Every finding on record at Pavilion of Bridgeview, The

Based on interview and record review, the facility failed to treat a resident in a dignified manner and ensured that (R1) had on clothing attire when resting in bed. This affects one of three residents (R1) reviewed for improper nursing care. R1 face sheet shows R1 has dementia. R1 MDS shows R1 is dependent on staff assistance for activities of daily living for dressing. R1 observed resting in bed awake and alert, R1 was not interview able. R1 was dressed in a orange gown/dress. 6/17/26 at 11:47am V5 (R1 power of attorney) said on Mother's day when she visited R1, R1 was observed with no clothing on while resting in bed, only the linen was covering R1 body. V5 said she made V2 (DON) aware. V5 sent photos showing R1 without clothing and resting on soiled linen. 6/17/26 at 1:00pm V2 (Director of Nursing) said V5 made her aware that R1 did not have on clothing during her visit with R1 on mother's day, V2 said her expectation is that the residents are cleaned and dressed as they desired. V2 said R1 has never requested to be unclothed under her blanket. The resident rights for people living in the long term care facilities denotes in-part Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

Based on interview and record review, the facility failed to follow its room-to-room transfer policy for R1 by not notifying R1's power of attorney of a room change for one of three resident's review for transfers. Findings Include:On 12/18/25 at 11:27am, V3 (Social Service Director) said, we did not notify V11 (R1's Power of Attorney) for R1 room transfer on 9/16/25.R1 power of attorney paperwork dated 8/22/25 documents: V11. R1's electronic record did not document any notification on 9/16/25.Room to room transfer policy dated 4/2014 documents: Prior to the room transfer, the resident, his or her roommate (if any), and the resident's representative (sponsor) will be provided with information concerning the decision to make the room transfer.

Based on observation, interview, and record review the facility failed to ensure that food kept in the refrigerator was labeled with open and use by date to prevent food borne illness and failed to ensure kitchen staff beards and hair were covered with required hair net and beard guard. This failure has the potential to affect 128 residents. Findings include:On 9/29/2025 between10:04am to 10:10am, during kitchen observation with V10, Dietary Manager, 2 quarter pans of pureed eggs dated 09/26/25 not specifying whether it is open date or used by date. V10 stated it is pureed eggs, and it does not have a used by date. I (V10) cannot see a used by date that must be the prepared date. V10 stated the cook should have put the used by date to show that this is the prepared date. During the same observation 1/2 quart eggs dated 9/28/25 not specifying whether it is open date or used by date. V11, Dietary Aide observed with long beard without beard guards or hair net. V10 stated that all hair should be covered with hair nets and beard guard.Facility policy Hair Restraints/Jewelry/Nail Polish documents in part that food and nutrition services shall wear hair restraints and beard guards. Procedure listed includes but not limited to beard guards or masks will be worn as indicated.Facility policy on Labeling and Dating Foods dated presented dated 2017 documented in part that to decrease the risk of food borne illness and provide highest quality, foods is labeled with and the date by which the item should be discarded dates opened. Facility policy on Storage of Refrigerated Foods from food and nutrition services with revised date 2017 documented in part that refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Listed procedure includes but not limited to food in the refrigerator should be labelled with use by date

Based on observation, interview and record review, the facility failed to clean and maintain the dryer lint screens thoroughly to provide a safe environment for the residents. This failure has the potential to affect all 131 residents at the facility.Findings include:Facility census, dated 12/01/25, documents 131 residents residing at the facility.On 12/02/2025 at 12:20pm, during a tour of the laundry area with V9 (Housekeeping Manager), 4 dryers were observed. V9 opened the lint compartment of dryer #4. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. Dryer #3 had a sign stating that the dryer did not work and V9 confirmed that dryer#3 was not working properly and not in use. V9 opened the lint compartment of dryer #2. The lint compartment floor had loose lint on the floor and the lint screen was fully covered with lint. V9 opened the lint compartment of dryer #1. The lint compartment floor had a large amount of loose lint on the floor and the lint screen was fully covered with lint. V9 said, These (lint compartments) obviously have not been cleaned recently. They (lint screens/compartments) are cleaned out every 2 hours. When asked the purpose of cleaning the lint compartments of the dryers, V9 replied, It can cause a fire and burn the place.Record review of facility document titled, Lint Screen Cleaning/Drain Cleaning, undated, documents, in part, All Laundry personnel should be trained to clean lint screens in dryers. These screens will eventually be covered with lint and must be cleaned. If not cleaned, the screens will prevent air from circulating through the dryers and is a definite fire hazard. After every 2 to 3 loads: Shut off dryer, remove lint screen from bottom of dryer, brush off all lint from screen, replace screen in dryer.Record review of the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.Record review of facility job description titled, Laundry Aide, undated, documents, in part Maintains all laundry equipment and informs facility's manager as to any maintenance needs.

Based on interview and record review, the facility failed to follow policy and procedure and failed to use and follow a valid PRN (as-needed) order for four residents (R9, R39, R122, and R147) receiving psychotropic medications, as required by federal regulations and facility policy. These failures affected 4 residents (R9, R39, R122, and R147) in a sample of 57 residents reviewed for psychotropic medications.Findings include: R9 's medical record showed that R9 was admitted to the facility [DATE] with diagnosis list that includes but not limited to Chronic obstructive pulmonary disease, type 2 diabetes mellitus with ketoacidosis without coma, delusional disorder, restlessness and agitation, major depressive disorder, and retention of urine. On hospice care. R9's MDS (Minimum Data Set) dated [DATE] scored BIMS (Brief Interview for Mental Status) at 03 indicating at R9 is cognitively impaired. Section E coded 0 for behavior R9's medical record MAR (Medication Administration Record) E-POS (Electronic Physician Order Sheet) showed order dated [DATE] for Ativan (Lorazepam) powder apply to skin – wrist topically every 4hours as needed for agitation, anxiety gel. Give 0.5ml (Milliliter) (0.25mg). This order does not have stop date as required by federal regulation. On [DATE] R9 has another order for Ativan (Lorazepam) oral concentration 2mg/ml. give 0.5ml by mouth every 4hours as needed for anxiety 0.5ml every 4hours PRN. This order does not have stop date as required by federal regulation. On [DATE] R9 to Ativan solution 2mg/ml inject 0.5mg intramuscularly every 8hours as needed for anxious. This order does not have stop date as required by federal regulation. R9s medical record MAR showed documentation that Ativan is being administered without order clarification regarding stop date. On [DATE] between 12:40pm and 12:47pm, V26 RN (Registered Nurse/Hospice case manager) stated in part that (R9) has two orders of PRN (as needed) Ativan used for Restlessness and Agitation orders are to administered sublingual and the other one is rubbed on the skin if she can't take it sublingually. When surveyor asked about stop date for antipsychotic medications used as PRN, V26 stated, we don't use a stop date; we are unable to gauge the dying date/transition date. The medication is use for symptoms management. Regarding 14 days stop date and re-assessment we don't use stop date, that must be something with (for) the facility. When asked about the policy on the care provider decision not adhering to federal regulation on this matter, V25 stated that we don't have any policy regarding that. But I will check and send the policy to the administrator (V1) but let me check with my supervisor. On [DATE] at 2:03pm, V26 (RN/Registered Nurse Hospice Case Manager said, A 14-day period is the candidate timeframe for a GDR (gradual dose reduction), and the resident's symptoms are documented every week. We (hospice staff) hold a weekly IDG (Interdisciplinary Group) meeting during which we discuss the patient and the patient's needs. We do not send documentation to the facility. The IDG includes our (hospice company) doctors and social workers, but it does not include any staff from the facility (resident's facility). The facility communicates with us (hospice)directly. I (V26) come in personally and speak with the facility nurses and with the resident's family. The symptoms are ongoing because we are managing them every week, so we (hospice staff) don't renew PRN (as needed) psychotropic medications every 14 days. A nonpharmacological approach to her (resident) demands was put in place first. For myself, this includes being present with her, sitting and talking with her, talking about her son who passed away, talking about baseball, and anything that helps calm her down. Activities such as folding Kleenex and towels are also used. The facility staff should be doing these interventions as well, although I cannot speak to their nonpharmacological approaches. Because we (hospice staff) complete the IDG without facility staff present, we obtain the plan of care, provide the updated plan of care, and place it in the binder. It (having facility staff present) would not hurt to involve the facility more directly and attend the IDGs. When we (hospice) come to the table and speak with the medical director, the facility is seeing and reporting what they observe and report back to us (hospice staff). It does not sound like a bad idea. The policy titled Hospice Care for Nursing Facility Residents-Psychotropic Medications presented documents that care hospice follows skilled nursing facility regulations related to psychotropic medications for hospice patients that reside in a nursing facility. Psychotropic Medication includes but not limited to anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. Procedure listed includes but not limited to there is a 14-day limit on all PRN (As needed) orders for psychotropic medications. R39's face sheet documents diagnoses' that include, but are not limited to anxiety disorder, dementia, and Alzheimer's Disease. R39's physician order, ordered date: [DATE]; end date: indefinite, documents, in part, Ativan Oral Tablet 1 MG (Lorazepam), Controlled Drug, Give 1 mg by mouth every 6 hours as needed for agitation; Medication Class: Antianxiety Agents; For (Indication for Use): Agitation. This order does not have a stop date as required by federal regulation. R122's face sheet documents diagnoses' that include but are not limited to anxiety disorder. R122's physician order, ordered date; end date: indefinite, documents, in part, hydroxyzine Pamoate Capsule 25 MG: Give 1 capsule by mouth every 6 hours as needed for Anxiety related to anxiety disorder, unspecified (F41.9) 25mg cap every 6hrs as needed.; Medication Class: Antianxiety Agents; Related diagnoses: Anxiety disorder. This order does not have a stop date as required by federal regulation. R147's face sheet documents diagnoses' that include but are not limited to repeated falls and weakness. R147's physician order, ordered date [DATE]; end date: indefinite, documents, in part, hydroxyzine HCl Oral Tablet 25 MG (Hydroxyzine HCl); Give 25 mg by mouth every 8 hours as needed for Anxiety; Medication Class: Antianxiety Agents; Chemicals; Indication for Use: Anxiety. This order does not have a stop date as required by federal regulation. On [DATE] at 11:00am, V28 (RN/Registered Nurse/Care Plan Coordinator/Psychotropic Nurse) said, A 14-day period is the facility policy for the use of PRN (as needed) psychotropics. Examples of psychotropic medications include Seroquel, Trazodone, Clonidine, Lexapro, Hydroxyzine, and Xanax. The rationale is that they need to be re-evaluated to see if the medication is affecting the resident, and whether it (psychotropic medication) is still necessary. I (V28) don't know why they (staff) would be documenting a zero on the behavioral sheets and still giving the medication (psychotropic medication). Zero means the resident has no behaviors. Regarding hospice, when giving Ativan PRN, the policy does not exclude hospice residents. Generally, Ativan is used for end-of-life care. When you need it, you need it, such as when they (residents) are having respiratory distress or agonal breathing. We (facility staff) are supposed to follow our policy. In my (V28) professional opinion, it depends on the hospice patient and the orders. Some residents are on Ativan and never use it; sometimes they (residents) use it within 14 days. Based on facility policy, it (PRN psychotropic medication for residents on hospice) should still follow the same procedure. The correct indication for use should be listed in the diagnosis of the resident. Regarding how we (facility staff) monitor per CMS regulations: for new patients, I (V28) make the NP (nurse practitioner) psych aware and ensure diagnoses are present, identify what the target behaviors are, and ensure tracking based on ancillary orders and nurses entering the information into the EMAR (electronic medical admiration record). We (facility staff) do GDRs (gradual dose reductions). Pharmacy sends over the list of who is due for a GDR. The Psych NP oversees it. Sometimes we attempt a GDR and are not successful, and sometimes we do not attempt it at all. It's (R147's hydroxyzine order) discontinued now. R147's order (hydroxyzine order) was put in wrong. Her (R147) brother died and should have been a one-time dose. The black box warning for psychotropic medications lets us know that this medication can be a danger for certain residents. When asked which certain residents, V28 replied, Most of the population here (residents residing at the facility). On [DATE] at 1:47pm, V3 (Director of Nursing/DON) said, Psychotropic PRN (as needed) medications are ordered for 2 weeks or 14 days to be reevaluated. The purpose is to see if the resident still needs the medication, check resident behaviors if worse or better. Record review of facility's Informed Consent For Psychotropic Medication, undated, documents, in part, Antianxiety drugs: Purpose: To reduce anxiety that impedes normal functioning, drug may be used as an antiseizure medication or as a muscle relaxant. Possible side effects: Drowsiness, confusion, apathy, fatigue, dizziness, unsteady gait, nausea, vomiting, headache, rash and blurred vision. Record review of facility policy titled, Abuse Prevention Program, dated 10/2022, documents, in part, This (Name of Facility) facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents. In order to do so, the facility has attempted to establish a resident sensitive and resident secure environment The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect exploitation, misappropriation of property, deprivation of goods and services by staff and mistreatment of residents. This will be done by: establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment; assuring that physical restraints are used sparingly and properly, and that chemical restraints are not used. Record review of facility policy titled, Psychotropic Medication, dated 11/2013, documents, in part, Prior to starting a psychoactive drug consider the resident rights: the right to be informed about the resident's condition, treatment options, relative risk and benefits of treatment, required monitoring, expected outcomes, the right to refuse and the right to be free of chemical restraints. All informed consents have a black box warning identifying an increased risk for death in the elderly when using antipsychotic medication. The resident has the right to be free from any physical or chemical restraints imposed for the purposes of discipline or convenience and not required to treat the resident's medical symptoms. When used as a restraint the facility must use the least restrictive alternative for the least restrictive amount of time and document the ongoing reevaluation of the need for the restraint. The prescribing and administration of psychotropic drugs is based on a comprehensive assessment of the resident. Residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, and behavioral interventions. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents must be free of unnecessary drugs. (Unnecessary drugs are any drug when used in excessive dose, excessive duration, without adequate monitoring or without adequate indications for its use or in the presence of adverse consequences which indicate the dose should be reduced or discontinued.) Psychotropic drug is any drug that affects brain activities associated with mental processed and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti­psychotics, anti-depressants, anti-anxiety and hypnotics. Residents do not receive psychotropic drugs pursuant to PRN orders unless that medication is necessary to treat a diagnosed specific condition. PRN orders for psychotropic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of the medication and documents their rationale for continued use in the resident's medical record for the duration of the PRN order. If antipsychotic medications are administered as PRN dosages repeatedly over several days, the Physician should discuss the situation with staff and evaluate the resident as needed to determine whether the use is appropriate, and the symptoms are responding to the medication. Documentation Requirements: 1. An informed consent form signed by the resident or legal representative for the appropriate medication(s) and dose. A new consent will be completed if a dose increases, or a new drug is started. 2.Evaluation and Education of resident and resident representative and documentation of such. 3. An initial and annual Psychoactive Medication Screening, which will include: a. Behaviors exhibited b. Psychiatric diagnosis and/or dementia diagnosis and stage as documented. c. Rule out any transitory conditions that could cause a change in behavior d. Possible causative factors. e. Non-pharmaceutical interventions f. Possible risks/complications. g. Results of Gradual Dose Reduction. h. Justification to proceed or not to proceed. 4. A Psychoactive medication quarterly screening is to be completed at least quarterly. The following information is reviewed and evaluated; a. The residents targeted symptoms and the effect of the medication on the severity, frequency and other characteristics of the symptoms. b. Any changes in the residents' function during the past quarter as identified in the MDS, CAM or physician notes. c. If the resident experienced any psychotropic related adverse consequences during the previous quarter. d. If a reduction was attempted and the outcome. e. If reduction attempt is contraindicated f. The rational for continuing the medication. 5. Episodic behavior intervention charting is completed for each resident receiving psychoactive medication. Orders for the medications must include: e. Reason or problem for which given. 10. Physician's orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders. a. To prevent continued administration of potentially hazardous medications without appropriate review and authorization, drugs not specifically limited to duration of use and number of doses when ordered will be controlled by automatic stop orders. b. One (1) day prior to the date the stop order is to become effective, the Nurse on duty must contact the Attending Physician to determine if the medication is to be continued. Record review of the Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels. Your facility must be safe, clean, comfortable, and homelike.

