Every finding on record at Oregon Living and Rehabilitation Center

Based on interview and record review the facility failed to ensure a resident's pain was managed for 1 of 3 (R1) residents reviewed for pain in the sample of 5. The findings include: On 4/16/26 at 10:57 AM, V5 Licensed Practical Nurse (LPN) said R1 was in the skilled unit at the facility for therapy for a fractured sacrum. V5 said R1 was in a lot of pain and anxiety. V5 said R1 had hydrocodone-acetaminophen prescribed for pain.On 4/16/26 at 9:20 AM, V8 Complainant (R1's sister in law) said the facility was not meeting R1's needs by not controlling R1's pain.R1's Hospital Discharge Instructions dated 3/23/26 shows R1 was admitted to the hospital with acute hypoxic respiratory failure and a pelvic fracture after a fall on driveway. Orthopedics recommended a non-operative plan for now, as R1 is a high risk for surgery due to fragile respiratory status. Medication list: Hydrocodone-acetaminophen 10-325 mg tablet by mouth every 4 hours as needed for moderate pain.R1's Progress Note by V9 Medical doctor, dated 3/26/26 shows Patient very uncomfortable, and I think there is a significant amount of anxiety. We will try to stay in front of his pain and obviously therapy within the facility will be paramount to his success.On 4/16/26 at 9:54 AM, V3 LPN said when R1 was admitted the wrong dose of hydrocodone-acetaminophen was ordered (5/325 mg) which was not helping R1's pain. V3 said we got the order changed to the correct dose of hydrocodone-acetaminphen10/325 mg.R1's Progress Note dated 3/26.26 shows This nurse was made aware that resident's pain is not being well controlled with the current as needed hydrocodone-acetaminophen 5/325mg every 4 hours. After some investigation, it was discovered that the hospital discharge paperwork had the order hydrocodone-acetaminophen for 10-325mg every 4 hours as needed. After calling the pharmacy and speaking with V9 the ok was given to change the order to hydrocodone-acetaminophen 10-325 mg every 4 hours as needed for moderate pain.R1's Pain assessment dated [DATE] shows Over the last 5 days how much of the time has pain made it hard for you to sleep at night: Frequently. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain: Almost constantly.R1's Medication Administration Record (MAR) for March 2026 shows that R1 received hydrocodone-acetaminophen 5/325 mg, give 1 tablet every 4 hours as needed for pain from 3/25/25 to 3/30/26. This same MAR shows R1 started receiving hydrocodone-acetaminophen 10/325 mg, give 1 tablet every 6 hours as needed for pain on 3/31/26 (still not the correct admission order of hydrocodone-acetaminophen 10/325 mg, every 4 hours). This same MAR shows R1's pain levels before administering the medications were documented as 5-9 out of 10.R1's Nurse Practitioner Progress Note dated 3/29/26 shows Patient is at facility for subacute rehab following a fall at home with multiple rib fractures. Patient is resting in his bed for today's visit. He reports that he is having a lot of pain, it is difficult for him to move and participate in activities. He's having trouble sleeping because of his pain and his mood is poor due to his current physical condition.R1's After Visit Summary from the Orthopedic Doctor dated 3/31/26 shows Your medication list: hydrocodone-acetaminophen 10-325 mg Take one tablet every 4 hours as needed for moderate pain (confirming R1's pain medication should be every 4 hours).R1's Pain assessment dated [DATE] shows : Over the past 5 days, how much of the time has pain made it hard for you to sleep at night: Almost constantly. Over the past 5 days, how often have you limited your participation in rehabilitation therapy sessions due to pain: Occasionally. Over the past 5 days, how often have you limited your day-to-day activities (excluding rehabilitation therapy sessions) because of pain: Almost constantly. Pain intensity: 9.R1's MAR for April 2026 still has the incorrect order of hydrocodone-acetaminophen 10/325 mg, give 1 tablet every 6 hours as needed for pain, which was administered until family initiated R1's discharge on [DATE].On 4/16/26 at 2:30 PM, V2, (DON) Director of Nursing said R1's admitting orders for R1 was hydrocodone-acetaminophen 10/325 every 4 hours but V9 (R1's doctor at the facility) had called in the order for hydrocodone-acetaminophen 5/325 mg as needed every 4 hours. V2 said the facility had got the correct orders but the doctor called in hydrocodone-acetaminophen 10/325 mg every 6 hours instead of every 4 hours. V2 said the staff sent a fax to verify the order with V9 but did not get a response back and did not follow up. V2 said that is why R1's MAR shows as 10/ hydrocodone-acetaminophen 325 every 6 hours. V2 said staff should have followed up with V9 to clarify the order since R1 was having pain.The facility's Pain Management Policy dated 4/11/26 shows to ensure all residents receive timely, appropriate, and effective pain assessment and management in order to maintain the highest practicable level of comfort, function, and quality of life. Administer medications as ordered, including scheduled and as needed medications.

Based on observation, interview, and record review the facility failed to follow policy for obtaining vital signs for residents receiving skilled services for 3 of 3 residents (R1, R2, R3) reviewed for quality of care in the sample of 5.The findings include: 1. On 4/16/26 at 10:57 AM, V5 Licensed Practical Nurse said R1 was in the skilled care unit for therapy for a fractured sacrum. V5 said R1 was receiving oxygen via nasal canula. V5 said vitals including blood pressure, pulse, temperature, respirations, and oxygen saturations are taken on residents in the skilled unit daily and as needed. V5 said when a resident is on oxygen it is important to check oxygen saturations to make sure the resident is getting the right amount of oxygen and vitals help show if a resident is experiencing a change in condition.On 4/16/26 at 11:51 AM, V2 Director of Nursing said residents at the facility for skilled therapy have a full assessment and vitals taken every 24 hours and as needed. V2 said if the resident is on oxygen there may be additional oxygen saturation checks ordered.R1's Facesheet shows R1 was admitted to the facility on [DATE] and discharged on 4/4/26.R1' Vitals Summary shows from 3/23/26-4/4/26 (13 days) R1's oxygenation saturation was checked once on 3/24/26. R1's pulse was checked 4 out of 13 days, blood pressure was checked 5 out of 13 days, respirations checked 5 out of 13 days, and temperature checked 6 out of 13 days.R1's Physician Orders shows an order dated 3/23/26 for 4 Liters oxygen nasal cannula due to history of shortness of breath and chronic obstructive pulmonary disease. These same orders do not contain any specific orders for checking oxygen saturation. 2. On 4/16/26 at 11:10 AM, R2 was sitting in a wheelchair in his room waiting for lunch. R2 said the staff checked his blood pressure today, but they don't do it every day, maybe every third day or so. R2's Facesheet shows R2 was admitted on [DATE] for skilled services.R2's Vitals summary shows out of the 34 days R2 has been at the facility R2's blood pressure has been checked 19 out of 34 days, oxygen saturation checked once, pulse checked 15 out of 34 days, respirations checked 15 out of 34 days, and temperature checked 16 out of 34 days.3. On 4/16/26 at 11:15 AM, R3 was sitting her wheelchair in her room. R3 said the staff check her pulse once in a while and they checked her blood pressure yesterday, but don't check that all the time. R3's Facesheet shows R3 was admitted to the facility on [DATE] for skilled services.R3's Vitals summary shows out of the 16 days that R3 has been at the facility R3's blood pressure was checked 9 out of 16 days, pulse was checked 9 out of 16 days, oxygen saturation was checked once, respirations were checked 7 out of 16 days, and temperature was checked 8 out of 16 days.The facility's Resident Examination and Assessment Policy dated 3/21/25 shows the purpose of this procedure is to examine and assess the resident for any abnormalities in health status, which provides a basis for the care plan. Residents receiving skilled services will have an assessment completed at least once per shift. Focused system-specific assessment- respiratory: increased work of breathing, oxygen saturation, lung sounds, cough characteristics. 1. Vital signs: blood pressure, pulse, respiration, temperature.

The facility failed to ensure accurate reconciliation and disposition of controlled substances. The facility also failed to have adequate policies for the reconciliation and disposition of controlled substances. These failures resulted in the facility being unable to account for a resident's controlled substances. This failure has the potential to affect all residents residing in the facility. The findings include:The facility provided census for 4/2/26 showed 65 residents resided at the facility. The facility's North Unit Controlled Substance Accountability Record Card-Sheet Count (commonly referred to as a card count sheet, CCS. The CCS is a count/record of the controlled substance cards, not the individual tablets. The facility also counted the controlled substance count sheets as well as the medication cards.) The facility was unable to produce the CCS for the North unit for the time period between the morning of 2/18/26 and the evening of 2/20/26. The following entries in the facility's CCS sheets were identified: 1.) 11/12/25 at 6:00 PM showed 1 controlled substance count sheet had been removed and 6 had been added for a total change of 5. The sheet showed there were 34 sheets at the beginning of the shift and 34 at the end (no change in the number of sheets despite a change of 5 sheets.) This error carried forward through 4 CCS counts until it was identified on 11/15/25 at 6:00 AM. 2.) 11/19/25 at 6:00 PM showed 1 sheet was removed and 3 sheets were added. The entry showed the start of this shift began with 35 and there were 39 at the end. (Based on the sheets added and removed, there should have been 37 sheets.) The 11/20/25 entry at 6:00 AM showed the shift started with 39 sheets then at the end of the shift there were 36 sheets. There were no documented sheet additions or subtractions during this shift. 3.) 1/30/26 at 6:00 PM showed the shift started with 45 sheets, 5 were added and the total sheets were 60 (should be 50). The next entry on 1/30/26 at 10:00 PM showed a write-over and the total sheets was 61 with no additions or subtractions. The following entry on 1/31/26 at 6:00 AM showed 51 sheets at the beginning and end of the shift with no additions or subtractions. 4.) The 2/8/26 entry at 6:00 AM showed 42 sheets were on hand at the beginning of the shift, one sheet was removed and there remained 42 sheets at the end of this shift (should be 41 sheets). On 2/9/26 at 2:00 PM the log showed another sheet removal, and the count was 41 (should be 40). These errors carried forward until, unexplainably, the 2/10/26 count at 6:00 showed the sheet count changed to 39. Additionally, the number of controlled substance bottles on 2/9/26 at 10:00 PM was 7 bottles with no additions or subtractions of bottles. The next entry on 2/10/26 at 6:00 AM showed there were now only 6 bottles (none had been documented removed/wasted.) 5.) 3/2/26 at 6:00 PM showed 40 sheets on hand and one sheet was added and one sheet was removed; however, there were 39 sheets at the end of the shift (should remain at 40). This error carried forward on the 3/2/26 at 10:00 PM entry until it was corrected on 3/3/26 at 6:00 AM. On 4/2/26 at 2:12 PM, V2 (Director of Nursing) described the nursing process for the CCS sheets and their purpose. V2 stated the CCS is a record of all controlled substance cards, bottles, and patches. V2 stated the CCS also tracks the number of controlled substance count sheets. (The controlled substance count sheets is a record for the number of pills in each card or the volume of liquid in the bottle.) V2 said the CCS errors identified on the sheet do not add up. V2 stated she was not aware of the controlled substance bottle discrepancy of 2/9/26 and she should have been notified. V2 stated the purpose of the CCS count is to prevent staff from taking the controlled substance count sheet and the corresponding card and the facility being unaware of the discrepancy (a deterrent). V2 said by having a running tally of all cards and sheets, it makes this scenario much more difficult to occur, and if it did occur, it would be identified at shift change. V2 stated the CCS, when completed, were placed in a folder in the copy room, staff would start a new sheet, and she would collect them. V2 was asked, because the CCS sheets only have room for 9 entries, or enough room for only 2-4 days of entries, and as soon as the sheets are completed they are removed from the nurses' cart what would prevent staff from taking the CCS sheet, the controlled substance count sheet, the corresponding controlled substance card, and then just starting a new CCS sheet with a count that reflects what was in the cart? V2 replied there are no controls in place to prevent or catch this scenario. V2 stated there is a CCS count sheet missing during the time frame of R1's hydrocodone-acetaminophen medication being delivered on 2/18/26. V2 said the nurse reported her initials were forged on the next available CCS sheet following R1's hydrocodone-acetaminophen delivery. V2 said the facility was unable to determine when R1's hydrocodone-acetaminophen went missing and who possibly took the medications. (Most likely medications were removed between 2/18/26 and 2/20/26. They were not identified as missing until 3/4/26.) On 4/2/26 at 8:00 AM, the facility's controlled substance policy was requested. On 4/2/26 at 9:48 AM, the facility's Medication Administration policy (reviewed 1/30/26) was provided. The entirety of the controlled substance section is as follows, VII. Control Substances -Nurses shall take an additional step of signing out control substances on a controlled substance count sheet for each individual resident. - Nurses shall count the controlled substances at shift change and when handing off a cart if during a non-standard shift change. The count should be between the oncoming nurse and the off going nurse prior to turning over the keys. - Counts include individual resident counts and total number of cards/bottles and sheets. - Any time a new medication is delivered the nurse shall account for new card/bottle and sheet to count sheet. - Any time a card or bottle is empty the nurse shall account for the removal of the items on the count sheet. Any discrepancies shall be reported to the DON. The policy does not discuss wasting of controlled substances, who may waste controlled substances, or witnessing the wasting of controlled substances. The policy does not discuss the storage of controlled substances. The policy does not show what staff should do with completed CCS or controlled substance count sheets, who is responsible for maintaining the count sheets, and if any reconciliation should be done from one CCS sheet to the next. On 4/2/26 at 11:36 AM, V1 (Administrator) stated All we have for a controlled substance policy is what is in the medication policy.

Based on interview and record review the facility failed to report an allegation of misappropriation of resident property to the State Agency as well as local law enforcement. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3. The findings include:The facility's Investigation Report for 3/4/26 showed, On March 4, 2026, this writer (V1 Administrator) was informed of a potential misappropriation of a resident's narcotic medication. The concern was raised following the identification of a discrepancy in narcotic count records . A potential discrepancy (gap) was identified between narcotic counts and documented administration. A prn (As Needed) medication was delivered in months prior but no sheet or card could be located.It was determined that the discrepancy could have resulted from documentation errors, specifically: 1) Failure to sign out PRN narcotic medications at the time of administration. 2) Incomplete or missing entries on narcotic log sheets. 3) Improper paper handling.The investigation concluded that the initial concern of narcotic misappropriation was unsubstantiated. The discrepancy identified could be attributable to documentation omissions rather than diversion. R1's February 2026 Medication Administration Record (MAR) showed, Screen for pain every shift (three times a day). The entire month of February showed staff documented 0 for this pain assessment on a scale of 0 to 10. R1's MAR showed an order for hydrocodone-acetaminophen 5-325 milligram (mg) (a combination narcotic and over-the-counter pain medication) to be given every 12 hours as needed for pain. R1's MAR showed she only had one documented administration of hydrocodone-acetaminophen, which was on 2/14/26 at 2:34 PM. R1's MAR showed only this one order for hydrocodone-acetaminophen, which started on 11/11/25 and was discontinued on 3/4/26. On 4/2/26 at 10:22 AM, a record of all controlled substances delivered to the facility by the pharmacy was requested. The facility provided a sheet titled Daily Narcotic Usage. The sheet showed 60 tablets of hydrocodone-acetaminophen were delivered on 2/18/26 for R1. (At twice-daily administration, if given the maximum frequency, this delivery should have lasted 30 days; approximately March 20, 2026.) On 4/2/26 at 10:43 AM, V2 (Director of Nursing-DON) stated the facility was unable to locate R1's controlled substance count sheets for her HA. V2 stated R1 had 60 tablets of hydrocodone-acetaminophen delivered on 2/18/26 and these could not be accounted for. On 4/2/26 at 3:07 PM, V1 (Administrator) stated in hindsight this allegation should have been reported to the State Agency. V1 stated this allegation had not been reported to local law enforcement. The facility's Abuse Prevention Program (policy, reviewed 9/18/25) showed, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy showed, Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment or misappropriation of resident property has been made, the administrator, or designee, shall notify Department of Public Health's regional office immediately by telephone or fax. Public Health shall be informed that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of resident property has been reported to the administrator and is being investigated. The facility shall also contact local law enforcement authorities (i.e., telephoning 911 where available) in the following situations.When there is a reasonable suspicion that a crime has been committed in the facility by a person other than a resident.

Based on interview and record review the facility failed to prevent the diversion of a resident's controlled substance. This applies to 1 of 3 residents (R1) reviewed for misappropriation in the sample of 3. The findings include:R1's admission Record (Face Sheet) showed R1 was admitted to the facility on [DATE] with diagnoses to include but not limited to dementia, anxiety, and depression. R1's 2/26/26 Quarterly Minimum Data Set (MDS) showed she was unable to respond to questions such as her ethnicity and race, and she was unable to complete the Brief Interview for Mental Status test. R1's MDS showed she had short and long-term memory problems. The MDS showed she had not received as needed pain medication in the previous 5 days and she had no signs or symptoms of pain in the previous 5 days. R1's February 2026 Medication Administration Record (MAR) showed, Screen for pain every shift (three times a day). The entire month of February showed staff documented 0 for this pain assessment on a scale of 0 to 10. R1's MAR showed an order for hydrocodone-acetaminophen 5-325 milligram (mg) (a combination narcotic and over-the-counter pain medication) to be given every 12 hours as needed for pain. R1's MAR showed only one documented administration of hydrocodone-acetaminophen, which was on 2/14/26 at 2:34 PM. R1's MAR showed this was her only order for hydrocodone-acetaminophen, which was started on 11/11/25 and was discontinued on 3/4/26. R1's March 2026 MAR showed no documented administrations of her as needed hydrocodone-acetaminophen medication prior to it discontinuing on 3/4/26. R1's March MAR showed the as needed hydrocodone-acetaminophen order was transitioned to a scheduled order of hydrocodone-acetaminophen 5-325 mg, which was to be given twice daily starting on 3/4/26. R1's MAR showed her first scheduled dose of hydrocodone-acetaminophen was not administered until 6:00 PM on 3/6/26 for a pain rating of 0 out of 10. R1's pain assessment from 3/1/26 through 3/6/26, completed every shift, showed a documented pain of 0 out of 10. The facility's Investigation Report for 3/4/26 showed, On March 4, 2026, this writer (V1 Administrator) was informed of a potential misappropriation of a resident's narcotic medication. The concern was raised following the identification of a discrepancy in narcotic count records . A potential discrepancy (gap) was identified between narcotic counts and documented administration. A prn (As Needed) medication was delivered in months prior but no sheet or card could be located.It was determined that the discrepancy could have resulted from documentation errors, specifically: 1) Failure to sign out PRN narcotic medications at the time of administration. 2) Incomplete or missing entries on narcotic log sheets. 3) Improper paper handling.The investigation concluded that the initial concern of narcotic misappropriation was unsubstantiated. The discrepancy identified could be attributable to documentation omissions rather than diversion. On 4/2/26 at 8:15 AM, all completed or wasted controlled substance counts sheets for all residents in the facility were requested dating back to 1/1/26. On 4/2/26 at 9:56 AM, V2 (Director of Nursing-DON) stated the missing hydrocodone-acetaminophen was R1's. On 4/2/26 at 9:48 AM, V2 provided two binders with the residents' controlled substance count sheets in alphabetical order. The binder showed R1's only hydrocodone-acetaminophen controlled substance count sheets began on 3/6/26. The hydrocodone-acetaminophen count sheet starting on 3/6/26 showed it had been delivered that day. It was requested that V2 verify there were no further missing controlled substance count sheets prior to 3/6/26. On 4/2/26 at 10:22 AM, a record of all controlled substances delivered to the facility by the pharmacy was requested. The facility provided a sheet titled Daily Narcotic Usage. The sheet showed 60 tablets of hydrocodone-acetaminophen were delivered on 2/18/26 for R1. (At twice-daily administration, if given the maximum frequency, this delivery should have lasted 30 days; approximately March 20, 2026.) The facility's North Unit (R1's unit) Controlled Substance Accountability Record Card-Sheet Count (CCS). The CCS is a count/record of the controlled substance cards, not the individual tablets. The facility also counted the controlled substance count sheets as well as the medication cards. The facility was unable to produce the CCS for R1's medication cart for the period when R1's hydrocodone-acetaminophen was delivered on 2/18/26 or the days immediately following. The last CCS was on 2/18/26 at 10:00 AM (medications are typically delivered in the evening) and the next sheet starts on 2/20/26 at 6:00 PM. On 4/2/26 at 11:04 AM, V2 (DON) stated V4 (Licensed Practical Nurse-LPN) disputed her initials on the 2/20/26 CCS at 6:00 PM. On 4/2/26 at 12:04 PM, V4 (LPN) stated she had been shown the CCS sheet for 2/20/26 by V1 (Administrator) and she told V1 they were not her initials. V4 stated she left work around 2:00 PM, not 6:00 PM. V4 stated she was furious that someone forged her initials on the CCS. (The CCS entry for 2/20/26 was documented as being done by V4 at 6:00 PM) V4 stated the event that triggered the investigation was when R1's hydrocodone-acetaminophen transitioned to scheduled versus as needed. V4 stated she worked the day shift on 3/4/26, the day R1's scheduled hydrocodone-acetaminophen began. V4 stated the off-going night nurse reported she had requested a refill of R1's hydrocodone-acetaminophen. V4 stated she also called the pharmacy first thing in the morning, and she was eventually told R1's hydrocodone-acetaminophen could not be refilled because it was too soon. V4 stated R1 was non-verbal due to her dementia, and she rarely witnessed R1 showing and signs or symptoms of pain. V4 stated she could not recall giving R1 as needed hydrocodone-acetaminophen. V4 stated she was the nurse on 2/18/26 who received R1's hydrocodone-acetaminophen. V4 stated she signed and filled out the hydrocodone-acetaminophen controlled substance count sheets; she then filled out the CCS as having received two new cards; and then put the cards in the medication cart lock box. On 4/2/26 at 12:53 PM, V3 (LPN) stated she has taken care of R1 for a while. V3 stated she had never needed to give R1 as needed hydrocodone-acetaminophen for pain. V3 stated she was surprised when the order was changed from as needed to schedule because R1 showed no signs or symptoms of pain. On 4/2/26 at 1:27 PM, V6 (Certified Nursing Assistant-CNA) stated she knows R1 well. V6 stated the last time she recalls R1 having pain was a few months ago but otherwise never really saw her having pain over the past few months. No wincing or anything. On 4/2/26 at 2:12 PM, V7 (CNA) stated she knows R1 and she cannot recall R1 having pain in recent memory. On 4/2/26 at 2:12 PM V2 (DON) stated the start of the investigation was when it had been reported R1's hydrocodone-acetaminophen could not be filled because it was too soon. V2 stated she has been unable to locate R1's February hydrocodone-acetaminophen count sheets or the CCS for R1's hydrocodone-acetaminophen delivery. V2 stated these were searched for as a part of the facility's investigation. V2 stated the medications belong to the residents and the facility is responsible for them. V2 stated controlled substances, like hydrocodone-acetaminophen, are required to be counted, cards counted, and they need to be double locked due to the risk of diversion/misappropriation. V2 stated these controlled substances have a high risk for addiction and they have street value. V2 stated the facility could not account for R1's hydrocodone-acetaminophen. V2 stated there is no record the medications were destroyed. V2 stated the controlled substance counts sheets should be the most accurate reflection of a resident's controlled substances (when they were given, how much was administered, and the remaining amount) because the counts are verified at the beginning and end of every shift. On 4/2/26 at 3:07 PM, V1 (Administrator) stated the facility arrived at the determination R1's hydrocodone-acetaminophen was not diverted because no other resident's medications could be identified as missing, no nurse could be identified, it's possible it was a documentation issue, and R1's pain control schedule was not disrupted. V1 was asked, given the following information, how the facility could state this was possibly a documentation issue; there are two missing count sheets, a missing CCS for the time period in question, R1 had nearly no documented pain in February 2026 necessitating the need for hydrocodone-acetaminophen, R1's 2/18/26 hydrocodone-acetaminophen should have lasted 30 days, and the potential forgery of V4's initials on the CCS; V1 replied, We came to the conclusion based on no definitive evidence of diversion. We couldn't identify one nurse, so we looked at mishandling of the sheets, but I do see your thought process. The facility's Abuse Prevention Program (policy, reviewed 9/18/25) showed, Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy showed all employees are trained on what constitutes abuse, neglect, exploitation, and misappropriation of resident property.

