurse/LPN) who is the nurse assigned to R84 and showed observation made. V14 said that she is not aware that R84 has medication at bedside. V14 said that R84 did not have order for nasal spray. V14 added that R84 does not have order to have medication at bedside. V14 said that all resident's medication should be kept in medication cart and should be given by the nurse. V14 said that she will call the doctor. On 3/26/24 at 2:28PM, informed V3 (Assistant Director of Nursing/ADON) of above observation made. V3 said that no medication is allowed at resident's bedside unless ordered by primary care physician. All medications taken by a resident in the building should have physician order. On 3/26/24 at 5:02PM, informed V1 (Administrator) and V2 Director of Nursing (DON) of the above observation made and requested the policy. R84 was admitted on [DATE] with diagnosis listed in part but not limited to Acute respiratory failure with hypoxia, anxiety disorder. As of 2/26/24, the active physician order sheet does not indicate that R84 has an order for nasal spray. R84 is alert and oriented x 3. She can verbalize her needs. Facility's policy on Policy and Procedures- Pharmacy Services for Nursing Facilities Revised [DATE] indicates: IIA1: Equipment and supplies for administering medications Policy: The facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. Procedures: A. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications. 1. Lockable medication carts, cabinets, drawers and or rooms with well lit medication preparation areas. IIA2: Medication Administration- General Guidelines Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and by persons legally authorized to do so. Procedures: A. Preparation 1. Medications are prepared only by licensed nursing, medical, pharmacy or other personnel authorized by the state laws and regulations to prepare and administer medications. B. Administration 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications 2. Medications are administered in accordance with written order of the prescriber.

Based on observation, interview, and record review the facility failed to follow its infection control protocol for the after care of a nebulizer mask after resident use. This deficiency affects 1 of 3 (R84) residents in the sample of 21 reviewed for infection control. Findings include: On 3/26/24 at 12:21PM, observed R84's nebulizer mask exposed on top of the bedside drawer. No plastic bag available at bedside for the nebulizer mask. R84 said that the nurse administered her breathing treatment to her. On 3/26/24 at 2:28PM, informed V3 (Assistant Director of Nursing/Infection Control) of the above observation. V3 said that the nebulizer mask should be cleaned and placed in plastic bag after each use for infection control. Requested the policy from V3. R84 is admitted on [DATE] with diagnosis listed in part but not limited to Acute Respiratory Failure with Hypoxia, Anxiety Disorder. Active Physician order sheet indicates: Albuterol Sulfate HFA Aerosol Solution 108(90 Base) MCG/ACT Give 2 inhalation orally every 4 hours as needed for SOB or wheezing maximum 12 inhalations/24hrs; Ipratropium-Albuterol inhalation solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 3ml inhale orally every 6 hours as needed for wheezing. Facility policy on Nebulizer-Medication Administration effective 5/19/22 indicates: Guidelines: Nebulizer-Administering medications through a small volume (Handheld) Nebulizer 23. When equipment is completely dry, store in a plastic bag with the resident's name and the date on it.

Based on observation, interview, and record review the facility failed to ensure a resident was safely transferred for 1 of 4 residents (R3) reviewed for safety in the sample of 15. This failure resulted in R3 sustaining a laceration to the right lower leg needing an emergency room visit requiring 33 stitches to the laceration. The findings include: R3's electronic medical record accessed on 10/27/23 show R3 is a [AGE] year-old Russian speaking resident with diagnoses that include weakness, peripheral venous insufficiency, and diabetes. R3's facility assessment dated [DATE] show R3 has severe cognitive impairment. R3 needs maximal assistance for transfers from wheelchair to bed. R3's Facility Reported Incident (FRI) dated 8/25/23 sent to the state agency as final (date of incident 8/20/23) show, (R3) has received a skin tear from the transfer. R3 was immediately assessed. The right lateral leg was cleansed with normal saline, and a pressure dressing applied . On 8/20/2023 the two CNAs (agency CNAs) were assisting R3 back to bed. During the stand and pivot, resident knees buckled and the two staff members were able to assist her to a full standing position and pivot her to sitting on side of bed. The injury occurred by the skin rubbing against the bed frame and the area of injury aligns and can explain how the injury shape presented. The report also shows that R3's physician gave orders to send R3 to the emergency room (ER.) R3's Emergency Department (ED) notes dated 8/20/23 show, Large jagged laceration to right lower extremity. Patient- A 94 y/o came in from nursing home for laceration to right lower leg. Per EMS facility reports that her leg got caught on the sharp edge of the bed when she was being moved around. Laceration is actively bleeding. R3's ED discharge instructions dated 8/21/23 show: large, jagged laceration to right lower extremity. Wound closed with a total of 33 non- absorbent sutures. Wound wrapped in clean gauze. Instructed to follow up in 7 days for suture removal. On 10/27/23 at 10:15 AM R3 was in the common area. R3 had a dressing to the right lower leg. V6 (Registered Nurse/RN) who can also speak in Russian interpreted for this surveyor. R3 said she was fine and cannot recall what happened to her right lower leg. V6 said R3's wound to her right lower leg was due to an injury from the bed frame while R3 was being transferred by agency CNAs. On 10/27/23 at 10:30 AM, R3 was in her room. V8 (Wound Nurse) was providing wound treatment to R3. R3's right lower leg wound was irregular and jagged shaped. V8 said R3's right leg wound was a V shaped wound measuring 1.5 cm x 3 cm with tunneling 3.0 cm at 10 o'clock. V8 said this wound was from trauma sustained approximately two months ago from R3's bed frame after R3 was being transferred to her bed by the 2 agency CNAs. The wound had not healed yet. V6 (RN) who was also in the room pointed to R3's metal bed frame and said to this surveyor that she had applied paddings to the sharp edges on R3's metal bed frame. R3's metal bed frame was observed. There were missing protective caps of the sharp edges of R3's metal bed frame which was pointed out to V6. V6 said she will be adding more paddings. On 10/27/23 at 12:15 PM, V7 (RN) said she was R3's nurse on 8/20/23 when the incident happened. V7 said she was called in the room and saw R3's leg bleeding. V7 said she was told that both Certified Nursing Assistance (who were agency CNAs) were in the process of transferring R3. During the transfer, R3 was too close to the metal frame of the bed and that R3's right leg was scraped. V7 said she sent R3 to the local hospital and received sutures to her right leg. The wound has not completely healed. V7 said when transferring a resident, make sure there was enough space and away from the bed's metal frame to prevent injury. On 10/27/23 at 1:30 PM, V2 (Director of Nursing/DON) said she was the one who completed the investigation of the incident involving R3 and the 2 agency CNAs (V11 and V12). Both V11 and V12 placed R3 who was sitting in her wheelchair at the side of her bed. V11 and V12 did a pivot transfer and R3's legs buckled. R3's right leg skin rubbed against the bed frame and that had caused the injury. V2 (DON) said the bed frames have been padded. V2 stated the shape of R3's wound perfectly aligned with the shape of the metal frame that would cause the injury. R3 received 33 stitches in the emergency room . V2 said R3 has edema and fragile skin and was prone to wounds. V2 said in-services have been provided to V11, V12 and to other staff regarding safe transfers to prevent injuries. On 10/27/23 at 10:40 AM, V9 (Nurse Practitioner) said R3 sustained her right lower wound during transfers. It was an unfortunate incident that could have been avoided. V9 said staff should ensure residents were transferred safely to prevent injuries.

Based on interview and record review the facility failed to ensure a resident was free from physical abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 15. The findings include: R2's physician order sheet dated 10/23 show R2 has diagnoses that include hemiplegia, hemiparesis following cerebral infarction, and vascular dementia. R1's physician order sheet dated 10/23 show R1 has diagnoses that include idiopathic neuropathy and dementia with behavioral disturbances. The Facility Reported Incident-Final dated 8/11/23 (date of incident 8/8/23) sent to the state agency under conclusion show: R2 and R1 reside on the (XX) floor (at the time of the incident). R2 was sitting in the dining room next to the nurse's station when R1 walked by R2 and struck R2 on the right side of R2's face. Staff immediately responded and separated both residents. Physician ordered for R1 to be sent to the hospital for evaluation. R1 returned to the facility and had been placed on 1:1 monitoring. A head-to-toe assessment was completed on R2. Some redness was noted on the right side of R2's face, cold compress was applied. On 10/27/23 at 9:20 AM, R2 was in bed in his room. R2 was alert and pleasant. When asked about the incident of him being hit by another resident, R2 could not recall the incident. V3 (Assistant Director of Nursing/ADON) who was with this surveyor said R2 was moved from XX floor to ZZ floor per R2's family's request after R2 was struck in the face by R1. V3 said R2 was pleasant and quiet and keeps to himself. R1 was a wanderer and is now on 1:1 monitoring since the incident. V3 said when a resident hit another resident, it is abuse. On 10/27/23 at 9:30 AM, R1 was pacing back and forth on XX floor. R1 was being followed by a staff V13 (Certified Nursing Assistant/CNA). V13 said he was assigned to provide 1:1 monitoring to R1 today to prevent R1 from hitting other residents. On 10/27/23 at 11:27 AM, V1 (Administrator) said on 8/8/23, R2 was sitting quietly in the dining room when R1 walked by him and struck R2's right side of his face without provocation. R2 had redness to his face and R1 was sent for psychiatric evaluation. R1 came back to the facility. R1 had been on 1:1 monitoring to prevent R1 from hitting other residents. V1 said when a resident hit another resident-this can be classified as abuse. The facility policy on Abuse dated 9/8/22 show Abuse is the willful infliction of injury unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes deprivation by an individual, including a caretaker, of good and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including facilitated or enabled through the use of technology (mental abuse including but not limited, abuse that facilitated or caused by nursing home staff taking or using photographs recording in any manner that would demean or humiliate a resident.) Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that individual must have intended to inflict injury or harm.