Based on interview and record review, the facility failed to ensure preadmission screening assessments were completed as required for residents identified that have a mental illness. This failure affected four residents (R4, R5, R59, and R124) reviewed for pre-admission screening in the sample list of 57 residents. Findings include: R4 is [AGE] years old and have resided at the facility since 2021, past medical history include, but not limited to pot traumatic stress disorder, bipolar disorder current episode mixed, unspecified, major depressive disorder recurrent, unspecified, type 2 diabetes, etc. R4 has an MDS indicator for no PASARR 11 with diagnosis of post-traumatic stress disorder (PTSD), bipolar disorder and major depressive disorder. On 12/03/2025 at 9:30AM, requested resident's PASRR screening from the facility and they provided a copy of Federal Omnibus Budget Reconciliation Act (OBRA) pre-admission screening dated 01/03/2021. Surveyor requested for resident's PASARR screening from Maximus and V2 (Assistant Administrator) said that they do not have any screening from Maximus for the resident. R5's face sheet documents an admission date of 1/03/2025 with diagnoses that include but are not limited to hypomanic bipolar disorder (onset date 1/03/2025), depressed bipolar disorder (onset date 1/03/2025), major depressive disorder (onset date 1/03/2025), anxiety disorder (onset date 1/03/2025), mood (affective) disorder (onset date 1/03/2025), and unspecified mental disorder due to known physiological condition (onset date 1/03/2025). R5's Notice of PASRR (Pre-admission Screening and Resident Review) Level I Screen Outcome, dated 11/29/2024, documents, in part, PASRR Level I Determination: No Level II Required – No SMI (Serious Mental Illness). Evidence shows that R5's PASARR Level I Screen is inaccurate due to R5 having multiple mental Illness diagnoses including, but not limited to bipolar, depression, and anxiety disorder. Review of R5's health records do not show that a Level II Pre-admission Screening and Resident Review (PASARR) was completed for R5 even though R5 has multiple mental health diagnoses that include hypomanic bipolar disorder, depressed bipolar disorder, major depressive disorder, and anxiety disorder. R59's face sheet documents an admission date of 4/27/2021 with diagnoses that include but are not limited to anxiety disorder (onset date 5/20/2023), mood disorder (onset date 3/29/2023), depressive disorder (onset date 08/01/2021), and psychosis (onset date 4/27/2021). R59's OBRA-1 INITIAL SCREEN, dated 4/23/2021, documents, in part, Reasonable Basis To Suspect A Mental Illness: 1) The individual has been diagnosed with a mental illness verified by a DSM IV classification: No.; There are other indicators of mental health: No. Review of R59's health records do not show that a Level I or Level II Pre-admission Screening and Resident Review (PASARR) was completed for R59 even though R59 has mental health diagnoses that include anxiety disorder and depressive disorder. R124 is [AGE] years of age. Current diagnoses include but are not limited to Dementia with other behavioral disturbance, Other Specified Depressive Episodes, Generalized Anxiety Disorder, and Other Psychotic Disorder Not Due To A Substance or Known Physiological Condition. R124 was admitted to the facility on [DATE]. R124's comprehensive assessment dated [DATE] section C cognitive patterns documents a brief interview for mental status with a score of 14 out of 15. R124 is cognitively intact. On 12/03/2025 at 9:30 AM, V2 Assistant Administrator was inquired of PASARR (pre-admission screening and resident review) for residents in the facility for a mental disorder or related condition prior to being admitted . V2 said, We have a liaison at the hospital that does the screening. All the residents have to be screened. Can you explain what you mean by through Maximus? I'd have to check with Social Service. V2 provided R124's OBRA (Federal Omnibus Budget Reconciliation Act) pre-admission screening from 11/21/2018. On 12/3/25 at 12:06pm, V2 (Assistant Administrator) said, We (facility) receive the referral of the patient from the hospital prior to admission. Once the patient arrives here, we enter the information into MAXIMUS. If the PASARR form has not been completed before admission, Social Services requests it. The purpose of the PASARR is to make sure the individual is appropriate for nursing home placement and does not require a Level II evaluation. A Level II is the second level of screening. I (V2) do not request PASARR's to be completed, Social Services gets involved for PASARR requests. On 12/03/25 at 12:14pm, V25 (Social Services Director) said, When the patient comes here, we (facility staff) confirm that a PASARR has been completed when it is triggered. Admissions reviews the information and looks at the face sheet to identify any mental health diagnoses that would trigger the process. If the PASARR has not been completed, I (V25) go in and request the clinical information to determine if the patient is appropriate for a SNF (skilled nursing facility) based on the clinical packet. I (V25) would then initiate the PASARR and determine whether someone from MAXIMUS needs to come in to assess for a Level II. The purpose of the Level II is to determine whether the patient's psychiatric diagnosis is appropriate for our setting or if they require placement in another level of care. Examples of mental health or psychiatric diagnoses that may trigger the process include paranoid schizophrenia, bipolar disorder, major depressive disorder, delusional disorder, multiple personality disorder, and anxiety. On 12/3/25 at 12:31pm, V2 (Assistant Administrator) said, I (V2) review the PASARRs for the potential new residents to be admitted . I (V2) do not have any clinical experience. Record review of facility policy titled, admission Criteria, revised date 11/2020, documents, in part, Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-admission Screening and Resident Review program (PASARR) to the extent practicable. Pamphlet titled, Illinois Long-Term Care Ombudsman Program Residents' Rights for People in Long-Term Care Facilities, revised date 11/18, documents, in part, . Your facility must provide services to keep your physical and mental health, at their highest practical levels.

Based on observation, interview, and record review, the facility failed to ensure that chemical sprays were safely locked up when not in use by authorized facility staff to prevent accidental use by residents with diagnosis that includes respiratory disease/compromise for five of five residents (R9, R21, R66, R70, R117) reviewed for hazards and supervision. This failure affected five of five residents (R9, R21, R66, R70, R117) and has the potential to affect all 43 residents residing on the 2nd floor of the facility.Findings include:R9 's medical record showed that R9 was admitted to the facility 04/09/2024 with diagnosis list that includes but not limited to Chronic obstructive pulmonary disease, type 2 diabetes mellitus with ketoacidosis without coma, delusional disorder, restlessness and agitation, major depressive disorder, and retention of urine.R21's medical record admission record showed that R21 was admitted [DATE] with listed diagnosis that includes but not limited to Chronic obstructive disease, type 2 diabetes mellitus without complications, major depressive disorder recurrent, unspecified asthma, and localized edema.R66 medical record admission Record showed that R66 was admitted on [DATE] with diagnosis information list that includes Acute respiratory failure and hypoxia, chronic obstructive pulmonary disease, and pain in left knee.R70's admission record showed that E70 was admitted to the facility on [DATE]. Listed diagnosis includes but not limited to unspecified Chronic bronchitis, hemiplegia unspecified affecting right dominant side, major depressive disorder recurrent and weakness.R117 medical record admission Record documented that R117 was admitted [DATE] and with diagnosis information list that includes but not limited to Interstitial pulmonary disease, major depressive disorder recurrent, and anxiety On 09/29/2025 at 10:31am, R21 observed sitting in wheelchair. Disinfectant spray was observed on the dresser. R21 stated in part she uses it whenever her roommate (R70) or self (R21) pooped or there is a smell in the room.R21's diagnosis includes COPD (Chronic Obstructive Pulmonary Disease includes but not limited. R70 has a diagnosis list that includes respiratory problem Bronchitis. V6 Registered Nurse (RN) then stated she (R21) should not be spraying that in the room.On 9/29/2025 at 11 :16am, V3 DON (Director of Nurse's) stated in part the expectation of staff in making rounds, includes making sure any hazardous chemical in use in this case Lysol disinfectant spray are not stored inappropriately.On 9/29/2025 at approximately11:44am, V9, Housekeeping Manager stated, the facility don't use this type of disinfectant product, (R21) must have bought it (on-line store). The disinfectant spray has caution information to keeps out of reach of children with physical hazard that it is flammable, hazard to humans and Domestic humans.On 09/29/2025 between 11:45am to 11:47am, V8 CNA (Certified Nurse's Aide) stated in part that rounds are made every two hours and if medications are left at bedside typically tell the nurse. I (V8) was so busy today, I did not recall. She (R21) usually has lots of things at her bed side on the table. The room is a little bit darker, I (V8) did not see any (disinfectant), If I see it, I will take it because I don't think she should have it. On 09/30/202025 at 12:34pm, R9 observed in bed in a low position, responds to name call. On R9 dresser at the bedside a can of odor neutralizer observed on the dresser in the room with danger information that stated extremely flammable aerosol with instruction to keep out of reach of children. On 09/30/2025 at approximately 12:42pm, V17 (LPN) was shown the aerosol. V17 stated in part that the family brought it for the resident, and we (staff) have told them many times not to. V17 stated that R9 is a hospice patient, and I (V17) think she has diagnosis of COPD.R9 diagnosis list includes but not limited to COPD (Chronic Obstructive Disease).On 9/30/2025 between 12:49pm to 12:51pm, V20 ADON (Assistant Director of Nurses) was made aware of this observation. V20 stated that no chemical like aerosol should be used by the resident especially if they have a roommate.On 12/02/2025 at approximately 10:02am during R9's wound care observation with V24 (Wound Care Nurse). One can of lemon air freshener left at R9's bedside table. When this was shown to V24, V24 stated this should not be stored at bedside but not to give any excuse at times the family members bring them (Air freshener) into the building (Facility).On 12/02/2025 at 10:16am, when this was shown to V20 ADON (Assistant Director of Nurse's) and V13 RN (registered Nurse) was shown the air freshener, they both stated that it should not be at bedside. V13 stated I did not realize that it was there the family must have brought it for her.On 12/2/2025 at approximately10:25am, observed from the hallway on the windowsill of R66 and R117's room one can of air freshener and a can of insecticide (OFF). R117 observed with oxygen in use. On 12/2/2025 at approximately 10:26am, V19 RN (Registered Nurse) was shown the two cans, and she stated that R117 is not supposed to have those. Any resident with respiratory issue she should not be spraying that around them. R117 then stated, they are mine and I used them. V19 told R117 that she is not supposed to have it at bedside. Review of R66 roommate to R117 showed listed diagnosis that includes but not limited to Acute respiratory failure and hypoxia, chronic obstructive pulmonary disease.On 12/2/2025 at approximately 11:51am, V3 (DON) stated that the rationale for not keeping the air freshener products at bedside is to prevent aerosols in the air that can affect those residents with respiratory problem like Asthma or COPD. The facility policy titled Hazardous Materials and Waste Storage with no date documented in part that the purpose of the policy is that the facility shall ensure that hazardous materials and waste are stored in a safe manner to prevent injury to residents, visitors and staff. All hazardous materials shall be received into the facility by appropriate staff and stored in a supply room closet for chemicals only.Facility Safety and Supervision of Resident policy presented with no date documents in part that under the policy statement that facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities

Based on observation, interview, and record review, the facility failed to properly document medication administration of controlled medications on the controlled drug receipt/record/disposition form for three residents (R32, R63, and R140) and failed to properly document shift change accountability on the controlled substances check form per facility policy. These failures have the potential to affect 22 residents on 2nd, 18 residents on 3rd, and 15 residents on 4th floor that receive controlled medications reviewed during medication storage review.Findings include:On 09/29/2025 at 10:42 AM, the 4 [NAME] medication cart was reviewed with V12 LPN. The shift change accountability for controlled substances record has missing nurse initials for 09/21/25 on 2nd and 3rd shift.R140's controlled drug receipt record/disposition form documents Hydrocodone-Acetaminophen *Controlled Drug* Oral Tablet 5-325 mg (milligrams) give 1 tablet by mouth every 8 hours as needed for pain. Review of R140's controlled drug receipt record/disposition form documents 15 tabs remain. The count of the medication card identified 14 tabs remained in the package. V12 said, I gave it at 9 AM, I was going to sign it out. The 09/29/2025 9AM dose of Hydrocodone was not documented as administered by V12 on the controlled drug form. On 09/29/2025 at 10:45 AM, R140's controlled drug receipt record/disposition form documents Alprazolam Oral Tablet 0.25 MG *Controlled Drug* give 1 tablet by mouth one time a day related to Anxiety Disorder. Review of R140's controlled drug receipt record/disposition form documents 25 tablets remain. The count of the medication card identified 24 tablets remain. V12 said, I forgot to sign it this morning. The 09/29/2025 9AM dose of Alprazolam was not documented as administered by V12 on the controlled drug form.On 09/29/25 at 10:54 AM, the 4 East medication cart was reviewed withV13 RN Registered Nurse. R32's controlled medication Tramadol 50mg (milligrams) one tab by mouth every 8 hours prn (as needed) does not have a controlled drug receipt record/disposition form. There is a handwritten paper being used to document the medication. V13 RN was inquired of the paper. V13 said, I'm not sure what happened when it was delivered, this is what everyone has been using. The last documented dose of medication on the handwritten paper states 6/12 (2025). On 09/29/2025 at 11:07 AM, the 3 [NAME] medication cart was reviewed with V23 RN Registered Nurse. The shift change accountability for controlled substances record has missing nurse initials for 09/08/2025 2nd and 3rd shift, 09/11/2025 2nd and 3rd shift, 09/27/2025 2nd and 3rd shift, and 09/28/2025 1st, 2nd, and 3rd shifts. On 09/29/2025 at 11:40 AM, the 2 East medication cart was reviewed with V7 RN Registered Nurse. The shift change accountability for controlled substances record has missing nurse initials for 09/05/2025 1st and 2nd shift, 09/11/2025 3rd shift, 09/12/2025 2nd and 3rd shift, 09/13/2025 1st shift, 09/14/2025 3rd shift, 09/15/2025 1st shift, 09/22/2025 3rd shift, 09/23/2025 1st, 2nd, and 3rd shift. On 09/29/2025 at 11:43 AM, R63's controlled drug receipt record/disposition form documents Pregabalin Capsule 75 mg (milligrams) give 1 capsule by mouth one time a day related to other specified Polyneuropathies. Review of R63's controlled drug receipt record/disposition form documents 11 tabs remain. The count of the medication card identified 10 tabs remained in the package. V7 was inquired of the medication. V7 said, She's the only one I haven't signed. The 9AM dose of Pregabalin was not documented as administered by V7 on the controlled drug form.On 09/29/2025 at 2:23 PM, R140's medication administration record documents V12 administered the dose of Hydrocodone related to R140's pain rate of 5 at 09:03 AM. The Xanax dose is documented as administered at 9AM by V12 on the medication administration record. Review of R32's physician orders document her Tramadol was originally ordered on 08/08/2024 and discontinued 07/17/2025. Physician order notes state per pharmacy recommendation; med has not been dispensed. On 09/30/2025 at 12:36 PM, V3 DON (Director of Nursing) was inquired of concerns identified during medication administration. When administering medications and controlled substances, when should it be signed out? V3 said, Document after administration ensuring resident took medication. If not, you'd have to go back and document why it wasn't taken. When the nurse pulls out the narcotic medication from the box it should be checked against the control record and MAR (medication administration record). Take the medication, write remaining amount, and administer it then sign it out. If a medication is received from the pharmacy without a controlled substance accountability record, what should be done? V3 said, We would call the pharmacy and ask them to send a log. If not, we have blank controlled substance records. We would copy the medication on the sheet with another nurse, prescription number, instructions of administration, day received, amount received. They should follow up with me so I can reach out to pharmacy. It's not ok to use a blank sheet of paper. The control log has what we need to be documented. V3 further said, The oncoming and off going nurse should be counting the narcotics together then sign the end and start of shift page. The Nursing Policy and Procedure revised 11/2020 states in part: Policy StatementThe facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. Policy Interpretation and Implementation3. Controlled substances must be counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals must sign the designated controlled substance record.4. If the count is correct, an individual resident controlled substance record must be make for each resident who will be receiving a controlled substance. This record must contain: a. name of the resident, b. name and strength of the medication, c. quantity received, d. number on hand, e. name of physician, f. prescription number, g. name of issuing pharmacy, h. date and time received, i. time of administration, j. method of administration, k. signature of person receiving medication, and l. signature of nurse administering medication.9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. The 3.3 Controlled Substance Policy states in part: PolicyMedications classified by the FDA as controlled substances have high abuse potential and may be subject to special handling, storage, and record keeping.Procedure: 4 b. All schedule II controlled substances (and other schedules if facility policy so dictates) will be counted each shift or whenever there is an exchange of keys between off-going and on-coming licensed nurses. The two nurses will: 1. Inspect both the drug package and the corresponding count sheet to verify the accuracy of the amount remaining. 2. Both nurses will count the number of packages of controlled substances that are being reconciled during the shift/shift count and document on the Shift Controlled Substance Count Sheet. 3. Both nurses will count the Controlled Substances count sheets and verify the accuracy of the number of remaining count sheets. 4. Both nurses will sign the Shift/Shift Controlled Substances Count Sheet acknowledging that the actual count of controlled substances and count sheet matches the quantity documented.he United Rx Pharmacy 5.4 Controlled Substance Medication policy states in part: PolicyMedications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws regulations.Procedure: 6. Controlled substances will be dispensed by the pharmacy along with an Individual Charting Record. This record will be maintained by the nursing staff at the time of each administration of the medication as follows: a. place charting record in narcotic box or binder, b. record each dose at the time of administration, c confirm the amount of controlled drug remaining is correct prior to assembling required dose for administration- i. date, ii. Time, iii. Dosage, iv. Signature of nurse who administered dose, v. number of does remaining.V7 RN's Registered Nurse job description dated and signed on 05/22/2024 states in part: Maintains knowledge of necessary documentation requirements. I have reviewed this job description and I understand all my job duties and responsibilities. V12 LPN's Licensed Practical Nurse job description dated and signed on 11/08/2022 states in part: Maintains knowledge of necessary documentation requirements. I have reviewed this job description and I understand all my job duties and responsibilities. V13 RN's Registered Nurse job description dated and signed on 02/17/2023 states in part: Maintains knowledge of necessary documentation requirements. I have reviewed this job description and I understand all my job duties and responsibilities.