Based on interview and record review, the facility failed to implement interventions to prevent a confused resident (R1) from wandering into another resident's (R2) room. This failure resulted in both residents being found in bed together and R2 was inappropriately exposed. This failure affected one (R1) of three residents reviewed for quality of care in the sample of 3.The findings include:1. Review of facility's final incident report reads in part: on 01/16/2026, staff entered a resident room and observed a fully dressed female resident lying in bed with a male resident. The male resident was unclothed. The male resident's hands were observed resting on the bed, and the female resident's hands were positioned at her sides. No movement or sexual activity was observed at the time of discovery. Both residents appeared calm and exhibited no signs of distress. Staff immediately separated the residents.A post-incident body assessment of the female resident revealed clothing intact with incontinence brief in place. No injuries, bruising, or signs of trauma were noted. The male resident also exhibited no injuries. Both residents were interviewed and were unable to recall how or why they were in bed together or whether any interaction had occurred. The staff witness reported that no motion, refusals, verbalizations, or indications of negative or inappropriate behavior were observed. The male resident has no prior history of sexually inappropriate behavior and is typically quiet and remains in his room.The investigation was conducted in accordance with facility policy and federal regulations. Based on the findings, the allegation of sexual abuse is determined to be unsubstantiated. No further behaviors or concerns have been observed.R1's face sheet documented an admission date of 02/28/2023 with a past medical history not limited to: Alzheimer's Disease, need for assistance with personal care, mood [affective] disorder, psychosis, anxiety disorder and Dementia. R1's abuse/neglect assessment dated [DATE] documented R1 scored 6 that indicates she is at high risk for abuse/neglect (high: 6-7 intense: 8-12).R1's wandering/elopement assessment dated [DATE] documented resident is at high risk for wandering/elopement due to diagnosis of Dementia/Alzheimer's/confusion, independently mobile, paces/wanders, and history of elopement/wandering. R1's Minimum Data Set (MDS) Section C Brief Interview for Mental Status (BIMS) Evaluation (page 11 of 59) dated 01/09/2026 indicated R1 has severe cognitive impairment.R1's care plan last reviewed 01/16/2026 reads in part: has diagnosis of dementia and utilizes staff assistance with activities to ensure highest level of psycho-social functioning. Interventions included: allow her to socialize with others in common areas and encourage R1 to participate in group programs. R1's care plan also documented she is an elopement risk/wanderer related to impaired safety awareness, dementia, and Alzheimer's disease. Interventions included: distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, has a baby and enjoys caring for it, provide structured activities such as toileting, walking inside, and reorientation strategies including signs, pictures and memory boxes.R1's progress note dated 01/16/2026 at 09: 12 PM (21:02) documented that R1 was in another male resident bed fully dressed.On 01/22/2026 at 10:40 AM, observed R1 seated at a table in the common area on 200 unit near nurse's station with other residents, engaging in a puzzle activity. At 10:52 AM, attempted to interview R1 in her room. She was alert to self and unable to recall any details of incident in R2's room.2. R2's face sheet documented an admission date of 06/16/2025 with a past medical history not limited to: Dementia, mood [affective] disorder, anxiety, alcohol abuse, and insomnia. R2's MDS Section C Brief Interview for Mental Status (BIMS) Evaluation (page 10 of 54) dated 12/08/2025 documented score of 13/15 and indicated an intact cognitive response. R2's progress note dated 01/16/2026 at 09:00 PM (21:00) documented that R2 was in his bed with a fully dressed female (R1) resident. Residents were separated. Neither resident was upset or recalled the incident. R1 was unbothered.On 01/22/2026 at 10:34 AM, R2 was observed sitting in his recliner chair in his room watching television. R2 said last week after supper, while in his room getting ready for bed, a woman (R1) wandered into his room and sat down on his bed. R2 then said he told her to leave several times, but she wouldn't get off his bed or leave his room. R2 indicated that the woman (R2) was fully dressed, and he was wearing a t-shirt and underwear. R2 said he was standing in front of her when a bunch of staff came in and started hollering and took her out of my room then he went to bed. R2 said he never laid in bed with the woman (R1) or did anything with her. On 01/22/2026 at 01:28 PM, V1 (Administrator) said she talked with V7 (Activity Aide) who said R1 was last seen on the couch in the 200 unit common area by the nurse's station around 6:30 PM. V7 did not see R1 after that. V1 added that residents had just finished having dinner and staff were getting other residents ready for bed during that time. On 01/22/2026 at 02:55 PM, V6 (Certified Nursing Assistant) said R1 wanders and goes into other resident's beds, is a typical behavior of hers. V6 added that R1 wanders often, and staff can usually redirect her. V6 then said she last saw R1 around 06:15 PM in the larger dining room on the 200 unit and last saw R2 in the smaller dining room on the unit around 06:30 PM. V6 also said both residents can ambulate per self. V6 said R1 most likely left her dining room and was either looking for a bathroom or her room and when someone sees her, she is redirected. V6 added that everyone must have been busy that no one saw her walking down the hall and said there is usually an activity aide in the common area but if she was on break or in the bathroom or assisting another resident, she didn't see R1 wander down the hall. On 01/22/2026 at 03:30 PM, V7 (Activity Aide) said that she was works on the 200 unit and is supposed to stay in the common room at all times and does 1:1 activities with the residents. V7 then said on the night of 01/16/2026, a staff member walked R1 into the common room after dinner around 06:30 PM and sat her down on the couch. V7 said she did not engage in any 1:1 activity with R1 because she was watching television. V7 then said she heard some commotion going on down the hall about 7:00 or 07:30 PM and noticed that R1 was no longer in the common area at that time. V7 added that she did not know what time R1 had left the common room and did not recall whether she (V7) had left the common area. On 01/22/2026 at 04:31 PM, V1 (Administrator) said residents are encouraged to partake in activities to prevent wandering along with individualized interventions that are care planned for the resident.On 01/22/2026 at 04:34 PM, V2 (Regional Director of Operations), said an activity aide is assigned to the dementia unit from 4:00 to 8:00 PM. The aide is to stay in the common area and keep residents engaged in activities until they are put to bed.Resident Wandering and Elopement last reviewed 03/21/2025 reads in part: the facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement.Residents with dementia who wander may pose a risk to themselves due to the inability to identify the hazards.MDS will be completed as well as care plan with individualized interventions.

Based on interview and record review, the facility failed to ensure a dermatologist referral was sent when residents were experiencing skin rashes as ordered by the physician for six of ten residents (R1, R7, R8, R9, R10) reviewed for quality of care in the sample of ten. The findings include: 1. R1's admission Record shows he was admitted to the facility on [DATE]. R1's Order Summary Report shows an order for a dermatologist referral due to ongoing rash not improving with treatment. This order was entered on October 30, 2025. The facility's List of Rash Data dated 2025 shows R1 acquired a rash to his torso starting on October 11, 2025. On November 25, 2025, at 10:08 AM, R1 said that he has a rash on both of his arms and other places on his body. R1 said he gets cream applied, but it makes the itching worse. R1 said the facility does not know where the rash came from. 2. R7's admission Record shows he was admitted to the facility on [DATE]. R7's Order Summary Report shows an order for a dermatologist referral due to ongoing rash entered on October 30, 2025. The facility's List of Rash Data dated 2025 shows R7 has been experiencing a rash to his arms and back off and on for three months. 3. R8's admission Record shows she was admitted to the facility on [DATE].R8's Order Summary Report shows an order to refer R8 to a dermatologist due to an ongoing rash was entered on October 30, 2025.The facility's List of Rash Data dated 2025 shows R8 has been experiencing a rash to her arms and chest since July 2025.4. R9's admission Record shows she was admitted to the facility on [DATE].R9's Order Summary Report shows an order to refer R9 to a dermatologist due to an ongoing rash was entered on October 30, 2025.The facility's List of Rash Data dated 2025 shows R9 began a rash to her right shoulder on October 16, 2025.5. R10's admission Record shows she was admitted to the facility on [DATE].R10's Order Summary Report shows an order to refer R10 to a dermatologist due to an ongoing rash was entered on October 30, 2025.On November 25, 2025 at 8:27 AM, V3 Wound Care Nurse said she started working at the facility in September 2025. V3 said there was a few residents that were experiencing rashes. V3 said some residents got referrals to see a dermatologist. Some residents rashes did not improve after treatments ordered by the physicians. V3 said some residents are still itchy. V3 said there are currently multiple residents that are experiencing some type of rash but the cause is still unknown.On November 25, 2025 at 1:46 PM, V14 Medical Records/Human Resources said she started taking on the responsibility of making residents' appointments a few weeks ago. V14 said the doctor puts the referral order in the computer system and the nurse then gives V14 the order. V14 said she calls the particular office and lets them know that she has a referral. V14 said she then faxes over all of the required documents to that office. V14 said she waits a few days to get a call back from the doctors office and if she doesn't receive one, then she follows up with a phone call after one week. V14 said she does not have any fax confirmations of R1, and R7-R10's referrals to the dermatologist. V14 said she is still waiting on a call back for R9 and R10. V14 said there was a different staff member that was working at the facility that handled the referrals. V14 said she did not know which doctor this previous staff member sent the referrals to. V14 said that V3 Wound Care Nurse asked her today (November 25, 2025) if R1 and R7 had appointments scheduled to see the dermatologist. V14 said she called the dermatologist office today and made R1 and R7's dermatologist appointments. I had to make those appointment today, they did not have appointments made prior to today.The facility's Comprehensive Person-Centered Care Plans policy reviewed March 21, 2025 shows, A comprehensive, person centered care plan that includes measurable objective and timetables to meet the resident's physical, psychosocial and functional need is developed and implemented for each resident. Each resident's comprehensive person centered care plan will be consisitent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to receive the services and/or items included in the plan of care.

Based on observation, interview, and record review, the facility failed to ensure that food was prepared appropriately to meet the needs of a resident with chewing difficulties for 1 of 3 residents (R1) reviewed for therapeutic diets in the sample size of 3. This failure resulted in R1 receiving diced ham instead of ground ham as recommended for a mechanical soft diet per facility's dietary spreadsheet recommendations and led to R1 having a choking episode.The findings include:R1's face sheet documented last admission date of 03/27/2025 with a past medical history not limited to vascular parkinsonism, dementia, anxiety, depression, dysphagia, and cognitive communication deficit.Review of R1's electronic medical records showed a speech therapy order dated 06/09/2025 for swallowing therapy related to treatment of swallowing dysfunction and treatment of oral function for feeding.R1's therapy/nursing communication form dated 07/01/2025 documented to continue with mechanical soft diet consistency .Review of nutritional care form dated 09/11/2025 completed by V9 (Registered Dietician) indicated that R1 has chewing issues . Review of R1's incident report submitted to the Department of Public Health (IDPH) indicated that on 11/03/2025 at 05:45 PM (1745), R1 was in dining room on same date at dinner time and served a diet as ordered. R1 had just started to eat when the V5 (Certified Nursing Assistant) heard R1 start gurgling. V5 observed R1's lips turn blue, and resident was unable to cough up food. V5 asked R1 if she was choking, and she nodded yes. V5 attempted to give her the Heimlich while another aide went to get the nurse (V4-Licensed Practical Nurse). V5 had already given two abdominal thrusts and noted resident coughed up food. R1 said she was okay. When V4 arrived, R1 was observed sitting in the dining room. R1 stated, I couldn't get certain pieces down. R1 coughed up visible food/liquids after incident. Physician was notified and orders were received to downgrade R1's diet to pureed, and for speech therapy to evaluate and treat. R1's progress note dated 11/04/2025 at 10: 41 PM (22:41) indicated that certified nursing assistant (CNA) reported R1 was gurgling, observed her lips turned blue, and resident was unable to cough up food. CNA initiated the Heimlich maneuver and nurse was immediately notified. When nurse (V4) arrived in the dining room, R1 was observed sitting in the dining room eating a cookie. Resident stated, I couldn't get certain pieces down. CNA had initiated the Heimlich maneuver and after approximately one minute, airway was cleared, and resident began to cough and eventually was able to speak.CNA (V5) stated she was in the dining room, assisting residents with feeding when she heard a gurgling sound behind her. CNA turned around and resident (R1) was blue. CNA asked R1 if she was choking, and she nodded yes. R1 could not cough up the food, so CNA patted her on the back and lifted her arm with no response. CNA had to give the Heimlich Maneuver and after giving two abdominal thrusts, the food came out and R1 was okay.R1's progress note dated 11/04/2025 at 10:45 PM (2245) indicated R1's diet was downgraded to pureed until further notice.R1's speech therapy (ST) evaluation and plan of treatment dated 11/07/2025 indicated that R1 was being seen due to a choking incident on 11/04/205 that required abdominal thrusts to expel food. Prior ST intervention in June 2025 due to choking incident. Downgraded to puree solids from regular solids at that time, eventually upgraded to mechanical soft solids following ST intervention. Patient presents at assessment with mild oral and suspect mild pharyngeal dysphagia (swallowing disorder) with increased risk for aspiration/choking due to cognitive impairment. Continue puree solids and thin liquids, crush medications in applesauce. Continue supervision during oral (PO) intake due to multiple choking events.On 11/12/2025 at 09:45 AM, V1 (Administrator) stated that R1's incident date was incorrectly submitted to IDPH, and the actual incident date was 11/04/2025.R1's active orders as of 11/12/2025 showed an order for pureed diet with start date of 11/04/2025. Review of discontinued orders showed: general diet, mechanical soft texture, regular consistency that was discontinued on 11/4/2025.R1's care plan with print date of 11/12/2025 reads in part: swallowing problem related to coughing or choking during meals or swallowing med, initiated 11/05/2025. Interventions included: follow prescribed diet, monitor for signs of dysphagia, refer to speech therapist, resident to eat only with supervision, and diet changed to puree until speech therapy evaluation for safety.On 11/12/2025 at 10:17 AM, observed R1 lying in bed. R1 said she did not recall anything about the choking incident.On 11/12/2025 at 11:50 AM, V5 (CNA) said was sitting in the dining room assisting another resident with meal and R1 was seated behind her. V5 then said she heard a gurgling sound then turned around and asked R1 is she was choking; R1 nodded her head up and done. V5 added that R1's lips were dark blue and her whole face was turning blue from a lack of oxygen. V5 patted R1 on the back and lifted her arms, but nothing happened so V5 went behind R1 and gave her two upward abdominal thrusts. V5 said that R1 coughed food that looked like tiny ham chunks with some phlegm. V5 added that she was unsure of what R1's diet was at the time of incident but said the food on R1's plate looked like it was a regular diet because she had the scalloped potatoes with diced ham. V5 then said about a year ago, R1 went through the same situation and had choked on food. On 11/12/2025 at 12:03 PM, V4 (Licensed Practical Nurse) said on the day of R1's incident, a resident came up to the nurse's station and said [R1] choked. V4 indicated she went to the dining room and V5 (CNA) told her what happened. V4 added that when she approached R1, she was attempting to eat a cookie but V4 took away the cookie and brought R1 to the nursing station to assess her. V4 said when she asked R1 what happened, R1 said I couldn't get it down. V4 added that R1 has had choking/coughing issues in the past and her diet at time of incident was mechanical soft.On 11/12/2025 at 12:33 PM, V2 (Director of Nursing) said V4 (LPN) called her on day of incident and said that R1 had choked in the dining room. V2 added that she spoke with V6 (Food Service Director) who said R1 was served the correct diet but had choked on her food. Review of facility's weekly menu for week of 11/02/2025 (Sunday) provided by facility on 11/12/205 indicated the evening meal for Tuesday (11/04/2025) was crispy onion scalloped potatoes and ham, parslied carrots, bread/margarine, cookies and milk. Review of facility's dietary spreadsheet provided by V6 on 11/12/2025 dated 11/04/2025 indicated for the meal of scalloped potatoes and ham, the ham should be gnd (ground) for a mechanical soft diet. On 11/12/2025 at 1:40 PM, V6 (Food Service Director) said gnd means ground then indicated the dietary staff should be following the spreadsheets so the ham for mechanical soft diets should have been ground. V6 then indicated he was told by the dietician (V9) in the past that 1/4 inch diced ham is fine enough for the mechanical soft diets.On 11/12/2025 at 02:13 PM, V7 (Cook) said she worked on the day of R1's incident and was told by V6 since she started a few months ago that the ham is fine enough when diced for the mechanical soft diets. V7 then said she refers to the dietary spreadsheets every night and dietary staff are to follow them. On 11/13/2025 at 09:05 AM, V9 (Registered Dietician) said she didn't recall any specifics about R1 at time of interview but indicated that a resident is placed on a mechanical soft diet when they are having issues with chewing or if speech therapy made the recommendation. At 09:11 AM, V9 said the spreadsheets are there to be followed by dietary staff with every meal. When surveyor informed V9 of spreadsheet indicating ground ham, not diced, V9 said oh, well corporate dietitians made the recommendations to substitute diced ham for ground as an acceptable substitution because the pieces are between 1/2 inch to 1/4 inch in size and should be in the mechanical soft diet policy. V9 added that meats are either diced or ground based on the resident's tolerance but could not indicate which meat texture was tolerated by R1.On 11/13/2025 at 09:40 AM, observed in a small bowl provided by V6 (Food Service Director), several pieces of diced ham that each appeared to be the size of a green pea. V6 indicated this is the size of the ham used by the facility and is 1/4 inch by 1/4 inch in size which comes prepackaged to the facility. On 11/13/2025 at 11:30 AM, V1 (Administrator) said R1 was on a mechanical soft diet with no specifications for ground or diced meat at the time of incident. On 11/13/2025 at 12:04 PM, V10 (Speech Language Pathologist) said he did an evaluation on R1 after a recent choking incident then indicated that R1 was on a mechanical soft diet, but he was unsure of any meat texture specifications. V10 added that he reviewed R1's records and spoke with staff who reported a previous choking episode in June 2025, so his evaluation was based off nursing documentation and what he was told by staff. V10 then said he will need to further assess consistencies with R1's swallowing before making any dietary recommendations. Therapeutic Diets policy last reviewed 03/07/205 provided by facility on 11/12/2025 indicated the facility will provide a therapeutic diet that is individualized to meet the clinical needs of a resident to achieve outcomes of care. These therapeutic diets should coincide with therapeutic diets on the facility's menu extensions.mechanically altered diets will be considered therapeutic diets . The dietician and dietary manager record in the resident's medical record significant information relating to the resident's response to his or her therapeutic diet.Dental soft (Mechanical Soft) policy dated 2022 provided by facility on 11/12/2025 indicated this consistency modified diet is for individuals with limited or difficulty in chewing regular textured foods. This diet may also be used by a speech language pathologist (SLP) in the treatment of dysphagia and needs to be individualized for specific food tolerances and modified, as needed, per recommendations from the SLP. As with any diet modification, this diet should be individualized to meet the resident's needs and chewing abilities. Meat is ground or chopped into bite-sized pieces (1/2 inch or smaller) . Some communities may further differentiate the mechanical soft diet by using mechanical soft chopped meats or mechanical soft ground meats.please contact Dinning for access to these diet spreadsheets. Please consult with your SLP if your community is using a mechanical soft chopped meat or mechanical soft ground meat for dysphagia.(Policy did not indicate that diced ham is an appropriate substitute for ground ham for mechanical soft diets)

Based on observation, interview, and record review, the facility failed to ensure the resident refrigerator was kept at a temperature at or below 41 degrees Fahrenheit. This applies to all residents in the building.The findings include:The facility's resident roster provided to surveyors on 9/9/25 showed 70 residents residing in the building.On 9/10/25 at 12:54PM, the resident food and drink refrigerator temperature was 44 degrees Fahrenheit. The refrigerator had many items of food and drink located in it.The facility's log for the resident food and drink refrigerator for September 2025 showed temperatures ranging from 44-48 degrees Fahrenheit from 9/1/25-9/10/25.On 9/10/25 at 1:07PM, V2 (Director of Nursing) stated, I believe night shift nurse's check the refrigerator temperature for the resident refrigerator. It should be below 42 degrees. If it's not, then they should adjust the dial in there and recheck it. V2 then obtained the form located on the front of the refrigerator and noted there are no directions for nurses to know what the acceptable temperature is or what actions to take if the temperature is not in a safe zone.The facility's policy titled, Foods Brought by Family/Visitors dated 3/29/24 showed, 10. All resident refrigerators will have an internal thermometer to monitor for safe food storage temperatures. Units must maintain safe internal temperatures in accordance with state and federal standards. If the temperature is not maintained at 41 degrees Fahrenheit or below, the food will be discarded .