Based on observation, interview and record review, the facility failed to protect a cognitively impaired resident from severe injury(s) by failing to effectively monitor the resident; and failed to implement interventions from resident's behavioral plan of care which resulted in R50 being emergently transferred to local hospital for treatment of multiple fractures to the wrist and forearm. This failure affected 1 (R50) of 34 residents in the sample reviewed for accident/hazards. Findings include: On 01/24/23 at 10:23 AM, reviewed list of department reportables for last 6 months that showed R50 obtained a fracture of unknown origin in November 2022. At 12:10 PM, R50 was observed asleep in her wheelchair in room on the first-floor unit. There were no assistive devices or protective coverings observed on or near R50 that could have prevented her from receiving any further injury(s). Reviewed R50's electronic medical records with the following noted: R50 is a cognitively impaired resident with past medical history including but not limited to: Insomnia, Dysphagia, Aphasia, Cognitive Communication Deficit, Unsteadiness on Feet, Lack of Coordination, Weakness, History of Falling, and Displaced Spiral Fracture of Shaft of Right Ulna. MDS (minimum data set) dated 01/13/2023 showed R50 with a BIMS (Brief Interview of Mental status) score of 99 denoting severe cognitive impairment and an inability to complete the interview due to this severe cognitive decline. This same MDS showed a behavior being exhibited 4 to 6 times during the period of assessment and required extensive assistance in all activities of daily living including (but not limited to) transfers and toileting. Care plan with last completion date of 01/17/2023 reads in part, The resident is/has potential to be physically aggressive. Dementia, Poor impulse control during providing care, procedures or assistance. Resident is combative, pounding on the table with her right hand due to confusion. Goal: The resident will not harm self or others through the review date. Interventions showed: Monitor behavior episodes and attempt to determine under-lying cause. Monitor/document/report PRN and signs and symptoms of resident posing danger to self and others. When the resident becomes agitated, intervene before agitation escalates. The resident has severely impaired cognitive function or impaired thought processes related to Difficulty making decisions, Impaired decision making. Resident is unable to complete her BIMS interview. The resident has a communication problem r/t Expressive Aphasia, Language barrier, Slurring. Date initiated for all was 04/12/2022. Current physician orders with start date of 4/18/22 showed to, monitor behaviors with codes used: Behavior Code 0=No Behavior 1=Fear/Panic 2=Anger 3=Scream/Yell 4=Danger/Self/Others 5=Delusions 6=Hallucinations 7=Sad/Tearful 8=Emot. withdrawal/Withdrawal act. 9=Other(describe) Interventions- 1=Music, aromatherapy 2=Reminiscence, reality orientation 3=Exercise, activity 4=1:1 5=Reduce Stim 6=PRN given Outcome- I=Improved S=Same W=Worse Side Effects 0=None 1=EPS 2=Tardive Dys. 3=Hypotension 4=Inc. behavior 5=Sedation/drowsiness 6=Inc. falls/dizziness. R50's eMar (electronic medication administration record) reviewed from November 2022 to present that showed inconsistent behavioral monitoring was completed as ordered by physician, and no documented behavioral notes found from 11/10/2022 through 11/28/2022 (date of incident). R50's Health Status Note dated 11/28/2022 09:00 showed, Resident noted with blue/green in color discoloration to right forearm. When site is touched pt c/o pain and is noted grimacing. Pt is A&0 x 1 and is unable to verbalize what happened. Pt is very combative and is noted to swing arms at staff during care. Tylenol administered. Pt does have dialysis today. Contacted MD by phone and updated. Received orders for stat x ray of right forearm, ulna, radius, hand 2 view. All orders carried out. R50's Radiology Note dated 11/28/2022 13:45 showed, Relayed x-ray result to NP of MD by phone. Received orders to send pt. to Glenbrook hospital for treatment and evaluation (Dx fx to distal ulna and ulnar styloid) All orders carried out. DON made aware. R50's eMar (electronic medication administration record) Hour of Administration Note dated 11/28/2022 21:29 showed, The resident was not received at the taken over of the shift. It was reported that the resident fell and had fracture at the distal ulna. Presently in the hospital. Records from the hospital dated 11/28/2022 showed, 2 views of right radius and ulna show a spiral fracture of the mid to distal diaphysis of the right ulna. Nurse Practitioner Note dated 11/29/2022 10:30 showed, f/u closed displaced spiral fracture of shaft of the right ulna. FALLS: Maintain fall and safety precautions. BEHAVIORAL CHANGES: Nursing staff reports increased agitation and combativeness toward staff during nursing care. In-house psych consulted and patient's Seroquel dose was adjusted to 50mg TID. Records from the orthopedic visit dated 12/19/2022 showed, R ulnar shaft fx (fracture). Short arm cast, NWB (non-weight bearing), finger/elbow ROM (range of motion), f/u (follow up) 4 weeks. On 01/25/2023 at 2:06 PM, interview V9 (Advanced Practice Registered Nurse) who said this last week, R50's behaviors are better which could be contributed to the increase in seroquel. She then said her behavior has been regulated by psych because they were having issues with her agitation and she gets in moods where she doesn't like to be bothered. When asked what staff should be doing to manage her behaviors, V9 said R50 should be monitored, staff should keep day/night orientation, keep her busy and at ease, and calm her with redirection and/or activities. When asked if any different interventions could be implemented by staff to prevent this behavior, V9 said staff could pad her chair for example to prevent injury, and she is not sure why this was not implemented prior. V9 added that facility staff reported R50 was sent out due to pain to her arm from banging on the table then said that she has never witnessed any resident pounding on a table which would cause a fracture. On 01/25/2023 at 3:00 PM, V10 (Medical Doctor) said he knew R50 previously, she's had a cognitive decline over the last few years, some of which is irreversible. He added that R50 is at risk for having traumatic fractures. V10 then said R50's behavior issues are mainly managed by psych as well as facility staff and he was not aware R50 had a behavior of banging her hand/arm on the table. V10 added that R50's fracture could have been the result of direct impact or a fall. On 01/25/2023 at 3:30 PM, V16 (Registered Nurse) said R50 is alert 1-2, transfers with 1 assist and has the tendency to be combative. V16 said her personal actions such as, body language and tone, along with explaining what she is doing to R50 helps calm her and lessen combative or resistive behaviors. On 01/25/2023 at 3:00 PM, V17 (Restorative Aide) said R50 is combative at times but he talks nice to her, holds her hand to calm her both of which lessen her combative and/or resistive behaviors. A scientific research paper pertaining to spiral fractures from Encyclopedia of Forensic Sciences (Second Edition), 2013 via ScienceDirect reads, Spiral fractures occur due to torsion or twisting force that produces a fracture that circles or spirals around the shaft.

Based on observation, interview, and record review, the facility failed to properly label and store multiple refrigerated food items; failed to identify and discard expired dairy products within acceptable timeframe; and failed to follow their facility standards and guidelines for food labeling and storage. Findings include: On [DATE] at 10:48 AM, during initial tour of kitchen with V7 (Dietary Manager), surveyor entered walk in fridge #1 and observed a crate filled with vitamin A&D milk cartons dated [DATE], one carton was undated. Also observed in this same fridge, a ,d+[DATE] stack of yellow cheese wrapped in clear cling wrap that was not labeled or dated. On [DATE] at 10:50 AM, entered walk in freezer #1 and observed a large box of opened and exposed waffle fries that were not properly stored and unlabeled. At 10:53 AM, V7 opened reach in refrigerator #1 and surveyor observed an opened and unlabeled jar of grape jelly, a package of turkey, a package of ham, and a package of yellow cheese all individually wrapped in clear cling wrap, and all were unlabeled. On [DATE] at 10:56 AM, V7(Dietary Manager) said any food item that is expired or unlabeled should be thrown away immediately, then said she's been having issues with some milk cartons being undated. Reviewed facility standards and guidelines for food labeling and storage last revised [DATE] that showed, foods are labeled and dated for identification purposes and to ensure they are discarded within acceptable time frames according to HACCP guidelines; opened and perishable items are discarded after 72 hours or dated with the use by date; items not considered perishable are dated when the original container is opened.

Based on observation, interview and record review, the facility failed to develop and implement care plans for 4 (R1, R3, R4, R5) of 4 residents considered at-risk for elopement in the sample of 5 reviewed for care plans for elopement risk residents. Findings include: 1. R1 is a [AGE] year old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's elopement risk assessment dated [DATE] shows R1 with an elopement score (wandering) of 12 which equals high risk for elopement. On 8/26/22 at 10:45 AM, V2 (Director of Nursing) stated, An assessment score of 5 or above is considered at-risk for elopement and should not be allowed outside the facility without direct supervision. On 7/31/22 an initial incident report filed by the facility reads in part: Elopement. (R1) [AGE] year old female resident, long-term resident, admitted on [DATE]. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident (R1) was assisted by staff to sit in front of the building on bench with other residents to get some fresh air. R1 is ambulatory with walker and primary language is Russian. R1 was visiting with other residents and at approximately 11:45 AM. At 12:05 PM, receptionist received a call from police department who indicated an elderly female resident in an orange shirt was in their possession. At this time the nurse assigned was in search for resident as she (R1) was due for a blood sugar check. The nurse had gone outside and noted resident with police officers across street. At 12:15 PM police escorted resident back to the building, where a staff member who is Russian speaking translated for resident (R1) who stated she was trying to go home. Incident report initiated, elopement risk re-evaluated, 1 to 1 staff monitoring initiated. Immediate corrective/protective actions taken: 1. Staff and resident interviews initiated. 2. 100% elopement risk assessments of all residents initiated. 3. Review and revision of elopement binders, assessment, and care plan . 4. In abundance of caution-initiated staff education with an emphasis on elopement guidelines, supervision of residents while visiting outdoors. On 8/26/22 at 10:35 AM surveyor asked V2 (director of nursing) about the elopement incident. V2 stated It was a Sunday 7/31/22 and I was not in the building. I received a call that police called the facility bringing back the resident (R1) who is alert orient x 1 or 2. She does things pretty much herself always stays in her room or in the dining room and mingles with other residents. She's been here for years and has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1) was not with a family member though, she was by herself. I was told by (V3) that she walked down to the reception area and looked outside and saw residents outside so wanted to go outside and so the receptionist guided her to sit outside the chair outside the double doors in front of the building. After a few minutes later, the agency nurse (V4) was looking for her because she needed to get her blood sugar check. This was around 11:45 AM. The nurse was agency (V4- Licensed Practical Nurse/LPN) it was the first time he worked with us. The CNA (Certified Nurse Assistant) was (V5). She was on the floor taking care of residents. The police came in and dropped her off. The last time the nurse (V4) saw the resident she was sitting in her room at 11:30 am and he went to look for resident. Surveyor asked whether R1 was at risk for elopement. V2 stated, Yes. We did an assessment of R1 in July, and she scored a 12 which is considered high-risk. Any score above a 5 is considered high risk. Surveyor asked whose responsibility it was to monitor R1. V2 stated, It's the nurse (V4). Surveyor asked whether R1 should have been allowed outside without proper supervision. V2 stated, Well she was with other residents and their family members. Surveyor asked if it was the responsibility of other residents and their respective family members to watch R1 who was unrelated to them. V2 stated, Yes you're right, it's our responsibility. Review of R1's records show no elopement-specific plan of care developed or implemented for R1. 2. R3 is [AGE] year-old resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's elopement risk assessment dated [DATE] shows R3 at 13 indicated high risk. R3's care plan dated 8/26/22 reads in part, The resident is an elopement risk/wanderer with impaired safety awareness, wanders aimlessly. Goal: the resident's safety will be maintained through the review date. Resident will not leave facility unattended. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Monitor for tailgating when visitors are in the building. Provide direct staff supervision for resident when attending an out-of-facility activity. Wander band: check elopement risk wrist band every shift. 3. R4 is a [AGE] year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R4's elopement risk assessment dated [DATE] shows R4 with a score of 10 = high risk for elopement. R4's care plan dated 12/20/22 reads in part, The resident is a wanderer. Disoriented to place. Per nursing, resident was noted with wandering the hallways and looking into co-resident's rooms. He was able to be redirected and was not seeking exits. Goal: The resident's safety will be maintained through the review date. Interventions: Check elopement risk band every shift. Check for proper functioning of the audible alarm system regularly and as needed. 4. R5 is a [AGE] year-old with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's elopement risk assessment dated [DATE] shows R5 with an elopement score of 8 = high risk for elopement. R5's care plan dated 7/25/22 revised 8/1/22 reads in part, The resident is an elopement risk/wanderer. History of attempts to leave facility unattended. Impaired safety awareness. Goal: Resident will not leave facility unattended through the review date. Interventions: Check elopement risk band. Check for proper functioning of the audible alarm system regularly and as needed. Monitor for tailgating when visitors are in the building. Provide direct staff supervision for resident when attending an out of the-facility activity. Interview with V6 (LPN) on 8/26/22 at 11:56 AM stated, We have mostly dementia patients with total care on this floor. They are with confusion and some behaviors. I'd say most this floor is dementia residents (R1) is alert and oriented x 1 and she is gets around using a walker with slow gait. She is not allowed to go downstairs any more without being with her visitors. She was never really allowed to go downstairs even before this incident when she escaped. Surveyor asked if she (R1) was the only resident at risk for elopement on the floor. V6 stated, Yes just her. Surveyor asked if (R1) was always at risk for elopement. V6 stated, Now she is but she never was before. Interview with V7 (agency CNA/Certified Nursing Assistant) on 8/26/22 at 12:07 PM stated, have to watch (R1) every 15 minutes or more because she likes to wander. I work with her when I'm here and this is the second time, I am here working on this floor with her. I was told today she wanders and to watch her closely. My nurse talked about all the patients to watch, and I have about 15 residents to take care of and so I watch (R1) every 15 minutes. Surveyor asked how she was able to watch someone every 15 minutes if you have 15 other residents, V7 stated, I tell her to stay in her room and to sit down and she stays there. Surveyor asked if she speaks Russian language. V7 stated, No but she sits down when I tell her. Surveyor asked if she got any training on what to do when someone like (R1) wanders off. V7 stated, No, I was just told to watch her every 15 minutes. Surveyor asked how that was possible because the nurse had to find her so she could talk with surveyor. V7 stated, Well I was in the dining room helping pass trays so I can't watch her all the time. Surveyor asked how many other residents she was told is able to escape out of the floor and building. V7 stated, I was told just her, I think. No one told me anyone else. Interview with V8 (Registered Nurse/RN) at 12:20 PM stated, I've been working here for over [AGE] years. I work both floors. R1 is Russian speaking, and I can speak Russian. R1 is confused but she usually does not wander. She wandered out probably because she followed somebody outside is probably what happened the last incident. Surveyor asked if R1 was considered an elopement risk. V8 stated, She is considered one now because she escaped but I do not see her as an elopement risk because this is not like her to try to open doors and she never verbalizes that she wants to go home. Surveyor clarified whether she was considered an elopement risk prior to the incident. V8 stated again, No she was not but she is now, but I don't think she is an elopement risk after that too, but we are told she is, and we have to monitor her. Surveyor asked if there were any other residents on the floor at risk for elopement out of the facility. V8 stated, No. She is the only one. Surveyor asked what training she received pertaining to elopement risk. V8 stated, I was in-serviced sometime this week and they give us a book to tell us what to do. Surveyor asked what they were trained to do. V8 stated, I don't have R1 today but the nurse who has her needs to monitor her frequently. Surveyor asked during her recent training whether she was to monitor anyone else. V8 stated, No just (R1).