Based on observation, interview, and record review, the facility failed to 1. ensure a resident had a physician's order to keep a prescribed inhaler at the bedside for one (R21) resident, 2. failed to remove expired stock Loratadine medication and two unlabeled prescription Fluticasone/Salmeterol oral inhalation Diskus from the medication cart. This failure has the potential to affect 43 residents receiving medication on the 2nd and 4 residents (R24, R91, R92, and R124) receiving Loratadine stock medication on the 4th floor during medication storage review. On [DATE] at 10:31am, R21 was sitting in their wheelchair with Fluticasone propionate nasal spray noted on the bedside table with no label no name and not in manufacturer packet and no pharmacy labeled package. R21 stated that it is mine and I (R21) use it all the time. The nurse gave it to me. It's mine. When the surveyor made V6 (Nurse) aware and shown the medication and was asked about the facility policy on medication administration that includes medication been left at bedside. V6 (RN) stated I don't know if she can keep it at bedside, but I will check her orders. Both surveyor and nurse checked the EMAR (Electronic Medication Administration) there was no order to keep at bedside or self-administer any medication. R21 medical record EMAR and Physician order showed R21 has an order fluticasone propionate nasal to be administered 1 (one) spray each nostril one time a day but there was no order to keep at bedside. V6 stated that the facility protocol and policy on medication storage is that medications should be kept in the med cart. V6 stated that she did not give the medication to R21 because it was scheduled for 6am. On [DATE] at approximately 11:16am, V3 (Director of Nurses') stated in part that the resident should be educated and an order to keep medication at bedside should be obtained (from the physician) or NP (Nurse Practitioner) and it is the expectation that staff will make rounds alternating between the licensed staff (RN/LPN) and the C.N.As and correct whatever is not appropriate. As at [DATE] and [DATE] the facility was unable to present any physician order for R21 to self-administer any medication. On [DATE] at approximately 4:38pm, V3 acknowledge that R21 should not have the nasal spray at the bedside without physician order. Findings include: On [DATE] at 10:47 AM, the 4 [NAME] medication cart was reviewed with V12 LPN. Review of the stock medication notes a bottle of Loratadine 10mg (milligram) medication (Antihistamine) 300 tablet bottle is in the medication drawer with an expiration date of 08/25. V12 LPN was inquired of the bottle. V12 said, It says [DATE]. V12 was asked if the bottle was expired. V12 said, Yes. On [DATE] at 11:52 AM, review of the 2 East medication cart identified 2 unlabeled, undated, and unboxed Fluticasone/ Salmeterol oral inhalation powder 500mcg (micrograms)/50 mcg medication Diskus in the 3rd drawer of the cart. V7 was inquired of the medication. V7 said, I'm not sure who they belong to. They weren't in the box. I'll just toss those. On [DATE] at 12:36 PM, V3 DON (Director of Nursing) was inquired of concerns identified during medication administration. The [DATE] Pharmacy 4.1 Prescription Labels Policy states in part: Policy: Medications are labeled in accordance with State and Federal laws as well as facility requirements. Procedure: 2. Improperly labeled medications should be rejected and returned to United Rx upon delivery. 6. Medications labels are not altered, modified, or marked in any way by nursing personnel. Contents are not transferred from one container to another. Under no circumstances are unattached labels requested or accepted from the pharmacy. Only the pharmacist may place a label on the medication container. The United Rx Pharmacy Medication Administration Guidelines (Long Term Care Facilities) states in part: Ten Guidelines: The Right Medication. Check the expiration date on the medication. The Medication Storage in the Facility policy states in part: Policy: Medications and biological are stored safety, securely, and properly following the manufacturer or supplier recommendations. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: 14.Outdated, contaminated, or deteriorated drugs and those in containers, which are cracked, soiled or without secure closures will be immediately withdrawn from stock. They will be disposed of according to drug disposal procedures and reordered from the pharmacy if a current order exists. The facility policy on Administering Medications presented with review date11/2020 documents that medications shall be administered in a safe and timely manner and as prescribed. Policy Interpretation and Implementation listed includes but not limited to residents may self-administer their own medications only if the attending physician in conjunction with the interdisciplinary team Care Planning has determined that they have decision-making capacity to do so safely, and resident has successfully completed a competency for self -administration. Facility policy on Storage of Medications and Medical Supplies documented that the facility shall store all drugs and biologicals and medical supplies in a safe, secure and orderly manner. Highlights on medication containers indicated that drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Facility policy on titled Self-Administration of Medication with revised date 4/2017 documents that the resident has the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Listed policy interpretation and implementation includes but not limited to self-administration medications must be stored in a safe and secure place, which is not accessible by another resident. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self -administration for return to the family or responsible party. Facility Safety and Supervision of Resident policy presented with no date documents in part that under the policy statement that facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on interview and record review, the facility failed to follow their admission criteria policy by failing to ensure that staff obtained information needed for the care of one resident from the attending physician prior to admission, failed to ensure that staff follow their medication administration policy by failing to administer prescribed diabetic medications and failed to notify the physician that medication was not available. This failure affected one (R135) of one resident reviewed for quality of care. R135 was admitted to the facility from the hospital, alert and oriented and was found unresponsive and cold to touch at the facility the following day. Death certificate listed cause of death as hypertension and diabetes mellitus.Findings include:R135 [AGE] years old admitted to the facility on [DATE], face sheet listed the following past medical history among others; type 2 diabetes with hyperglycemia, acute cystitis with hematuria, essential primary hypertension, mixed hyperlipidemia, hypotension unspecified, hyperkalemia, etc.Hospital record dated 9/16/2025 documented active problems of type 2 diabetes, primary hypertension, hyperkalemia, mixed hyperlipidemia, anemia, etc. R135 received the following medications at the hospital among others: insulin lispro (Humalog pen) 1-5units subcutaneously three times a day with meals, insulin lispro (Humalog) pen 1-4 units subcutaneously nightly, etc. Same hospital record documented to continue the following medications: aspirin 81mg tablet, ergocalciferol 1,250ncg (50,000unit) capsule, glyburide 5 mg tablet, Januvia 100mg tablet, lisinopril 10mg tablet, pioglitazone 30mg tablet, simvastatin 40mg tablet. Discharge condition, stale, discharge disposition subacute rehab facility.Physician order dated 9/17/202 listed in part: Actos 30mg, give 1 tablet by mouth one time a day for DM, hold if blood sugar is <70, Atorvastatin 40mg, give 1 tablet by mouth at bedtime for hyperlipidemia, glyburide oral tablet 5mg, give 1 tablet by mouth two times a day, hold if blood sugar is <70, sAXagliptin 5mg tablet, give 1 tablet by mouth one time a day for DM, hold if blood sugar is <70, Sitagliptin phosphate 100mg, give 1 tablet by mouth one time a day for diabetes.Vital sign section of the medical record showed that the only blood sugar documented for the resident was 210, on 9/16/2025 at 21:34.Medication administration record (MAR) for September 2025 showed that R135 did not receive any of the above medications from the time of admission [DATE] at 19:56) to 9/17/2025 at 17:30 when the resident expired at the facility, all staff initialed the MAR with the number 9 indicating medicine was not available.On 12/3/2025 at 3:38PM, V34 (LPN) said that she admitted the resident, did a body assessment on him. V34 said that he received a report from the hospital before resident arrived and they told her that he is diabetic, she also reviewed the hospital record and texted a list of his medication to the doctor who told her to keep the same. V34 said that she did a blood sugar on the resident as a standard for admission, she did not inform the doctor that the resident is diabetic and did not receive any orders for blood glucose check from the doctor. V34 said that she did not give resident any medications that day because it was already late, his medication did not come from pharmacy yet and she did not have access to the emergency medication box. V34 added that there was no other staff on ground with access to the emergency box. V34 added that she did not notify the doctor or DON (Director of Nursing) that resident's medication was not available. Surveyor presented a medication administration record (MAR) where V34 signed that she gave resident atorvastatin 40mg at 21:00 on 9/16/2025at 2100 and she said, I don't know why I signed, I might have marked it in error.Fire department report dated 9/17/2025 documented in part: crew was dispatched for the full arrest, upon arrival [AGE] year-old male was found unresponsive and pulseless. Nursing home staff stated they found the patient unresponsive and started CPR immediately. Nursing home staff stated the last known well was 40 minutes prior to patient contact. Crew was unable to palpate carotid pulse, crew noted patient was apneic. Crew noted rigor mortis and that patient was cold to touch. A 4 lead EKG was obtained showing asystole, time of death was 17:30. ALS assessment started at 17:18 as documented in the report.Progress note dated 9/17/2025 16:55:00 by V35 (LPN) documented the following: Received patient in bed with HOB elevated, alert, and oriented stated that he is here for therapy, denies any pain or discomfort at this time. VS 98.0-82-18-122/66. 02 saturation 97% blood sugar 177. will continue to monitor.V35 documented on 9/17/2025 at 17:20:00, observed patient pale and cool to touch unable to obtain vital signs and blood sugar, code called 911 called MD, notified. Family friend called and message left to call the facility.On 12/02/2025 at 3:06PM, V9 (LPN) said she was assigned to the resident on day shift on 9/17/2025, V9 does not recall checking resident's blood sugar or administering any medication to resident. Review of medication administration record (MAR) V17 signed her initials with a letter 9 in the medication administration boxes. Surveyor presented this to V17 who said that the letter 9 indicated that the medication was not available. When residents are admitted sometimes it takes a while for their medications to come in. V17 was asked if she notified the physician that the medications are not available or tried to pull them from the emergency box, and she said no.On 12/03/2025 at 4:04PM, V35 (LPN) said that she was assigned to resident on 9/17/2025, when she arrived at work, she went and introduced herself to resident, went back to get her medication cart, gave resident's roommate medication and when she got to resident, she thought he was sleeping, she tried to wake resident up and realized that he was not breathing. Surveyor presented the above documentations to V35 and asked V35 to clarify how a patient can be alert and oriented at 16:55:00 and was unresponsive and cold to touch at 17:50:00 (25 minutes later). V35 said she did not know, maybe her timing was wrong in her progress note.On 12/03/2025 at 10:18AM, V3 Director of Nursing (DON) said that when resident's medications are not available, nurses are supposed to call the doctor to let them, they can also pull the medication from the emergency box, they are also supposed to document the notification in progress note.On 12/3 2025 at 11:28AM, V27, Pharmacist said that they delivered medication for resident on 9/17/2025 at 4:11PM, and he will send the manifest or proof of delivery. V27 added that the facility can call them if they any medication urgently or they can pull the medication from their emergency box. On 12/3/2025 at 1:58PM, V33, Certified Nursing Assistant (CNA) said that she recalls the resident, he refused breakfast and lunch on 9/17/2025, stating that he does not have any appetite. V33 said that she left the lunch tray in resident's room and when she came back, he still did not want the food so V33 removed the tray and reported to the nurse.On 12/4/2025 at 10:18AM, V36, Attending Physician said that he never saw the resident and his nurse practitioner (NP) never saw the resident, he does not recall anything about the resident. V36 said that the resident was just assigned to him, he was not part of resident's care at the hospital, and it usually take him and his team 24 to 48 hours to see a new resident. V36 said that the facility has an in-house NP, maybe they saw the resident. he does not recall anyone calling him for medication reconciliation for the resident. V36 does not know anything about resident's medication not being available and no one contacted him.On 12/4/2025 at 11:56AM, V37 (In-House Nurse Practitioner) said that she has worked at the facility since June 2025, works Monday to Friday from 9:00AM to 2:00PM. V37 said that R135 was admitted in the evening around 8:00PM on 9/16/2025 so she did not see the resident that day. She normally sees the new admissions during the day unless the attending physician or their nurse practitioner already saw the resident. V37 said that she did not see the resident the whole day on 9/17/2025, she does not know why except that she thought that the doctor or his NP saw the resident. By the time she went to see the resident he was no longer there. V37 said that no one called her regarding resident's medication, they will usually reconcile the medication with the attending, but no one notified her the following day that resident's diabetic mediations were not available.admission criteria policy revised 11/2020 states in part that the facility will only admit residents who's medical and nursing care needs can be met. Under policy interpretation and implementation, #5 stated, prior to or at the time of admission, the resident's attending physician must provide the facility with information needed for the immediate care of the resident, including orders covering at least: type of diet, medication orders, including (as necessary) a medical condition or problem associated with each medication and routine car orders to maintain or improve the resident's function until the physician and care planning team can conduct a comprehensive assessment and develop a more detailed interdisciplinary care plan. United RX medication administration policy dated July 2024, states in part # 23, if medication is ordered but not present, call the pharmacy or supervisor to obtain medication.

Based on observation, interview and record review, the facility failed to have a five percent (5%) or lower medication error rate. There were 3 medication errors out of 33 medication opportunities resulting in a 9% medication error rate for 3 (R70, R79, and R129) residents reviewed during medication administration. This failure has the potential to affect all 131 residents in the facility.Findings include:On 09/30/2025 at 08:14 AM V17 LPN Licensed Practical Nurse signed out each medication as administered after preparing the medication prior to them being administered to R70. On 09/30/2025 at 08:30 AM, V17 administered 1 tablet of Senokot S Oral Tablet 8.6-50 mg (milligrams) to R79. R79's physician order states: Give 2 tablet by mouth one time a day for Constipation. On 09/30/2025 at 08:44 AM, V17 prepared R129's Senexon-S Tablet 8.6-50 MG give 2 tablet by mouth every 12 hours for Constipation. V17 only prepared 1 tablet for administration. On 09/30/2025 at 08:46 AM, V17 LPN prepared R129's Metamucil 4 in 1 Fiber Oral Packet (Psyllium) give 1 packet by mouth one time a day for Constipation mix in 8oz of liquid physician's order. V17 removed a container of Psyllium from the stock medication. Upon opening the container, V17 removed a clear plastic medication cup from the inside of the powder medication and scooped out an unmeasured amount and put it into a clear cup. V17 is using her bare hands. V17 was inquired of the amount measured. V17 said, I measured 19 ml's (milliliters), but I think it's too much. V17 poured the powdered medicine back into the clear medication cup from the inside of the container. V17 slowly emptied small amounts of the medication back into the container until she reached 15ml of powder. V17 held the clear medication cup up in the air and informed this surveyor she had measured 15mls of the powder. V17 returned the medication powder back into the cup and diluted it with an unmeasured amount of water. V17 did not verify the amount of Psyllium to be administered due to using a house stock container of the medication and not an individual packet per the physician order. V17 did not accurately measure the powdered Psyllium by holding the medication cup in the air at her eye level. V17 did not measure the amount of water needed to mix the medication per the physician order. On 09/30/2025 at 08:53 AM, V17 only administered 1 tablet of Senexon-S Tablet 8.6-50 mg. R129's physician order states give 2 tablets by mouth every 12 hours for Constipation. On 09/30/2025 at 9:10 AM, V17 LPN (Licensed Practical Nurse) was inquired of the medication administration. Why is it important to check the MAR (medication administration record) and physician orders before administering medication to a resident? V17 said, To make sure I give everything the resident is supposed to get. The house stock Psyllium has a clear medication cup inside the container, how is this a concern during medication administration? V17 said, Because we touch the cup and put it back in the jar. It's spreading germs to other residents.How do you ensure reliability and accuracy when taking measurements? V17 said, Measure and sit it down to make sure it's an accurate amount.When administering medications, when should it be signed out? V17 said, I should do it after I give the medication because if the resident refuses it, I have to chart it. On 09/30/2025 at 12:36 PM, V3 DON (Director of Nursing) was inquired of concerns identified during medication administration. Why is it important to check the MAR (medication administration record) prior to giving the medication? V3 DON said, The meds are ordered by the physician and to give the correct dose. It's the five rights, right person, right route, right medication, right dose, right time. If done that would prevent the error. How do you ensure reliability and accuracy when taking measurements? V3 said, To measure I would set the cup down and look at it eye level. Holding it in hand it could shift. When administering medications when should it be signed out? V3 said, Document after administration ensuring resident took medication. If not, you'd have to go back and document why it wasn't taken. The July 2024 Pharmacy 5.2 Medication Administration Policy states in part: Purpose: To administer all medications safely and appropriately to aid residents to overcome illness, relieve, and prevent symptoms, and help in diagnosis. Procedure: 3. Review the resident's Medication Administration Record (MAR). Read each order entirely. 18. Return to medication cart and document medication administration with initials in appropriate spaces on Medication Administration Record (MAR). The United Rx Pharmacy Medication Administration Guidelines (Long Term Care Facilities) states in part: Ten Guidelines: The Right Medication. Check the expiration date on the medication. Verify each medication against the MAR. The Right Dose. Pay special attention to orders like give 2 tabs, 1/2 tabs etc. The Right Documentation. Sign MAR immediately after administering the medications. V17 LPN's Licensed Practical Nurse job description dated and signed on 06/13/2024 states in part: Maintains knowledge of necessary documentation requirements. I have reviewed this job description and I understand all my job duties and responsibilities. V17 LPN's medication administration competency dated and signed on 06/25/2024 states in part: Type of validation: return demonstration. Safely administers medications- 2. Documents initials in MAR/TAR (treatment administration record) after administration or treatment. V17's glucometer competency dated 06/25/2024 states in part: cleans and understands proper maintenance of glucometer per manufacturer. V17's blood glucose monitoring written competency dated 06/28/2024 states in part: 7. The blood glucose machine must be cleaned after use, using the facility approved disinfectant wipes and allowed to dry. V17 marked true. V17's hand hygiene competency dated 06/25/2024 documents return demonstration: pass.

