Every finding on record at Pittsfield Manor

Based on interview and record review, the facility failed to ensure residents were free from theft for 2 of 2 residents (R1, R2) reviewed for misappropriation of property in the sample of 5.Findings include: 1. R1's undated face documents R1 admitted to the facility on [DATE]. R1's face sheet documents diagnoses of: Type 2 Diabetes Mellitus with other circulation complications, low back pain, unspecified pain left hip. R1's Minimum Data Set (MDS), dated [DATE], documents R1 has moderate cognitive impairment with a Brief Interview of Mental Statis (BIMS) of 12. On 6/2/2026 at 9:39AM, R1 was sitting in her room in her wheelchair. R1 stated she had had her debit card stolen. R1 stated one night, in middle of night, a Certified Nursing Assistant (CNA) was in her room looking around and when R1 asked her what she was doing she told R1 she was looking for her ear bud. R1 stated a few days later, R1 noticed her debit card was missing. R1 stated she reported the incident and the facility took care of it. R1 stated she had 2 purchases on her bank statement that she did not make. R1 stated one was at local gas station and other was where someone had been playing games on the computer. R1 stated she had never had anything stolen at the facility before and she has no concerns and feels safe. R1 stated her debit card had been used to make the two transactions. R1's bank statement, print date 11/19/2025 at 15:49, documents 2 transactions on 11/16/2025. First transaction dated 11/16/2025 at 9:34 PM at (gas) station, for $41.00 with second transaction dated 11/16/2025 at 10:05PM (online) https for $29.99. The facility final report provided to IDPH, dated 11/22/2025, documents on 11/19/25, R1 reported that her debit card was missing, when she contacted the bank, she realized that there were 2 charges that she had not made. R1's roommate, R2, also reported missing cash from her wallet during the investigation. Administrator began her investigation. All proper notifications were made. All residents were interviewed, and no other residents had any missing items. With the help of the County police department, cameras from the local gas station were viewed, and we were able to identify the possible suspect based on their vehicle. On 11/20/25, V8, County Deputy, met with V6, CNA/Certified Nursing Assistant, to discuss the missing items. The report documented V6 denied having took them. Per policy, V6 was put on suspension pending final investigation. V6 has since been terminated, and the States Attorney will take the investigation further. 2. R2's undated face sheet documents R2 was admitted to the facility on [DATE]. R2 face sheet documents diagnoses of: Pneumonia, unspecified organism, trans ischemic attack, unspecified severity without behavioral disturbances, mood disorder and anxiety, unsteadiness on feet, dyspnea, lack of coordination. On 6/2/2026 at 9:30AM, R1 stated $20 was stolen from her roommate's billfold.On 6/2/2026 at 9;31AM, V2, Director of Nursing/DON, stated R1 had reported to staff about debit card missing and staff reported to V1, Administrator. V2 stated she was notified by V1 and assisted with the investigation. V2 stated staffing schedules were pulled for last couple of days on the night shift. V2 stated as part of investigation, residents and staff were interviewed. V2 stated the (local) County sheriff's department was notified. V2 stated after obtaining R1's bank statement, the police had the camera footage pulled from the local gas station and V6's car was observed at the gas station at time of charge. V2 stated the officer came to the facility and interviewed V6. V2 stated V6 denied all allegations and was on suspension pending discharge. V2 stated V6 had been employed at the facility less than 20 days. V2 stated V6 called in while on suspension stating V6 was going to quit. V2 stated termination was done with no intent to ever rehire. V2 stated R2 was R1's roommate and was in hospital and family reported $20 missing from R2's billfold. On 6/2/2026 at 2:17PM, V2, DON, stated R1 is alert and orientated x3. V2 stated R2's cognitive status had changed after her hospital admission. V2 stated when R2 returned to the facility from the hospital, she was placed on hospice and did expire at the facility.V2 stated she would expect residents at the facility no to have misappropriation of property/theft and the facility to follow its policy.The facility abuse prohibition and reporting policy, revised 11/28/19, documents the facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation and use of any physical or chemical restraint not required to treat resident's symptoms. The policy documents Misappropriation of Resident Property: 1. No person shall misappropriate or steal any resident property. Any person who becomes aware of any alleged misappropriation or theft of resident property shall report the inicident ot the administrator immediately. 2. The administrator or designee shall investigate the alleged misappropriation or theft of resident property. 3. The administrator or designee shall be responsible for supervising the investigation and reporting the results of the investigation to IDPH. 4. The administrator or designee shall notify the resident's representative and or responsible part of the alleged misappropriation or theft and the results of the facility's investigation of the incident.

Based on observation, interview, and record review, the facility failed to ensure a dependent resident received passive range of motion as recommended by therapy after being discharged from therapy and failed to ensure restorative services were provided for 3 of 3 (R11, R30, R31) residents reviewed for range of motion in a sample of 49. This failure resulted in R31 having a decline in condition and becoming dependent on staff for activities of daily living.Findings include:1. R31's Face Sheet, dated 1/15/2026, documents R31 was admitted on [DATE] with diagnosis of Muscle wasting and atrophy, not elsewhere classified, multiple sites, Type 2 diabetes mellitus with diabetic neuropathy, unspecified, Muscle weakness. R31's Care Plan, not dated, does not address contractures to R31's hand and knees. R31's Minimum Data Set, dated [DATE], documents R31's short- and long-term memory is ok and R31 is independent with cognitive skills for daily decision making. It also documents upon admission, R31 was setup assist with eating and oral hygiene, no functional imitation with range of motion to upper and lower extremities and partial/moderate assist with upper body dressing, putting on and taking off shoes. Section O: Restorative Nursing Programs: ROM (Range of Motion) documents 0 for passive and active range of motion. R31's Minimum Data Set (MDS), dated [DATE], documents R31's short- and long-term memory is ok. It also documents R31 is independent with cognitive skills for daily decision making and dependent on staff for activities of daily living. Section O: Restorative Nursing Programs: ROM (Range of Motion) documents 0 for passive and active range of motion. R31's General Order, dated 10/17/2025, documents Palm Guard to left hand due to contracture. R31's Point of Care History Restorative Nursing does not address range of motion. On 1/13/2025 at 10:00 AM, R31 was observed lying in bed, hands closed tight. No palm guards in place. The palm guard was observed on the chair next to the bed. R31 attempted to open hands without success. At 12:15 PM, R31 was observed in the dining room, hands closed. No palm guard in place. No staff was seen performing ROM or any exercises with R31 during this observation/investigation. On 1/14/2025 from 10:00 AM to 1:00 PM, with benefit of 15minutes to 30-minute observations, the palm guards were not in place. No range of motion observed. No staff was seen performing ROM or any exercises with R31 during this observation/investigation. On 1/15/2025 at 9:33 AM, observed R31 sitting in a wheelchair. Palm Protectors in place to both hands. On 1/13/2025 at 10:00 AM, R31 stated her hands are contracted. R31 stated initially, she was able to utilize her 3 fingers on her hand, but now she is not able use any. R31 stated she is not able to open her hand on her own. R31 stated she does not currently receive therapy and has not had anyone perform range of motion on her hands or knees. R31 stated she previously was able to use the sit to stand but now cannot because her hands are more contracted. R31 stated because of the contractures she is not able to hold on to the handles of the sit to stand and has to use the full body lift. R31 stated she was able to use the bathroom but now is not able to because she can't use the stand-up lift. R31 stated she has to be fed because she can't hold the utensils. 1/13/2025 at 10:30 AM, V9, Licensed Practical Nurse (LPN), stated R31's hands and legs are contracted. V9 stated R31 is to have palm protectors in place every day. V9 stated the circular padding between R31's knees are to be in place at all times. V9 stated R31 has had a decline. V9 stated R31's level of care needs has increased. V9 stated R31 is now dependent on staff for all activities of daily living (ADLs). On 1/15/2025 at 9:40 AM V16, Certified Nurse Aide, CNA, stated that R31 is to have palm guards in place to both hands every day because she is not able to open her hands. V16 stated R31 has had a decline. V16 stated R31 used the sit to stand when first coming to the facility. V16 stated she has since changed to the full body lift because of her hands are not able to hold onto the bar. V16 stated she does not perform range of motion every day. V16 stated therapy performs the range of motion. On 1/15/2025 at 9:55 AM, V36, Physician, stated R31 is to have palm protectors in her hands every day. V36 stated R31's hands and knees are contracted. V36 stated R31 now has a circular pillow in place to R31's knees. V36 stated this was put in place after R31 obtained a pressure ulcer. On 1/20/2026 at 1:57 PM, V36 stated upon admission R31 had contractures to her hands and knees. V36 stated he would expect the facility to provide range of motion to R31's hands and knees. V36 stated he is aware of the resident's decline. V36 stated the lack of range of motion contributed to R31's contractures worsening. V36 stated if a person has a contracture and range of motion is not performed, the contracture will get worse. V36 stated R31 is to have her palm protectors in both hands every day. V36 stated he is surprised and would have thought range of motion was being completed. V36 stated he was notified of the wound to R31's knees caused by the pressure of the knees pressing together. V36 stated he would have expected the facility to put appropriate interventions in place to prevent the pressure ulcer from occurring. 2. R30 's Face sheet, dated 1/15/26, documents R30 was admitted to the facility 04/02/2020, with diagnosis of Unspecified protein-calorie malnutrition, Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Admission, Pneumonitis due to inhalation of food and vomit, Ocular pain, unspecified eye, Fever, unspecified Alzheimer's disease with late onset, Cystic fibrosis, unspecified, Pressure ulcer of sacral region, stage 2(History Of) Dysphagia, oral phase, and Pain in left knee. R30's Care Plan, dated 6/28/2024, documents Problem: R30 is at risk for contractures related to decreased mobility. 4/12/2025 Approach: Donn [NAME] guards in AM and doff palmer guards around supper time. 6/28/2024 Approach: PROM Program: Encourage (R30) to participate in PROM exercises. R30's Therapy Recommendation/Communication, dated 3/27/2025, documents R30 is at risk for further contractures to both hands. Recommends bilateral palmer guards. R30's Physician Orders, dated 05/12/2025, documents Apply palmar guards in the AM & off before bed to maintain skin integrity due to hand contractures. R30's Point of Care History Restorative Nursing Passive Range of Motion, documents nothing from 12/4/2025 to 1/1/2026, 1/4/2025, and 1/6/2026 to 1/14/2026. R30's Point of Care History Restorative Nursing Splint Assistance last documented Splints in place 12/3/2025 and nothing after. On 1/12/2025 at 9:30 AM observed R30 in bed with hands closed tights. Unable to open hands upon command. No palm guards in place. at 12:15 PM observed sitting in reclining wheelchair in dining room no palm protectors in place. No staff was seen performing ROM or any exercises with R30 during this observation/investigation. On 1/13/2025 1010 AM, R30 was observed in reclining wheelchair, hands closed tightly. No palm guard in place. 12:00 PM in dining room. No palm guard in place. No staff was seen performing ROM or any exercises with R30 during this observation/investigation. On 1/14/2025 9:30 AM to 10:10 AM, R30 was observed sitting in reclining wheelchair hands closed tightly. No palm guard in place. At 12:30 PM in dining room. No palm guard in place. 1:20 PM sitting in wheelchair next to bed. No palm guard in place. 2:50 PM lying in bed. No palm guard in place. On 1/15/2025 at 9:25 AM, R30 was lying in bed with palm protectors in both hands. On 1/15/2025 at 9:30 AM, V16, CNA, stated R30 cannot open hand independently and is to have the palm protectors in her hand every day. V16 stated they do not do complete range of motion daily and V14, Physical Therapy, performs the range of motion. On 1/15/2025 at 9:40 AM V36, CNA, stated V16 does the range of motion. V36 stated R30's hands are contracted and is supposed to have the palm protector and range of motion daily. 3. R11's Facesheet, dated 1/13/26, documents R11 was admitted to the facility on [DATE] with diagnosis of Cerebra infarction/Cerebral Vascular Accident (CVA), Hemiplegia, affecting left nondominant side, Dysphagia, Depression, Spondylosis without myelopathy or radiculopathy, cervical region, Benign prostatic hyperplasia, Occlusion and stenosis of right carotid artery, Type 2 Diabetes Mellitus (DM), Anxiety disorder, Hypertension, Atherosclerotic heart disease (ASHD), and a pulmonary embolism (PE). R11's Care Plan, dated 3/7/25, documents R11's Resident Care Information: Supportive Devices/Special Equipment: uses a long-handled grabber tool, wheelchair with left foot pedal on at all times, encourage physical improvement by encouraging participation in the AJ's fitness program. 3/14/25: R11 has a history of left sided CVA. Interventions: Encourage R11 to participate in ADL's (activities of daily living), encourage R11 to participate in group exercise class. 4/29/25: R11 is at risk for decrease in cardiovascular tolerance. Interventions: Encourage R11 to preform exercises given by therapy to improve functional status this quarter, encourage R11 to utilize NuStep on level 2 for approximately 15 minutes several times each week. 3/11/25: R11 has a risk for decline in transferring related to history of left sided CVA with weakness and contracture. Interventions: Encourage R11 to call for assistance before attempting to transfer, use assistive devices as needed: walker, wheelchair. R11's MDS, dated [DATE], documents R11 has a severe cognitive impairment and requires partial/moderate assistance from staff for ADLs and transfers. Section O: Restorative Nursing Programs: ROM (Range of Motion) - at least 15 minutes per day for 7 calendar days. Transfer - at least 15 minutes per day for 7 calendar days. Dressing and/or Grooming - at least 15 minutes per day for 7 calendar days. On 1/12/26 at 10:30 AM, R11 was seen sitting in his wheelchair in his room. R11's left side was flaccid from a CVA with his left hand slightly contracted. R11 stated no one does anything with his left arm or leg. No staff was seen performing ROM or any exercises with R11 during this observation/investigation. On 1/13/26 at 10:05 AM, R11 stated he has not had anyone do ROM with him and no one does any exercise with him today or any day. No staff was seen performing ROM or any exercises with R11 during this observation/investigation. On 1/14/26 at 9:05 AM, when R11 was asked about his left hand being contracted, R11 stated, They do nothing with my arm. No one comes to do exercises or anything with me. I do my own at night. I fill a water bottle and use it for a weight. When asked if they have ever put a folded washcloth or anything in his hand to keep it from contracting, R11 stated They did it once at night and it came out while I was sleeping and no one has done it since. No staff was seen performing ROM or any exercises with R11 during this observation/investigation. On 1/14/26 at 10:02 AM, when asked about who does ROM for residents, V20, Certified Nursing Assistant (CNA), stated, We don't do any ROM with the residents. The Fitness Center/Therapy staff is the ones who does the ROM and exercises with the residents. On 1/15/26 at 10:10 AM, V25, Occupational Therapist (OT), stated, The floor CNAs and/or the Restorative CNA, are responsible for ROM and exercises for the residents. We give them a Restorative Program to follow for a resident, and it is their responsibility to keep that program going with the resident. On 1/15/26 at 10:13 AM, V25, OT, stated she worked with R11 from March to May 2025 for transfers, ROM, and restorative program. V25 stated R11's insurance only gave him six visits, so he wasn't with them long. V25 stated R11 has a Restorative Program, and the CNAs/Restorative CNA should be doing Passive ROM (PROM), weightlifting for his good arm, and the (brand name) machine with him. R11's Therapy Recommendation/Communication Record, dated 4/24/25, documents, Adaptive Equipment: Manual Stand Aid. Suggested Nursing Restorative Program: AROM (Active ROM) to be done. Summary recommendations to provide as the resident tolerates: Encourage resident to utilize (Brand name exercise machine) on level 2 for 15 minutes 3-5 times a week. R11's Exercise Program Record, dated 5/5/25, documents Free Weights/Other Exercises: RUE (right upper extremity) shoulder, elbow, wrist - weight 3, 10-15 reps, 2-3 sets. LUE (left upper extremity) PROM shoulder, elbow, wrist, and fingers - 10 reps 1-2 sets - move within available range. The Facility's Nursing Rehab Policies, dated 11/2006, documents, It is the policy of the facility to provide a program to assist the resident to achieve and maintain the maximum level of function physically, mentally and socially. Procedure: Restorative nursing care shall be a part of every resident's individual care plan. The purpose of the program is to assist the resident to achieve and maintain the maximum level of function physically, mentally and socially. The nursing personnel shall receive special instruction, demonstrations and supervision in rehabilitation techniques. They include the following: 1. Good body mechanics: Body mechanics are the efficient use of the head, trunk and extremities. When one learns to apply the principles of good body mechanics, one is better able to work without undue fatigue and muscle strain. 2. Positioning and Turning: This includes maintaining good body alignment in standing, sitting and lying position. Turning indicated by condition of resident and condition of resident's skin. 3. ROM Technique: Residents shall be assisted in maintaining maximum range of motion.

Based on interview and record review, the facility failed to ensure the Certified Nursing Assistant's 12 hour training was completed. This has the ability to affect all 67 residents residing in facility. Findings include:During an employee record review on 1/15/2026, the following was indicated:1. V28, Certified Nurse Assistant (CNA), hired on 9/12/2023. The facility was not able to provide documentation of V28's dementia and 12-hour annual training.2. V20, CNA, hired on 8/21/2024. The facility was not able to provide documentation of V20's dementia and 12-hour annual training.3. V29, CNA, hired on 8/30/2023. The facility was not able to provide documentation of V29's dementia and V12-hour annual training.4. V33, CNA, hired on 2/17/2022. The facility was not able to provide documentation of V33's dementia and V12-hour annual training.5. V34 hired on 6/6/2024. The facility was not able to provide documentation of V33's dementia and V12-hour annual training.On 1/14/2025 at 2:10 PM V35, Human Resources, stated education listed is what she has for education.The facility's Inservice Training policy, revised date 9/11/25, documents the facility shall provide an ongoing in-service program designed to cover job skill, training, and on-going education. The Long-Term Care Facility Application for Medicare and Medicaid (CMS 671), dated 1/13/2026, documents 67 total residents in facility.

Based on observation, interview, and record review, the facility failed to provided dignity for 4 of 10 (R2, R28, R40 and R62) residents, reviewed for residents' rights in a sample of 49. Findings include:1. On 1/12/2026 at 12:10 PM, R40 was sitting up to his wheelchair in the dining room, with his meal tray in front of him and he was not eating. V14, Physical Therapy, was standing next to him and was asking him if he needed help with eating or if he was hungry. R40 stated he was hungry; V14 picked up R40's fork and gave R40 a bite of his chicken pot pie while standing over him. 2.1/12/2026 at 12:15 PM, V14, Physical Therapy, was standing next to R62 and asked her if she needed any help. R62 did not answer her. V14 then picked up R62's fork and was feeding her mashed potatoes while standing over her. On 01/14/2026 at 10:53 AM, V12, Certified Nurse Assistant (CNA), stated he would sit down to feed a resident and not stand over them. On 01/15/2026 at 10:50 AM, V1, Administrator, stated she would expect the staff to sit with the resident that they are giving feeding assistance to. On 01/15/2026 at 11:15 AM, V30, Physical Therapist, stated if they are assisting resident with eating and are giving bites of food to them, they would sit next to the resident. On 01/15/2026 at 11:20 AM, V31, CNA stated she would sit next to the resident when giving them bites of food. On 01/15/2026 at 11:25 AM, V4, Registered Nurse/RN that she would sit next to the resident if she was feeding a resident. 3. R2's Facesheet, dated 1/13/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Osteoporosis, Hypertension (HTN), Anemia, Hypothyroidism, Pervasive Developmental Disorder, Dysphagia, Epilepsy, Schizoaffective disorder depressive type, Radiculopathy, Neuromuscular dysfunction of bladder, Obesity, Wedge compression fracture of third lumbar vertebra, and Mild intellectual disabilities. R2's Care Plan, dated 4/14/25, documents R2's Resident Care Information: Bowel and Bladder: Incontinent with bowel at times/urinary catheter record urine output each shift, Independent to toilet Incontinence Products: Large Pull ups Catheter Care Provide each shift and PRN (as needed). 10/1/24: R2 is on enhanced barrier precautions related to urinary catheter. Interventions: Gown and gloves will be worn when performing high contact care. 11/29/23: R2 has an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. Interventions: 18 French 10 ML (milliliter) urinary catheter as ordered, change catheter and drainage bag as ordered/needed, provide catheter care each shift and PRN. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and requires partial/moderate assistance for most activities of daily living (ADLs) and supervision/touching assistance for transfers. R2 has urinary catheter in place and is occasionally incontinent of bowel. On 1/12/26 at 10:35 AM, R2 was seen sitting in her recliner with her door open. A urinary catheter was hanging on her walker in front of her and was uncovered and viewable from the door. On 1/12/26 at 11:34 AM, V5, CNA, was seen assisting R2 from her recliner to her wheelchair. V5 placed the urinary catheter underneath the wheelchair and was left uncovered and viewable from the door. On 1/12/26 at 11:40 AM, during the lunch observation in the main dining room, R2 was seen in her wheelchair at a table with her urinary catheter hanging off the bottom of her wheelchair and uncovered. On 1/13/26 at 10:08 AM, R2 was seen in her recliner with her urine catheter hanging from the walker and uncovered. On 1/15/26 at 2:05 PM, R2 stated she would prefer her urinary catheter to be in a bag or always covered. 4. R28's Facesheet, dated 1/15/26, documents R28 was originally admitted to the facility on [DATE] with diagnosis of End stage renal disease, Frontal lobe and executive function deficit, Major depressive disorder, Type 2 diabetes mellitus, Psychomotor deficit, Neuromuscular dysfunction of bladder, atrial fibrillation, Urinary tract infection, Dysuria, Chronic obstructive pulmonary disease, Overactive bladder, Anxiety disorder due to physiological condition, seizures, dementia, Hypertension, Cerebral palsy and Hereditary spastic paraplegia. R28's Care Plan, dated 3/1/24, documents R28 has an indwelling foley catheter related to neurogenic bladder with retention. Interventions: 16 fr (French) silicone 10 cc catheter as ordered, change catheter and drainage bag as ordered/needed, provide catheter care every shift and PRN. It continues 12/17/22: R28's Resident Care Information: Enhanced barrier precautions d/t foley catheter and ileostomy, Bowel and Bladder: Ileostomy, Indwelling Foley catheter, dependent with emptying both. R28's MDS, dated [DATE], documents R28 is cognitively intact and is dependent on staff for toileting, bathing, dressing, and requires partial/moderate assistance for other ADLs. R28 has urinary catheter in place. On 1/12/26 at 11:40 AM, during the lunch observation in the main dining room, R28 was seen in her wheelchair at a table with her urinary catheter hanging off the bottom of her wheelchair and uncovered. On 1/15/26 at 2:10 PM, V37, CNA, stated, We are supposed to keep the resident's urinary catheter covered at all times in the blue bags. On 1/15/26 at 2:15 PM, V2, Director of Nursing (DON), stated, I would expect the staff to keep the resident's urinary catheter covered at all times. Residents' Rights for people in Long-term Care Facilities, dated 10/2014, documented, Your facility must provide services to keep you physical and mental health, and sense of satisfaction. It continues, Your facility must make reasonable arrangements to meet your needs and choices.