Based on observation, interview and record review, the facility failed to monitor a confused resident from wandering out of the facility on to a nearby busy road and later to be discovered by local police with no identification. The facility failed to follow its policy and procedures in monitoring of residents at risk for elopement and failed to train staff in identifying residents considered at risk for elopement. This failure applies to 4 (R1, R3, R4, R5) of 4 residents reviewed for supervision and monitoring of elopement risk in the sample. Findings include: 1. On 7/31/22 an initial incident report filed by the facility reads in part: Elopement. (R1) [AGE] year-old female resident, long-term resident, admitted on [DATE]. Diagnosis include [CONDITION(S)], Dementia, chronic kidney disease. Resident (R1) was assisted by staff to sit in front of the building on bench with other residents to get some fresh air. R1 is ambulatory with walker and primary language is Russian. R1 was visiting with other residents and at approximately 11:45 AM. At 12:05 PM, receptionist received a call from police department who indicated an elderly female resident in an orange shirt was in their possession. At this time the nurse assigned was in search for resident as she (R1) was due for a blood sugar check. The nurse had gone outside and noted resident with police officers across street. At 12:15 PM police escorted resident back to the building, where a staff member who is Russian speaking translated for resident (R1) who stated she was trying to go home. Incident report initiated, elopement risk re-evaluated, 1 to 1 staff monitoring initiated. Immediate corrective/protective actions taken: 1. Staff and resident interviews initiated. 2. 100% elopement risk assessments of all residents initiated. 3. Review and revision of elopement binders, assessment, and care plan . 4. In abundance of caution-initiated staff education with an emphasis on elopement guidelines, supervision of residents while visiting outdoors. On 8/26/22 at 10:35 AM surveyor asked V2 (director of nursing) about the elopement incident. V2 stated It was a Sunday 7/31/22 and I was not in the building. I received a call that police called the facility bringing back the resident (R1) who is alert orient x 1 or 2. She does things pretty much herself always stays in her room or in the dining room and mingles with other residents. She's been here for years and has diagnosis of dementia. The receptionist (V3) comes here only on Sundays, and she lets a few residents to go sit outside to get fresh air when they are with their family members. (R1) was not with a family member though, she was by herself. I was told by (V3) that she walked down to the reception area and looked outside and saw residents outside so wanted to go outside and so the receptionist guided her to sit outside the chair outside the double doors in front of the building. After a few minutes later, the agency nurse (V4) was looking for her because she needed to get her blood sugar check. This was around 11:45 AM. The nurse was agency (V4- Licensed Practical Nurse/LPN) it was the first time he worked with us. The CNA (Certified Nurse Assistant) was (V5). She was on the floor taking care of residents. The police came in and dropped her off. The last time the nurse (V4) saw the resident she was sitting in her room at 11:30 am and he went to look for resident. Surveyor asked whether R1 was at risk for elopement. V2 stated, Yes. We did an assessment of R1 in July, and she scored a 12 which is considered high-risk. Any score above a 5 is considered high risk. Surveyor asked whose responsibility it was to monitor R1. V2 stated, It's the nurse (V4). Surveyor asked whether R1 should have been allowed outside without proper supervision. V2 stated, Well she was with other residents and their family members. Surveyor asked if it was the responsibility of other residents and their respective family members to watch R1 who was unrelated to them. V2 stated, Yes you're right, it's our responsibility. Interview with V3 (Receptionist) on 8/26/22 at 11:15 AM stated, It was a Sunday at around 11:45 in the morning and I sat the resident outside along with her two co-residents who were all from the second floor. I knew this resident I've seen her, and I know her when I was with activities department. I know their faces. I know she is from the second floor, and she is capable of walking around and she can intermingle with other Russian-speaking residents. (R1) cannot speak English. Surveyor asked if he could speak Russian. V3 stated, No. There were other people in line at the reception area about 4 or 5 people and were here to visit. I held the door for the resident. I helped 3 out 5 guests checking so it was busy. I motioned to her, and she understood. I opened the door for her I need for you to sit for you and don't go anywhere. I just motioned to her to sit on the bench. She was on the bench for a while 15 20 minutes. When this was all occurring, I received a call from the police who asked me if we have a missing resident who was wearing an orange top. I said oh gosh! When I looked outside (R1) was no longer sitting outside so everybody started looking outside. Surveyor asked who was conducting the search. V3 stated, Me, the nurse from agency, and another nurse tried to help. That was all. Surveyor clarified how he conducted this search. V3 stated, Well, I didn't really look but the agency nurse did. Surveyor asked where R1 was discovered by the police.V3 stated, She was sitting outside by the side of the road by a restaurant. They brought her to our facility and then the police said she cannot release her to you until we got a face sheet that identified her. The police brought her back inside around 12:15 PM. I called V2 right away when it happened, and I called V1 (Administrator) first. Surveyor asked the procedure for missing residents that wander off out of the building. V3 stated, When resident is missing, I notify all both floors that an elopement is going on. I have to do the paging first. I was in-serviced when I was trained upon hiring the first day, I was hired in 2017. I was in-serviced again the following week or week after this incident but I do not recall any other time. We have a list up front to say the person is an elopement risk. R1 was not on this list but she is on this list now. There are 4 residents on this so now there are 5 residents. Records provided to the surveyor by V2 on 8/26/22 show total of 7 residents shown to be an elopement risk. Telephone interview with V4 (agency Licensed Practical Nurse/LPN) on 8/27/22 at 10:15 AM stated, Yes I remember that weekend. It was a Sunday and I never worked at that place before, so everyone was new to me including (R1). I was going to do blood sugar check and I asked the (V5 Certified Nurse Assistant/CNA) if she saw R1 because I didn't really know what she looked like. I couldn't find V5 either and found in one of the resident rooms and she told me she didn't know either where R1 was and told me to look in the dining room. I told her if she could help me because I had no clue how this woman looked. The next thing I know is that the front desk calls up to the floor and said that one of my residents was found by the police by the side of the road I think she said. Surveyor asked what time he last saw R1. V4 stated, Well I did my AM med pass so probably early in the morning around 8:30 or 9:00 when she was in her room. Surveyor asked whether R1 was allowed to go outside the building without supervision. V4 stated, I don't know. Like I said, it was my first time in the facility and I didn't know this resident. Surveyor asked whether there was any orientation of any sort for R1, the type of floor she resided on, or any of the type of residents he was about to take care of. V4 stated, Well I knew that most of the residents were confused but I wasn't told anything specific about R1. On 8/26/22 at 11:52 AM, V2 (Director of Nursing) escorted surveyor to R1's room where resident was observed still sleeping in bed. V2 stated to R1, Hello (R1), how are you? Are you okay? R1 woke up but appeared confused and disoriented and started speaking Russian to V2. Surveyor asked if she understood what R1 was saying. V2 stated, No. Surveyor asked how R1 was to be identified as she did not wear any bracelet or any other identifier on her person. V2 stated, We don't use bracelets or anything like that because we consider this a dignity issue. Surveyor asked how R1 would be identified if the resident were to wander off again outside the building or even how agency staff were to know who they were passing medications to. V2 stated, I'm not sure because we have never used any identification on any of our residents for as long as I know, and I think it's a company policy, but I will check in to it. Interview with V6 (LPN) on 8/26/22 at 11:56 AM stated, I take care of both wings on this floor. (R1) is on that side (pointing to the left of the nursing station). We have mostly dementia patients with total care on this floor. They are with confusion and some behaviors. I'd say most this floor is dementia residents (R1) is alert and oriented x 1 and she is gets around using a walker with slow gait. She is not allowed to go downstairs any more without being with her visitors. She was never really allowed to go downstairs even before this incident when she escaped. Surveyor asked if she was the only resident at risk for elopement on the floor. V6 stated, Yes just her. Surveyor asked how R1 is currently being monitored. V6 stated, We do a tracking form to make sure she is being monitored every 15 minutes. Surveyor asked to see form. Form with last known tracking was documented at 6:00 AM (it is almost noon). V6 asked surveyor if she can fill in the forms before presenting it to surveyor but was denied request. Surveyor asked whether she should be documenting on the monitoring form as she observes the resident. V6 stated, Yes, sorry. Surveyor asked if (R1) was always at risk for elopement. V6 stated, Now she is but she never was before. Interview with V7 (agency CNA/Certified Nursing Assistant) on 8/26/22 at 12:07 PM stated, have to watch (R1) every 15 minutes or more because she likes to wander. I work with her when I'm here and this is the second time, I am here working on this floor with her. I was told today she wanders and to watch her closely. My nurse talked about all the patients to watch, and I have about 15 residents to take care of and so I watch (R1) every 15 minutes. Surveyor asked how she was able to watch someone every 15 minutes if you have 15 other residents, V7 stated, I tell her to stay in her room and to sit down and she stays there. Surveyor asked if she speaks Russian language. V7 stated, No but she sits down when I tell her. Surveyor asked if she got any training on what to do when someone like (R1) wanders off. V7 stated, No, I was just told to watch her every 15 minutes. Surveyor asked how that was possible because the nurse had to find her so she could talk with surveyor. V7 stated, Well I was in the dining room helping pass trays so I can't watch her all the time. Surveyor asked how many other residents she was told is able to escape out of the floor and building. V7 stated, I was told just her, I think. No one told me anyone else. Interview with V8 (Registered Nurse/RN) at 12:20 PM stated, I've been working here for over [AGE] years. I work both floors. R1 is Russian speaking, and I can speak Russian. R1 is confused but she usually does not wander. She wandered out probably because she followed somebody outside is probably what happened the last incident. Surveyor asked if R1 was considered an elopement risk. V8 stated, She is considered one now because she escaped but I do not see her as an elopement risk because this is not like her to try to open doors and she never verbalizes that she wants to go home. Surveyor clarified whether she was considered an elopement risk prior to the incident. V8 stated again, No she was not but she is now, but I don't think she is an elopement risk after that too, but we are told she is, and we have to monitor her. Surveyor asked if there were any other residents on the floor at risk for elopement out of the facility. V8 stated, No. She is the only one. Surveyor asked what training she received pertaining to elopement risk. V8 stated, I was in-serviced sometime this week and they give us a book to tell us what to do. Surveyor asked what they were trained to do. V8 stated, I don't have R1 today but the nurse who has her needs to monitor her frequently. Surveyor asked during her recent training whether she was to monitor anyone else. V8 stated, No just (R1). On 8/26/22 at 10:45 AM, V2 (Director of Nursing) stated, An assessment score of 5 or above is considered at-risk for elopement and should not be allowed outside the facility without direct supervision. We have about 7 or 9 residents, (I'm not sure the number), that we assessed that are an elopement risk, most are on the same floor as (R1) so she isn't the only resident we have that we monitor and the staff is all trained to know this because it is all in the green binder we have on each floor. 2. R3 is [AGE] year-old resident with diagnoses of anxiety disorder, depression, [CONDITION(S)] with alcohol-induced mood disorder. R3's elopement risk assessment dated [DATE] shows R3 at 13 indicated high risk. R3's care plan dated 8/26/22 reads in part, The resident is an elopement risk/wanderer with impaired safety awareness, wanders aimlessly. Goal: the resident's safety will be maintained through the review date. Resident will not leave facility unattended. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation. Monitor for tailgating when visitors are in the building. Provide direct staff supervision for resident when attending an out-of-facility activity. Wander band: check elopement risk wrist band every shift. 3. R4 is a [AGE] year-old with diagnosis listed in part with dementia with behavioral disturbance, [CONDITION(S)], and chronic obstructive pulmonary disease. R4's elopement risk assessment dated [DATE] shows R4 with a score of 10 = high risk for elopement. R4's care plan dated 12/20/22 reads in part, The resident is a wanderer. Disoriented to place. Per nursing, resident was noted with wandering the hallways and looking into co-resident's rooms. He was able to be redirected and was not seeking exits. Goal: The resident's safety will be maintained through the review date. Interventions: Check elopement risk band every shift. Check for proper functioning of the audible alarm system regularly and as needed. 4. R5 is a [AGE] year-old with diagnosis listed in part with [CONDITION(S)] disease, major depressive disorder with severe psychotic symptoms, unsteadiness on the feet. R5's elopement risk assessment dated [DATE] shows R5 with an elopement score of 8 = high risk for elopement. R5's care plan dated 7/25/22 revised 8/1/22 reads in part, The resident is an elopement risk/wanderer. History of attempts to leave facility unattended. Impaired safety awareness. Goal: Resident will not leave facility unattended through the review date. Interventions: Check elopement risk band. Check for proper functioning of the audible alarm system regularly and as needed. Monitor for tailgating when visitors are in the building. Provide direct staff supervision for resident when attending an out of the-facility activity.