Based on observation, interview, and record review, the facility failed to follow their policy for infection control related to 1. Failed to clean glucometer after resident use, 2. failed to ensure that reusable equipment (blood pressure cuff/machine) was cleaned between use of residents, 3. failed to perform hand hygiene after removing gloves, and before preparing resident medications, 4. failed to put on gloves to dispense a powder stock medication (used bare hand to dispense), 5. Failed to remove a medication cup (not manufacturer provided) stored inside the stock powder medication. These failures applied to four (R5, R70, R79, and R129) of four residents reviewed during medication administration in the sample of 57 residents. Findings include: On 09/30/2025 at 08:14 AM V17 LPN (Licensed Practical Nurse) signed out each medication as administered after preparing the medication prior to them being administered to R70. 09/30/202508:16 AM, V17 knocked and entered R70's door. V17 moved R70's overbed table and adjusted R70's bed upright then administered her medications. On 09/30/2025 at 08:18 AM, V17 did not wash her hands or perform hand hygiene with hand sanitizer upon leaving the room or before preparing medication for the next resident.On 09/30/2025 at 08:17 AM, V17 LPN knocked and entered R79's room door. V17 performed blood glucose monitoring for R79 which resulted in a reading of 312 mg/dL (milligrams/deciliter). V17 also performed a blood pressure reading with a wrist blood pressure cuff. The blood pressure reading was 136/88, pulse 75. V17 left R79's room, returned to the medication cart, and did not wash her hands or perform hand hygiene with hand sanitizer. V17 did not sanitize the blood glucometer or blood pressure cuff after using the equipment for R79. V17 placed the equipment back on the top of the medication cart. On 09/30/2025 at 08:25 AM, V17 dropped R79's Diltiazem Tablet 60 MG onto the top of the medication cart. V17 picked up the pill and threw it into the garbage can on the cart. V17 said, Oh, let me get that. V17 put on a glove and took the pill out of the garbage can and placed it into the sharps (needle and syringe) disposal container on the medicine cart. V17 removed the glove from her hand and put it into the garbage can. V17 did not wash her hands or perform hand hygiene with hand sanitizer. V17 continued on with preparing R79's insulin and medications. On 09/30/2025 at 08:30 AM, knocked and entered R79's room door. V17 put on a pair of gloves and administered R79's insulin into her Left upper abdomen. V17 removed her gloves and administered R79's oral medications. V17 left R79's room, returned to the medication cart, and did not wash her hands or perform hand hygiene with hand sanitizer. On 09/30/2025 at 08:39 AM, V17 knocked on R5's room door and introduced herself. V17 adjusted R5's over bed table and sat the head of the bed up by pressing the button on the arm of the bed. V17 administered R5's medications. V17 left R5's room, returned to the medication cart, and did not wash her hands or perform hand hygiene with hand sanitizer. On 09/30/2025 at 08:42 AM, V17 took R129's blood pressure with her wrist blood pressure machine. R129's blood pressure reading was 121/68, pulse 79. V17 left R129's room and did not sanitize the blood pressure machine. V17 placed the blood pressure machine onto the top of the medication cart.On 09/30/2025 at 08:46 AM, V17 LPN prepared R129's Metamucil 4 in 1 Fiber Oral Packet (Psyllium) give 1 packet by mouth one time a day for Constipation mix in 8oz of liquid physician's order. V17 removed a container of Psyllium from the stock medication. Upon opening the container, V17 removed a clear plastic medication cup from the inside of the powder medication and scooped out an unmeasured amount and put it into a clear cup. V17 is using her bare hands. V17 was inquired of the amount measured. V17 said, I measured 19 ml's (milliliters), but I think it's too much. V17 poured the powdered medicine back into the clear medication cup from the inside of the container. V17 slowly emptied small amounts of the medication back into the container until she reached 15ml of powder. V17 held the clear medication cup up in the air and informed this surveyor she had measured 15mls of the powder. V17 returned the medication powder back into the cup and diluted it with an unmeasured amount of water.There is an infection control concern due to a clear medication cup being stored inside the medication container. V17 did not perform hand hygiene and put on gloves prior to dispensing the medication from the house stock medication container causing it to be contaminated. V17 left R129's room, returned to the medication cart, and did not wash her hands or perform hand hygiene with hand sanitizer. On 09/30/2025 at 9:10 AM, V17 LPN was inquired of the medication administration. What should be done by the nurse before preparing medication for the resident? V17 said, I should do hand hygiene, I forgot to do it. It's so we don't pass germs around.When using medical equipment such as a blood pressure machine and a blood glucometer between residents what should be done? V17 said, I could wipe it off with a bleach wipe. I don't have any on my cart. It's so we don't spread things around.When gloves are moved from your hands what should be done and why? V17 said, I should do hand hygiene, it's to prevent spread of germs.On 09/30/2025 at 12:36 PM, V3 DON (Director of Nursing) was inquired of concerns identified during medication administration with infection control.What should be done by the nurse before preparing medication for the resident? V3 said, We should hand wash or use hand sanitizer to prevent the spread of germs.When using medical equipment such as a blood pressure machine and a blood glucometer between residents what should be done? V3 said, Glucometer sanitize in between each resident with a bleach wipe and let it air dry. Blood pressure cuff clean with disinfectant wipe and let dry between residents. When gloves are removed, what should be done? V3 said, Hand washing or use of hand sanitizer to prevent spread of germs for infection control. The revised 03/2020 Handwashing/Hand Hygiene Policy states in part: This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 5. Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: d. Before and after performing any invasive procedure (e.g. fingerstick blood sampling), l. Upon and after coming in contact with a resident's intact skin, (e.g. when taking a pulse or blood pressure, and lifting a resident), u. After removing gloves or aprons. 6. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: d. Before preparing or handling medications, j. After removing gloves. 8. The use of gloves does not replace handwashing/hand hygiene.The revised 10/13/17 Policy and Procedure Cleaning/Disinfecting/Maintaining Glucose Meter states in part: The Glucose meters will be disinfected between each resident's use to prevent the spread of microorganisms including blood borne pathogens. Disinfection of the machine will be completed with Clorox Healthcare Bleach Germicidal and Disinfectant Wipes Towelettes.Procedure: Cleaning 1. [NAME] nonsterile gloves. 2. Inspect for blood/debris/dust/line anywhere on the meter. 3. Open the towelette container or package and remove one towelette. 4. Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. 5. Dispose of the towelette. Disinfecting 6. Obtain a second towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to remove blood borne pathogens. The meter must be maintained wet for 1 minute for all bacteria except C-diff. 7. Once the exterior of the glucometer has remained wet for the appropriate contact time, the meter may be wiped dry with a dry cloth. 10. Dispose of the used towelette. 11. Remove gloves. 12. Wash hands.The July 2024 Pharmacy 5.1 Medication Administration Policy states in part: Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Tips for safe medication administration2. Follow good infection control practices. a. Cleanse hands before each medication pass. Cleanse hands when contact is made with a medication. Cleanse hands whenever they are contaminated. You may use an antiseptic foam or gel such as Septisol or All Care.b. Never touch any of the medication with fingers. The Cleaning Disinfection Resident Care Items Equipment policy states in part: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Blood borne Pathogens Standard.PROCEDUREThe following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care:Non-critical items are those that come in contact with intact skin but not mucous membranes.Non-critical resident-care items include bedpans, blood pressure cuffs, crutches and computers, etc.Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location).Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals).Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions.Stethoscope / B/P CuffExamine stethoscope for damages. Report damaged equipment to your supervisor.Select facility EPA approved disinfectant wipe (e.g., ethyl or isopropyl alcohol).Applying firm pressure in a circular motion, use disinfectant wipe to clean stethoscope ear pieces, tubing, diaphragm and bell.Wash and dry your hands thoroughly.Return the stethoscope to its designated storage area.Discard disposable equipment and supplies in designated containers.Clean and disinfect the surface area used to clean the stethoscope.Wash and dry your hands thoroughly.

Based on interview and record review, the facility failed to provide a resident with adequate staff supervision during a shower for a resident who requires substantial maximal assistance with bathing/showering. This failure applies to one of three residents (R2) reviewed for accidents/supervision and resulted in R1 sustaining a femur fracture. Findings include: R2 has a diagnoses history of Paraplegia, Multiple Sclerosis, Morbid Obesity, and Cognitive Communication Deficit who was admitted to the facility 04/06/2024. The facility's Incident Investigation Report dated 04/09/2025 documents on 04/01/2025 R2 was taken for her regularly scheduled shower, she was set up with her items per usual with the shower chair locked, she reported she dropped the towel and when she reached down to grab the towel, she slid from the shower chair; Upon interview with the CNA (Certified Nursing Assistant) stated she set the resident up per her request, lathered the soap and towel and allowed her privacy per the resident's request; R2 was admitted to the hospital for closed fracture of the distal left femur; R2 is at high risk for falls due to weakness and impaired mobility, she is paraplegic, has limited range of motion to her left upper and lower extremities to where she will require staff assistance; based on staff interviews, R2 clearly prefers and or requests privacy during showers so staff should always respect that preference by allowing sufficient space and avoiding unnecessary exposure; This includes maintaining a respectful distance while offering assistance that maintains that privacy; Plan of care in place and updated. Witness statement from R2 dated 04/03/2025 documents the Director of Nursing called R2 on the phone to interview her regarding her fall in the shower room and R2 reported on 04/01/2025 her CNA (Certified Nursing Assistant) V4 set her up in the shower, when she reached for a towel that fell , she slid from the shower chair. Undated Witness statement from V4 (CNA) documents she placed R2 in the chair and transported her to the shower room and R2 informed her that she would use the call light when she was ready to come out so she will set everything up for her, R2 requested her privacy and she is alert and oriented to person, place, time, and situation; the chair was locked to secure her, R2 informed her she tried to reach and grab her towel and fell over in the chair. Undated Witness statements from V8 (Registered Nurse) and V9 (Licensed Practical Nurse) stated they heard R2 yelling for help in the shower room and responded to assist, and she reported she dropped her towel and fell from the chair. R2's Fall Risk Evaluation dated 04/06/2024 documents she had 1-2 falls in the past three months, and had predisposing risk factors including 1-2 predisposing diseases present, balance problem while standing, requires use of assistive devices, and takes 1-2 high risk medications. R2's Quarterly Minimum Data Set assessment dated [DATE] documents she requires substantial maximal assistance with most activities of daily living including bathing/showering self, and tub/shower and toilet transfers. R2's Current Care Plan initiated 04/08/2024 documents she has an ADL (Activity of Daily Living) self-care performance deficit related to Hemiplegia, Impaired balance, Limited Mobility, and Limited ROM. R2 has weakness and impaired mobility she has a diagnosis of Multiple Sclerosis. R2 is a paraplegic and has limited range of motion to her Left upper and Lower extremities. She requires staff assist. She has spasticity and rigidness to extremities that inhibit movement; she is non ambulatory and transfers via sit to stand with assist with interventions including: she requires extensive assist of (1-2) staff to provide bath/shower twice a week and as necessary; and R2 requires Mechanical Lift (sit to stand) with (2) staff assistance for transfers. R2's Current Care Plan initiated 04/08/2024 documents she is at risk for incontinence related to Impaired Mobility, Physical limitations due to weakness and impaired mobility, having diagnoses of Multiple Sclerosis, Paraplegia and requires staff assist; she is non ambulatory and transfers via sit to stand with assist with interventions including check every two hours, upon request, and as needed for incontinence. R2's Current Care Plan initiated 04/06/2024 documents she is at risk for falls due to weakness and impaired mobility, and diagnoses of Multiple Sclerosis and Paraplegia and has limited range of motion to her left upper and lower extremities, and requires staff assist; R2's Current Shower/Bathing Care Plan initiated 11/06/2024 documents she enjoys her shower on scheduled days and would prefer privacy at times. R2's Incident progress note dated 4/1/2025 at 5:00 PM documents she was heard screaming for help in the shower room. Staff observed she was on her knees, leaning forward with left shoulder against the wall then sat back placing her buttocks on the floor and legs bent backwards on each side. Shower room call light is not on. R2 verbalized that she is taking her shower and was trying to get a towel, but the chair flipped over, and she ended on the floor. Her left leg is in severe pain, and she complained of severe pain on left leg. Physician notified and ordered to call 911 due to possible fracture or dislocation; at 11:21 PM Post Fall Evaluation documents the fall was not witnessed. Fall occurred in the bathroom. Resident was reaching for item(s) at time of the fall; Fall resulted in an emergency room visit/hospitalization and R2 was admitted due to a closed fracture of left femur. R2's progress note dated 4/2/2025 at 03:03 AM documents she was admitted to Christ Hospital with an admitting diagnosis of a closed fracture to left femur. R2's Fall Risk assessment dated [DATE] documents she was heard screaming for help from the shower room, staff observed her on her knees with the shower room call light not on, she reported she was taking her shower and was attempting to get a towel, her chair flipped over and she ended up on the floor and her left leg is in severe pain with predisposing situational risk factors included requesting privacy during her shower. R2's Hospital Report dated 04/01/2025 documents she received an Orthopedic Surgery Consult due to left femur fracture, she presented with left knee pain after a fall in the shower, her Multiple Sclerosis limits her ability to ambulate, emergency department x-rays revealed a distal femur fracture. On 04/14/2025 at 10:19 AM V6 (Restorative Aide) stated she's worked in the facility for nearly five years. V6 stated she is familiar with R2 and she had been in the facility nearly a year. V6 stated R2 was very alert. V6 stated R2 did not have a history of refusing care. V6 stated R2 requires sit to stand assistance with a mechanical lift for transfers with two person assistance. V6 stated R2 was able to reposition her legs in the sit to stand equipment, could hold on to the bars on the mechanical lift however her hands were shaky. V6 stated R2 could sometimes unhook herself from the sling. V6 stated R2 needed staff to provide her with incontinence care and could not clean herself after an incontinent episode. V6 stated she has had experience showering R2 and R2 would allow her to be present while she was in the shower. V6 stated there is typically one person in the shower with R2. V6 stated R2 needed assistance with showering. V6 stated she would let R2 clean her face, neck and upper body and she would try to clean her bottom however because of the shakiness of R2's hands she would assist her with cleaning her lower body. V6 stated R2 has never asked her to be left unattended while in the shower. V6 stated if R2 did ask for privacy during a shower, she wouldn't be able to leave her unattended however she could have possibly turned her back or pulled the curtain closed. V6 stated however, she would not have been able to leave R2 unattended. V6 stated she cannot leave a resident unattended in the shower that is not independent. V6 stated she could notify the nurse that R2 requested privacy during a shower, but couldn't leave her unattended. On 04/14/2025 at 10:42 AM V7 (Certified Nursing Assistant) stated she has worked at the facility for four months and has worked with R2 only a few times. V7 stated R2 would ask for privacy while having a bowel movement and we would usually just step outside the door but never too far away. V7 stated R2 required sit to stand assistance with a mechanical lift for transfers with two-person assistance. V7 stated R2 is relatively independent and likes to do things on her own but during showers a staff would always be with her. V7 stated she has never provided a shower to R2 however if R2 requested privacy during a shower she would have closed the curtain and stayed inside the shower. V7 stated the shower is relatively big and she could stand on the opposite side with the curtain closed. V7 stated there is no situation she could think of where she would leave R2 alone in the shower. V7 stated she wouldn't leave R2 alone in the shower because of her fall risk and in case she needed help with something. On 04/14/2025 at 11:00 AM V4 (Certified Nursing Assistant) stated she did not work with R2 often. V4 stated R2 was alert and oriented times four. V4 stated 04/01/2025 may have been her first time working with R2. V4 stated she assisted R2 to the shower on 04/01/2025 sometime after 3PM during the second shift. V4 stated when she and R2 arrived to the shower, she set R2 up, handed her all her personal items, put on her shower cap and shoes, locked her chair, and handed her the call light because R2 requested for her to step out and give her privacy. V4 stated she insisted on staying in the shower to help R2, however R2 was adamant about her stepping out and giving her privacy to shower herself. V4 stated she stepped out of the shower within arm's reach and then afterward heard R2 fall in the shower. V4 stated R2 reported to her verbatim that she dropped her towel, tried to reach over and pick it up and ended up slipping out of the chair. V4 stated she was not inside the shower room when this incident took place but was within arm's reach outside the shower room door. V4 stated R2 required moderate assistance and sometimes supervision for the majority of daily tasks. V4 stated R2 requires a sit to stand for transfers which is provided by the aide but other than that can do things for herself. V4 stated R2 has physical limitations from the legs down but is able to perform other hygiene tasks on her own. V4 stated if residents that need assistance for transfers and hygiene tasks ask for privacy while showering, she has to respect that, and was always told they have the right to have privacy if they are alert and oriented. On 04/14/2025 at 12:11 PM V3 (Director of Nursing/Registered Nurse) stated she spoke to R2 on 04/03/2025 as part of the investigation into her fall incident on 04/01/2025. V3 stated R2 told her on 04/01/2025 she was in the shower washing her upper body, the towel dropped to the floor and she went down to grab the towel and she flipped over. V3 stated she asked R2 did she ask for assistance during this incident and asked her why didn't she pull the call light and R2 replied she had the call light and thought she could reach the towel herself and when she bent down the call light was no longer in reach. V3 stated when she interviewed V4 (Certified Nursing Assistant) she said she had literally just stepped outside the door because R2 insisted she wanted her privacy during her shower. V3 stated that V4 informed she set R2 up in the shower room, asked her if she wanted her to stay, R2 replied no she wanted her privacy, and V4 honored her request. V3 stated V4 reported her cart was across on the other side of the wall and she went to grab something off of the cart and R2 was heard yelling for help. V3 stated R2 requires sit to stand with transfers and as far as bathing she knows she requires the extensive assistance of one staff member but is care planned for two if she needs extra assistance because she has Multiple Sclerosis. V3 stated as far as she knows there is usually one staff assisting R2 with showers and they promote R2's independence with cleaning areas that she can reach and clean herself such as her upper body. V3 stated R2 can't reach her back or peri area. V3 stated based on the level of assistance R2 needs there should be a staff present as much as needed for her safety. V3 stated with R2 being a relatively younger lady we should provide a level of independence as well as keeping her safe so there's always a fine line and we have to keep them safe and promote their autonomy. V3 stated ways to promote privacy for R2 is having staff at arm's reach, if there's a shower curtain pull the curtain back, step off to the side, or be in a position to be able to reach her if she needs assistance such as if she drops a towel or if she's ready for them to wash her back or needs an extra item. V3 stated yes staff should educate R2 on her safety needs if she requests them to leave the shower room and provide her with privacy. V3 stated the shower bath policy states we should never leave the resident unattended and the fall management policy does state that the facility has to honor their preferences while keeping them safe and therefore V4 should have been with R2 but felt she was honoring her request for privacy as well. V3 stated, do we leave residents unattended?; no. V3 stated in this instance although R2 was asking for privacy and it was her choice, she cannot refute the policy. V3 stated if R2 still insists on privacy during showers the staff can ask the nurse for assistance as well. The facility's Shower/Tub Bath Policy received 04/10/2025 states: Stay with the resident throughout the bath. Never leave the resident unattended in the tub or shower. The facility's Fall Management Policy received 04/10/2025 states: The facility's challenge is to balance protecting the resident's right to make choices and the facility's responsibility to comply with regulations. The responsibility to respect a resident's choices is balanced by considering the potential impact of these choices on other residents and the facility's obligation to protect the residents from harm. The facility will educate the resident regarding significant risks relate to a residents choice.

