Every finding on record at Piatt County Nursing Home

Based on interview and record review the facility failed to supervise a resident during a nebulizer treatment, resulting in the resident falling from bed and sustaining a right hip dislocation. This failure affects one of three residents (R77) reviewed for falls on the sample list of 31.Findings Include: The facility's Falls and Fall Risk Managing policy dated January 2026 documents facility staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The facility's Administering Medications Through a Small Volume Nebulizer policy dated January 2026 documents the purpose of the procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway. Nurses are to remain with the resident for the entire treatment and upon completion, they are to obtain a post-treatment pulse, respiratory rate, and listen to lung sounds. R77's Medical Diagnoses list dated July 2026 documents R77 was diagnosed with Right Femur Fracture, Dislocation of Internal Right Hip Prosthesis, Sternum Fracture, Orthopedic Fracture, Heart Failure, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Depression, and Anxiety. R77's Care Plan dated 7/9/26 documents R77 requires one assist for bed mobility and a full mechanical lift with two staff assist for transfers. R77's Fall Risk dated 7/9/26 documents R77 was high risk for falls related to a recent history of falls, ambulatory and incontinent, predisposing disease, recent hospital stays, taking high risk medications, and has had a change in medication or change in dosage in the past five days. The facility's Final Incident Report dated 7/17/26 documents on 7/15/26 R77 was found on the floor beside R77's bed by staff. R77 stated R77 was trying to put their nebulizer mask back on the nightstand after the nebulizer treatment was completed and R77 just fell right off the bed. R77 complained of head and right knee pain. R77 was sent to the emergency room. R77 was diagnosed with a superior dislocation of the right hip. R77 underwent a closed reduction procedure before returning to the facility. The facility identified the root cause of the fall to be R77 attempting to place the nebulizer mask on the nightstand which caused R77 to roll off of bed to the floor. Nursing staff were educated regarding nebulizer administration. R77's Femur and Pelvis X-ray dated 7/15/26 documents R77 had a fall and sustained a superior dislocation of the right hip. On 7/27/26 at 12:50 PM V18 Licensed Practical Nurse (LPN) stated he was the nurse on duty on 7/15/26 when R77 fell from the bed. V18 stated V18 administered R77's nebulizer treatment and then left the room while it was running. R77 was alone in the room. V18 confirmed V18 should've stayed in the room with R77 until the nebulizer treatment was completed. V18 confirmed R77 was a fall risk at the time. On 7/27/26 at 11:50 AM V2 Director of Nurses (DON) stated V18 LPN did not follow the facility's nebulizer policy. V18 should've stayed with R77 during the entire nebulizer treatment. V18 was written up for failing to do so. All nurses were re-educated on proper nebulizer treatment administration. R77 was sent to the emergency room when R77 complained of pain to R77's right knee. R77 was found to have a right hip dislocation due to the fall. R77 underwent a closed reduction and returned to the facility.

Based on interview and record review, the facility failed to complete required monthly infection surveillance and monitoring for resident infections for five of the previous seven months (January through May 2026). This failure has the potential to affect all 88 residents residing in the facility. Findings include:On 7/28/2026 at 12:30 PM, review of the facility's infection control surveillance records from 1/1/2026 through the time of survey document that no monthly infection line listings or infection surveillance logs had been completed for January, February, March, April, or May 2026.On 7/28/2026 at 3:37 PM, V2, Director of Nursing, verified that infection surveillance logs and infection line listings were not completed for January through May 2026. V2, Director of Nursing, stated the expectation is for the Infection Preventionist to complete the monthly infection line listing and mapping to monitor infections and identify trends.The facility's Surveillance for Infections policy, last reviewed in 2026, documented the facility will collect information from individual resident infection reports, complete a monthly line listing of infections by resident, and analyze the information to identify infection trends and patterns for ongoing surveillance and prevention activities.The Long Term Care Facility Application for Medicare and Medicaid form dated 7/28/26 documents 88 residents reside in the facility.

Based on observation, interview and record review the facility failed to ensure food items were labeled with a date when received/opened. These failures have the potential to affect all 88 residents residing in the facility. Findings include: On 7/26/26 at 10:30 AM the kitchen and food storage areas were toured with the assistance of V19, CDM (Certified Dietary Manager). Upon entering the walk-in cooler, several food items stored on the shelves had not been dated upon receiving/opening. Six packages of shredded cheese were on the shelf, two packages of the shredded cheese were not labeled with a received date. One package of shredded cheese had been opened and returned to the shelf without a date the item was opened. Five containers of cranberry juice were not labeled with a received date. One open container of cranberry juice was not labeled with the opened date. Four apple juice containers, three kiwi strawberry juice containers, four containers of orange juice, two containers of ice tea thickener, and one container of thickener water were not dated when received. One container of thickener water was opened and not labeled with the open date. Three containers of ham base were not labeled with received dates. One pork base container had been opened and was not labeled with the opened date. There was one box full of tomatoes not dated when received, eleven blueberry containers with no received date, one container of open blue berries with no date opened, eight strawberry containers with no received date and one container of strawberries was open with no opened date on on the box. On 7/26/26 at 11:00 AM V19,CDM (Certified Dietary Manager) stated The staff working on Friday night (7/17/26) put the items from the truck away and I guess they are the ones who should dated the items before putting them on the shelf. We follow our Food Delivery policies. The facility policy titled Food Storage (Dry, Refrigerated and Frozen) dated 2016 documents :General storage guidelines to be followed:1. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded.The facility's undated policy titled Delivery Guidelines states All perishable food items shall be promptly covered, labeled, and stored in the refrigerator or freezer.The Long Term Care Facility Application for Medicare and Medicaid form dated 7/28/26 documents 88 residents reside in the facility.

Based on observation, interview, and record review the facility failed to use required personal protective equipment during the transfer of a resident on contact isolation and failed to prevented cross contamination during incontinence care and urinary catheter care for three of four residents (R26, R68, R76) reviewed for infection control on the sample list of 39. Findings Include: 1. R26's Physician Order dated June 2025 documents R26 is to be on contact isolation related to Methicillin-Resistant Staphylococcus Aureus (MRSA) of the foot. On 6/17/25 at 8:45 AM V8 Certified Nurse's Assistant (CNA) and V18 CNA transferred R26 using a full mechanical lift. R26 was on contact isolation for Methicillin-Resistant Staphylococcus Aureus (MRSA) of the right foot. Neither V8 nor V18 wore gowns during the transfer. On 6/17/25 at 9:00 AM V2 Director of Nurses confirmed R26 is on contact isolation related to MRSA of his foot and both V8 and V18 should have been wearing both gloves and gowns during the transfer. The undated Contact Precautions sign posted on R26's door documents staff must put on gloves and a gown before entering the R26's room. 2. The facility's Diarrhea and Fecal Incontinence policy dated September 2010 documents residents must be cleaned after each episode of incontinence. Disposable items soiled with feces must be handled to prevent contamination of the environment with feces. R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68 has some cognitive impairment, uses a wheelchair, is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene and transfers. R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown related to physical debility and urinary incontinence. On 6/16/25 at 11:05 AM R68's room has a strong foul odor. On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast. R68 stated she cannot control her bowels, but she always must go after she eats. R68 stated she had diarrhea after breakfast and has been sitting in it ever since. R68 stated the diarrhea has moved up into her perineal area and on her stomach and up her back. R68 stated her bottom is very painful and feels like it is on fire. On 6/16/25 at 11:13 AM both V8 CNA and V9 CNA entered R68's room with the mechanical lift and began to assist R68 in getting cleaned up. V9 donned gloves and used disposable perineal wipes to clean the bowel movement from R68's perineal area. After cleaning the perineal area, V9 used the same soiled gloves to assist R68 in turning on her side, V9 touched R68's thigh and gown. V9 then preceded to use disposable wipes to clean the bowel movement on R68's bottom. Once cleaned, V9 continue to use the same soiled gloves and touched R68's leg, arm, and clean incontinence brief. At that point, V9 CNA removed her soiled gloves and put on clean gloves however did not clean hands at all in between. On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant confirmed she should have changed her gloves after cleaning R68's perineal area and washed her hands or used sanitizer between glove changes. V9 confirmed she should not have touched R68's arm, leg, clothes, and clean incontinence brief with soiled gloves. 3. The Electronic Medical Record under the section Medical Diagnoses dated 6/17/25 documents the primary diagnoses for R76 are Chronic Lymphocytic Leukemia of B-CELL type not having achieved remission and secondary diagnosis for R76 is Infection and Inflammatory Reaction due to indwelling urethral catheter, subsequent encounter and Urinary Tract Infection. V18, CNA (Certified Nurse Assistant) performed incontinence care for R76 on 6/17/25 at 2:03 PM. V18 washed her hands and placed gloves on. V18 had positioned R76 to do care and R76 had a bowel movement. V18 with the same pair of gloves on touched R76 and positioned him on his side facing the wall so V18 could clean his buttocks area, V18 also pulled the privacy curtain, touch R76's personal items to find disposable wipes, picked up the disposable wipes and placed on end of the bed and V18 also placed a plastic bag on the end of the bed for trash. With the same pair of gloves V18 cleaned R76's buttock's area in order for R76 to be free of bowel movement. V18 then went and picked up a disposable pad and a clean depends with the same gloves on and placed the pad under R76 and positioned the depends next to V18's buttock's area. V 18 then reposition R76 on his back to position him for catheter care. V18 then removed the gloves and put a new pair of gloves on to perform catheter care without washing or sanitizing her hands. V18 started catheter care for R76, when V18 completed cleaning the shaft of the penis V18 cleaned under the scrotum sack with the same washcloth and not changing the area of the cloth. V18 took a clean washcloth to clean the catheter tubing and went over the catheter tubing twice with the same area of the washcloth and only cleaned about 4 inches of the catheter tubing. V18 stated upon completion of the catheter care on 6/17/25 at 2:25 PM, I should of changed gloves before I even started to clean R76 up, did not realize I had touched so many things. I did not realize I went over the catheter tubing twice with the same area of the cloth, I thought I flipped the cloth. The facility's policy titled Catheter Care, Urinary with the revision date of 06/2023 documents under #16 and #17: 16. For a male resident: Use a washcloth with warm water to cleanse the meatus. Cleanse the glans using circular stokes from the meatus outward. Change the position of the washcloth with each cleansing stroke. With a clean washcloth, rinse with warm water using the above technique. Return foreskin to normal position. 17. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to end of catheter tubing.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to label insulin, eye drops, and nose spray containers with the date opened for three of eighteen residents (R24, R33, R46) reviewed for medication administration on a sample list of 39. B. Based on observation, interview, and record review the facility failed to discard expired insulin for two of eighteen residents (R3, R68) reviewed for medication administration on a sample list of 39. Findings include: a. The facility's Storage of Medications Policy dated 2023 documents that all injectable medications, eye drops, nose spray, ear drops, liquid medications shall be labeled with date upon opening containers. R24's Medication Administration Record (MAR) dated [DATE] documents R24 is receiving Fluticasone Propionate nose spray. R33's MAR dated [DATE] documents R33 is receiving Dorzolamide HCl-Timolol eye drops. R46's MAR dated [DATE] documents R46 is receiving Lantus insulin. On [DATE] between 3:18 PM and 3:50 PM, the Team One and Team Three medication carts were observed. R24's bottle of nose spray (Fluticasone) was open and did not have an open date on the bottle. R33's bottle of eye drops (Dorzolamide HCL/Timolol) were open and did not have an open date on the bottle. R46's insulin vial (Lantus) was open and did not have an open date on the vial. On [DATE] at 3:28 PM, V2 Director of Nursing (DON) stated insulin, eye drops, and nasal spray should have the opened date on the container. On [DATE] at 3:42 PM, V6 Licensed Practical Nurse (LPN) stated insulin, eye drops, and nose sprays should be labeled with the date when opened. b. The facility's Storage of Medications Policy dated 2023 documents the facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. R3's Medication Administration Record (MAR) dated [DATE] documents R3 is receiving Admelog insulin. R68's MAR dated [DATE] documents R68 is receiving Lantus insulin. On [DATE] between 3:18 PM and 3:50 PM, Team One and Team Three medication carts were observed. R3's insulin (Admelog) vial had an open date of [DATE] and an expiration date of [DATE]. R68's insulin (Lantus) vial had an open date of [DATE] and instructions to discard after 28 days. On [DATE] at 11:11 AM, V2 Director of Nursing stated the expired insulins should have been destroyed by the nursing staff.