Based on interview, observation, and record review, the facility failed to maintain resident safety and to provide safe transfers, including using a gait belt and having sufficient fall interventions in place for 5 of 17 residents (R2, R14, R39, R46, R61) reviewed for safe transfers and fall precautions in the sample of 49.The findings include: 1. R2's Facesheet, dated 1/13/26, documents R2 was originally admitted to the facility on [DATE], with diagnoses of Type 2 Diabetes Mellitus (DM), Osteoporosis, Hypertension (HTN), Anemia, Hypothyroidism, Pervasive Developmental Disorder, Dysphagia, Epilepsy, Schizoaffective disorder depressive type, Radiculopathy, Neuromuscular dysfunction of bladder, Obesity, Wedge compression fracture of third lumbar vertebra, and Mild intellectual disabilities. R2's Care Plan, dated 6/13/23, documents R2 is at risk for falling related to decreased mobility, urinary catheter use, pain, history of falls, advanced age, generalized weakness, DM, HTN, and osteoporosis. Interventions: PT (physical therapy) to eval and treat, (non-slip surface) to recliner, staff to always ensure urinary catheter securement device in place, remind R2 to be mindful of limitations, and ask for help when needed, especially when not feeling well, ensure resident's walker is within resident's reach, provide R2 with specialized equipment as needed: wheeled walker. It continues 12/21/25: R2's Resident Care Information: Mobility: dependent in wheelchair, Safe Resident Handling Procedures-Transfer Method: assist x1 walker, Supportive Devices/Special Equipment: walker, urinary catheter, lift recliner. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and requires partial/moderate assistance for most Activities of Daily Living (ADLs) and supervision/touching assistance for transfers. On 1/12/26 at 11:34 AM, V5, Certified Nursing Assistant (CNA), was seen assisting R2 from her recliner to her wheelchair with R2 holding onto her walker. V5 was holding onto R2's right arm pit only, V5 had gait belt wrapped around his own waist, and at no time did V5 place the gait belt around R2. While R2 was standing and holding onto her walker, V5 let go and went behind her to get the wheelchair positioned behind R2, then R2 sat down on the wheelchair. The Facility's Fall Log for the past six months documents R2 has had falls on 8/29/25, 10/19/25, and 10/22/25. The Facility's Gait Belts Policy, dated 12/2002, documents, It is the policy of the facility that all direct care staff shall use a gait belt when transferring or ambulating residents. Purpose of using a gait belt: for the protection of both staff and residents during ambulation and transfers. Procedures: 1. All direct care staff will have a gait belt available for use with transfers. 2. No resident will be transferred or ambulated without the use of a gait belt, unless to do so is contraindicated and this would be identified on resident's plan of care. 3. No staff will transfer or ambulate a resident by his/herself if the transfer takes the assist of two. 4. proper body mechanics will be used when transferring a resident. 5. All new staff will be orientated on the proper use of gait belts and proper body mechanics. 6. Any staff found not using a gait belt, not using it properly, or not using proper body mechanics will be reprimanded as per personnel policies. 2.On 01/13/2026 at11:20 AM, R14 was sitting in his room, between the bed and the wall in his high back reclining chair. His call light was not within reach, and it was lying on the floor. R14 was sitting on the edge of his high back reclining chair attempting to stand up. V15, Registered Nurse (RN), was called and she called for V5, CNA. They entered R14's room and lifted under R14's arms and thighs and lifted him back into his chair without the use of a gait belt. R14's Physicians order sheet, dated 1/15/2026, documented diagnoses of Unspecified dementia, unspecified severity, with agitation and Cerebral infarction, unspecified. R14's Care Plan, dated 10/17/2025, documented, Approach: Assist resident to bed in between meals as tolerated. Approach: Alternate Call light. R14's MDS, dated [DATE], documented that his cognition was severely impaired. and that he was dependent upon staff for transferring to and from his high back wheelchair. R14's Fall risk assessment, dated 11/6/2025, documented he was a high fall risk. 3. 01/14/2026 10:10 AM, R39 was sitting on the toilet. V12, CNA, entered R39's bathroom and she was standing up holding on to her wheelchair. V12 assisted R39 with pulling up her pants and adjusting her clothing but did not place a gait belt on R39 and held on to the back of her pants as she transferred back to her wheelchair. V12, CNA, stated the reason he did not put a gait belt on her was because she was already standing up. R39's Physician's order sheet, dated 1/15/2026, documented diagnoses of Unspecified symptoms and signs involving cognitive functions and awareness, Type 2 diabetes mellitus with other diabetic kidney complication and Chronic atrial fibrillation, unspecified. R39's MDS, dated [DATE], documented she was rarely to never understood and she required partial to moderate assistance for toilet transfers. R39's care plan, dated 9/25/2024, documented, Approach: Safe Resident Handling Procedures-Transfer Method: Assist of one with walker On 01/15/2026 at 11:20 AM, V31, CNA, stated she would place a gait belt on the resident when they are being transferred. On 01/15/2026 at 11:27 AM, V4, RN, stated if she saw a resident trying to stand up, she would put a gait belt on them and help them. On 01/15/2026 at 10:50 AM, V1, Administrator, stated she would expect the staff to use a gait belt on the resident when transferring them. 4.R61's Face Sheet, print date of 1/13/26, documented R61 has diagnoses including dementia, anxiety, atrial fibrillation, chronic kidney disease, dysuria, urinary tract infection, osteoarthritis, and acute candidiasis of vulva and vagina. R61's MDS (Minimum Data Set), dated 12/10/25, documented R61 is severely cognitively impaired and requires partial to moderate assistance with mobility. R61's Fall Risk Assessment, dated 1/6/26, documented R61 is at high risk for falls. R61's Care Plan, undated, documented R61 has pain related to osteoarthritis, history of right and left humerus fracture. R61 is at risk for falling related to diagnosis of dementia, history of falls and weakness. On 1/12/26 at 12:54 PM, V12, CNA (Certified Nurse Assistant), was observed as she pushed R61 in her wheelchair from the dining room into R61's room. V12 stated to Surveyor, the nurse took my gait belt. V12 then put her hand under R61's right arm/shoulder and assisted R61 to stand from the wheelchair and up to her walker. V12 assisted R61 onto and off the toilet by lifting under R61's shoulders. V12 did not use a gait belt at any time during this observation. On 1/12/26 at 1:05 PM, a sign that documented Please do not lift from under my shoulders was observed on R61's wall above her recliner. On 1/13/26 at 11:40 AM, V19, LPN (Licensed Practical Nurse), stated, (R44) injured her right shoulder a long time ago and it still bothers her. (R44) gets lidocaine patches on it, she (R44) is holding her right shoulder now. On 1/13/26 at 11:42 AM, R61 was observed in the dining room as she rubbed her right shoulder. On 1/13/26 at 12:11 PM, V18, CNA, stated, (R61) must have a gait belt around her when she transfers because she was recently hospitalized and is weaker than she was before her hospital stay. 5. R46's Face Sheet, print date 1/14/26, documented R46 has diagnoses including dementia, congestive heart failure, chronic kidney disease, glaucomatous flecks bilaterally, muscle wasting and atrophy, osteoarthritis, and hypertension. R46's MDS, dated [DATE], documented R46 is severely cognitively impaired and requires partial to moderate assistance with ambulation. R46's Fall Risk Assessment, dated 11/10/25, documented R46 is at high risk for falls. R46's Event History document, undated, documented R46 experienced falls on 9/2/25, 9/3/25, 10/26/25, 11/19/25, 11/21/25, 12/5/25, 12/22/25, 1/10/25, and 1/11/25. R46's Care Plan, undated, documented R46 is at risk for falling related to dementia, chronic kidney disease, muscle wasting, and repeated falls. Approaches include move bedside table away from bed to prevent injuries and increased staff rounding related to COVID-19 infection, non-skid strips in front of recliner, fall mat beside bed, grip socks at all times, keep electric bed in the lowest position, and non-skid mat in recliner chair. On 1/14/26 at 10:09 AM, R46 was observed lying in her bed with a bedside table next to the bed. No non-skid strips were observed in front of R46's only chair in her room, nor was a non-skid mat in R46's chair as documented in R46's care plan. On 1/14/26 at 10:36 AM, V18, CNA, stated R46's fall interventions are bed in lowest position and a mat next to R46's bed. V18 stated R46 is currently eating in her room due to her having COVID and R46 sits in the chair in her room for meals. On 1/15/26 at 11:10 AM, V2, Director of Nursing/DON, stated the facility does not have a fall policy and only has a policy on the immediate care after a resident sustains a fall. V2 stated she and the IDT (Interdisciplinary Team) conduct a root cause analysis of the fall and implements interventions based on the analysis. V2 stated she expects fall care plan interventions to be in place as documented in the individual resident's care plan. V2 stated the facility nurses and CNAS should be using gait belts when transferring. V2 stated the CNAS should use gait belts when transferring R61. The facility's Safe Resident Handling policy, revision date of 11/2012, documented the facility is dedicated to providing quality care to residents who have entrusted their lives to us. Our Safe Resident Handling Program is designed to meet the following goals: Improve working conditions by reducing the incidence of back fatigue and musculoskeletal injuries. Maintain a high level of resident dignity and quality care. Standardize all lifting procedures and provide the tools to lift safely. Protect staff and residents from injury. Purpose: This program is designed to limit and remove as much manual lifting as possible. Every staff member is expected to support this program 100% and with tat commitment the program will be successful. Staff Responsible: Nursing, CNAS, Therapy. Procedure: 1. All resident will be assessed for safe resident handling and moving. The assessment will consider: The residents needs/rights and ability to participate with transfer or lifts, the variability in resident behaviors and cognition, staff, and resident safety. 2. Transfers without using a mechanical lifting device are limited to: Assisting residents wo are ambulatory or stable with weight bearing transfer in and out of bed, wheelchairs, chairs, shower chair, tub and stool or commodes. It continues, #9. When physically transferring residents, gait belts will be used to maintain appropriate techniques. The facility's Emergency Care Policy, revision date of 6/27/24, documented Immediate Care of the Resident. A. Falls: 1. Check the resident immediately for ability to move extremities, check for bruised areas and/or cuts. 2. Check resident's ability to explain what happened; evaluate resident's condition before the fall. 3. Interview anyone who witnessed the accident. Determine, if possible where, how, and when the accident occurred. 4. Check for any apparent dislocation or possible fracture. If any signs of this are noted, stabilize resident until ambulance arrives. 5. Exercise special care in transferring the resident, being careful not to cause further injury. Immobilize with splint, if necessary. 6. Call the resident's physician. 7. If head injury has occurred, notify physician and monitor vital signs and neuro checks.

Based on observation, interview, and record review, the facility failed to perform complete incontinent care 4 of 6 (R2, R5, R30, R61,) residents reviewed for incontinent care in a sample of 49. Findings include:1. R30's Care Plan, dated 12/13/2023, documents Resident care information. Approach: Bowel and Bladder: Incontinent Toileting: x2 total assist Incontinence Products- standard brief med. It also documents 10/27/21 Problem: R30 is at increased risk for skin injury R/T (related to) poor nutritional intake, incontinence, decreased mobility, generalized muscle weakness and diagnosis of dementia. Approach: Provide incontinent care after each incontinence episode. R30's Minimum Data Set (MDS), dated [DATE], documents R30 has short and long-term memory problems. It also documents R30 is incontinent and dependent on staff for toileting. On 1/14/2026 at 10:50 AM, V26, Certified Nurse Assistant (CNA), and V27, CNA, performed incontinent care. R30 was incontinent of urine and bowel. Using a wipe, V26 cleansed R30's peri area and inner and outer labia. V26 and V27 assisted R30 onto her left side. V26 then using wipes cleansed R30's entire right buttocks, partial left buttock, leaving stool around the anal area, between the buttocks and on outer lower left buttock. V26 then placed clean incontinent brief beneath R30. V26 and V27 then rolled R30 on to her right-side revealing stool to R30's left outer buttock. V26 then using a wipe cleansed the stool from the left buttock. V26 did not cleanse R30's inner thighs and the stool from R30's anal area and between R30's buttocks. 2. R5's Care Plan, dated 6/19/2025, documents resident is at increased risk for pressure ulcers R/T (related to) decreased mobility, generalized muscle weakness following recent illness and hospitalization. Approach: Provide incontinent care after each incontinent episode. it also documents Resident Care Information Bowel and Bladder: incontinent of both, xi briefs, assist x 1 change in bed R5's MDS, dated [DATE], documents R5 has cognitive impairment, frequently incontinent of bowel and bladder, and dependent on staff for toileting. On 1/13/2025 at 10:00 AM, V9, Licensed Practical Nurse, performed incontinent care. R5 was incontinent of urine. V9 opened R5's soiled incontinent brief, and using a wet washcloth, cleansed R5's groin, top of scrotum and penis. V9 assist R5 onto his right side and cleansed R5's left buttock and partial right buttock. V9 then turned R5 onto his back and applied clean brief. V9 did not cleanse beneath R5's scrotum and the entire right buttock. 3. R2's Facesheet, dated 1/13/26, documents R2 was originally admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM), Osteoporosis, Hypertension (HTN), Anemia, Hypothyroidism, Pervasive Developmental Disorder, Dysphagia, Epilepsy, Schizoaffective disorder depressive type, Radiculopathy, Neuromuscular dysfunction of bladder, Obesity, Wedge compression fracture of third lumbar vertebra, and Mild intellectual disabilities. R2's Care Plan, dated 4/14/25, documents R2's Resident Care Information: Bowel and Bladder: Incontinent with bowel at times/urinary catheter record urine output each shift, Independent to toilet Incontinence Products: Large Pull ups Catheter Care Provide each shift and PRN (as needed). 10/1/24: R2 is on enhanced barrier precautions related to urinary catheter. Interventions: Gown and gloves will be worn when performing high contact care. 11/29/23: R2 has an indwelling urinary catheter related to neuromuscular dysfunction of the bladder. Interventions: 18 fr (French) 10 ML (milliliter) urinary catheter as ordered, change catheter and drainage bag as ordered/needed, provide catheter care each shift and PRN. R2's MDS, dated [DATE], documents R2 is cognitively intact and requires partial/moderate assistance for most activities of daily living (ADLs) and supervision/touching assistance for transfers. R2 has urinary catheter in place and is occasionally incontinent of bowel. On 1/14/26 at 1:20 PM, V16, CNA, and V22, CNA, were observed performing peri/catheter care for R2. R2's brief was unfastened, urinary catheter seen. V16 used wet washcloths and wiped across R2's peri area, both groins, between labia, and wiped the urinary catheter from exit down the tube. V16 kept same gloves on and put her soiled gloves in the soapy water basin to get another wet cloth to continue cleaning R2. R2 was turned to her left side and V16 wiped R2's anal area, showing feces. V16 then obtained wipes and cleaned the feces, then changed gloves. R2 was turned only to her left side with the cleaning of R2's right buttock. R2 was not turned to the right side to clean her left buttock. A clean brief was put on. The catheter care was completed while using soiled gloves and contaminated water throughout the process. 4.) R61's Face Sheet, print date of 1/13/26, documented R61 has diagnoses including dementia, anxiety, atrial fibrillation, chronic kidney disease, dysuria, urinary tract infection, osteoarthritis, and acute candidiasis of vulva and vagina. R61's MDS, dated [DATE], documented R61 is severely cognitively impaired and requires partial to moderate assistance with toileting hygiene. R61's Care Plan, approach start date 1/6/26, documented R61 has a UTI (urinary tract infection) with a goal of UTI will be resolved during this quarter. Approaches include administer antibiotic as ordered, assist R61 with pericare/incontinence care as needed. R61's progress noted, dated 1/7/26 at 9:24 PM, documented resident continues on PO (by mouth) cefdinir (antibiotic) post hospitalization for UTI. On 1/12/26 at 12:54 PM, V12, CNA, was observed as she pushed R61 in her wheelchair into R61's restroom and assisted R61 onto the toilet. V12 did not perform hand hygiene nor did V12 don gloves prior to removing R61's soiled adult brief. Urine and feces were observed in R61's adult brief. R61 finished toileting, V12 then assisted R61 with standing, and V12 wiped the feces from R61's inner buttock. V12 did not cleanse R61's frontal/labia region at all. R61 did not cleanse herself at all nor did V12 verbal cue R61 to cleanse her frontal region. On 1/15/26 at 11:13 AM, V2, DON (Director of Nursing), stated she expects the facility nurses and CNAS to provide complete incontinent care and they should properly cleanse all areas potentially exposed to urine and/or feces. The facility's Perineal Care policy, revision date of 11/2018, documented objective: 1. To cleanse the perineum. 2. To prevent infection and odors. Equipment: 1. Washbasin, 2. Disposable gloves, 3. Soap and water or perineal cleanser or disposable pericare wipes, 4. Clean washcloths, 5. Bath towel, 6. Incontinent under pad, 7. Skin care product. Procedure: 1. Explain the procedure to the resident and bring equipment to the bedside. Screen resident for privacy. 2. Expose perineal area. 3. Wash hands and put on disposable gloves. 4. Wash perineal area with soap and water, perineal cleanser, or wipes. Begin cleansing from the cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. On a circumcised male resident, wash the skin folds at the top of the penis using a circular motion. Begin at the urethra and work downward. On an uncircumcised male resident, pull back the foreskin and wash the tip of the penis. Carefully return the foreskin to its natural position. Be sure to clean from front to back. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel if using perineal cleanser or soap and water. Not necessary to pat dry resident if using wipes. 6. Apply skin care to product to skin. 7. Remove gloves and wash your hands. 8. Assist resident to a comfortable position. 9. Observe condition of resident's skin and report any significant finding to nurse.

Based on observation, interview, and record review, the facility failed to perform hand hygiene before and after glove changes, failed to perform hand hygiene in between residents during care, and failed to properly handle drinking glasses and medications for 10 of 15 (R1, R30, R33, R34, R40, R42, R49, R56, R61and R62) residents, reviewed for infection control, in a sample of 49. Findings include:1. On 1/12/2026 at 12:10 PM, R40 was sitting up to his wheelchair in the dining room, with his meal tray in front of him and he was not eating. V14, Physical Therapy, was standing next to him and was asking him if he needed help with eating or if he was hungry. R40 stated he was hungry, and V14 picked up R40's fork and gave R40 a bite of his chicken pot pie while standing over him. V14 then went over to R62, and without benefit of hand hygiene, started giving her bites of her mashed potatoes. On 01/15/2026 at 10:50 AM, V1, Administrator, stated she would expect the staff to wash their hands in between residents after providing care. On 01/15/2026 at 11:15 AM, V30, Physical Therapist, stated if they were assisting a resident with eating and went to help another resident, she would wash her hands. On 01/15/2026 at 11:20 AM, V31, Certified Nurse Assistant (CNA), stated she would wash her hands after assisting a resident with their meal and before helping another resident. On 01/15/2026 at 11:25 AM, V4, Registered Nurse/RN, stated she would wash her hands after assisting a resident with their meal. 2. R30's Care Plan, dated 12/13/2023, documents resident care information. Approach: Bowel and Bladder: Incontinent Toileting: x2 total assist Incontinence Products- standard brief med. It also documents 10/27/21 Problem: (R30) is at increased risk for skin injury R/T (related to) poor nutritional intake, incontinence, decreased mobility, generalized muscle weakness and diagnosis of dementia. Approach: Provide incontinent care after each incontinence episode. R30's Minimum Data Set (MDS), dated [DATE], documents R30 has short and long-term memory problems. It also documents R30 is incontinent and dependent on staff for toileting. On 1/14/2026 at 10:50 AM, V26, CNA, and V27, CNA, performed incontinent care. V26 performed hand hygiene and applied clear gloves. V26 then opened R30's soiled incontinent brief. V26 then removed and changed clear gloves. No hand hygiene performed. V26 then used the wipes to clean R30's peri area. V26 then removed soiled gloves and applied new pair of clear gloves. No hand hygiene performed. V26 and V27 then turned R30 onto the left side and V26 cleansed R30's buttocks. V26 removed soiled gloves walked across the room and grabbed clear gloves from the box on wall and applied clean gloves. No hand hygiene performed. V26 then removed the soiled incontinent brief from beneath R30 and handed to V27. V27 took a hold of soiled incontinent brief and linen. V27 then removed 1 glove. V26 using soiled gloved hand reached into pocket, grabbed glove, and handed to V27. V27 then applied the glove. No hand hygiene performed. V26 and V27 then rolled R30 onto her right side and cleansed stool from R30's buttock. V26 and V27 assisted R30 onto her back. V26 then removed soiled glove and applied another pair of clear gloves. No hand hygiene. On 1/14/2025 at 10:55 Am V26 stated that she was not going to wash her hands or perform hand hygiene between glove changes because she wouldn't be able to apply her gloves. V26 stated that the blue gloves work fine but the clear gloves do not and do not allow for you to reapply when washing hands. 3) On 1/12/26 at 11:50 AM, V11, Activity Assistant, was observed as she was passing cups of drinks to residents in the Memory Care dining room. V11 placed her hand over the top of the cups with her fingers touching top rim of the cups. V11 placed a clothing protector on R33. V11 did not perform hand hygiene after touching R33 and then proceeded to pass drink cups by touching the top rim to R34 and R61. 4) On 1/12/26 at 11:58 AM, V12, CNA (Certified Nurse Assistant), was observed as she picked up a sandwich with her bare hands off R34's plate and fed it to R34. V12 did not perform hand hygiene nor don gloves before feeding R34. 5) R1's face sheet, print date of 1/14/26, documented R1 has diagnoses including dementia, sepsis, COPD (chronic obstructive pulmonary disease), obstructive and reflux uropathy, benign prostatic hyperplasia, and osteoarthritis. R1's MDS, dated [DATE], documented R1 is severely cognitively impaired and requires substantial to maximal assistance with ADLS (activities of daily living). R1's Care Plan, undated, documented R1 requires an indwelling urinary catheter related to urinary retention. On 1/13/26 at 11:51 AM, R1 was observed in the dining room on the Memory Care Unit. R1's indwelling urinary catheter bag and tubing were observed sitting directly on the floor under his wheelchair. On 1/14/26 at 12:05 PM, R1 was observed in the dining room on the Memory Care Unit with his indwelling catheter bag and tubing directly on the floor. On 1/14/26 at 1:51 PM, V18, CNA, and V23, CNA, were observed as they transferred R1 from his wheelchair to his bed via a sit to stand lift. V18 and V23 donned gloves and gowns. V18 removed R1's pants and adult diaper that was soiled with feces. V18 then retrieved a trashcan from the floor of R1's room, placed the trash can directly on top of R1's bed on R1's bed linens, then went to R1's dresser drawer and obtained a new adult disposable brief while wearing the same disposable gloves as was used to remove R1's soiled adult brief. V18 then proceeded to cleanse R1's indwelling catheter site and penis while wearing the same gloves as was used to retrieve the trash can and adult brief from R1's dresser drawer. V18 did not perform hand hygiene nor don clean gloves prior to cleansing R1's penis. On 1/15/26 at 11:15 AM, V2, DON (Director of Nursing), stated she would expect facility staff to perform hand hygiene before passing drinks and food to residents. V2 stated facility staff should not touch the top rim of resident cups. V2 stated facility staff should not touch food with their bare hands. V2 stated CNAs should perform hand hygiene and don new gloves before performing indwelling catheter care. V2 stated facility staff should not place a trashcan on residents' beds nor linens. V2 stated indwelling urinary catheter bags nor tubing should be on the floor of the facility. 6. R42's Facesheet, dated 1/13/26, documents R42 was originally admitted to the facility on [DATE] with diagnosis of dementia with psychotic disturbance, cerebral infarction affecting right dominant side, hemiplegia and hemiparesis, peripheral vascular disease, atherosclerotic heart disease, overactive bladder, anxiety disorder, and hypertension (HTN). R42's Care Plan, dated 3/16/23, documents R42 is at increased risk for pressure injury and impaired skin integrity related to edema, decreased mobility, incontinence, generalized muscle weakness. Interventions: Provide incontinent care after each incontinent episode. 4/17/25: R42's Resident Care Information: Enhanced barrier precautions, Bowel and Bladder: Incontinent of both, assist x 2 changed in bed. R42's, MDS, dated [DATE], documents R42 has a severe cognitive impairment and is dependent on staff for ADLs. R42 is always incontinent of both bowel and bladder. On 1/12/26 at 12:53 PM, V5, CNA, and V10, CNA, was seen assisting R42 from wheelchair to his bed and checking for incontinence. There was an Enhanced Barrier Precaution (EBP) sign on door, Personal Protective Equipment (PPE) cart outside door. Neither CNA donned PPE. V10 did not do hand hygiene before donning gloves. After transfer, V10 kept the same gloves the entire time. V10 pulled R42's pants down, rolled R42 and removed sling from under him, covered R42 up, and touched several items in the room all with the same soiled gloves on and no hand hygiene. On 1/15/26 at 2:15 PM, V2, DON, stated, I would expect staff to wear appropriate PPE and perform hand hygiene when required. 7. 1/13/26 at 9:10 AM, V4, Registered Nurse (RN), was observed passing medications to R49 and R56. During this med pass, V4 was seen popping the medications out of the card, with some medications missing the medicine cup and landing on the medication cart, with V4 then picking the medication up with her fingers and putting it into the medicine cup. V4 was also seen getting a pill from the medicine cup with her fingers and putting it back into a bottle of medicine. The Facility's Enhanced Barrier Precautions Policy, dated 3/28/24, documents, It is the policy of the facility to use proper PPE during high-contact resident care activities that provide opportunities for transfer of MDROs (multi-drug-resistant organisms) to staff hands and clothing. 3. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. The Facility's Infection Control Policy, dated 12/17/19, documents, Standard Precautions: Standard Precautions are based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precaution should be applied to the care of all residents regardless of the suspected or confirmed presence of an infectious agent. Standard precautions include but are not limited to 1. Hand hygiene. 3. Proper use of PPE (gloves, gowns, mask, et.). Transmission-based Precautions: The purpose of isolation techniques is to protect the resident and personnel from infection and to halt the spread of the infectious agent. Emphasis will be placed on isolating the disease, not the resident. All isolation precautions will fall into one of the following categories: 1. Airborne precautions. 2. Contact Precautions. 3. Droplet Precautions. Hand washing is the foundation of controlling infectious disease. Personnel must wash their hands when coming on duty; when they are visibly soiled; when they are between residents; before and after they blow their nose; after eating or off break; after they handle dressings, urinals, bedpans, needles, or syringes; after toileting use; and when they complete duty. Unless hand washing is specifically required, antimicrobial agents such as alcohol-based hand rubs (AHBR) are appropriate for cleaning hands and can be used for direct resident care.