Based on interview and record review, the facility failed to follow a resident's plan of care by not having two staff assist while providing care for a resident at risk for falls and documented to require two staff assistances with bed mobility and ADL's (activities of daily living). This failure applied to one (R1) of one resident reviewed for accidents and supervision and resulted in R1 rolling out of bed during care and then having to be emergently transferred to the local hospital's medical intensive care unit for treatment of laceration to the back of her head, which required sutures. Findings include: Facility incident report dated 6/22/22 at 2:30 PM written by V2 (Director of nursing) reads in part, Resident (R1) is an [AGE] year-old long term care resident in the facility with diagnosis of morbid (severe) obesity due to excess calories, chronic diastolic heart failure, [CONDITION(S)], anxiety disorder, lack of coordination, bilateral contracture, history of falling. In conclusion, a complete and thorough investigation was conducted to include review of medical records. Resident is alert and oriented x 3, BIMS (brief interview of mental status) score 15 and she can verbalize her needs. Based on the results of the investigation and staff interviews the facility has determined that on 6/22/22, resident rolled out of bed during incontinence care, hitting her head on the floor sustaining scalp laceration with moderate amount of bleeding. CNA/certified nursing aide stated that he pivoted to reach for the incontinence pad on the bedside table next to resident's bed and was noted resident sliding off the bed. CNA attempted to hold onto resident's body but unable to break the fall due to resident's kept off the bed and landed on the floor. CNA and nurse on duty stated that prior to the incident resident was repositioned in the center of the bed. The results of the investigation have been discussed with resident and physician. All agreed with the plan of care. EMS (Emergency Medical Services) form dated 6/22/2022 at 14:32:30 (3:32 PM) reads in part, Dispatched for [AGE] year-old female patient who fell from her bed. Upon arrival, EMS crew met patient in her room, patient was lying supine (on her back) on the ground and had blood pooling around the back of her head and one of the staff members was holding towels and supporting the patient's head. Patient was alert and oriented 3/3. Staff members stated they were giving the patient a bath in her bed and when the patient went to roll over, she went too far and fell out of her bed. Staff stated patient fell to the floor onto her back and hit her head on the floor. Staff did inform EMS crew that patient was on blood thinners. EMS crew assisted patient to cot and performed assessment and noted patient had an injury on the right back corner of her head. The injury appeared to be approximate size of a quarter in circumference and approximate half inch laceration. Patient denied any neck pain and was complaining of having a headache. EMS crew bandaged wound and moved patient to MICU (Medical Intensive Care Unit). Interview with V2 (Director of Nursing) on 7/29/22 at 10:25 AM stated, I did the fall investigation and R1's nurse was V3 (RN) and V4 was an agency CNA/Certified nursing aide. V3 told me that she was doing her rounds when V4 (agency CNA) was about to do incontinence care for R1, and she helped him put R1 to the center of the bed and then she left the room after doing so. V4 mentioned upon interview that he turned the patient to her left side, and he pivoted around to get the resident's incontinence brief when the patient rolled out of bed and on to the floor. The resident is morbidly obese so if you see her, she is hard to catch if she is about to fall. Surveyor asked whether during her investigation if she detailed whether R1 held on to anything while she was being turned, V2 stated, Normally she could hold on to a side rail, but she does not have any to hold on to. Surveyor asked whether R1 was a fall risk, V2 stated, She is not a fall risk. She is wheelchair and mostly bed-bound and she has not fallen before. On 7/29/22 at 10:40 AM, R1 was observed lying atop a bariatric (wide bed) bed which was raised high above surveyor's waist level. There were no floor mats on either side of bed or any side rails that were up to prevent R1 from falling out of her raised bed. On the left side of the bed was a bedside table with metal rollers. Behind this table was a large oxygen tank situated beside and below the left-hand side. These were concerns as potential fall hazards. R1 appeared disheveled and had bruising to both her arms. Surveyor asked R1 how she was feeling and asked if she remembered when she fell , R1 stated, I'm not feeling well today. I fell not too long ago. There was this CNA that turned me when he was cleaning me up and next thing you know I rolled over out of this high bed and fell on the ground. I was bleeding a lot from my head, and they sent me to the hospital. I was in a lot of pain, and they gave me something for it. I got all stitched up, but I still have headaches now and I was sent back to the hospital just last week again. Surveyor asked if she recalled if there were one or two people helping her turn to her side during care, R1 stated, There was only one and I only get one person most of the time. 7/29/22 at 10:55 AM V6 (RN) stated, I'm the nurse for R1 today yes. There's one CNA (V7) for her, she's with the agency but she's currently on break. Surveyor asked about R1 and what she could tell the surveyor about her, V6 stated, Well she's alert and oriented times three and she is able to make her needs known. She was recently hospitalized due to her having some respiratory distress issues due to her chronic heart failure and fluid overload and she just came back recently. (R1) stays mostly in her bed and we try to get her up around 11 or so for lunch and then we put her back to bed right after dinner. Surveyor asked whether R1 was considered a fall risk, V6 stated, She is not a fall risk and she doesn't try to stand up on her own. She does need extensive assistance when in bed and I guess where she'd fallen out, but I think that was the first time. Surveyor asked that now that R1 had fallen (as she mentioned) whether R1 was considered a fall risk, V6 stated, No. I don't think so. Surveyor asked if there were any other instructions provided to her to follow after R1 fell , V6 stated, I wasn't given any instructions. 7/29/22 at 11:32 AM V3 (RN) with V2 (Director of Nursing) present, stated, I was the nurse on duty when R1 fell from the bed. I was doing my rounds and I happened to come in when V4 (CNA/certified nursing aide) was going to provide incontinence care for (R1), so I helped prop her up and put her in the middle of the bed. I then left to finish my rounds and prepare my medications. V4 called me later and said that the patient was on the floor. I asked V4 to go get help because I saw bleeding on her head, and I also saw blood on the floor. Surveyor asked where R1 may have hit her head to determine the area of bleeding, V3 stated, I don't really know. When I came in there was blood on the floor and I think she either hit the front or back of her head when she fell to the floor and hit the bedside table. It has metal castors, and she could have hit it but that I don't know. I just know her head was at the foot of this bedside table when I came in and saw her on the ground. Surveyor asked what kind of assistance R1 needs to safely reposition her in bed and whether she was a fall-risk. V3 stated, She is considered a fall risk because she needs maximum assistance. Surveyor asked what she meant by maximum assistance, V3 stated, She is difficult to turn in bed because she is obese, so she needs 2 people to turn her to her side. Surveyor asked whether she helped her aide (V4) turn R1 to her side to assist in bed mobility as per her care plan, V3 stated, I didn't help turn her. I didn't help at all it was the agency CNA (V4) that turned her to left side to do incontinence care and she rolled out of bed. I left and I finished my rounds and prepared my medications. 7/30/22 at 1:47 PM V4 (agency CNA) stated, Yes, I was the CNA that was caring for R1 when she fell . She was alert and orient x 4. When I turn her, she usually grabs on to something but she wasn't feeling well that day so she must have not grabbed on to anything when I turned her. I turned around to get her (brief) and when I turned back around, she rolled out of bed to the ground. After she fell , I ran and got the nurse and told her R1 fell , and we needed to get her up. The nurse came and she started to look at her and she was bleeding. Surveyor asked if V3 (nurse) or any other staff helped him turn R1 as per her plan of care, V4 stated, Nobody helped me turn R1. I've taken care of R1 several times and she only need one person to turn her. That is how she has been doing it as far as I know. Surveyor asked what position the bed was in when he turned R1 to her side. V4 stated, We have to lift the bed up high, so we are close to the patient. Surveyor asked if he saw where R1 may have hit her head on, V4 stated, I don't know. She had her oxygen tank, and a bedside table was on the side of the bed she fell on , but she could have hit her head on the ground. I don't know. I only saw her rolling and it was too late to grab her. Surveyor asked if he was informed that R1 was at risk for falls, V4 stated, It was never endorsed to me she was a fall risk Surveyor asked to clarify whether anytime during his assignments with R1 if he was informed that R1 was a fall risk and/or needed 2 people to turn her in bed, V4 stated, No. Never. Interview with V5 (MDS/Care plan nurse) on 7/29/22 at 1:20 PM with V2 (director of nursing) present in the interview stated, I do the MDS for R1 and part of the IDT (interdisciplinary team) to assist in making the care plans. Surveyor asked to describe the resident's activities of daily living (ADL's) requirements, V5 stated, R1 has always needed extensive assist because she has right hand contracture, she has morbid obesity and she declined more after she fell . Surveyor asked what she meant by extensive assist, V5 stated, She needs extensive assist to do her ADL's and needs 2-persons to do most of them. Surveyor asked what it meant for extensive assist x 2 for bed mobility as prescribed in the MDS, V5 stated, It means she need at least 2 persons to turn her from side to side in bed. Surveyor asked whether the facility followed this plan of care and whether this requirement was met, V5 stated, No we did not meet this requirement because she needed 2 people and there was only one as I was told. Interview with V8 (agency CNA) on 7/29/22 at 2:30 PM stated, I'm an agency CNA but I've had R1 a couple of times. She's usually not in her room when I'm here but I sometimes put her back to bed. Surveyor asked if anyone helps her put R1 back to bed, V8 giggled slightly and said, No, that would be just me. Surveyor asked if she thought the question was funny, V8 stated, No. I'm just saying that I take care of this entire section here and I don't normally get much help. Surveyor asked whether R1 was considered a fall risk, V8 stated, No. Nobody told me she was. Is she? Surveyor asked if she is provided any in-service training on anyone at risk for falls, V8 stated, I can't say they do. They don't even tell me anything about any of the residents. I get my assignment and that's it. Surveyor asked and clarified whether at any time she started working at the facility whether the facility provided any form of training or orientation to the residents' care requirements, V8 stated. No. Interview with V9 (Advance Practice RN) on 7/31/22 at 12:46 PM stated, I am one of the NP's that see R1 at that facility and yes I am very familiar with her. She is very alert and knows what is going on with her care. According to (R1) she fell out of her bed in the midst of patient care. Surveyor asked if she knew whether R1 was considered a fall risk. V9 stated, No. I wouldn't consider her a fall risk. She's very alert and knows what's going on with her care but I'm not told by the facility she is at risk for falls. Surveyor asked if she knew that upon admission R1 was considered a fall risk based on her assessments and care plan, V9 stated, I wasn't aware of that either, but I guess you can say that could be the case because she does require a lot of assistance in doing things. Surveyor asked whether she'd agreed if the facility care planned for R1 to require 2 people to assist in bed mobility whether the facility should follow that plan of care, V9 hesitated to answer but stated. I can't really say. Progress Note written by V9 (Advance Practice RN) on 6/23/2022 at 12:00 PM includes: Patient seen and examined today, sitting up in bed with no signs of acute distress. When asked about recent incident, patient reports that when she was turning over during incontinence care yesterday, she rolled out of the bed and onto the floor obtaining a laceration to the head and was immediately sent to the hospital. CT head and neck were negative, and sutures were placed to the back of her head. At current, patient reports a dull headache that started since hitting her head yesterday. She endorses pain is alleviated by analgesics. No other active complaints at this time. Patient denies any chest pains, palpitations, shortness of breath, nausea/vomiting, fevers/chills. Appetite and bowel/bladder habits stable. Labs reviewed with cardiology. Nursing staff reports low grade fever yesterday; plan discussed with nursing staff. Fall: CT scan head and neck negative. Laceration with sutures to right side of head. Right upper extremity hematoma. Maintain fall and safety precautions. Continue prn (as needed) analgesics. PT/OT as indicated. Generalized Weakness/Debility: PT/OT/ST evaluation/treatment as indicated. PRN pain medicine as ordered. Fall precautions in place. MDS (minimum data set) assessment dated [DATE] showed R1 requiring extensive assist with a minimum of 2 person assist for bed mobility (turning and repositioning while in bed). A subsequent post-fall MDS dated [DATE] showed R1 to remain to require extensive assist with a minimum 2-person assist in bed mobility. Activities of daily living care plans dated 10/11 21 reads in part, The resident has an ADL (activities of daily living) self-care deficit related to impaired balance, limited mobility, weakness. Diagnosis: obesity, contracture right hand, ADL needs and participation vary. Interventions: ADL's: Bed mobility: total (assist) x 2 (staff). Transfer: total x 2; Walking: n/a; Toilet use: total x 2; Personal hygiene: total x 2; Bathing: total x 2. Date initiated 10/11/22. Revision on 6/29/22. Care plans related to fall risk dated 10/11/21 reads in part, Resident is at risk for falls. The resident has balance or walking impairments. The resident has a history of falls. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. The resident has vision impairments. The resident has urinary incontinence, resident has bilateral artificial knees. Goal: Prevent a serious fall related injury. Interventions: Be sure call light and other personal items are in reach; check the environment for clutter or trip hazards and area is well lit; Keep bed in lowest position acceptable by the resident when the resident is in bed; 6/22/22 resident rolled out from bed and sustained laceration on the back of her head. monitor wound on the back of her head (laceration) every shift for signs and symptoms of infection; Suture removal in 2 weeks; Provide resident with wider bed. Policy dated 3/27/21 titled Standards and Guidelines: Falls states in part, It will be the standard of this facility to complete an initial assessment, on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. As part of the initial assessment, the facility will help identify individuals with history of falls or risk factors for subsequent falling. On admission, the nurse should assess and document/report items such as vital signs, mental status, gait, pain, medications and active diagnoses. The staff will discuss the resident's risk factors for falling and obtain orders from the physician for appropriate fall preventative devices as is needed. The staff will evaluate, and document falls that occur while the resident is active in the facility census. If a resident sustains a fall while a resident, staff should attempt to identify possible causes of the fall. Based on evaluation of an existing fall (s) pertinent interventions will be implemented by staff such as, but not limited to: resident education if appropriate, staff re-education regarding transfer techniques and safety during ADL care, resident footwear, appropriate lighting, maintaining close proximity of frequently used items, medication reviews, toileting programs, use of hip protectors, referral to therapy for strengthening/coordination/balance, addressing medical issues such as [CONDITION(S)] and dizziness, discontinuing, or changing problematic medications, use of fall prevention programs that provide more frequent supervision and restraints, if warranted.