Based on observation, interview, and record review the facility failed to maintain call lights within reach for one of one resident (R68) reviewed for call lights on the sample list of 39. Findings Include: The facility's Call Light Policy dated October 2010 documents when residents are in bed or confined to a chair staff are to make sure the call light is within easy reach of the resident. R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68 has some cognitive impairment, uses a wheelchair, is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene and transfers. R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown, is legally blind, and staff are to place the call light within easy reach, place frequently used personal items within easy reach and respond to requests for assistance promptly. R68 is at risk for neglect and staff should ensure all needs are met while maintaining dignity and quality of life. On 6/16/25 at 11:05 AM R68's room has a strong foul odor. R68's call light is not within her reach. R68 is sitting in her wheelchair and the call light is behind her wheelchair and attached to the side of the bed under the covers. On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast. On 6/16/25 at 11:10 AM V8 Certified Nurse's Assistant (CNA) was called into the room and confirmed R68's call light was not within her reach. V8 apologized and stated she would return with the mechanical lift and another staff member to assist in getting R68 cleaned up. V8 confirmed call lights should be secured within reach of the residents and resident needs are to be addressed promptly. On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant (CNA) stated if R68 had been given her call light then she would have used it when she felt the need to have a bowel movement. V9 stated R68 is quick to use her call light because she doesn't like to sit in her soiled brief. V9 confirmed she could tell R68 was very upset and she shouldn't have been made to sit in a soiled incontinence brief for so long.

Based on record review and interview, the facility failed to provide a notice of bed hold to a resident being discharged to a local hospital. This failure affects one resident (R11) out of one reviewed for hospitalization on the sample list of 39. Findings include: R11's Census Detail dated 6/18/25 documents R11 was hospitalized starting on 8/20/24 through 8/26/24. R11's comprehensive Electronic Medical Record did not contain a notice of bed hold provided to R11. On 6/17/25 at 9:17 AM, R11 stated she had been to the hospital several times for various reasons. R11 further stated she did not remember anyone telling her anything about being able to come back to the facility nor that the facility would hold a bed for her. R11's Minimum Data Set, dated [DATE] documents R11 received a score of 15 out of a possible 15 during a Brief Interview for Mental Status indicating R11 is cognitively intact and without memory recall problems. On 6/17/25 at 3:50 PM, V3, Administrative Assistant, stated there was not a bed hold notice for R11 from the 8/20/25 hospitalization.

Based on interview and record review, the facility failed to transmit minimum data set resident assessments for significant change in status, and discharge, in the required time frame. These failures affect one resident (R5) out of one reviewed for minimum data set transmissions on the sample list of 39. Findings include: R5's Minimum Data Set for significant change in status dated as completed 5/16/25 did not document any transmitted or accepted date. R5's Minimum Data Set for discharge with return anticipated, likewise dated as completed 5/16/25, did not document any transmitted or accepted date. The Centers for Medicare and Medicaid Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2024 documents these minimum data sets for R5 are required to be transmitted within 14 days of the completion date. On 6/17/25 at 1:58 PM, V5, Minimum Data Set Assistant, stated he was not sure about the timing requirements for the Minimum Data Sets as he was new to his position. On 6/17/25 at 2:00 PM, V19, Dementia Unit Coordinator/ Dementia Unit Minimum Data Set Coordinator, stated in general a facility has 14 days to complete a resident's Minimum Data Set and another 7 days to transmit. V19 stated R5's Minimum Data Sets should have been transmitted before today (6/17/25). V19 further stated the computer system is supposed to select all of the Minimum Data Sets that have been completed since the previous transmission and transmit them all in one batch. V19 reviewed the batch reports for transmitted Minimum Data Sets from 5/11/25 through 5/20/25 and stated neither of R5's Minimum Data Sets were transmitted. On 6/17/25 at 2:10 PM, V4, Assistant Director of Nursing, stated the Minimum Data Sets are transmitted through a computer system (IQIES) operated from the Centers for Medicare and Medicaid Services. V4 continued to state that someone at the facility needed to manually designate on their computer that R5's Minimum Data Sets were ready to be transmitted so their computer would transmit the Minimum Data Sets, and no one had designated R5's Minimum Data Sets as ready to be transmitted. On 6/17/25 at 2:16 PM, V2, Director of Nursing/ Minimum Data Set Coordinator, examined her computer screen and stated R5's Minimum Data Sets should have been transmitted by now (6/17/25). V2 further stated she would need to do a correction on R5's Minimum Data Sets and get them transmitted. V2 stated it was facility staff who made an error by not designating R5's Minimum Data Sets as ready to be transmitted. V2 concluded by stating that generally there is a pattern for transmitting the Minimum Data Sets where a facility has 7 days from the assessment reference date to do the physical assessment of the resident, another 7 days to encode the Minimum Data Set, and another 7 days to transmit the Minimum Data Set.

Based on observation, interview, and record review the facility failed to maintain dignified quality of life for one of one resident (R68) reviewed for dignity on the sample list of 39. Findings Include: The facility's Quality of Life - Dignity policy revised in 2024 documents each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Staff should always treat resident with respect and dignity. Treating with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Demeaning practices and standards of care that compromise dignity are prohibited. Staff should promote dignity and assist residents as needed by promptly responding to a resident's request for toileting assistance (incontinence care). R68's Medical Diagnoses List dated June 2025 documents R68 is diagnosed with Diarrhea, Legal Blindness, Age-related physical debility, and Depression. R68's Minimum Data Set, dated [DATE] documents R68 has some cognitive impairment, uses a wheelchair, is always incontinent of bowel and bladder, and is dependent on staff for toileting hygiene and transfers. R68's Care Plan dated 9/25/24 documents R68 is at risk for skin breakdown, is legally blind, and staff are to place the call light within easy reach, place frequently used personal items within easy reach and respond to requests for assistance promptly. R68 is at risk for neglect and staff should ensure all needs are met while maintaining dignity and quality of life. On 6/16/25 at 11:05 AM R68's room has a strong foul odor. R68's call light is not within her reach. R68 is sitting in her wheelchair and the call light is behind her wheelchair and attached to the side of the bed under the covers. On 6/16/25 at 11:05 AM R68 stated she did not know where the call light was but had been looking for it because she has been needing to be changed for a long time and is very uncomfortable and in pain. R68 stated she is partially blind. R68 stated her bottom is burning from diarrhea and she has been sitting in it since shortly after breakfast. R68 stated she cannot control her bowels, but she always has to go after she eats. R68 stated she had diarrhea after breakfast and has been sitting in it ever since. R68 stated the diarrhea has moved up into her perineal area and on her stomach and up her back. R68 stated her bottom is very painful and feels like it is on fire. R68 stated she is very angry and upset with the situation and can't believe that staff left her in her room without her call light. R68 stated if she had her call light, she would've called staff when she knew she was having the bowel movement so they could change her quickly, so she did not have to sit in it. R68 stated she must be lifted with the full mechanical lift to get into bed and she cannot move her wheelchair on her own. R68 stated she hurts so bad and just wants to be cleaned up and not feel so gross. R68 stated the situation is horrible and she feels disgusting. On 6/16/25 at 11:10 AM V8 Certified Nurse's Assistant (CNA) was called into the room and confirmed R68's call light was not within her reach. V8 apologized and stated she would return with the mechanical lift and another staff member to assist in getting R68 cleaned up. V8 confirmed call lights should be secured within reach of the residents and resident needs are to be addressed promptly. On 6/16/25 at 11:13 AM both V8 CNA and V9 CNA entered R68's room with the mechanical lift and began to assist R68 in getting cleaned up. During cleaning, R68 jerked in pain and yelled out for V9 to be easy because her bottom is burning. R68's bottom was very dark red in appearance. On 6/16/25 at 11:30 AM V9 Certified Nurse's Assistant stated if R68 had been given her call light then she would have used it when she felt the need to have a bowel movement. V9 stated R68 is quick to use her call light because she doesn't like to sit in her soiled brief. V9 confirmed she could tell R68 was very upset and she shouldn't have been made to sit in a soiled incontinence brief for so long.

Based on interview and record review the facility failed to prevent an injury by failing to ensure a bed was in a low position for one (R1) of three residents reviewed for falls on the sample list of three. This failure resulted in R1 sustaining a laceration to the right forearm, a hematoma, and spinal fracture which required emergency medical treatment. Findings include: The facility's Managing Falls and Fall Risk Policy with a revision date of 12/2021 documents that staff will identify and implement relevant interventions to try to minimize serious consequences of falling. R1's Care Plan initiated on 9/3/2019 documents that R1 was at risk for injury related to mobility status. This Care Plan documents that R1 has a history of skin tears, bruises, and a history of falls. This Care Plan documents an intervention for the bed to be in the lowest, most appropriate position when resident is resting in bed. R1's Incident report dated 4/14/2025 documents R1 was found on the floor next to the bed at 10:40 PM by V9, Certified Nurse's Assistant. This report documents R1 had large laceration to the right forearm and a large hematoma (bruised knot) to the right forehead. R1 was sent to the emergency room for evaluation. This report documents V6, Licensed Practical Nurse found that R1's bed was not in the low position stated in the Care Plan. R1's emergency room summary dated 4/15/2025 documents that R1 had a fall out of bed that resulted in broken bones to R1's spine and a contusion on R1's forehead. This report documents R1 required pain medication (Norco) to relieve R1's pain from the injuries. On 5/5/2025 at 1:37 PM, V9 stated he was doing his 10 PM resident checks and walked into R1's room and saw her on the floor and immediately went and got the nurse. V9 stated R1's bed was in the high position when he found R1 on the floor which isn't facility protocol. V9 stated that he was 6 foot tall, and the bed was at his hip level. V9 stated he went and got V6 for help. On 5/5/2025 at 11:37 AM, V6 stated on 4/14/25 around 10:40 PM, V9 came and told me that R1 was lying on the floor. V6 stated when she walked into the room, R1 was laying on the floor next to the bed. V6 stated that she noticed R1 had a pretty good-sized goose egg on her head from falling out of bed. The goose egg was the size of a fist. V6 stated she called 911 and kept R1 on the floor in the same position. V6 stated that the bed was not in the low position and that it was up higher than she thought it should be. V6 stated that R1's bed was at her waist level, and she is 5 foot 5 inches tall. On 5/5/25 at 2:13 PM, V2 Director of Nursing stated R1's intervention of a low bed was put into place upon admission (9/13/2019) to reduce her risk of injury if she were to fall out of bed. On 5/5/2025 at 2:51 PM, V10 (R1's Nurse Practitioner) stated she saw R1 in the facility after the fall with injury. V10 stated R1 had bruising to her face. V10 stated R1's injuries were a result of her fall on 4/14/25. V10 stated that if the bed was in a lower position at the time of the fall R1's injuries would not have as bad.

Based on the interview and record review, the facility failed to provide safe and effective supervision during a total body mechanical lift transfer to prevent a traumatic fall. This failure resulted in R1 falling from R1's transfer sling, striking R1's head on an adjacent bedside table, and landing on the floor, resulting in a collarbone fracture and scalp laceration requiring emergency medical treatment at the hospital. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list dated 2/6/25 documents R1's diagnoses include: Neuropathy, Left Knee Pain, Hyperlipidemia, Arthritis, Anxiety, and Depression. R1's Minimum Data Set (MDS) dated [DATE] documents R1 has severely impaired cognition and is totally dependent on staff for transfers. On 2/10/2025 at 09:50 AM, V4 Certified Nursing Assistant (CNA) and V5 Certified Nursing Assistant reported R1's transfer is supposed to be completed by two staff members using the total body mechanical lift. On 2/10/25 at 12:13 PM V8 CNA stated that (on 1/5/25) V8 was behind the total body mechanical lift, using the remote and lifted R1 from the bed while V7 CNA was at R1's wheelchair, and V8 began moving R1 from over the bed to towards the wheelchair. V8 stated V8 heard a click, the left clip of the sling near the left shoulder came undone, and R1 fell from the sling, landing on the floor. V8 stated R1 yelled in pain, and V8 went to get the nurse. V8 stated no staff was near or supporting R1 while V8 was moving the lift. The facility incident report dated 1/13/2025 documents V7/V8 (Certified Nurse Aides) were providing a total body mechanical lift transfer for R1 on 1/5/2025 from the bed to the wheelchair. The same report documents V8 moved the total body mechanical lift after lifting R1 from the bed while V7 was adjusting the wheelchair, and the securing clip from the sling to the lift came undone, causing R1 to fall onto the floor and R1 was sent to the hospital emergency department for evaluation and treatment. The report does not document any other staff were present during V7/V8's transfer of R1 on 1/5/2025. The hospital report dated 1/5/2025 documents that facility staff reported R1 had a fall from the total body mechanical lift on 1/5/2025. The same record documents R1 sustained a left clavicle (collarbone) fracture and scalp laceration requiring staples as a result of the fall. The report documents R1 complained of pain while in the emergency department and received narcotic pain medication. The facility incident investigation dated 1/5/2025-1/13/2025 documents a signed witness statement from V7 (Certified Nurse Aide) describing R1's fall on 1/5/2025. V7's statement documents R1 was in the sling attached to the total body mechanical lift when V7 was behind R1's wheelchair adjusting linens, and R1 attempted to position R1's self after V8 moved R1 from over the bed and R1 fell from the lift onto R1's left side on the floor and was yelling in pain. V7 reportedly instructed for V8 to get the nurse. The facility incident investigation dated 1/5/2025-1/13/2025 documents a signed witness statement from V8 (Certified Nurse Aide) describing R1's fall on 1/5/2025. V8's statement documents R1 was in the sling attached to the total body mechanical lift when V8 moved R1 away from the bed and R1 adjusted R1's self. V8 documents hearing a click, and R1 fell from the sling. V8 documents are going to get the nurse after the fall. The report dated 1/5/25 documents V11 Licensed Practical Nurse being called to the room per CNA. The report documents R1 laying on the floor on his stomach, with bleeding noted from the left side of R1's head. The report documents R1 complained of pain to the left hand which he was laying on. The report documents R1 was being transferred per mechanical lift, and R1 was unable to give a description of the incident due to pain. The report documents R1 complained of left hand/arm pain and an ambulance was called to transport R1 to the hospital. The facility In-Service attendance roster dated 1/6/2025 documents facility nursing staff received training to use two staff for total body mechanical lift and procedures. On 2/10/25 at 1:28PM V9 Restorative CNA provided a document that states all new hires are trained immediately upon hire that two staff assist with all lift transfers. One staff to manage the lift and one staff to support the resident hands on. On 2/6/25 at 09:45 AM V1 Administrator provided a policy titled Lift Machine, Using a Mechanical dated 2001, with revision dates 2017 and 1/2025. Line One documents that at least two trained staff are needed to safely move a resident with a mechanical lift. Line Twelve documents to gently support the resident as she/he is moved.