Based on observations, interviews, and record review, the facility failed to implement their policy to adequately monitor residents during smoking times, ensure residents' turn over their smoking materials, and determine who is an active smoker for 2 (R6 and R81) of 3 residents reviewed for smoking in the sample of 48. Findings include: 1. R6 is a [AGE] year old female admitted to the facility on [DATE] with diagnosis including but not limited to Benign Neoplasm of Meninge, Cognitive Communicating Deficit, Dysphagia, Weakness, Chronic Viral Hepatitis C, and Encephalopathy. According to R6's MDS (Minimum Data Set) assessment dated [DATE], under section C, R6 has BIMS (Brief Interview of Mental Status) score of 13 indicating intact cognition. R6's care plan dated 11/20/2023 reads in part, (R6) is a smoker. Interventions: Instruct resident about the facility policy on smoking: locations, times, safety, concerns; Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. R6's Smoking assessment dated [DATE] reads in part, Which of the following products does (R6) use? Tobacco. No additional smoking safety or interventions documented in R6's smoking assessment. 2. R81 is a [AGE] year old male admitted to the facility on [DATE] with diagnosis including but not limited to Type 2 Diabetes Mellitus, Weakness, Major Depressive Disorder, Personal History of Transient Ischemic Attack, and Chronic Kidney Disease. According to R81's MDS (Minimum Data Set) assessment dated [DATE], under section C, R81 has BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. R81's care plan dated 07/23/2024 reads in part, (R81) is a smoker. Interventions: Instruct (R81) about the facility policy on smoking: locations, times, safety, concerns; Notify charge nurse immediately if it is suspected (R81) has violated facility smoking policy. R81's Smoking assessment dated [DATE] reads in part, Smoking Safety Notes: Does not smoke. 3. On 09/30/2024 at 11:35 AM V1 (Administrator) provided a list listing of residents who smoke, R6 and R81 not listed on the list. On 10/01/2024 at 03:24 PM Surveyor observed R81 smoking alone on the smoking patio. No smoke monitor nor other staff present on the smoking patio at this time. Surveyor observed code pad leading to the smoking patio. On 10/01/2024 at 03:28 PM Surveyor interview R81 who stated, I have been smoking independently since I've been here, so for seven months. I keep my cigarettes and lighter in my room. Staff gave me the code to go outside. My (family member) came on Friday to bring me cigarettes. Usually, I buy my own cigarettes when I get my money by the end of the month. On 10/01/2024 at 03:30 PM Surveyor interviewed V1 (administrator) who stated, R81 should not be smoking independently, staff should be monitoring resident during smoking times. R81 signs himself in and out, R81 doesn't have money to buy cigarettes, his (family member) came here over the weekend though, so they probably brought R81 cigarettes. On 10/02/2024 at 11:15 AM Surveyor observed R6 smoking on the smoking patio. V23 (Activity Aid) present on the smoking patio. On 10/02/2024 at 11:24 AM Surveyor interview R6 who stated, I stopped smoking two months ago, but I restarted this morning. I had cigarettes from yesterday, somebody gave them to me, but there was no available staff to take me out to the smoking patio. I don't know who gave the cigaretts, I don't know if he works here or lives here but I see him all the time. On 10/02/2024 at 11:30 AM Surveyor interview V23 (Activity Aid) who stated, I am a smoking monitor. I assist smokers during smoking times. I get the cigarettes and lighter for the smokers from the receptionist, the receptionist holds on to the cigarettes and lighters. There are no residents who are allowed to keep cigarettes and lighters in their room. Before any resident is allowed to smoke, they have to sign a Smoker's Contract. There is no existing smokers' list, usually, the social service tells us who is allowed to smoke. I check with social service infrequently, usually, when there is a new resident who is trying to go out to smoke. R6 and one other resident are our only smokers. R81 is a smoker who can smoke independently and doesn't need assistance and monitoring. R81 is well enough to have a code to the security door an let himself out. I monitor smoking times it in the morning, at 11:00 AM and 1:30 PM. There is a 3rd smoking time 6:30 PM and that's when CNAs and nurses assist smokers. On 10/02/2024 at 11:52 AM Surveyor interview V25 (Social Service Director) who stated, there are two identified smokers in the facility, there are also additional smokers, who don't have cigarettes at this time but identify as smokers. They should be listed on the smokers' list. Cigarettes and lighters are labeled and stored at the front desk, residents should not have access to cigarettes and lighters without monitoring. The independent smokers still have to be monitored, no one should be on the smoking patio, smoking alone. Smoking residents always require supervision. On 10/02/2024 at 12:20 PM Surveyor interview V2 (Director of Nursing) who stated, nurses and CNAs monitor smokers during 6:30 PM smoke break, but I'm not sure who is assigned to do it. It's mostly CNA who is available. There is a list of smokers at the front desk. On 10/02/2024 at 12:25 PM Surveyor walked over to the front desk to verify the smokers' list; no list found. 4. The facility Smoking Program Details document dated 09/10/2024 reads in part, There are 3 designated smoking times daily for 15 minutes each time. Cigarettes and all smoking materials are kept at the receptionist desk and available for the designated staff member who is doing the monitoring. Smoking areas are located on the patios in the backyard and during inclement weather outside the front door. Residents are monitored during each smoking time. Current list of residents who smoke: (R6 and R81) not listed. The Facility Smoking Safety Policy dated January 2016 reads in part, Per facility policy, all residents who choose to smoke are required to turn over smoking materials for the health, safety, and security reason. All residents shall receive monitoring consistent with policy, and plan od care.

Based on observation, interview, and record review the facility failed to ensure a resident who required extensive assist with toileting was provided incontinent care in a timely manner for 2 or 4 residents (R2, R9) reviewed for Activities of Daily Living (ADL) in the sample of 13. The findings include: 1. R9's Physician Orders printed 5/5/24 showed her original admission to the facility was 4/19/24 with diagnoses to include: dementia, major depressive disorder, and diabetes. An Order dated 4/29/24 shows to turn and reposition every 2 hours and as needed. R9's Care Plan initiated on 4/30/24 shows she has an ADL deficit related to confusion, impaired balance, and limited mobility. She has a diagnosis of dementia and requires total assist with ADLs., is non ambulatory, and is incontinent of bowel and bladder. This care plans shows an intervention for bed mobility: the resident requires (extensive assist) by 2 staff to turn and reposition. An intervention for Personal Hygiene shows R9 is totally dependent on (1) staff for hygiene. The Toilet Use intervention dated 5/1/24 shows the resident is not toileted. R9's progress noted dated 4/29/24 at 9:18PM shows she was readmitted to the facility . wound to sacrum .requires total assistance x 2 staff to accomplish ADL tasks at this time. On 5/4/24 at 9:27 AM, R9 was in the dining room in a reclining wheelchair. R9's chair was in the reclining position, with R9 resting on her back and bottom. Her legs were in the upright position, and her knees were bent. At 11:53AM, R9 was still in the back of the dining room in her wheelchair, in the reclined position. At 11:57AM, R9 was served lunch and V6 (Certified Nurse Assistant-CNA) began feeding R9. R9 remained sitting on her bottom, and her legs remained in the upright position, extending off the bottom of the chair. At 12:07PM, V4 (CNA) said she would be changing R9 after lunch. On 5/4/24 at 1:02PM, V4 wheeled R9 in her reclining chair to her room. V4 said she was assigned to R9 for the day, and R9 was already up in her chair when her shift started (at 7:00AM). V4 said this is the first time she has changed R9 (6 hours after her shift started). V4 and V5 (CNA) used a mechanical lift to transfer R9 from her chair to her bed. V4 removed R9's pants and incontinence brief. The front of R9's brief appeared wet with urine. After cleaning R9's perineal area, V4 rolled her to her left side to remove her brief. The back of R9's brief was visibly saturated with urine. R9 had a bordered dressing to her coccyx that was saturated, no longer adhering to her skin, and falling off. V4 placed R9 on her back and said her dressing was wet and needed changed. V4 said she did not know R9 had a wound to her bottom, this was the first time she had seen it. V4 verified her (R9's) incontinence brief was saturated with urine. V9 was asked if there were any special interventions in place for R9 regarding her wound, care etc., and she said not that I'm aware of, she just came back recently from the hospital. On 5/5/24 at 9:58AM, V3 (Wound Care Nurse) said R9 should be turned and repositioned every 2 hours and she should be checked for [incontinence brief] changes every 2 hours. It is very important for incontinence care every 2 hours and as needed to keep R9's wound dressing clean and dry. On 5/5/24 at 11:49AM, V15 (Registered Nurse-RN) said it is important to keep residents clean and dry, especially if they have a wound. V15 said the residents should be checked every 2 hours for toileting, or as needed. On 5/5/24 at 11:55AM, V16 (RN) said it is important to make sure the residents are clean and dry. V16 said toileting and incontinence care should be done frequently, every 2 to 2.5 hours or as needed. 2. R2's facility assessment dated [DATE] shows she has severe cognitive impairment, is always incontinent of bowel and bladder, and is dependent on staff for toileting. R2's ADL care plan revised on 4/15/24 shows she requires total assistance by one staff with personal hygiene, and toilet use. R2's care plan for bowel and bladder incontinence revised 4/15/24 has an intervention to check for incontinence care every 2 hours and as needed. On 5/4/24 at 9:23AM, R2 was sitting in her wheelchair in the dining room at a table, drinking apple juice. R2 was observed at 9:40AM, in the dining room, resting her head on the table. At 10:07AM, R2 was sitting in her wheelchair, in the dining room. At 11:02AM, V5 wheeled R2 from the dining room table to her room. V5 said she started her shift at 7:00AM, she was the assigned aide for R2, and this was the first time she was changing R2 (4 hours after the start of her shift). V5 said she checked her around 8 and she did not need changed then. V5 put a gait belt on R2 and helped her stand from the wheelchair and pivot to the bed. Upon standing, the back of R2's pants were visibly wet with urine. After assisting R2 to bed, V5 removed her pants and incontinence brief. R2's incontinent brief was saturated with urine and soiled with stool. V5 cleaned R2's peri-area, and used multiple wipes to clean R2's bottom of stool. A new incontinence brief and clean pants were put on R2, and V5 transferred her back to her chair and wheeled her to the dining room. On 5/4/24 at 9:50 AM, V5 said R2 is not able to tell them she needs go to the bathroom and she is usually incontinent of urine. On 5/4/24 at 10:00AM V4 said they normally take R2 to the bathroom after breakfast, and after lunch. On 5/5/24 at 12:16AM, V16 (CNA) said R2 should be toileted about every 2 hours, she should be taken to the bathroom after breakfast and after lunch.