Based on observation, interview, and record review, the facility failed to implement a resident's fall risk care plan by not maintaining the resident's environment free of clutter or trip hazards and by not maintaining the resident's bed in the lowest position while in bed. This failure applied to one (R1) of four residents reviewed for care plans. Findings include: R1 is an [AGE] year-old long term care resident in the facility with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/29/22 at 10:40 AM, R1 was observed lying atop a bariatric (wide bed) bed which was raised high above surveyor's waist level. There were no floor mats on either side of bed or any side rails that were up to prevent R1 from falling out of her raised bed. On the left side of the bed was a bedside table with metal rollers. Behind this table was a large oxygen tank situated beside and below the left-hand side. These were concerns as potential fall hazards. R1 appeared disheveled and had bruising to both her arms. Surveyor asked R1 how she was feeling and asked if she remembered when she fell , R1 stated, I'm not feeling well today. I fell not too long ago. There was this CNA that turned me when he was cleaning me up and next thing you know I rolled over out of this high bed and fell on the ground. I was bleeding a lot from my head, and they sent me to the hospital. I was in a lot of pain, and they gave me something for it. I got all stitched up, but I still have headaches now and I was sent back to the hospital just last week again. Surveyor asked if she recalled if there were one or two people helping her turn to her side during care, R1 stated, There was only one and I only get one person most of the time. Activities of daily living care plans dated 10/11 21 reads in part, The resident has an ADL (activities of daily living) self-care deficit related to impaired balance, limited mobility, weakness. Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions: ADL's: Bed mobility: total (assist) x 2 (staff). Transfer: total x 2; Walking: n/a; Toilet use: total x 2; Personal hygiene: total x 2; Bathing: total x 2. Date initiated 10/11/22. Revision on 6/29/22. Care plans related to fall risk dated 10/11/21 reads in part, Resident is at risk for falls. The resident has balance or walking impairments. The resident has a history of falls. The resident takes medications that may cause dizziness, loss of balance, or impair judgement. The resident has vision impairments. The resident has urinary incontinence, resident has bilateral artificial knees. Goal: Prevent a serious fall related in [NAME]. Interventions: Be sure call light and other personal items are in reach; check the environment for clutter or trip hazards and area is well lit; Keep bed in lowest position acceptable by the resident when the resident is in bed; 6/22/22 resident rolled out from bed and sustained laceration on the back of her head. monitor wound on the back of her head (laceration) every shift for signs and symptoms of infection; Suture removal in 2 weeks; Provide resident with wider bed. 7/29/22 at 10:55 AM V6 (RN) stated, I'm the nurse for R1 today yes. There's one CNA (V7) for her, she's with the agency but she's currently on break. Surveyor asked about R1 and what she could tell the surveyor about her, V6 stated, Well she's alert and oriented times three and she is able to make her needs known. She was recently hospitalized due to her having some respiratory distress issues due to her chronic heart failure and fluid overload and she just came back recently. (R1) stays mostly in her bed and we try to get her up around 11 or so for lunch and then we put her back to bed right after dinner. Surveyor asked whether R1 was considered a fall risk, V6 stated, She is not a fall risk and she doesn't try to stand up on her own. She does need extensive assistance when in bed and I guess where she'd fallen out, but I think that was the first time. Surveyor asked that now that R1 had fallen (as she mentioned) whether R1 was considered a fall risk, V6 stated, No. I don't think so. Surveyor asked if there were any other instructions provided to her to follow after R1 fell , V6 stated, I wasn't given any instructions. Interview with V5 (MDS/Care plan nurse) on 7/29/22 at 1:20 PM with V2 (director of nursing) present in the interview stated, I do the MDS for R1 and part of the IDT (interdisciplinary team) to assist in making the care plans. Surveyor asked to describe the resident's activities of daily living (ADL's) requirements, V5 stated, R1 has always needed extensive assist because she has right hand contracture, she has morbid obesity and she declined more after she fell . Surveyor asked what she meant by extensive assist, V5 stated, She needs extensive assist to do her ADL's and needs 2-persons to do most of them. Surveyor asked what it meant for extensive assist x 2 for bed mobility as prescribed in the MDS, V5 stated, It means she need at least 2 persons to turn her from side to side in bed. Surveyor asked whether the facility followed this plan of care and whether this requirement was met, V5 stated, No we did not meet this requirement because she needed 2 people and there was only one as I was told. Interview with V8 (agency CNA) on 7/29/22 at 2:30 PM stated, I'm an agency CNA but I've had R1 a couple of times. She's usually not in her room when I'm here but I sometimes put her back to bed. Surveyor asked if anyone helps her put R1 back to bed, V8 giggled slightly and said, No, that would be just me. Surveyor asked if she thought the question was funny, V8 stated, No. I'm just saying that I take care of this entire section here and I don't normally get much help. Surveyor asked whether R1 was considered a fall risk, V8 stated, No. Nobody told me she was. Is she? Surveyor asked if she is provided any in-service training on anyone at risk for falls, V8 stated, I can't say they do. They don't even tell me anything about any of the residents. I get my assignment and that's it. Surveyor asked and clarified whether at any time she started working at the facility whether the facility provided any form of training or orientation to the residents' care requirements, V8 stated. No.