Based on observation, interview, and record review the facility failed to report repetitive instances of verbal and physical abuse of a resident (R45) by V13 Certified Nurse's Assistant and failed to report a resident to resident physical altercation to the facility's Administrator. These failures resulted in V13 having continued access to R45 in which V13 provided direct cares and in the further instances of verbal and physical abuse of R45 by V13. As a result of this abuse R45's hands and chest were bruised and R45 displayed emotional symptoms of residual harm as evidenced by flinching(making sudden startled movements) and increased behaviors with cares. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. This failure has the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. These Failures resulted in an immediate jeopardy. The Immediate Jeopardy began on 1/9/24 when V16 Certified Nurse's Assistant failed to report an incident of abuse to V1 Administrator after witnessing V13 verbally abuse R45 during a shower. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: 1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. V16's Employee Termination Form dated 3/19/24 documents V13 was terminated on 3/13/24. This form documents that V16 verbally and physically abused R45 on 3/6/24 and physically abused R45 on 3/13/24 in which R45 was bruised. On 4/3/24 at 8:37 AM, V9 CNA stated V13 was verbally abusive to R45. V9 stated V9 did not report the abuse to V1 Administrator. V9 stated this occurred on 1/9/24. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45. V7 stated V7 did not report the abuse to V1 Administrator because she was scared of V13. On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/2/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch and she still does. V7 stated, I really feel like she still remembers and is now more combative. V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45. This statement documents V16 was afraid to say anything about the abuse V16 witnessed. On 4/3/24 at 12:00 PM, V1 Administrator stated V1 was not aware of the verbal and physical abuse of R45 by V13 that occurred on 1/9/24, 3/6/24, and 3/12/24 because the CNAs who witnessed the abuse did not report the abuse to him. V1 stated the abuse did occur and R45 was bruised as a result. The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/9/24, 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (24 shifts after the first instance of abuse occurred on 1/9/24). On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit. The facility's census sheet dated 4/1/24 documents R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32 reside on the Dementia unit. 2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back. R35's left thumb appeared a little bigger then the other. The facility's Abuse Report dated 4/5/24 documents V1 Administrator was made aware of an allegation of abuse on 4/1/24. This report documents upon investigation, R35 and R69 did have a physical altercation on the evening of 3/31/24. This report documents that the on-call nurse was notified but not V1, Administrator. On 4/4/24 at 9:41 AM, V1 Administrator stated there was an altercation between R35 and her room mate. V1 stated V1 was not immediately notified of the incident. The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance. 1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator. 2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office. 3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions. 4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care. 5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility. 6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse. 7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when residents becomes combative during cares. 8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures. 9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures. 10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24. 11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care. 12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care. The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11 PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM.

Based on observation, interview, and record review the facility failed to ensure the right to be free from physical and verbal abuse by staff. R45, who resides on the dementia unit, was subjected to physical and verbal abuse on three separate occasions by V13 Certified Nurse's Assistant. R45's hands and chest were bruised, R45 was fearful showing emotional symptoms following the incidents as evidenced by increased behaviors with cares, making more sudden abrupt startled movements when approached by caregivers. These failures affect one (R45) of six residents reviewed for abuse on the sample list of 47. This failure resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 1/9/24 when V13 Certified Nurse's Assistant verbally abused R45 during a shower, V13 was suspended from work 3/13/24. V1 Administrator was notified of the Immediate Jeopardy on 4/4/24 at 10:00 AM. The surveyor confirmed by interview and record review that the Immediate Jeopardy was removed on 4/4/24, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of their Removal plan and Quality Assurance monitoring. Findings include: R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. The facility's Allegation/Summary conclusion dated 3/19/24 documents on 3/13/24 at approximately 1:45 PM during a team meeting, V16 CNA (Certified Nurse's Assistant) made the comment to the group that V13, CNA was mean to (R45) and suggested that a bruise seen on (R45's) hand was from Where (V13) was holding her down. V7, CNA then added she witnessed an incident the week prior where V13 threatened R45 after R45 became aggressive during care. On 4/3/24 at 8:37 AM, V9 CNA stated V13's tone was very aggressive with the residents. A couple months ago, on 1/9/24, I was giving R45 a shower. R45 was becoming combative so I asked V13 for help. R45 made a noise and then said, oh poo. V9 stated V13 then got in R45's face and meanly said, Oh Poo! back to R45 and then hissed like a snake in R45's face very aggressively. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 CNA and I went into R45's room. V7 stated they were transferring her to bed and changing her. V7 stated they were talking to R45 and we were trying to get R45's shirt off but it wasn't working and she was tensed up. V7 stated V13 then tried to force her to take the shirt off without saying anything. V7 stated this caused R45 to try to fight her and R45 began to punch and scratch V13. V7 stated V13 then grabbed both of R45's wrists and pinned them against her chest and got face to face to R45 and was touching nose to nose and said, I will snap your wrists if you wont's let us get you to bed. I will snap your legs. V7 stated they then hooked her up to the mechanical lift and got R45 in the bed. V7 stated V7 took R45's pants off. V7 stated as they were trying to change R45, V13 kept pinning R45's arms to her chest. V7 stated once they were done V13 took a blanket and threw it on her (R45). On 4/3/24 at 8:33 AM, V7 CNA stated after the 3/6/24 incident with V13, R45 was scared. V7 stated during the incident R45 appeared scared, her eyes were great big. V7 stated after that, during cares R45 would flinch (making sudden startled movements) and she still does. V7 stated, I really feel like she still remembers and is now more combative. V16's undated witness statement documents on 3/12/23, V16 CNA was helping V13 CNA with getting R45 up. R45 was hitting at V16's face and V13 then pinned R45's arms to her chest and said stop hitting or I will break your arms. Attempts were made to contact V16 for interview, however V16 was unable to be reached. The facility's census sheet dated 4/1/24 documents R45 resides on the Dementia unit. The facility's daily staffing sheet documents V13 worked on the Dementia unit on 25 occasions between 1/9/24 and 3/12/24. V13's Employee Termination Form dated 3/19/24 documents, On March 6th (2024), (V13) verbally abused a resident (R45) by using profanity and physically threatened her during care. and On March 13th (V13) held the same resident's hands down hard enough to bruise her hand and wrist, as well as leaving a small bruise on the resident's chest. She also cursed and threatened the resident during this incident. On 4/3/24 at 12:00 PM, V1 Administrator stated V13 was terminated for the physical and verbal abuse of V13. V1 stated V13 did have bruising as a result of this abuse. The Immediate Jeopardy that began on 1/9/24 was removed and the deficient practice corrected on 4/4/24 when the facility took the following actions to remove the Immediacy and correct the noncompliance: 1. On 3/13/24, V13 Certified Nurse's Assistant was suspended by V1 Administrator pending an investigation, V13 was terminated from employment on 3/19/24. On 3/22/24, V39 Unit Coordinator was also terminated from employment by V1 Administrator. 2. On 3/19/24, V1 Administrator reported the abuse to the county sheriff's office. 3. On 4/4/24, V2 Director of Nursing updated R45's care plan with new interventions. 4. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when R45 becomes combative during care. 5. On 4/3/24, V30 Social Service Director completed risk of abuse assessments on all residents in the facility. 6. On 4/4/24, V30 and V3 ADON updated care plans for the residents who were newly identified as at risk for abuse. 7. On 4/4/24, V2 inserviced the Nurses, CNAs, and activity staff on interventions for when residents becomes combative during cares. 8. On 3/13/24, V1 Administrator, V2 Director of Nursing, V30 Social Service Director re-evaluated the abuse policy and procedures. 9. On 3/13/24, 3/14/24, and 4/4/24, V26 Administrative Assistant and V40 Human Resource Specialist re-educated all staff on the facility protocol for reporting abuse, the types and signs of abuse, and the facility's abuse prevention policy and procedures. 10. On 3/14/24, V1 Administrator developed a quality assurance plan to ensure continuing education of all staff on facilities abuse reporting procedure, skills for identifying and preventing abuse, and how to manage an incident of abuse. This process began on 3/14/24, the audit has been completed weekly, on 3/21/24, 3/28/24 and 4/4/24. 11. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing CNA and Nurse education on interventions with residents who are combative or resistant with care. 12. On 4/4/24, V2 Director of Nursing developed a quality assurance plan to ensure continuing compliance with the updating of care plan interventions for residents who are combative with care. The facility presented an abatement plan to remove the immediacy on 4/4/24 at 2:11PM. The survey team reviewed the abatement plan and was unable to accept the plan to remove the immediacy. The abatement plan was returned to the facility for revisions on 4/4/24 at 2:41 PM. The facility presented a revised abatement plan on 4/4/24 and the survey team accepted the abatement plan on 4/4/24 at 4:07 PM.

Based on interview and record review, the facility failed to monitor and maintain Certified Nursing Assistant (CNA) required twelve hours of inservice training per year to ensure continued competence. This failure has the potential to affect all 82 residents residing in the facility on the sample list of 47. Findings include: V20's training record documents, V20's Continuing Education Hours completed for 2023 total 7.00 hours. V27's training record documents, V27's Continuing Education Hours completed for 2023 total 11.50 hours. V28's training record documents, V28's Continuing Education Hours completed for 2023 total 11.50 hours. On 4/04/24 at 10:15 AM, V2 Director of Nursing states V2 is aware of the required Certified Nursing Assistant (CNA) requirement of 12 hours of annual education. V2 indicates V15, Wound Nurse, is responsible for monitoring CNA education and informing those CNA's that are in need of completing education hours. V2 acknowledges V2 and V15 are aware that several CNA's do not have the required 12 continuing education hours for 2023. V2 confirmed V20, V27, and V28 training record documentation for 2023. The facility's Long Term Care Application for Medicare and Medicaid dated 4/1/24 signed by V1 Administrator documents there are 82 residents residing in the facility.

Based on observation, interview, and record review the facility failed to follow it's abuse prohibition policy by failing to report allegations of abuse to the facility Administrator and prevent further resident abuse. These failures affected three (R45, R35, and R69) of six residents reviewed for abuse on the sample list of 47. These failures have the potential to affect all 24 residents (R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32) residing on the Dementia unit. Findings include: The facility's Abuse Prohibition policy dated 8/22/16 documents all residents have the right to be free from verbal and physical abuse. This policy documents the definition of physical abuse as, the infliction of injury on a resident that occurs other than by accidental means. This policy documents the definition of verbal abuse as, the use by an employee or agent of oral, written or gestured language that includes disparaging and derogatory terms to a resident or within his or her hearing or seeing distance, regardless of the resident's age, ability to comprehend or disability. This policy also documents that, A facility employee or agent who becomes aware of alleged abuse or neglect of a resident shall immediately report the matter to the facility administrator. 1. R45's careplan dated 8/24/20 documents R45 has a diagnosis of Dementia with behavioral disturbance, Anxiety, and Chronic pain. This care plan documents R45 has a history of becoming combative with cares and has care planned interventions to stop care and re-approach when combative. On 4/3/24, R45's right hand had faded bruising between the pointer finger and thumb. V16's Employee Termination Form dated 3/19/24 documents V13 was terminated for verbally and physically abusing R45 on 3/6/24 and 3/12/24. On 4/3/24 at 8:37 AM, V9 Certified Nurse's Assistant (CNA) stated V13 was verbally abusive to R45 on 1/9/24 and she did not report it to V1, Administrator. On 4/2/24 at 3:21 PM, V7 CNA stated on 3/6/24 at 5:30 PM, V13 was physically and verbally abusive to R45 and that she did not report it to V1, Administrator. V16's undated witness statement documents on 3/12/23, V16 CNA witnessed V13 physically abuse R45 and documents V16 did not report it to V1, Administrator. On 4/3/24 at 12:00 PM, V1 Administrator stated V9, V7, nor V16 reported the verbal and physical abuse of R45 inflicted by V13 on 1/9/24, 3/6/24, and 3/12/24. V1 stated the Administrator is supposed to be notified immediately of all abuse allegations. The facility's staffing sheets document V13 worked on the Dementia unit on which R45 resides on 1/10/24, 1/15/24, 1/16/24, 1/18/24, 1/20/24, 1/21/24, 1/24/24, 1/30/24, 2/3/24, 2/4/24, 2/6/24, 2/7/24, 2/12/24, 2/13/24, 2/17/24, 2/21/24, 2/26/24, 2/27/24, 3/2/24, 3/3/24, 3/5/24, 3/6/24, 3/11/24, and 3/12/24 (16 shifts after the first instance of abuse occurred on 1/9/24). On 4/3/24 at 10:30 AM, V26 Administrative Assistant stated V13 works mostly on the Dementia unit and can provide care to all residents on this unit. The facility's census sheet dated 4/1/24 documents R66, R77, R70, R3, R47, R55, R20, R74, R9, R59, R76, R45, R62, R79, R19, R8, R35, R10, R69, R61, R5, R65, R36, and R32 reside on the Dementia unit. 2. On 4/01/24 at 9:30 AM, R35 stated someone bent her thumb back last night. The facility's Abuse Report dated 4/5/24 documents that on 3/31/24 there was a physical altercation between R35 and R69 and that V1 was not notified of this altercation until the next day. On 4/4/24 at 9:41 AM, V1 Administrator stated there was a physical altercation between R35 and R69 last night (3/31/24). V1 stated no one reported the altercation to him. V1 stated the Administrator is supposed to be notified immediately.