Based on observation, interview, and record review, the facility failed to ensure hot liquids were served at a safe temperature for all residents residing in the facility, failed to ensure a resident was transferred with a gait belt for 1 resident (R41). The findings include:1) The facility's roster provided to surveyors on 9/9/25 showed 70 residents residing in the building.On 9/9/25 at 12:20PM, V3 (Dietary Manager) showed surveyor the facility coffee and hot water machine. V3 stated, The machine is set to 205 degrees Fahrenheit. That is set by the company that services it.On 9/9/25 at 12:26PM, R34,R45,R54, and R61 all had hot coffee served to them. All residents stated the coffee was too hot to drink and it needed to cool awhile before drinking it. The coffee was observed to be steaming in all 4 resident's mugs.On 9/10/2025 at 7:58AM, V3 obtained the temperatures of the hot coffee and hot water that was poured into the carafes and being taken out to the dining area. The hot coffee temperature was 173 degrees Fahrenheit, and the hot water was 154 degrees Fahrenheit. V3 stated, We don't have a process for hot liquids it just goes right from the machine that is always set at 205 degrees Fahrenheit and it goes straight to the carafe and out to the residents.On 9/10/25 at 8:08AM, The first resident was being served hot coffee. The temperature of the hot coffee was 170 degrees Fahrenheit, and the hot water was 138 degrees Fahrenheit. On 9/10/25 at 1:07PM, V2 (Director of Nursing) stated, I'm not sure if we do hot liquid assessments or what the safe temperature for hot liquids would be. You want it hot enough that it's enjoyable but not hot enough to burn them if they spill it.On 9/10/25 at 1:32PM, V5 (Regional Director of Operations) stated, We have never done hot liquid assessments for our residents. I'm not sure where we would even document that in our system. Our policy for serving hot liquids is 180 degrees or below are safe to serve to residents.The facility's policy titled, Safety of Hot Liquids dated 3/21/25 showed, Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission and on change in condition. Appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury .4. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include maintaining hot liquids serving temperature of not more than 180 degrees Fahrenheit .2) R41's electronic face sheet printed on 9/11/25 showed R41 has diagnoses including but not limited to history of falls, type 2 diabetes, chronic kidney disease, depression, and muscle weakness.R41's facility assessment dated [DATE] showed R41 has no cognitive impairment and requires substantial/maximal assist for ambulation.R41's physician's orders dated 5/14/25 showed, 1 assist, gait belt for all transfers.R41's fall risk assessment dated [DATE] showed R41 is a high fall risk.R41's care plan dated 6/3/25 showed, (R41) has limited physical mobility related to weakness, syncope, and assistance required for ambulation .(R41) is able to ambulate with restorative aide, gait belt, and her four wheeled walker.R41's nursing progress notes dated 8/15/25 showed, Patient was ambulating with her walker and tripped and fell. She bumped her back against the walker .Patient states her back is tender where she bumped it IDT (Interdisciplinary Team) reviewed the resident's fall. Root cause of fall determined to be unsteady gait/ambulation; resident being assisted to the toilet without a gait belt when ambulating .On 9/9/2025 at 1:27PM-, R41 stated, It was the middle of the night, and I had a girl come in and help me to the bathroom because I can't go on my own. I lost my balance and I fell towards my back and side area. I was walking with the walker because therapy said I could walk that far with the walker with help. She did not have the belt around me. I don't remember what I was wearing on my feet. I was either barefoot or had the slip-on shoes on. It all happened so fast. I fractured a few ribs. Now that I fell, they make sure they put the belt around me, and I continue to ask for help to get up. Before I came here, I was falling pretty much every week, if not more.The facility Incident Report Investigation dated 8/16/25 showed, On 08/16/25 at 5:35PM, (Local Imaging Company) called and faxed results of x-rays reveals subacute fractures of the lateral right 5th,6th and 7th ribs. Subacute is in healing stages, most likely fractures are related to falls prior to admission. Physician was called and faxed results.On 9/10/25 at 11:17AM, V6 (Certified Nursing Assistant) stated, I was transferring (R41) to the bathroom in the night, and she used her walker. I did not have a gait belt on her. She started to fall sideways, and I couldn't grab onto her fast enough and she fell on her bottom and then fell over to her side. I know I should have had the belt on her, but she is usually pretty steady so I didn't think it would be an issue.On 9/10/25 at 1:07PM, V2 (Director of Nursing) stated, Staff should have used a gait belt when transferring (R41) to help keep the resident steady and if they are going to fall then you have something to grab onto to either lower them safely or prevent the fall.The facility's policy titled, Safe Lifting & Movement of Residents dated 3/21/25 showed, In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents .4. Gait belts shall be used on residents unless residents are independent with ambulation, or supervision only, or contraindicated in the resident's care plan.

Based on observation, interview, and record review the facility failed to prevent cross contamination during incontinence care, thoroughly clean a glucometer and blood pressure wrist cuff after use, and ensure hand hygiene was completed during medication administration for 4 of 4 residents (R73, R1, R60, & R10) reviewed for infection control in the sample of 36.The findings include: 1. On 9/9/2025 at 10:5l AM, V12 Certified Nursing Assistant (CNA) answered R73's call light and stated she needed to get items to change the resident due to being incontinent of urine and stool. At 10:58 AM, V12 CNA, V15 CNA, and V14 CNA came into R73's room to provide care; they all applied gloves. V12 held up a blanket and sheet in front of the resident's groin while V14 provided care. R73 was incontinent of urine and stool. V14 washed R73's groin and penis folding over washcloth as she did it. V14 rinsed and dried R73's groin and penis. R73 stated he needed to use the urinal. V14 did not change her gloves after providing care or wash her hands. V14 went into R73's bathroom, brought his urinal back and gave it to him to use. V14 moved the blanket and sheet back for the resident to use the urinal. V12 took the urinal when he was done. V14 changed gloves. V14 grabbed a wet washcloth and towel and provided perineal care. V14 did not change her gloves. V14 grabbed a clean incontinence brief and laid it on top of the resident's blanket. V14 changed her gloves. R73 was turned onto his left side; he was incontinent of stool. V14 washed, rinsed, and dried his buttocks and anus. V14 did not change her gloves. V14 folded over the incontinence pad and pushed it under the resident. V14 pulled up the side of the incontinence brief and secured it in place. R73 was turned onto his other side. V12 washed and dried R73's left buttock. V12 changed her gloves and secured the incontinence brief in place. V12, V14, and V15 were asked when gloves were to be changed. V14 stated gloves are changed after care. V15 stated gloves were to be changed after being dirty and before touching anything clean. V12, V14, and V15 were asked what they saw during the care provided. V12 stated she saw V14 touch R73's blanket after providing care and she had not changed her gloves. V15 stated V12 provided incontinence care but did not change her gloves before putting the clean incontinence brief on the resident. On 9/10/25 at 2:41 PM, V2 Director of Nursing stated gloves are to be changed when going from dirty to clean and that is for infection control. The Face Sheet dated 9/10/25 for R73 showed diagnoses including right sided hemiplegia, Parkinson's Disease, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, cerebral infarction, type 2 diabetes mellitus, hypokalemia, dysarthria following cerebral infarction, paranoid schizophrenia, muscle weakness, insomnia, pneumonia, paroxysmal atrial fibrillation, dysphagia, and essential hypertension. The Minimum Data Set (MDS) dated [DATE] for R73 showed moderate cognitive impairment; dependent for personal hygiene; substantial/maximal assistance needed for shower/bath; and occasionally incontinent. The Care Plan dated 7/11/25 for R73 showed, Toileting: R73 is incontinent of bowel and bladder. R73 is dependent on staff for peri care, use of the bedpan, changing clothing, and linens as needed. The facility's Perineal Care policy (3/21/25) showed, the purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. Wash perineal area. Thoroughly rinse perineal area. Dry area thoroughly. Remove gloves and discard into designated container. Wash and dry hands thoroughly. Reposition the bed covers or clothing. Make the resident comfortable. 2. On 09/10/2025 at 11:23 AM, observed V4 (Licensed Practical Nurse) obtain R1's blood sugar in the resident's room. V4 then returned to her med cart and placed the glucometer in the top drawer of med cart then documented in R1's electronic administration record. At 11:25 AM, when asked by surveyor how and when the glucometer is disinfected, V4 said oh I forgot and after use then removed the glucometer from the top drawer and proceeded to wipe down the glucometer with a cavi wipe (germicidal disposable wipe) then placed the glucometer back into the top drawer. (V4 was not observed using this glucometer on any other residents.) R1's face sheet documented an admission date of 08/28/2025 with a past medical history not limited to type 2 diabetes mellitus. R1's active physician orders as of 09/11/2025 provided by facility showed orders to check blood glucose as need for signs and symptoms of hyper/hypoglycemia and to administer insulin lispro per sliding scale based off blood sugar obtained before meals and at bedtime. 3. On 09/10/2025 at 11:33 AM, observed V4 apply gloves to both hands while in R60's room then instilled one drop of refresh tears (carboxymethylcellulose sodium) to each eye. V4 then removed the gloves and threw them in R60's garbage can. V4 returned to the med cart and proceeded to document in R60's electronic administration record. Surveyor did not observe V4 perform any hand hygiene after removing the gloves. At 11:42 AM, V4 said she should have performed hand hygiene after removing her gloves/administering eye drops. R60's face sheet documented an admission date of 02/11/2022 with a past medical history not limited to dementia and hypertension. R60's active physician orders as of 09/11/2025 provided by facility showed orders instill one drop of refresh tears ophthalmic solution in both eyes three times a day for dry eyes. Review of R60's medication administration record on 09/11/2025 showed V4 documented administering R60's eye drops at the 12:00 PM scheduled dose time. 4. On 09/10/2025 at 11:36 AM, V4 said she needed to obtain a blood pressure reading for R10 prior to medication administration. V4 took a blood pressure wrist cuff from the top of med cart and proceeded into R10's room and obtained her blood pressure. V4 returned to the med cart and placed blood pressure wrist cuff on top of cart but did not observe V4 sanitize the cuff. V4 then prepped R10's blood pressure medication and administered the med to R10 at 11:38 AM. At 11:40 AM, V4 indicated that she cleans the cuff between residents with a cavi wipe. Surveyor did not observe V4 sanitize blood pressure wrist cuff during observation. (V4 was not observed using this blood pressure cuff on any other residents.) R10's face sheet documented an admission date of 012/17/2024 with a past medical history not limited to hypotension. On 09/11/2025 at 10:59 AM, V2 (Director of Nursing/Infection Preventionist) said hand hygiene should be performed after administering eye drops, removing gloves and/or in between residents to prevent spreading any infections. V2 added that resident equipment should wiped down with a cavi wipe and follow contact time per guidelines on back of container. V2 then indicted that V4 should have kept the glucometer and blood pressure cuff wrapped with a cavi wipe for two minutes after use to disinfect, and to prevent transmission of any germs between residents. Medication Administration policy provided by facility that was last reviewed 03/21/2025 reads in part, . staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable . Hand Hygiene policy provided by facility that was last reviewed 03/21/2025 reads in part, proper hand hygiene practices reduce the transmission of pathogenic microorganisms to residents, visitors, and other staff members. All personnel working in the long term care facility are required to wash or sanitize their hands before and after resident contact; . after removing gloves. Application of Eye Medication policy provided by facility that was last reviewed 03/21/2025 reads in part, the purpose of this procedure is to provided guidelines for the instillation of eye ointment or drops to treat eye infections and to soothe of lubricate the eye. steps in procedure included to .put on gloves.administer eye drops as prescribed.remove gloves and discard in designated container. Wash and dry your hands thoroughly. Super Sani-Cloth (germicidal disposable wipe) partial label photo provided by V2 (DON) showed, disinfects in 2 minutes. On 09/12/2025, obtained Sani-Cloth manufacture label guidelines (pdihc.com) to disinfect and deodorize that indicated to unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. Let air dry. (see attached manufacturer labels).

Based on interview and record review, the facility failed to obtain accurate weights for a resident, failed to implement dietician recommendations for a resident. These failures apply to 1 of 1 residents (R44) reviewed for nutrition in the sample of 36.The findings include:R44's electronic face sheet printed on 9/11/25 showed R44 has diagnoses including but not limited to cerebral infarction, peripheral vascular disease, flaccid hemiplegia, and absence of left leg above knee. R44's facility assessment dated [DATE] showed R44 has no cognitive impairment. R44's care plan dated 7/10/25 showed, (R44) is at risk for nutritional problems .RD (Registered Dietician) to evaluate and make diet changes recommendations as needed. On 9/9/25 at 3:13PM, R44 stated he thinks he has had some weight loss but isn't sure how much. R44 stated he gets weighed on a monthly basis. R44's weight log showed, 6/19/25 149.1lbs, 6/22/25 172.3lbs (23.2lb weight gain within 3 days), 7/7/25 150.8lbs (21.5lb weight loss within 15 days). No documentation was present in R44's electronic medical record showing R44 was re-weighed following his 6/22/25 or 7/7/25 weight. R44's RD note dated 8/14/25 showed, Notified by nursing resident triggers for weight loss. Resident continues on a general, regular diet. Insidious/significant weight loss last 30 days. Continue to monitor weekly weights Recommend to add to weekly weights x 4 weeks to monitor . On 9/11/25 at 10:25AM, V21 (Licensed Practical Nurse) stated, All weights and trends are handled by the wound care nurse. I don't see that (R44) is on weekly weights, if he was there would be an order for it. R44's physician's orders for September 2025 showed no orders for R44 to have weekly weights. On 9/11/25 at 11:12AM, V19 (Lead Certified Nursing Assistant) stated, I give the list out of all the weights at the beginning of the month to the aides and the list of weekly weights when they are due. (R44) is not on the list for weekly weights. V19 provided the current list of residents with weekly weights and R44's name was not present. On 9/11/25 at 11:32AM, V13 (Wound Care Nurse) stated, It is my understanding that when the RD makes recommendations, I will take them to the physician and get them approved by the physician and enter the orders and ensure they are implemented. If (R44) does not have an order for weekly weights and they are not being done, then we are not following the RD's recommendations. When the weights are entered into (computer system), it will trigger for significant weight loss or gain, and we should then re-weigh the resident to ensure accurate weights are obtained.On 9/11/25 at 12:05PM, V2 (Director of Nursing) stated, Weights are obtained monthly and as ordered by the physician. When the RD makes recommendations, we should be sending those recommendations to the physician for orders and then entering them into the residents chart.The facility's policy titled, Weight Assessment and Intervention dated 3/21/25 showed, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .4. Any weight change of 5% or more since the last weight assessment will be retaken for confirmation. If the weight is verified, nursing will notify the Dietician in writing .3. Interventions will be care planned and implemented where indicated and re-evaluated with next weighing .

Based on observation, interview, and record review, the facility failed to complete weekly wound assessments for a resident (R5), failed to identify a new pressure ulcer for a resident (R5), failed to develop a pressure ulcer care plan for a resident (R39). These failures apply to 2 of 4 residents reviewed for pressure ulcers in the sample of 36.The findings include:1) R5's electronic face sheet printed on 9/11/25 showed R5 has diagnoses including but not limited to vascular parkinsonism, dementia without behaviors, anxiety disorder, depression, mood disorder, and anemia. R5's facility assessment dated [DATE] showed R5 has mild cognitive impairment and has one stage 2 pressure ulcer. R5's care plan dated 6/13/25 showed, (R5) has pressure ulcers/skin breakdown related to advanced age resulting in natural thinning and fragility of skin, impaired cognition, unspecified dementia, impaired perfusion to the tissues, chronic kidney disease, need for assistance from staff with ADLs (Activities of Daily Living), and bowel and bladder incontinence resulting in excess moisture exposure to the skin. During a move skin probably slides to some extent against sheets or chairs. (R5) [NAME] maintains relatively good position in chair or bed most of the time but occasionally slides down resulting in friction and shear to skin low pressure air mattress to relieve pressure. R5's skin breakdown risk assessment dated [DATE] showed R5 is at risk for skin breakdown. R5's weekly wound assessment dated [DATE] showed, Right buttock stage 2 improving 20% yellow wound bed, no drainage 0.5cmx0.8cmx0.1cm (centimeters). No weekly wound assessments were present in R5's electronic medical record from 8/6/25-9/11/25. On 9/11/25 at 11:32AM, V13 (Wound Care Nurse) stated, I just started this position on Monday. (R5) has not been seen or had a wound assessment since 8/5/25 by our wound Nurse Practitioner. Wounds should be assessed at least weekly and with any changes. The nurse's are doing their treatments daily so they are looking at them but not doing a full assessment. I would assume they would let someone know if the wound has worsened but I honestly have no idea what it looks like. On 9/11/25 at 1:18PM, V13 performed a wound assessment for R5. R5's pressure ulcer measured 2cmx0.5cm with no drainage and wound bed was pink. During this observation, surveyor identified a new, open pressure ulcer. V13 obtained measurements of 0.5cmx0.5cm with no drainage and stated this would be classified as a stage 1 pressure ulcer. V13 stated she was not notified prior to this assessment of any new skin concerns for R5. On 9/11/25 at 1:32PM, V5 (Regional Director of Operations) stated, We have not been getting the weekly wound assessments done for (R5) but I'm not sure why because everyone else gets seen that needs to. If a wound is open then I believe that is a stage 2, not a stage 1. The facility's policy titled, Skin Conditions-Wound Policy dated 2/7/25 showed, To provide proper monitoring, treatment, and documentation of any resident with skin abnormalities .all caregivers are responsible for preventing, caring for, and providing treatment for skin ulcerations .Assessment protocols .2. Measurements must be completed weekly by the same licensed person when at all possible. 3. At the time a skin issue is discovered it must be measured . 2. R39's admission Record (Face Sheet) showed an initial admission date of 3/22/19 with diagnoses to include but not limited to dementia, morbid obesity, and cellulitis. R39's 3/18/25 Nurse Practitioner Wound Care note showed she had a new deep tissue injury to her right heel. The wound note showed, Heels: offload with heel protector or pillow. R39's 9/9/25 Wound Care note showed she had a deep tissue injury to her right heel. The wound note showed, Heels: offload with heel protector or pillow. R39's Care Plan showed no specific care plan for her deep tissue injury, only a pressure ulcer prevention care plan. R39's care plan showed, [R39] has the potential for pressure ulcer development, skin break down, and impairment to skin integrity. The care plan showed no specific intervention to offload her heels only, [R39's] heels will be kept free of pressure as resident allows. Date Initiated: 09/25/2020 and I require Pressure relieving/reducing device on bed/chair. Date Initiated: 03/27/2019. R39's Physician Orders showed no order to offload her heels. On 09/11/2025 at 8:37 AM, V18 Certified Nursing Assistant (CNA) stated she references CNA charting for pressure injury interventions. V18 stated the CNA charting pulls information from the nursing care plan. V18 stated she does offload R39's heels while she is in bed. On 9/11/2025 at 8:41 AM, V8 CNA stated the CNA charting pulls from the nursing care plan, which provides the CNA's with pressure injury interventions such as offloading. V8 stated she does offload R39's heels when she is in bed. On 9/11/2025 at 10:34 AM, V13 Wound Care Nurse stated typical interventions for residents at risk for pressure injuries would be chair cushions, air mattresses, repositioning, and offloading. V13 said offloading a resident heels would be a typical intervention for a resident at risk for pressure injuries to their heels. V13 stated CNAs are made aware of interventions through the care plan. V13 stated, if a resident has a pressure injury, they should have a specific care plan showing the resident has pressure injuries as well as the interventions to address the injuries. V13 stated R39 does not have this type of care plan, she does not have an intervention to offload heels, and she should have both. V13 stated the purpose of these care plan interventions are to promote wound healing. V13 stated R39's heel wound is improving.