Based on observation, interview and record review, the facility failed to provide an adaptive call light for 1 of 24 residents (R85) reviewed for call light in a sample of 20. Finding includes: On 12/14/2021, at 11:30 am R85 said that R85 has been calling for help but no one was responding. When asked the last time anyone rounded on R85, R85 replied no one has been in here since after breakfast. This surveyor observed R85 press the call light for assistance. R85 was pressing the call light as hard as R85 could, but the call light was not coming on. V4 (LPN - Wound Nurse) was called into R85's room and R85 was asked to press the call light. R85 pressed the call light but the call light didn't come on. V4 was asked if R85 should have a call light R85 can operate, and she said yes. At 11:45 am this writer called V2 (Director of Nursing) into R85 room. R85 was asked to press on the call light. R85 pressed on the call light but the call light didn't come on. V2 agreed that R85 should have an adaptive call light that R85 can press with the palm of the hand instead of the fingers. Policy: Facility Policy Standard and Guidelines: SG Call Lights Revised 3/27/2021 Standard: It will be the standard of this facility to respond to the resident's requests and needs via notification call light system. Guidelines: 2. Demonstrate use of the call light and request return demonstration as needed as some residents are as some residents are unable to understand how to properly operate the call light.

Based on observation, interview, and record review the facility failed to lock Schedule 2 medications behind two restricted access locks and failed to refrigerate one medication that required refrigeration in one of two medication rooms reviewed for medication storage. This has the potential to affect three residents (R44, R88, R94). Findings include: On 12/16/21 at 11:40 AM the medication refrigerator in the first-floor medication room contains liquid lorazepam 2mg/ml (milligrams/milliliter) for R88-30 ml, R94-30 ml, and R44-25.5 ml. V5 (LPN/Licensed Practical Nurse) said, there should be one lock on the fridge and a lock on the medication room door. On 12/16/21 at 11:45 AM a medication cart contained lorazepam 30 ml, unopened, for R44. V5 (LPN) said, This should be in the fridge. It will probably have to be thrown out. I will have to talk to the ADON (Assistant Director of Nursing). On 12/16/21 at 11:50 AM V2 (DON/Director of Nursing) said there should be two locks for the (lorazepam) in the refrigerator. One for the medication room door and one for the refrigerator. On 12/16/21 at 3:10 PM V3 (ADON/Assistant Director of Nursing) said, the (lorazepam) was received yesterday. I called the pharmacist and she said it should be stored in the fridge. We put it in the box to be destroyed. On 12/16/21 at 3:15 PM V6 (Pharmacist) said, the (lorazepam) should be stored in the fridge. I would recommend that it be wasted if it has been out that long. Policy: Standards and Guidelines: SG Medication Storage revised 3/27/21 Standard: It will be the standard of this facility to store medications, drugs and biologicals in a safe, secure and orderly manner. 4. The facility shall not use discontinued, outdated or deteriorated medications, drugs or biologicals.

Based on observation, interview, and record review the facility failed to provide a working call light for one of 20 residents (R57) reviewed during the survey for call lights in the sample of 24. Findings include: On 12/14/21 at 12:32 PM R57 said that R57 had pain. R57 rubbed R57's shoulders and upper chest. The call light button was pressed. The wall panel did not light up and the light over the door in the hall did not light up. V7 (Scheduler) came into the room to deliver the lunch tray. V7 was informed by the surveyor the call light was not working and that R57 was in pain. On 12/15/21 at 10:48 AM the call light does not light over the door or at the wall panel when the button was pushed. On 12/15/21 at 10:50 AM V8 (LPN/Licensed Practical Nurse) said, if the call light is not working they should call maintenance so that it can be fixed right away. The Work Order Binder at the desk was checked. There was no work order for the call light repair in R57's room. On 12/15/21 at 1:20 PM V9 (Maintenance) said, I got on it right away yesterday. I pulled the monitor and put another cord on it. It worked yesterday. I went back this morning because it wasn't working. This is an old building. Policy: Standards and Guidelines: Preventative Maintenance and Workorder System revised 4/2021 All work orders will be generated by team members and transmitted to the Maintenance Department. 2. Where authorized, responsibilities will include repairs, alteration, minor construction, and remodeling related to maintenance.

Based on observation, interview, and record review, the facility failed to follow their policy on implementation of infection control protocol by failure to perform hand hygiene and changing gloves when providing incontinence care. This deficiency affected 1 (R61) out of 5 residents review for incontinence care. Findings include: R61 is a [AGE] year old female originally admitted on [DATE] with medical [DIAGNOSES REDACTED]. On 10/13/20 at 11:02 AM, V23 (Licensed Practical Nurse) said, (R61) had a bowel movement, I am going to change (R61) but I am going to ask for assistance. V24 (Licensed Practical Nurse) came to the room to assist. V23 cleaned R61 and removed the undergarment that appeared wet and with fecal matter. V23 proceeded to take the new undergarment, using the same pair of gloves and without performing any hand hygiene or changing the dirty gloves. On 10-13-2020 at 11:20 AM, V23 said, I removed the soiled diaper with urine and feces and I forgot to change my gloves and wash my hands before taking and putting the clean diaper. I know is an infection control problem using the same dirty gloves. On 10/13/20 12:05 PM, V24 said, I observed V23 clean the patient feces and urine and failed to change the gloves and performed hand hygiene before putting the clean diaper. On 10/15/20 at 8:56 AM, V2 (Director of Nursing) said, My expectation of the nursing staff is for them to perform hand hygiene before they start providing incontinence, when going from dirty to clean, to perform hand hygiene and change the gloves, they should not be using the same pair of gloves after cleaning feces to put a new/ clean diaper. Policy: On 10-15-2020 at 8:50 AM, V2 presented policy titled: Hand Hygiene, with revised date 3-2018, which reads: This facility considers hand hygiene the primary means to prevent the spread of infections, use an alcohol-based rub before moving from a contaminated body site to a clean body site during resident care. On 10-16-2020 at 9:30 AM, V2 presented policy titled: Personal protective Equipment use, dated 3-2018, which reads: remove gloves promptly after use, before touching non-contaminated items.

Based on observation, interview, and record review, the facility failed to ensure that a low pressure air loss matress was in working order and failed to turn and reposition a resident per physician order. This failure contributed to one resident (R2) obtaining two facility-acquired pressure ulcers that became infected and necrotic (dead tissue). Findings include: R2 is an [AGE] year old originally admitted to the facility on [DATE] for long term nursing care and with [DIAGNOSES REDACTED]. On 8/3/20 at 11:50 AM, R2 was observed in her bed fully dressed and lying on her back. R2 was lying atop beige crumpled bedsheets with a dark blue mattress that appeared to be deflated as her body sunk down the center of the bed down to the bed coils. An electronic pump mechanism was attached to the footboard and an indicator light to show the device was functioning was off (not lit) and a dial was set at 150 psi. At 1:15 PM, R2 remained in the same position on her backside atop the deflated mattress. On 8/3/20 at 1:20 PM, V14 (CNA.-Certified Nurses Aide) was walking past R2's room. V14 pointed to R2's room and stated, Yes, she's mine (referring to her resident she was assigned to). Asked if there was another aide working with her, V14 stated, Yes, she's over there on that side (pointing to the other wing); This is my side. On 8/3/20 at 2:40 PM, surveyor entered the R2's room where she appeared to be in the same position on her backside and with the air pump indicator light was not lit. On 8/3/20 at 2:45 PM, V9 (Wound care nurse) provided surveyor a list of facility wounds as requested. V9 stated, Did you want to see wound care because I already did them this morning. Surveyor asked who did wound care, V9 stated, I do. I'm here Monday to Friday. Asked about her wound list provided the the surveyor, V9 stated, I have all these that I do (pointing to her list) and these are the only two that are facility-acquired (pointing to R2). Surveyor asked if nurses do wound care, V9 stated, On the weekends they do. On 8/4/20 at 10:50 AM, V3 (Assistant Director of Nurses) was asked who did wound care in the facility. V3 stated, We have a Wound care nurse (V9) who does it Monday to Friday, and our nurses do the treatments on the weekends. Surveyor asked V3 where nurses documented, V3 stated, It's all in the charts, we don't have electronic records yet so its all on paper. On 8/4/20 at 11:00 AM, V9 showed surveyor her wound surveillance report and was asked about where nurses document what they did. V9 stated, Well I chart on the TAR (Treatment Administration Record) and also in the nurses notes. Surveyor asked if there was any other areas or forms used to document interventions such as turning and repositioning, V9 stated, No just nurses notes and it should be signed off on the TAR. Surveyor asked V9 about the treatment order, V9 stated, Well they are supposed to be turning and repositioning her but I guess they don't document it anywhere. Asked how staff know when to turn and reposition R2 if there is no flow-sheet or documentation showing which position R2 should be in after being turned, V9 stated, I don't know but I will let my director of nurses know. Records in the nurses notes written by V9 (wound nurse) show: 4/23/20: Noted with blanchable redness on left hip applied foam dressing after normal saline wash. MD aware. Skin monitored weekly. 4/24/20: 9A seen by wound doctor with N.O. (new order) noted and carried out. 5/5/20: 8A skin assessment done. Left hip with deteriorating wound, noted with 100% necrotic tissue, approximately 3 x 3.5 x 0. Right hip with blanchable redness. Resident high risk for further skin breakdown related to incontinence to both bowel and bladder, contracted to bilateral lower extremities, unable to shift weights. Nursing note records show no documented entries to show turning or repositioning of R2. TAR's presented to the surveyor show the order Turning and Repositioning at frequent intervals to be blank and with only an FYI to the nurses. On 8/4/20 at 12:30 PM, V9 (Wound Nurse) and V18 (CNA) showed R2's wound treatments to the surveyor. V9 approached R2 and explained to the resident the procedure. V9 observed that the bed was deflated and stated, I did check this earlier and it was working but I see it's still not inflating so perhaps it could be the tubing. I already called the company to replace it and they said it will be replaced sometime today. Surveyor asked V9 to explain the air mattress pump functions, V9 stated, The dial has to be inflated to 125 psi setting suited for (R2's) weight and the green light should be lit showing normal pressure. Asked the importance of the correct pump setting, V9 stated, Well it can't be over inflated or else it doesn't work properly but for some reason it's still not working anyway. V9 proceeded with the treatment demonstration and with V18 (CNA) turned R2 to her side. V9 first removed a layer of incontinence pad described to the surveyor as a hip-hugger. V9 removed the hip hugger to reveal another incontinence pad, and then the bandage on her pressure sores. V9 removed the right hip dressing to show a tennis ball-sized wound. Surveyor asked V9 to describe the wound, V9 stated, It was just blanchable redness at first probably around April and the next time I say it it was already necrotic. Right now it appears to have a lot of slough and old necrotic tissue about 5 by 6 centimeters. It was just blanchable redness at first and she scratched it and it just like happened over night and was necrotic the next morning. V18 then turned R2 to her other side to show her left hip pressure ulcer that appeared to be a golf ball-sized hole. V9 stated, The left hip wound is undermining at around 10:00 o'clock and 12:00 o'clock (describing the location of the undermining tissue of the wound). Surveyor asked how deep the wound was, V9 stated, It's about 3 centimeters deep. Surveyor asked V9 to describe the undergarments R2 had on, V9 stated, After we do the treatments, she has a wound dressing (bandage) on her wounds, she has a diaper because she's incontinent, then there's a hip hugger (incontinence briefs with foam padding on each side of the hips). V9 stated, Those are the hip huggers we put on her to keep her from scratching herself. Surveyor asked if the facility tried other means to keep R2 from scratching, V9 stated, No, it's just a behavior she has. Asked if they tried other methods to address R2's itching and V9 stated, No. At the conclusion of the wound treatments, surveyor asked again about R2's wounds. V9 stated, Both the wounds to her left and right hip is facility-acquired meaning she got them when she was here. Yes, they are considered avoidable and she should not have gotten them. Surveyor asked about turning and repositioning and to show how nurses document that it's being done, V9 stated, Well the nurses are supposed to turn (R2) at least every two hours but we don't put it anywhere. Physician order [REDACTED]. The same physician order [REDACTED]. TAR's(Treatment Administration Record) were transcribed from the doctor's order as Turn and Reposition at frequent intervals and with a hand-written FYI next to the order but had no initials or signatures by nurses to document that the frequent turning was accomplished. On 8/4/20 at 1:20 PM, V14 (CNA-Certified Nurses Aide) was asked about R2. V14 stated, Yes she is my resident again. I usually have her and I took care of her yesterday too. Surveyor asked when the last time she went in to see R2, V14 stated, I saw her earlier when I changed her (referring to her incontinence briefs). Asked the time she went in to change her, V14 stated, I don't know maybe early in the morning. Asked when else she saw R2, V14 stated, Well I peek in and watch her and she was okay why is there something wrong. Asked if she goes and turns R2, V14 stated, Oh yes we do that too, I did that earlier when I changed her. Asked if anyone helped in turning R2, V14 stated, No I did it myself but sometimes I ask someone to help but everyone's always busy so I just do it. Asked how often R2 needed to be repositioned while in bed, V14 stated, I don't know, until they (nurses) tell me. All OBRA quarterly assessments (MDS-Minimum Data Set) dated 1/8/2020, 4/6/2020, 6/23/2020, and 7/10/2020 show R2 to be totally dependent of full staff performance for bed mobility requiring 2 staff to turn and reposition while in bed. All four of R2's MDS quarterly assessments show R2 at risk for developing pressure ulcers but do not include any turning and repositioning program in all the four MDS's. Interview with V15 (Wound Doctor) on 8/4/20 at 1:30 PM, states, I've been seeing R2 since the beginning of the year. I see her every Friday when I do my wound rounds at the facility. She should be on a low air loss mattress because she came in with a stage 3 pressure ulcer. If you tell me that mattress was not functioning since yesterday, that should have been changed immediately. I hope they did. Surveyor asked V15 if he considered R2's wounds to be avoidable, V15 stated, Her wound is avoidable. If she is capable of healing her other wounds I would have to agree with you and say her wounds are avoidable. Surveyor asked whether he ordered turning and repositioning for R2, V15 stated, Turning and repositioning at a minimum of 2 hours or less I always order for someone at risk for pressure injuries. I also agree that she should not have obtained these other two wounds if she was being turned and repositioned at least every two hours to off-load any pressure on her skin. Surveyor asked about microclimates of wounds, V15 stated, Microclimates are contributing factors such as linens, covers, padding impact wound healing. Excessive-padding, linens, coverings can be a problem and there shouldn't be that much padding on her. There should be minimal coverings over her wounds. I wasn't aware that there was that many layers of padding because when I come in to see her wounds, the staff already have her wounds ready for me to see. I'll be there (facility) this Friday so I'll address this with the staff. Asked about about necrotic wounds, V15 stated, Wound necrosis cannot happen over night. If she (R2) was scratching herself, she could not caused necrosis of her wound right away as the nurse told you. That would be incorrect. If she was scratching her wounds, the staff should have seen this before hand and also regularly off-loaded the pressure. Her skin doesn't just become necrotic. This is why it is important to turn and reposition a patient to take the pressure off otherwise the wound will die (necrosis) due to pressure not being relieved on the body part or bony prominence. Surveyor asked about his orders, V15 stated, If I say turn and reposition every two hours at a minimum, that should not be written as a FYI as it is an order not a recommendation.