Based on interview and record review the facility failed to ensure the dignity of one (R57) of four residents reviewed for dignity in a sample list of 47 residents. Findings include: R57's Minimum Data Set (MDS) dated [DATE] documents R57 as cognitively intact. R57's Final Incident Report to the State Agency dated 4/3/24 documents R57 reported V19 Certified Nurse Aide (CNA) used the 'F' (expletive) word and it is offensive to women. On 4/1/24 at 10:00 AM, R57 stated, There is a male CNA (V19) that comes in my room and uses the 'F' (expletive) word like it is okay to say that. (V19) always brings in another female CNA in with him. (V19) says things like 'F*** (expletive) this and f*** (expletive) that' when he talks to the other CNA and when he talks to me. It is very disrespectful. First of all, I do not require two CNA's to help me with anything. Second of all, I do not allow the use of the 'F' (expletive) word from anyone. I have told (V19) not to say that but he continually does. On 4/3/24 at 10:30 AM, V1 Administrator stated V19 should not use profanity in front of any residents. V1 stated profanity should not be used in resident areas. On 4/4/24 at 12:00 PM, V19 Certified Nurse Aide (CNA) stated V19 was previously reprimanded for using foul language in front of residents and may have used expletives in the presence of R57. The facility policy titled 'Quality of Life-Dignity' revised August 2009 documents staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. Demeaning practices and standards of care that compromise dignity are prohibited.

Based on observation, interview, and record review the facility failed to provide access to a hand washing sink for two residents (R21, R12) of 18 residents reviewed for accommodation of needs in a sample list of 47. Findings Include: 1. R21's electronic health record diagnosis list, printed on 4/3/24 at 3:05 PM, documents the following diagnoses: Chronic Obstructive Pulmonary Disease, History of Falling, Right Knee Pain, Abnormal Gait and Mobility, Unsteadiness on Feet, Neuropathy, Muscle Weakness, and Anxiety Disorder. R21's Minimum Data Set, dated dated dated [DATE] documents R21 is cognitively intact and uses a wheelchair for mobility. On 4/2/24 at 4:00 PM, R21 stated I have to use the sit-to-stand lift to go to the toilet and it's tight in there, but we manage. I'd really like to use the sink to wash my hands and face, comb my hair and brush my teeth, I can't get my wheelchair anywhere close to the sink. I like to do as much as I can for myself. The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wide wheelchair. 2. R12's electronic health record diagnosis list printed on 4/4/24 includes the following diagnoses: Parkinson's Disease, Unsteadiness on Feet, and Abnormal Gait and Mobility. R12's Minimum Data Set (MDS) dated [DATE] documents R12 is cognitively intact and uses a walker and wheelchair for mobility. On 4/2/24 at 11:00 PM, R12 stated his room does not accommodate his needs as he uses a wheelchair and his bathroom is crowded and he can't get to the sink . The sink is observed to be between a wall and a cabinet and does not have enough space to roll a wheelchair under it. R21 is sitting in a wheelchair. On 4/4/24 at 11:00 AM, V1 Administrator confirmed there is not enough space to wheel a wheelchair up to the sinks in (R12 and R21's) rooms.

Based on observation, interview, and record review the facility failed to prevent falls by ensuring a residents personal safety alarm was in working order, using an inappropriate sized mattress on a residents bed and failed to ensure a residents fall interventions were in place. This failure affects three (R19, R35, and R27) of five residents reviewed for falls on the sample list of 47. Findings include: 1.) R19's nurse's notes written by V4 Licensed Practical Nurse dated 3/10/24 at 2:41 PM, documents R19 was found on the floor laying on her stomach. R19 was noted to have a contusion above the right eyebrow. R19 was sent to the emergency room for an evaluation. On 4/02/24 at 11:43 AM, V4 stated on 3/10/24 she had just got done with lunch and she heard someone say that someone was on the floor. V4 stated she ran out there and R19 was laying on the floor on her side and the right side of her face was bleeding. V4 stated she sent her our due to her being on a blood thinner. On 4/2/24 at 11:49 AM, V5 Activity Aide stated R19 fell around 12:45 PM, stated she was on the other side of the dining room. V5 stated R19's chair alarm did not sound. On 4/2/24 at 11:58 AM, V6 Certified Nursing Assistant (CNA) stated V6 entered the dining room after R19 fell and they found that her alarm was not sounding. On 4/2/24 at 12:00 PM, V7 CNA, stated upon entering the dining room after R19 fell the alarm was not sounding. The alarm was changed out after that. On 4/2/24 at 2:42 PM, V2 Director of Nursing stated on the day of her fall her chair alarm did not alarm. A kinked wire caused the malfunction. We used the alarm to notify us when she is getting up. 37813 2.) R35's Incident report dated 2/6/24 at 12:30 PM documents R35) was being turned by two CNA's (Certified Nurse's Aides) to right side in bed while providing care. The mattress fell out from under (R35) due to an incorrectly sized frame. The incident report also documents (R35's) bed frame was switched out by maintenance due to equipment needing repair. There is no documented injury to (R35). On 4/4/24 at 1:00 PM V2, Director of Nursing stated Maintenance took (R35's) Bariatric bed out for repair and put the Bariatric mattress on a regular bed. The mattress was too big and this caused a fall hazard. It was immediately corrected. 41970 3.) R27's undated Medical Diagnosis list documents R27's medical diagnoses as Dementia, Abnormalities of Gait and Mobility, Muscle Wasting and Atrophy, Osteoarthritis of Knee, Muscle Weakness, Difficulty in Walking and Heart Failure. R27's Minimum Data Set (MDS) dated [DATE] documents R27 as cognitively intact. This same MDS documents R27 depends on two staff member and a total body mechanical lift for transfers. R27's Care Plan interventions dated 11/22/23 documents R27 uses a bed alarm, a full mattress at bedside when in bed. This same careplan documents an intervention dated 12/13/22 that R27 utilizes a total body mechanical lift with two staff for transfers. R27's Fall Risk Assessment documents R27 as a high fall risk. R27's Nurse Progress Note dated 3/31/2024 at 2:13 AM documents (R27) is awake at 2:00 AM and has been seated near the nurses station since 10:00 PM (3/30/24) because she was attempting to get out of bed and needed closer supervision. R27's Nurse Progress Note dated 3/31/24 at 7:03 AM documents (R27) was placed in her bed and then changed by (V24) Certified Nurse Aide (CNA) around 4:20 AM this morning (3/31/24). Once (V24) CNA stepped out to grab the total body mechanical lift and seek assistance, (R27) rolled out of bed. (R27) was found on her Left side and it is unclear if she had hit her head or not since it happened while (V24) CNA momentarily stepped out of the room. R27's Fall Investigation dated 3/31/24 documents R27 was found on the floor of her room after being left alone momentarily on 3/31/24 at 4:40 AM. This same investigation documents (R27) was at the nurses station from 10:00 PM (3/30/31) to 4:20 AM (3/31/24) being supervised due to other attempt to get out of bed earlier in the evening (3/30/24). This same investigation documents R27's call light was within five to ten feet of R27 (at time of fall). This same investigation documents (R27) was placed in her bed, incontinence care was given by (V24) Certified Nurse Aide (CNA) around 4:20 AM on 3/31/24. Care was complete and (V24) CNA left the room to get a second assist for total body mechanical lift to get (R27) up in chair. When (V24) returned, (R27) was on the floor. (R27) stated she was trying to go home . (R27) was observed on her Left side next to the bedside table and it is unclear if she had hit her head. (R27) was confused and unable to determine if she hit her head. On 4/3/24 at 3:00 PM, V2 Director of Nurses (DON) stated (V24) was assisting R27 to get up for the day just prior to R27's fall. V2 stated R24 had a fall mat in place prior to her fall but V24 CNA removed the fall mat and then left R27's room to retrieve the total body mechanical lift to transfer R27 from her bed to her wheelchair. V2 DON stated The rooms are tight so it would be difficult to bring in the total body mechanical lift prior to removing the fall mat. V2 DON stated V24 CNA could have gotten another person to assist 'but we (facility) just don't have enough staff for that'.

Based on observation, interview, and record review the facility failed to support the appropriate use of psychopharmacologic medications for residents, failures include: completing residents' psychotropic medication assessments, determine the cause of residents' behaviors considering nonpharmacological interventions, providing parameters for the use of as needed (PRN) antianxiety medication, and providing a rational for duplicative therapy nor required gradual dose reductions for residents receiving psychotropic medications. These failures affects two (R19, R28) of six residents reviewed for psychotropic medication use on the sample list of 47. Findings include: The facility's psychotropic medication policy dated 03/2021 states, 2. The facility supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, medical, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. The facility supports the goal of determining the underlying cause of residents having difficulty sleeping so the appropriate treatment of environmental or medical interventions can be utilized prior to psychopharmacological medication use. 5. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. 1.) On 4/01/24 at 12:15 PM, during lunch meal, R19 was lethargic and tearful asking what is wrong with me? R19 was attempting to feed self but unsuccessful causing tearfulness. On 4/01/24 at 11:39 AM, V44 (R19's family member) stated she feels R19 is overmedicated and as a result, not eating well. V44 states R19 is sleeping all day and night. R19's PASSAR (Preadmission Screening and Resident Review) dated 2/28/24 documents there no Serious Mental Illness or Intellectual/Developmental Disability. R19's Electronic Medical Record documents R19 was admitted on [DATE] with the following diagnoses: Depression, Anxiety, Dementia without Behavioral Disturbance, Psychotic Disturbance, and Mood Disturbance. This Medical record documents R19 was admitted to the facility for treatment of a Urinary Tract Infection. R19's admission orders dated 2/29/24 documents an order for Escitalopram (antidepressant) 20 milligrams by mouth once daily for anxiety. R19's physician order dated 3/1/24 documents an order for Ativan 0.5 milligrams by mouth as needed every two hours PO as needed for anxiety/restlessness. This order does not include parameters or nonpharmacological interventions that should be utilized prior to it's use. R19's medical record does not include a psychotropic assessment or that an attempt was made to determine the underlying cause for R19's behaviors for the use of the Escitalopram or Ativan. R19's physician's order dated 3/3/24 documents an order for Risperidone 0.25 milligrams every morning for anxiety. R19's psychotropic medication assessment dated [DATE] does not include what nonpharmacological interventions were attempted prior to ordering the Risperidone. R19's physician order dated 3/21/24 documents an order for Trazodone (antidepressant) 25 milligrams by mouth every night for depression. R19's medical record does not include a psychotropic medications assessment for the use of the Trazodone or a rational for the duplicative therapy for the use of the Escitalopram and Trazodone. On 4/02/24 at 1:50 PM, V2 Director of Nursing stated that a psychotropic medications assessment was not completed when R19 admitted to the facility or after the Trazodone was added. V2 stated there are no parameters listed for the use of the Ativan. V2 stated there is no documentation of what nonpharmacological interventions were attempted prior to the use of the psychotropic medications. V2 stated there is no explanation for the duplicative therapy for the antidepressants. 41970 2.) R28's undated Face Sheet documents R28 admitted to facility on 12/10/2018. R28's Minimum Data Set (MDS) dated [DATE] documents R28 is moderately cognitively impaired. R28's Physician Order Sheet (POS) dated April 2024 documents R28's medical diagnosis as Huntington's Disease, Bipolar Disease, Anxiety Disorders and Dysphagia. This same POS documents a physician order starting 1/26/21 with no end date listed for Bupropion Hydrochloride (HCL) Extended Release (ER) 100 milligrams (mg) twice daily for Depression. This same POS documents a physician order starting 7/15/23 with no end date for Risperidone 1 milligram (mg) daily for Huntington's Disease and a separate physician order starting 7/14/23 with no end dated for Risperidone 2 milligrams (mg) daily for Huntington's Disease. This same POS documents a physician order starting 8/7/21 with no end date for Trazodone 25 milligrams (mg) daily for Insomnia. R28's Note to Attending Physician/Prescriber dated 8/2/23 documents (R28) has been receiving Trazodone 25 milligrams (mg) once daily for Insomnia since 11/2019. Dose reduction attempts should be made for sedative/hypnotic medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS). R28's Note to Attending Physician/Prescriber dated 9/6/23 documents (R28) has been receiving Bupropion Sustained Release (SR) 100 milligrams (mg) twice daily for Depression since it was increased 1/2021. Dose reduction attempts should be made for anti-depressant medications at least twice in the first year and then yearly to ensure drug effectiveness with minimal side effects. This same report documents V33 Physician responded by checking a pre-printed response of Condition is not well controlled. Documentation of the specific clinical rational for your declination is required per Centers For Medicare and Medicaid Services (CMS). The facility was unable to provide documentation of R28's pharmacy recommendation for a gradual dose reduction. On 4/2/24 at 1:00 PM V2 Director of Nurses stated the facility is supposed to attempt to reduce the dosage of Psychotropic medications. V2 DON stated the facility is unable to provide documentation of any reduction attempts for R28. V2 DON stated the facility discussed this problem at the last Quality Assurance Improvement Plan (QAPI) meeting in March. V2 DON stated We (facility) knew this was a problem, we just had not come up with a plan to try to fix this problem yet.