Based on interview, observation, and record review, the facility failed to provide a hearing assist device to maintain hearing ability for 1 of 1 resident (R43) reviewed for resident hearing assist devices in the sample of 49.The findings include: R43's Facesheet, dated 1/13/26, documents R43 was originally admitted to the facility on [DATE], with diagnosis of Dementia, Psychotic disturbance, mood disturbance, anxiety, Benign prostatic hyperplasia, hypertension (HTN), hearing loss bilateral, Spinal stenosis, cervical region, intervertebral disc degeneration thoracolumbar region, and Retention of urine.R43's Care Plan, dated 4/18/25, documents 12/27/23: R43's Communication: R43 is very hard of hearing as well as his vision is poor. R43 uses a white board with large print to communicate with staff as well as others. R43 needs assistance with understanding verbal and written medical information. 4/18/25: R43's Resident Care Information: Hearing: hard of hearing Device: no hearing aids but does have a hearing amplification device with headphones but chooses not to wear, staff should speak loud and clear and if resident is still unable to hear utilize the whiteboard in resident's room. Supportive Devices/Special Equipment: high back reclining w/c, scoop mattress, tubi grips to bilateral lower extremities, hearing amplification device but chooses not to wear and whiteboard. R43's Minimum Data Set (MDS), dated [DATE], documents R43 has a severe cognitive impairment and is dependent on staff for Activities of Daily Living (ADLs). R43 is always incontinent of both bowel and bladder.R43 is deaf or extremely hard of hearing. During this investigation and observations, there was no method of communication assistance seen. All staff were wearing a surgical mask and R43 was unable to read anyone's lips. R43 appears frustrated at times frequently stating, I cannot hear you.On 1/12/26 at 11:03 AM, R43 was seen lying in bed, was not awake, and did not wake up with questions asked due to being deaf. There was no white board or other hearing assistance device seen in the room.On 1/13/26 at 9:50 AM, V3, Certified Nursing Assistant (CNA)/Shift Coordinator, and V8, CNA, were observed in R43's room to get him back to bed and check for incontinence. Both CNAs were trying to talk to R43 with R43 yelling, I can't hear you. and neither one used a white board or assistive device and was trying to talk loudly in R43's ear with R43 still saying, I can't hear you. When asked about using a hearing assist device, V3 stated, He used to have a hearing assist device, but I think the family took it home because I don't see it anywhere.On 1/13/26 at 10:15 AM, R43 was seen in a wheelchair for breakfast, then assisted back to bed after breakfast. R43 was observed unable to communicate with staff, stating he can't hear anyone, and he can't read lips due to everyone wearing a mask. Staff was speaking loudly with R43; R43 yelled, I can't hear you.On 1/14/26 at 8:55 AM, R43 was seen in a wheelchair at his doorway. R43 was given a piece of paper and pen and asked, Have they tried writing things down with you to communicate better? and R43 stated, They don't write things down.On 1/14/26 at 10:20 AM, V24, R43's Nephew, was seen visiting him. V24 stated, There is a hearing assist device that plugs into headphones; it is kept in (R43's) drawer, along with a small white board. They used to have a large white board to use, but that disappeared. V24 stated he visits once a week or once every other week, and the hearing assist device is always available and kept in his drawer because it belongs to the facility. V24 stated there is no other family that visits and he has never taken the device home. V24 was seen with the device plugged up into headphones and speaking into the device to talk to R43 with R43 responding to him appropriately.On 1/15/26 at 1:40 PM, V2, Director of Nursing (DON), stated, I would expect all staff that are communicating with (R43) should be using either the white board or the hearing assist device that is kept in his room. If you don't use it, yelling in his ear doesn't help because all he tells you is 'I can't hear you.'The Facility's Communication with Hearing Impaired Residents and Non-English-Speaking Residents Policy, dated 6/1/22, documents, The facility shall provide a means in which to communicate with both hearing impaired and non-English speaking residents. The facility provides auxiliary hearing aids or qualified interpreters hearing-impaired residents and non-English speaking residents where necessary to afford such residents an equal opportunity to benefit from the services provided by the facility.

Based on interview and record review, the facility failed to put interventions in place prevent 1 of 1 (R31) residents from developing a pressure ulcer in a sample of 49. Findings include:R31's Care Plan, last reviewed/revised dated 1/13/2026, documents Problem: Resident is at increased risk for pressure ulcers R/T (related to) decreased mobility, generalized muscle weakness, DM (Diabetes Mellitus), CKD (Chronic Kidney Disease), hx (history) of lung cancer, hx of falls.R31's Progress Notes, dated 01/08/2026 at 5:57 PM, documents, During incontinence cares CNA (Certified Nurse's Assistant) staff called this nurse into the room to show me 2 pressure areas and a bruise. Resident has a 9cm (centimeters) by 4cm bruise to the middle of her left thigh. Resident has a 2cm-by-2cm stage 2 pressure injury to her L knee, this nurse cleansed the area with soap and water, applied a collagen sheet, and a secondary dressing. Resident has a 2cm by 0.5cm Stage 1 pressure injury to her right knee. This nurse applied skin prep. PCP (primary care physician) notified. Attempted to contact POA (power of attorney) left a voicemail.R31's Braden scale, dated 9/24/2025, 10/7/2025 and 10/14/2025 document R31 is at risk for pressure ulcers.R31's Skin Integrity Events - Pressure Injury, dated 1/8/2025, documents on 1/8/2025 an open 2cm by 2cm Stage 2 pressure injury to left knee.R31's progress Notes, dated 1/10/2026 at 3:30 AM, treatment to bilateral knees applied, treatment was uncomfortable to resident, Resident stated it was painful to separate knees for the treatment to be done. Heel boots and knee pillow in place to prevent further pressure injury.R31's Wound detail report, dated 01/13/2026 at 10:30 AM, documents 01/08/2026 at 12:27 PM a 2cm x 2cm unspecified ulcer was observed. On 01/13/2026 at 04:27 PM 100% of wound cover in slough with yellow or tan, cloudy and thick exudate observed to wound bed. Wound edges/margins are Irregular and wound edges; Macerated/soft. Healing status declining.R31's Progress Note, dated 01/13/2026 at 4:28 PM, documents that Stage 2 pressure injury to left knee noted to have slough present to wound bed with current treatment. No odor, warmth, and seropurulent drainage noted. Order changed at this time due to slough present at wound bed with drainage to calcium alginate with silver and cover with dry dressing.R31's Physician Order, dated 1/8/2026 - 1/13/2026, documents Cleanse wound to L knee with wound cleanser, pat dry, apply collagen sheet, and cover with secondary dressing BID until healed.On 1/13/2025 at 10:30 AM observed V9, Licensed Practical Nurse (LPN), perform treatment to left knee. V9's knees observed pressing together and pressure relieving device between lower thighs. Wound bed observed with a yellow slough to wound bed. Drainage present. Wound edges were macerated.On 1/13/2025 at 10:30 AM, V9 stated the area to R31's inner thighs was a pressure ulcer. V9 stated the wound occurred from R31's knees pressing together due to contractures. V9 stated they put pillows in place and they did not work. V9 stated they have put a pressure relieving device in place now. V9 stated when applied correctly, it relieves pressure between her knees. V9 stated the pressure relieving device was applied after the pressure ulcer occurred.On 1/15/2025 at 9:40 AM, V16, CNA, stated R31's knees press together and that they were putting pillows between her knees. V16 stated after R31 got the wound they put a pressure relieving device in place.On 1/15/2025 at 9:55 AM, V36, CNA, stated R31's hands and knees are contracted. V36 stated R31 now has a circular pillow in place to R31's knees. V36 stated this was put in place after R31 obtained a pressure ulcer.On 1/20/2026 at 1:57 PM V37, Physician, stated upon admission R31 had contractures to her hands and knees. V37 stated he would expect the facility to provide range of motion to R31's hands and knees. V37 stated he is aware of the resident's decline. V37 stated the lack of range of motion contributed to R31's contractures worsening. V37 stated if a person has a contracture and range of motion is not performed, the contracture will get worse. V37 stated R31 is to have her palm protectors in both hands every day. V37 stated he is surprised and would have thought that range of motion was being completed. V37 stated he was notified of the wound to R31's knees caused by the pressure of the knees pressing together. V37 stated he would have expected the facility to put appropriate interventions in place to prevent the pressure ulcer from occurring.The facility's Pressure Injury/Pressure Ulcer prevention and Treatment Protocol, dated 10/16/2024, documents that Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical' or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/ or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Principles: 3. All high and moderate risk residents will be assessed for the needs of the items below. If the intervention is initiated, it will be added to the care plan. A. Special mattress and wheelchair cushions B. PROM's C. Protein and/or Nutritional Supplements D. Turning and positioning schedule E. Skin checks F. Elbow/heel protectors/bridging of heels.

Based on observation, interview, and record review, the facility failed to provide timely treatment for 1 of 3 residents (R68) reviewed for change of condition in the sample of 33. This failure resulted in R68 delay in treatment and requiring hospital admission. Findings include: 1. R68's nursing notes, dated 12/01/2024 at 10:17 AM, documents attempted to contact radiology for x-ray results and left message on answering machine. R68's nursing notes, dated 12/1/2024 at 1:23 PM, documents, contacted Nurse Practitioner unable to obtain x-ray results and resident continues with decline in physical mobility, cough with yellow sputum, afebrile, wheezing bilateral upper lobes. and received NO (nurse order) for Ceftriaxome IM QD (daily) x 3 days. CBC (complete blood count) and CMP (comprehensive metabolic profile) on Monday 12-02-24. R68s' nursing notes, dated 12/01/2024 at 11:13 PM, documents, resident experiencing nasal congestion, denies dyspnea or shortness of breath. Resident afebrile at 98.4 F. Diffuse wheezing auscultated to bilateral lungs. Resident denies experiencing a productive cough. Resident has brisk capillary refill with no cyanosis present. HOB elevated pulse oximetry at 98% on room air. R68's final x-ray results, dated 12/2/2024 at 7:41AM, documents minimal bibasilar airspace disease, may represent atelectasis, aspiration or pneumonia. R68's nursing notes, dated 12/02/2024 at 09:02 AM, documents, resident noted to have increase in weakness requiring use of sit-stand. He continues to have cough, congestion, and wheezing heard in upper and bilateral lobes. Vitals were 145/77, 89% on RA (Room air), (initiated PRN oxygen at 2L) , T (Temperature):100, RR (Respiratory Rate) 20 (Pulse), P 77. He states during exertion he is SOB (Short of breath) but not at rest. Resident placed into isolation r/t (related to) s/s (signs and symptoms) and awaiting test at this time. On 12/2/2024 at 10:33AM, R68 stated, I am sick that is why I am in isolation R68's Hospital history and physica,l dated 12/2/2024 at 4:11PM, documents coarse lung sounds throughout with diffuse expiratory wheeze. Complaint community acquired pneumonia. R68's hospital admission history and physical documents R68 complains of body aches, weakness and non -productive cough. R68's history and physical documents assessment and plan ; community acquired pneumonia, supplemental oxygen via nasal cannula, titrate as able, vitals every 4 hours, respiratory failure. On 12/5/2024 at 12:50PM, V1, Administrator, stated she took R68 to the local hospital for an X-ray on Saturday 11/30/2024, as (x-ray company) could not be at facility until Monday. V1 stated when called hospital for x-ray results were told x-ray results not be read until Monday. V2 stated X-ray results came in sometime on Monday. The facility policy Change in a resident's condition, revised 12/02, documents, the facility shall promptly notify the resident, and /or residents's representative, and his or her attending physician of changes in the resident's condition and/or status. The policy documents the nurse will notify the resident's attending physician when there is a significant change in the resident's physical , mental , or psychosocial status; deemed necessary or appropriate in the best interest of the resident. The facility policy diagnostic service dated revised 11/28/17 documents provision has been made for promptly and conveniently obtaining required clinical laboratory , x-ray and other diagnostic services from clinical laboratory or diagnostic service, physicians office or hospital.

Based on observation, interview, and record review, the facility failed to properly store medication, label tuberculin vial, and maintain medication carts locked. This has the potential to affect all 80 residents living in the facility. Findings include: 1. On 12/2/2024 at 10:30 AM, Memory Lane medication Cart was observed unlocked and out of sight of nurses. 2 nurses observed sitting at the nurse's station with back to medication cart. On 12/9/2024 at approximately 11:00 AM V2, Director of Nursing, stated she expects the medication carts to be locked when not in use. 44967 2. On 12/2/24 at 11:45 AM, V4, Registered Nurse (RN), was seen walking away from her med cart, which was unlocked, and computer screen open to resident, sitting next to nurses desk and by dining room. V4 opened the med room and attempted to open fridge, but could not find a key that would open the fridge.V4 contacted Director of Nursing (DON), attempted keys from other floor, and still not able to open. On 12/2/24 at 12:22 PM, Maintenance was called to cut lock off when the DON came with keys that she had in her office and opened the fridge. Upon opening, there was a vial of Tuberculin (TB) in the fridge with a label on the vial indicating it was for the facility stock with a delivered date of 9/27/24. The vial and the box was opened and not dated, the vial appeared half full. On 12/2/24 at 1:05 PM, V4, RN, stated, The TB vial in the fridge is used for both staff and residents. If I would find it undated to when it was opened, I would discard it. When told it does not have a date opened, V4 stated, I will go throw it away now and let the Infection Prevention nurse know to replace it. On 12/9/2024 at 12:15 PM, V16, Licensed Practical Nurse/LPN, stated the medication carts are to be locked when not in use. V16 stated when the TB is opened, an open date is applied. V16 stated TB is good for 30 days after opening, and the open date is important because it tells when that discontinue date is. V16 stated the mult dose TB vial is used for all residents and is a stock medication The Tuberculin Purified Protein Derivative (Mantoux) Tubersol package insert, dated April 2016, documents, A vial of TUBERSOL which has been entered and in use for 30 days should be discarded. The facility's Pharmaceutical Procedures policy, dated 1/5/23, documents, IV. Procurement and Labeling of Drugs: Drug Labeling: E. Each floor stock container shall bear the name and strength of the medication, lot and control number, expiration date (when applicable), and any other appropriate accessory or cautionary information. V. Care and Storage of Medications A. Drug supplies for the facility shall be stored under proper conditions of sanitation, temperature, light, refrigeration, and moisture. B. Residents' medications shall be properly labeled and stored at or near the nurses' station in: 1. a locked cabinet, or 2. a locked medication room, or 3. one or more locked mobile medication carts. All mobile medication carts shall be under the visual control of the responsible nurse at all times when not stored safely and securely - either in a locked room or otherwise made immobile.

Based on interview, observatoin, and record review, the facility failed to store food products and wash hands to prevent food borne illness. This failure has the potential to affect all 80 residents living in the facility. Findings include: On 12/02/24 at 8:56 AM, the kitchen was entered for initial tour. A large plastic storage container of flour did not have a lid on it. A large plastic storage container of roll oats and thickener both had a measuring cup in them with the handles in the product. A bag of brown sugar has a measuring spoon in it laying on top of the brown sugar. In the walk in refrigerator on the bottom shelf there is a box of beef on top of a box of pork which is on top of box of pork. These 3 boxes are not separated by drip tray. On 12/5/24 at 11:37 AM, V22, Dietary Aide, donned gloves with no hand hygiene, made a grilled cheese sandwich, removed gloves, put bread away, went to the walk-in refrigerator and put cheese away, came out of the walk-in and removed gloves, and washed hands. On 12/5/24 at 11:53 AM, V22 grabbed a glove and entered the walk-in refrigerator. V22 came out of the walk-in refrigerator with a large bag of chopped lettuce and a large bag of cheese. V22 put on one glove, reached into the lettuce and got a handful and placed it in bowl, then reached into the bag of cheese and got a handful and placed it in the bag. V22 removed her glove, got a new glove, went to the walk in refrigerator, and came out holding 2 frozen chicken patties, placed them in the air fryer, and removed her gloves. On 12/5/24 at 12:00, V23, Dietary Aide, with his bare hand, rubbed the end of his nose, took a food tray, put the food tray back on the service line, removed the plate of food, place it on a new food tray, got a soda can, and fruit salad, and served it to the dining room. On 12/2/24 at 9:10 AM, V3, Kitchen Manager, stated the storage bins should not have measuring cups or spoons stored in them. She stated she will fix the meat in the walk in refrigerator. On 12/9/24 at 8:14 AM, V1, Administrator, stated the facility does not have a policy on how to defrost meat in the the refrigerator, kitchen staff hand hygiene, or glove use. V1 stated she expects staff to not stack boxes of different meats on top of each other while in the refrigerator, and staff should wash their hands before donning gloves and after removing gloves. The Application of Medicare and Medicaid, dated 12/5/24, documents the facility has 80 residents living in the facility.

Based on interview, observation, and record review, the facility failed to provide timely and complete incontinence care, including proper hand hygiene and glove changes for 5 of 5 residents (R8, R34, R36, R46, R76) reviewed for incontinence care in the sample of 33. The findings include: 1. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with diagnoses of Need for assistance with personal care, muscle weakness/wasting and atrophy, Lack of coordination, Generalized anxiety disorder, Depression, Vitamin deficiency, and Chronic obstructive pulmonary disease. R8's Care Plan, dated 11/11/24, documents R8's Resident Care Information: R8 is to be assessed for incontinence of bowel and bladder every 2 hours, Bowel and Bladder: Incontinent x2 assist, Incontinence Products Briefs: standard XL brief, Offer bed pan for toileting. R8's Minimum Data Set (MDS), dated [DATE], documents R8 is cognitively intact and is dependent on staff for other Activities of Daily Living (ADLs). R8 is always incontinent of both bowel and bladder. On 12/2/24 at 11:50 AM, V6, Certified Nursing Assistant (CNA), in to provide incontinent care to R8. V6 donned gloves and searched every drawer for wipes, and was unable to find any, so doffed her gloves and left the room, then came back with wash cloths and put them into the sink. V6 donned gloves again and unfastened R8's brief and tucked it between her legs, V10, CNA, came in to help, with no hand hygiene while she donned gloves, and began wiping R8's groins, folded the wash cloth, then wiped once down the middle of R8's vagina, then R8 was rolled to her left side, showing stool. V6 used a wet wash cloth and wiped R8's anal area, then realized they needed more wash cloths, so V10 left the room to obtain more, came back in the room with no hand hygiene seen done, V10 donned gloves, wet more cloths from the sink and handed them to V6 and V6 wiped R8's anal area and Right buttock, then rolled R8 to the right, and the soiled brief and linen removed from under R8. There was no wiping of R8's left buttock, which had small amount of feces seen. R8 was then rolled to her back and the brief secured. There was no drying of R8 at any time during incontinence care. Both CNAs doffed their gloves, with no hand hygiene after care and before leaving the room. 2. R34's Face Sheet, undated, documents R34 was admitted to the facility on [DATE], with diagnoses of Atherosclerotic heart disease (ASHD), Anemia, Malignant neoplasm of skin, Atrial fibrillation, Weakness, Hypertension, and Hyperlipidemia. R34's Care Plan, dated 11/26/24, documents R34's Resident Care Information: Bowel and Bladder: Continent Toileting: Assist of two, Incontinence Products: XL Incontinence brief. R34's MDS, dated [DATE], documents R34 is cognitively intact and is dependent on staff for ADLs, including toileting. R34 is always incontinent of both bowel and bladder. On 12/2/24 at 12:26 PM, R34 was lying in bed with V10, CNA, and V6, CNA, getting ready to do incontinent care on R34. R34's brief was unfastened and tucked between his legs. V10 had a few washcloths and wet them from running water in the sink, then used the wet washcloths to wipe R34's peri-area, both groins, his testicles, and the shaft of R34's uncircumcised penis. At no time was R34's foreskin retracted and penis properly cleaned. R34 was turned to his right and the soiled brief was removed, then V10 wiped R34's anal area and buttocks, and applied a new brief to R34. Both CNAs doffed their gloves, then put R34's pants on him. There was no hand hygiene seen done before care, during glove changes, or after care, or before leaving the room. There were only wet washcloths with no cleansing product used during incontinent care. 32874 3. R36's Minimum data set (MDS), dated [DATE], documents R36 is dependant on staff for toileting. R36's MDS documents R36 is always incontinent of stool and urine. R36's care plan, dated 10/27/2021, documents R36 is at risk for skin injury related to poor nutritional intake, incontinence. R36's care plan documents document incontinent care after each incontinent episode. On 12/03/24 at 11:25AM, during incontinent care, R36 was turned to right side by V14, CNA. V14 washed V14's hands with soap and water, then donned gloves. R36 was incontinent a large amount of stool extending into vaginal area. V14, CN,A with folded wash cloth, wiped down R36's left groin, then folded wash cloth and cleaned right groin. V14, with clean wash cloth, then wiped down R36's peri area, and did not separate the labia to clean. 4. R46's cae plan, dated 9/17/2024, documents R46 has had multiple UTI's in the past 12 months. R46's care plan documents assist R46 with peri care after each use of restroom. On 12/03/24 at 9:58AM V8, CNA, entered room, placed gait belt on R46, assisted R46 to stand with walker, and walked to bathroom within room . V8 removed adult diaper which had stool in it, as verified by V8. V8 then took clean wipes standing behind R46 at back of stool and swiped from from to back twice, then got another wipe and cleansed rectal area. V8 then removed gloves and donned new gloves and swiped from front to back of R46's peri area. V8, CNA, then wiped buttock and pulled up adult brief. V8, CNA, did not separate the labia during care, or dry R46. 42108 5. R76's Care Plan, dated 9/11/2024, documents, Problem: Resident Care Information Approach: Bowel and Bladder: incontinent of both bowel and bladder, wears large (incontinence briefs). It also documents, 11/26/2024 Problem: (R76) has a UTI (Urinary Tract Infection). R76's MDS, dated [DATE], documents R76 is severely cognitively impaired, always incontinent of bowel and bladder, and dependent on staff for toileting. On 12/5/2024 at approximately 12:45 PM, V25, Certified Nurse Assistant (CNA), and V26, CNA, performed toileting for R76. R76 was incontinent of urine. V26 and V25 assisted R76 into the standing position. V26 then pulled R76 pants and undergarment down. V26 then removed the urine soiled undergarment and placed in the trash. V26 then assisted R76 into the sitting position on toilet. V26 and V25 left the room. At 12:50 PM, V25 and V26 returned and assisted R76 with toileting. V26 applied incontinent brief. V25 and V26 assisted R76 into a standing position. Using a wet wipe, V26 wiped R76's buttocks 3 times, and pulled R76's incontinent brief and pants up. On 12/5/2024 at 12:51 PM, V26, stated she (V26) was not sure R76 used the toilet. On 12/5/2024 at 12:51 PM, V25 stated she (R76) usually voids during transfer to toilet. On 12/9/2024 at approximately 11:00 AM, V2, Director of Nursing, stated she expects staff to perform incontinent care on a resident if they are incontinent, even if they use the toilet afterwards. On 12/9/2024 at 12:15 PM, V16, Licensed Practical Nurse/LPN, stated she would expect the staff to cleanse all areas of incontinence and follow the policy. V16 stated she would expect them to cleanse the peri and groin area, labia, penis, buttocks, and all areas that urine would touch. V16 stated even if the resident voided after being incontinent, she would expect incontinent care to be performed. On 12/9/2024 at 12:27 PM, V11, CNA, stated when cleansing a resident, she cleanses all areas of incontinence. V11 stated if the resident is incontinent and voids on the toilet, she performs incontinent care including the labia, penis, peri area, inner thighs, both buttocks, any area that the urine would touch. The Facility's Perineal Care Policy, dated 11/2018, documents, Objective: 1. To cleanse the perineum. 2. To prevent infection and odors. Equipment: 1. Washbasin. 2. Disposable gloves. 3. Soap and water or perineal cleanser or disposable peri-care wipes. 4. Clean washcloths. 5. Bath towel. 6. Incontinent underpad. 7. Skin care product. Procedure: 1. Explain the procedure to the resident and bring equipment to the bedside, screen resident for privacy. 2. expose perineal area. 3. Wash hands and put on disposable gloves. 4. Wash perineal area with soap and water, perineal cleanser or wipes. Begin cleansing from cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. On a circumcised male resident, was the skin folds at the top of the penis using a circular motion. begin at the urethra and work downward. On an uncircumcised male resident, pull back the foreskin and wash the tip of the penis. carefully return the foreskin to its natural position. Be sure to clean from front to back. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel if using perineal cleanser and or soap and water. No necessary to pat dry resident if using wipes. 6. Apply skin care product to skin. 7. Remove gloves and wash your hands. 8. Assist resident to a comfortable position. 9. Observe condition of resident's skin and report any significant findings to nurse. The Facility's Proper Hand Washing Procedure, undated, documents Proper handwashing is the most effective way to reduce microorganisms to prevent the spread of infection. Total [NAME] for effective hand washing should take 20 seconds. When to wash hands: Employees must wash their hands: After removing disposable gloves, after engaging in any activity that would contaminate hands, after touching anything that contaminates hands.