Based on observation, interview and record review, the facility failed to ensure that a resident received hospice orders that specifically addressed pain management and symptom control for anxiety and shortness of breath which affected one resident (R164) of six residents reviewed for hospice in a sample of 24. This deficient practice caused R164 to experience pain over a two day time frame, anxiousness and shortness of breath. Findings include: R164 was admitted to the facility on [DATE]. R164's hospital records dated 3/28/18 document no significant past medical history except for a significant episode of pain in her back for one week. R164 was admitted to the hospital after a fall and lower extremity weakness. In the emergency room , R164 was found to have cord compression and lower extremity paralysis. A computerized tomography (CT) scan of the chest and abdomen revealed: Lesion centered in left T3 ([MEDICATION NAME] level 3) with a posterior element extending to the spinal canal resulting in severe canal stenosis with a right renal mass measuring 6.2 centimeters. CT of the thorax revealed: A large destructive paraspinal mass involving T2 ([MEDICATION NAME] level 2), T3 and T4 ([MEDICATION NAME] level 4) with encroachment of left spinal canal T2-T3. IMPRESSION: 1) Acute cord compression 2) Paraspinal mass 3) Right renal mass likely renal cell [MEDICAL CONDITION] 4) status [REDACTED]. Per the hospital physician progress notes [REDACTED]. R164's hospital records dated 3/28/18 document that her pain medication regimen included: [MEDICATION NAME] 1 mg (milligram)/0.5 ml (milliliters) IVP (intravenous push) every two hours as needed, [MEDICATION NAME] 650 mg oral every six hours as needed, [MEDICATION NAME] 50 mg oral every eight hours as needed and [MEDICATION NAME] 4 mg oral every six hours. R164's Medication Administration Record [REDACTED]. R164 signed a consent for hospice on 3/31/18. R164 was assessed and admitted to Hospice by V27 (Hospice Nurse) on 3/31/18 prior to transferring to the nursing home facility. V27 documented, in part, in R164's Clinical Notes, Patient made it very clear she wants no aggressive measures and prefers comfort care. V27 continues to document, Patient has had increasing pain to bilateral shoulders since 3/28 but rarely complains-states pain remains 3 to 5/10 despite [MEDICATION NAME] given regularly. Patient will need increasing pain management and perhaps adjunct medications to control spinal metastasis pain like steroids. V27 did not obtain transfer orders for R164 or orders for pain management despite the documentation of constant pain. V27 documented, Admission RN (Registered Nurse) can call (physician) for assist in reconciling meds at the facility. Profiled patient with (pharmacy) but did not order or call (primary physician) since facility and admission RN will need to anyway. Upon admission to the facility on [DATE], R164 was seen by V21 (Hospice Nurse). On 4/5/18 at 9:10am, V21 indicated that she saw R164 on 3/31/18. V21 indicated that R164 was in pain, short of breath and moderately anxious when she assessed her. V21 stated, I did not order oxygen or [MEDICATION NAME] because the resident refused. Goal of Hospice is aggressive symptom management. V21 indicated that R164 complained that [MEDICATION NAME] did not help her pain. So despite R164 indicating that [MEDICATION NAME] did not help her pain, V21 indicated that Tylenol was ordered for the pain. V21 stated, Another nurse was coming on 4/1. We address symptoms as they come up. R164's assessment on 3/31/18 is documented as V21 described it in R164's Hospice Clinical Notes. On 4/1/18, V22 (Hospice Nurse) visited R164. V22 documented, (R164) complained of pain in neck and shoulders with no relief from Tylenol. V22 documents that she lets the facility nurse know about R164's pain and to administer Tylenol. V22 documents, No other medication at this time to give patient. Team to follow up this week. On 4/5/18 at 9:32am, V22 stated, I saw (R164) at 6:30pm. Patient complained of pain in shoulders and neck. She said [MEDICATION NAME] and Tylenol did not work. I told her the case manager would get the pain medication as soon as possible. V22 indicated that she was surprised that no pain medications were ordered by admission nurse. V22 stated, She should've had stronger pain medications on board. I was to follow up to the admission and make sure that resident had medications ordered. I sent out an e-mail to the (Hospice) manager to find something for pain control. If I was more proactive then she wouldn't have had to wait until 3:30pm on 4/2/18 to get stronger pain medication. Hospice goal is to provide end of life care and provide comfort care. On 4/1/18, no pain medications, anxiety medications or oxygen was ordered for R164. On 4/2/18 at 10:47am, this State surveyor found R164 in bed, highly anxious and in pain. R164 indicated that she let the nurses know about the pain. At 11:05am, R164 indicated that she was short of breath, very nervous and in pain in the back. R164 stated, I was getting [MEDICATION NAME] in the hospital but here I only get Tylenol. And it's not helping. I've been in pain for two days. On 4/2/18 at 1:55pm, V26 (Family Member) came to the nurses station and requested anxiety medication for R164. At 2:04pm, V20 (Physician Assistant) was asking V19 (RN-Registered Nurse) why there were no orders for pain, anxiety and oxygen in R174's chart. V20 stated, Hospice should have ordered a comfort kit for her. Call them as soon as possible. On 4/2/18 at 2:07pm, V19 phoned Hospice to see when R164's Case Manager was going to arrive at the facility. R164's [MEDICATION NAME] 50 mg pain medication, oxygen 2 liters per nasal cannula and [MEDICATION NAME] 0.5 mg for anxiety were not ordered until 4/2/18 at 2:30pm. All orders were initiated immediately. On 4/4/18 at 2:40pm, V19 stated, Hospice expectation is that pain is controlled. When Hospice admits someone, they should already order strong pain medication. When I came on Monday there was a note that (Hospice) was aware that patient needed stronger pain medication. R164's Hospice Clinical Notes indicate that the facility called hospice on 4/1/18 at 7:42pm for medications. V19 stated, I called hospice on Monday before 8:00am to let them know that (R164) needed pain medication. V19 indicated that on 4/2/18, R164 became short of breath and anxious so V20 was notified. On 4/4/18 at 3:40pm, V20 indicated that when she saw R164 on 4/2/18 she had to order oxygen, [MEDICATION NAME] and [MEDICATION NAME]. V20 stated, She should not have been in that condition. She was admitted on Saturday and I was seeing her Monday afternoon. There was no comfort kit or any pain medications or antianxiety medications ordered. V20 indicated that the Hospice physician should have given all the orders. V20 indicated that if the orders were in place then R164's condition on 4/2/18 could have been prevented or controlled. According to R164's physician order [REDACTED]. [MEDICATION NAME]-increase frequency to 0.5 mg orally every two hours as needed was also ordered. On 4/3/18, [MEDICATION NAME] was changed from as needed to scheduled doses every six hours and [MEDICATION NAME] was changed from as needed to every six hours scheduled doses as well. On 4/5/18 at 10:20am, V24 (Vice President of Operations for Hospice) stated, After review of the case, this is not the protocol that we follow. Goal is to coordinate with acute care hospital but also with facility, family and care provider. Expect to provide coordination so no delay in care. We take response for pain to goals of care to formulate a care plan. Upon review, I found a few gaps in providing patient comfort. We have to anticipate needs. We have identified pain as an active problem that hospice residents have. We need to anticipate problems. The nurse should have made her visit to (R164) first thing on Monday. Again, our care pathway or clinical program was not followed. R164's Care Plan that was formulated by the Hospice agency documents: Pain/Physical Comfort, altered. Goals: Verbalizes pain control and/or appears comfortable without signs or symptoms of pain. Optimal pain control with appropriate medications. Interventions: Assess and monitor level of comfort including location, intensity and character of pain. Instruct in pain medication, administration, actions, side effects. Respiratory Status, altered. Goals: Optimal respiratory comfort. Patient and Family Goals: Goal #1-Comfort care with hospice. Interventions: Manage signs and symptoms and improve Quality of Life. An undated facility policy titled, Hospice Care, documents: PHILOSOPHY OF HOSPICE CARE: Hospice is not a place but a concept of care designed to provide comfort and support to residents who have a limited life expectancy (usually 6 months or less). The goal of Hospice care is to improve the quality of the resident's life by offering comfort, pain control, and dignity rather than a curative treatment. Hospice care addresses all symptoms of the resident's disease with a special emphasis on controlling pain.