Based on interview and record review the facility failed to implement antibiotic stewardship practice for residents by ordering prophylactic antibiotics. This failure affects two residents (R60, R35) reviewed for antibiotic stewardship on the sample list of 47. Findings Include: R35's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Tablet 250 MG (Cephalexin) Give 1 tablet by mouth one time a day for Urinary Tract Infection. This order is documented as initiated 6/17/23 and has been given continually since that date. R35's March Medication Administration Record (MAR) documents (R35) was given Macrobid Oral Capsule 100 MG 1 capsule by mouth two times a day related to Urinary Tract Infection from 3/3/24 to 3/21/24 . There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R35) has been given these antibiotics. There is no documentation to support (R35) has a physician's order to be evaluated by a Urologist the entire time (R35) has been given these antibiotics. R60's Physician's Order Summary dated 4/3/24 includes a physician's order for Cephalexin Oral Capsule 250 MG (Cephalexin) Give 1 capsule by mouth one time a day related to personal history of Urinary Tract Infections. This medication has been given continually since 6/22/23. There is no documentation to support a Urine Culture and Sensitivity has been performed in the entire time (R60) has been given this antibiotic. There is no documentation to support (R60) has a physician's order to be evaluated by a Urologist the entire time (R60) has been given this antibiotics. There is no documentation to support the physician ordering antibiotics for R60 nor R35 has been consulted as to the efficacy of prolonged antibiotic therapy without culture and sensitivity. On 4/3/24 at 3:30PM V2, Director of Nursing stated the Medical Director orders prophylactic antibiotics and I am aware of the guidelines, but we have to follow his orders. The facility's Antibiotic Stewardship policy dated 1/19/19 states Antibiotic usage and outcome data will be collected and documented using a facility approved surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility wide Antibiotic Stewardship through the Quality Assurance Process.

Based on observation, interview and record review the facility failed to properly perform and complete catheter care, and maintain urinary drainage collection chambers off of the floor. The facility also failed to treat and complete physician ordered recommendations after the development of a penile wound for two of three residents (R53 and R52) reviewed for indwelling catheter use on the total sample list of 39. This failure resulted in R53's penile wound worsening and becoming split from the urethral opening to the scrotal sac area. Findings include: 1) R53's medical record documents the following diagnosis: Retention of Urine, Benign Prostatic Hyperplasia without lower Urinary Tract Symptoms. On 5/8/23 at 1:26 PM R53's urinary drainage collection chamber bag was laying on the floor at the end of the bed. R53's medical record did not contain a comprehensive care plan for the use of an indwelling urinary drainage device or a comprehensive care plan after the development of the wound to R53's penis. R53's medical record documents on 2/8/23, (V10 Wound Physician) here on 2/6/23 to assess wounds. Resident has a urethral split to penis due to foley. Area measures 1x0.5cm with light serous drainage. 10% devitalized tissue, 90% subcutaneous noted. Will apply petroleum jelly to area daily, V10 recommends an urology consult. (V7 Physician) notified, states to continue to monitor. R53's Wound Evaluation and Management summary completed by V10 Wound Physician documents, on 2/6/23, NON - PRESSURE WOUND PENIS FULL THICKNESS, Etiology - Trauma/Injury Duration less than 1 day, Wound Size (L x W x D): 1 x 0.5 x 0 cm, Surface Area: 0.50 cm^2, Exudate: Light Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ) DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 30 days, PLAN OF CARE REVIEWED AND ADDRESSED, Recommendations: Urology consult. Chronic stable wound with insignificant amount of necrotic tissue and no signs of infection. Monitor closely for now. R53's Wound Evaluation and Management summary dated 2/13/23, completed by V10 documents Non-Pressure Wound Penis, Full Thickness, Etiology: Trauma/Injury, Wound Size: 1 x 0.5 x 0 cm. Periwound radius: turbid exudate, Exudate: Moderate Serous, Thick adherent devitalized necrotic tissue: 10 %, Other viable tissues: 90 % (SubQ) (subcutaneous), Wound progress: Deteriorated, DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's physician order summary documents, Petrolatum Gel (White Petrolatum), Apply to HEAD OF PENIS topically every night shift for urethral split, start date: 2/8/23, discontinue date: 2/14/23. R53's Treatment Administration Records dated February 2023 documents the completion of physician ordered treatment of Petrolatum Gel from 2/8/23 through 2/14/23. R53's medical record documents on 2/16/2023 at 2:53 PM, by V5 Physician, Examined residents penis - due to long term foley placement, the urethral opening has elongated and eroded inferlaterally. There also appears to be either a growth on distal posterior foreskin or simple hypertrophy - hard to tell. Have given ok for urology referral. R53's Wound Evaluation and Management summary's, completed by V10, dated 2/20/23, 2/27/23, 3/13/23, 3/20/23, 3/27/23 document: Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's medical record did not document the initiation or completion of physician ordered recommendation of Petroleum jelly apply once daily from 2/20/23 through 5/7/23. R53's medical record documents on 4/7/23 at 1:17 PM, Resident unable to go to urology appointment related to unable to fit in the van in chair. (V7) notified that resident's chair will not fit in transport van, Resident had previously used a wheelchair with a high back and had issues with sliding out and leaning to the side. (V7) asked staff to cancel the appointment for resident. R53's Wound Evaluation and Management summary's, completed by V10, dated: 4/10/23, 4/24/23 and 5/1/23, documents Non Pressure Wound Penis, Full Thickness, Etiology (quality) Trauma/Injury, Wound Size (L x W x D): 1 x 0.5 x 0 cm. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. R53's medical record did not document R53's physician recommended Urology appointment was rescheduled after the cancellation of R53's urology appointment on 4/7/23. R53's medical record documents on 5/8/2023 at 3:21 PM, V3 Registered Nurse wrote to V7 Physician (V10 Wound Physician) recommended a urology consult for penile wound, (R53) was unable to go in the van in current wheelchair. (V10) is still concerned and wants you to take a look at wound or allow him to go to urologist if we can find him a wheelchair he can go in. Please advise. V7 responded on 5/8/23 at 5:03 PM, (R53) really needs to see urology. R53's medical record documents on 5/8/23 at 9:47 PM, V12 Registered Nurse wrote to V7 Physician, Resident's Foley catheter has been changed 3 times in one week for non-patency. Current Foley size is 18Fr, may we increase to 20Fr? Resident may also benefit from a suprapubic catheter as the shaft of the penis is torn all the way to his scrotum. R53's Wound Evaluation and Management Summary dated 5/8/23 completed by V10 documents, NON - PRESSURE WOUND PENIS FULL THICKNESS, Etiology (quality) Trauma/Injury, Duration > 83 days, Wound Size (L x W x D): 2 x 0.5 x 0.05 cm, Surface Area: 1.00 cm^2, Exudate: Light Serous, Other viable tissues: 100 % (SubQ), Wound progress: Deteriorated. DRESSING TREATMENT PLAN: Primary Dressing(s): Petroleum jelly apply once daily for 23 days, PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Urology consult. On 5/09/23 at 10:45 AM V3 Registered Nurse stated, I just returned from (medical leave), (R53) developed the (penis wound) when I was off, (R53) had a urology appointment but the wheelchair wouldn't work in the van so it was cancelled. (V10 Wound Physician) wants (R53) to see a urologist, (R53) needs a urethral splint. (R53's) catheter caused the wound. On 5/09/23 at 1:10 PM V3 RN stated, I found out (R53) admitted to us in January 2023 and from taking a look at the record, (R53) had catheter issues at the other nursing facility he came from, we did not document that we identified the (penile wound) until February 2023. V3 stated, I think the April Urologist appointment was the first appointment that was available for (R53), I was not able to find any further documentation that the appointment has been rescheduled or if (V10) was notified. I saw the order for the Petroleum jelly was stopped on 2/14/23, I have no idea why. On 5/9/23 at 1:15 PM during wound care observations, R53's penis was fillet opened from the tip of the urethral opening down to the scrotum. The wound bed had light pink tissue. When asked R53's if the penile wound was sore (causing pain), R53 replied yes, more than you know. On 5/10/23 at 4:00 PM V10 Wound Physician stated, urethral splits are caused from chronic long term catheter use, the friction of the catheter rubbing causes it, they start out as small slits and can get bigger, when patients get these type of things they need to see a urologist. (R53's) was pretty stable for a long time and recently got worse. V10 confirmed R53 needs to be seen by a urologist. V10 stated, patients with these need to have the catheter repositioned frequently and petroleum jelly applied. On 5/10/23 at 2:00 PM V3 RN stated, the only time we go over (V10's) recommendations with (V7) is if it is medications, otherwise we start the the other recommendations. The petroleum jelly and the urology consult should have been initiated. I spoke to (V9 Licensed Practical Nurse- Wound Nurse) and she said they had applied the petroleum jelly for a few days and it was causing more drainage to the open area, so they discontinued it, I dont know if it was a miscommunication or what, I did not see a follow up or documentation if (V10) had been notified. On 5/10/23 at 12:00 PM V2 DON stated, catheter bags should be placed on the bottom of the bed rail, not on the floor. The facility's policy, with a revision date of November 2020, titled Pressure Ulcers/Skin Breakdown - Clinical Protocol documents, Treatment/Management: 1- They physician will authorize pertinent orders related to wound treatments. 2- The physician will help identify medical interventions related to wound management. The wound nurse/designee will initiate a care plan which will include the location/type of area in the problem statement, a realistic goal, and any/all interventions that are pertinent to the treatment and healing of the wound. The facility's policy, with a revision date of September 2014, titled Urinary Catheter Care documents, Infection Control: 2-b: Be sure the catheter tubing and drainage bag are kept off the floor. Steps in the procedure: 13- With nondominant hand separate the labia of the female resident or retract the foreskin of the uncircumcised male resident. 15- For female: Use a washcloth with warm water and soap to cleanse the labia. Use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. Next, change the position of the washcloth and cleanse around the urethral meatus. 17- Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. The following items should be documented in the residents medical record: 1- The date and time that catheter care was given. 40385 2.) On 5/08/23 at 9:39 AM R52 was lying in bed. R52's urinary catheter collection bag was touching the floor, and not secured to the bed. R52 stated R52 has had the catheter for several months and it was inserted after admission. R52's catheter cleaning/care is performed by the Certified Nursing Assistants (CNAs) 3-4 times per week. R52's Care Plan dated 5/1/23 and R52's May 2023 Order Summary do not document to perform routine catheter care/cleaning. R52's urinary catheter order dated 1/17/23 documents R52's catheter was ordered/inserted due to chronic wounds. R52's catheter care report dated 1/8/23 - 5/9/23 do not consistently document catheter care as being completed each shift three times daily. On 5/09/23 at 9:46 AM V32 and V17 CNAs performed R52's catheter care/cleaning. V17 cleansed R52's inner and outer labia with a wash cloth. V17 wiped across the top of the catheter approximately 1/2 inch, near the insertion site. V17 did not wrap the cloth around the catheter and clean the length of the catheter in a downward motion. R52 asked if V17 was going clean R52's catheter. V32 then provided catheter care in the same way as V17. V32 did not clean R52's catheter. On 5/09/23 at 9:56 AM V17 stated V17 was hired approximately 5 months ago and received training on catheter care. V17 stated cleaning the length of the catheter was not part of the training. V17 confirmed V17 did not clean the catheter during R52's catheter care. On 5/09/23 at 10:00 AM V2 Director of Nursing stated catheter care is done by the CNAs at least once per shift/three times daily and documented on the catheter care task report. V2 expects the catheter to be cleaned during catheter care. V2 confirmed the urinary drainage bag should be kept off of the floor and hooked on the bedframe.