Based on interview, observation, and record review, the facility failed to perform hand hygiene, change gloves, and properly store soiled lines for 7 of 8 (R8, R34, R36, R46, R64, R73, R76) reviewed for infection control in the sample of 33. Findings include: 1. R64's Face Sheet, print date of 12/5/24, documents R64 was admitted on [DATE] and has a diagnosis of Dementia. On 12/03/24 10:27 AM, V9, Certified Nurses Aide (CNA), and V10, CNA, entered R64's room to provide incontinent care for R64. R64's incontinent brief was removed. It had a small amount of feces. V9 cleansed the rectal area, buttocks, changed gloves with no hand hygiene in between, cleansed the peri area, changed gloves with no hand hygiene in between, and placed a new incontinent brief on R64. 2. R73's Face Sheet, print date of 12/3/24, documents R73 was admitted on [DATE] and has diagnosis of Dementia with psychotic disturbance. On 12/2/24 at 11:30 AM, V32, CNA, and V33, CNA, entered R73's room to provide incontinent care and to turn and reposition R73. R73's soiled adult incontinent brief was removed. It was soiled with feces. V32 cleansed R72's penis with pre moistened peri-wash cloths, rolled R73 over on to his right side, and with pre-moistened prewash cloths, R73's rectal area and buttocks were cleansed. V32 removed her gloves, got a wash cloth wet and put liquid soap on it, donned new gloves, cleansed the scrotum of feces, then dried the rectal area, buttocks, and scrotum. V32 placed a new incontinent brief. V32 and V33 both changed gloves without hand hygiene, positioned R73 for comfort. During the care, V33 threw the soiled sheet and bed pad on the floor. V33 placed the soiled items in a bag removed her gloves, failed to perform hand hygiene, and then left the room. On 12/9/24 at 10:47 AM, V2, Director of Nursing, stated staff should preform hand hygiene before donning gloves, between glove changes, and after removing gloves. V2 stated that soiled linens should not be thrown on the floor. 32874 3. On 12/03/24 at 11:25AM, during incontinent care on R36, V8, CNA, with gloved hands, wet wash cloths. V8 wiped front to back, and with visible stool on gloves of right hand, V8 used left hand to remove glove from right hand . No hand sanitizing done prior to donning new right glove. 4. On 12/03/24 at 9:58AM, V8, CNA, entered room and placed a gait belt on R46, assisted R46 to stand with walker, and walked R46 to bathroom within room. V8, CNA, donned gloves V8 did not sanitize hands prior to donning gloves. V8 placed adult diaper and wipes on back of stool; adult diaper fell on floor. V8, CNA, doffed gloves and got another diaper from drawer. V8, CNA, did not sanitize hands prior to removal or donning new gloves. V8 removed adult diaper, which had stool in it, as verified by V8, CNA. V8 removed gloves; did not sanitize hands prior to donning gloves. V8 then took clean wipes standing behind resident at back of stool and swiped from from to back twice then got another wipe and cleansed rectal area. V8 then removed gloves and donned new gloves without sanitizing hands. 42108 5. R76's Care Plan, dated 9/11/2024, documents Problem: Resident Care Information Approach: Bowel and Bladder: incontinent of both bowel and bladder, wears large pull ups. It also documents 11/26/2024 Problem: (R76) has a UTI (Urinary Tract Infection). R76's MDS, dated [DATE], documents R76 is severely cognitively impaired, always incontinent of bowel and bladder and dependent on staff for toileting. On 12/5/2024 at 12:45 PM, V25, Certified Nurse Assistant (CNA), and V26, CNA, performed toileting for R76. R76 was incontinent of urine. V26 and V25 applied gloves and assisted R76 into the standing position. R76 was incontinent of urine. V26 then removed the urine soiled undergarment and placed in the trash. V26 then assisted R76 into the sitting position on toilet. V26 and V25 removed gloves and left the room. At 12:50 PM, V25 and V26 returned and assisted washed hands, applied gloves and R76 with toileting. V26 applied incontinent brief. V25 and V26 assisted R76 into a standing position. Using a wet wipe, V26 wiped R76's buttocks 3 times. Using the same soiled gloves, V26 pulled R76's clean incontinent brief and pants up. On 12/9/2024 at 12:15 PM, V16, Licensed Practical Nurse/LPN, stated she expects the staff to use good hand hygiene and change gloves as appropriate. On 12/9/2024 at 12:27 PM, V11, CNA, stated when cleaning a resident the gloves are changed after touching soiled and before touching clean undergarments and clothing. 44967 6. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Fracture of left humerus, Cellulitis, Morbid obesity, Urinary incontinence, Cardiomegaly, Malignant neoplasm of endometrium, Chronic Kidney Disease -stage 2, Hemiplegia, Aphasia, Urinary Tract Infection, and Type 2 Diabetes Mellitus. R8's Care Plan, dated 11/11/24, documents R8 Resident Care Information: R8 is to be assessed for incontinence of bowel and bladder every 2 hours, Bowel and Bladder: Incontinent x2 assist, Incontinence Products Briefs: standard Xl brief, Offer bed pan for toileting. R8's MDS, dated [DATE], documents R8 is cognitively intact and is dependent on staff for other ADLs. R8 is always incontinent of both bowel and bladder. On 12/2/24 at 11:50 AM, V6, CNA, provided incontinent care to R8. V6 donned gloves and searched every drawer for wipes and was unable to find any, so V6 doffed her gloves and left the room, then came back with wash cloths and put them into the sink. V6 donned gloves again and unfastened R8's brief and tucked it between her legs. V10, CNA, came in to help. No hand hygiene was done while she donned gloves. V10 began wiping R8's groins, folded the wash cloth, then wiped once down the middle of R8's vagina, then R8 was rolled to her left side, showing stool. V6 used a wet wash cloth and wiped R8's anal area, then realized they needed more wash cloths, so V10 left the room to obtain more, came back in the room with no hand hygiene done. V10 donned gloves, wet more cloths from the sink and handed them to V6, and V6 wiped R8's anal area and right buttock, then rolled R8 to the right, and the soiled brief and linen removed from under R8. There was no wiping of R8's left buttock, which had small amount of feces. R8 was then rolled to her back and the brief secured. There was no drying of R8 at any time during incontinence care. Both CNAs doffed their gloves with no hand hygiene done after care and before leaving the room. 7. R34's Face Sheet, undated, documents R34 was admitted to the facility on [DATE], with diagnoses of Atherosclerotic heart disease (ASHD), Anemia, Malignant neoplasm of skin, Atrial fibrillation, Weakness, Hypertension, and Hyperlipidemia. R34's Care Plan, dated 11/26/24, documents R34's Resident Care Information: Bowel and Bladder: Continent Toileting: Assist of 2, Incontinence Products: XL Pullups. R34's MDS, dated [DATE], documents R34 is cognitively intact and is dependent on staff for ADLs, including toileting. R34 is always incontinent of both bowel and bladder. On 12/2/24 at 12:26 PM, R34, was lying in bed with V10, CNA, and V6, CNA, getting ready to do incontinent care on R34. R34's brief was unfastened and tucked between his legs. V10 had a few wash cloths and wet them from running water in the sink, then used the wet wash cloths to wipe R34's peri-area, both groins, his testicles, and the shaft of R34's uncircumcised penis. At no time was R34's foreskin retracted and penis properly cleaned. R34 was turned to his right and the soiled brief was removed, then V10 wiped R34's anal area and buttocks, and applied a new brief to R34. Both CNAs doffed their gloves, then put R34's pants on him. There was no hand hygiene done before care, during glove changes, after care, or before leaving the room. There were only wet wash cloths with no cleansing product used during incontinent care. The Facility's Perineal Care Policy, dated 11/2018, documents Objective: 1. To cleanse the perineum. 2. To prevent infection and odors. Equipment: 1. Washbasin. 2. Disposable gloves. 3. Soap and water or perineal cleanser or disposable peri-care wipes. 4. Clean washcloths. 5. Bath towel. 6. Incontinent underpad. 7. Skin care product. Procedure: 1. Explain the procedure to the resident and bring equipment to the bedside, screen resident for privacy. 2. expose perineal area. 3. Wash hands and put on disposable gloves. 4. Wash perineal area with soap and water, perineal cleanser or wipes. Begin cleansing from cleanest area in front to the most soiled area in back. Be sure that a clean surface of the washcloth is used for each wipe. On a female resident, clean the labia and its folds first. On a circumcised male resident, was the skin folds at the top of the penis using a circular motion. begin at the urethra and work downward. On an uncircumcised male resident, pull back the foreskin and wash the tip of the penis. carefully return the foreskin to its natural position. Be sure to clean from front to back. 5. After cleansing is complete, rinse if necessary, and then dry the resident by patting skin gently with a clean bath towel if using perineal cleanser and or soap and water. No necessary to pat dry resident if using wipes. 6. Apply skin care product to skin. 7. Remove gloves and wash your hands. 8. Assist resident to a comfortable position. 9. Observe condition of resident's skin and report any significant findings to nurse. The Facility's Proper Hand Washing Procedure, undated, documents Proper handwashing is the most effective way to reduce microorganisms to prevent the spread of infection. Total [NAME] for effective hand washing should take 20 seconds. When to wash hands: Employees must wash their hands: After removing disposable gloves, after engaging in any activity that would contaminate hands, after touching anything that contaminates hands.

Based on interview and record review, the facility failed to prevent abuse for 1 of 1 residents (R63) reviewed for abuse in the sample of 33. Findings include: R63's Face Sheet, print date of 12/9/24, documents R63 was admitted on [DATE] and has a diagnosis of Dementia. R63's Minimum Data Set, dated dated [DATE], documents R63 is severely cognitievely impaired. R73s' Face Sheet, print date of 12/3/24, documents R73 was admitted on [DATE] and has diagnosis of Dementia with psychotic disturbance. R73's Minimum Data Set, dated dated [DATE], documents R73 is severely cognitively impaired. R73's Nurses Note, dated 11/03/2024 09:29 PM, documents, CNAs (Certified Nurses Aides) observed res. (resident) go into wife's (R63s') room, argue with her, and then hit her in face x 2. Staff intervened and assisted res. out of room. Res. very HOH (hard of hearing) and has difficulty understanding others. Appears to get frustrated with wife and staff d/t (due to) not understanding. Attempted to use communication board or writing things out on paper, but doesn't appear to understand that either. Res. taken to own room and assisted res to bed. Res up to br (bathroom) and back to bed at this time is resting well. Steristrips intact to old skin tear on rt elbow. On 12/9/24 at 9:40 AM, V29, Certified Nurse Aide, stated, After dinner, I was with another resident (R77) in the hall by the dining room because she was having an episode. I heard (R73) and (R63) having a commotion. They were having a disagreement. (R63) was getting aggravated with (R73). (R73) was standing in front of (R63) and he slapped her in the face. I left (R77) and went to separate them and redirect (R73). I went back to (R77). When I turned around, (R73) was back in-front of (R63) and he slapped her again. I am not sure who I told the nurse that was on duty that night or the morning nurse. I did not let (V1, Administrator) know. The policy Abuse Prohibition and Reporting, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraining not required to treat resident symptoms.

Based on interview and record review, the facility failed to report an allegation of abuse to the Illinois Department of Public Health for 1 of 1 resident (R63) reviewed for abuse in the sample of 33. Findings include: R63's Face Sheet, print date of 12/9/24, documents R63 was admitted on [DATE] and has a diagnosis of Dementia. R63's Minimum Data Set, dated dated [DATE], documents R63 is severely cognitievely impaired. R73's Face Sheet, print date of 12/3/24, documents R73 was admitted on [DATE] and has diagnosis of Dementia with psychotic disturbance. R73's Minimum Data Set, dated dated [DATE], documents R73 is severely cognitively impaired. R73's Nurses Note, dated 11/03/2024 09:29 PM, documents, CNAs (Certified Nurses Aides) observed res. (resident) go into wife's (R63s') room, argue with her, and then hit her in face x 2. Staff intervened and assisted res. out of room. Res. very HOH (hard of hearing) and has difficulty understanding others. Appears to get frustrated with wife and staff d/t (due to) not understanding. Attempted to use communication board or writing things out on paper, but doesn't appear to understand that either. Res. taken to own room and assisted res to bed. Res up to br (bathroom) and back to bed at this time is resting well. Steristrips intact to old skin tear on rt elbow. On 12/3/24 at 8:50 AM, V1, Administrator, stated she does not have an abuse investigation for R73. V1 stated there is a follow up note in his record because R73 did not slap his wife; he was trying to wake her up from her chair by shaking the chair. V1 stated she did not find out about this incident until they came across the note, also in his record. On 12/3/24 at 2:09 PM, V31, Director of Memory Care, stated, I was not here when the abuse allegation happened. I was notified later that evening by a CNA. She said they (R73 and wife) had gotten into it at the dining table and the nursing staff called (V1) and took care of it. The next day I came in and read the note about him hitting her. I went and asked (V1) if she was aware, and she said she wasn't. I left it at that, because it is (V1's) job to investigate abuse. On 12/3/24 at 2:34 PM, V30, Licensed Practical Nurse, stated, On 11/3/24, a Certified Nurses Aide (CNA) came and told me that he was getting excited and slapped his wife. I told (V2, Director of Nurses) called the family, and the Doctor. I did not let (V1) know. On 12/9/24 at 9:40 AM, V29, Certified Nurse Aide, stated, After dinner, I was with another resident (R77) in the hall by the dining room because she was having an episode. I heard (R73 and R63) having a commotion. They were having a disagreement. (R63) was getting aggravated with (R73). (R73) was standing in front of (R63), and he slapped her in the face. I left (R77) and went to separate them and redirect (R73). I went back to (R77). When I turned around, (R73) was back in-front of (R63), and he slapped her again. I am not sure who I told the nurse that was on duty that night or the morning nurse. I did not let (V1) know. The policy Abuse Prohibition and Reporting, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraining not required to treat resident symptoms. It continues, B. Initial steps and reports of alleged abuse or neglect 1. Facility employee or agent who becomes aware of alleged abuse or neglect of resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator then the facility employee or agent should immediately report the matter to the facility DON (Director of Nurses) 2. If the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee shall provide the Illinois Department of Public Health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more that 2 hours after the matter becomes known or not later that 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. It continues, 7. If the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. It continues, Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected, other staff or residents who may have witnessed the incident, and any other person who may have information related to incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewed in the course of the investigation. 4. the Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health.' It continues, 1. the shift nurse on duty who is first made aware of any allegations of abuse or neglect concerning any resident shall immediately examine the resident involved to determine whether the resident is an any distress or has suffered any injury. The nurse shall take all steps necessary to protect the resident from danger, and document as necessary. 2. If the incident involves suspected abuse, then the shift nurse shall assure that the suspected abuser has no further contact with the resident involved or withany other resident.

Based on interview and record review, the facility failed to investagate an allegation of abuse for 1 of 1 resident (R63) reviewed for abuse in the sample of 33. Findings include: R63's Face Sheet, print date of 12/9/24, documents R63 was admitted on [DATE] and has a diagnosis of Dementia. R63's Minimum Data Set, dated dated [DATE], documents R63 is severely cognitievely impaired. R73's Face Sheet, print date of 12/3/24, documents R73 was admitted on [DATE] and has diagnosis of Dementia with psychotic disturbance. R73's Minimum Data Set, dated dated [DATE], documents R73 is severely cognitively impaired. R73's Nurses Note, dated 11/03/2024 09:29 PM, documents, CNAs (Certified Nurses Aides) observed res. (resident) go into wife's (R63s') room, argue with her, and then hit her in face x 2. Staff intervened and assisted res. out of room. Res. very HOH (hard of hearing) and has difficulty understanding others. Appears to get frustrated with wife and staff d/t (due to) not understanding. Attempted to use communication board or writing things out on paper, but doesn't appear to understand that either. Res. taken to own room and assisted res to bed. Res up to br (bathroom) and back to bed at this time is resting well. Steristrips intact to old skin tear on rt elbow. On 12/3/24 at 8:50 AM, V1, Administrator, stated she does not have an abuse investigation for R73. V1 stated there is a follow up note in his record because R73 did not slap his wife; he was trying to wake her up from her chair by shaking the chair. V1 stated she did not find out about this incident until they came across the note, also in his record. On 12/3/24 at 2:09 PM, V31, Director of Memory Care, stated, I was not here when the abuse allegation happened. I was notified later that evening by a CNA. She said they (R73 and wife) had gotten into it at the dining table and the nursing staff called (V1) and took care of it. The next day, I came in and read the note about him hitting her. I went and asked (V1) if she was aware, and she said she wasn't. I left it at that, because it is (V1's) job to investigate abuse. On 12/3/24 at 2:34 PM, V30, Licensed Practical Nurse, stated, On 11/3/24 a Certified Nurses Aide (CNA) came and told me that he was getting excited and slapped his wife. I told (V2, Director of Nurses), called the family, and the Doctor. I did not let (V1) know. On 12/9/24 at 9:40 AM, V29, Certified Nurse Aide, stated, I don't know anything about (R73) hitting his wife (R63) in her room. After dinner, I was with another resident (R77) in the hall by the dining room because she was having an episode. I heard (R73 and R63) having a commotion. They were having a disagreement. (R63) was getting aggravated with (R73). (R73) was standing in front of (R63), and he slapped her in the face. I left (R77) and went to separate them and redirect (R73). I went back to (R77). When I turned around, (R73) was back in front of (R63), and he slapped her again. I am not sure who I told the nurse that was on duty that night or the morning nurse. I did not let (V1) know. The policy Abuse Prohibition and Reporting, dated 11/28/19, documents, The facility actively prohibits resident abuse including neglect, corporal punishment, involuntary seclusion, misappropriation of property, injuries of unknown source, exploitation, and use of any physical or chemical restraining not required to treat resident symptoms. It continues, B. Initial steps and reports of alleged abuse or neglect 1. Facility employee or agent who becomes aware of alleged abuse or neglect of resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator then the facility employee or agent should immediately report the matter to the facility DON (Director of Nurses) 2. If the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee shall provide the Illinois Department of Public health with initial notice of the alleged abuse or serious bodily injury as soon as possible, but not more that 2 hours after the matter becomes known or not later that 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. It continues, 7. If the incident involves alleged abuse and substantiated evidence indicates that another resident of the facility is the perpetrator of the abuse, then the administrator shall take all steps necessary to protect all residents in the facility from abuse until the alleged perpetrator can be evaluated. It continues, Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. 2. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected, other staff or residents who may have witnessed the incident, and any other person who may have information related to incident. 3. The Administrator shall keep copies of all notes from the interviews conducted by the Administrator or other facility interviewed in the course of the investigation. 4. the Administrator shall be responsible for supervising the investigation and reporting the results of the investigation to the Illinois Department of Public Health.' It continues, 1. the shift nurse on duty who is first made aware of any allegations of abuse or neglect concerning any resident shall immediately examine the resident involved to determine whether the resident is an any distress or has suffered any injury. The nurse shall take all steps necessary to protect the resident from danger, and document as necessary. 2. If the incident involves suspected abuse, then the shift nurse shall assure that the suspected abuser has no further contact with the resident involved or withany other resident.

Based on interview record review, the facility failed to provide 2 of 5 residents (R46, R73) with written documentation as to why they were being sent to the hospital, for residents reviewed for transfer in the sample of 33. Findings include: 1. R73's Face Sheet, print date of 12/3/24, documents R73 was admitted on [DATE] and has diagnosis of Dementia with psychotic disturbance. R73's Minimum Data Set, dated dated [DATE], documents R73 is severely cognitively impaired. R73's Nurses Note, dated 11/06/2024 03:54 PM, documents, Resident returned from (local emergency room ) with no new orders or changes in condition. Per the hospital record, no new findings were identified. The left pupil, which had been noted as dilated earlier, was documented in the hospital as a previous finding from an earlier event (likely related to an injury from a past fire-related incident). This was confirmed in the hospital record, and no acute concerns regarding the pupil were raised. The resident's blood and blood clots in the urine were evaluated during the ER (emergency room ) visit; however, no additional issues were noted, and the urinary findings were not considered a new or urgent concern at this time. The attending physician at the hospital cleared the resident for return to the facility, and no further acute interventions were required. Resident's condition remains stable, and they will continue to be monitored closely for any changes. On 12/9/24 at 11:30 AM, V28, Licensed Practical Nurse, stated she does not remember if she gives anything to the resident in plain verbage as to why they are going out to the hospital. 32874 2. R46's face sheet, dated 11/18/2024, documents admitted [DATE]; latest return from hospital. R46's record does not document R46 was orientated or prepared for hospital transfer. On 12/3/2024 at 10:16AM, R46 stated she had been to the hospital several times this past year. On 12/5/2024 at 8:30AM, V16, Licensed Practical Nurse (LPN), stated the facility does not hand the resident anything in regards to reason for transfer. V16 stated there is no information handed specifically to the resident. V16 stated the information is given to the emergency medical staff. On 12/5/2024 at 8:50AM V2, Director of Nursing (DON), stated the facility does not provide the resident anything in writing in regards to reason for transfer. The facility policy transfer of a resident dated, revised 1/11/2023 documents, it is the policy of the facility to have established procedures for all types of resident transfers. The policy documents upon order by the physician to transfer a resident to the hospital , the family and /or representative and hospital shall be notified. The policy documents nurse will communicate information necessary to meet resident needs during resident transfer to the hospital.

Based on interview and record review, the facility failed to initiate a level 2 Preadmission Screening and Resident Review (PASARR) for one of 3 residents (R32) reviewed for PASAAR in the sample of 33. Findings include: 1. R32's face sheet, undated, documents diagnoses of Schizoaffective disorder, depressive type, and pervasive developmental disorder, unspecified. R32's PASARR level one report, dated 5/25/2023, documents, there is no evidence of a condition of an intellectual/developmental disability or a serious behavioral health condition. If changes occur or new information refutes these findings , a new screen must be submitted. On 12/05/24 at 1:39 PM V27, Social Services, stated on admission R32 did not have a diagnosis of schizoaffective or pervasive personality disorder. V27 stated when the physician added a diagnosis of schizoaffective disorder and pervasive on 10/10/24, there was no Level 2 PASAAR done. V27, Social Services, stated a level 2 should be done with her change in diagnosis. On 12/9/2024 at 10:45AM, V1, Administrator, stated the facility does not have a policy on PASAAR. V1 stated she would expect the facility to follow the Illinois Department of Public Health (IDPH) guidelines on PASAAR requirements.