Based on observation, interview and record review, the facility failed to follow their physician prescribed care plan and failed to implement pressure sore interventions to prevent the development of a facility-acquired pressure sore for one resident (R76) of four residents reviewed for pressure sores in a sample of 24. This failure caused R76 to develop an avoidable pressure sore to the sacrum. Findings include: R76 Face sheet dated 4/4/18 shows R76 with [DIAGNOSES REDACTED]. On 4/3/18 at 10:38am, R76 was observed asleep in bed on her back and the head of the bed up at a 30 degree angle. R76 was atop an air mattress with a pump attached to the footboard with the pump showing it was on static mode and not on alternating pressure to off-load pressure and was set at 280 lbs pressure. At 10:49 am, V10 (Wound care director) and V11 (Wound Care Nurse) prepared R76 for her daily wound care dressing changes. V11 with gloved hands removed a comforter and blanket off of R76 who was wearing a hospital gown and diaper underneath her gown. V11 lifted up R76's gown and started removing the diaper and turned R76 to her left side and showed an old dressing applied to her sacral area. The wound dressing was heavily stained with a brown color and had a noticeable fecal odor. V11 stated, They must have just changed her. V10 and V11 proceeded to change her soiled wound dressings after applying the prescribed ointment onto the wound and replacing it with a clean dressing. V10 then asked V11 to turn R76 to the other side in order to remove the layers of sheets that were observed under R76 which included several sheets, an incontinence pad, and a fitted sheet. After the procedure, V10 was asked who made the bed for R76, V10 stated, The CNA's make the beds but they shouldn't be using fitted sheets for those mattresses, is that why you're asking. On 4/3/18 at 12:56 PM, R76 was again observed laying on her back with her head raised at 30 degrees and in the same position. The mattress pump was again set at 280 lbs (facility records show R76 to be at 156 lbs) 04/04/18 1:50 AM R76 was asleep lying on her back with the air mattress set on 150 lbs. and with the static light turned on showing no alternating pressure to off-load pressure was occurring. On 4/4/18 at 3:00 am R76 was observed in the same position with no one turning and repositioning R76. At 3:50 am R76 was observed in the same position on her back. V13 (CNA) was asked what his duties were during the night, V13 stated I'm supposed to turn and reposition only the ones with wounds. Asked which ones on his side of the floor he turned and repositioned V13 could not answer which residents he was to turn and reposition. Asked if he was the only one to work his side of the floor, V13 stated, There's three of us (CNA's) we all have our own sections. Direct observations of R76's room do not show V13 or any other staff going into R76's room from 1:50am -3:50 am to turn and reposition R76 who remained asleep on her back. MDS (Minimum Data Set) dated 2/7/18 section G functional status shows bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) at extensive assistance and two-person physical assistance. This same MDS section M for skin conditions shows: Is resident at risk for developing pressure ulcers? Answer: Yes. Current number of unhealed pressure ulcers at each stage; all answered as zero for none showing that R76 had no pressure ulcers upon admission/entry or reentry. MDS CAA (Care Area Assessment) completed by V10 (wound care nurse) dated 2/7/18 states No for existing pressure ulcer showing R76 did not have any pressure ulcers at the time of this assessment. V10 writes on the same form, Resident is high risk for pressure sore. R76's care plan dated 2/27/18 states, Resident has pressure ulcer on sacrum unstageable, resident has history of denuded sacrum, she is totally dependent for bed mobility, history of abdominal [MEDICAL CONDITION], incontinent of bowel and bladder. Has [DIAGNOSES REDACTED]. Facility form titled, Weekly Pressure Ulcer Report (dated 3/26/18), shows (R76) with facility-acquired unstageable pressure sore to sacrum and an unknown date as to when the wound was first identified. Measurements shown for the sacrum wound measures 2.8 centimeters (length) X 1.8 centimeters (width) X unknown depth. This same form asks Is resident seeing wound specialist with the answered No. 4/4/18 at 11:00 pm with V1 (Administrator) states, We've in-serviced the staff about the air mattresses. I know what you mean about the over padding but it's a habit that's hard to break. We've in-serviced before but it looks like we need to do more. 4/4/18 interview with V14 (Wound Doctor) at 12:45 pm states, I've just started seeing (R76) and I'm normally brought for debridement (surgical removal of dead tissue) of a wound if the family approves and from my recollection we are treating her with Santyl ointment to the wound. I do expect as I do with all my patients that the facility follow their wound protocols for off- loading (relieve pressure) of the wound which includes turning and repositioning and should be placed on a group II- type bed (alternating air mattress). In order to facilitate wound healing, as you may already know, the area of the wound should have some cooling effect and the mattress will do this if there isn't an overabundance of padding or sheets as this defeats the whole cooling process that I just explained. This has been a challenge in most facilities that I'm in and they (the facility) should all know this yet it's still a challenge for them to keep staff from overly padding these types of residents. Policy and procedure titled, Pressure Ulcer/Wound Management (dated 10/04) states: Policy: to promote healing of pressure ulcers, facility will use standardized protocols or follow physician's specific orders for wound care. Treatment objectives to promote optimal wound healing are: Relieve pressure, clean the wound bed of necrotic tissue (if present), protect healthy tissue, evaluate/correct nutritional deficiencies, treat consistently with appropriate products.

Based on interview and record review, the facility failed to provide supervision and put in place interventions to prevent 1 resident who has a fall history, from going to the basement unsupervised, and falling to the floor without her chair alarm on, out of 4 residents (R3) reviewed for falls. R3 was hospitalized and sustained Contusion and Subgaleal Hematoma to the left eye. Findings include : R3 has [DIAGNOSES REDACTED]. R3's Incident Report indicated that on 11/4/11 at 3:15 PM, R3 was found in the bathroom lying on the floor, with her buttocks on the wheelchair leg rest, and her left hand holding on to the bathroom rails. R3 was found in the bathroom alone without staff supervision, after her wheelchair alarm triggered. On 1/20/12 at 2:55 PM, E5 ( nurse ) said that on 11/4/11, she found R3 sitting on her wheelchair foot rest in her bathroom, after her chair alarm sounded. E5 said R3 was by herself. E5 continued that her wheelchair alarm was reapplied, and R3 was placed in the Assisted Dining Area. R3's 11/23/11 incident report indicated that at around 5:10 PM, R3 was again found in the facility basement, lying on the floor. On 1/20/12 at 2:45 PM, E4 ( nurse aide assigned to R3 ) said that she last saw R3 by the nurses station, when she took her break around 4:30 PM. After her break, E4 said that E6 ( housekeeper/laundry ) called E7 ( nurse ) to go downstairs. E4 said she went with E7 to the basement, and saw R3 on the floor, away from her wheelchair. E4 said that R3 was bleeding. E4 also said that she did not remember hearing R3's alarm, but knows that her alarm was attached to her wheelchair. E4 added that R3 would wheel herself to the hallways, and even to the big dining room, which is located in front of the elevator that leads to the basement. E4 said that R3 had tried to stand up before from her wheelchair, but cannot really stand up good. E4 also said that R3 had fallen before, and had only been using a chair alarm prior to her 11/23/11 fall. According to E3 ( nurse ) on 1/20/12 at 2:25 PM, the last time she saw R3 on 11/23/11 prior to being found in the basement, R3 was in the Assisted Dining Room in front of the TV. E3 said that prior to that, R3 was placed by the nurses station. E3 said that she was later alerted by staff, that R3 was found in the basement floor. E3 said she does not remember hearing R3's chair alarm during the incident. E3 also said that she thinks that R3 had fallen in the bathroom before the 11/23/11 incident. E6 ( housekeeper/laundry ) said on 1/20/12 at 12:15 PM, that she was working in the laundry room which is near the basement elevator, when she heard R3 scream for help. E6 said that when she went out of the laundry room door, she saw R3 in front of her wheelchair with her face down on the floor. E6 continued that the wheelchair was across the elevator. E6 also said that she did not hear R3's chair alarm, when she found R3. R3's 9/29/11 Risk for Falls care plan showed, that her 11/4/11 fall was added in the care plan. However, review of facility's fall investigation did not really determine what caused R3 to fall on 11/4/11. R3 fell from her wheelchair because she was on the toilet without any staff supervision, and cannot be left by herself in areas she shouldn't be at, unsupervised. Added to this, R3's chair alarm did not really alert the staff to assist her in time, to prevent her from falling. R3's wheelchair alarm mainly alerted E5 that R3 had already fallen in the bathroom. Despite this, there was no new intervention put in place immediately after the 11/4/11 fall, to prevent R3 from falling further. Per R3's care plan, a urinalysis and urine culture and sensitivity was only initiated on 11/7/11. It also did not discontinue or replace or revise R3's use of chair alarm, although it does not prevent R3 from falling. R3 should also not be left by herself in areas not monitored by staff, as staff is aware R3 can unlock her wheelchair, and wheel herself to different areas of the facility. Facility's incident investigation of R3's 11/23/11 fall incident showed that no staff was with R3, when R3 went to the basement by herself. E3 and E4, both assigned to R3 on 11/23/11 also verified that they were not with R3, when R3 fell at the basement. E3 last saw R3 on 11/23/11 at 5 PM by herself at the Assisted Dining Room, and even questioned other staff if they wheeled R3 to the Assisted Dining Room, as E3 saw R3 by the nurses station prior to this. On 1/20/12, E6 and E4 both said at 12:15 PM and 2:45 PM, that they have seen R3 by the big dining room before. The big dining room area is in front of the elevator that goes down to the basement. Per R3's 11/23/11 report, R3 was found unsupervised on the basement floor. Her alarm was also not triggered, and it is the same device she has been using after her 11/4/11 fall. R3 sustained laceration at the left forehead and hematoma, which resulted to her hospitalization on [DATE]. R3's hospital record printed on 11/26/11 indicated that she had contusion, abrasions, and subgaleal hematoma. Her 12/9/11 office visit also shows that R3's 3.5 x 7 cm hematoma over the left eye was persistent, that an Incision and Drainage of the Hematoma was performed at the office.