Based on observation, interview, and record review the facility failed to identify significant weight loss, notify the physician and Registered Dietitian, implement nutritional interventions, complete nutritional assessments, and record nutritional supplement intake for two (R13, R16) of four residents reviewed for nutrition in the sample list of 39. These failures resulted in R13 experiencing an additional significant weight loss of 6.65 % in one month. Findings include: The facility's Impaired Nutrition/Unplanned Weight Loss Clinical Protocol revised October 2020 documents the nursing department are responsible for monitoring resident weights. Significant weight loss is identified as a loss of at least 5% in one month, 7.5 % in 3 months, and 10 % in 6 months. The physician will review possible causes of weight loss. Interventions will be implemented to address weight loss. The Dietitian and Physician will determine the resident's diet including if nutritional supplements need to be added. Monitoring weight loss/nutrition includes evaluating the care planned interventions, evaluating the resident's response to the interventions, determine weight monitoring intervals, identifying additional risk factors such as pressure ulcers, fever, or acute illness, and observing/reporting significant weight loss. The facility's Nutritional Assessment policy revised September 2011 documents nutritional assessments will be conducted upon admission and with changes in condition that include a risk for impaired nutrition. These assessments will be used to develop interventions to address the resident's risk for impaired nutrition. The Dietitian's component of this assessment will include the estimated calorie, protein, nutrient and fluid needs, and if the resident's intake is adequate to meet nutritional needs. 1. R13's Minimum Data Set, dated dated dated [DATE] documents R13 has short and long term memory impairment, had a significant weight loss within the last month, and is not on a prescribed weight loss regimen. R13's Care Plan revised 4/25/23 documents R13 had significant weight loss noted 1/9/23 and 4/5/23. Interventions dated 1/7/22 include to notify the family and physician of significant weight loss, review diet, intakes, disease process, and behaviors to determine cause, and the dietitian should assess the resident annually and as needed to ensure needs are met. R13's Care Plan dated 7/2/19 documents R13 is at risk for nutritional deficit and includes an intervention revised on 5/4/23 that documents the dietitian evaluated R13 on 2/10/23 with no recommendations, on 3/14/23 with no recommendations, and on 4/28/23 with recommendations. R13's dated 5/10/23 documents R13 weighed 169.2 pounds (lbs.) on 12/1/22, 163.6 on 1/9/23, 153.8 on 1/31/23 (5.64 % loss since 1/9/23), 160 on 2/7/23, 159 on 3/2/23, 156.2 on 3/8/23, 153 on 3/16/23, and 150.4 on 4/3/23 (5.41% loss since 3/2/23). There are no recorded weights again until 5/4/23 when R13 weighed 140.4 lbs (an additional 6.65 % loss since 4/3/23, and a 17% loss since 12/1/22). There are no documented nutritional assessments after 12/15/22 in R13's medical record. There is no documentation that R13 was assessed by V25 Registered Dietitian between 1/1/23 and 2/9/23, or that R13's physician was notified of R13's significant weight loss noted on 1/31/23. R13's Dietary Notes document on 2/10/23, R13 has an unstageable pressure ulcer of the right heel. R13's weight was stable between 160-170 lbs with decrease to 153 on 1/31/23 and returned to 160 on 2/7/23. R13 was started on a frozen nutritional supplement two days prior on 2/8 (of the prior year). On 3/14/23 R13 receives a frozen nutritional supplement twice daily. R13's wound healed and weight has been stable for 60 days. No nutritional changes were recommended. On 4/28/23 V25 recommended the addition of a nutritional shake twice daily. There is no documentation that V25 assessed R13 after 3/14/23 until 4/28/23 (25 days after R13's significant weight loss noted on 4/3/23). R13's Nursing Notes document on 4/12/23 R13's significant weight loss was reported to the practitioner with no new orders given. On 5/4/23 the practitioner was notified and gave orders for 60 cc (Cubic Centimeters) of (nutritional supplement) twice daily and obtain weekly weights for one month. R13's May 2023 Order Summary includes physician orders to administer a frozen nutritional supplement twice daily for weight loss initiated on 2/23/23 and to administer 60 cc of (nutritional supplement) twice daily initiated on 5/4/23. R13's January 2023 through May 2023 Medication Administration Records (MARs) document R13 received a frozen nutritional supplement once daily, that was ordered from 2/8/22 until 2/23/23. The MAR does not document the amount consumed of the 60 cc nutritional supplement initiated on 5/4/23. There is no documentation that any new nutritional supplements/interventions were implemented to address R13's January weight loss prior to 2/23/23 when the frozen nutritional supplement was increased to twice daily, and then no additional nutritional supplements were implemented to address R13's April 2023 weight loss until 5/4/23 when the nutritional supplement 60 cc was ordered. On 5/08/23 at 11:54 AM R13 was sitting in R13's room eating. R13's meal ticket documented a frozen nutritional supplement as part of R13's noon meal. R13's meal tray included reuben sandwich, peas, potato salad, and cheesecake, and did not contain a frozen nutritional supplement, and R13 had only ate 1/4 of a reuben sandwich. On 05/08/23 at 12:06 PM R13's meal tray did not contain a frozen nutritional supplement, and R13 had not ate any more of R13's food, besides the 1/4 sandwich. On 5/9/23 at 12:08 PM V17 Certified Nursing Assistant (CNA) delivered R13's meal tray to R13's room. The meal tray contained a hot dog, cake, bag of chips, and 2 % milk, and did not contain a frozen nutritional supplement. R13's meal ticket included a frozen nutritional supplement. R13's meal tray did not contain a frozen nutritional supplement at 12:21 PM and 12:27 PM. On 5/9/23 at 12:35 PM V17 stated the frozen nutritional supplements are served by the dietary department with the meal trays. V17 confirmed R13 was not given a frozen nutritional supplement as part of the noon meal. V20 CNA stated if the frozen nutritional supplement is listed on the meal ticket, then R13 should be getting it. On 5/09/23 at 12:37 PM V19 Licensed Practical Nurse stated (nutritional supplement) is given by the nurses and the amount consumed is recorded on the MAR. The frozen nutritional supplement is served by dietary, and the nurse is responsible for documenting the amount consumed. On 5/10/23 at 1:00 PM V25 Registered Dietitian stated V25 began employment at the facility in January 2023. The facility sends a weekly list of resident names for V25 to see. The information submitted to V25 does not include the amount of weight lost. V25 does not give any recommendations until V25 rounds at the facility. V25 was not sure what V25 would expect the facility to do to address resident weight loss in the interim until V25 evaluates the resident. V25 stated V25 completes nutritional assessments documented under the assessments section of the electronic medical record. The assessments are completed upon admission, annually, and with any significant changes. V25 confirmed the frozen nutritional supplement is ordered for R13's weight loss. V25 stated V25 evaluated R13 on 2/10/23 and V25 did not order any new interventions since the frozen nutritional supplement was implemented two days prior by the physician. V25 evaluated R13 in March and R13's weight had stabilized. V25 did not evaluate R13 again until 4/28/23 and recommended the addition of a nutritional shake twice daily. V25 stated V25 did not receive notification in April of R13's significant weight loss until 4/28/23. Additional supplements may have prevented R13's weight loss and confirmed not receiving the frozen nutritional supplement may have affected R13's weight. V25 stated if residents are trending weight loss V25 would expect the facility to follow their weight monitoring policy. In the past V25 has made recommendations to monitor weights weekly, but V25 recently stopped doing that because V25 wasn't sure it was something V25 should be doing. On 5/09/23 at 3:36 PM V2 Director of Nursing stated weights are obtained monthly unless otherwise ordered. If the resident triggers for a significant weight loss then we notify the physician and dietitian. V25 rounded on 4/26 and 4/28/23 during April. Per R13's care plan, V25 evaluated R13 on 2/10/23 with no new recommendations, 3/14/23 with no new recommendations, and on 4/28/23 with the recommendation to add nutritional shakes twice daily. V2 reviewed monthly dietitian reports and stated V2 did not see documentation that R13 was evaluated by a dietitian in January 2023. On 5/1/23 we increased the frozen nutritional supplement and stopped the shakes due to R13 not liking the shakes. The nurses are responsible for documenting the amount consumed of each supplement. On 5/10/23 at 10:25 AM V2 stated we ran a weight report on 1/24/23 and R13 did not flag for weight loss at that time. The next weight report was not done until 2/16/23 and R13 triggered a significant weight loss. V2 stated weight reports are only done on a monthly basis and that is how R13's significant weight loss on 1/31/23 was missed. There is no documentation that R13's January significant weight loss was reported to the physician and dietitian, and confirmed there were no new nutritional interventions implemented until February 2023. R13 had a significant weight loss on 4/5/23 and V25 did not evaluate R13's weight loss until 4/28/23. There were no new nutritional interventions implemented in March or April until 4/28/23. On 5/10/23 at 1:28 PM V2 stated nutritional assessments should be completed quarterly, annually, and with any significant changes including significant weight loss. V2 confirmed R13's medical record does not document a nutritional assessment was completed after December 2022. 38859 2) R16's physician order summary documents, Mighty Shakes Sugar Free with meals for skin support, start date: 11/15/2022. R16's wound evaluation and management summary dated 5/8/23 documents Moisture Associated Skin Damage to Sacrum, 2 centimeters by 2 centimeters by 0.3 cm. R16's Dietary Meal ticket documents, Supplement: Might Shakes- No sugar. On 5/8/23 at 12:17 PM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained a Reuben Sandwich, Peas, Salad in a cup, cheesecake, milk and tea. There was no might shake on R16's tray. On 5/9/23 at 11:53 AM R16's lunch meal tray was on R16's over the bed table in front of R16. The tray contained chicken, rice, turtle cake, milk and tea, There was no mighty shake on R16's tray. On 5/9/23 at 11:54 AM V11 Dietary Aide stated, we give the mighty shakes if someone has an order, we sent the mighty shakes out on the hall trays if they eat in their room. On 5/10/23 at 12:00 PM V2 DON stated, dietary serves mighty shakes and nurses should follow up if (the resident) received them and how much they drank. R16's care plan documents R16 has potential for Nutritional Deficit related to history of Colitis, Diverticulitis, Gastro Esophageal Reflux Disorder, weakness. Interventions: Serve Nutritional supplements as ordered.

Based on interview and record review the facility failed to implement an intervention from a previous fall which resulted in a recent fall and subsequent injury for one cognitively impaired resident (R1). R1 was sent to the emergency room and diagnosed with a fracture of the greater trochanter of the right femur (Hip) following a fall at the facility on 9/23/22. R1 is one of three residents reviewed for falls in the sample of three. Findings include: R1's Physician Order Sheet dated October 2022 documents R1 was diagnosed with Anxiety Disorder, Chronic Fatigue, Unsteadiness on Feet, Alzheimer's Disease, Muscle Weakness, and Indwelling Urethral Catheter. The same POS documents an order to check the function and placement of R1's chair alarm. R1's Morse Fall Scale dated 8/2/22 documents R1 was at high risk for falls related to a history of falls, use of an ambulatory aide, impaired gait, impaired cognition, and often overestimates or forgets limits. R1's Care Plan dated 8/6/22 documents R1 was high risk for self injury and falls and was to have a bed and chair alarm in place in order to help prevent further falls. R1's Minimum Data Set, dated dated dated [DATE] documents R1 was severely cognitively impaired, used a walker and wheelchair and required extensive assistance of one staff person for transfers. R1's Incident Report dated 9/23/22 documents at approximately 8:00 PM, R1 was in the hallway when she stood up on her own and fell to the floor in front of her wheelchair. R1 stated I'm trying to get out of here. R1 was on her back and no injury was noted at the time of the fall. R1 was able to transfer back to her wheelchair with staff assistance and denied pain. R1 went to sleep but by the next morning had developed pain/weakness in her right hip. R1 was transferred to the emergency room and diagnosed with a fracture of the greater trochanter of the right femur. At the time of the fall, R1 was only orientated to person, R1 was confused, was attempting to ambulate without assistance, had a recent Urinary Tract Infection and had increased confusion and behaviors noted multiple times earlier that same day and earlier that same shift. R1 also had a urinary catheter in place. R1's prior fall intervention of a chair alarm was not in place at the time of her fall. R1's Diagnostic Imaging Report of the Right Hip dated 9/24/22 documents R1 sustained a mildly comminuted non-displaced fracture of the greater trochanter of the right femur. On 10/17/22 at 4:08 PM V6 Certified Nurse Assistant stated on 9/23/22 she came out of resident's room and saw R1 standing in front of her wheelchair. V6 stated R1 was unsteady and fell to the ground. V6 stated R1 had been more confused and anxious than normal that shift and earlier that evening R1 was climbing out of bed and constantly trying to stand on her own. V6 stated the staff decided to put R1 in her wheelchair and in the hallway so they could attempt to supervise her more closely. V6 stated when R1 fell , there was no other staff in the hallway except her and she had just exited another resident's room. V6 stated she was not aware R1 had a chair alarm that needed to be in her wheelchair when she was in it. V6 stated if she had known this, she would have put the chair alarm in her wheelchair. V6 stated if R1 had the chair alarm on her wheelchair at the time of the fall, it might have alerted her (V6) sooner that R1 was attempting to stand and she could have gotten to R1 more quickly and potentially prevented the fall and subsequent injury. On 10/17/22 at 3:30 PM V4 Licensed Practical Nurse stated she was R1's nurse at the time of the 9/23/22 fall. V4 stated R1 was a high fall risk and was not safe in her room alone due to her increased confusion, anxiousness, and impulsive behavior. V4 stated R1 had poor safety awareness and required supervision. R1 also had a urinary catheter bag at the time of the fall. V4 confirmed R1 was supposed to have a chair alarm in place at the time of the fall however staff had not moved it from R1's recliner to R1's wheelchair when they placed her in the wheelchair. V4 confirmed if R1 had the chair alarm in place at the time of the fall, it could have alerted staff to her standing up and staff could have possibly gotten to her sooner and prevented the fall and subsequent injury. On 10/19/22 at 1:30 PM V2 Director of Nurses confirmed R1 was a high fall risk. R1 was confused, had poor safety awareness, required assistance for safe transfers, and was impulsive. V2 confirmed at the time of the fall R1 was supposed to have a chair alarm in place and did not. V2 confirmed staff should have moved R1's chair alarm from her recliner to her wheelchair when she was in her wheelchair. V2 confirmed if the chair alarm would have been in place like it should have, staff could have been made aware of R1 attempting to stand and might have gotten to her sooner in order to prevent the fall and subsequent injury. On 10/19/22 at 2:05 PM V11 Nurse Practitioner confirmed R1 was a high fall risk with previous falls and all fall interventions should be in place at all times. V11 confirmed staff should have placed R1's chair alarm on her wheelchair when she was transferred into it. V11 confirmed if R1 had the chair alarm in place it could have alerted staff to the unassisted transfer sooner and could have prevented the fall with subsequent injury. The Managing Falls and Fall Risk Policy dated December 2021 documents the facility will identify interventions related to the resident's specific fall risks in order to prevent the resident from falling and to try to minimize complications from falling. Resident's requiring alarm devices are to be closely supervised during tasks to reduce opportunities for attempting independent mobility.