Based on interview and record review the facility failed to ensure a referral was made for a hearing aid request for 1 of 3 residents (R2) reviewed for resident rights in the sample of 13. The findings include: R2's facility assessment date 4/19/24 shows she has severe cognitive impairment, and is dependent on staff for Activites of Daily Living. This assessment shows R2 has minimal hearing difficulty. R2's physician order set printed 5/5/24 shows she has a diagnosis of dementia. R2's order set shows an order on 10/13/23 may have audiology evalation and May recieve the services of dentist/opthamologist, and audiologist PRN. On 5/4/24 at 2:28 PM, V33 (family member) said she had reported concerns to the director (V34). On 5/6/24 at 10:38AM, V34 (Liaison) said she is the liaison and does take resident and family complaints. V34 said she is usually the first one the family contacts, especially in the beginning. V34 said R2's family member contacted her on March 17, 20204, about concerns with Activity of Daily Living care and she reported those to the Director of Nursing (DON). V34 said there was a request made in the beginning of the year, February 2024, asking if she [R2] could have hearing aids. V34 said she let V2 (DON) know. V34 said if a concern is brought to her, she passes it on to the appropriate department. On 5/6/24 at 9:20AM, V1 (Administrator) said they have an audiology service that comes to the facility to see the residents. V1 said social services puts together the request for audiology. If a request is made for a resident, they would make a referral to audiology. On 5/6/24 at 11:36AM, V2, DON, said she was not aware a request was made for R2 to get hearing aids. V2 said social services may have received the request for hearing aids. V2 said if there was a request made, or if the resident had to go out to be seen by audiology, there would be an order. V2 reviewed R2's orders and verified there was no order for audiology. V2 said if a request was made, they would contact the place to schedule the appointment if it was an outside office, or would add the resident to the schedule for R2 to be seen in house. V2 said she would have made sure an evaluation was done if she received the request. On 5/6/24 at 2:38PM, V35 (Social Service Director) said if a request is made for hearing aids, she would add the resident to the list and have the audiologist see the resident on the next visit. V35 said they have an audiologist that comes every 6-8 weeks, and she provides them with a list of residents who need evaluations. V35 said she was unsure when the audiologist was last at the facility, but they will be at the facility on 5/10/24. V35 said she just started in this position March 25, 2024, and no list was provided to her on who was last seen, or who still needed to be seen. V35 said she did not have a request for R2 to seen by audiology. V35 verified R2 was not on the list to be seen on 5/10/24 but could be added if needed. On 5/6/24 at 4:39 PM, V1 verified that a referral was never made to audiology, and that R2 was added to the list to be seen on 5/10/24. The facility policy Care of Hearing Impaired Resident revised 11/2013 shows Arrange for consultation with an otologist if needed.

Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure injury, failed to ensure a pressure injury dressing was kept clean and intact, and failed to assess and implement treatment for a resident with a newly identified pressure injury for 2 of 3 residents (R3, R9) reviewed for pressure injury in the sample of 13. The findings include: 1. R9's Physician Orders printed 5/5/24 showed her original admission to the facility was 4/19/24 with diagnoses to include dementia, major depressive disorder, and diabetes. An Order dated 4/29/24 shows to turn and reposition every 2 hours and as needed, and offload heels while in bed every shift. A physician ordered dated 5/1/24 shows coccyx-clean with NSS [normal saline solution], apply medihoney, calcium alginate, cover with bordered dressing every 8 hours as needed for wound care if soiled or displaced. R9's record shows her weight on 4/29/24 was 129.2 pounds. R9's Care Plan initiated on 4/30/24 shows she has an ADL deficit related to confusion, impaired balance, and limited mobility. She has a diagnosis of dementia and requires total assist with ADLs., is non ambulatory, and is incontinent of bowel and bladder. This care plans shows an intervention for bed mobility: the resident requires (extensive assist) by 2 staff to turn and reposition. An intervention for Personal Hygiene shows R9 is totally dependent on (1) staff for hygiene. The Toilet Use intervention dated 5/1/24 shows the resident is not toileted. R9's care plan initiated on 5/1/24 shows R9 has actual skin impairment .pressure ulcer - stage 3 - Coccyx. Interventions include pressure relieving mattress to protect the skin while in bed, keep skin clean and dry. There were no interventions to off load heels while in bed, or to turn and reposition every 2 hours as needed. R9's progress noted dated 4/29/24 at 9:18PM shows she was readmitted to the facility . wound to sacrum .requires total assistance x 2 staff to accomplish ADL tasks at this time. On 5/4/24 at 9:27 AM, R9 was in the dining room in a reclining wheelchair. R9's chair was in the reclining position, with R9 resting on her back and bottom. Her legs were in the upright position, and her knees were bent. At 11:53AM, R9 was still in the back of the dining room in her wheelchair, in the reclined position. At 11:57AM, R9 was served lunch and V6 (Certified Nurse Assistant-CNA) began feeding R9. R9 remained sitting on her bottom, and her legs remained in the upright position, extending off the bottom of the chair. The back of her chair had been raised, with her sitting in a partial upright position. At 12:07PM, V4 (CNA) said she would be changing R9 after lunch. On 5/4/24 at 1:02PM, V4 wheeled R9 in her reclining chair to her room. V4 said she was assigned to R9 for the day, and R9 was already up in her chair when her shift started (at 7:00AM). V4 said this is the first time she has changed R9 (6 hours after her shift started). V4 and V5 (CNA) used a mechanical lift to transfer R9 from her chair to her bed. V4 removed R9's pants and incontinence brief. The front of R9's brief appeared wet with urine. After cleaning R9's perineal area, V4 rolled her to her left side to remove her brief. The back of R9's brief was visibly saturated with urine. R9 had a bordered dressing to her coccyx that was saturated, no longer adhering to her skin, and falling off. V4 placed R9 on her back and said her dressing was wet and needed changed. V4 said she did not know R9 had a wound to her bottom, this was the first time she had seen it. V4 verified her incontinence brief was saturated with urine. V9 was asked if there were any special interventions in place for R9 regarding her wound, care etc., and she said, not that I'm aware of, she just came back recently from the hospital. On 5/4/24 at 1:30PM, V7 (LPN) was preparing the new dressing for R9. V7 said this was the first time he saw R9's wound. V7 and V3(Wound Care Nurse) turned R9 on her side and removed the soiled dressing, partially in place to the coccyx. There was an irregular pale white shaped wound to the left and right buttock area extending over a small portion of the coccyx. The wound edges were pink and slightly red around the outer most aspect. The inside of the wound appeared clean. V7 cleaned the wound with normal saline, applied medihoney, and placed a calcium alginate square dressing over the wound. V7 then covered the wound with a bordered foam dressing, dating the outer dressing. No date was observed on the soiled dressing that was removed. After completing the wound care, V7 and V3 left. V4 finished covering R9 and left the room. R9's heels were left resting directly on the bed. At 2:55PM, V7 went into R9's room. R9's heelswere resting on the mattress, and her toes were resting on the end of the bed. R9 had a box attached to the foot of the bed, controlling the air mattress. The top of the box had a white sticker that said, continuous 150. V7 said they always put R9's heels up, but he wasn't sure where the pillow was, maybe they sent it to laundry. After looking around R9's room, V7 left the room and got a pillow and came back in and placed it under the lower portion of R9's legs, by the ankles. V7was asked to verify the setting on the air mattress pump. V7 said yes the arrow on the dial was set at 120. V7 said the company adjusts the setting when they set the bed up, we (nurses) don't touch it. On 5/4/24 at 3:07PM, V3 said the air mattress setting is determined by resident weight. V3 looked at R9's machine and said it should be set at continuous- 150 (what the sticker showed on top). She looked at the machine and said it was between 130 and 150. V3 changed the dial to align with 150. She said if it's too firm, it defeats the purpose, and if it's too soft it wouldn't help either. The weight needs to be distributed evenly. V3 looked at the sticker and said she placed it on the machine based of [R9's] weight. On 5/4/24 at 1:40PM, V7 said R9 should be repositioned every 2 hours, and her heels should be elevated when she is in bed. V7 said the goal would be to keep R9's dressing clean and intact. On 5/5/24 at 9:58AM, V3 said R9 should have her heels offloaded while in bed. She should have an air loss mattress and be turned and repositioned every two hours. If she is up in her chair, they should be checking to see if she needs her [incontinence brief] changed. They can also reposition her in her chair every two hours. V3 said it is very important for R9 to have incontinent care every 2 hours and as needed to keep her dressing as clean and dry as possible. She does not have a catheter, so they have to keep her clean. On 5/5/24 at 11:51AM, V16 (RN) looked at the setting on R9's air mattress machine. V16 verified the arrow on the dial was set at 180. V16 said the machine is set when the company sets the mattress up. V16 pointed at the white sticker that said, continuous 150 and said she did not know why it was set at 180, and she would change it to 150 because that is what the sticker said. V16 said it is important to keep residents clean and dry. Toileting and incontinence care should be done every 2 to 2.5 hours. V16 said when R9 is up in her chair, they should be taking her to bed for toileting/incontinence care and laying her down, so she is not sitting there on her bottom. V16 said they try not to keep her up a long time, and it would be hard to reposition her in her chair. On 5/5/24 at 1:10PM, V2 (Director of Nursing) said pressure ulcer interventions include an air mattress, turning and repositioning every two hours, and keeping the resident clean of urine and stool. V2 said it is very important to check the resident every two hours to make sure they are clean and dry. 2. R3's Facility assessment dated [DATE] shows she had severe cognitive impairment and required partial to moderate assistance from staff with toileting, upper and lower body dressing, and personal hygiene. This assessment shows she required supervision or touching assistance with sitting to standing, toilet transfers, and walking. This assessment showed she was at risk for skin impairment but had no unhealed pressure injuries. R3's Physician Orders printed 5/5/24 shows she had diagnoses to include dementia, type II diabetes with foot ulcer, major depressive disorder, generalized anxiety, and morbid obesity. R3's order dated 12/5/23 shows Skin assessment one time a day every 7 days. On 5/4/24 at 11:20AM, V3 (Wound Care Nurse) said on admission, R3 had wounds, but they resolved. V3 said R3 had no wounds when she discharged to the hospital (3/17/24), that were identified to her. On admission she had MASD (moisture associated skin disorder) to her abdominal fold, a skin tear to her left buttock cheek, pressure ulcer to left inner foot, fungal infection to her right great toe, and skin stripping to right. V3 said the last assessment by wound care, was completed on 11/22/23. V3 said the nurse will notify her (wound care) of any new skin concerns. The nurse would assess the new wound, call the doctor and obtain orders, and notify her. She will then do the assessment. On 5/5/24 at 12:16PM, V29 (CNA) said she cared for R3 prior to her going to the hospital. V29 said right before she left, she had an opening on her heel. She could not remember for sure which heel. V29 said it looked like a sore, it was red, and it hurt to touch. V29 said it looked like if you had a scab, and then pulled the scab off, there was definitely dead skin there. V29 said R3 said her heel was hurting. I was showering her, and she said it hurt. The CNAs do skin checks during showers, and she would report anything .scratches, redness, bruise, cracked skin, anything that doesn't look right to the nurse. V29 said they also document on the shower sheet. V29 said R3's nurse was not on the floor, so she reported the sore to the nurse covering the other side (V30-LPN), and she came and looked at it. V29 said R3 did not say how it happened, just said it hurt. On 5/5/24 at 12:35PM, V30 said she was working on the floor with R3 on a previous shift. V30 said an activity girl (V31-Activity Director) told her that R3 had a sore on her foot. V30 said she told [V31] to make sure she reported it to the wound care nurse. V30 said she was not R3's nurse and did not assess the wound. She said she did not report it to R3's nurse (V32-nurse) that day, because it was towards the end of the shift. On 5/5/24 at 1:00PM, V31 said she remembered R3. V31 said she reported a wound she saw on R3's heel to the nurse. V31 said she noticed R3 had been very busy. She had croc like shoes on, and her heel was out of the back (soft, rubber, slipper like shoes that slide on and off, leaving the back of the foot exposed). V31 said R3 did not have socks on, and the back of her heel was out. That's how she saw it. V31 said she told the nurse (V30) right away. She remembers V30 went over and looked at it and was cleaning it. V31 verified the date she noticed the sore was on 3/15/24, which was election day at the facility. She had it noted on her calendar. On 5/5/24 at 1:10PM, V2 (DON) said it sounds like R3 could have had a blister to the back of her heel from walking in her crocs. The blister may have opened, caused from friction to the heel. V2 reviewed R3's record and said there was no assessment of the wound. V2 said when a new wound is found the nurse should provide first aide, notify the doctor, obtain an order, and wound care would follow up. V2 said yes she believe a blister to the heel would be considered a pressure injury. R3's Bath/Skin check list dated 3/11/24 and 3/14/24 shows yes in the skin clear box. No areas of concern are identified on the body diagram on these sheets. Review of R3's progress notes show no assessment or identification of a wound to R3's heel, prior to her discharge to the hospital on 3/17/24. An assessment of R3's heel wound was requested and not provided by the facility. The facility policy Prevention of Pressure Ulcers/Injuries revised 1/2019 shows: 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. 2. The most common site of a pressure ulcer is where the bone is near the surface of the body including the back of the head around the ears, elbows, shoulder blades, backbone, hips, knees, heels, ankles, and toes. Risk Assessment 5. CNAs will inspect the skin on a daily basis when performing or assisting with personal care or ADL.s b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Mobility/Repositioning At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. Risk Factor-Friction and Shear 9. Shoes need to be monitored for proper fit to avoid development of blisters, corns, and calloused areas. The Pressure Ulcer/Skin Breakdown - Licensed Professional Policy revised 12/2018 shows: Assessment and Recognition 2. In addition the nurse shall describe and document/report the follow a. Full assessment of the pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue. Treatment/Management 1. The physician will order pertinent wound treatment, including pressure reduction surfaces, wound cleaning and debridement approaches, dressing .

Based on interview and record review, the facility failed to identify a vascular diabetic wound until it was necrotic for one of three residents (R2) reviewed for wounds in the sample of 12. Findings include: R2's electronic medical record show R2 was admitted to the facility on [DATE] with diagnoses that include dementia, diabetes and chronic kidney disease. On 12/1/23 at 10:22 AM, V20 (R2's son) said when R2 was still at the facility, he noted a large wound on R2's left foot by his heels that was black. V20 also said the time he was visiting R2, no staff was turning and repositioning R2. V20 said he had reported his concerns to the staff. R2's Wound Assessment detail report dated 9/27/23 show R2's Braden scale was high risk. Wound Information: -Facility Acquired, Vascular diabetic ulcer left heel. Purple ecchymosis (dark purple) 75% and necrotic 25% with bloody drainage. Wound measurement- 3.70 centimeters (cm) x 2.8 cm x 0.10 cm. R2's electronic treatment sheet dated 9/28/23 show left heel cleanse with normal saline (NSS) paint with betadine cover with ABD pad and kerlix. On 12/1/23 at 12:10PM, V8 (Wound Nurse) said R2 was admitted to the facility with no wounds. V8 said on 9/27/23, R2 was found to have an open area to his left heel. V8 said by the time the wound was found it was necrotic (with dead cells) and dark purple measuring 3.70 centimeters (cm) x 2.8 cm x 0.10 cm. V8 said staff has been told to check residents skin and report to her any abnormality. This surveyor requested R2's skin assessments prior to 9/27/23. There were no skin assessments provided except R2's shower sheet dated 9/26/23 with notes: indicate location of breakdown, heels-dark. V8 said she was not made aware of this. V8 said skin assessments should be done to check any resident skin abnormalities/open areas. On 12/1/23 at 1:45 PM, V2 (Director of Nursing-DON) said after R2's wound to the left heel was found, the care plan was updated with interventions put into place of monitoring residents skin, offloading heels and monitoring staff to turn and reposition residents in bed. V2 also said staff had to be reeducated to notify her and the wound nurse of any skin abnormality so interventions will be put into place sooner. R2's careplan shows: R2 has actual skin impairment to skin integrity and remains at risk for further skin breakdown . intervention dated 10/2/23 includes, monitor skin during AM. HS care, monitor document location size and treatment of skin injury .off load heels when in bed.