The facility failed to ensure hospice interventions were implemented as ordered for 1 of 1 resident (R6) reviewed for hospice in the sample of 36. The findings include:On 9/9/25 at 9:48 AM, R6 was laying on her left side in bed asleep. R6 had an air mattress in place that was not turned on. The setting on the sir mattress was set at 6. V12 Certified Nursing Assistant (CNA) was in the hall and was asked to check R6's air mattress. V12 confirmed the air mattress was not on and stated it should be turned on. V12 stated she did not know what the setting on the air mattress should be and would check with the nurse. On 9/9/25 at 10:34 AM, V10 Licensed Practical Nurse (LPN) stated R6 had the air mattress because hospice recommended it. V10 stated R6 had the air mattress due to her weight; she is small and bony. V10 stated the air mattress is to prevent pressure injury. On 9/9/25 at 10:36 AM, V13 LPN stated she flipped the switch on the air mattress and the green light came on. V13 confirmed the air mattress works; however, it had not been turned on. The Physician Orders for R6 dated September 2025 showed she was admitted to hospice on 8/18/25. The air mattress setting order was obtained on 9/9/25 and stated to set the mattress at 3. On 9/10/2025 at 2:41 PM, V2 Director of Nursing (DON) stated R6 has an air mattress that was provided by hospice because she is frail. V2 stated they called hospice for the settings for the mattress yesterday. On 9/11/2025 at 9:44 AM, V10 LPN stated when someone goes on hospice they deliver the equipment including the mattress that night or the next day. It is usually done quickly. V10 stated she did not know anything about ha hospice care plan for R6. On 9/11/25 at 9:53 AM, V10 stated she found out that the hospice notes have categories listed on them and a care plan. The Hospice Note dated 9/3/25 for R6 did not show any information related to the air mattress on her bed or plan of care related to the air mattress. The facility's Care Plan dated 9/7/25 for R6 did not show she was receiving hospice care, R6's care plan was revised on 9/10/25 under the risk for pressure ulcers/skin breakdown focus to show she has a low air loss mattress, but it did not include the setting for the mattress. The Face Sheet dated 9/11/25 for R6 showed diagnoses including dementia, muscle weakness, dysphagia, abnormal posture, osteoarthritis, restlessness, agitation, severe vascular dementia with mood disturbance, unspecified psychosis, hyperlipidemia, hypertension, hypothyroidism, and aortic valve stenosis. On 9/11/25 a policy regarding hospice was requested, no policy available.

Based on interview and record review, the facility failed to ensure that a cognitively impaired resident was treated with dignity and respect by not preventing a staff member from communicating to the resident (R1) in an inappropriate and unprofessional manner while providing personal care services. This failure affected 1 of 4 (R1) residents reviewed for dignity in a sample size of 4. Findings include: R1's medical record indicated that resident last admitted to the facility on [DATE] with a past medical history not limited to: hypertension, dementia, anxiety, and urinary tract infection. R1's Minimum Data Set (MDS) Section C for cognitive patterns dated 02/19/2025 documented that R1's cognition is severely impaired. Review of facility's final incident report with incident date of 02/26/2025 at 1300 (1:00 PM) revealed that a comment was overheard outside the beauty salon. It was reported that the beautician [V3] stated to a resident, you b***h about a lot. Beautician was removed and investigation initiated. Beautician states that the comment was in relation to the resident having a difficult day complaining about several things in the time she was in the salon .The beautician relays the comment was a statement to engage the resident in what was going on not to inflict any type of harassment or threat. She admits she should have used complain not b***h. Interviews with resident involved revealed no issues and no recall of incident. R1's progress noted dated 02/26/2025 at 13:22 (1:22 PM) documented, there was an incident with the hairdresser which is being addressed by Administrator. [Medical Doctor] notified. Administrator notifying family. On 03/05/2025 at 12:55 PM, V3 (Beautician) said on the day of the incident, she was trying to have a conversation with R1 while she (V3) was doing her hair but R1 wasn't happy and complained that V3 was hurting her and that she didn't want to have her hair done. V3 said that R1 was extra cranky because of her recent surgery. V3 (Beautician) said while she attempted to wash R1's hair, that R1 continued to complain so V3 asked R1 if she likes to b***h. V3 then said that she called V8 (Family Member) and asked her to talk with her mother (R1) so that she could finish doing R1's hair. V3 (Beautician) added that she talks like a sailor and thought she knew R1 well enough to talk openly to her. V3 also said that she apologized to R1 and to V8 (Family Member) for her poor word choice and should not have used the word b***h. On 03/05/2025 at 01:16 PM, V8 (Family Member) who is R1's daughter said that R1 has dementia and can't remember having her hair done from week to week. V8 then said the facility contacted her and indicated that V3 (Beautician) was asked to leave the facility because she was overheard making an inappropriate comment to R1. V8 added that she was not upset with V3's (Beautician) poor word choice because she knows R1 complains often due to her cognition. On 03/05/2025 at 01:40 PM, R1 was observed lying in bed resting. R1 did not recall alleged incident and was not interviewable due to impaired cognition, alert to self only. On 03/05/2025 at 02:02 PM, V1 (Administrator) said she was told that V3 (Beautician) said something along the lines of, do you like to b***h a lot? V1 added that she went to the beauty parlor, spoke with R1 in private but she couldn't recall what was said to her. V1 (Administrator) then informed V3 about their abuse policy and escorted her out of the building and initiated her investigation. When asked if it is the facility's responsibility to ensure that all staff are trained and are knowledgeable in how to react and respond appropriately to a resident and/or resident behavior, V1 (Administrator) said staff attend abuse in-services upon hire and annually. V1 added that it is her expectation for staff to be in control of their behavior, behave professionally, and understand how to work with the nursing home population. On 03/05/2025 at 02:25 PM, V1 (Administrator) said V3 (Beautician) last attended an abuse in-service in October of 2024, then said upon V3's hire, the previous administrator should have gone over the abuse policy, conducting herself in a professional manner when working with nursing home residents, and the expected customer service etiquette. Resident Rights policy with last review date of 03/29/2024 reads in part: To ensure that resident rights are respected and protected. To inform residents of their rights and provide an environment in which they can be exercised . Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Copies of our resident rights are posted throughout the facility, and a copy is provided to each employee upon hire. Each employee has a duty to read and learn the residents' rights .Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights .The resident has the right to be treated with consideration, respect and full recognition of his or her dignity and individuality, including privacy in treatment and in care for his or her personal needs. (Never use nicknames, such as Honey, Sweetie, Gramps, or Cutie. Nicknames show disrespect for the person).

Based on interview and record review the facility failed to ensure a resident's peripheral intravenous access site was flushed for 1 of 1 residents (R1) reviewed for intravenous catheters in the sample of 5. The findings include: R1's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include hypertension, systemic sclerosis, chronic heart failure, hepatic failure, atrial fibrillation, and reduced mobility. R1's February 2025 eMAR (electronic Medication Administration Record) showed an order for Sodium Chloride Solution 0.9%, use 10 ml intravenously every 8 hours for flush from 2/1/25 through 2/10/25. This eMAR shows R1's IV flush was not completed on the overnight shift on 2/2/25, 2/3/25, 2/6/25, and 2/7/25. R1's eMAR notes showed these were not completed due to not having an RN (Registered Nurse) available to administer them when they were scheduled. On 2/26/25 at 10:08 AM, V5 LPN (Licensed Practical Nurse) said R1 was on an intravenous push antibiotic that the facility's RN's were taking care of. V5 said, This facility does not allow LPNs to do the flushes. If necessary, they (RNs) would come in . On 2/26/25 at 11:22 AM, V7 LPN said she can not do peripheral line intravenous flushes because the facility does not allow LPN's to administer them. On 2/26/25 at 11:55 AM, V2 DON (Director of Nursing) said, LPNs can not flush here. Typically if we have someone here on an IV antibiotic we try to make sure that it is every 24 hours to make sure we can meet their needs. As far as RN coverage, if there is no RN available, myself or the other RN managers comes in to pick it up and do the IVs. We try to get the flushes at the same time as RN coverage but it doesn't always work out . Some of [R1's] flushes were missed. The ones that were missed were mostly night shift because my night shift RN called off. They should have called the on-call to let them know the RN called off. The on-call would have let us know so that myself or one of our other administrative RNs could come in . The facility's policy and procedure regarding peripheral IV access maintenance and flushing was requested. On 2/26/25 at 1:00 PM, V3 DON said the facility does not have such a policy that covers the maintenance of peripheral IVs. The facility's policy and procedure titled Catheter Insertion and Care with revision date of July 2016 showed, Insertion of Peripheral IV Catheter . Policy: Peripheral IV catheters will be inserted by nurses with demonstrated competency in IV therapy

Based on observation, interview, and record review the facility failed to provide a homelike environment for 4 of 4 residents (R1, R2, R6, R7) reviewed for residents rights in the sample of 8. The findings include: R1's face sheet showed she was admitted to the facility 9/14/22 with diagnoses to include acute respiratory failure with hypoxia, hemiplegia and hemiparesis following cerebrovascular disease, Type 2 diabetes, hypertension, hyperlipidemia, bipolar disorder, and anxiety disorder. R1's facility assessment dated [DATE] showed she has no cognitive impairment. R2's face sheet showed he was admitted to the facility 12/9/22 with diagnoses to include atherosclerotic heart disease, Type 2 diabetes, acute cystitis without hematuria, hyperlipidemia, mood disorder, anxiety disorder, and depression. R2's facility assessment dated [DATE] showed he has no cognitive impairment. R6's face sheet showed he was admitted to the facility 9/1/16 with diagnoses to include epilepsy, abnormalities of gait and mobility, major depressive disorder, peripheral vascular disease, and osteoarthritis. R6's facility assessment dated [DATE] showed he has no cognitive impairment. R7's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include acute kidney failure, hypertension, hyperkalemia, dehydration, and major depressive disorder. R7's facility assessment dated [DATE] showed she has no cognitive impairment. On 12/20/24 at 1:01 PM, R6 said I am the resident council president. We have been asking about a clock in the dining room. You look at the clock to see when the next thing is going to be. They said they haven't replaced it because it has something to do with the scheme of the decorations. We don't know why we can't just get a solid color or something . Someone went and got a small digital clock and put it next to the sink in the corner yesterday but you can't see it. The one that was in there at one time was very big and easy to see. It had fallen off the wall and broke. That was a long time ago. When I took over as resident council president, the previous president had been trying to get a clock in the dining room too. I've been president for over a year now. A long while ago there were two clocks but we just want one. I want to be able to know what time it is, how long before the next activity, how long until a meal, I'm pretty active here and doing things all the time. We discuss this at almost every resident council meeting and we will be discussing it at the next one as well. On 12/20/24 at 10:39 AM, R1 said, . They told us we can't have a clock in the dining room because it doesn't 'fit with the decor'. We really would like one in the dining room but they basically said 'screw you, you aren't getting one' . We [the residents] offered to purchase the clock ourselves but she said no. We want a clock for during meals, during resident council meetings, and during activities . On 12/20/24 at 10:51 AM, R2 said, There is no clock in the dining room because the regional lady said she is not going to repair or replace decorations . we want one in the dining room so we can tell what time it is and know if you need to finish up what you are doing so you can get to an appointment or something. People just like to know what time it is in general. It has been discussed in resident council meetings and the regional lady was there. On 12/20/24 at 1:32 PM, R7 said, We need a clock in the cafeteria. We all talk about needing a clock in the dining room all the time. The person who owns this place thinks its too 'tacky' to have a clock. We talked about it in resident council. There still isn't a clock in there that I know of. We want a clock in there so we can see what time it is. We are in there a long time . we just would like to know what time it is. On 12/20/24 at 1:22 PM, V4 (Activity Aide) said, The residents are always asking what time it is and complain to me that there is no clock in the dining room during activities. I told them they should bring it up in resident council and they have said that they have brought it up before. A resident bumped into it and it fell and broke. It was never replaced and I don't know why. They just want to see the time. If they had a clock in there it would help them with activities. I was here on Wednesday (12/18/24) and that little digital one was not in there. I was off yesterday so when I came in today, I saw one of the other staff members showing a resident that it was there today. On 12/20/24 at 2:35 PM, V1 (Administrator) said she was looking through old resident council meeting notes and she saw the residents were asking about a clock in February 2024. V1 said it was decided at the time (February 2024) that a clock is a decoration and so it would not be replaced. V1 said one of the meetings she has been invited to since she became the administrator (7 months ago) the dining room clock was brought up again but she was unable to recall what was discussed other than that the issue had been resolved. On 12/20/24 at 2:35 PM, V9 (Regional Director of Clinical Operations) who was present during V1 (Administrator's) interview interjected a clock is a decoration and would not be replaced. V9 said the issue of the resident's wanting a clock in the dining room was resolved previously. V9 said it was not resolved to the satisfaction of the residents because there was no clock placed in the dining room. V9 said the resolution was that resident's were told they can ask a staff member what time it is, the facility could assist the resident in obtaining a watch by contacting their power of attorney and requesting a watch, or the residents can go back to their room or another area of the facility and check the time. V9 said the small digital clock was placed in the dining room the day before the surveyor came into the facility. The State of Illinois Residents' Rights for People in Long-Term Care Facilities booklet with revision date of 5/18 showed, . You have the right to . Your facility must provide services to keep your physical and mental health, and sense of satisfaction .

Based on observation, interview, and record review the facility failed to ensure dishes were submerged in the sanitizing sink for at least 60 seconds and failed to ensure sanitized dishes were handled with clean hands. This has the potential to effect all 66 residents residing in the facility. The findings include: The CMS 671 dated 7/29/24 shows that there are 66 residents residing in the facility. Facility provided Diet Type Report dated 7/30/24 shows that there are no residents that receive a tube feeding and all residents receive food and drinks from the dietary department. 1. On 7/29/24 at 9:27 AM, V12 (Dietary Manager) used a chemical sanitizer test strip on a coffee mug after a cycle through the dish machine and the test strip showed there was no sanitizer being run through the machine. At 9:31 AM, V12 tried a second attempt and the test strip still showed there was no sanitizer being run through the machine. V12 then went to get maintenance to fix the dish machine. If the dish machine cannot be fixed, V12 said that staff will use the three-compartment sink to wash and sanitize the dishes until it gets fixed. On 7/29/24 at 9:35 AM, V16 (Dietary Aide) said the dish machine sanitizer concentration was tested at around 9:15 AM and read 100 parts per million (ppm). On 7/29/24 at 10:06 AM, V12 told V16 to start using the three-compartment sink to get the dishes from breakfast washed. On 7/29/24 at 10:17 AM, V16 began washing four water pitchers with lids in the three compartment sink. After washing and rinsing the first pitcher, V16 dipped it in the third sink filled with sanitizer solution, removed it immediately, and placed it in a rack to dry. V16 did the same thing with the second and third pitchers. With the fourth pitcher, V16 dipped the pitcher twice and removed it from the sanitizer sink and placed it in a rack to dry. When finished with the pitchers, V16 washed the pitcher lids in the first sink, tossed them into the sanitizer sink, and removed them after less than 30 seconds in the sanitizer solution. At 10:29 AM, V16 began to remove the pitchers with lids from the rack to put them away. When V16 grabbed two of the pitcher lids, they fell from V16's hands and into the garbage underneath the three-compartment sink where they were left to dry. V16 proceeded to grab the pitcher lids from the garbage, put the lids into the wash sink, and continued to put away the rest of the sanitized dishes left on the rack without washing her hands. On 7/29/24 at 11:03 AM, V12 said employees should wash their hands before handling sanitized dishes after they have touched or handled the trash. 2. On 7/29/24 at 11:16 AM, V15 (Cook) began to puree food for lunch. V15 started with the hamburgers. At 11:28 AM, V15 finished the pureed hamburgers and brought the food processor container, food processor lid, and food processor blade to the three-compartment sink. V15 first washed and rinsed the food processor container and placed it into the sanitizer solution. V15 then washed and rinsed the lid and the blade and placed them into the sanitizer solution. All items were removed at 11:30 AM and the blade and lid were left in the sanitizer solution for less than 30 seconds. On 7/29/24 at 11:32 AM, V15 began to puree the green beans for lunch. At 11:37 AM, when finished with the green beans, V15 brought the food processor container, food processor lid, and food processor blade to the three-compartment sink. V15 started with washing and rinsing the food processor lid and placing it into the sanitizer solution. V15 then washes and rinses the blade and places it into the sanitizer solution. V15 washed and rinsed the food processor container and then placed it into the sanitizer solution. V15 removed the food processor container after approximately being in the sanitizer solution for ten seconds while all other items remained in the solution for at least one minute. On 7/29/24 at 11:03 AM, V12 said items should be submerged in the sanitizer solution for at least 60 seconds before being removed. Facility Cleaning Dishes - Manual Dishwashing policy dated 5/18/2017 states, . Sanitize dishes: . 3. Place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer (or see chart below) . The below chart states when quaternary ammonium sanitizer is used, the necessary contact time is per the manufacturer. Product label for the facility sanitizer states, Food Contact Surface Sanitizing Performance: This product is an effective food contact sanitizer in 1 minute at 1 fl. oz. (fluid ounce) per 4 gal. (gallon) of 500 ppm (parts per million) hard water (200 ppm active) on hard non-porous surfaces .

Based on observation, interview, and record review the facility failed to ensure residents receiving a pureed diet received a full four ounce (oz) scoop of pureed hamburger. This applies to 4 of 4 residents (R26, R24, R8, R55) reviewed for pureed diets in the sample of 17. The findings include: Facility Diet Type Report shows R26, R24, R8, and R55 receive pureed diets. Facility provided list of residents that use a three-compartment plate shows R26, R24, R8, and R55 receive their pureed meals in a three-compartment plate. On 7/29/24 at 11:59 PM, pureed bread, mashed potatoes, pureed green beans, and pureed hamburger were at the service line for pureed residents. The mashed potatoes, pureed green beans, and pureed hamburgers all had a 4 oz scoop. The pureed bread had a 1 oz scoop. All scoops were the correct sizes. On 7/29/24 between 12:00 PM and 12:45 PM, V15 (Cook) served and plated lunch for the facility. The portion sizes for residents receiving pureed foods in three-compartment plates appeared small. V15 would place the pureed bread and pureed hamburger in one compartment, the pureed green beans in the second compartment, and the mashed potato in the third compartment. On 7/29/24 at 12:58 PM, facility provided test tray of the pureed meal consisted of green beans in one compartment, mashed potatoes in the second compartment, and the pureed bread and pureed hamburger sharing the third compartment. On 7/29/24 at 1:40 PM, V15 said to accommodate putting all four pureed items into the three-compartment plate, V15 put one full scoop of pureed bread and approximately a half scoop of pureed hamburger into the same section. On 7/31/24 at 11:35 AM, V14 (Dietary Manager) said V15 should have provided each resident with one full scoop of pureed hamburger.