Based on interview, and record review the facility failed to ensure that a resident was not subjected to manual restraint by staff during incontinence care and failed to follow care plan interventions. This failure affects one (R16) of three residents reviewed for abuse in a sample list of 35. This failures resulted in R16 sustaining skin tears to hands and multiple bruises to R16's arms after calling out for help when staff held R16's hands down during incontinence care. Findings include: R16's resident dashboard dated 4/5/22 includes the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . R16's MDS (Minimum Data Set) dated 1/21/22 documents R16 is severely impaired and requires extensive assistance of two or more staff members for transfer, bed mobility, and toileting. R16's Care Plan documents (R16) exhibits agitation and may become at times combative. [MEDICATION(S)] as ordered. Date Initiated: 10/28/2021 Revision on: 3/29/2022 (R16) will exhibit agitation less than 5x by next review. Date Initiated: 10/28/2021 Revision on: 01/24/2022 Target Date: 04/22/2022. Check to determine if behavior is due to pain or discomfort; address as appropriate. Date Initiated: 10/28/2021 Engage by smiling, small-talk, conversation, and redirection. Date Initiated: 10/28/2021 If combativeness is observed, document on reverse of Behavior Tracking Log and notify the nurse. Date Initiated: 10/28/2021 Monitor and record behavior via behavior tracking document; include response to interventions. Notify nurse if behavior persists or worsens. Date Initiated: 10/28/2021 Provide reassurance and re-orient to surroundings and staff. Date Initiated: 10/28/2021Re-approach with two caregivers. Date Initiated: 10/28/2021. The facility's final report to state agency dated 3/25/22 documents On 3/23/22 (V21) CNA (Certified Nurse's Aide) reported to V23, LPN (Licensed Practical Nurse) (R16) had been calling out for help and it sounded like he was in pain. (V21) went into the room to help (V20) transfer (R16). (V20) told (V21) he had to hold (R16's) hands down to change (R16). On 4/5/22 at 2:15PM V20, CNA (Certified Nurse's Aide) stated (on 3/23/22) I went into (R16's) room to change him. (R16) was incontinent of urine and Bowel Movement (BM). (R16) had started to take off his clothes and (incontinence garment). (R16) was fighting me and I held (R16's) wrists down to clean (R16) and change (R16). I did know if (R16) was being difficult I should have got more staff to help. (R16) was covered in urine and BM. I wanted to keep (R16's) hands out of it. I am a permanent CNA on the hall (R16) is on. On 4/5/22 at 2:22PM V21, CNA (Certified Nurse's Aide) stated (On 3/23/22) I was in the hall outside (R16's) room. I heard (R16) screaming out 'help me help me'. (R16) sounded like (R16) was in pain so I went into (R16's) room. (V20) was already in the room. (V20) told me he had to hold (R16) down because (V16) was fighting. I noticed (R16's) hand was bleeding. (R16) said 'get your brother (V20) out of here. He is too rough.' (R16) was pointing at (V20) when (R16) said your brother. I helped (V20) finish cleaning (R16) up. Something about it just didn't seem right to me so I reported it to (V23) LPN (Licensed Practical Nurse). Soon after that, (V20) was out of the facility. On 4/5/22 at 3:00PM V23 stated On 3/23/22 I was the nurse responsible for (R16). I was actually giving report to the next shift when (V21) came to me and reported that she had heard (R16) calling out as if (R16) was in pain 'help me'. (V21) said she went in (R16's) room and (V20) told her he had to hold down (R16) because (R16) was fighting him when he tried to clean (R16) up. (V21) said she thought (R16) was bleeding from (R16's) hands. I immediately reported it to Administration and (R20) was suspended so they could investigate. I did a full body assessment of (R16). I found actively bleeding skin tears on both (R16's) hands and bruises on both (R16's) forearms. I cleaned and dressed the skin tears. The bruises were red and purple like new bruises. I had seen (R16) within the hour before this and (R16) did not have the skin tears or bruises. I documented it. (R16) can be combative and resists care, but if you explain what you are doing and get help (R16) will usually be OK. R16's Progress note dated 3/23/2022 at 5:24PM by (V23 LPN) documents New areas noted to residents skin; Skin tear to Right dorsum (back of hand), Skin tear to Left dorsum (back of hand). Bruises noted to Right dorsum, Right outer wrist, Right hand 1st digit, Right inner forearm, Left inner forearm, Left inner wrist Left hand 5th digit. Power of Attorney notified. On 4/5/22 at 4:00PM V1, Administrator stated I was notified shortly after the incident on 3/23/22 (V16), our Finance Manager was the Manager on call and she called me as soon as she had initiated the investigation. By the time I was called (V20) had already been escorted out of the building by the Registered Nurse in the building at that time. We investigated and concluded since there were no witnesses in the room at the time we could not prove it was abuse, but we all agreed it was a bad choice (V20) made to attempt to provide care without help when (R16) was resistive. The RN supervisor has done one-on-one education with (V20) concerning how to approach residents when they resist care. The facility's policy Abuse, Neglect, Involuntary Seclusion, Misappropriation of Resident Property, Injuries of Unknown Origin, and Social Media dated 8/22/16 under Prevention of Abuse) states 19. Appropriate interventions to address identified behaviors will be included on Resident Care Plans, and reviewed as/when change occurs. These interventions will be communicated to the direct care givers.

Based on interview and record review, the facility failed to provide safety and supervision for R1 and R2. R1 had a fall from bed that resulted in a fractured left femur. R1 and R2 each had avoidable falls that resulted in injuries requiring medical treatment. R1 and R2 are two residents reviewed for falls in the sample of three. Findings include: On 12/21/21, V7 Administrative Assistant, provided an incident investigation dated 10/19/21 and 12/14/21 for R1. On this same date, V7 also provided an incident investigation dated 10/6/21 for R2. 1.) R1's Order Report Summary dated 12/21/21, document R1's diagnoses as History of Falling, [CONDITION(S)], Unspecified Fracture of Left Pubis, Sequela, Nondisplaced Zone III Fracture of Sacrum, Sequela, other specified Disorders of Bone Density and Structure, unspecified, unspecified intracapsular Fracture of Right Femur, Fracture of unspecified part of Right Clavicle, Difficulty Walking, not elsewhere classified, and Displaced Intertrochanteric Fracture of Left Femur. R1's Minimum Data Set (MDS) dated [DATE], documents R1 requires extensive assistance for bed mobility, transfers, toilet use, is not steady and requires staff assist to stabilize. R1's Nursing Admission Screening/History dated 7/1/21, documents R1 has an unsteady gait, poor balance, and a history of falling/recent falls, is confused, and has long and short-term memory problems. R1's Alarms assessment dated [DATE], documents R1 attempts self-transfer and does not use call light. R1's Morse Fall Scale dated 10/13/21, documents R1 is a high fall risk due to an impaired gait and over estimating and/or forgetting limits. The facility's Final Report of Resident Incident of 12/8/21, documents R1 was in R1's room, pressed the call light and requested assist to transfer to commode. V6 CNA entered R1's room and prepared items for R1 and placed R1's walker in front of R1 for transfer. V6 then turned from R1 to close the curtain for privacy and as V6 turned away from R1, R1 stood alone, lost R1's balance and fell to R1's left side, V6 was unable to intervene fall. The report documents upon inspection R1's left foot was noted to be rotated outward and a leg length discrepancy noted. This report documents R1 had a surgical nailing of R1's femur. On 12/8/21, R1 was transferred to one hospital for left hip pain of 10/10 on the pain scale. On 12/9/21, R1 was transferred to another hospital for possible surgery. A written witness statement by V6 CNA on 12/8/21 documents R1 called to use the commode - V6 put R1's walker in front of R1 and V6 turned to draw the curtains for R1's privacy and R1 got up and tried to move by R1's self and lost R1's balance and fell . R1's Emergency Department Observation Record dated 12/8/21, per V10 Medical Doctor, documents patient (R1) presented after fall from her (R1) nursing facility for evaluation of likely hip fracture, left hip fracture was confirmed on imaging. R1's Diagnostic Imaging Report dated 12/8/21, documents acute comminuted fracture involving the intertrochanteric region of the proximal left femur with soft tissue swelling. R1's Operative Report dated 12/9/21, documents the title of the procedure as Cephalomedullary nailing of left proximal femur using a nail system measuring 11.5 (inches) x 20 (inches). On 12/22/21 at 9:47 AM, V2 Director of Nursing (DON) stated on 12/9/21 V6 CNA should have pulled the curtain as soon as she (V6) entered the area, that one little thing could have prevented a broken hip. 2.) R2's undated Face Sheet, documents R2's diagnoses as History of Falls, Other Secondary Parkinsonism, Cognitive Communication Deficit, Muscle Weakness, generalized, and Other Lack of Coordination. R2's MDS dated [DATE], documents R2 requires extensive assistance for bed mobility and transfers, is not steady and requires staff assistance to stabilize, has bilateral lower extremity impairments and uses a wheelchair for locomotion. R2's Morse Fall Scale dated 8/9/21, documents R2 has a history of falls, impaired gait, and over estimates/forgets limits. R2's Alarms assessment dated [DATE], documents alarm use for history of falls, climbing out of bed, sliding out of chair/wheelchair, and attempts to self transfer. R2's Care Plan dated revision on 8/10/21, documents R2 is at risk for injury related to declining functional status. The facility's Unwitnessed Fall Report dated 10/6/21, documents V8 Licensed Practical Nurse (LPN) responded to R2's alarm and observed R2 lying face down on the floor with right shoulder under body, head against the heater vent, feet under upright wheelchair, and television remote in R2's left hand. The report documents R2 being log-rolled to R2's back and bleeding noted to above R2's right eyebrow measuring approximately 0.5 cm- 1.0 cm with a hematoma to R2's right forehead. This reports documents R2 was transported the the Emergency Department for evaluation and treatment. This same report documents R2 at times does try to transfer self when in room unsupervised. This report documents after dinner V5 CNA assisted R2 to R2's room per R2's request, per V5, R2 did not want to get into bed so V5 made sure R2 had R2's television remote and the call light within reach. This report documents R2 dropped the television remote and bent over to pick it up and fell forward. R2's Emergency Department Report dated 10/6/21, documents: patient (R2) has evidence of contusion with swelling superior and lateral to right orbit, there are multiple superficial linear lacerations present that appear to penetrate into the dermal layer. On 12/21/21 at 2:38 PM, V3 CNA stated R2 told V5 CNA that R2 wanted to go to his room. V3 stated the CNA V5 is an agency CNA. V3 stated V3 was on break, V5 remained on the unit, and when V3 was coming back V3 heard R2's call light so V3 went to R2's room but R2 was already on the floor. V3 stated R2 had cut around R2's eye and no one was in the room with R2. V3 stated when V3 asked V5 what happened V5 stated V5 didn't know R2 was a fall risk or that R2 couldn't be left alone in R2's room. V3 stated V3 gave V5 the cheat sheet listing information for each resident that documented don't leave alone in room referring to R2. V3 stated V3 left V5 alone on the floor other than the nurse and did not call for the float CNA to come to the floor. On 12/22/21 at 11:19 AM, V8 Licensed Practical Nurse (LPN) stated around the time of the incident with R2, V8 is typically doing treatments so it's difficult for V8 to know what people are doing. V8 stated V3 did tell V8 that V3 was going on break and V8 was aware there was an agency CNA on the floor but didn't know if it was V5's first time working. V8 stated V8 assumed the CNA, V5 was aware of fall safety precautions for R2. V8 stated R2 is to be close to the nurse's desk for fall monitoring while R2 is in R2's wheelchair for fall safety precautions. On 12/21/21 at 3:03 PM, V2 DON stated V5 should have went on break with V3 and V3 should have called the float CNA to come assist while V3 and V5 went on a break instead of leaving V5 alone on the floor, this is definitely an error on our part. The facility's Falls and Fall Risk, Managing Policy dated Revised 1/2021, documents based on previous evaluations and current data, 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. 3.) R1's Order Report Summary dated 12/21/21, document R1's diagnoses as History of Falling, [CONDITION(S)], Unspecified Fracture of Left Pubis, Sequela, Nondisplaced Zone III Fracture of Sacrum, Sequela, other specified Disorders of Bone Density and Structure, unspecified, unspecified intracapsular Fracture of Right Femur, Fracture of unspecified part of Right Clavicle, Difficulty Walking, not elsewhere classified, and Displaced Intertrochanteric Fracture of Left Femur. R1's Minimum Data Set (MDS) dated [DATE], documents R1 requires extensive assistance for bed mobility, transfers, toilet use, is not steady and requires staff assist to stabilize. R1's Nursing Admission Screening/History dated 7/1/21, documents R1 has an unsteady gait, poor balance, and a history of falling/recent falls, is confused, and has long and short-term memory problems. R1's Alarms assessment dated [DATE], documents R1 attempts self-transfer and does not use call light. R1's Morse Fall Scale dated 10/13/21, documents R1 is a high fall risk due to an impaired gait and over estimating and/or forgetting limits. The facility's Witnessed Fall Report dated 10/19/21, documents a Certified Nursing Assistant (CNA) (V4) heard resident's (R1) bed alarm and responded to find R1 trying to climb out of bed. V4 asked R1 to hold on for assistance while V4 was trying to turn on the light. The report stated R1 ignored V4 and continued to attempt to climb out of bed. The report documents V4 returned immediately after turning the light on saw R1 losing R1's balance. The report documents V4 tried to stop R1 from falling and could not so V4 lowered R1 to the floor. This report documents R1 sustained two skin tears to R1's right elbow measuring 3.5 centimeters (cm) by 4.3 cm and 2.2 cm by 3.3 cm. This same report documents predisposing factors as poor lighting, gait imbalance, and impaired memory. This report also documents a written statement by V4 CNA which states R1's bed alarm was going off and when V4 got in there, R1 had crawled to the bottom of R1's bed and was half way out when V4 told R1 to stop until V4 turned on the lights, when V4 turned back around R1 was falling and V4 helped R1 fall to the floor. V4 documented R1 cut R1's arm pretty bad. On 12/22/21 at 9:47 AM, V2 DON stated V4 CNA should have turned the light on when entering the room, you have to be ready for anything at all times - this could have prevented (R1's) injuries.