Based on observation, interview, and record review, the facility failed to ensure fall interventions were in place for a resident who is at high risk for falls. This failure applied to one of three residents (R1) reviewed for safety in the sample of 12. Findings include: R1's face sheet shows she is [AGE] year-old female with diagnoses including metabolic encephalopathy, dementia, unspecified severity with agitation, major depressive disorder, scoliosis, unsteadiness on feet, repeated falls, muscle weakness and difficulty walking. R1's Final Incident Report dated 11/10/23 documents on 11/8/23 at 9:00 AM, (R1) sustained a fall from her bed resulting in a laceration over her right eye requiring skin glue. R1's CNA (Certified Nursing Assistant) was completing her morning activities of daily living and when she turned to get the wheelchair, (R1) fell out of her bed. (R1) was sent out to the local hospital and returned the same day, she sustained a laceration above the right eye with skin glue applied. R1's Minimum Data Set assessment shows she's severely cognitively impaired, requires extensive two person assist with dressing and extensive assist with transfers and toileting. On 12/1/23 at 9:53 AM, R1 was observed in the dining room with a healed laceration above her right eye. R1 said she had a fall but could not recall the details. A sign was posted above R1's bed in her room showing she is extensive assist with two staff. On 12/1/23 at 9:45 AM, V11 (RN) said R1 has dementia, and her behaviors are progressing. She was R1's nurse when she fell on [DATE]. She was in another resident's room and heard crying from R1's room. When she entered R1's room, R1 was on the floor. She had a three-to-four-inch laceration above her right eye and was bleeding. V11 said V21 (Former CNA) said she rolled out of bed. V11 said she called out for help and R1 was transferred to the local hospital. She is not sure how R1 was transfered, but each resident has a sign above their bed that indicates how they transfer. On 12/1/23 at 9:57 AM, V12 (Restorative Aide) said R1 is an extensive two person assist with transfers and bed mobility. She has a history of falls and attempts to get out of bed. She was here when R1 had her fall on 11/8/23. When she entered the room, R1 was laying on the floor mat on the floor. Her bedside table was near her head. Her bed was not in the lowest position and her side rail was in an upright position. She was bleeding above her right eye. V21 (Former CNA) said she walked out of the room to grab something and R1 rolled out of bed. The bed should have been in the lowest position and the side rail should have been down. V12 said V21 no longer works at the facility. On 12/1/23 at 12:35 PM, V2 (DON) said V21 was terminated because of the incident related to R1. On 12/1/23 at 1:21 PM, V2 (DON) said V21 was providing care and left R1 at the bedside to grab a chair and R1 fell on the floor mat on the floor. She was not sure what R1 hit her head on. R1 had a laceration above her eye. R1 is a fall risk and requires two persons assist with cares. R1's bed should be in a low position and the side rails should be upright for safety. V21's statement dated 11/8/23 documents she did not see R1 fall. I stepped out of the room to grab a chair after I dressed her. R1 rolled onto the floor from the bed. I heard her fall and she was on the floor mat. R1's current care plan initiated on 3/10/23 documents she is a HIGH risk for falls related to confusion, dementia, history of fall, muscle weakness, unsteadiness on feet and difficulty walking with interventions for a safe environment the bed in a low position and side rails as ordered. The care plan documents R1 has a self care deficit with interventions for half side rails up for safety during care provision, requires extensive two person assist with toileting, transferring and bed mobility. The facility's Fall Management Policy revised 2015 states, Based on previous evaluations and current data, the staff will identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling . All residents shall be screened for the potential for falls, using the fall risk screening tool .staff will initiate falling prevention protocol .

Based on interview and record review, the facility failed to ensure that a resident was not housed in the same room as a resident that was placed on contact isolation to prevent the spread of infection for one of three residents (R5) reviewed for infection control in the sample of 12. Findings include: R5's Face Sheet shows diagnoses of: malignant neoplasm of the rectum, urinary retention and colostomy. R5's Urine Culture Report from 8/17/23 shows that he has no current infections. R4's Nursing Notes date 9/25/23 shows, Resident transported into the unit .from oncology appt (infusion visit) .(urinary) catheter still in placed .chemo implanted port remain intact .resident return from appt (appointment) with a scheduled f/u (follow up) oncology/infusion visit . R4 and R5's Census Reports show that they resided in the same room on 9/27/23. R4's Nursing Notes dated 9/27/23 shows, Discussed with nurse on duty new order for Macrobid (antibiotic) 100 mg (milligrams) BID (twice a day) x 7 days r/t (related to) E.Coli ESBL (Extended-spectrum beta-lactamases) and contact isolation. R5's Census Report shows that R5 was moved to a different room on 10/2/23 (5 days after R4 was placed on isolation). R5's Nursing Notes do not document that R5 had a room change between 9/27/23 and 10/2/23. R4's Census Report shows that R4 was in the same room between 9/27/23 to 10/2/23. On 12/1/23 at 11:04 AM, V5 (Infection Control/Licensed Practical Nurse) said that anyone diagnosed with and who is receiving treatment for ESBL should be placed on isolation immediately. V5 said that if the resident has a roommate, either the resident or the roommate should be moved out of the room to prevent the spread of infection. V5 said that they have never had an issue with finding appropriate placement for a resident on contact isolation. V5 said that room changes should be documented in the nursing notes when they are done. At 2:19 PM, V5 said that when R4 developed ESBL, they spoke about it, and they were going to move R5 to a different room. The facility's Contact Precautions Policy revised on 5/22 shows, Contact Precautions require the use of gown and gloves on every entry into a resident's room. The resident is given dedicated equipment .and is placed into a private room .

Based on observation, interview, and record review, the facility failed to ensure that 1 of 3 residents (R1) reviewed for abuse, was free from abuse from a staff member. This failure resulted in R1 suffering an abrasion to her face, sore ribs, and feeling angry and taken advantage of. Findings include: On 6/27/2023 at 11:45 AM, V1 (Administrator/Abuse Coordinator) states she reviewed tapes of the incident that occurred on 6/18/2023, resident was in and out of her room making noise. Resident attempted to leave and went downstairs at about 4:00 AM then went to her room. At around 6:15 AM, R1 came down again and got through the front doors. V5 (CNA) came downstairs and grabbed the back of R1's wheelchair and pulled R1 backwards, and V1 believes resident knocked her own glasses off her face. On 6/27/23 at approximately 2:35 PM, while reviewing incident video with V1 (Administrator/Abuse Coordinator). V1 states there is no one at the reception desk at 6:00 AM in the morning. Observed at 6:15:43 AM, R1 comes into view propelling herself in a wheelchair and pushing a rollator walker and approaches the exit door. R1 pushing on the bell (which V1 states alerts the staff) several times and fidgets with the door. Eventually R1 pulls open the sliding glass exit door at 6:17:03 AM and goes through the door into the vestibule. The second exit door opens automatically and R1 goes out the door and is sitting at the entrance of the facility. Observed at 6:17:46 AM, V5 (CNA) comes into view and walks out of the doors and without any pause or hesitation, immediately grabs the resident's wheelchair and starts to pull her backwards towards the sliding glass doors. R1 starts swinging her hands backwards as if trying to remove or keep V5 from moving her. V5 uses left hand and is consistently trying to move R1's hand. V5 at one point tries to propel R1 forward and R1's feet stops the forward progress. V5 then turns R1 backwards and pulls R1 into the vestibule. About halfway into the vestibule, R1 stands up and V5 immediately grabs R1 by the back of her shirt and pulls R1 down and backward into the wheelchair. R1 falls back into the chair and R1 rocks and tilts to the left side a couple of times before stabilizing. V5 then continues to pull the resident backwards in the wheelchair into the facility. V5 then sits in a chair in the lobby with R1 in front of her. R1 moves her upper body forward and V5 pulls her back by R1's shirt. R1 again starts to strike behind her. V5 then gets up and starts wheeling R1 backwards down the hallway. R1 starts resisting and swinging backwards. V5's left hand and arm is observed moving erratically with R1's and there is a lot of swinging and movement near the left of R1's face that is difficult to see on the video. R1 then tries to hold onto one of the side rails in what looks like an attempt to stop V5 from moving her. V5 pulls R1's hands away from the safety railings. V5 is holding onto R1's arms and at some point, during the scuffling, R1's glasses are knocked off. Observed at 6:19:23 AM, V6 (RN) coming down the hallway. V6 is seen talking to resident for a short time and R1 is talking and pointing. R1 is not swinging at V6 or trying to hit her. There is no physical altercation between V6 and R1. R1 appears to then leave with V6 calmly and voluntarily. On 6/27/23 at 2:47 PM, while still viewing the video tape of the incident surveyor asked V1 (Administrator) if she thought V5 did anything inappropriate in the video. V1 states she doesn't like the approach V5 took to go get R1. V1 states, She [V5] doesn't know how to handle aggressive resident's, which is apparent from this [video]. On 6/27/2023 at 11:02 AM, R1 states that V5 (CNA) worked every other day and is always nasty. R1 states that V5 was taunting her, and she went to go find the nurse to get medication. R1 states she didn't know why she was doing that, and she just ignored her. R1 states she couldn't find the nurse and she was done at this point. She took her stuff and walker. R1 states she went down to the first level with her stuff and went to open the door downstairs and the alarm went off. V5 states she tried to get up from the wheelchair to take her walker and leave. R1 states V5 (CNA) said Sit Down, and the CNA pushed her down into the chair. R1 states she tried to get up again to leave and the 2nd time she shoved me back into the chair and my glasses fell . I tried to get up a 3rd time and she closed fist punched me in the left eye. R1 states they have cameras in the facility. R1 states V5 (CNA) smacked her with a closed fist. R1 states, I certainly did not see that coming. R1 states she was wheeled to her room, and she called 911. On 6/29/2023 at 10:34 AM, R1 states, It made me angry when V5 was pushing me back when I wanted to leave. She had no right to put her hands on me. I have 4 broken ribs and it got irritated when she pushed me, and it was painful. She smacked me in the face with a closed fist. I was in shock that she punched me. I didn't think they were supposed to do things like that. While crying R1 states I was angry that V5 took advantage of my handicap, and I wasn't able to defend myself. I couldn't stand up and defend myself! On 6/28/23 at 1:59 PM, V5 states R1 and another resident were cursing, talking loud, and saying racist things. The first time R1 went to get on the elevator I attempted to stop her and she said, leave me the F*** alone. V5 states she called V6 the supervisor because the nurse was not available. Later she was doing her rounds and V9 (nurse) called her and said that R1 had gotten out and can she go get R1. V5 states R1 was inside the 2 glass doors, and I attempted to push her inside and she stopped. When I first saw her, I just grabbed the back of the wheelchair she was sitting in. I told her you can't go out the doors. I grabbed the wheelchair turned it and she kept stopping it with her feet, so I turned it around and backed into the door. Surveyor asked, At any point did the resident try to get out of the chair. V5 said, No she was just fighting a lot. She was swinging her arms back to hit me because she didn't want me pushing the wheelchair. Surveyor asked, At any point did you pull her back into the chair. V5 states, No, I didn't pull her back into the chair. She was always in the chair. V5 states R1 was alert and oriented and she (V5) had worked with her before. V5 states, Yes, at 6 am it was appropriate for her to pull R1 into the facility against her will. Surveyor asked, do you think it is appropriate to pull someone down from behind into a wheelchair. V5 states, No, of course not. They can hurt themselves. V5 states I would think that is abuse if I saw someone do that. Surveyor asked if it is appropriate to pull R1 back into the facility when she is fighting and saying she doesn't want to go in. There was a long pause and V5 said, Ordinarily, no. Surveyor asked, why was it okay to do it this time with R1. V5 states, because of the time of day and no one was waiting for her. On 6/27/2023 at 12:57 PM, V4 (Licensed Practical Nurse) states he remembers R1. V4 states, R1 was alert and oriented and cooperative. On 6/27/23 V3 (CNA) states R1 was a nice lady. V3 states R1 was alert and oriented and could transfer by herself. V3 states R1 kept to herself and stayed in her room. V3 states R1 was never combative, and she never got any reports that she was. On 6/28/2023 at 10:10 AM, V6 (RN) states R1 is completely alert and oriented. V6 states the first time V5 (CNA) called her because R1 had left the unit. V6 states she saw her downstairs. V6 states, R1 was saying she didn't want to be at the facility. V6 states she tried to calm her down and eventually got her to go back upstairs. V6 states she got a 2nd call, said the resident was trying to leave. V6 states when she got to the lobby, V5 was trying to get R1 back to the unit. V5 was wheeling her backwards and R1 was swinging and resisting by swinging her arms. V6 states, I intervened and told V5 to just go. V6 states she told R1 to calm down. She said she wanted to go. V6 states she told R1 leaving against medical advice (AMA) and R1 said she would sign anything because she wanted to go. I believe R1 is self-responsible for her care. She has the competence to sign the AMA form and leave if she wants. I believe that she has the right to leave, and we would just document that she refused to sign AMA if she didn't sign the form. V5 states, if she had seen R1 outside, the first thing she would do is talk to R1, tell her to stay calm, and redirect her to the facility. V6 states, I wouldn't approach the situation with aggression so that it does not escalate. Police report dated 6/18/2023 and reported at 6:20 AM documents: Officer was told when he arrived that R1 was sent to the hospital. Officer interviewed resident in the emergency room . R1 told officer she tried to leave the facility and was stopped physically by her CNA. R1 stated she was struck in her left eye by a closed fist of the CNA. R1 advised the officer that her CNA also pushed her by the shoulder into a chair. Officer observed redness upon R1's upper left cheek near her eye. Nurse told officer that R1 tried to leave and was told she couldn't leave based on her mind and no means of transport or shelter and that R1 was restrained at this time and the process was started to have R1 involuntarily committed. Hospital records dated 6/18/23 documents R1 reported that the CNA at the facility pushed her down into a chair and after that, punched her in the face. Page 11 documents: Patient presents to the emergency room with reports of abuse at her nursing home. Patient is to be Alert and oriented times 3. No evidence of active psychiatric disease clouding her decision making. Emergency Department (ED) Notes: Patient states: I was hit in the left eye by a CNA at the facility she was living. The CNA kept pushing her down every time she tried to get up. V15 (nurse) from the facility stated they were petitioning the patient, psych evaluation, due to patient attempting to leave against medical advice and being combative with the staff members. R1's left eye was noted to be red with a small abrasion. R1's MDS (Minimum Data Set) dated June 13, 2023, documents R1's cognition to be intact. R1's Abuse and Neglect Care Plans documents the following intervention: Approach in a friendly, calm manner; treat with dignity and respect. Dated 3/20/2023. The facility's Abuse Prevention Program policy dated 10-2022 documents the following. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on observation, interview, and record review the facility failed to safely provide incontinence care to a resident by not having two staff members provide the care. This failure resulted in a resident hitting his head which resulted in a five day hospitalization for a subdural hematoma. This applies to 1 of 3 residents (R1) reviewed for safety and supervision in the sample of 17. The findings include: R1's Admission Record dated 6/16/23 shows he is a [AGE] year old male and his diagnoses include, but are not limited to, Alzheimer's disease, severe protein calorie malnutrition, type 2 diabetes, acute respiratory failure, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, anemia, heart disease, disorder of the brain, encephalopathy, cerebral infarction, dementia, altered mental status, and anxiety. R1's Minimum Data Set (MDS) dated [DATE] shows R1 is not cognitively intact and requires extensive assistance by two or more staff members for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed). R1's current Care Plan provided by the facility shows R1 is blind, hard of hearing, and is on anticoagulant (blood thinners) therapy and therefore, should avoid activities that could result in injury. This same care plan shows R1 has an ADL (activities of daily living) self-care performance deficit and requires extensive assistance by two staff to turn and reposition him in bed and for his toileting needs. R1's Medication Review Report dated 6/16/23 shows R1 has an order for Apixaban (anticoagulant) to be given twice a day both prior to (4/25/23) and after R1 was hospitalized (5/31/23) for his head injury. R1's After Visit Summary from the hospital dated 5/31/23 shows he was hospitalized from 5/27/23 to 5/31/23. R1's Facility Transfer Report (FTR) dated 5/31/23 from the hospital shows R1's hospital admitting diagnoses includes intracranial hemorrhage for which he was admitted on [DATE]. The FTR includes a consult note from the hematologist with the reason for consultation being subdural hematoma on anticoagulation therapy. The FTR includes a Neurocritical Care Attending Note which shows, Patient is critically ill and at high risk of clinical deterioration due to acute subdural hematoma. The FTR includes a brain CT scan which shows, Impressions: New from prior study 4/20/23, a subtle small right frontoparietal hyperdense extra-axial fluid collection, most likely subdural hematoma. The facility's Incident Note for R1 on 5/27/23 at 7:12 AM shows Upon CNA during rounds resident was being cared for and was turned over in bed to be changed and was turned to (SIC) far and bumped his head against the siderail, with further observation resident noted having reddened area to right side of head. The facility's Health Status Note for R1 on 5/28/23 at 12:59 AM shows, Resident was admitted to hospital with admitting dx (diagnosis) right frontal subdural hematoma . On 6/16/23 at 9:28 AM, R1 was lying in his bed with his left leg hanging off the edge of the bed and his head about a third of the way down from the top of the bed. There was a sign above R1's head of bed showing R1 is blind and wears hearing aids. R1 was unable to engage in a conversation or answer questions. On 6/16/23 at 9:38 AM, V15, CNA, was observed as she provided incontinence care, including turning and positioning, to R1 without any other staff assistance. On 6/16/23 at 9:44 AM, V16, Licensed Practical Nurse (LPN), said R1 requires total assistance with his care. On 6/16/23 at 11:32 AM, V13, Certified Nursing Assistant (CNA), said she was providing incontinence care for R1. V13 said she turned R1 on his side and he jolted forward and hit his head on the side rail, so she went and got the nurse to assess him. When the nurse was finished, V13 finished cleaning R1 and was lowering R1's bed and the fan fell over and hit R1 on his head in the same area where he had just hit it on the side rail. V13 said there was a red area on R1's right temple area. V13 said she was providing R1's care by herself. V13 said R1 needs two people to do his incontinence care because he moves around a lot, but no one was helping her. On 6/16/23 at 11:17 AM, V14, LPN, said she was the day nurse the morning after R1 hit his head. V14 said R1 had a hematoma to his right frontal forehead. V14 said she told V2, (DON) Director of Nursing, that R1 was taking blood thinners and V2 recommended they send R1 to the hospital.