Based on observation, interview, and record review, the Facility failed to provide feeding assistance for 3 of 5 residents (R8, R41, and R52) reviewed for nutrition and feeding assistance in the sample of 33. The findings include: 1. R41's Face Sheet, undated, documents R41 was originally admitted to the facility on [DATE], with diagnoses of Generalized muscle weakness/wasting, falls, Lack of coordination, Hemiplegia/Hemiparesis affecting left side, Cerebral infarction, Trans Ischemic Attack (TIA), Anxiety disorder, Sacroiliitis, Right artificial shoulder joint, Hypertension (HTN), Anemia, Atrial Fibrillation, Chronic Kidney Disease (CKD) - stage 3, and prediabetes. R41's Care Plan, dated 11/15/24, documents R41 has had a 9% weight loss over 90 days. Interventions: Offer R41 house supplement with breakfast and lunch. It continues 9/18/24: Resident Care Information: Mobility: X1. Encourage ambulation to and from meals with staff assist. Regular diet/thin liquids Assistance for eating: set up; feeds self. R41's Minimum Data Set (MDS), dated [DATE], documents R41 is cognitively intact and is independent for eating. R41's Nutritional Assessment, dated 9/19/24, documents Feeding Capabilities: Independent/Supervised. R41's Physician Order (PO), dated 8/22/24, documents Weekly Weight. Once A Day on Fri. R41's PO, dated 5/29/24, documents Regular Diet. R41's PO, dated 11/15/24, documents House Supplement 4oz with breakfast and lunch. R41's Dietary Note, dated 10/22/24 at 1:26 PM, documents, RD (Registered Dietician) eval (evaluation) for Oct (October) wt (weight) loss. Ht (Height) 59 10/1 wt 130# (pounds) with wt loss of 10.3% x 90 days and 14.1% x 180 days. 10/18 wt 130.2# BMI (Body Mass Index) 26.29. History of gradual wt loss, wts currently stable x 2months. Regular diet. Past intakes appear not to be meeting needs. Overall wt per BMI remains acceptable. Rec (recommend) adding house supplement with breakfast and lunch for additional support, goal is to prevent further wt loss. Monitor and f/u (follow up) as indicated. R41's Administrator Note, dated 11/8/24 at 9:45 AM, documents, Resident triggered for a weight loss @ (at) 90 days. Supplemental shakes requested TID (three times daily). MD (Medial Doctor) notified, will monitor weekly. On 12/2/24 at 1:00 PM, R41 was seen sitting in her room eating lunch (salisbury steak, mashed potatoes with gravy) on a normal plate and regular utensils. R41 was trying to use a fork to eat while her hands were shaking and her food was falling off the fork and all over. There was no supplemental shake seen on her lunch tray. V12 and V13, R8's Daughters, were visiting, and brought in pizza for R8 and R41, to eat and stated R8 and R41 should not use a fork to eat because they shake so much, the food just falls off and flies all over the room. V12 and V13 stated no one ever helps either R8 or R41 to eat. On 12/5/24 at 1:00 PM, R41 was seen in the dining room with regular plate and silver ware. R41 had a ham sandwich and was just eating the pieces of ham, R41 had a cup of juice and a cup of milk in front of her. There was no supplemental shake seen on her lunch tray. V24, CNA, stated, (R41) uses a sippy cup ([NAME] Cup) because she shakes so bad and can't use a regular cup. (R41) usually gets finger foods, such as sandwiches and such, so she can use her fingers to eat. (R41) is on a regular diet with regular texture. (R41) has a cup of juice and a cup of milk with her lunch today. V24 stated she is not aware of R41 getting any kind of supplement, and she doesn't see one with her lunch. On 12/9/24 at 12:20 PM, R41 was seen sitting at the dining room table eating spaghetti with a normal plate and normal utensils. R41 was seen shaking badly with spaghetti falling off her fork. R41 was picking up her piece of garlic bread and eating it, after trying to eat the spaghetti with a fork. On 12/9/24 at 12:22 PM, V28, was seen assisting other residents with feeding. When asked about R41 needing assistance, V28 stated, I don't normally work with (R41), but I can see she does shake badly. V28 asked V37, Licensed Practical Nurse/LPN, about R41 needing feeding assistance. V37 walked up to R41 and asked her if she needed help, and R41 stated No. R37 walked away without assisting R41. On 12/9/24 at 12:45 PM, R41 was seen leaving her dining room table with minimal amount of spaghetti eaten, and most of her piece of garlic bread. 2. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Fracture of left humerus, Cellulitis, Morbid obesity, Urinary incontinence, Cardiomegaly, Malignant neoplasm of endometrium, Chronic Kidney Disease -stage 2, Hemiplegia, Aphasia, Urinary Tract Infection, and Type 2 Diabetes Mellitus. R8's Care Plan, dated 11/11/24, documents R8 Resident Care Information: Diet: Regular/thin liquids, Finger foods when available. Assistance for eating: set up for meals Adaptive Equipment: scoop plate/Kennedy cups. R8's MDS, dated [DATE], documents R8 is cognitively intact and requires set up/clean up assistance for meals, and substantial assistance to dependent on staff for all other ADLs. R8's Physician Order (PO), dated 3/15/24, documents, Pro-Stat AWC (amino acids-protein hydrolys) - 17-100 gram-kcal/30 mL, Twice A Day. R8's PO, dated 4/29/23, documents, Diet: Regular. R8's electronic medical record, under vitals: Weights: documents R8's weight on 1/19/24 was 161.3lbs, and with the most recent weight of 184lbs. R8's Dietician Note, dated 6/23/24 at 5:07 PM, documents, RD eval May wt gain. Ht 62 5/7 wt 172# with wt gain of 11.7% over 180 days. 6/4 wt 176#. BMI 32.19-obese. Diet is regular, per meal card sent K cups and finger foods. Intake appears adequate to meet needs based on wt history. Prostat AWC 30ml TID continues with current wounds on right toe and shin, not identifed as pressure wounds. No changes at this time. Monitor and f/u as indicated. On 12/2/24 at 12:25 PM, R8 seen with plate of food on bedside table. R8 was sitting in chair trying to eat with fork. R8 was very shaky and food falling all over. No staff seen attempting to help R8 with eating. No special utensils or plate was used. On 12/2/24 at 1:00 PM, R8 was seen sitting in her room eating lunch. R8 was trying to use a fork to eat, with food falling all over. V12 and V13, R8's Daughters, were at R8's bedside assisting R8 to eat. V12 and V13 brought in pizza for R8 and her roommate (R41) to eat. V12 and V13 stated R8 cannot use a fork to eat and they have talked to the facility, including the kitchen staff, about giving R8 finger foods because she uses her fingers to eat most of the time. V12 and V13 stated R8's lunch had meat (salisbury steak), and mashed potatoes and gravy, which she cannot eat with her fingers, and it falls off the fork due to R8 shaking. V12 and V13 stated R8 is supposed to have a special plate with sides on it, and they are supposed to bring her finger foods, and they don't, so the family will bring in something R8 can eat with her hands. V12 and V13 stated R8's roommate, R41, is the same way, and no one every helps them eat, and they are so shaky that food falls all over. On 12/5/24 at 12:55 PM, R8 was seen sitting in her room, R8 stated her grandson came in and brought her lunch and helped her. R8's plate for this meal had curved edges and regular silverware sitting on the table. The Facility's Special Needs Policy, dated 11/28/17, documents, To address special needs, this facility will provide the necessary care and treatment, including medical and nursing care, consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences. Purpose: to properly provide routine and emergency care and treatment to residents with special needs pertaining to parenteral fluids, respiratory care, prostheses, and dialysis. Procedure: 1. Comprehensive care plans will be developed based on resident assessments, goals, and preferences in accordance with assessment and care plan procedures. 2. The facility will utilize a systematic approach for the management of special needs, including efforts to identify risk; stabilize, reduce, or remove underlying risk factors; monitor the impact of the interventions; and modify the interventions as appropriate, including emergency situations. The Facility's Nursing Rehab Policy, dated 11/06, documents, It is the policy of the facility to provide a program to assist the resident to achieve and maintain the maximum level of function physically, mentally, and socially. 33112 3. R52's Face Sheet, print date of 12/5/24, documents R52 was admitted on [DATE] and has diagnoses of Parkinsonism and Neurocognitive disorder with Lewy Bodies. R52's Minimum Data Set, dated dated [DATE], documents R52 has moderate cognitive impairment and requires set up clean-up assistance with dining. R52's Care Plan, dated 11/11/22, documents, Resident Care Information. Approach: Regular Diet, thin liquids. Assistance for eating; set up tray Adaptive Equipment; Kennedy cups; curved spoon takes meals in main dining room. On12/2/24 at 12:25 PM, R52 was served her lunch of Salisbury steak, corn, and mashed potatoes. No staff offered to open up her silverware or cut up her meat. R52 sat and stared at her plate, and holding her rolled up silverware. At 12:35 PM, R52 was trying to cut up her meat. R52 was unsuccessful. R52 was placing the knife on top of the Salisbury steak and trying to get the knife up to her mouth and lick the knife. R52 was unsuccessful. R52 was attempting to eat her mashed potatoes with her knife. R52 backed away from her table in her wheelchair. R52 pushed with her feet backwards to the middle of the dining room. No staff attempted to redirect her or encourage her to eat. At 12:57 PM, R52 asked staff to cut up her meat. V10, Certified Nurses Aide (CNA), stated she could do it for her, and did. V10 walked away. R52 was unable to get the food into her mouth. At 1:16 PM, V4, Registered Nurse (RN), asked R52 if she was done. R52 stated No, I can eat more. V4 asked R52 if she needed help, R52 stated Yes. V4 gave her 3 bites while standing up at her side. R52 then tried to feed herself again. V4 then pushed her wheelchair closer to the table and walked away. R52 tried to feed herself. V4, from across the room, said, Hold up you're really struggling today let me help you, and pulled up a chair and began to feed her. On 12/9/24 at 8:30 AM, V1, Administrator, stated the facility does not have a feeding policy, but she would expect staff to assist any resident with eating if they needed it.

Based on observation, interview, and record review, the facility failed to supervise and prevent an altercation for 2 of 2 (R3, R4) residents, reviewed for incidents and accidents in a sample of 5. This failure resulted in R4 being sent to the local emergency department after an altercation with R3 and sustaining facial contusion, contusion of both forearms and contusion to her right shoulder. Finding includes: R3's Minimum Data Set, dated dated [DATE], documented R3 was unable to complete the questions to gauge his cognition. It continued to document he was severely impaired for decision making, Physical behavioral symptoms directed towards other that had been occurring for 1 to 3 days and that he also had the ability to put others at significant risk for physical injury. R3's Face Sheet, undated, documented diagnoses of Dementia with agitation, Dementia with Anxiety and Blindness Right and Left eye. R3's Care Plan, dated 8/8/2023, documented, When (R3) is displaying s/s of behaviors offer to call his wife (V16, R3's wife). It continues, If (R3) displays behaviors during cares, allow him space and attempt task at a later time. R4's MDS, dated [DATE], documented R4's cognition was severely impaired. R4's Face Sheet, undated, documented a diagnosis of Dementia without behavioral, psychotic mood or anxiety disturbance. R3's Progress notes, dated 04/03/2024 at 1:00 PM, documented, [Recorded as Late Entry on 04/04/2024 11:04 AM] Resident was very confused and agitated with staff, Resident was yelling, help call the police, and was exit seeking. Resident did become combative with staff, and bit this nurse's arm, but did not break the skin. Resident was redirected, and his wife was called for a distraction. R3's Progress notes, dated 04/03/2024 at 2:19 PM, documented, Resident was increasingly agitated, with minimal success in redirecting with multiple different approaches attempted. His wife came to facility and talked with him to calm him. Resident setting in his room with his wife listening to a ballgame. R3's Progress notes, dated 04/04/2024 at 09:23 AM, documented, (Resident) continues to have behaviors. (Resident) was assisted down to ride the exercise bike with therapy ad he refused to stand up and participate. Staff unable to redirect and had to bring (Resident) back to his room and assisted into recliner. Continues on rexulti medication change. R3's Progress notes, dated 04/06/2024 at 3:01 PM, documented, Resident was verbally aggressive this afternoon for a short period and was redirected with some effort. R3's Progress notes, dated 04/12/2024 at 2:22 PM, documented, Resident having verbal and physical behaviors towards staff. Stating he was going to get his hammer and hit this nurse and other staff. Redirected to recliner in room and resident continued to attempt to stand up and yell and hit staff. (as needed) Ativan given and able to redirect resident back into recliner and rest at this time. R3's Progress notes, dated 04/12/2024 at 10:56 PM, documented, (Resident) has extreme outburst with verbal and physical behaviors. Attempted to give prn Ativan, and (resident) spit it at nurse. (Continued) to attempt to de-escalate (resident) with no effect. CNA holding (resident) arms, as he was attempting to hit other (resident). Called (resident) wife/POA (Power of Attorney) and she came to facility with her daughter and finally got (resident). to lay down and rest. No further behaviors reported this (hour of sleep). MD (Medical Director) here this pm to give injection in rt knee. Tolerated well (without complaints). R3's Progress notes, dated 04/25/2024 at 10:43 PM, documented, Resident very aggressive with staff, kicking out and grabbing staff. Resident yells shut up and leave me alone when asked if we can help. Resident rolling in (wheelchair) at this time, one on one with staff. R3's Progress notes, dated 04/26/2024 at 11:38 AM, documented, (Resident) continues to have agitation and behaviors towards staff. He yells out at staff and does not want anyone touching him he states. He is having hallucinations that he is on the battlefield and people are trying to kill him. Staff able to redirect and resident currently resting in bed at this time. R3's Progress notes, dated 04/28/2024 06:53 AM, documented, Resident observed throwing drawers in resident room, physical and verbal behaviors towards staff as staff were attempting to redirect resident. CNA's notified nurses. Nurses attempted to redirect resident as well. Resident continued with physical behaviors which made resident very unsteady causing nurses to lower resident to floor for safety precautions. Resident continued to scream and yell out and continued with physical behaviors. Nursing staff notified MD on the phone and gave orders to administer 1 time dose of IM (Intramuscular) 2MG (miligram) dose of Ativan. POA contacted and made aware of behaviors and orders from MD for one time order of im Ativan. Verbal consent given from POA at this time. MD states he is sending script to pull from stat safe. R3's Progress notes, dated 04/29/2024 at 10:15 PM, CNA reported that she heard a noise. Upon arriving at a female Resident's room she turned on the light and observed from the doorway this Resident was standing beside female Resident's bed and CNA observed a lamp in his right hand. Before she could get to Resident he hit the female Resident in the right side of the head with the lamp. Resident had noted to have ahold of the lamp shade that was still attached to the lamp and started tearing up the lamp shade. CNA reported that Resident called the lamp a horse. While attempting to redirect Resident from the area he reached for a plastic cup and hit female Resident in the head then attempted to hit CNA with lamp. Resident then was able to remove light bulb and threw it on the other side of the bed causing it break on the floor. Second CNA made the nurse aware. Resident redirected out of the room to his room. This nurse observed Resident attempting to ambulate unassisted and he lost his balance, when this writer attempted to assist Resident he became combative. With assist of CNA, Resident redirected to his recliner. Resident continued to talk about a horse to staff.in his room with no noted behaviors. He continued to talk about the horse as he was leaving with EMTs (Emergency Medical Technicians) Policeman present. The facility's Abuse Final for R3, dated 5/3/24, documented, .Interventions in place to ensure increased supervision of hall. Incident was behaviorally related due to the medication change and resident mental status. Will continue to monitor resident and redirect from behaviors. Staff in serviced on making sure that they are stationing themselves centrally on the hall to ensure resident safety. R4's Progress note, dated 04/28/2024 at 11:21 PM, documented, It was reported to this nurse that res was lying in bed sleeping CNAs heard a loud noise and CNAs ran to check on resident, a male resident was in her room and had hit res in the head with a lamp and then a cup, Res very upset very agitated, c/o rt eye pain, when this nurse assessed res Pupil active, no discoloration to eye res said she had vision but blurry, res had no bumps or lacerations to head, res was sent out to (local Hospital) for evaluation per (Emergency Medical Services). R4's Progress note, dated 04/29/2024 at 01:31 AM, (Resident) returned from (Local Hospital) with contusion to left forearm/right forearm/right shoulder strain and slightly red facial contusion near (right) eye, Right shoulder and forearm negative negative of fracture and CT (CAT scan) of face with contrast results negative of fractures. R4's Local Hospital Record, dated 4/28/24, documented, History of chief complaint: Patient struck about the head with a lamp and fist by male resident of the Nursing home. Patient complains of bilateral forearm pain and right shoulder pain. She suffers from dementia. It continues, Impression: #1 facial contusion, contusion of both forearms, contusion right shoulder. On 5/10/2024 at 5:19 PM, R3 was sitting at the table calmly waiting for dinner. R4 was standing at the big picture window watching a squirrel eat birdseed. On 5/20/2024 at 11:15 AM, R3 was sitting in his bedside chair and his call light was within reach. R3 was taking his shoes and socks off. There were no activities being performed, during this investigation, in the memory unit. There was 1 Certified Nurse Assistant (CNA) in the dining area with a few residents present. On 5/20/24 at 1:15 PM, V13, Certified Nurse Assistant, (CNA), stated on/around 4/28/24 around 11:00 PM, everything was going fine. He continued to state he and the other CNA had just walked up and down the hallway and R3 was in his bed. He continued to state he went to the nurse's station to get report, was there about 5 minutes and they heard a loud noise. V13 and V15, CNA, ran to R4's room and when they entered, V13 saw R3 with a lamp in his hand. The other CNA, (V15), told him to go get the nurse and he did. He also stated he did not see R3 hit R4. When asked if he was made aware R3 had behaviors earlier that day, he said he was made aware. When V13 was asked about if R3 had any special interventions for behaviors, he stated there are interventions on the care plan. On 5/20/24 at 2:35 PM, V15, CNA, stated she just got to the Memory Care Unit and was getting report when her and V13, CNA, heard a loud noise. They ran to R4's room, turned on the light, and saw R3 swinging the lamp. She was able to get the lamp from the resident, and at the same time, R3 grabbed R4's cup and hit her in the head with it. V15 continued to state R3 thought it was a horse. V15 also stated that doesn't usually work in the Memory care unit and was unaware of R3's increased behavior issues. On 5/20/24 at 2:20 PM, V14, Licensed Practical Nurse (LPN), stated when she came to the nursing home, the incident with R3 and R4 just happened. V14 assessed both and sent both residents to the hospital. She did not witness the incident. V14 also stated R3 has had increased behaviors for the past month, and they were changing his medication. She continued to state they redirect him, talk to him, but since he is blind, he really doesn't watch tv. She also stated she does not recall if she was told he was having behaviors earlier that day, and he was really a sweet person. V14 continued to state his dementia was advancing, and with his blindness it has gotten worse, and he was very sensitive to loud noises. On 5/10/24 at 4:03 PM, V4, CNA, stated, I was working on the day shift, and he (R3) was fine. Nothing about him was out of the ordinary. He does have bad vision. He can only see shadows. On 5/10/24 at 3:30 PM, V2, Director of Nurses (DON), stated, (R3) has a BIMS (Brief Interview of Mental Status) of 1. He lives on the Memory Unit. He got a hold of a lamp in another resident's room (R4) and hit her over the head with it. She was not hurt, but both parties went to the ER (emergency room ) to be checked out. A police report was filed. He has very poor vision. His family says that he is totally blind, but he can see shadows. When this happened, they were immediately separated. (V1) and I were notified. (R3) was in the middle of a med (medication) change. He was being taken off of Seroquel and had started Rexulti. When (R1) came back, he was placed on 1 to 1 supervision until the next morning. He really didn't understand, but he did know that he hurt someone. (R4) she didn't remember anything about it. The next morning, she thought she was in a golfing accident. Staff told me he thought he was trying to saddle his horse. The next morning, neither of them remembered. Doctors have been keeping a close eye on him and have changed his meds. He does have behaviors but nothing violent. He is doing much better now. This happened in the middle of shift change between evening and night shift. On 5/10/24 at 4:10 PM, V3, Memory Unit Director, stated, (R3) would have his moments when he would get agitated, but nothing threw up flags to us that he needed constant supervision. When he does get agitated, he is very easy to redirect. This happened during shift change, so both evening shift and night shift were present. On 5/20/2024 at 2:45 PM, V1, Administrator stated she has increased staff on the memory hall for extra supervision. On 5/21/2024 at 10:21 AM, V1, Administrator, stated they do not have a specific policy related to Dementia Care or Supervision of Residents.