Based on observation, interview and record review, the facility failed to assess residents for the ability to safely operate power lift reclining chairs and develop and implement policies and procedures related to the operation/use of these power lift chairs. These failures affect two of 20 residents (R1, R2) who use power lift chairs in the sample of 20. These failures resulted in R1's fall from the power lift reclining chair. R1 was found on the floor face down and was sent to the emergency room with a laceration requiring sutures and staples, severe neck pain and found to have acute fractures of C1/C2 cervical vertebrae. R1 admitted to Hospice upon return to the facility with a diagnosis of C1 fracture. Findings include: 1. R1's Face Sheet dated 8/24/21 document R1's diagnoses including Displaced Posterior Arch Fracture of First Cervical Vertebra, Displaced Fracture of Second Cervical Vertebra, Palliative Care with date of onset of 8/13/21. R1's Progress Notes dated 11/29/2020 document R1 has a history of [CONDITION(S)] (CVA) with residual left arm [CONDITION(S)] and left leg weakness. R1's Progress Notes dated 1/29/21 document R1 has left side [CONDITION(S)]. R1's Brief Interview for Mental Status documents R1's Cognitive Status on 6/29/21 as moderately impaired. R1's Incident Report dated 8/13/21 at 5:00am documents R1 was found on the floor of R1's room when an unidentified Certified Nursing Assistant (CNA) responded to R4, R1's roommate yelling for help. On arrival, V4, Registered Nurse (RN) noted R1 laying on R1's left side with the left side of R1's face to the floor and bleeding. R1 had a Deep gash to left forehead with blood oozing out of it. V4 attempted to stop the bleeding by applying pressure but was unsuccessful and R1 was complaining of severe neck pain. R1 stated R1 was attempting to raise R1's recliner but accidentally raised it too far and fell out of it. R1 also sustained a skin tear to the left forearm. This report also documents R1 is able to use the call light independently and last used the bedpan at 4:30am. R1 had been putting R1's right leg out of the bed and stated R1 needed to go somewhere so the staff placed R1 in R1's recliner with footrest up and remote in pocket of recliner. R4 had put the call light on and yelled out for assistance. R1 was noted face down on the floor and R1's recliner in an upright elevated position. R1 told V4, RN that R1 was leaning forward when using R1's recliner controller when R1 fell . R1 returned to the facility with a diagnosis of C1 and C2 spine with staples and sutures to the forehead and scalp. R1 was admitted to hospice on 8/13/21. There is no documentation R1 was assessed for the ability to safely operate the power lift reclining chair. There is no documentation R1 was provided education on how to operate the power lift reclining chair. On 8/24/21 at 9:50am, V9, Consumer Call Center Representative for the lift chair company stated R1's power lift chair was discontinued in 2007. V9 stated the company would provide the company's basic manual for consumers. V9 stated R1 would have to be able to stand up and take steps independently to be safe to operate and properly use the power lift recliner. V9 stated R1 would have to be aware and have cognitive ability to safely operate the remote to the power lift chair. R1's Care Plans dated 8/16/21 document R1 was diagnosed with terminal illness: C1 fracture, and was admitted to Traditions Hospice on 8/13/21. On 8/23/21 at 2:30pm, R1 was in lying in bed with eyes closed and use of accessory muscles were observed with breathing. There are two signs similar to each other on R1's wall directing staff to ensure R1's call light is attached to R1's clothing to help remind R1 to use it when R1 needs something. R1 had bruising to the left eye and a laceration extending towards top of head/scalp with a large bump and hematoma to the area and left side of R1's head. On 8/23/21 at 2:50pm, V2, Director of Nursing (DON) stated the facility reviews and investigates the falls. V2 stated on 8/13/21, R1 was confused and told staff she wanted to go somewhere but didn't know where. R1 kept putting R1's right leg over the side of the bed and was restless so staff used a full mechanical lift to transfer R1 in to R1's power lift reclining chair. V2 stated V2 did not ask nor know if R1's call light had been attached to R1's clothing prior to staff leaving R1's room after transferring R1 in to the power lift reclining chair. V2 stated R1 has left side paralysis from a previous [CONDITION(S)] (CVA) and is dependent on staff to transfer with a full mechanical lift. V2 was unaware if the chair had been evaluated or where the facility took R1's power lift reclining chair after R1's fall on 8/13/21. V2 stated V2 was unsure regarding other resident falls out of power lift chairs or if the facility had a policy and/or procedure on use of power lift chairs. V2 stated assessments for safety of use of power lift reclining chairs are in the Restorative Assessments for each resident. The Basic Operation Manual is dated April 2021 and documents the intended use of this device is that of a device with motorized positioning control that is intended for medical purposes and that can be adjusted to various positions. The device is used to provide stability for patients and to alter postural positions. This device will provide lift assistance for people who have difficulty rising from a seated position to a standing position. This manual also documents, WARNING! Do not attempt to stand up until you can stand safely, are steady on your feet, and can bear weight. We recommend the use of assistance aids and/or an attendant for enhanced stability. The undated Guidelines for Nursing Homes, Ergonomics for the Prevention of Musculoskeletal Disorders documents, OSHA (Occupational Safety and Health Administration) Description: Lift cushions and lift chairs. When to Use: Transferring residents who are weight-bearing and cooperative but need assistance when standing and ambulating. Can be used for independent residents who need an extra boost to stand. Points to Remember .Lift chairs are operated via a hand-held control that tilts forward slowly, raising the resident. Residents need to have physical and cognitive capacity to be able to operate lever or controls. 2. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has a short term memory problem and has behaviors of inattention and altered level of consciousness. R2's Minimum Data Set (MDS) dated [DATE] documents R2 requires supervision of one staff member for transfers. R2's Incident Report dated 8/15/21 at 9:09am documents R2 was found on R2's buttocks in front of R2's lift reclining chair with the chair in the upward/raised position. R2's blanket was laying next to R2 on the floor. R2 stated R2 was trying to get up from R2's chair and slid on to R2's buttocks. This report documents V10, Licensed Practical Nurse (LPN) heard R2 yelling from R2's room and found R2 positioned on R2's buttocks in front of R2's chair. This report documents R2 is independent in R2's room using R2's rolling walker and that the Restorative program would assess resident abilities to reposition recliner correctly. R2's Progress Notes dated 8/16/21 document R2 was in-serviced on the proper ways to operate R2's lift chair. R2 stated R2 knows how to operate it but R2 had pushed the wrong button. There is no further explanation regarding what button R2 was trying to push or what ways were included in R2's education related to operating the lift chair. There is no documentation the manufacturer's manual was used to educate R2. There is no documentation prior to R2's fall that R2 had received education on safe operation/use of the power lift chair. On 8/24/21 at 9:24am, V1, Administrator stated the facility was unable to find an operation manual/guidelines for use of the power lift chairs that were in the facility being used by residents. V1 also stated the facility does not have a policy/procedure in place regarding assessing for resident's ability to operate the power lift chair safely or education for residents regarding power lift reclining chair use. On 8/24/21 at 9:50am, V9, Consumer Call Center Representative for the lift chair company stated the remote should not be placed in the seat when not in use and should be locked/disconnected when not in use. V9 stated the company would provide the company's basic manual for consumers. V9 stated R2 would have to be aware and have cognitive ability to safely operate the remote to the power lift chair. On 8/24/21 at 1:35pm, R2's power lift reclining chair was positioned up/elevated off the floor with the remote placed on the seat of the chair. On 8/25/21 at 3:00pm, V2, DON stated the root cause of R2's fall was R2's inability to safely operate the power recliner controller.

Based on observation, interview and record review the facility failed to notify the physician and obtain an order for [REDACTED]. Findings include: The Readmission assessment dated [DATE] states that R4 was readmitted to the facility with the [DIAGNOSES REDACTED]. The same assessment in the section titled "Skin Condition" documents that R4 has two pressure ulcers, one on the right buttocks measuring less than 0.25 cm (centimeters) and one on the coccyx measuring 3.0 cm. Both pressure ulcers are documented to be stage 2. Nurses Notes dated 5/4/11 at 2 PM states that R4 was returned to the facility and the skin assessment was completed. R4 had two open areas, the right buttock area which was less than 0.25cm open and the lower coccyx area had an approximate 3cm open area. The "Weekly Pressure Ulcer Healing Assessment Treatment Plan" dated 5/4/11 states R4 had a stage two pressure ulcer located on the right buttock. The size of this area was less than 0.25cm. with no measurable depth. The area had no exudate, was red in color and the surrounding skin color was red. There is not a physician's orders [REDACTED]. The next documentation on the same form is dated 5/10/11 and states the pressure area was a stage 2 with a size of 1cm, unable to measure depth, no exudate, pain was present, red in color and the surrounding skin color was red. At this time, on 5/10/11 an order was obtained that states, "[MEDICATION NAME] ointment to redness/excoriation on buttocks Q shift (every shift) until healed..." The Weekly Pressure Ulcer Healing Assessment Treatment Plan dated 5/4/11 for R4's lower coccyx area documents: location is lower coccyx, stage two, size at 3cm, unable to determine depth of area, no exudate, color is red and surrounding color is red. The same form dated 5/10/11 documents the pressure ulcer for the lower coccyx was stage two, measuring 3 cm, unable to determine depth, pain was present, color was red and the surrounding skin color was red. On 5/10/11 at 11:45am E5, CNA (Certified Nurses Assistant) positioned R4 on his right side to clean his buttock due to R4 having liquid stool. R4 did not have any type of treatment covering either pressure ulcer, both areas were exposed to open air. E5, using disposable cloths, started at the bottom of the buttocks and went up and over both areas with the disposable cloths which had visible liquid stool on them E5 continued to clean R4 with disposable cloths, contaminating both open areas with liquid stool. Stool was visible on the disposable cloths and the open areas were contaminated a total of three times. E7, LPN (Licensed Practical Nurse) on 5/12/11 at 9:15 am measured the two pressure ulcers. The right buttock area measured 2cm x 2cm with E7 stating the depth was not able to be measured, the color was red, pain was still present and the surrounding skin color was red. The pressure ulcer located on the coccyx measured 2cm x 3cm, slight measurement to the depth, color was red, pain present and the surrounding skin color was red. E7, LPN stated at 9:20am on 5/12/11 that the two areas were larger and had gotten worse. Nurses Notes dated 5/12/11 at 9:15am reads "....right buttock pressure area 2cm x 2cm and coccyx area 2cm x 3cm. both remain stage II, current treatment not healing areas. Physician notified."