Based on interview and record review the facility failed to ensure adequate supervision to resident (R58) who has multiple episodes of falls to prevent from future falls as indicated in his care plan. R58 was left unattended/unsupervised in the dining room and sustained a right [CONDITION(S)] requiring hospitalization . This deficiency affects one (R58) of 3 residents in a sample of 26 reviewed for Fall prevention management. Findings include: R58 is admitted on [DATE] with diagnosis to include Dementia, [CONDITION(S)], [CONDITION(S)] and Depression. R58 is at high risk of falls. He has a total of 10 episodes of multiple falls from 5/17/21 to 4/19/22. Most recent fall sustained right [CONDITION(S)] requiring hospitalization . R58's fall prevention care plan intervention dated 7/14/21 indicated: place resident in supervised area while awake. R58's progress notes dated 4/19/22 indicated: Unwitnessed fall at approximately 11:15pm, R58 sustained a fall while sitting in his wheelchair in the dining room. Staff responded to R58's call for help and the resident was found lying on his right. There was no break in his skin noted and R58 was complaining of right-sided hip pain. R58's physician gave orders to transfer him to hospital for further evaluation. Tylenol 650mg was given orally for pain. Vital signs: BP135/71, PR 68, RR 19, T-97.6F, 97% O2 sat on room air. On 4/21/22 at 2:02pm V2 Director of Nursing (DON) said that R58 is a demented resident who needs constant supervision/monitoring due to high risk of falls and multiple incidents of falls. He was placed in the dining room late in the evening for supervision because he tends to get out of bed when he was in his room. He was monitored by CNA, but staff left him unattended without informing the nurse on the floor that the CNA needs to leave R58 in the dining room. R58 was found on the floor complaining of right hip pain. R58 was sent out to the hospital for evaluation and was admitted for a right [CONDITION(S)]. On 4/21/22 at 2:50pm, V2 DON said that they don't have a fall coordinator to complete the root cause analysis of the fall. V2 said that they usually discuss it during the morning meeting, but they have not done it this week due to current survey in the facility. R58 was readmitted on [DATE] from the hospital with diagnosis of right [CONDITION(S)] due to fall. R58's care plan was not yet updated as of 4/21/22. On 4/22/22 at 10:03am observed R58 lying in bed sleeping, his bed is pushed to the wall by the window and has floor mat on the right side of the bed. On 4/22/22 at 10:08am, V32 LPN said that she has been taking care of R58. He is confused, can be combative and resistive to care. He has poor safety awareness and attempts to get out from bed. He needs closer supervision due to his fall risk and multiple fall incidents. V32 said he had fall recently in the dining room and sustained right [CONDITION(S)]. No surgery was ordered due to his age. They are keeping him in bed with 2-person log rolling using abductor pillow or 2 pillows. No abductor pillow or 2 pillows found at bedside of R58. On 4/22/22 at 10:11am, V11 RN said that he worked on 4/19/22 (3-11 shift) the day that R58 fell . V11 said that V14 CNA placed R58 in the dining room for closer supervision because he was restless, agitated and attempts to get out from bed. V11 said that V14 told him that she was leaving at 11pm when her shifts end, leaving R58 unattended in the dining room. V11 said that he did not go to the dining room because he must do his charting at the nursing station. V11 said that V33 CNA from 11-7 shift did not stay with R58 because she must do her rounds. Then V11 heard R58 yelling for help from the dining room. V11 said he found R58 lying on the floor on his right side and complaining of pain. R58 was sent to the hospital for evaluation per his physician order. V11 said that if he had sat next to R58 in the dining room then the fall could have been prevented. On 4/22/22 at 10:23am, V2 DON said that R58 should be placed by the nursing station rather than in the dining room for closer 1:1 supervision by V11. On 4/22/22 at 12:10pm, V33 said that she is the assigned CNA for R58 on 4/19/22. V33 said that they have 2 CNAs and 1 Nurse on 4th floor for 11-7 shift. V33 said that she arrives on the unit at 11pm and saw R58 in the dining room by himself. V33 said that the nurse did not tell her to stay with R58 in the dining room for close supervision. V33 said that she made her rounds and checked her other residents. V33 said that if she knew that she needed to stay with R58 for close supervision, she would've stayed with the resident and prevented the fall. Facility's fall risk screening policy indicated the nursing staff in conjunction with the attending physician, consultant pharmacist, therapy staff and others will seek to identify and document resident risk factors for falls. Interpretation and implementation: 1) Based on the result of screening a plan of care will be developed and updated as needed. This plan of care will be reviewed with the resident and his family for input and review. 6) The staff with the support of the attending physician, will evaluate functional and psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living (ADL) capabilities, activity tolerance, continence and cognition. 8) The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. 9) The care plan will be developed and updated including identified risk and developed interventions. Facility's fall committee: 1. On a daily basis the fall committee will review all accidents/incidents/unusual occurrences that have occurred within the last 24hrs period. 2. The facility's IDT (interdisciplinary team) will meet and review all resident accident/incidents/unusual occurrences. This team provides investigation and interventions. 3. Based on this review, the meeting will determine how or if the care plan goals and approaches need revisions or additions and or make other recommendations in an effort to prevent reoccurrences Facility's Fall prevention activities Pre and post falls 4. For residents who have been identified at risk for falls upon admission, a care plan shall be developed which includes the resident and his family input for interventions that have or have not worked in the past. Additional interventions will be developed to promote a safe environment. The residents' individual needs for staff assistance will be assessed. Then the resident will be a placed on a fall prevention program. 6. As a fall occurs the nurse on duty will initiate a new intervention to prevent further falls. The pan of care will be updated at this time. The revisions to the fall care will be monitored for effectiveness and adjustments made as needed. The fall committee will review the revised plan of care and the resident's response at fall committee.

Based on interview and record review, the facility failed to follow their policy to use a gait belt for a resident identified as a fall risk for one (R1) of three residents reviewed for falls. This failure resulted in R1 being taken to the emergency department and diagnosed with [REDACTED]. Findings include: Emergency department trauma note dated 10/27/19 denotes R1 presented as trauma consult with subdural hematoma status [REDACTED]. Hospital records dated 10/26/19 - 10/27/19 denotes: CT of the head performed. CT impression: left parietal and parieto-occipital scalp hematoma. R1's [DIAGNOSES REDACTED]. R1's 10/26/19 fall report denotes: V6's(CNA) statement as I was at the doorway of her room and V15(Nurse) was walking beside R1, V15 stopped at the nurse's cart when R1 passed the doorway. Both V15 and I called R1 to comeback. R1 tried to walk backwards and turn. Fall Risk Evaluation dated 10/17/19 denotes: R1 as At Risk, due to intermittent confusion, 1-2 falls in past 3 months, poor vision, balance problem while standing and walking, and decreased muscular coordination. Physical Therapy Evaluation dated 10/10/19 by V14 (Physical Therapist) denotes: Reason for referral due to decline in functional abilities and increasing fall risk. Balance is poor. R1's Functional Status assessment dated [DATE] denotes: Extensive assistance with one-person physical assist for transfers and locomotion on and off the unit. Extensive assist is defined as staff provide weight bearing support. Balance during transition and walking is denoted as not steady, only able to stabilize with staff assistance for moving from seated to standing position. as Activity for walking or turning around did not occur. Devices normally used: wheelchair, no walker. On 11/19/19 at 11:10AM V16, Nurse, said we always use a gait belt on all one-person assist residents. V16 said she verbally reports when residents need devices and gait belts. On 11/19/19 at 12:10PM V15, Nurse, said he was assigned to R1 on 10/26/19. V15 said he reported to V6, Certified Nursing Assistant (CNA), that R1 required 1 assist with transfers and walking. Before the fall V15 had seen V6 walking by R1 and then she was standing in R1's room's doorway. V15 said R1 had walked past her room and when she was called to come back she tried to turn and lost her balance. V15 said R1 hit her head when she fell . V15 said he is not sure if the CNA had her hands on R1 while R1 was walking. V15 said he cannot remember if V6 had a gait belt on R1. V15 said when R1 fell V6 was standing in front of R1 and not in the proper position to assist her. V15 said he saw a bump and could feel it was raised on the back of R1's head. V15 said R1 developed pain and was provided pain medication and ice to her head. V15 said he notified the Physician of the fall and current anticoagulation therapy and he was instructed to send R1 to the hospital for evaluation. On 11/20/19 at 9:44 AM, V6 said she was walking along side R1 on 10/26/19 to take her to the bathroom. V6 said she had been assigned to R1 before. While walking to her room R1 had walked past her door, V6 said she called R1 to come back. V6 said she was standing by R1's door, and R1 was between her room and the next room. V6 said while R1 was walking back to the room she lost her balance, fell back, and hit her head. V6 said R1 was using her walker and she did not put a gait belt on R1. V6 said she has not had to use a gait belt while working in the facility. V3 said if she is told to use a gait belt or sees it in the care plan she will use it. On 11/19/19 at 3:00PM V12, CNA, said if a resident has a sign with the letter G over the bed she is to use a gait belt. V11, CNA, said she only uses a gait belt if the transfer status is a 1 and G otherwise a gait belt is not used. V11 said V3, Restorative Nurse, trained her on the use of gait belts. On 11/19/19 V18, CNA, said she uses the gait belt to assist residents with transfers and walking. V18 said she would hold onto the gait belt while walking with a resident and would not let go of the belt while walking. On 11/19/19 V16 said gait belts are used on all one assist residents. On 11/19/19 V17, Therapy Manager, said R1 was on caseload from 10/10/19 until 10/23/19. During this time R1 was not safe to walk on her own due to poor balance and poor standing ability. V17 said R1 required assist to stand and would not be able to safely stand and turn around without physical assistance from staff. V17 said for R1 she would recommend 1 assist to walk with hands on and the use of a gait belt. V17 said for safety she would not recommend walking in front of someone with balance issues. On 11/19/19 V14 said she treated R1 10/10/19; 10/11/19; and 10/22/19. At the time R1 was discharged from therapy she required assistance from staff, needed encouragement, and told V14 in Philippine she was afraid of falling. V14 said she communicated with R1 in Philippine language because this is R1's primary language. V14 said when R1 was discharged from therapy she did not have the endurance to walk from the dining room to her room, and at times could only walk 10 feet. V14 said R1 had declined since the evaluation on 10/10/19. V14 said R1 was unsafe to turn around by herself. V14 said for safety R1 required one person, hands on assistance, walker, and use of a gait belt. V14 said R1's feet shuffled or hesitated, and she would fatigue while walking. V14 said R1 fluctuated in her ability to walk. On 11/19/19, V3 said R1 had a history of [REDACTED]. V3 said on 10/26/19 R1 was ambulating to the bathroom with staff assistance, stumbled, and fell back before staff could catch her. The fall occurred in the hall outside of R1's room. V3 said she was not in the building when the fall happened. V3 said R1 had been declining and was recovering from pneumonia. The root cause of the fall on 10/26/19 was determined to be weakness and unsteady gait. V3 said V13, Restorative CNA, trains staff on transfer status cards and gait belt use. V3 said the CNA involved was from an agency and she does not train agency staff regarding resident care. V3 said the number 1 on a transfer card is used to identify residents who require extensive assist by 1 person and staff is expected to be hands on and use a gait belt. On 11/19/19 V2, Director of Nursing, said as far as our understanding R1's subdural hematoma is related to her fall. V2 said residents at risk for falls include residents who have fallen in the past. On 11/20/19 at 9:48AM V2 said agency staff is made aware of resident care needs verbally in huddles, shift to shift report, and bed side rounds. V2 said the agency does competency testing for their staff. V2 said all facility staff and agency staff is expected to follow facility policies. V2 said the restorative and therapy departments discuss resident's ambulation and transfer status and identify who needs a gait belt for transfers and / or ambulation. On 11/20/19, V13 said at orientation for facility staff she discusses gait belt use and the Resident Handling Policy. V13 said CNAs are instructed to have a gait belt on them at all times. V13 said all CNAs are issued a gait belt. V13 said it is not reasonable to expect a CNA to work a shift without a gait belt. V13 said she does not train any agency staff on the use of gait belts. V13 said she instructs staff that a transfer status of 1 and G require the use of a gait belt. V13 said a gait belt can be used at any time, not only when designated by G or 1. On 11/20/19 at 10:30AM, V17 said on or before 10/26/19 R1 did not have contraindications for the use of a gait belt. On 11/20/19 at 1:10PM, V2 said the Resident Handling Policy was revised in (MONTH) 2019. The changes made included a new transfer category for a lift and the disciplinary action section, V2 said she does random checks for gait belt use, but none are documented. V2 said she has not disciplined any one related to gait belt violations. On 11/20/19, V3 said it would not be reasonable for a CNA to work a shift without a gait belt being used. V3 said all CNAs are supposed to use gait belts including agency CNAs. On 11/20/19, V10, Care Plan Nurse, said if asked about a resident's transfer or ambulation status based on review of the balance assessment, denoted on the Minimum Data Set section G0300, marked not steady then she would instruct CNAs to use hands on assist and a gait belt. V10 said a gait belt is used to guide or stabilize a resident. On 11/20/19 V9, Nurse Practitioner, said she was following R1 due to her declining status. V9 said R1 had been declining cognitively, becoming weaker, and she determined her Dementia was progressing. R1 had negative results for any acute process contributing to her decline. Due to R1's declining status V9 said she was at increased risk for falls and based on the facility Resident Handling Policy, the best practice for safety would be to use a gait belt during transfers or walking. V9 said R1 did not have a contraindication for gait belt use on or before 11/19/19. V9 said some contraindications would include pelvic fractures, rib fractures, abdominal mass, and things that could be aggravated by the belt. V9 said being on a blood thinner would increase a resident's risk of developing a subdural hematoma. V9 said R1 did not have symptoms of a subdural hematoma prior to 10/26/19 and the fall is probably related to R1's subdural hematoma. V9 said R1's age and use of blood thinner increase her risk for complications related to subdural hematoma. V9 said the adverse risks of a subdural hematoma includes hemorrhage, loss of function, and death. According to nurse's notes dated 11/19/19, noted raised area on the back of her(R1's) head measured 2.5 centimeters in length and 1.5 centimeters in width. Gait Belt Policy(undated) denotes: Gait Belt usage is mandatory for all resident handling, except for bed mobility and medical contraindications. Fall Management Policy(undated) denotes: The staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Based on interview and record review the facility failed to supervise and maintain a resident's safety and failed to follow their abuse policy by not reporting or investigating an injury of unknown origin for 1 of 3 residents (R10) reviewed for accidents and incidents in a total sample of 11. This failure resulted in R1 being hospitalized with a [DIAGNOSES REDACTED]. Findings include: The Face Sheet documents that R10 was admitted to the facility with a [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] documents that R10 had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment and requiring extensive assistance with all activities of daily living (ADLs). The plan of care dated 4/2017 documents that the resident has cognitive impairment and impulsive behaviors related to Dementia. The Nurse's Notes dated 9/6/17 documents that the Physician was paged and made aware of R10 having complaints of severe abdominal pain to the right upper quadrant and right lateral back. R10 was transferred to the local hospital and admitted with a right rib fracture and urinary tract infection [MEDICAL CONDITION]. R10 was readmitted to the facility on [DATE]. The Hospital records dated 9/16/17 documents that R10 was admitted with a [DIAGNOSES REDACTED]. Resident noted with 2 linear bruises to the right lower ribs and the right flank, each bruise measures approximately 3 cm. Resident also noted with small bruises to the mid back around (T5 and T6). Resident's abdomen tender over bruised flank. CT of the chest done and documents that resident had a non-displaced rib fracture to the 8th and 9th rib that correlates with the location of the bruise. On 3/20/19 at 12:00pm V2 (DON) stated There's no reportable or investigation regarding an injury of unknown origin for this resident (R10). This happened before I came and I can't find anything. On 3/21/19 at 3:15pm V16 (Restorative Nurse) stated R10 was a high fall risk. The resident required extensive assist with all ADLs. The resident was non-ambulatory, incontinent and sometimes combative and resistive to care. The resident was also taking high risk medications. I'm not sure what interventions were in place at the time of the incident. On 3/22/19 at 1:00pm V21 (Physician) stated The resident may have had a history of [REDACTED]. I'm not sure why the resident would have had bruising to the ribs and back. I don't have any other [DIAGNOSES REDACTED]. The facility's Abuse Policy documents that Injuries of unknown source are to be investigated and reported when the source of the injury was not observed by any person or the source of the injury could not be explained by the resident, and the injury is suspicious because of the extent of the injury or the location of the injury.