Based on observation, interview, and record review, the facility failed to implement a system to track and trend infections, and failed to implement infection control procedures including isolation precautions and personal protective equipment (PPE) to prevent the spread of infection. These failures resulted in 23 residents devloping Gastroenteritis, including 8 residents (R10, R29, R32, R37, R41, R52, R56, R160) currently experiencing Gastroenteritis in the facility. These failures have the potential to affect all 58 residents in the facility. The Immediate Jeopardy began on 12/3/23, when R56 developed Gastroenteritis and the facility failed to implement isolation precautions including personal protective equipment. Subsequently, 22 other residents have developed Gastroenteritis. On 12/21/23 at 2:52 PM, V1, Administrator, V2, Director of Nursing, V14, Infection Preventionist, and V51, Regional Director, were notified of the Immediate Jeopardy. The surveyors confirmed by observation, interview, and record review, the Immediate Jeopardy was removed on 12/21/23, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: The employee call off log documented on 11/27/23, V22, Dietary Aide, called off work because of Gastrointestinal symptoms. Subsequently, from 11/27/23 to 12/15/23, 23 staff developed Gastroenteritis. The facility's Infection Control Tracking documented on 12/3/23, R56 developed Gastroenteritis symptoms, and no isolation precautions were implemented. From 12/3/23 to 12/21/23, 23 additional residents developed Gastroenteritis including R5, R7, R9, R10, R16, R20, R23, R25, R28, R29, R30, R31, R32, R37, R41, R44, R45, R50, R52, R54, R56, R111, R160. During the survey, R10, R29, R32, R37, R41, R56, R160 were experiencing gastroenteritis. On 12/18/23 through 12/21/23, there was no signage on the doors indicating any of the residents were on contact isolation. R32's Nurse's Note, dated 12/10/2023 at 9:28 PM, documents, 7pm Resident's urine is dark. Decreased urine output. States she has not drank much fluids today d/t (due to) it upsets her stomach. VS (Vital Signs) 134/68 (blood pressure) 74 (pulse) 20 (respiration) 97.0 (temperature) SpO2 (oxygenation saturation) 95% RA (room air). Made on call (V61, Nurse Practitioner, NP)) aware. Gave order for Saline IV 1 L (liter) at 75 ml (milliliter) per hour and Zofran (nausea medication) 4 mg (milligram) every one tab every four hours for n/v (nausea/ vomiting). R32's Nurse's Note, dated 12/11/2023 at 12:29 AM, documents, IV continues. Resident was incontinent of a large loose stool at 9 pm. Resident given PRN (as needed) Zofran at 7:15 pm for c/o (complaint of) nausea. Urine color improving. Resident has drank a little water. R32's Nurse's Note, dated 12/11/2023 at 2:39 AM, documents, Linens changed after earlier incontinent loose stool. R32's Nurses Note, dated 12/11/2023 at 11:16 PM, documents, Resident BS (blood sugar) 552 at HS (hour of sleep). Emesis x 1, milk with pieces of mandarin oranges. Zofran given. Made (V62, NP) aware. Stated to continue with sliding scale as ordered for BS (blood sugar) over 400. Monitor and report. Also made aware of emesis, recent IV fluids, and loose stools. Novolog sliding scale given as ordered. Will monitor. R32's Nurse's Note, dated 12/11/2023 at 11:19 PM, documents,10:30 pm Emesis x one. Resident diet 7-Up given with effectiveness. R32's Nurse's Note, dated 12/12/2023 at 10:13 AM, documents, Resident noted to have elevated blood glucose at 556 this AM. while still refusing to eat. Insulin given and MD (Medical Doctor) notified, rechecked after 30 minutes and blood glucose was 507. Resident continues to feel nauseous and refusing to eat. MD stated to send out to ER (emergency room ) for evaluation r/t (related to) elevated blood glucose. POA (Power of Attorney) aware of sending out to ER for evaluation. R32's Nurse's Note, dated 12/12/2023 at 03:32 PM, documents, Resident back from ER visit. No new orders at this time. Resident received IV fluids and insulin in ER. Encourage fluids and monitor blood glucose. R32's Nurse's Note, dated 12/13/2023 at 9:41 AM, documents, Resident states she is feeling just a little better today. Zofran given for nausea. AM blood glucose was low at 56, gave large glass of juice and she ate her breakfast sausage, rechecked and it was 119. Continued to encourage to increase fluids at this time. R32's Nurse's Note, dated 12/16/2023 at 2:05 AM, documents, Resident c/o (complaint of) nausea at HS (hour of sleep/bedtime). Gave PRN Zofran with effectiveness. HS BS 92. Offered snack but Resident stated, 'I don't need it'. Resident encouraged to eat and drink fluids. Covid test: negative. R32's Nurse's Note, dated 12/16/2023 at 11:35 AM, documents, Resident states that she still does not feel well and does not feel like getting up out of bed at this time, she is very nauseous, so Zofran was given at this time. R32's Nurse's Note, dated 12/18/2023 at 1:58AM, documents, Resident continues to feel nauseated and achy, refused her meds and meals. Requested ice water only. (Indwelling urinary catheter) patent, Tylenol given prn as ordered. MD aware and has given orders to monitor blood Glucose closely. R32's Nurse's Note, dated 12/19/2023 at 10:57 AM, documents, Fax sent to MD regarding resident, she has a 102.2 fever, and diarrhea. PRN Tylenol given. awaiting response from MD. R32's Nurse's Note, dated 12/19/2023 at 03:04 PM, documents, Labs received and Potassium is 5.2 and sodium is 129. Call placed to (V62) with results. (V62) states to send resident to ER. Ambulance called and arrived to facility within minutes. Resident does express she wants to go. Resident is a diabetic and is not well controlled. Resident continues with diarrhea and fever despite Tylenol. Urine is dark yellow draining per catheter. Resident is heading to ER now. R32's Nurse's Note, dated 12/19/23 at 6:22 PM, documents, Spoke to (Local Hospital) who reported that resident is being transferred to (Regional Hospital). Only dx (diagnosis) at this time: Hyperglycemia. On 12/19/23 at 10:50 AM, R32's room was entered with V8, Licensed Practical Nurse, LPN, to administer Acetaminophen for a fever of 102.5 degrees. R32 was being cleaned up of an incontinent episode of diarrhea. R32's room had an extreme foul odor related to the stool. There was not an isolation cart containing personal protective equipment or isolation precaution signage outside of R32's room. On 12/19/23 at 10:40 AM, V8 stated R32 has had loose stool and nausea for the last 3 weeks, and the doctor is aware. R16's Nurse's Note, dated 12/09/2023 at 9:25 PM, documents, Called to room at this time, resident having another emesis. T (Temperature) 98.1 P (Pulse) 120 R (Respirations) 20 BP (Blood Pressure) 178/97 O2 (Oxygenation) 92 @ 2L(Liters). Call made to on call dr. for (V42) at this time. On call doctor recommended resident to go to (Local Hospital) to get fluids. Call then made to make POA aware and she agreed to have resident taken to ER for evaluation and treatment. 911 called at 9:30pm. R16's Nurse's Note, dated 12/10/2023 at 12:20 AM, documents, Call received at this time from (Local Hospital) in regard to resident being sent back to facility. Stated hospital nurse gave resident fluids and Zofran. All testing came back negative. Resident diagnosed with Gastroenteritis. Order received for Zofran 4mg q (every) 4-6hr per rectum if unable to take orally PRN. R16's Nurse's Note, dated 12/22/2023 at 3:47 PM, documents, CNA notified writer that resident has had an episode of diarrhea, isolation has been started. No fever at this time. resident has no complaints at this time. POA aware, administrator aware, MD was faxed to notify. The Gastrointestinal Log, dated 12/2023, documents R16 began to have emesis on 12/9/23, and was not put on isolation when symptoms of gastroenteritis began. R41's Nurse's Note, dated 12/06/2023 at 11:56 PM, documents, 11:30 pm Moderate amount of loose stool x 1. VS 138/64 74 20 97.1 SpO2 97% RA. Covid test negative. Resident given clear soda. PRN Imodium given. Resident given Tylenol at HS med pass for c/o general discomfort. Will make (V15, Medical Director) aware. R41's Nurse's Note, dated 12/07/2023 10:52 PM, documents, NA (Nurse Aide) reported that she had an episode of vomiting, temperature is 99.5. R41's Nurse's Note, dated 12/11/2023 at 1:49 AM, documents, Two loose stools x two with PRN Imodium. Fluids encouraged. No emesis or c/o nausea. T 97.6. No c/o voiced. R41's Nurse's Note, dated 12/16/2023 at 12:14 AM, documents, Resident's Imodium 2 mg one tab after every loose stool with a max of three times/day continues as needed per (V15), is aware of numerous loose stools with foul odor and is also aware of coccyx being red and irritated with barrier cream being applied. Notes: monitor and report significant changes. The Gastrointestinal Log, dated 12/2023, documents R41 began to have nausea and diarrhea on 12/7/23, and was not put on isolation. On 12/20/23 at 1:58 PM, V6, Certified Nurse Assistant (CNA), stated, (R41) had diarrhea yesterday. She hasn't had any today. V6 stated the (GI bug) went on for about 2 weeks. On 12/20/23 at 2:08 PM, V18, LPN, stated R56 had GI issues recently. On 12/20/23 at 12:10 PM, V16, Dietary Manager, stated, I am the only one (of kitchen staff) that has not had the GI bug. Employees that were sick needed to be symptom free for 24 hours with a doctor's note before they came back. On 12/21/23 at 9:10 AM, V27, Cook, stated he did have Gastrointestinal symptoms and he needed to stay home for 24 hours after he was symptom free. On 12/20/23 at 10:15 AM, V14, Infection Preventionist, was questioned about the GI (Gastro-Intestinal) Bug that has been in the building, V14 stated, I can't figure it out. I don't know where it is coming from. We have had to give some IV (Intravenous Fluids). The doctor did not want any testing done. I have not contacted the County Health Department because I don't know how. (V1, Administrator) is the one who calls them. V14 stated she is tracking the GI issues in the facility. The November and December Monthly Antibiotic Control log was reviewed at this time. This log failed to document any GI issues. A copy of V14's tracking was requested at this time. On 12/20/23 at 2:20 PM, V14 stated the facility does not have any residents that are currently having symptoms of nausea, vomiting or diarrhea. V14 stated, The last resident was (R32) and she went to the hospital yesterday (12/19/23), so there are no current residents. It started around the 5th (12/5/23), the main part was the 8th through the 11th (12/8/23 - 12/11/23). V14 stated the two residents that needed IV fluids while having GI symptoms were (R32) and (R41) (R41 did not require fluids). V14 stated R32 needed fluids twice. On 12/21/23 at 10:15 AM, V14 stated, Employees who contracted the GI bug had to be symptom free for 24 hours before returning to work. On 12/20/23 at 10:28 AM, V1, stated, I did not report to the County Department of Health. It was not the flu (Influenza Virus), RSV (Respiratory Syncytial Virus) or COVID. The doctor was not ordering any tests. Why would I? V1 was asked if she had considered the Norovirus, V1 stated, No. On 12/21/23 at 10:00 AM, V1 stated, When the residents were experiencing nausea, vomiting, or diarrhea the residents stayed in their room until they were symptom free for 24 hours. The staff wore masks because we were on COVID precautions, they wore gloves and used frequent hand washing. We did not require gowns while caring for the residents or put isolation signs or carts outside of room. At this time, we do not have any current cases. We had 2 residents receive IV fluids (R32 and R41) (R41 did not require IV fluids) and 2 residents were sent to the hospital because of it (R32 and R16). We do not have a specific GI policy and procedure. We use the basic infection control policy. On 12/21/23 at 12:00 PM, V2, Director of Nursing, (DON), stated, If a resident was having symptoms, they had to be in the room for 24 hours until they were symptom free. We did COVID tests and notified their primary care provider. Once notified, they (doctors) just said to monitor. We did not have any specific isolation just general isolation. The doctors never gave an order regarding the type of isolation or for isolation. We did in-service for hand washing. Employees that were ill stayed home until they were symptom free. On 12/20/23 at 1:45 PM, V20, Local Health Department Registered Nurse, stated, I was not aware that (the facility) was having an outbreak of Gastroenteritis. I would have expected them to notify us. I would have contacted them to see if they needed anything from us. I would have told them to pull the guidance from the IDPH (Illinois Department of Public Health) website, do they need help understanding it? I would expect contact isolation to be put in place, PPE (Personal Protective Equipment) by doors, signage on doors, testing of the stool to determine what bug is going around. 44967 On 12/19/23 at 10:17 AM, R29 was on the toilet requesting assistance, as she had large amount of loose stool, both in her brief and in the toilet. V6, Certified Nursing Assistant (CNA), entered to assist R29. R29 was attempting to clean herself up, however, had stool all over herself, including her hands. V6 unfastened R29's brief and tucked it between her legs. R29's pants were wet and soiled with loose stool, and were removed by V6. After V6 gathered the soiled pants and brief to put in a plastic bag, V6 went to a dresser drawer in R29's room to gather more supplies with the same soiled gloves on. V6 then applied a gait belt around R29, a clean brief and pants on her lower legs, all with the same soiled gloves on. V6 assisted R29 to stand up and hold onto her walker while V6 wiped stool off R29's back, buttocks, and anal area. V6 reached between R29's legs and wiped from front to back with a lot of stool seen on the cloths/wipes, one dry washcloth used to reach between R29's legs once more, then brief and pants pulled up with same soiled gloves on. R29's shirt had stool on the bottom of the shirt, which was pulled down over her clean pants, while V6 stated she had to change her shirt because it had stool on it. The Gastrointestinal Log, dated 12/2023, fails to document R29 having symptoms of diarrhea. On 12/18/23 at 10:20 AM, R10 was sitting in a recliner in the living area, napping, covered with blanket, wheelchair next to the recliner, and no staff present. On 12/18/23 at 12:55 PM, R10 was assisted back to her bed, with a strong smell of urine and feces. V7, CNA, came in to do peri-care on R10. R10's pants were pulled down which showed loose stool in her pants. R10's brief was unfastened and tucked between her legs. V7 wiped R10's groins once each, then using same wipe, wiped once down middle of her vagina, and pushed that wipe between R10's legs. As R10 was rolled over, V7 noticed loose stool was up R10's back and all over her buttocks. V7 began wiping R10's stool and asked to get another CNA to assist her. V7 used soiled gloves and pulled the sheet over R10 while she waited for help. V6, CNA, entered to assist and wiped R10's groins once, used same cloth and wiped R10's vagina once. R10 was rolled to her right side and V7 began to wipe R10's back, and anal area. Using the same gloves, V7 put a new incontinent brief and bed pad down, then applied barrier cream to R10's anal area. R10 started to have more diarrhea and was allowed to finish her bowel movement (BM). Both CNAs doffed their gloves, gathered soiled linen and trash bags without gloves on, then left the room without doing hand hygiene. On 12/18/23 at 1:18 PM, V6 and V7 went back into R10's room to clean her up after her bowel movement. R10's brief was tucked between her legs. R10 was rolled to her right side and her anal area was briefly wiped, and her soiled incontinence brief was pulled out from under her. Using the same soiled gloves, V7 applied a new incontinence brief and bed pad to the bed. There was no further wiping of R10's vagina, groins, or buttocks after her BM. V7 used same soiled gloves to pull resident up in bed. V7 doffed her gloves, covered R10, then exited the room without hand hygiene done. The Gastrointestinal Log, dated 12/2023, documents R10 as having diarrhea beginning on 12/5/23, and R10 was not put on isolation. 42108 On 12/21/2023 at 9:25 AM, R160 stated she was having diarrhea. R160 stated she feels weak and sick to her stomach. On 12/21/2023 at 9:40 AM, R37 stated she has had diarrhea for the last couple of days. R37 stated she has told the staff. R37 stated she has not been on any isolation precautions. On 12/21/2023 at 9:23 AM, R56 stated she has had diarrhea yesterday and today. R56 stated she just goes in the toilet and flushes. On 12/21/2023 at 9:33 AM, R52 stated she is nauseated and unsure why. R52 stated she has not had any diarrhea. R52 stated that she was in her room with the door closed, and was isolated, and not sure why. On 12/21/2023 at 12:30 PM, V15, Medical Director, stated he was the Medical Director for the facility. V15 stated he was notified of residents having GI symptoms. V15 stated he would have not been notified of every resident that had the symptoms, because he is not everyone's physician. V15 stated he was not aware of specific number of residents and staff with the GI symptoms. V15 stated if there was an outbreak, he would be notified. V15 stated he is not sure what that number is, and the facility would have the specifics. V15 stated he would expect the facility to contact the health department and follow their recommendations. V15 stated he would expect the facility to communicate the recommendations to him. When asked why the residents were only tested for COVID? V15 stated during this time, COVID had more GI symptoms than respiratory. V15 stated there are more than COVID respiratory infections, there is RSV and Flu as well. V15 stated it takes time for norovirus results to come back. V15 stated, The first step with residents with GI symptoms would be isolation. The resident should be in isolation. It would start there. V15 stated he had 1 resident with IV therapy recently but is unsure, due to not having the chart, if this was because of the nausea or vomiting or poor intake. The facility's policy Infection control, dated 12/17/2019, did not address what type of infection control procedures should be implemented regarding Gastroenteritis. Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, last updated July 2023 documents Documented LTCF (long-term care facilities) outbreaks have been caused by various viruses (e.g., influenzas virus, rhinovirus, adenovirus, norovirus and bacteria (e.g., group A streptococcus, B. Pertussis, non-susceptible S. pneumoniae, other MDROs (multi drug resistant organisms, and Clostridium difficile). Thes pathogens can lead to substantial morbidity and mortality and increased medical cost; prompt detection and implementation of effective control measures are required. The Guidelines documented Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. The Guidelines documented healthcare personnel caring for patients on Contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE (personal protective equipment) upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, C. difficile, noroviruses and other intestinal tract pathogens; RSV). The Immediate Jeopardy that began on 12/3/23 was removed on 12/21/23 when the facility took the following actions: 1. The facility's DON, V2, completed an audit of all residents for signs and symptoms of infection, including GI illness. 2. The facility's Administrator, V1, completed an audit of all staff to ensure no one is currently working with signs and symptoms of any infection, including GI illness, and the employee infection log is completed. 3. Facility infection control policies were reviewed by Regional Nurses, V50 and V51, to ensure it is acceptable with Standards of Practice. 4. V1, Administrator, V2, DON, and Infection Preventionist were in serviced by Regional Nurses, V50 and V51, regarding policies 01.11 Infection Control, 3.29 Categories of Transmission based precautions, 3.45 Standard Precautions. This in-servicing included how to identify an outbreak, track, and trend an outbreak to prevent further infection, implementing contact precautions, isolating affected residents, using personal protective equipment, and educating staff on preventing the spread of infection, including Gastroenteritis. 5. Facility initiated in-servicing all staff, concerning policies 01.11 Infection Control, 3.29 Categories of Transmission based precautions, 3.45 Standard Precautions. This in-servicing includes reporting signs and symptoms of infection, including Gastroenteritis prior to reporting to work, use of PPE and contact isolation. No staff will be allowed to work without in-servicing. 6. All nurses will be in serviced by V2 or designee regarding completing an assessment (Infection tracker event) for any resident displaying signs and symptoms of infection, including Gastroenteritis, at the time symptoms are exhibited. 7. The DON/or designee will be responsible for tracking all infections moving forward. 8. The Administrator/Designee will audit 3 employees weekly for 1 month to ensure staff is not working while symptomatic of Gastroenteritis and then ongoing. 9. The facility's DON/Infection Preventionist will review infection tracker events 3 times per week for 1 month to ensure reporting and treatment of infections as well as tracking and trending of infections. From 12/26/23 through 12/29/23, the survey team validated the removal of the immediacy by interviewing V6, V9, V11, V18, V30, V43, V48, V55, V57, about the in-services they received related to the types of isolation, use of PPE, when to assess resident for signs of infection, who to notify of an infection and when to call off. V34, V56, V58, V59 all stated they were in-serviced on when to call off from work and how long they need to stay off work. R3's, R6's, R8's, R27's, R43's and R54's rooms were observed with isolation signage and carts. The facility audits, in-services and policies were reviewed.