Based on observation, interview and record review the facility failed to ensure opened, multi-dose vials/bottles of medication, including insulin pens and eye drops, were labeled with expiration dates for 5 of 5 residents (R15, R23, R41, R59, R14) reviewed for medication storage in the sample of 17. The finding include: R15's July 2024 Order Summary Report showed a physician order for R15 to receive 40 units of Glargine insulin, SQ (subcutaneously), twice a day. R23's July 2024 Order Summary Report showed a physician order for R23 to receive 14 units of Fiasp insulin, SQ, three times a day, before meals. R41's July 2024 Order Summary Report showed physician orders for R41 to receive 100 units of Tresiba insulin, SQ, at bedtime, and 6 units of Lispro insulin, SQ, before meals and at bedtime. R59's July 2024 Order Summary Report showed a physician order for R59 to receive 55 units of Lantus insulin, SQ, twice a day. R14's July 2024 Order Summary Report showed a physician order for R14 to receive one drop of Latanoprost eye drops, to both eyes, once a day at bedtime. On 7/29/24 at 9:50 AM, the 100-wing medication cart of the facility was reviewed with V2 (Director of Nursing/DON). The following medications were found opened, with no identified expiration dates, by this surveyor and V2 (DON): one Glargine insulin pen for R15, one Fiasp insulin pen for R23, one Tresiba insulin pen and one Lispro insulin pen for R41, one Lantus insulin pen for R59, and one bottle of Latanoprost eye drops for R14. V2 (DON) stated insulin pens and bottles of eye drops are to be dated when opened so staff know when the medication expires. The facility's Medication Administration policy dated 7/28/23 showed, The expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi-dose container, the date opened shall be recorded on the container. The facility's Insulin Administration policy dated 7/28/23 showed, Check the expiration date, if drawing from an opened multi-dose vial. If opening a new vial, record expiration date on the vial .

Based on observation, interview, and record review the facility failed to ensure mechanically altered diets were the appropriate consistency. This failure resulted in R10 requiring emergency care after choking on pizza. This applies to 1of 19 (R10) residents reviewed for mechanically altered diets in the sample of 19. The findings include: The facility face sheet for R10 shows diagnosis to include chronic obstructive pulmonary disease, dysphagia and history of cerebral infarction. The facility assessment dated [DATE] shows R10 to be cognitively intact and requires limited assistance with eating. The Physician Order Sheet dated April 2023 shows R10 was ordered a mechanical soft texture diet. A nursing progress note dated 4/15/2023 shows R10 was feeding himself his dinner and was heard by staff to be coughing and spitting out mucous and pieces of pizza. The note goes on to show R10 was breathing but his airway sounded constricted, so the Heimlich maneuver was attempted with no success. 911 was called and R10 was taken to the hospital. A second note later that same day shows the emergency room staff reported to the facility the emergency medical services (EMS) team used forceps to remove a piece of pizza from R10's throat and R10's breathing was much better. R10 was being admitted to the hospital for observation. On 8/16/23 at 4:33 PM, V10 Certified Nursing Assistant (CNA) said she was watching the residents eat in the dining room that night. V10 said all the residents received pizza for dinner and the pizza was very crispy and a lot of the residents were needing help getting it cut up so they could chew it. V10 said she heard R10 coughing and was spitting out phlegm and pizza. V10 said R10 told her he was fine, but she went and got the nurse anyway. V10 said it sounded like his airway was obstructed but was still breathing. V10 said the nurse did preform the Heimlich but no food came out. 911 was called and R10 was taken to the hospital. V10 said she talked with the cook that night after the incident and he told her that the pizza got too crispy when he cooked it. On 8/16/23 at 2:14 PM, V9 cook said, I was the cook serving the food that night and R10 was on a mechanical diet. The menu showed to serve the pizza softened. The menu's never say to cut up the mechanical soft meals. I used the convection oven for the pizza, and it crisped it up real nice. In hindsight the pizza was to firm for his needs, I'm used to working in restaurants. On 8/16/23 at 1:28 PM, V3 Dietary Manager (DM) said the facility no longer serves pizza to the residents. V3 said the pizza was too difficult to chew for R10 and should have been cut up for him. On 8/16/23 at 1:44 PM, V5 Dietician said if a resident is on a mechanical soft diet the food should be cut up into small pieces, there is a greater risk of choking for a resident with swallowing difficulty and being served whole foods. The facility kitchen staff should follow the menu and the recipes. On 8/17/23 at 8:40 AM, V12 Speech Therapist said I would expect mechanical soft foods to be ground meats and soft breads, not hard or crunchy. V12 added pizza should be soft doughs, with the meats ground up. The Speech Therapy notes dated 4/10/2023 for R10 shows a recommendation of mechanical soft textures and thin liquids with occasional supervision. The local hospital emergency documentation dated 4/15/2023 shows EMS removed a foreign body with a laryngoscope and forceps from R10's throat. R10 was admitted to the hospital for observation. The follow up Physician note dated 4/24/2023 shows R10 was sent to the hospital on 4/15/2023 for an aspiration event and a foreign body was removed. R10 was treated with antibiotics and evaluated by speech therapy. The facility menu for 4/15/2023 shows pizza was served to the residents. The menu for the residents eating a mechanical soft diet shows moist pizza with ground meat. The recipe for sausage pizza provided to me by the facility shows using biscuit mix, add water and form a crust and place into pans. The directions goes on to show to bake the pizza in a conventional oven.

Based on observation, interview and record review the facility failed to implement infection control policies and recommendations from the Centers of Disease Control (CDC) regarding isolation of COVID-19 residents related to cohorting of COVID-19 residents, ensuring signage for the specific use of PPE (personal protective equipment) was posted, and ensuring staff wore the appropriate PPE to prevent the spread of COVID-19. These failures have the potential to infect high risk residents with COVID-19 and spread the disease of COVID-19 to negative residents. This applies to 11 of 11 residents (R1-R11) reviewed for infection control in the sample of 11. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when the facility began receiving positive COVID-19 results. The Immediate Jeopardy was identified on [DATE]. V1 (Administrator) was informed of the Immediate Jeopardy on [DATE]. This surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on [DATE], however, noncompliance remains at a Level 2 because additional time is needed to evaluate the implementation and effectiveness of the in-service training. The findings include: The facility's Resident Roster dated [DATE] showed there were 62 residents residing in the facility. The Roster showed that 18 residents are COVID-19 positive and 9 residents are listed as Patients Under Investigation (PUI's), for COVID-19 due to exhibiting COVID-19 symptoms or being exposed to a resident that is COVID-19 positive. An email dated [DATE] to the Illinois Department of Public Health showed that as of [DATE], 24 residents and 11 staff members had tested positive for COVID-19. The email also showed one resident with COVID-19 had expired. 1. The Resident Roster dated [DATE] showed R2, R4, and R5 were listed as PUI's. On [DATE] at 9:15 AM, an initial tour of the facility's locked memory care unit was completed with V3 Certified Nursing Assistant (CNA). R4 was seated in her room with her door open. An isolation/PPE cart was placed in hallway by R4's door. No isolation signage was noted on R4's door. When V3 CNA was asked about the isolation cart outside of R4's door, V3 stated, She (R4) is supposed to have a droplet isolation sign on her door. She is on isolation because her roommate tested positive for COVID-19 last night and was moved to the COVID unit. If you go in her room, you need to wear a gown, surgical mask over your N-95 mask, gloves and a face shield. On [DATE] at 9:18 AM, R2 was seated in her room with her door open. No isolation signage was noted on R2's door. V3 CNA stated, (R2) is supposed to be on droplet isolation too. Her roommate tested positive for COVID-19 this weekend. On [DATE] at 9:25 AM, this surveyor and V3 CNA observed V5 (Hospital Phlebotomist) enter R2's room with only an N95 mask and goggles on. V3 CNA made no attempt to inform V5 that R2 was a patient under investigation for COVID-19 and on droplet isolation. At 9:35 AM, V5 exited R2's room. When V5 was asked why she did not don the PPE required for droplet isolation, V5 stated, I was just here to draw (R2's) blood. I was not aware she is on droplet isolation. There is no isolation sign on her door. On [DATE] at 9:28 AM, R5 was seated in her room with her door open. No isolation signage was noted on R5's door. V3 CNA stated R5 should be on droplet isolation because R5's roommate had recently tested positive for COVID-19. On [DATE] at 9:30 AM, V4 Registered Nurse stated, We are not even supposed to have PUI's on this unit (memory care unit). (R2, R4, and R5) are supposed to have droplet isolation signs on their doors. Before you enter their rooms, staff must wear an N-95 mask covered by a surgical mask, a gown, a face shield, and gloves. On [DATE] at 10:20 AM, V2 Director of Nursing (DON)/Infection Preventionist stated, We currently have PUI overflow residents on our memory care unit. All PUI residents are on droplet isolation and should have an isolation sign on their door. Prior to entering a PUI room, staff must don a surgical mask over their N95 mask, gown, face shield and gloves. We assume all PUI residents are COVID-19 positive due to being exposed or having symptoms. 2. The Resident Roster dated [DATE] showed R1, R10, and R11 were listed as COVID-19 positive. The Roster also showed R6-R9 were listed as PUI's. R6's COVID-19 test dated [DATE] showed R6 was negative for COVID-19. R7's COVID-19 test dated [DATE] showed R7 was negative for COVID-19. R8's COVID-19 test dated [DATE] showed R8 was negative for COVID-19. R9's COVID-19 test dated [DATE] showed R9's results as inconclusive for COVID-19. On [DATE] at 9:50 AM, a tour of the facility's PUI rooms was completed with V2 Director of Nursing (DON)/Infection Preventionist. No isolation signage was noted on the entry doors of the PUI unit. No isolation signage was noted on the doors of the PUI rooms. On [DATE] at 9:52 AM, on the PUI unit, R6 and R7 (both PUI residents/COVID-19 negative) were seated their room with the door to their room open. R6 and R7 were not wearing masks. Directly across the hall from R6 and R7's room, R11 (COVID-19 positive) was seated in their room with the door to his room open. R11 was not wearing a mask. On [DATE] at 9:54 AM, on the PUI unit, R8 (PUI resident/COVID-19 negative) and R9 (PUI resident/COVID-19 inconclusive result) were seated in their room with the door to their room open. R8 and R9 were not wearing masks. Directly across the hall from R8 and R9's room, R10 and R11 (both COVID-19 positive) were seated in their room with the door to their room open. R10 and R11 were not wearing masks. On [DATE] at 9:55 AM, V2 DON stated, Yes, we do have COVID positive residents on the PUI unit. We just haven't had time to move them to the COVID unit yet. On [DATE] at 3:15 PM, V2 DON stated, The COVID-19 negative residents in the PUI unit should have been separated immediately from the COVID-19 positive residents on the PUI unit. (V1 Administrator) had asked one of our nurses to move the plastic barrier wall that separates the COVID-19 unit and PUI unit to incorporate 2 more (COVID-19 positive rooms) this weekend. It was overlooked and never got done. The doors of the rooms of COVID-19 positive residents should be closed. If they can't be closed due to safety reasons, the residents should have a mask on. On [DATE] at 12:28 PM, V12 Medical Director stated, The facility is currently in the middle of a COVID-19 outbreak. I know they had multiple positive cases turn up over the weekend .If a resident becomes symptomatic, tests positive for COVID-19, or is a PUI, they should immediately be placed on droplet isolation with a sign on the door of their room. Doors of COVID-19 positive residents should be shut. If they can't have the door shut, the residents need to wear masks. COVID-19 positive residents should be in a separate area from PUI residents, not across the hallway. On [DATE] at 11:35 AM, V14 County Public Health Administrator stated, Any resident that receives an inconclusive result on their COVID-19 test should be treated like they are positive. They should not be cohorted with a resident that is COVID-19 negative or positive. That resident should be isolated in his/her own room. They should be retested immediately. On [DATE] at 11:43 AM, V1 Administrator stated R8 and R9 should not have been cohorted or in the same room since R9's COVID-19 test result dated [DATE] was inconclusive. V1 stated, Since (R9's) result was inconclusive, we would be unsure if she has COVID-19. The facility's COVID-19 Outbreak Control Policy dated [DATE] showed, A resident with known or suspected COVID-19, immediate infection prevention and control measures will be put in place .c. In any event a resident with suspected or unconfirmed COVID-19 should not be cohorted with residents who are known to be positive for active COVID-19 disease until such a time as they are confirmed to be positive through [DIAGNOSES REDACTED]-CoV2 testing .f. Place resident on both contact and droplet precautions . The Immediate Jeopardy that began on [DATE] was removed on [DATE], when the facility took the following actions to remove the immediacy: 1. Corrected cohorting as of [DATE]. 2. In-servicing on proper resident cohorting in accordance with CDC guidance started on [DATE] and completed on [DATE] for all admissions staff, supervisory staff, and nursing staff. Staff will not be allowed to return to work until completed. 3. Corrected isolation signage on [DATE]. 4. Implemented on [DATE], a facility checklist for resident admissions or room moves to ensure all necessary steps up to, including isolation signage, is completed. To be reviewed by the DON and Administrator with validation through observation per occurance. 5. Re-inservicing all facility staff on proper PPE usage and quarantine signage to be completed on [DATE]. Staff will not be allowed to return to work until education is completed.

Based on interview and record review, the facility failed to hold anticoagulant medications for one of one residents (R21) reviewed for anticoagulant use in the sample of 20. This failure resulted in the resident having a critical high lab value and needing to be sent to the hospital. The findings include: The Admission Record printed on 9/12/19 by the facility shows R21 has [DIAGNOSES REDACTED]. The facility assessment dated [DATE] shows R21 has moderate cognitive impairment. The orders summary report from 3/1/19-3/31/19 shows R21 was receiving [MEDICATION NAME] (blood thinner). The nurse progress note dated 4/8/2019 shows Resident sent to (local hospital emergency room ) per ambulance for FFP (fresh frozen plasma) due to elevated INR (international normalized ratio-a test to see how well the blood clots). The orders summary report from 3/1/19-3/31/19 shows on 3/19/19 R21's [MEDICATION NAME] order was 3.5 mg every evening. Coagulation (clotting) lab results dated 3/21/19 show R21's INR level was 6.6, which is a critical high level. New orders on the lab results, written by V9 (Nurse Practitioner-NP) show Hold [MEDICATION NAME] today and tomorrow, recheck labs on Saturday (3/23/19). On 9/12/19 at 8:12 AM, V2 Director of Nursing (DON) was asked for the 3/23/19 coagulation lab results for R21 because the lab results were not in R21's electronic medical record. At 9:02 AM, V2 Director of Nursing (DON) said she was not able to produce the PT/INR lab for 3/23/19 because it was not done. All labs from 3/18/19 through 4/10/19 were requested. The next PT/INR that was done for R21 was on 4/8/19 in which the results show R21 had an INR level of 22, which is a critical high level. R21's Medication Administration Record [REDACTED]. On 9/12/19 at 9:42 AM, V8 LPN (Licensed Practical Nurse) said when PT/INR results come in we call the NP and get new orders and then document the orders. V8 said it is important to follow the doctor's orders. On 9/12/19 at 10:14 AM, V10 RN (Registered Nurse) said when a resident's PT/INR results come in if the results are not a panic or critical high the nurses put them in the binder for the NP to review when she comes in on Mondays and Thursdays, the same day as labs are done. If the lab results show a panic high or a critical high result, the nurses would call the NP (Nurse Practitioner) or the doctor to get new orders. On 9/12/19 at 11:02 AM, V10 verified on the (MONTH) and (MONTH) 2019 MAR indicated [REDACTED]. On 9/12/19 at 12:47 PM, V9 NP said it is important to ensure orders are followed when you have a resident with a critical high INR level. V9 said The previous Director of Nursing (DON) managed the resident's INRs. V9 said she wrote new orders on 3/21/19 to hold the [MEDICATION NAME] for 2 days and recheck her INR levels on Saturday. V9 said on 4/8/19 the DON realized the orders had not been processed and she notified her (NP). V9 said she told previous DON to get a stat PT/INR lab. V9 said the facility called her back and told her that R21's INR level was 22. I told them to send her to the hospital immediately because she needs blood products. V9 said it was a pretty critical situation because R21 could have spontaneously bled from pretty much anywhere in her body with an INR of 22. On 9/12/19 at 1:45 PM, V2 (Current DON) said she would have expected the nurses to hold the [MEDICATION NAME] per the NP's orders, until new orders were received. The facility's undated policy and procedure titled Lab and Diagnostic Test Results-Clinical Protocol shows Nursing staff will consider the following factors to help identify situations requiring prompt physician notification concerning lab or diagnostic test results .4. High or toxic drug levels. If a atest was obtained to monitor the blood level of a medication and the level is reported as high (above the therapeutic range) or toxic, the nurse will notify the physician promptly and will not give the next dose until the situation has been reviewed with the physician. The facility's undated policy and procedure titled Medication Orders shows the purpose of the procedure is to establish uniform guidelines in the receiving anad recording of medication orders. The procedure shows 2. A current list of orders must be maintained in the clinical record of each resident. 3. Orders must be written and maintained in chronological order.