Based on interview, observation, and record review, the facility failed to assess residents for fall precautions, failed to implement appropriate fall interventions, and failed to ensure resident safety during transfers, for 5 of 7 residents (R6, R8, R10, R20, R27) reviewed for falls and transfers in the sample of 44. This failure resulted in R6 having a fractured left hip and having a closed vs open reduction of her left hip with nailing surgery. The findings include: 1. R6's Face Sheet, undated, documents R6 was admitted to the facility on [DATE], with the diagnoses of Dementia, Atrial Fibrillation, Major depressive disorder, Type 2 Diabetes Mellitus (DM), and Left femur fracture. R6's Care Plan, dated 3/02/23, documents R6 is at risk for falls related to diagnosis of dementia, unsteadiness on feet, muscle wasting and atrophy, depression, incontinence and use of psychotropic medication. Interventions: 12/18/23: Staff to keep resident within view while in common area, 12/12/23: Occupy resident with meaningful distractions, 12/5/23: Observe frequently and place in supervised area when out of bed, 11/20/23: Encourage shoes while ambulating, 10/2/23: Encourage resident to stay in common areas when it is not bedtime. Redirect with activity, 9/6/23: Dycem replaced on wheelchair and cushion, 8/27/23: encourage resident with an activity while other residents are being put to bed, 8/14/23: PT (physical therapist)/OT (occupational therapist) to evaluate chair positioning, 8/14/23: Call don't fall signs placed in resident room, 6/26/23: Dycem applied to wheelchair and on top of wheelchair cushion, 4/20/23: Make sure resident is wearing grip socks while ambulating, 4/20/23: Grip tape applied to the floor in front of the toilet, 4/10/23: Make sure tennis balls are on the wheeled walker 3/2/23: Provide with wheelchair and walker, Encourage to use side rails/enablers as needed. R6's Minimum Data Set (MDS), dated [DATE], documents R6 has a severe cognitive impairment and requires extensive assistance from one to two staff members for all Activities of Daily Living (ADLs). R6 is occasionally incontinent of urine and always continence of bowel. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R6 has had a falls on 6/21/23, 6/25/23, 7/7/23, 7/13/23, 7/20/23, 8/10/23, 8/26/23, 9/4/23, 9/25/23, 11/6/23, 12/4/23, 12/5/23, and 12/10/23. R6's Admission Fall Risk Assessment, dated 3/1/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 4/24/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 7/29/23, documents R6 is a High Fall Risk. R6's Fall Risk Assessment, dated 12/4/23, documents R6 is a High Fall Risk. R6's Nursing Note, dated 4/1/23 at 6:00 PM, documents, CNA reported to nurse that resident had fallen after standing from dining room and tripped over the foot of her walker and lost her balance. CNA stated she did not hit her head. Neuros (neurological checks) and VS (vital signs) WNL (within normal limit), during assessment of LLE (left lower extremity) resident verbalized 7/10 pain to left hip. MD (Medical Doctor) made aware and gave orders to send resident to ER (emergency room ) and stated to update him with results once notified of results. POA (Power of Attorney) notified as well. There is no new fall intervention seen in R6's Care Plan after her fall on 4/1/23. R6's Nursing Note, dated 4/3/23 at 6:51 AM, documents, Resident found sitting on floor next to her walker in her bedroom. Residents bottom was facing the window and her legs/feet were facing the bedroom door. Resident states she was trying to go to the bathroom and her knees started to buckle so she knelt down and sit on her butt. VSS (vital signs stable) (see vitals), Head to toe assessment complete with no s/s (signs/symptoms) of rotation, deformity, shortening of limbs noted. No s/s of bruising or open wounds. Residents states, I am ok I just wanted to get to the bathroom then go eat breakfast. Educated resident on using call light for help and she verbalized understanding. Fall was witnessed by CNA (see Event) Dr. notified, and POA Notified. R6's Social Service Note, dated 4/10/23 at 10:25 AM, documents, Root Cause Analysis: Investigation into falls on 4/3 and 4/1 were completed by the IDT (Interdisciplinary team). It was determined that on 4/1 resident was standing from breakfast with w/w (wheeled walker). Resident tripped over the flip flop decor on bottom of wheelchair. Decor was removed and replaced with tennis balls. On 4/3 resident was attempting to transfer herself to the bathroom with w/w when her legs buckled and she lowered herself to the floor. Assist resident in mornings, and make sure that she has assistance when needed due to weakness in morning. R6's Care Plan Intervention, dated 4/10/23, documents Make sure tennis balls are on the wheeled walker. R6's Nursing Note, dated 4/19/23 at 6:15 AM, documents, [Recorded as Late Entry on 04/21/2023 11:33 AM] Called to (unit) by staff to find resident laying on the floor on her back with her head down by the sink. She denies pain moves all extremities without difficulty. She does have a 0.5 cm (centimeter) skin tear noted on her Rt (right) elbow that was cleansed and Steri-strips applied. Staff reports that there were no lights on in the room when they entered the room the floor was dry and resident had regular socks on her feet with no shoes on. Resident assisted off the floor by 2 staff at this time. R6's Social Service Note, dated 4/20/23 at 11:11 AM, documents, Root Cause Analysis: Investigation into fall on 4/19/2023 was completed by the IDT. It was determined that resident fell while ambulating in her room. Make sure the resident is wearing grip socks while up ambulating. There is no new fall intervention added to R6's Care Plan after her fall on 4/19/23. R6's Nursing Note, dated 4/20/23 at 3:20 AM, documents, Resident was found sitting on the floor in the her bathroom yelling out for staff. She stated she went to get off of the stool and slipped down to the floor. Denies hitting head. Stated she landed on her buttocks and sat against the bathroom door. She complained of left hip pain immediately and leg is bent up. She will not let us straighten leg out stating the pain is absolutely horrible. Large skin tear noted to left elbow with scant amount of bleeding noted. R6's Nursing Note, dated 4/20/23 at 3:51 AM, documents, Resident did have rubber sole shoes on, floor level dry and free of clutter. She was ambulating with use of walker. Denied any dizziness or other complications. Room was well lit. R6's Social Service Note, dated 4/20/23 at 11:13 AM, documents, Root Cause Analysis: Investigation into fall on 4/20/2023 was completed by the IDT. It was determined that resident fell off the toilet while taking herself to the bathroom. Resident was sent to ER and determined that her left hip was broke. (sic) Grip tape was placed in front of toilet. R6's Care Plan Intervention, dated 4/20/23, documents, Grip tape applied to the floor in front of the toilet. On 12/20/23 at 9:35 AM, there was no grip tape seen in front of R6's toilet as specified in the Care Plan. R6's Nursing Note, dated 4/21/23 at 9:50 AM, documents, Called (Regional Hospital) and rec'd (received) update on resident, surgery scheduled for today at 2:30 PM, having a closed vs open reduction of left hip with nailing, not looking at discharge until next week possibly. R6's Nursing Note, dated 6/21/23 at 9:55 PM, documents, Resident was observed on the floor on her knees leaning against the bed in an unoccupied room. There was another female Resident sitting on the side of the bed. This Resident stated she was trying to get on the bed. Two staff transferred Resident to w/c (wheelchair). ROM (range of motion) WNL x 4 extremities. No injuries noted to head or body. Noted both knees to have small pinkish area on each. Resident stated her knees hurt. Resident was moving both feet to move w/c without c/o (complaint of) or noted difficulty then ambulated to toilet from w/c with use of w/w and assist of two staff with no c/o or noted difficulty. Dr. at facility to see Resident and assessed her with NNO (no new orders). Tylenol given with no further c/o knee pain. Made RN (Registered Nurse) DON (Director of Nursing) and POA/daughter aware of this event. Will fax Dr. with an update. VS 134/64 78 20 98.0 SpO2 96% RA (room air). Not compliant with Neuros. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 6/21/23. R6's Nursing Note, dated 6/25/23 at 3:32 PM, documents, CNA's reported that resident had slid out of wheelchair in sitting area. Resident observed sitting in upright position in front of wheelchair. Resident completed ROM to all extremities without limitations or pain voiced. Resident denies pain/discomfort at this time. Resident vs WNL, resident neuros WNL to resident baseline. MD notified and POA made aware. R6's Care Plan Intervention, dated 6/26/23, documents Dycem applied to wheelchair and on top of w/c cushion. R6's Nursing Note, dated 7/7/23 at 6:53 PM, documents, Resident found on floor next to toilet. She was between the wall and toilet sitting on her buttocks holding onto the assist bar. Resident was attempting to transfer self off of the toilet. No injuries noted at this time. Denies any pain at this time. Had rubber sole shoes in place, pants were mostly pulled up chair was locked and in doorway. Daughter (Name) notified of incident. Doctor notified. Neuros started and WNL, ROM WNL. Staff educated not to leave room while she is on toilet. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/7/23. R6's Nursing Note, dated 7/13/23 at 9:01 PM, documents, Res (resident) noted to tip recliner over in the common room and rolled out of it onto the floor. When this nurse arrived, res was lying on her stomach with her Right arm pinned below her. 3 staff members rolled res over onto her back to assess further. ROM WNL. No rotation or shortening of extremities. VS WNL neuro checks WNL. skin tear noted to right lower arm with bruising surrounding area. Bruise noted to right elbow and to left knee. Skin tear cleansed and steri-strips applied. No other injuries noted. Res denied pain elsewhere. Assisted back to recliner. Began conversing with staff again. Continue to monitor vs with neuros per protocol. MD made aware via fax. To notify family in the morning at a more decent hour. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/13/23. R6's Nursing Note, dated 7/20/23 at 10:59 PM, documents, 8:10 PM Resident was observed laying on her left side on the floor beside her bed. Her w/c (wheelchair) was near her. Resident stated she was trying to get into bed. No injuries noted to head or other areas. ROM not done d/t (due to) Resident c/o pain to both hips and lower back. BS (blood sugar) 205. Resident alert and verbal. Made Dr. aware. New order given to send to ER to eval (evaluate) and tx (treat). Made POA/daughter aware. Ambulance called. Resident sent to (local hospital) ER via ambulance. Sent Face Sheet, orders and DNR (Do Not Resuscitate). Made RN (Registered Nurse) at (local hospital) ER aware and gave report. Administrator and RN, DON aware. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 7/20/23. R6's Nursing Note, dated 8/10/23 at 6:50 PM, documents, Resident slid out of wheelchair trying to reach for items. Fall witnessed did not hit head and just slid to floor. She did land on her buttocks with no injuries noted and no complaints of pain. ROM WNL. Daughter notified of her sliding out of her wheelchair with no injuries. Doctor notified. Will consider adding [NAME] to top of cushion to help prevent sliding. R6's Care Plan Intervention, dated 8/14/23, documents, Call Don't Fall signs placed in resident room. R6's Nursing Note, dated 8/26/23 at 8:30 PM, documents, Resident observed on floor in kitchen laying on her right side, w/c was near her feet. Resident did hit her head. ROM WNL x 4 extremities. Resident rubbed her head stating that is where she hit her head, mid left back of head. No area noted. No other injuries noted. VS 134/70 74 20 97.6 SpO2 96% RA. Made Dr. aware of this event, Resident hitting head mid left side, Coumadin use, recent INR (International Normalized Ratio). Stated to monitor and report significant changes. Aware of HS (hours sleep) meds and stated to continue with meds as ordered. Made POA/daughter aware and she agrees with Dr. Made Administrator aware. At this time a slightly elevated area is noted to mid left back of head. Area is pinkish. Resident given PRN Tylenol d/t to stating, Oh, it hurts a little, when asked if her head hurt. Denies pain anywhere else. Resident is alert and verbal. Moves all extremities with no noted difficulty or c/o. R6's Care Plan Intervention, dated 8/27/23: encourage resident with an activity while other residents are being put to bed. R6's Social Service Note, dated 8/27/23 at 2:18 PM, documents, Root Cause Analysis: Investigation into fall on 8/26/2023 was completed by the IDT team. It was determined that resident fell while attempting to ambulate. When staff is working with other residents for bed and behaviors, encourage resident with a independent activity to keep her busy. R6's Nursing Note, dated 9/4/23 at 3:33 PM, documents, Resident was found in dining room. Resident was in front of wheelchair on her left side. Resident stated she was a little sore. No shortening, ROM x 4, Neuros and vitals WNL. POA aware. Admin aware. MD faxed. Will continue to monitor. R6's Care Plan Intervention, dated 9/6/23, documents, Dycem replaced on WC and cushion. R6's Social Service Note, dated 9/6/23 at 7:48 PM, documents, Root Cause analysis: IDT completed investigation into fall on 9/4/2023. It was determined resident fell sliding out of the wheelchair, Dycem added to wheelchair. R6's Nursing Note, dated 9/25/23 at 2:02 PM, documents, Resident stated went into her room, shut the door and got up to go the bathroom. Resident was found sitting in her room on her bottom, with feet straight out. ROM unchanged. Denies any c/o pain or discomfort. Vitals within normal limits. Dr. notified of incident. POA notified. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 9/25/23. R6's Social Service Note, dated 10/2/23 at 12:05 PM, documents, Root Cause Analysis: Investigation into fall on 9/25/2023 was completed by the IDT team. It was determined that resident fell while in room attempting to transfer her self. Staff encouraged to redirect resident to common areas when not in bed, and engage her with activities. R6's Care Plan Intervention, dated 10/2/23, documents, Encourage resident to stay in common areas when it is not bedtime. Redirect with activity. R6's Nursing Note, dated 11/6/23 at 7:45 PM, documents, Resident was sitting in wheelchair in her room at foot of bed near bathroom door. She stood up and starting walking across the room. Her legs gave out and she sat down on the floor. Her feet were bare, lights on, floor level, clean, dry and free of clutter. Could not get to resident fast enough before she fell , she did not hit her head. ROM done with no complaints of pain. No external fixation or shortening of legs noted. She did complain of general pain after a while, PRN Tylenol given with relief. MD notified and daughter to be notified. Will continue to monitor. R6's Care Plan does not have any new interventions added to the Care Plan after this fall on 11/6/23. R6's Social Service Note, dated 11/9/23 at 10:04 AM, documents, [Recorded as Late Entry on 11/20/2023 10:05 AM] Root Cause Analysis: Investigation into fall completed by the IDT. It was determined that resident fell while attempting to ambulate to the bathroom. Resident to have shoes and grip socks on while ambulating. R6's Nursing Note, dated 12/4/23 at 1:30 PM, documents, [Recorded as Late Entry on 12/04/2023 07:37 PM] Resident was in common area and was trying to transfer self into recliner and slid onto bottom. Head was not hit and no injury noted. Will pass along to nurse to make Dr. and POA aware of event. R6's Nursing Note, dated 12/5/23 at 1:50 PM, documents, Resident attempted to transfer to recliner in common area and fell to floor. Resident did not hit her head. CNA was unable to get to her in time. B/P 159/76 P 76 R 22 T 97.5 SpO2 98% ROM WNL Resident had no c/o pain. Resident was transferred up from floor to recliner. R6's Care Plan Intervention, dated 12/5/23, documents Observe frequently and place in supervised area when out of bed. R6's Nursing Note, dated 12/10/23 at 5:27 PM, documents, CNA states she heard patient yelling out. Went to assess and patient was noted in sitting position in dining room with wheelchair next to her. Writer assess patient and she stated she did not hit her head. Patient was noted in sitting position next to wheelchair. Patient was in a well lit area and appropriate fitting shoes. Patient able to move all extremities with ease. Denies pain or discomfort at this time etc. denies needing to go to the bathroom. Assist for floor to bed via (full body mechanical lift). Neuro checks WNLs. R6's Care Plan Intervention, dated 12/12/23, documents, Occupy resident with meaningful distractions. R6 was left unsupervised and found on the floor. On 12/19/23 at 9:27 AM, R6 was sitting in recliner watching movie with other residents, with no staff seen in the room. On 12/20/23 at 9:35 AM, R6 was seen sitting in her wheelchair in the dining room doing activities with staff. There were no Call Don't Fall signs posted in R6's room, and there was no grip tape in front of her toilet as specified in the Care Plan. On 12/19/23 at 10:04 AM, V5, Certified Nursing Assistant (CNA), stated, We try to keep our residents supervised to help keep them from falling, and there are interventions placed in their care plan for falls. On 12/26/23 at 10:40 AM, V6, CNA, stated, No, (R6) does not have a Dycem on her wheelchair. 2. R8's Face Sheet, undated, documents R8 was admitted to the facility on [DATE], with the diagnoses of Dementia, Overactive bladder, Dysuria, and Anxiety disorder. R8's Care Plan includes Problem, start date of 7/24/23, R8 is at risk for falling related to decreased mobility, generalized weakness, dementia, incontinence, psychotropic medication use. Interventions: 9/25/23: Scoop mattress added to bed, 8/14/23: Dycem added to wheelchair, 7/24/23: Ensure that commonly used or reached for items are within close proximity to R8 while in bed, Ensure familiar items are present in room such as old pictures of resident when young, with parents, etc., familiar decorations from resident's prior home, or familiar afghan/blanket on bed, Use simple sentences with ADL (Activities of Daily Living) cares including nouns and verbs only (example: Use the toilet), Utilize verbal and tactile cues. Organize supplies from left to right to provide visual stimulation with tasks and task segmentation, Use simple, familiar commands and words that are familiar to the resident (i.e. [NAME] = bathroom), Hold chair steady for R8 during transfers, Provide frequent reminders and assistance for toileting and other personal care ADL needs, Alternate Call Light, Encourage R8 to use side rails and hand rails as needed. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R8 had falls on 6/1/23, 6/16/23, 8/11/23, and on 9/16/23. R8's Clinical Record documents R8 also had falls 3/14/23, 3/25/23, 4/2/23, 5/3/23, 5/12/23, 5/16/23, 5/17/23. R8's Care Plan did not include R8 as a fall risk with interventions until 7/24/23, after R8 had fallen nine times. R8's MDS, dated [DATE], documents R8 has a severe cognitive impairment and is dependent on staff for ADLs and is frequently incontinent of urine and occasionally incontinent of bowels. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. R8's Nursing Note, dated 3/14/23, documents, Resident was found on floor in bed room next to his bed on his bottom. Residents back was against the bed, feet pointing to his roommates bed and resident was not in non skid socks at that present time. Resident states he slid out of bed on his bottom trying to get somewhere. Head to toe assessment completed. No apparent injuries noted. No bruising noted. No wounds or bleeding noted. No limb deformity noted. Mobility unaffected. Did c/o pain to right hip but per resident and resident POA he has prior hip surgery and has had hip pain to left hip since. Resident able to bend bilateral knees to abdomen without c/o, able to rotate and flex bilateral arms without c/o. NEURO intact (neuros started due to unwitnessed fall) Bed was at lowest position and call light was within reach. R8's Administrator Note, dated 3/19/23 at 2:43 PM, documents, Root Cause Analysis: Investigation into fall on 3/14/2023 completed by IDT (Intradisciplinary team). It was found that resident was trying to transfer himself without assistance, and fell from bed. Call don't fall signs places in residents room to remind him to call for assistance. On 12/20/23 at 9:32 AM, there was no Call don't fall signs seen in R8's room. R8's Administrator Note, dated 3/28/23 at 2:13 PM, documents, Root Cause Analysis: Investigation into fall on 3/25/2023 completed by IDT. It was determined resident was trying to stand without assistance. Make sure resident is in a supervised area, and wearing slip resistant socks. R8's Nursing Note, dated 4/2/23 at 9:29 AM, documents, Resident observed on floor facing in upright position in front of toilet. Resident voiced that he was trying to go to the bathroom and slid off of the toilet. No injuries noted. VS WNL, Neuro assessment completed with no abnormalities noted to resident baseline. ROM completed x 4 extremities without pain/discomfort. Resident denies pain at this time. MD notified, POA notified. R8's Social Service Note, dated 4/10/23 at 12:06 PM, documents, Root Cause Analysis: Investigation into fall on 4/2/2023 was completed by the IDT team. It was determined that the resident was attempting to transfer himself to the bathroom. staff educated to ask resident frequently if he needs to use the bathroom in hopes to avoid resident attempting to transfer himself. R8's Nursing Note, dated 5/3/23 at 2:48 PM, documents, Resident observed sliding from wheelchair while trying to self transfer to bed. Resident non skid socks were on, but one was turned where grippers were not in correct position. No injury noted. VSS. No c/o pain voiced. POA aware. MD notified via faxed. R8's Nursing Note, dated 5/11/23, documents, Root cause analysis: resident was attempting to transfer self and slid out of wheelchair. Resident noted to be wearing gripper socks inappropriately. Resident to wear slippers with rubber soles or shoes when up in chair. Care plan updated. R8's Nursing Note, dated 5/12/23 at 8:50 PM, documents, [Recorded as Late Entry on 5/13/2023 1:32 AM] Resident was assisted to the floor by staff. He has slumped down so far in his wheelchair his back was the only thing still in the chair. Resident was assisted to the floor by CNA before he tumbled out on his own. Staff was called to assist resident back up in wheelchair. Resident had been readjusted several times in wheelchair prior to this because he keep sliding down. No injuries noted. Doctor notified. Family will be notified. Will continue to monitor. R8's Nursing Note, dated 5/16/23 at 6:53 AM, documents, Resident was found on floor in his room. Back against the wall and stated he hit his head. No bumps noted. Resident was trying to transfer self and was reaching for shoes. Area was free of clutter and floor was dry. Resident states he should have known better. Educated resident on using call light and waiting for assistance. Resident did receive skin tear to left tricep 10 cm by 2 cm. Cleansed with wound cleanser and non-adherent pad applied and gauzed wrapped. Did use steri-strips to place some skin back together. Red mark to right shoulder. Vital signs are 97%, 98.3, 162/94, 78, 12. Does complain of head pain. Neuros are WNL. ROM x4. MD faxed. POA aware. DON (Director of Nursing) notified. Will continue to monitor. R8's Nursing Note, dated 5/17/23 at 8:29 AM, documents, Resident observed on common room area floor, reported by CNA. Resident sitting upright facing tv with wheelchair facing residents right side. Blocks noted to left side of resident on floor. BLE noted equal, ROM to X4 extremities without limitations. Resident denies pain/discomfort. Edema continues to BLE. MD made aware. R8's Nursing Note, dated 6/1/23 at 4:05 PM, documents, Resident had witness fall with no injury. ROM (range of motion) WNL (within normal limits). V/S (vital signs) WNL. Did not hit head. Assist x 2 and gait belt back to w/c (wheelchair). Son and MD made aware. R8's Nursing Note, dated 6/16/23 at 11:14 PM, documents, Resident observed on floor in BR (bathroom) at 7:30 pm. Resident stated he had to go and attempted to transfer self from w/c to toilet. Noted moderate amount of urine on floor near toilet that was not from Resident. Resident stated he hit his head possibly on the door or floor, touching the top left side of head. No noticeable injury. Resident was sitting on his buttocks slightly leaned to right side with right arm holding him up. ROM x 4 with no shortening or rotation noted. Resident did initially c/o right leg pain when he extended the right leg but was able to bend leg and pull it toward him several times with no c/o or noted difficulty. (Name) RN DON (Director of Nursing) also assessed. With assist of three Resident was transferred to his w/c with no c/o pain or discomfort. Resident then used by feet to move around in w/c without c/o pain or noted difficulty. Noted a 2 cm s/t to top of right hand. Area cleansed. Two steri-strips applied. VS 122/74 74 18 98.0 SpO2 94% RA. Made on call (Name) AGNP (Adult-gerontolgy nurse practitioner) aware and of Resident's initial c/o right leg pain. NNO. Stated to monitor and report significant changes. Made POA/son (Name) aware. Resident later c/o of low back pain then denied stating, I guess I'll be sore by morning. Neuros continue to be WNL. R8's Nursing Note, dated 8/11/23 at 12:18 PM, documents, Resident slid out of wheelchair onto his buttocks in dining area during lunch. Fall was witnessed by unit coordinator and 2 CNA staff. No injury noted. ROM WNL for resident. No c/o pain voiced. Neuro WNL for resident. Resident assisted to bathroom per request. MD notified via fax. LM for POA. Awaiting return call. R8's Social Service Note, dated 8/14/23 at 3:11 PM, documents, Root Cause Analysis: Investigation into fall on 8/11/2023 was completed by the IDT team. It was determined that resident slid out of chair while repositioning himself. Dycem added to wheelchair. R8's Care Plan and Intervention, dated 8/14/23, documents Dycem added to wheelchair. On 12/20/23 at 9:32 AM, there was no Dycem to R8's wheelchair seen. R8's Nursing Note, dated 9/16/23 at 12:57 AM, documents, Res rolled out of bed ROM WNL, neuro check started, no pain voiced. R8's Social Service Note, dated 9/25/23 at 9:55 AM, documents, Root cause Analysis: Investigation into fall on 9/16/2023 completed by the IDT. It was determined resident rolled out of bed. Scoop mattress was added to bed for residents safety. R8's Care Plan and Intervention, dated 9/25/23, documents Scoop mattress added to bed. 3. R10's Face Sheet, undated, documents R10 was admitted to the facility on [DATE], with diagnoses of Cerebral infarction, Hemiplegia, Dementia, COVID-19, UTI, Osteoporosis, long term use of Anticoagulants, DVT, and Right hip fracture. R10's Care Plan, dated 11/21/23, documents R10 is at risk for falling r/t generalized weakness, high fall risk medications, pain, dx of OA, hemiplegia, muscle wasting and atrophy, abnormal posture, HTN, and anemia. Interventions: Give resident verbal reminders not to ambulate/transfer without assistance, Grip strips to floor in front of recliner, place call don't fall signs in resident room and on walker and wheelchair, re-educate to call for assistance, Encourage R10 to use environmental devices such as hand grips, hand rails, etc., Therapy to educate Staff on proper transfer technique. It continues R10 requires assistance with her everyday ADLs r/t a diagnosis of dementia. Interventions: Remind R10 the importance of eating, Offer food she likes, easy food to chew, Offer to open packages, cut her food for her, Lay her supplies out left to right, Offer toothpaste within 6 inches of eye level. R10's MDS, dated [DATE], documents R10 has a severe cognitive impairment and requires extensive assistance from one or two staff members for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing, and requires supervision with set up help for eating. R10 is always incontinent of both bowel and bladder. The Facility's Fall Log, dated 6/1/23 through 12/18/23, documents R10 had a fall on 6/9/23, and 10/2/23. R10's Nursing Note, dated 4/30/23 at 8:25 PM, documents, Res slid out of wheel chair d/t leaning forward to pick up a piece of food off floor, no injuries ROM WNL, no pain voiced. R10's Nursing Note, dated 6/9/23 at 4:24 PM, documents, Resident observed on floor in room sitting in upright position, wheelchair facing in front of resident. Resident denies pain/discomfort. ROM x all extremities without limitations. POA made aware, md notified. VS and neuros WNL. R10's Nursing Note, dated 10/2/23 at 5:35 PM, documents, MD aware of fall and states monitor and report significant changes. R10's Nursing Note, dated 10/3/23 at 9:59 AM, documents, No injuries noted from fall. Will continue to monitor. R10's Social Service Note, dated 10/4/23 at 5:51 PM, documents, Root Cause analysis: Investigation into fall on 10/2 completed by the IDT. It was determined that resident slid from bed, while attempting to transfer. Resident encouraged to call for assistance before attempting to self transfer. On 12/18/23 at 10: 20 AM, R10 was seen sitting in a recliner in living area, napping, covered with blanket, with her wheelchair next to recliner, and no staff present in the living area. On 12/19/23 at 9:27 AM, R10 was sitting in a recliner watching movie with other residents with no staff present in the room. On 12/19/23 at 10:04 AM, V5, CNA, stated, We try to keep our residents supervised to help keep them from falling and there are interventions placed in their care plan for falls. On 12/20/23 at 9:38 AM, R10's fall interventions, according to his Care plan, include verbal reminders not to ambulate without assistance, grip strips to floor in front of recliner, call don't fall signs in room, on her walker and wheelchair. R10 resting in recliner in living area, there is no sign on her walker/wheelchair, no signs posted in her room, there are no grip strips in front of her recliner, and no staff members seen. 4. R27's Face Sheet, undated, documents R27 was admitted to the facility on [DATE], with the diagnoses of Dementia, Falls, Anxiety disorder, and Blindness both eyes. R27's Care Plan, dated 4/25/23, documents R27 is at risk for falls related to diagnosis of dementia, blindness, weakness, use of psychotropic medication, and incontinence. Interventions: 12/18/23: Observe frequently, and place in supervised area when out of bed, 12/10/23: Provide toileting assistance every 2 hours and PRN (as needed), 5/18/23: Enhanced supervision in the dining room; reminders to wait for staff assist with ambulation, Instruct resident to call for assist before getting out of bed or transferring. 4/25/23: Instruct resident to call for assist before getting out of bed or transferring. Encourage resident to stand slowly, Encourage resident to use side rails/enablers as needed. It continues R27 has impaired vision related to blindness ri[TRUNCATED]

Based on interview and record review the facility failed to provide timely treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This resulted in R32 going 2 days without treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. R32's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R32's Minimum Data Set (MDS), dated [DATE], documents a Brief interview of mental status as a 14 which indicates R32 is cognitively intact. R32's MDS also documents R32 as limited assist of one staff member with transfers, bed mobility, walking, dressing, toilet use and hygiene. R32's Progress Note dated 7/22/2022 at 6:03 PM written by V17, Licensed Practical Nurse (LPN) documents This nurse and another staff member heard resident yelling help. Upon entering the room, resident was observed in floor in the bathroom doorway. She way laying on her right side. This nurse asked resident what she was doing at the time of the fall. She stated, She peed on the floor, so I put paper towels over it and was trying to step over them and I lost my balance. Resident c/o (complained of) pain in her right foot and right elbow. She stated, 'I hit my head real hard.' Neuros WNL (within normal limits) ROM (range of motion) X4 with some pain in [NAME] (upper right extremity). 3.75 cm (centimeter) X 2.5cm skin tear to right elbow. Cleansed with soap and water. 6 steri strips applied. Open to air. Resident c/o pain in right elbow. Right elbow has bruising and swelling. Educated resident on asking for help and using her call light when she needs assistance. Resident understood. MD (medical doctor) made aware. POA (Power of Attorney) called but was busy and was not able to leave a message. Will continue to monitor. R32's progress notes dated 7/22/2022 11:21 PM written by V16, Registered Nurse (RN) documents Resident continues to complain of pain to right elbow. Swelling continues with bruising. Skin tear has been bleeding a small amount at times, dressing applied. Response pending from MD. Elbow elevated on pillow and encouraged not to bend or move it to much at the elbow. Continues on routine Tylenol. Reminded to ask for assistance with all transfers. Will continue to monitor. R32's Progress Note, dated 7/23/2022 6:03 AM written by V16 documents Orders received for x-ray of right elbow to be done this morning. Immobilize elbow and monitor. Orders carried out and Bio tech x-ray notified. R32's Progress Note dated 7/23/2022 at 3:35 PM written by V11, LPN, documents Dressing to rt (right) elbow changed due to bleeding. (Xray company) here this afternoon to obtain x-ray of arm. R32's Mobile X-ray company faxed results to the facility, dated 7/23/22 at 6:09 PM, documented Acute avulsed (small chunk of bone attached to a tendon or ligament gets pulled away from the main part of the bone) fracture proximal ulna (olecranon process). Avulsed fragments vs osteophytes radial head and lateral condyle of humerus. Soft tissue swelling seen around elbow joint. R32's Progress Note, dated 7/23/200 9:12 PM documents Tear to right elbow. Right arm is immobilized and elevated on pillows for comfort. Does complain of pain continues on routine Tylenol. X-ray results still pending. Lung sounds remains diminished in bilateral lower bases. Continues to have a non productive dry cough. Sitting up in recliner for pain relief. She is using the stand aid to help with transfers. Will continue to monitor. This Note did not document R32's physician was notified of the x-ray results. R32's Event Report, dated 7/23/2022, includes documentation of pain assessment of right elbow and foot at an 8 on a scale of 1-10. this also documents location of injury to right elbow including bruising, bump, swelling and Range of motion painful/limited to upper extremity. R32's Progress Note, dated 7/24/22 at 10:10 AM documents (X-ray company) x-ray results received impression: acute avulsed fracture proximal ulna (olecranon process), avulsed fragments vs osteophytes radial head and lateral condyle of humerus and soft tissue swelling seen around elbow joint. On call (Nurse Practitioner) made aware and stated to immobilize arm, and to follow with ortho tomorrow 7/25/22. On 11/16/2022 at 2:30 PM V1, Administrator, states she expects her staff to provide prompt care when residents area experiencing a pain and swelling with limited ROM. V1 stated she expected staff to call the doctor after hours instead of faxing. V1 stated that V17 is no longer employed due to issues such as this occurrence. On 11/17/2022 at 8:40 AM V16 stated that V17 had faxed the doctor instead of calling the doctor about R32's fall. V16 stated she called the on called doctor and he returned the call around 4am and gave orders to have an Xray of R32's elbow to be completed in the morning. V16 stated that she called the portable Xray company to see if they could do the Xray because it was the weekend. R32's Progress Note, dated 7/25/2022 signed by Orthopedic doctor documenting: non-weight bearing (NWB) right upper extremity (RUE), encourage Range of motion (ROM) elbow flexion, and sling for comfort. R32's Physician services Note, dated 7/25/2033 documents that contains chief complaint right elbow fracture date of injury 7/23/2022. This document also includes documentation stating On July 23, 2022, patient was in the bathroom when she fell backwards and sustaining a direct impact injury onto her right elbow. She immediate pain in her elbow as well as 2 large skin tears. The Note documents Present clinical examination and imaging are consistent with a left olecranon fracture with displacement and intra articular extension. The family understands that the patient would need surgery to reestablish the extensor mechanism of her elbow, without surgery she will not be able to push up from a chair or pressed down on a walker. R32 stated on 11/15/2022 at 11:00 AM that she had fallen in the bathroom and broke her elbow a few months ago on a weekend and went to the orthopedic doctor on Monday. Policy titled Emergency Care policy Procedure documents immediate care of the resident for falls, check for any apparent dislocation or possible fracture. if signs of this are noted, stabilize resident until ambulance arrives. his document also states care of possible Fractures-transport to hospital. 2. R151's Nurse's Note, dated 10/28/2022 on 3:55 PM, documents, Resident has been attempting to exit memory lane doors this shift. She has been taken for walks and has participated with activities with staff this afternoon. At this time resident was being redirected away from doors by CNA (Certified Nurse Assistant) when laundry staff came through the doors resident turned around and lost her balance falling to the floor hitting her Rt (right) eyebrow on the handrail. Resident has a small laceration with a hematoma noted on Rt elbow bleeding stopped area cleansed and dry drsg (dressing) applied. Resident continues to c/o (complaint) of Rt (right) wrist pain MD (medical doctor) informed with orders rec'd (received) for portable 3 view Rt wrist X-ray. Test ordered from biotech at this time. R151's Nurse's Note, dated 10/29/2022 at 12:00 AM, documents, Resident had been sitting in chair in room, stating she can't walk because her right wrist hurt. Resident was able to walk without difficulty to bathroom with stand by assist. Resident continues with hematoma and bruising to right eyebrow line and eye. Small amount of blood noted at times after resident rubs area. PRN (as needed) Tylenol given for pain. Resident does move right wrist noted it hurts when she tries to grip items or lift items with hand. Currently resting quietly in bed. R151's Nurse's Note, dated 10/29/2022 at 10:00 AM, documents, This nurse confirmed x-ray order with (X-ray Company) and representative stated they did not have a tech (technician) for our area today and they would not be able to come to facility. Notified Nurse Practitioner and order was given to send by ambulance to ED (Emergency Department)/resident refusing to ambulate & c/o (complaint of) pain when attempting to use or grasp anything with right hand. R151's Nurse's Note, dated 10/29/2022 at 12:17 PM, documents, Nurse ED notified facility that resident would be returning with ortho (orthopedic) cast/fracture/right wrist. DON notified & stated she would notify administrator. R151's Hospital Disposition, dated 10/29/22, documents, Discharge DX (diagnosis). Closed fracture of distal end of right radius. On 11/16/22 at 12:08 PM, V19, Licensed Practical Nurse (LPN), stated, She (151) had been at the doors banging on them to get out. The CNA got her redirected and walking away from the doors. Then staff tell me that she has fallen. When I got there, she was on her bottom, sitting up against the wall. She did not complain of pain at all. I assessed her and got her back to her room. Once back in the room she complained of pain of the wrist. There was no swelling or bruising. She continued to complain of wrist pain but no hip pain. Her leg did not have any rotation or shortening. I ordered a STAT (immediately) wrist X-ray. I did not realize that the X-ray had not been done because I was off for a bit after the shift on 10/28/22. If (the mobile X-ray company) had not come for me in a timely manner, I would have called the company and found out what is going on and if they couldn't come, I would have called the doctor and gotten an order to send her to the emergency room . On 11/16/22 at 3:45 PM, V14, LPN, stated, I took care of her (R151) after her first fall (10/29/22). I realized that (X-ray company) did not come for her wrist, I called them, and they said that they did not have a technician available. I called the doctor and got an order to send her to the ER (emergency room ). When I called report to the ER, I told them she was having pain in her wrist and pain with standing. I was not sure if the difficulty with standing was from her wrist because she would use it to pull up or if it was her hip. The hospital just did a wrist X-ray not a hip X-ray. She just held her wrist and complained of pain. She didn't complain of hip pain for me. R151's Face Sheet, undated, documents that R151 was admitted on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R151's MDS, dated [DATE] documents R151 is severely cognitively impaired. On 11/21/22 at 11:30 AM, V1, Administrator, stated that she expects X-rays to be done timely and if not to call the doctor and get and order to send the resident out to the hospital.