Based on observation, interview, and record review the facility failed to ensure the safety of a resident during personal care for 2 residents (R34, R27) dependent on staff for care. The facility failed to supervise residents with a history of falls for 2 residents (R39, R16) in the sample of 20. This failure resulted in R34 sustaining a traumatic fracture of her left arm, significant bruising to her neck, and significant bruising and swelling to her left arm. This failure also resulted in R39 sustaining a fracture of her left hip. The findings include: 1. On (MONTH) 10, 2019 at 9:04 AM, R34 was in her room with the lights low and was laying in her bed with her eyes closed. On (MONTH) 10, 2019 at 3:39 PM, R34 had deep purple bruising around her upper left arm which wrapped completely around her arm. R34's arm was swollen from the shoulder down to her elbow. The back of R34's neck had vibrant red and purple bruising. As nursing staff was gently attempting to move the hospital gown down from R34's shoulder she winced and yelled out. On (MONTH) 10, 2019 at 3:09 PM, V17 (R34's daughter) said a nurse from the facility contacted her on Sunday (9/8/19) at about 8:30 PM and told her R34's left arm had excessive bruising and swelling. V17 said she was told that the nurse practitioner was notified and they had an order for [REDACTED]. V17 said when she saw her mother's arm it was totally bruised and somewhat misshapen. V17 said the nurse told her that she thought (R34's) arm was broken. V17 said she told the nurse that she wanted her mother sent to the emergency room for evaluation. V17 said R34 does not have mobility in her arms or her legs and is a total lift for transfers. V17 said her mother cannot move herself about in bed because she had failed hip replacements which had to be removed which left her immobile. R34's nursing progress note entered on (MONTH) 8, 2019 at 8:05 PM by V20 RN (Registered Nurse) showed, With HS (bedtime) care CNAs (Certified Nursing Assistants) brought to my attention a bruise encircling resident's left upper arm. Swollen. Area marked. Painful with movement . X-rays ordered . POA (Power of Attorney) notified . Another nursing progress note was entered by V20 at 8:56 PM which showed, Resident's daughter here, wants resident sent to (hospital) for evaluation . R34's progress note titled, Hospice Aide Visit Note, dated (MONTH) 10, 2019 showed, Left shoulder from elbow to the front up to chest to behind patient's neck is deep dark purple. R34's acute care hospital Emergency Department Provider note dated (MONTH) 8, 2019 at 10:33 PM showed Shoulder Trauma Primary Complaint Shoulder Trauma L (left) shoulder patient is a (mechanical) lift and is otherwise bedbound, staff are unaware of any recent falls . is transferred using a (mechanical) lift, does not walk, in fact has no hip joints . R34's imaging results from the acute care hospital dated (MONTH) 9, 2019 showed R34 had a comminuted proximal humeral fracture (a break in the upper arm bone in two places). R34's MDS (Minimum Data Set) dated (MONTH) 29, 2019 showed R34 is dependent upon the assistance of two staff members for bed mobility and dressing and requires the use of a mechanical lift and the assistance of two staff members for transfers. R34's care plan initiated on (MONTH) 21, (YEAR) showed R34 is dependent upon two staff for bed mobility and dressing. R34's nursing progress note dated (MONTH) 29, 2019 showed, .Total dependence with 2 assist in transfers with the use of (mechanical) lift and a purple sling. Does not assist in dressing any longer, required extensive 2 assist. Bed mobility is an extensive 2 assist . On (MONTH) 12, 2019 at 3:05PM, V19 CNA (Certified Nursing Assistant) said she did morning cares for R34 on the morning of (MONTH) 8, 2019 by herself including washing her up and dressing her. V19 said when they were trying to get R34 ready for bed on Sunday night (September 8, 2019) they had a terrible time getting her shirt off. V19 said they had to take it off the good arm and then try to get it off of the bad arm because she was in pain. On (MONTH) 12, 2019 at 2:55PM, V22 Corporate Administrator said she did the investigation of R34's fracture. V22 said V19 washed up and dressed R34 by herself on the morning of Sunday, (MONTH) 8, 2019. The facility's investigation into the (MONTH) 8, 2019 incident involving R34 and completed on (MONTH) 11, 2019 showed it was determined that V19 had provided cares by herself on Sunday, (MONTH) 8, 2019. The facility's investigation conclusion showed, The fracture most likely occurred during the process of am (morning) care on 9/8/19 in the simple act of putting on her t-shirt and moving the contracted shoulders to do so The CNA who provided care during that time was interviewed and investigated . On (MONTH) 11, 2019 at 10:35 AM, V16 RN ( Hospice Registered Nurse) said she sees R34 on a weekly basis and had last seen her on the previous Tuesday after Labor Day, (MONTH) 3, 2019. V16 said R34 does not typically complain of pain but when she came in on Monday, (MONTH) 9, 2019, she was clearly in pain. V16 said they are making adjustments to her pain medication schedule to try and give her some relief. V16 said they were discussing discharging R34 from hospice because she had not shown any decline in her condition for the previous two months. V16 said we will likely see a decline now due to the fracture. On (MONTH) 11, 2019 at 2:11 PM, V23 CNA said she took care of R34 on (MONTH) 8, 2019 and (MONTH) 9, 2019. V23 said R34 was her usual self on (MONTH) 8 but on (MONTH) 9, 2019 she was complaining of pain. V23 said when she went into R34's room on the morning of Sunday, (MONTH) 9, R34 was already cleaned up and dressed. V23 said she and V15 CNA started to use the mechanical lift to get R34 out of bed she started yelling Ouch. V23 said throughout the day on (MONTH) 9, R34 continued to say ouch and yell loudly when they were providing cares. V23 said it was unusual for her to yell out. V23 said R34 kept her left arm stiff and by her side on (MONTH) 8 and at one point she had to pick it up and move it for her. V23 said R34 probably yelled out when she did that but she does not remember. On (MONTH) 12, 2019 at 9:41 AM, V20 RN said the CNAs called her to R34's room on Sunday (September 8) to look at R34's arm. V20 said when she saw R34's arm she was dumbfounded. V20 said her left arm was swollen and bruised and had an indention on the outside of her arm. V20 said, I am furious because somebody knows what happened. On (MONTH) 12, 2019 at 10:20 AM, V18 Orthopedic Surgeon said he reviewed R34's xrays at the request of R34's family. V18 said in regards to R34's xrays the fracture was caused by some sort of trauma. V18 said the bruising around the back of R34's neck would not typically be caused by a fractured humerus (shoulder). R34's physician order [REDACTED]. 2. On (MONTH) 10, 2019 at 9:41 AM, R39 was in her room laying in bed with her eyes closed. On (MONTH) 10, 2019 at 12:45 PM, R39 was in a reclining wheelchair and being pushed out of the dining room by a staff member. R39 had her head tilted back and R39's eyes closed. On (MONTH) 10, 2019 at 12:45 PM, R39's daughter said this is not a good time to talk because her mother is not doing well and they are going to admit her to hospice services today. R39's face sheet showed R39 was readmitted to the facility on (MONTH) 1, 2019 with [DIAGNOSES REDACTED]. R39's nursing progress note dated (MONTH) 29, 2019 at 2:50 PM showed R39 had an unwitnessed fall in her room and was experiencing left hip pain. The same note showed the physician was notified and ordered a mobile xray of the left hip. A nursing progress note entered by V24 at 9:42 PM showed R39 was being sent to an acute care hospital for a minimally displaced fracture through the femoral neck (broken hip). The facility provided incident reports for R39's documented falls since (MONTH) 2019 which showed R39 to have 12 unwitnessed falls between (MONTH) and (MONTH) 2019 and 1 witnessed fall. The (MONTH) 8, 2019 incident showed R39 was found on the floor in her room. The (MONTH) 11, 2019 incident showed R39 was found on the floor between the heating unit and bed. The (MONTH) 16, 2019 incident showed a CNA (Certified Nursing Assistant) witnessed R39 kneeling on the floor of her room. The (MONTH) 19, 2019 incident showed R39 was found laying on the floor between the bed and the heater. The (MONTH) 20, 2019 incidents showed R39 was found on the floor outside of her bathroom in her room at 12:15 PM and was found on the floor in front of the doorway to her room at 9:03 PM. The (MONTH) 26, 2019 incident showed R39 was found again between her bed and the heating unit. The (MONTH) 11, 2019 incident showed R39 was found laying on her bathroom floor. The (MONTH) 12, 2019 incident showed R39 was found on her bathroom floor. The (MONTH) 16, 2019 incident showed R39 was found laying on the dining room floor. The (MONTH) 11, 2019 incident showed R39 was found on the floor at the foot of her bed. The (MONTH) 26, 2019 incident showed R39 was found on the floor by her bathroom in her room. The (MONTH) 28, 2019 incident showed R39 was found on the floor of her room. R39's nursing progress note dated (MONTH) 18, 2019 at 10:25 PM showed R39 was found in her room laying on the floor. There was no incident report for this fall. R39's nursing progress note dated (MONTH) 2, 2019 at 11:11AM showed, (R39) is up ad lib (as she chooses) with wheeled walker and requires supervision to limited assistance for activities of daily living. R39's care plan for falls which was initiated on (MONTH) 29, (YEAR) showed R39 was at risk for falls due to [DIAGNOSES REDACTED]. The care plan showed no intervention added to include increased supervision at any time. R39's physical therapy discharge summary dated (MONTH) 27, 2019 showed R39 required multiple verbal cues for safety when moving from sitting to standing and R39 forgot her walker at times. R39's physical therapy discharge summary dated (MONTH) 14 2019 showed discharge recommendations to include standby assistance in her room. The same (MONTH) 14, 2019 discharge summary showed R39 forgets to use call light, forgets to use her walker, and loses balance backward upon standing during transfers. R39's MDS (Minimum Data Set) dated (MONTH) 8, 2019 showed R39 requires extensive assistance of 2 staff members for bed mobility, transfers, and dressing. The same MDS showed R39 requires extensive assistance of 1 staff member for ambulation. R39's nursing progress note dated (MONTH) 8, 2019 at 11:01 AM showed, decline in condition, poor appetite, not attempting to help transfer or propel own wheelchair. Slow to respond . needs to be reminded to open eyes when being spoken to. On (MONTH) 11, 2019 at 1:59 PM, V23 CNA said prior to R39's fall on (MONTH) 28, 2019 she was a stand by assist with ambulation. V23 said R39 was known to get up and walk without stand by assist. V23 said she would see her in her room walking around and would have to stop her and sometimes she would just be walking down the hall. She used a walker. V23 said R39 does not fall frequently. On (MONTH) 12, 2019 at 12:03 PM, V12 CNA said R39 was being walked with a gait belt and supervision just as a precaution before her fall. V12 said she would not consider R39 to be a resident who falls frequently. V12 said when she arrives for her shift each day she reads the update book which includes information about residents who have had falls or changes to their care. On (MONTH) 12, 2019 at 2:15 PM, V2 DON (Director of Nursing) said R39 is on hospice services now and declining quickly. V2 said before R39's fall she was getting up without assistance. V2 said R39 fell frequently. V2 said she would expect fall interventions to include increased supervision. V2 said when a fall occurs the nurse on call will be called by the nurse at the facility and there will be interventions discussed and implemented immediately. V2 said the next morning when the interdisciplinary team meets they discuss the interventions and make changes if needed. The facility's policy titled Fall Prevention and Management with review date of (MONTH) 1, 2019 showed, To provide for resident safety and to minimize injuries related to falls; decrease falls Fall management/safety supervision is an interdisciplinary process designed to develop systems to provide individualized person-centered care Post Investigation: Immediate interventions may be instituted by the nurse to prevent further falls until IDT (interdisiplinary team) reviews based on the findins and the review of risk factors, environmental factors and other clinical conditions the residents comprehensive care plan is to include individualized person-centered interventions. 3. On (MONTH) 10, 2019 at 9:16 AM, R16 was using her feet to propel her wheelchair out of the dining room. A CNA assisted her to a common area and gave her some cards. R16 immediately left the table and began propelling herself about the unit independently. R16's fall incidents were provided by the facility for (MONTH) 28, (YEAR) through (MONTH) 17, 2019 which showed R16 to have 13 unwitnessed falls and 1 witnessed fall. R16's face sheet showed R16 to be [AGE] years old and was admitted to the facility originally on (MONTH) 16, (YEAR) with [DIAGNOSES REDACTED]. R16's face sheet showed R16 was readmitted to the facility on (MONTH) 21, 2019 with a new [DIAGNOSES REDACTED]. R16's care plan for risk for falls showed no interventions to include increased supervision were added until (MONTH) 15, 2019 when an intervention was added to encourage R16 to stay in high areas of visibility after meals and or common areas after meals and while not in bed. On (MONTH) 12, 2019 at 12:03 PM, V12 CNA said R16 would not be someone she would consider that falls frequently. V12 went on to say R16 has a seat belt with an alarm on it because she would stand up incessantly and is a fall risk. 4. On (MONTH) 10, 2019 at 9:14 AM R27 was sitting in her wheelchair in the dining room and had a large bruise to the right side of her forehead. R27's face sheet printed (MONTH) 12, 2019 at 10:22 AM showed R27 to be [AGE] years old and admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. R27's MDS (Minimum Data Set) dated (MONTH) 22, 2019 showed R27 requires the physical assistance of 1 staff member to propel her wheelchair and the physical assistance of 1-2 staff members for all cares. R27's incident report provided by the facility showed on (MONTH) 29, 2019 night shift staff reported that R27 had a raised and bruised area to her right forehead that is painful to touch. The report showed R27 was unable to state what happened due to her confusion but a CNA (Certified Nursing Assistant) said the bed remote had ricocheted while she was performing cares and hit R27 on the right side of her head. The same incident report does not include the name of the staff member providing cares. The incident report does not indicate there were any witnesses to the incident. R27's incident report provided by the facility showed on (MONTH) 1, 2019 a CNA reported a bruise on R27's left shoulder which measured 5.0cm x 3.0 cm and was dark blue to deep purple in color. The incident showed R27 was unable to explain what happened. The incident did not report any witness to the incident. R27's care plan with an initiation date of (MONTH) 1, (YEAR) showed R27 required extensive assistance by 1 staff for locomotion using a wheelchair. R27's nursing progress note dated (MONTH) 2, 2019 showed, IDT (Interdisciplinary team) reviewed resident room positioning and environmental . resident leans forward in wheelchair, will adjust positioning and move dresser in room. On (MONTH) 11, 2019 at 11:23 AM, V2 DON (Director of Nursing) said she knew the cause of R27's bruise to her head because the CNA came right out and told us that (R27) got hit in the head with the bed remote during cares.

Based on Observation, Interview and Record Review the facility failed to provide safety and supervision of a resident during a transfer with a mechanical lift. This failure resulted in R1 falling out of a sling during a mechanical lift transfer on 5/2/19 and sustaining a distal fracture of her right femur, closed head injury and laceration to her head. This applies to 1 of 5 residents (R1) reviewed for safety and supervision. The findings include: 1. The Progress Notes dated 5/2/19 for R1 showed, 11:30AM - Called to resident room by certified nursing assistant (CNA); Noted resident laying on the floor on her right side under the mechanical lift; resident responsive. Noted a large pool of blood under her head. Resident transferred back to bed; ice applied to area on her forehead; 3:54PM - Ambulance transferring resident to the hospital. Right knee slightly swollen, ice in place. The hospital Discharge Instructions dated 5/2/19 for R1 showed, Contusion of Face, Closed Fracture of Femur, Distal End, Dementia, Laceration - Injury. The Progress Note dated 5/2/19 for R1 showed, 10:45PM - R1 returned with an immobilizer to her right leg; Complete skin check completed. Three steri strips to right forehead. The Physician order [REDACTED]. On 5/14/19 at 8:56AM, V7 (CNA Supervisor) stated, R1 has been a mechanical lift transfer with two assist for the last two years. They told me the chair was at the foot of R1's bed and V4 (CNA) was on the resident's right side and hooked up all four straps. V3 (CNA) started to raise the mechanical lift and R1 went out the side. I would guesstimate the sling was not on there the right way and R1 fell out onto her right side. V7 stated falls from a mechanical lift can happen due to incorrect positioning of a resident, not holding onto a sling, hooks not attached correctly/completely, moving the mechanical lift to fast, mechanical lift legs not open or the sling not being the right size. On 5/14/19 at 9:12AM, V3 (CNA) stated, It happened so fast. V4 (CNA) checked the straps of the sling to the lift. I asked her if she was ready and she said yes. I raised the lift and the next thing I know R1 was out of the sling. I was at the front of the sling at R1's legs and she went out the right side. We think the strap (with loops) wasn't all the way back when it was put on the lift. The bottom one came undone but didn't rip. On 5/14/19 at 9:25AM, V2 (Director of Nursing - DON) stated no one should fall out of a mechanical lift. V2 stated some reasons a resident may fall out of a mechanical lift would be improper fitting of the sling, staff error, staff rushing, improper placement of the sling and loops not secure; they need to check those. On 5/14/19 at 10:34AM, V4 (CNA) stated when they lifted R1 up she slipped out from the side of the sling, landed on her elbow and hit her head. V4 stated R1 broke her right femur; doesn't know if the loop on the sling came undone and no one should ever fall out of a sling. The Minimum Data Set ((MDS) dated [DATE] for R1 showed a brief interview of mental status (BIMS) score of 6 which means severe cognitive impairment; extensive assist of two people for transfers. R1's current care plan printed on 5/14/19 showed on 5/17/17 an intervention of a mechanical lift with two staff assist was entered onto the care plan. The facilities Safe Lifting and Movement of Residents policy (4/2019) showed, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. Staff responsible for direct resident care will be trained in the use of manual and mechanical lift devices. On 5/14/19 at 8:29AM, R1 was sitting in a semi reclined wheelchair with a blanket over her lap, with her foot and part of right leg exposed and turned inward. R1 had bruises to her face and a healed cut to her forehead near the hairline. At 1:25PM R1 stated she fell but doesn't know how and stated her right leg hurts. At 1:30PM, R1's right leg was visible, had a brace on it and her foot was turned inward. 2. Based on Observation, Interview and Record Review the facility failed to ensure residents safety and supervision by leaving medications unattended at resident's tables in the dining room during breakfast. This applies to 3 of 5 (R2 & R5) residents reviewed for safety and supervision. The findings include: On 5/14/19 at 8:40AM, R2 was sitting in her wheelchair at a dining room table. R2 had a medicine cup with pills in it left on the table next to her. R2 was taking her spoon from the bowl in front of her with a hot cereal in it. R2 took 3 bites from the spoon but there wasn't any hot cereal on the spoon. R2 picked up the medication cup at her table and tried to dump the medications in her mouth twice. V6 (Registered Nurse - RN) was in the hall at her medication cart not watching R2. The nurses view was obstructed by decorations on the glass window and she was punching out medications from medication cards. R2's Medication Administration Record [REDACTED]. The Medical [DIAGNOSES REDACTED]. The MDS dated [DATE] for R2 showed a brief interview of mental status (BIMS) score of 3; severe cognitive impairment. On 5/14/19 at 8:40AM, R4 was sitting in a wheelchair at the dining room table. R4 had pills laying on a napkin on the table and a pill on the floor. V5 (Dietary Aide) walked by R4 an stated she had a pill on the floor. V5 picked the pill up off from the floor and took it to V6 who then brought another pill to R4 and dumped it on her napkin. V6 walked away. On 5/14/19 at 8:49AM, V5 stated that medications are left at the tables for residents to take. R4's MAR for (MONTH) 2019 showed on 5/14/19 the following 8:00AM pills were signed off as dispensed by V6 (RN): Acidophilus ([MEDICATION NAME]), [MEDICATION NAME] (diuretic), [MEDICATION NAME] (blood pressure medication), [MEDICATION NAME] Chloride (bladder relaxant), Potassium Chloride (potassium mineral supplement), Duloxetine HCL (nerve pain medication/antidepressant), [MEDICATION NAME] (nerve pain medication/anticonvulsant), [MEDICATION NAME] (acid reducer) and MagOx (magnesium mineral supplement). On 5/14/19 at 8:40AM R5 was sitting at a table in the dining room. There were pills laying on a napkin at the table. R5's MAR for (MONTH) 2019 showed on 5/14/19 the following 8:00AM pills were signed off as dispensed by V6 (RN): [MEDICATION NAME] (heart medication), Potassium Chloride (potassium mineral supplement), [MEDICATION NAME] ([MEDICAL CONDITION] medication), [MEDICATION NAME] (antacid), [MEDICATION NAME] (diuretic) and [MEDICATION NAME] (blood pressure medication). On 5/14/19 at 9:25AM, V2 (Director of Nursing - DON) stated medications are not to be left on the table and the nurse should stay with the resident to ensure the medications are taken. V2 stated this applied to alert and oriented residents as well. The facility's Medication Administration/General Guidelines (no date) showed, No one in this facility is allowed to self medicate unless an assessment has been made by their care plan nurse and a physician's orders [REDACTED]. Medications are to be administered at the time they are prepared. Remain with the resident while medication is being given.

Based on observation, interview and record review the facility failed to provide safety and supervision, and failed to revise and update interventions for a resident with repeated falls. These failures resulted in R24 sustaining a fracture and head injuries. The facility also failed to supervise a resident on a mechanically altered diet to ensure the correct food was consumed. This applies to 1 of 2 residents (R24) reviewed for safety in the sample of 19, and 1 resident outside the sample (R59). The findings include: 1. On [DATE] at 09:24 AM, R24 was sitting in R24's room alone, self propelling R24's wheelchair with bare feet. R24 said the first time I fell here I had a head injury. R24 said another time I was walking by myself and fell . R24 said I've fallen couple times since then. R24 said I broke my wrist, had lots of bruises, and hit my head at least once. R24 stated, I had several nasty falls here. On [DATE] at 09:22 AM, V6 (former Social Services/Admissions) said R24 had some falls and is not aware of R24's weakness. On [DATE] at 09:40 AM, V8 (Restorative/Administrative Nurse) said R24 has fallen multiple times. V8 said R24 has poor safety awareness and feels R24 can do it on R24's own. V8 said all falls are reported to me, the falls are discussed in the Interdisciplinary Team (IDT) meetings, the IDT team discussed interventions, and new interventions should be entered in the care plan immediately. On [DATE] at 03:51 PM, V2, Director of Nursing (DON), said when a fall occurs the facility will look at fall and figure out what needs done at the time. V2 said the next day in IDT the facility will look at the cause of the fall; what interventions were in place; and what can be done to prevent future falls. V2 said the IDT reviews the interventions with each fall and attempt to initiate new interventions right away. V2 said R24's care plan should have been updated with new interventions after each fall. R24's Admission Record printed (MONTH) 23, (YEAR) showed [DIAGNOSES REDACTED]. R24's Minimum Data Set (MDS) dated (MONTH) 28, (YEAR) showed R24 has a Brief Interview for Mental Status (BIMS) score of 6 (severe cognitive impairment); required extensive assistance of two or more staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; was frequently incontinent of urine; and had a fracture related to a fall in the six months prior to re-admission. R24's Morse Fall Scale dated (MONTH) 5, (YEAR) showed R24 is at high risk for falling, R24's care plan (revised [DATE]) showed (R24) is at high risk for falls, R24 has a history of left proximal humerus fracture with frequent falls. The interventions for this care plan include: anticipate and meet resident needs; ensure (R24) is wearing appropriate footwear, non-skid socks/shoes when ambulating. R24's care plan showed R24 had an actual fall on [DATE], [DATE], [DATE], [DATE], and [DATE]. The care plan showed no new interventions added until [DATE] (approximately two months after R24's falls). R24's care plan does not include falls on [DATE] and [DATE] with no new interventions implemented. R24's Health Status Notes entered by the nurses from (MONTH) 4, (YEAR) through (MONTH) 3, (YEAR) showed R24 fell eight times with injuries to include closed head injuries (on [DATE], [DATE], [DATE], and [DATE]) and a left forearm fracture ([DATE]). R24's Health Status Note dated (MONTH) 23, (YEAR) at 9:51 AM, showed R24 was heard yelling for help and found lying on the floor, on the left side, by the sink. R24 did not have shoes on and R24 was complaining of left forearm pain. R24's Radiology Report dated (MONTH) 23, (YEAR), showed R24 suffered a comminuted radial fracture and a ulnar fracture (forearm fracture). The facility's Patient Report regarding R24's fall on (MONTH) 12, (YEAR) at 11:50 AM showed R24 was barefoot and found on the floor with the right side of R24's head on the leg of the bedside table. This document showed blood was dripping on the floor from a laceration on the right side of R24's head. This document also showed R24 had a skin tear on the top of R24's right foot. This document showed R24 was sent to the local emergency department by ambulance. R24's Health Status Note dated (MONTH) 15, (YEAR) at 7:00 PM, showed R24 was found on the floor, lying on R24's back with R24's head between the roommate's bed and recliner. This note showed R24 responded verbally, but R24's speech was garbled. This note showed R24 was unable to follow verbal commands, unable to answer questions, was moaning at times, and had increased shortness of breath. This note showed R24 demonstrated increased restlessness and kept moving R24's arms and legs. At 8:00 PM, showed R24 continued to be restless, moving R24's arms and legs frequently. This note showed R24's speech was garbled, R24's pupils were non-reactive to light, R24 was unable to follow verbal commands, and R24 continued to be short of breath. At 8:30 PM, R24 was transported to a local emergency room by the ambulance (R24 fell three days before with no updated interventions implemented). R24's Nurses' Admission Record dated (MONTH) 19, (YEAR) at 5:55 PM, showed R24 returned back to the facility with multiple bruises all over her body; sixteen staples to her right forehead, over a laceration measuring 6.5 centimeters (cm); and three stitches to the top of her right foot, to a 2 cm skin tear. R24's Nursing Home Visit by the physician dated (MONTH) 8, (YEAR) showed R24 was hospitalized last month and R24 had a fall with a scalp injury. The facility's Fall Management dated (MONTH) 15, (YEAR) showed the policy, To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. This policy showed the purpose, Assist the resident in obtaining/or maintaining their highest level of function, minimize the risk of falls, and fall related injuries. It is our belief that a proactive approach is key to keeping our residents safe and free of injury related to falls. This document showed the procedure, 4. Report all falls during the morning Interdisciplinary meetings Monday through Friday. All falls will be discussed and any new interventions will be taken to care plan. 2. R59's Admission Summary Note showed R59 was admitted to the facility from a local hospital on [DATE] at 1:14 PM and lung sounds were clear. R59's ,[DATE] progress notes showed R59's [DIAGNOSES REDACTED]. R59's [DATE] Health Status Note showed, V4 (Licensed Practical Nurse-LPN) had received a report that R59 had a choking episode at the evening meal on [DATE]. The note also stated R59 was experiencing sign and symptoms of aspiration. R59's 8:35 PM Health Status Note of [DATE], Resident breathing shallow with periods of apnea. Stopped breathing for approx. 2 minutes during chest x-ray. Lung sounds barely audible . R59's [DATE] Health Status Note showed he died on [DATE] at 12:30 AM. R59's [DATE] Discharge Summary from a local hospital showed There was one episode towards the discharge that R59 could have aspirated. R59's [DATE] Care Plan showed R59 required extensive assist of one person to eat. R59's [DATE] Speech Therapy Evaluation and Plan of Treatment showed R59 is at risk for aspiration and is recommended to have a mechanical soft diet, thin liquids, and close supervision. R59's [DATE] Diet Order showed General diet, Mechanical Soft texture, Pudding consistency. On [DATE] at 1:56 PM, V14 (Certified Nursing Assistant) stated, I caught (R59's) family several times trying to feed (R59) .I would catch the family in (R59's) room trying to give (R59) food. The family was aware R59 was on a special diet and (R59) had restrictions, I told V4 (Licensed Practical Nurse) about it. On [DATE] at 2:15 PM, V3 (Lead Certified Nursing Assistant) stated, R59's family had been known to bring R59 food from outside the facility and feed (R59) in (R59's) room and the family was feeding (R59) again the night before (R59) passed. On [DATE] at 3:08 PM, V2 (Director of Nursing) stated, it's important to know if family members are bringing in food when they are on a mechanically altered diet due to the risk for aspiration. V2 stated if she had been made aware of the family bringing in outside food, then she would have counselled the family. The family visits should be monitored to ensure they did not continue bringing in outside food.

Based on observation, interview and record review the facility failed to provide restorative services after a resident was discharged from skilled therapy. This failure resulted in a decline in range of motion (ROM) and an inability to receive a prosthetic device as planned and for discharge home. This applies to 1 of 1 residents (R32) reviewed for mobility and range of motion in the sample of 19. The findings include: On 08/22/18 at 11:30 AM, R32 was sitting in a reclining wheelchair with the overbed table in front of R32 playing cards. R32 had a right [MEDICAL CONDITION] (BKA) and R32's left foot was on the floor. R32's left foot points down in a resting position. On 08/21/18 at 12:45 PM, R32 said R32 does not have a prosthetic. R32 continued to say, I'd like to be able to walk again and go home to run my business. R32 said, I thought I was supposed to get therapy and prosthetic, but I haven't had it yet. On 08/22/18 at 11:30 AM, R32 said I was supposed to have physical therapy when I started having issues with my right leg, but I've never had it, it's been like 4 months. R32 said, my foot slants down like that (pointing to R32's left foot that slants down toward the floor), so I can't walk anymore. R32 said, They (the facility) were supposed to talk to me about a special shoe (AFO), but they haven't done that yet either. R32 states, There's a girl that comes in and moves my arms around, but they don't do anything with my legs. On 08/23/18 at 08:48 AM R32 denies having shrink wrap (elastic sock used to shape the stump for fitting a of prosthetic) for R32's stump. States, I had one in my other room, but since they moved me down here, about 3 months ago, I haven't seen it since I moved rooms. On 08/23/18 at 09:09 AM, V6 (former Social Service Director/Admissions) said my understanding was the doctor came in and told R32, R32 cannot get a prosthesis because R32's noncompliant. V6 denies any interaction with a prosthetic company. V6 states, I believe that would be physical therapy. V6 said obtaining the prosthetic has been on R32's mind for a long time. V6 said, If (R32) is refusing or noncompliant it should be in nurses notes and/or the behavioral notes. On 08/23/18 at 09:25 AM, V7, Physical Therapy Assistant (PTA) said, I personally don't know much about R32; I've been here two months and I've never seen (R32). V7 said R32 is currently not receiving physical therapy (PT), but R32 was on the PT schedule (MONTH) through (MONTH) (YEAR). V7 read the computer screen and said R32 was seen for BKA and muscle weakness, but was discharged (MONTH) 20, (YEAR). V7 said the PT department does arrange prosthetics consultations. V7 said the prosthetic company comes in, does the fitting, and provides all the training with the prosthetic. V7 said, When I started in June, I did ask about a prosthetic for R32; I asked the company about it and the company said R32 was noncompliant. On 08/23/18 at 09:40 AM, V8, Restorative Nurse, said R32 currently is on an active range of motion (ROM) and a bed mobility program for restorative services, but no strengthening program. V6 said strengthening exercises are a different set of exercises that would work on R32's muscles and ROM is for joint mobility. V6 said the facility was providing amputation care exercises in preparation for R32's prosthetic leg, but it was stopped when R32 was hospitalized in (MONTH) and it was never restarted. V8 said the amputation care exercises maintain the strength and mobility in the leg, so R32 will be ready for a prosthetic leg. V8 said she is working with V7 regarding R32's prosthetic leg, but it's been a month or two since we discussed it. V8 said (R32) could potentially walk again with a prosthetic leg, but the longer it takes, R32 may not be able to walk again. V8 said Restorative evaluations are done quarterly with Minimum Data Set (MDS) calendar and as needed. V8 said, I have to rely on the restorative aides and certified nursing aides (CNAs) to report a decline to the nurse or myself. On 08/23/18 at 03:51 PM, V2, Director of Nursing (DON) said, I was told it's not the right grade of stump and the prosthesis will not fit. V2 said if a decline is identified with an Activity of Daily Living (ADL), then the nurse should screen for therapy. A resident's decline should be discussed in the Interdisciplinary Team (IDT) meeting we have weekly. V2 said if R32 didn't have coverage for the leg prosthetic, then R32 would be a charity case and the facility pays for screening/therapy. V2 said, No, the (PT)evaluation was not done when it was ordered in (MONTH) according to what I can see. V2 said the nurse should obtain an order for [REDACTED].>On 08/23/18 at 02:16 PM, V10, physician (MD), said he expected R32 was receiving PT/OT and Restorative Services needed to give R32 the best chance at getting a prosthesis and walking again. R32's admission record printed (MONTH) 22, (YEAR) showed [DIAGNOSES REDACTED]. R32's MDS dated (MONTH) 4, (YEAR) shows R32 was readmitted to the facility on (MONTH) 9, (YEAR) from an acute hospital stay. This MDS showed R32 is cognitively intact; requires extensive assistance of two or more staff members for bed mobility, toilet use, personal hygiene, and dressing; is totally dependent on two or more staff members for transfers; has had no days of Occupational Therapy (OT); received Active ROM 7 days in the last 7 calendar days; and received 7 days of bed mobility in the last 7 calendar days. R32's physician order [REDACTED]. R32's PT Evaluation & Plan of Treatment dated (MONTH) 28, (YEAR) showed R32 has [DIAGNOSES REDACTED]. This document showed R32's personal goal to walk again and return home to run R32's business. This document showed R32 demonstrates a good rehab potential. R32's Therapy Progress Report dated (MONTH) 4, (YEAR) showed R32 continues to demonstrate good rehab potential. R32's Therapy Progress Report dated (MONTH) 11, (YEAR) showed R32 continues to be unable stand two minutes in parallel bars with stand by assist to prepare for gait. This document showed a note to screen for possible prosthetic. This document shows R32 continues demonstrate good rehab potential. R32's Physical Therapy Discharge Summary dated (MONTH) 20, (YEAR) showed R32 continues to be unable to stand two minutes in the parallel bars with stand by assist to prepare for gait; PT to screen for possible prosthetic. This document showed discharge recommendations for the Restorative Nursing Program to facilitate R32 in maintaining the current level of performance and in order to prevent decline. The document showed the development and instruction of the following Restorative Nursing Programs was completed in the Interdisciplinary Team (IDT) meeting and the following recommendations were made: bed mobility program, Active ROM, and Passive ROM. R32's faxed order for a Transtibial Prosthesis (Prosthetic leg) showed the order was written on (MONTH) 2, (YEAR) and noted by facility staff on (MONTH) 11, (YEAR). R32's Patient Notes provided by the prosthetic company showed a consult for a transtibial prosthetic was completed on (MONTH) 20, (YEAR). This note showed R32 is in need of stump shrinkers to shape R32's residual limb for a prosthesis (two were provided) and R32 is need of an Ankle Foot Orthotic (AFO) on the left to control and reduce plantar flexion contracture. R32's Patient Notes provided by the prosthetic company dated (MONTH) 8, (YEAR) showed the shrinker fit and function were evaluated and look great. This documents showed R32's residual limb is shaped well and ready to be fit with a prosthesis. The note showed the prosthetic company will start the approval process for a K-1 Prosthesis. R32's Patient Note provided by the prosthetic company dated (MONTH) 12, (YEAR) showed liner fit and function were evaluated and fit well. This documents showed measurements and a mold were taken over the liner. R32's Phone Conversation note provided by the prosthetic company dated (MONTH) 7, (YEAR) showed the prosthetic company is awaiting authorization from R32's insurance company. This document showed the facility PTA reported R32's shrinker was removed because R32 developed sores. R32's Phone Conversation note provided by the prosthetic company dated May, 4, (YEAR) showed the prosthetic company is not going to provide a prosthesis to R32 since R32's condition is so much worse. R32's Phone Conversation note provided by the prosthetic company dated (MONTH) 13, (YEAR) showed V7 (PTA) was called to explain after the conversation on (MONTH) 4, (YEAR) with facility PTA, the prosthetic company was not moving forward due to R32's worsened condition. R32's Nursing Restorative Schedule for (MONTH) (YEAR) showed R32 is receiving the Bed Mobility Program six to seven times a week and the Active ROM program six to seven times a week to all extremities. The Nursing Home Visit from the physician dated (MONTH) 30, (YEAR) showed R32 was admitted after a prolonged hospitalization after a right BKA and severe coccygeal (buttock) decubitus ulcer. This document showed R32's goal is to return home once his ulcers are healed. The Nursing Home Visit from the physician dated (MONTH) 6, (YEAR) showed R32 is anxious to get R32's prosthesis and get back home. The document continued to show R32 is motivated to become ambulatory. It also showed R32 has been compliant with PT and OT and R32's upper and lower extremity strength should be adequate for R32 to adjust to the prosthesis. It showed the overall prognosis for R32 is good. The Nursing Home Visit from the physician dated (MONTH) 2, (YEAR) showed R32 is frustrated and feels (R32) is not getting the physical therapy (PT) (R32) needs. This document showed the plan is to continue physical therapy and occupation therapy. The Nursing Home Visit from the physician dated (MONTH) 28, (YEAR) showed R32 was recently hospitalized from (MONTH) 29, (YEAR) to (MONTH) 9, (YEAR) (10 days), underwent a left second toe amputation and has residual right-side weakness in the upper extremity from the removal of a brain mass earlier this year. This document showed the plan is to continue PT and OT. The Provider Note from the Nurse Practitioner dated (MONTH) 19, (YEAR) showed R32's left foot is numb with foot drop (toes pointing down to the floor, numbness, &/or difficulty to raise toes toward head). This document continued to show the plan is to continue with restorative therapy, the stump shrinker, and awaiting prosthetic. R32's care plan regarding an ADL self care deficit dated (MONTH) 28, (YEAR) showed interventions to include: prosthetic consult and bed mobility program with Restorative Nursing. R32's limited physical mobility care plan related to weakness dated (MONTH) 28, (YEAR) showed interventions to include active ROM with Restorative Nursing. R32's care plan dated (MONTH) 10, (YEAR) showed R32 verbalized a desire to return to the community. The facility's Strengthening Exercises - Below Knee Amputation dated (MONTH) 31, 2012, showed, These exercises will help you strengthen your muscles to best use of prosthetic leg. The facility's undated Passive Range of Motion Policy and Procedure showed, It is the policy of (the facility) that every resident will receive appropriate treatment and services to increase range of motion or to prevent avoidable decline in range of motion.

Based on Observation, interview and record review the facility failed to provide ordered rehabilitative services to a resident. This failure resulted in a decline in activities of daily living and an inability for the resident to receive a prosthetic leg. This applies to 1 of 1 residents (R32) reviewed for specialized rehabilitative services in the sample of 19. The findings include: On 08/22/18 at 11:30 AM, R32 was sitting in a reclining wheelchair with the overbed table in front of R32 playing cards. R32 had a right [MEDICAL CONDITION] (BKA) and R32's left foot was on the floor. R32's left foot pointed down in a resting position. On 08/21/18 at 12:45 PM, R32 said (R32) does not have a prosthetic. R32 continued to say, I'd like to be able to walk again and go home to run my business. R32 said, I thought I was supposed to get therapy and a prosthetic, but I haven't had it yet. On 08/22/18 at 11:30 AM, R32 said I was supposed to have physical therapy when I started having issues with my right leg, but I've never had it, it's been like 4 months. R32 said, my foot slants down like that (pointing to R32's left foot that slants down toward the floor), so I can't walk anymore. R32 said, They (the facility) were supposed to talk to me about a special shoe (AFO), but they haven't done that yet either. R32 states, There's a girl that comes in and moves my arms around, but they don't do anything with my legs. On 08/23/18 at 08:48 AM R32 denied having shrink wrap (elastic sock used to shape the stump for fitting a prosthetic) for R32's stump. R32 states, I had one in my other room, but since they moved me down here, about 3 months ago, I haven't seen it since I moved rooms. On 08/23/18 at 09:09 AM, V6 (former Social Service Director/Admissions) said my understanding was the doctor came in and told R32 he cannot get a prosthesis because R32 is noncompliant. V6 denied any interaction with a prosthetic company. V6 stated, I believe that would be physical therapy. V6 said obtaining the prosthetic has been on R32's mind for a long time. V6 said, If (R32) is refusing or noncompliant it should be in nurses notes and/or the behavioral notes. On 08/23/18 at 09:25 AM, V7, Physical Therapy Assistant (PTA) said, I personally don't know much about R32; I've been here two months and I've never seen R32. V7 said R32 is currently not receiving physical therapy (PT), but R32 was on the PT schedule (MONTH) through (MONTH) (YEAR). V7 read the computer screen and said R32 was seen for BKA and muscle weakness, but was discharged (MONTH) 20, (YEAR). V7 said the PT department does arrange prosthetics consultations. V7 said the prosthetic company comes in, does the fitting, and provides all the training with the prosthetic. On 08/23/18 at 03:51 PM, V2, Director of Nursing (DON) said, I was told it's not the right grade of stump and the prosthesis will not fit. V2 said if a decline is identified with an Activity of Daily Living (ADL), then the nurse should screen for therapy. A resident's decline should be discussed in the Interdisciplinary Team (IDT) meeting we have weekly. V2 said if R32 didn't have coverage for the leg prosthetic, then R32 would be a charity case and the facility pays for screening/therapy. V2 said, No, the (PT) evaluation was not done when it was ordered in (MONTH) according to what I can see. V2 said the nurse should obtain an order for [REDACTED].>On 08/23/18 at 02:16 PM, V10, physician (MD), said V10 expected R32 was receiving PT/OT and Restorative Services needed to give R32 the best chance at getting a prosthesis and walking again R32's admission record printed (MONTH) 22, (YEAR) showed [DIAGNOSES REDACTED]. R32's MDS dated (MONTH) 4, (YEAR) shows R32 was readmitted to the facility on (MONTH) 9, (YEAR) from an acute hospital stay. This MDS showed R32 is cognitively intact; requires extensive assistance of two or more staff members for bed mobility, toilet use, personal hygiene, and dressing; is totally dependent on two or more staff members for transfers; has had no days of Occupational Therapy (OT); received Active ROM 7 days in the last 7 calendar days; and received 7 days of bed mobility in the last 7 calendar days. R32's physician order [REDACTED]. R32's PT Evaluation & Plan of Treatment dated (MONTH) 28, (YEAR) showed R32 has [DIAGNOSES REDACTED]. This document showed R32's personal goal to walk again and return home to run R32's business. This document showed R32 demonstrates a good rehab potential. R32's Therapy Progress Report dated (MONTH) 4, (YEAR) showed R32 continues to demonstrate good rehab potential. R32's Therapy Progress Report dated (MONTH) 11, (YEAR) showed R32 continues to be unable stand two minutes in parallel bars with stand by assist to prepare for gait. This document showed a note to screen for possible prosthetic. This document shows R32 continues to demonstrate good rehab potential. R32's Physical Therapy Discharge Summary dated (MONTH) 20, (YEAR) showed R32 continues to be unable to stand two minutes in the parallel bars with stand by assist to prepare for gait; PT to screen for possible prosthetic. This document showed discharge recommendations for the Restorative Nursing Program to facilitate R32 in maintaining the current level of performance and in order to prevent decline. The document showed the development and instruction of the following Restorative Nursing Programs was completed in the Interdisciplinary Team (IDT) meeting and the following recommendations were made: bed mobility program, Active ROM, and Passive ROM. There are no Physical Therapy notes after (MONTH) 20, (YEAR). The Nursing Home Visit from the physician dated (MONTH) 30, (YEAR) showed R32 was admitted after a prolonged hospitalization after a right BKA and severe coccygeal (buttock) decubitus ulcer. This document showed R32's goal is to return home once R32's ulcers are healed. The Nursing Home Visit from the physician dated (MONTH) 6, (YEAR) showed R32 is anxious to get R32's prosthesis and get back home. The document continued to show R32 is motivated to become ambulatory. It also showed R32 has been compliant with PT and OT and R32's upper and lower extremity strength should be adequate for R32 to adjust to the prosthesis. It showed the overall prognosis for R32 is good. The Nursing Home Visit from the physician dated (MONTH) 2, (YEAR) showed R32 is frustrated and feels R32 is not getting the physical therapy (PT) R32 needs. This document showed the plan is to continue physical therapy and occupation therapy. The Nursing Home Visit from the physician dated (MONTH) 28, (YEAR) showed R32 was recently hospitalized from (MONTH) 29, (YEAR) to (MONTH) 9, (YEAR) (10 days), underwent a left second toe amputation and has residual right-side weakness in the upper extremity from the removal of a brain mass earlier this year. This document showed the plan is to continue PT and OT. The Provider Note from the Nurse Practitioner dated (MONTH) 19, (YEAR) showed R32's left foot is numb with foot drop (toes pointing down to the floor, numbness, &/or difficulty to raise toes toward head). This document continued to show the plan is to continue with restorative therapy, the stump shrinker, and awaiting prosthetic. R32's limited physical mobility related to weakness care plan dated (MONTH) 28, (YEAR) showed interventions to include: monitor, document, report any signs and symptoms of immobility (including contractures forming or worsening); PT and OT referrals as ordered and as needed. The facility's undated Therapy Program showed, Therapy services play a vital role in maintaining or regaining residents abilities. This documented showed, (The facility) strives to provide these services .

Based on observation, interview, and record review the facility failed to safely intervene to a resident's catastrophic reaction to care, this failure resulted in a resident receiving multiple large bruises and a hematoma to both the resident's arms. This applies to 1 of 3 residents (R1) reviewed for abuse in a sample of 3. The findings include: On (MONTH) 8, (YEAR) at 11:10 AM, R1 was sitting in R1's wheelchair in a common television (TV) area at the facility, wearing a cardigan to cover her arms. A large light purple bruise covered the back of R1's hand. This writer asked R1 about the bruise on R1's hand and R1 tried to pull up the sleeves on R1's cardigan and stated, They go all the way up. R1 said, They (the bruises) came from someone that scratched me. R1 continued to say, The woman that did this is still here, but I don't think she has a room. R1 self-propelled the wheelchair back to R1's room and V4, Licensed Practical Nurse (LPN), assisted R1 to remove the cardigan. R1 had bruises on both forearms. R1 had a large bruised area from R1's right wrist, extending up to the middle of R1's forearm. This large bruise had varying colors of black, dark and light purple, surrounded by a faint line of green/yellow discoloration. The top of R1's left wrist had a baseball sized bruise with light purple and green discoloration. The back of R1's left upper forearm, just below R1's elbow, had a golf-ball sized deep purple/black hematoma. R1 touched the hematoma to the left upper forearm and stated, That one hurts if I touch it. R1 said, I was scared so bad! R1 shook R1's head and looked down at the floor. R1 continued to say, I told them to get out of here; this is my room! R1 said, it happened at night time. On (MONTH) 8, (YEAR) at 1:40 PM, R1 self-propelled R1's wheelchair up to this writer in the hallway and said, Are you the one that is going to find out who did this to me (holding up her arms), I want to know. On (MONTH) 9, (YEAR) at 9:48 AM, V13, Certified Nursing Assistant (CNA) said she did R1's shower on Friday, (MONTH) 3, (YEAR) after breakfast. V13 stated, (R1) had no bruises then. V13 said V13 completed the skin check sheet with the shower on (MONTH) 3, (YEAR). The facility's Skin Check sheet signed (MONTH) 3, (YEAR) by V13 shows no skin issues. On (MONTH) 8, (YEAR) at 2:50 PM, V14 (CNA) said V16, Registered Nurse (RN), told me that R1 was trying to get R1's self in bed on the evening of (MONTH) 3, (YEAR). V16 said V16 started getting ready to provide bedtime care and R1 was fine. V14 said R1 didn't have a clean nightgown of R1's own, so V14 set out a green facility gown. V14 said R1 didn't want to wear the green facility nightgown and started yelling, Help! She's trying to kill me! V14 said V15 (CNA) came in after V15 heard the yelling. V14 said V15 asked R1 what was wrong and showed R1 the inside of R1's closet to verify R1's nightgowns were not in the closet. V14 said R1 started thrashing around in R1's wheelchair and cussing at V14 and V15. V14 said they explained to R1 that R1's nightgowns were in the laundry and would be washed first thing in the morning. V14 said R1 calmed down and agreed to wear the green facility nightgown for one night. V14 said V14 and V15 attempted to remove R1's shirt and R1 freaked out again. V14 said R1 was kicking, punching, and cussing at us (V14 and V15). V14 said they (V14 and V15) backed away from R1's wheelchair to try to calm R1 down, but R1 tried to get up out of the wheelchair by R1's self. V14 said, So V15 and I did a two assist transfer from the wheelchair to the bed. R1 was kicking, punching, biting, pinching, and yelling the whole time. V14 said, (R1) pinched me (showing this writer a small pea sized bruise on her right, inner, upper arm). V14 said I also have several bruises to my legs. V14 continued to say, once R1 was in bed R1 started to settle down a little. V14 said they were able to finish bedtime care, place the green facility nightgown, and cover R1 with blankets. V14 said when I started to leave R1's room, R1 started yelling and cussing at me again. V14 was asked what interventions should be used when a resident is agitated. V14 said, I honestly don't know what I was thinking (during the incident with R1); it just got so crazy I couldn't hear myself think. On (MONTH) 8, (YEAR) at 2:25 PM, V15 (CNA) said V14 went into R1's room first. V15 said V15 heard yelling coming from R1's room, so V15 went in R1's room. V15 said R1 told V15 that V14 wouldn't give R1 R1's own gown. V15 said V15 opened R1's closet and showed R1 that there were no clean nightgowns in the closet. V15 said V15 offered to look for a different gown, but R1 started yelling. R1 said to V15 that it was strange R1's nightgowns were not in the closet. V15 said V15 told R1 that the nightgowns were in laundry and would be washed in the morning. V15 said R1 calmed down and let V14 and V15 remove R1's shirt. V15 said then R1 started flailing R1's arms around and hitting R1's arms on the wheelchair. V15 said V14 and I decided to two assist R1 to get R1 in bed because R1 refused to stand or get in bed. V15 said R1 started kicking, swinging, punching, and pinching. V15 said, (R1) was freaking out and throwing a tantrum because we didn't have R1's own gown. V15 said, I have sixty hours of dementia training. V15 said in training V15 learned when a resident is agitated some of the following interventions can be attempted: Try to redirect the resident; change or switch out CNAs; or walk away and give the resident time to calm down. On (MONTH) 8, (YEAR) at 1:43 PM, V16, Registered Nurse (RN), said V16 administered R1's medications at dinner time, but hadn't done any assessments on R1 the evening of (MONTH) 3, (YEAR). V16 said I know the CNAs had a hard time getting R1 to bed. V16 said R1 didn't have R1's own nightgown so R1 was giving the CNAs trouble. V16 said V16 did not go in R1's room during the incident with R1. V16 said when R1 gets agitated, you just have to leave R1 alone. On (MONTH) 9, (YEAR) at 8:37 AM, V11 (CNA) said when V11 got R1 dressed the morning of (MONTH) 4, (YEAR), V11 noticed the bruises on R1's arms. V11 said V11 told R1 those are horrible bruises; what happened to you? V11 said R1 didn't remember what happened. V11 said V11 reported the bruises to V4, LPN, right away. V11 said, I've never had any problems with (R1). V11 said, I've seen (R1) agitated before; nothing much calms R1 down, except giving R1 space, if (R1) is safe and re-approaching later. On (MONTH) 8, (YEAR) at 11:21 AM, V4 (LPN) said V4 wasn't sure how R1 got the bruises on R1's arms. V4 said I worked the morning of (MONTH) 4, (YEAR); saw R1's bruised arms; completed a Skin Check Sheet; left a message for R1's Power of Attorney (POA); notified R1's Nurse Practitioner (NP); and notified V1 (Administrator). V4 said I asked R1 what happened and R1 said, A lady did it. V4 said R1 just gets more agitated if you try to do things when R1's agitated. V4 said I usually just leave R1 alone for a while and try to re-approach later. The facility's Skin Check sheet completed by V4 on (MONTH) 4, (YEAR) shows R1 has a 5.5 centimeters (cm) x 3 cm bruise to the back of R1's right hand; 4 cm x 2 cm bruise to R1's right wrist; and a 13 cm x 8 cm bruise to R1's right forearm. The facility's Skin Check sheet completed by V5, Administrative Nurse, on (MONTH) 5, (YEAR) shows R1 has a 4.1 cm x 4.0 cm dark area to back of right hand; 3.8 cm x 5.5 cm dark area to the right wrist; 12 cm x 10.5 cm dark area to right forearm; 0.4 cm x 0.4 cm, 2 cm x 1 cm, and 1.1 cm x 2.1 cm light reddish area to left wrist; 1.7 cm x 1.5 cm and 2.4 cm x 4.8 cm light reddish area to the left forearm. On (MONTH) 9, (YEAR) at 2:09 PM, V1, Administrator said R1's bruises were reported by V4 (LPN) and V5 (RN) on (MONTH) 4, (YEAR), in the afternoon. V1 said the facility determined R1's bruises were a result of R1's historical behaviors. V1 continued to say, R1 was banging and thrashing R1's arms around and hit the wheelchair and side rails. V1 said V1 watched the facility video surveillance of R1 from dinner on (MONTH) 3, (YEAR) until R1 went to bed and V1 saw no interactions with any other residents or times when the bruises may have occurred. V1 said V1 spoke to V16 (RN) on Sunday, (MONTH) 5, (YEAR), and V16 said R1 was absolutely wild. V1 said V1 asked V16 why there was no charting in R1's EMR about the incident if R1 was so wild. V1 said when R1 became agitated the CNAs should have made sure (R1) is safe, given R1 a break, and tried another staff member. There are no progress notes entered in R1's Electronic Medical Record (EMR) from (MONTH) 2, (YEAR) at 12:38 PM until (MONTH) 6, (YEAR) at 1:30 PM (R1's bruises were first reported on (MONTH) 4, (YEAR)). R1's facility Admission Record printed (MONTH) 9, (YEAR) shows [DIAGNOSES REDACTED].; major [MEDICAL CONDITION]; and anxiety disorder. R1's Minimum Data Set (MDS) dated (MONTH) 28, (YEAR) shows R1 has a Brief Interview for Mental Status (BIMS) score of 10 (moderate cognitive impairment); has verbal behavioral symptoms (threatening others, screaming at others, cursing at others); it is somewhat important for R1 to choose what to wear; it is very important for R1 to take care of her personal belongings; requires extensive assistance of two or more staff members for bed mobility; and requires extensive assistance of one staff member for transfers, dressing and personal hygiene. R1's Abuse/Neglect assessment dated (MONTH) 25, (YEAR) shows a score of 6 (high risk for abuse). A behavior note dated (MONTH) 6, (YEAR) shows it was reported that V14 and V15 (CNAs) were laying R1 down for the night and R1 was upset about not having R1's own nightgown. This note continues to say R1 was punching and banging R1's arms against R1's bed rails in anger. This behavior note was a late entry (not charted until 3 days after the incident). R1's behavior care plan (last revised (MONTH) 11, (YEAR)) shows (R1) has agitation and refusal of care at times, may become combative or verbally abusive to others related to dementia, anxiety and depression. R1's interventions include: avoid arguing, reasoning, or reacting to comment from resident; avoid rushing the resident and re-approach as needed; monitor behavior episodes and attempt to determine underlying cause; and document behavior and potential causes. The facility's Bruise - Investigation for Individualized Interventions dated (MONTH) 7, (YEAR) shows V14 and V15 (CNAs) were notified R1 was attempting to put R1's self to bed. V14 entered the room first and started getting R1 ready for bed. R1 wanted to wear one of R1's own nightgowns, but none were available. R1 became upset and yelled out, help me, she's trying to kill me. V15 heard the yelling and entered the room. V15 opened R1's closet to show R1 there was no gown in there. R1 responded by yelling they were trying to kill R1, calling them names, and told them to go to hell. The report continues to say R1 started hitting R1's arms on R1's wheelchair. R1 attempted stand and V14 and V15 transferred R1 into bed, as R1 continued to yell and hit/kick at them. It was reported that R1 was banging R1's arms on the side rails of the bed. On (MONTH) 14, (YEAR) V1 faxed a statement that the facility has no specific Dementia Care Policy.

Based on interview and record review the facility failed to ensure a resident's safety during a mechanical lift transfer. This failure resulted in R1 sliding out of the mechanical lift sling onto the floor and sustaining a fracture of the right leg on 1/12/14. This applies to 1 of 13 residents (R1) reviewed for safety in a sample of 15. The findings include: 1. The Minimum Data Set of 6/12/14 shows that R1 scored a 12 on the Brief Interview for Mental Status (Moderate Cognitive Impairment). This same document also shows that R1 is totally dependent on 2 or more staff for transfers. R1's Nurse's Notes(NN) dated 1/12/14 shows that state,"CNA(Certified Nursing Assistant) reported to nurse that resident slid out of (mechanical)sling and onto floor. (Mechanical) sling was up too far on resident's body. CNAs saw resident hit his head on the foot rest of is wheelchair....Resident complained of right leg hurting but can not pinpoint spot." The NN dated 1/13/14 state, "New order received to x-ray right knee." and "New order to send to ER for eval and treat." The facility Incident Report dated 1/12/14 states, "CNAs reported to nurse that resident slid off of (mechanical) lift sling prior to being lifted and onto the floor. CNAs reported that resident hit his head on foot rest of his wheelchair....resident does complain of right leg hurting but cannot pinpoint the pain." R1's right knee X-ray report dated 1/13/14 states, "There is an acute mildly displaced fracture of (the) medial femoral condyle." On 8/13/14 at 3:30 PM, R1 stated, "I was getting ready to go to bed. I was lifted up in the (mechanical)lift sling and then I fell out onto the floor. I landed on my right side. The CNAs told me the (mechanical) sling was too short. I fell about a foot (the drop was about a foot). I broke my leg just above my knee cap." The undated written statement from E13 (Certified Nursing Assistant-CNA) states, "On 1/12/14, (E14- CNA) and I went into (R1's) room to prepare him for bed. We hooked the sling up to the (mechanical lift) and pumped once or twice, (R1) then slipped off the wheelchair cushion onto the floor prior to us lifting him up. (R1) bumped his head on the foot rest of his chair and complained of his knee hurting..." The written statement from E14 dated 1/13/14 states, "On 1/12/14 while preparing (R1) for bed, E13 and I hooked the handles to the (mechanical lift) and pumped only once or twice. (R1) then slid off the (mechanical lift) sling and on to the floor. ... (R1) seemed to slip off the sling due to it being slippery. When he slid to the floor he bumped his head on the foot rest and complained he bumped his right knee...(E13) and I were unable to prevent him from slipping because it happened so fast." An untitled facility document dated 1/14/13 states, "From all the info I gathered, I am concluding this- that the (mechanical lift) sling was positioned up too far underneath him, but that when the staff removed his seatbelt from the chair and got him in position to transfer that he slid off the sling- while his bottom was still on the seat."

Based on observation, interview and record review, the facility failed to prevent the development and progression of a pressure ulcer. The facility failed to assess one resident (R2 ) for pain and provide preemptive measures, prior to dressing changes. These failures contributed to R2 developing a Stage I pressure area which progressed to an infected Stage 4 causing the resident pain and requiring surgical debridement. This applies to 1 of 3 residents (R2 ) reviewed for pressure ulcers in the sample of 6. The findings include: 1. R2 is a [AGE] year old male resident with [DIAGNOSES REDACTED]. E4 (Licensed Practical Nurse-LPN - Wound Nurse) identified R2 and R3 as the only residents in the building with pressure ulcers. E4 stated R2 has a facility acquired Stage III-IV area to his sacrum and R3 was admitted with an Unstageable wound to her coccyx. E4 stated R2 developed a Stage I which has progressed to a Stage III. E4 said R2 is scheduled for surgical debridement next week. E4 said R2 is non-compliant with repositioning and has been educated on the importance of pressure relief. E4 stated R3's wound is healing. R2's Minimum Data Set ((MDS) dated [DATE] showed R2 has no cognitive or communication deficits. The MDS showed R2 requires extensive and/or total assist of staff for activities of daily living (ADL's) and personal cares. The MDS identified R2 as having occasional pain. On 5/29/14 at 10:15 AM, wound care was given to R2 by E3 (Registered Nurse - RN). E3 stated she did not pre-medicate R2 for pain prior to the dressing change. E3 stated "he doesn't usually complain." R2's wound exhibited epiboly (rolled edges), full thickness injury with overt necrotic tissue present. On 5/29/14 at 1:45 PM, R2 stated he prefers not to be positioned on his left side because it makes him "so dizzy I could almost fall off the bed." R2 stated he does not refuse to be repositioned. R2 stated staff do not usually try to turn him. R2 states he does comply with lying on his left side because it is the only way he can see the Television. R2 stated his position of preference is his right side. During the surveyor's two days at the facility, (5/29/14 and 5/30/14), R2 was noted to be repositioned during random room checks. The facility did not provide any documentation of interventions attempted to minimize R2's dizziness. On 5/30/14 at 12:00 PM, E1 (Administrator)was asked if R2 was ever evaluated for the cause and/or possible interventions for his dizziness. E1 stated R2 did have a Neurology consult "in the past" but nothing recent. E1 said any documentation of R2 being seen by a Neurologist was so long ago it would be in his closed file. No documentation could be provided to show any efforts to re-arrange R2's room to increase his ability to visualize his TV in an effort to encourage position changes. On 5/30/14 at 7:10 AM, R2 stated he does have pain during his dressing changes and rated it as a 7-8 on the 1-10 pain scale (1=least pain, 10=most pain). R2 stated he is not offered any pain medication prior to dressing changes. R2 said when he is medicated for complaints of pain, he is only offered Tylenol. R2's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During the month of May, the MAR indicated [REDACTED]. No other PRN medications were given. R2's Comprehensive Pain Assessment (reviewed 3/21/14) shows documentation of a "10" on pain intensity "when moved." The medication history and treatment sections shows the use of "Tylenol PRN." A fax communication from the facility to R2's Primary Care Physician (PCP) on 1/22/14 showed he had two openings to his buttocks at that time. E4 verified R2 has a history of skin break down. The wound sheet dated 4/13/14 showed documentation of R2 with a "history of breakdown." According to the care plan for skin breakdown, R2 was on a pressure relieving mattress and had a pressure relieving chair pad due to his history/risk for breakdown. R2 was to be turned every 2 hours and as needed and positioned with pillows. The wound sheet of 4/3/14 shows a 1.2 cm X 1.5 cm reddened area to sacrum. The intervention listed on the care plan for 4/3/14 was to educate R2 on repositioning. The wound care sheet dated 4/10/14 described the area as a "red, blanchable area measuring 1.5 cm X 1.4 cm." No new interventions were added at this time. On 4/17/14 the wound documentation showed no improvement. Again, no new interventions were implemented in an attempt to prevent further decline. On 4/24/14, the wound documentation now showed R2 with a Stage I pressure area measuring 1.5 cm X 1.6 cm to sacrum. The facility still did not implement any new interventions despite the worsening of the area. A PUSH (Pressure Ulcer Healing Chart) was started with R2 having a score of 5 (0=healed. The higher the score the worsening of the wound.) On 5/1/14, R2's wound was identified as a Stage II wound, bed is red in color and measures 1.6 cm X 1.5 cm with a PUSH score of 7 (worsened). At this time a treatment of [REDACTED]. A physician's note dated 5/1/14 documents, "Patient has a stage 2 pressure ulcer on his sacrum." On 5/5/14, the wound care sheets documents the wound as a pale pink color wound bed measuring 1.6 cm X 1.5 cm X 0.3 cm with a PUSH score of 7 (no improvement). No new interventions were implemented according to the care plan. On 5/8/14 the wound sheet documents slough to wound with peri edges unattached. Peri wound bed red with 25% slough and 75% pink. The PUSH score at this time is 9 showing worsening of the wound. The wound care sheet reads: "(R2) Complains of pain when sitting. Resident allowing staff to position on lateral side only 'a little.' States that it makes him dizzy." The wound measurements are documented as 2.0 cm X 1.6 cm X 0.3 cm but there is no staging documentation. The care plan showed no new interventions attempted. On 5/12/14 at 3:30 PM, R2's PCP was sent a fax which reads; "coccyx wound has been worsening - has foul odor - serosang (serosanguanous drainage) - purulent yellow drainage." A debrideing agent was requested at this time and an order was received to cleanse the scrum with wound cleanser and apply Santyl (debrideing agent) and cover with a foam dressing. R2's PUSH score on this date is documented as a 10. The physician progress notes [REDACTED]. It has progressively gotten worse. He also had some drainage this week. I was notified and put him on an antibiotic. The patient reports....he (R2) does not like laying in a certain position but he is willing to try...." R2's PCP ordered [MEDICATION NAME] for "an infected wound" to the sacrum. Dietary was notified and Protein Powder was ordered. The 5/15/14 wound documentation showed R2's wound measured 2.0 cm X 1.6 cm X 0.5 cm with 75% slough and 25% full thickness Stage III wound. This wound care note reads, "exudate, foul odor, slough firmly adherent to wound bed. Wound edges unattached. Surrounding tissue red. Pain stated when on sore." At this time, the PCP referred R2 to a Surgeon for a Consult. On 5/20/14, R2 was seen by a surgeon. The surgical progress note documented, "The patient (R2) does have some soreness on his tailbone...There is a 4 cm by 3 cm by 2 cm stage three to four sacral decubitus with some superficial necrotic exudate and some foul smelling odor as well....(R2) with stage three to four infected sacral decubitus ulcer. A surgical debridement in the operating room would be recommended here....The patient understands the plan, he agrees and he is appreciative." The 5/20/14 wound documentation showed R2's wound measures 3.6 cm X 2.1 cm X 1.8 cm. with new orders, (from the surgeon), for R2 to be turned/repositioned every 30 minutes. "The resident is on alternating air mattress...wound is 90% slough 10% pink, foul odor present. Wound edges unattached peri wound red. Complains of mild pain when wound cleansed." R2's PUSH score is now at 11. The 5/26/14 wound documentation now measures 3.7 cm X 2.1 cm X 1.8 cm. Area with "90% slough 10% pink, foul odor. Red to peri wound...Surgeon appt June 4 for debridement." R2's PUSH score remains at 11, (no improvement). R2's care plan for "pain" contains the following intervention; "Nurse will administer pain medication 20-30 minutes prior to PT/OT (physical therapy/occupational therapy) exercises." It does not address pain related to the pressure ulcer. R2's care plan related to skin break down has no interventions to address his pain. The Stage III-IV pressure ulcer problem is identified. R2's care plan for repositioning showed he was to be turned every 2 hours until the new order on 5/20/14, at which time he was to be turned every 30 minutes. The care plan does not address interventions for R2 if he refused to turn. The care plan does not document any alternative measures nor interventions to encourage repositioning and/or to alleviate his complaints of dizziness and pain. Peri care was given to R2 by E8 and E9 (Certified Nursing Assistant, CNA) at 10:50 AM on 5/29/14. During the provision of cares, a previously unidentified, partial thickness open area was identified on R2's scrotum.