Based on observation, interview and record review, the facility failed to assess and identify causative factors contributing to falls, develop progressive interventions based on identified factors, and monitor and modify those interventions when needed for 4 of 8 residents (R10, R14, R28, R52), reviewed for falls in a sample of 30. This failure resulted in R52's falling and sustaining a laceration to the head requiring six staples. Findings include: 1. R52's Minimum Data Set (MDS), dated [DATE], documented, a medical diagnosis of Dementia, Laceration to scalp prior to admission of 2/28/20, abnormal posture, pain in right knee, lack of coordination, muscle wasting, repeated falls, unsteadiness on feet and severe mental cognition. The MDS documented R52 requires assistance of one staff member for transfers, walk in room, walk outside of room and toilet use. R52's MDS documents R52's balance during transition and walking as not steady and requires staff to assist with moving from seated to standing position, walking, turning around, moving on and off toilet and transfer between bed and chair or wheelchair. R52's Observation Report, Under Section entitled Fall Risk Assessment Tool, dated 6/29/21 and quarterly assessment dated [DATE], documented R52 was at High Risk for Falls. R52's Care Plan, dated 2/28/20, documented at risk for falling due to weakness, decreased mobility, [CONDITION(S)], muscle weakness, dementia, unsteady on feet and repeated falls. R52's Care Plan Approach dated 2/28/20 documents Call light in reach. R52's Care Plan Approach dated 5/11/20, documents Provide proper, well-maintained footwear. R52's Care Plan Approach, dated 10/16/20 documents Alternate call light. R52's Event Report (Fall Occurrence), documented R52 had falls on the following dates: 1/19/21, 3/15/21, 5/11/21, 6/5/21, 6/23/21, 7/1/21, 8/29/21. R52's Event Report, dated 1/19/21, documented R52 52 fell in her room. The Report documented it was an unwitnessed fall. The Event Report documented that immediate measure taken to address R52's fall was Alternate call. The Event Report documented the following Progress Note dated 1/19/21 Staff states resident was observed on bottom on the floor and resident states she was trying to get to the bed and 'went down'. Prior to fall resident was up in wheelchair reading a magazine with call light in reach. Resident was assessed with no injuries, ROM (range of motion) to all 4 extremities without complication, and no new skin issues noted. Resident VS (Vital Signs) WNL (Within normal limits). Resident encouraged to use call light for staff assistance when transferring and ambulation. There was no documentation on R52's Care Plan that the facility implemented any new interventions to address R52's fall on 1/19/21. R52's Care Plan had no documentation of revisions related to this fall. R52's Event Report, dated 3/15/21, documents R52 had an unwitnessed fall in her room. The Event Report documented R52 stated she slid from the bed. The Event Report documented the immediate measures taken were rest and increased toileting. R52's Care Plan Approach, implemented on 3/15/21 documents Encourage (R52) to use environmental devices such as hand grips, hand rails, etc. There was no documentation on this Care Plan related to increased toileting or increased supervision to prevent R52 from future falls. R52's Event Report, dated 5/11/21, documented R52 had an unwitnessed fall in her room. The Event Report documented R52 stated she lost balance and fell . The Event Report documented there were no immediate measures put into place after this fall. The Event Report under Section Notes documented the following Progress Note: Resident observed on floor in her room ear bathroom. Resident stated that she had just finished using the bathroom and walked out of the bathroom leaving her walker in the bathroom adding that she lost her balance and 'fell '. Resident denied hitting her head with no injury noted. ROM WNL x 4 extremities. No rotation or shortening noted. Resident did receive a 2 cm (centimeter) x (by) 3 cm skin tear to her right elbow and a small amount of blood. Area around skin tear staring to bruise and is purplish in color. Area Cleansed. Two steri-strips applied. Noted a small reddish abrasion to inner right wrist area. R52's Care Plan Approach, dated 5/11/21 documents Give verbal reminders to use walker with ambulation. R52's Event Report, dated 6/5/21, documents R52 was outside in the courtyard with family and fell . The Section Notes documented the following Progress Note Called by family to courtyard when resident lost balance and was assisted to the ground by family. R52's Care Plan Approach, implemented on 6/8/21, documents observe frequently. The Care Plan approach did not specify as to how frequently staff should observe R52. R52's Event Report dated 6/23/21, had no immediate interventions listed or where this fall took place. R52's Progress Note, dated 6/23/21 at 10:46 PM, documented Resident observed on floor at 7:15PM, laying slightly on her right side at the foot of her bed with head near door. Observed active red drainage from the back of residents head and on the floor. The Progress Note documented that R52 was sent via ambulance to a local hospital emergency room . R52's Progress Note, dated 6/23/21 at 10:51 PM documented R52 received six staples to a laceration at the back side of her head and would be returning to the facility. R52's Care Plan was not revised after this fall to include progressive interventions to address R52's fall and prevent her from future falls. R52's Event Report documented that on 6/30/21 at 12:56 PM, R52 fell in her room. The Report documented that R52 stated she was ambulating to the bathroom and her feet got caught and I went down. The Report documented the immediate interventions implemented were rest, ice and increased toileting. R52's Care Plan was not revised after this fall to include progressive interventions to address R52's fall on 6/30/21 and prevent her from future falls. R52's Event Report documented on 8/29/21, R52 had an unwitnessed fall in her room. The Report documented she was near closet without her walker and lost her balance. The Report documented she sustained a skin tear measuring 0. 5 cm on her right-hand 5th knuckle. The Report documented the immediate interventions implement were rest. R52's Care Plan was not revised after this fall to include progressive interventions to address R52's fall on 8/29/21 and prevent her from future falls. On 1/3/22 at 10:35 AM, V1, Administrator, stated the facility does not have a Care Plan and MDS Coordinator, and for now the Interdisplinary Team is working on the Care Plans and MDS charting. On 1/5/22 at 2:45 PM, V2, Director of Nursing (DON), stated she would expect with each fall occurrence, a new fall intervention should be documented and previous falls to be monitored of the effectiveness. On 1/6/22 at 3:00PM, V1 stated she would expect that R52 should be observed closely. On 1/6/22 at 9:50AM, V17, Certified Nurse Aide, stated that R52 has her moments of being in bed all day to up all day. 2. R10's, Face Sheet, undated, documented R10 had diagnoses of unspecified dementia, repeated falls, active seizures and [CONDITION(S)]. R10's Care Plan, initiated on 1/15/2020, documents R10 is at risk for falling related to dementia, [CONDITION(S)] activity, dx (diagnosis) of other lack of coordination, and difficulty walking, not elsewhere classified. R10's, MDS, dated [DATE], documented, severely impaired cognition, incontinent of bowel and bladder and assistance of two staff with all R10's care needs. R10's Observation Report (Fall Risk Assessment), dated 7/5/21, documented R10 at high risk for falls. The facility failed to complete a following quarterly Fall Risk Assessment. R10's Event Report, dated, 5/24/21, documented an un-witnessed fall in the dining room at 7:32AM, with [CONDITION(S)] activity to follow, this injury resulted in receiving 2 staples to the head and without a fall intervention documented. R10's Event report, dated 10/22/21, documented R10 had an un-witnessed fall, located in hallway. The Event Report documented R10 had a reddened area noted on her mid back. There was no documentation in R10's Care Plan that the facility implemented progressive interventions to address R10's fall on 10/22/21. R10's Event Report, dated 12/13/21, documented R10 had witnessed fall, with no injury. The Report documented no immediate intervention to address this fall. There was no documentation in R10's Care Plan that the facility implemented progressive interventions to address R10's fall on 12/13/21. R10's Event Report, dated 12/27/21, documents R10 had a fall in her room. The Report documented she had a red mark on her right shoulder. The Event Report documented no immediate intervention to address the fall. There was no documentation in R10's Care Plan that the facility implemented progressive interventions to address R10's fall on 12/27/21. 3. R14's Face Sheet, undated, documented a medical diagnosis of; dementia, fracture of left femur, closed for healing (history of), altered mental status, need for assistance with care, unsteadiness on feet, lack of coordination and repeated falls. R14's Care Plan, dated 4/02/20, documents R14 has a risk for falls related to diagnoses of dementia, pain, anxiety, unsteadiness of feet, polyuria, muscle weakness and atrophy, lack of coordination and [CONDITION(S)] medication use. R14's Care Plan Interventions are as follows with the following implementation dates: 12/14/2020, Observe frequently and place in supervised area when out of bed; 1/12/21, Monitor and assist more frequently for toileting needs through the day; 1/17/21, Occupy resident with meaningful distractions: activities of interest; 6/8/21, Encourage resident to use environmental devices such as hand grips, hand rails, etc.; 8/25/21, Provide toileting assistance every 2 hours and PRN (as needed) and Give resident verbal reminders not to ambulate/transfer without assistance. R14's MDS, dated [DATE], documented, severe mental cognition, assistance of two staff for all care needs, frequently incontinent of bowel and bladder and unsteady with balance during transitions and walking requires staff assistance. R14's, Observation Report (Fall Risk Assessment), dated 7/31/20, documented a high risk for falls. The facility failed to complete quarterly fall assessments. R14's Event Report, dated for the following fall occurrences; 8/21/21, 8/22/21, 10/19/21 and 10/6/21. R14's Event Report documented on 8/21/21, R14 was sitting in a chair in room and fell . R14's Event Report, dated 8/22/21, documents R14 was sitting in a chair in room and fell . R14's Event Report, dated 10/6/21, documents R14 fell in the dining room. The Event Report documented under Section Notes the following: Resident was sitting at table during breakfast and slid out of her chair on to the floor. R14's Event Report, dated 10/19/21, documented R14 was in the day room and found laying on the floor in front of the recliner with her wheeled walker beside her. The Event Report documented she sustained a skin tear to her right outer elbow. R14's Care Plan was not updated with progressive interventions to prevent falls after R14 fell on ,d+[DATE] and 10/19/21. The facility failed to present a Fall Prevention Policy and Procedure. On 1/6/22 at 2:30 PM, V2, Director of Nursing, stated that V1, Administrator had confirmed that the facility does not have a Fall Prevention Policy. 4. On 1/6/22 at 1:40 PM, R28 was observed in her recliner sleeping. R28's call light was not within her reach. The call light was clipped to the privacy curtain. R28's Face sheet, not dated, documents R28's has diagnoses of Low Back Pain, Chronic Pain, Abnormal Posture, Repeated Falls, Altered Mental Status, Difficulty Walking, Muscle Weakness, Unsteadiness on Feet, Muscle Wasting and Atrophy and [CONDITION(S)]. R28's Care Plan with a start date of 1/28/21 documents, PROBLEM: (R28) is at risk for falling related to (R/T) generalized weakness, [CONDITION(S)], sciatica and will put herself on the floor. The following are R28's Care Plan Interventions and the dates they were documented as initiated: 01/28/2021, Therapy to eval and treat as ordered; 02/15/2021,Keep call light in reach at all times and attach it to wheelchair/recliner/bed; 03/03/2021, Dycem applied to seat of wheelchair; 05/10/2021, Keep personal items and frequently used items within reach; 06/29/2021, Take resident to restroom often. Take resident to restroom when signs or symptoms of needing to void; 07/22/2021, Provide proper, well-maintained footwear; 07/31/2021, Observe frequently and place in supervised area when out of bed; 08/05/2021, Occupy resident with meaningful distractions: social and independent activities, offer to call her daughter, watch television program of choice; 08/25/2021, Assure resident is wearing eyeglasses. Assure eyeglasses are clean and in good repair; 08/30/2021, Give resident verbal reminders not to ambulate/transfer without assistance. R28's MDS dated [DATE] documents, R28 requires two-person physical assistance with transfers. The MDS documents R28 walks in room and needs extensive assist of two-person physical assist. R28's MDS documents R28 has severe cognitive impairment. The MDS documents R28 is unsteady and only able to stabilize with staff assistance with moving from seated to standing position, walking, turning around, moving on and off toilet and during surface to surface transfers. The facility Accident and Injury Reports from 9/2021 through 12/2021 documents R28 has had 11 falls in 4 months. R28's Event report dated 9/6/21 at 12:00 PM documents, Laying on right side on floor in front of w/c (wheelchair). Complains of pain right hip, right upper rib cage and right upper back. R28's Progress Note dated 9/06/2021 12:30 PM, documented new orders (N.O) for Xray of right hip, upper right rib cage, upper mid right back, and right hip. R28's Progress Notes dated, 09/07/2021 at 1:16 AM, documents Xray reports received and faxed to Doctor. Reports state that rt rib views show multiple healed rib fracture (fx) on right, osteopenia, and pleural apical plaque identified. Impression chronic changes. [MEDICATION(S)] spine, T12 and L1 compression deformities, age undetermined. Rt hip no acute fx or dislocations noted. Osteopenia. Res. (Resident) has been in bed this shift. Resting quietly. No c/o (complaints of) or s/s (signs and symptoms) of pain or discomfort noted. (R28) took Tylenol this pm without (w/o) issue. Small scab continues about right ear. No s/s of infection noted. Discolored areas with small scabs continue on bilateral lower legs. R28's Care Plan Intervention, revised on 09/07/2021, documents Encourage resident to use environmental devices such as hand grips, handrails, etc. R28's Progress Notes dated 09/08/2021 at 7:30 PM, documents (R28) was sitting in recliner yelling 'hey'. When going to room resident slid out of her recliner to the floor, couldn't get in room fast enough to stop resident from sliding all the way to the floor. Resident assisted up and into bed. No injuries noted. Resident had been complaining of back pain prior to incident. She would not sit in wheelchair properly and so she was assisted to bed. Resident did refuse her routine pain medication even after education given. Currently she is resting quietly in bed. Will continue to monitor. R28's Care Plan Intervention, dated 09/09/2021, documents Apply dycem to recliner. R28's Progress Note, dated 09/15/2021 at 12:23 PM, documents (R28) observed on floor by staff. Resident stated she had mild back pain, but no new areas or concerns noted at this time. Resident stated she was trying to get from her wheelchair to her recliner. Neuro WNL. VS 97.9 Pulse 82 RR (respiration) 20 O2 (oxygen saturation levels) 96% on RA (room air) BP (blood pressure) 134/62. MD notified and POA contacted to make aware of recent event. R28's Care Plan Interventions, dated 09/16/2021, document Reeducate resident safety measures: wait for assistance before transferring, ensure wheels are locked on wheelchair and that help is present before standing. R28's Progress Note, dated 9/17/2021 at 1:39 PM, documents (R28) observed on floor in bedroom to the side of her wheelchair, resident states 'I want in my chair', skin tear to left shin 3cm by 0.5cm steri strips applied, skin tear to left middle finger 2cm by 0.2cm steri strips and band aid applied, Right upper arm bruise 8 cm by 4 cm, hematoma to middle top forehead 5.5 cm by 4.5cm raised 0.5cm, Neuro are within normal limits, Resident does complain of back pain no injuries noted to back area, no shortening/deformity, ROM x4. medical doctor (MD) fax, POA called and left message. R28's Progress Note, dated 09/20/2021, at 3:56 PM, (R28) observed on floor in room, no injuries noted, no shortening/deformity, ROM x4, neuros within normal limits. Resident states I slid out of my chair resident cannot tell what chair she was in when she slid out. R28's Care Plan Interventions, dated 09/20/2021, document Call don't fall reminder sign within resident's sight in room and Assist resident from wheelchair to recliner after toileting immediately after meals unless resident chooses to self propel in her wheelchair. R28's Care Plan Intervention, dated 09/22/2021, documents Continue therapy to work on positioning in wheelchair and strengthening as needed. R28's Event report dated 9/27/21 documents at12:50 PM R28 was found in front of recliner. R28's Progress Note, dated 10/02/2021 at 06:14 PM, documents Resident was observed on the floor in her room. S/T to left knee cap. Edges well approximated, area cleansed and steri strips applied. POA was called and message left. MD was faxed. R28's Care Plan was not revised after R28 fell on [DATE] with progressive interventions to prevent her from falling in the future. R28's Progress Notes dated 10/04/2021 at 06:00 PM documents (R28) observed on floor in room by doorway, room was clean and uncluttered, wheelchair was by recliner, hematoma 3.5centimeter (cm) by 4 cm raised 1cm in middle forehead, middle of hematoma has a skinned area, slight bleeding noted, band aid applied so resident does not pick at area, neuros within normal limits, no shortening/deformity noted to extremities, ROM x4 resident states 'I was getting in my chair' resident educated to use call light. MD aware POA made aware. R28's Care Plan was not revised with progressive interventions after R28 fell on [DATE] to prevent her from falling in the future. There was no progressive interventions related to R28's need for increased supervision. R28's Progress Note, dated 10/10/2021 at 08:00 PM, documents Received call from Registered Nurse (RN) at hospital. States (R28) will be returning to facility. CT of head negative. States liquid dressing applied to laceration at upper forehead. Skin Tear (S/T) at forearm was scabbing over and left open to air (OTA). Dressing removed from old S/T at lower extremity (LE) and site is OTA. States can use vasoline to remove liquid dressing in 7 days if it has not worn off. R28's Progress Note, dated 10/10/2021 at 4:20 PM, documents Called to (R28)'s room at this time to find resident lying on her back in front of her recliner with bleeding noted on the floor and on residents head. Unable to assess resident for bleeding head wound resident would not lay still. R28's Care Plan was not revised with progressive interventions to prevent her from falling in the future after this fall occurred. R28's Progress Note, dated 11/09/2021, document at 7:00 PM R28) observed leaning against recliner with knees on floor and arms/elbows on seat of recliner. (R28) facing recliner. ROM to extremities with no sign/symptoms (s/s) increased difficulty of movement. (R28) assisted into low bed. Observed bruise at left knee, bruise on Rt knee, ecchymotic area on Rt elbow, and skin tear (S/T) at outer side of right knee. S/T site approximated and steri strips applied. R28's Care Plan Intervention, updated on 11/10/21, documents When resident is self propelling in wheelchair towards her room, offer to assist her into her recline. R28's Progress Note dated 11/18/2021 at 02:13 AM, documents (R28) observed on the floor, between foot of bed and bathroom door. Resident was found on her back with head at foot of bed, feet facing the bathroom door. Room was well lit with bed in low position, call light in reach. When asked what happened resident stated she didn't know. Resident was incontinent of stool and had large BM. Resident range of motion (ROM) within desired limits (WDL), extremities equal in length. No injuries are noted at this time. Resident does state that her back hurts, As needed (PRN) Tylenol given for pain. Resident was taken to the bathroom, incontinent care provided and assisted back to bed x2 staff. Resident was unable to bear weight while in bathroom with the assist x 2. Once in bed resident stated that she couldn't breathe, 96% on room air, 97.2, 99, 124/68, 16. 2liters/oxygen (O2) placed for comfort. HOB is elevated. Will continue to monitor. fax sent to MD, will update Power of Attorney (POA) at appropriate time. R28's Care Plan was not revised after the fall on 11/18/21 with progressive interventions to address her need for supervision and prevent future falls. On 1/5/22,V2, Director of Nurses (DON) stated, She has had a lot of falls. We know when she isn't feeling well or had a [CONDITION(S)] this happens more often. New interventions should be put in place with each fall.

Based on observation, record review and interview, the facility failed to provide supervision to prevent falling for 1 of 6 residents (R2) reviewed for falls in the sample of 6. This failure resulted in R2 falling, hitting her head and being sent to the emergency room (ER). R2 sustained a traumatic skull fracture, subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain) and subdural hematoma (a pool of blood between the brain and its outermost covering) that caused her death. This failure resulted in an Immediate Jeopardy when V4, Certified Nurse's Aide (CNA) left R2 unsupervised outside a physician's office building and R2 fell . This fall resulted in her death. The Immediate Jeopardy was determined to have begun on [DATE] when R2 fell sustaining a traumatic skull Fracture, subarachnoid hemorrhage, and subdural hematoma causing her death. While the Immediacy was removed on [DATE], the facility remains out of compliance at level 2 as the facility continues to educate staff as needed and evaluate the effectiveness of the interventions implemented. Finding includes: On [DATE], R2 was admitted to the facility with the following Diagnoses: [REDACTED]. R2's Minimum Data Set (MDS), dated [DATE], documented R2 had a Brief Interview of Mental Status (BIMS) score of 4, indicating she had severe cognitive impairment. R2's MDS documented her balance was not steady when walking and when turning around. The MDS documented R2 required supervision of one person for transfers and ambulation. The Care Plan, dated [DATE], documented R2 was at risk for falls with interventions to assist to activities and remind and encourage to call for assistance before getting out of bed or transferring. On [DATE], a [NAME]'s Hopkins Fall Risk Assessment Tool was documented upon R2's admission. It documented R2 was assessed at a high risk for falls due to age being greater than [AGE] years, having fallen within the last six months, currently taking two or more high fall risk drugs and behaviors of being impulsive. On [DATE], the [NAME]'s Hopkins Fall Risk Assessment Tool assessed R2 being no fall risk due to being unresponsive. On [DATE], R2's Accident and Incident Report documented R2 fell in the hallway while ambulating independently attempted to sit down in a chair and fell face first onto floor. R2 sustained an abrasion to bridge of her nose. On [DATE] at 2:43 AM, R2's Progress documented Reminded to use call light for staff assist. On [DATE] at 12:08 PM, an Accident and Incident Report documented R2 fell in the dining room while attempting to sit down. R2's Accident and Incident Report, dated [DATE] at 4:27 AM, documented R2 reported she had fallen out of bed sustaining 0.3 centimeters (cm) scrape on right elbow, 4 cm raised, bruised area behind right ear, pinpoint area to right ear lobe and 3 cm raised area in front of right ear. It documented R2 was sent to the emergency room with negative CAT Scan report and was sent back to the facility. The physician ordered to monitor for any changes. R2's Accident and Incident Report, dated [DATE] at 6:30 PM, documented R2 reported falling in the last two days. At 9:23 PM, a nurse's note documented full body assessment was completed with left hip bruise measuring 15 cm x (by) 8 cm, dark purple in color. Resident states that's when I fell and complained of area being sore. R2's Nurse's Note, dated [DATE] at 2:05 PM, documented R2 complained of dizziness and stated she had fallen one to two days ago. Physician order [REDACTED]. On [DATE], R2's Nurse's Note documented R2 had kneeled self to the floor stating she was dizzy. On [DATE] at 9:15 AM, R2's Nurse's Note documented R2 left in facility vehicle for dental appointment. At 10:33 AM, a nurse's note documented V4, Certified Nurse's Aide (CNA) and facility bus driver called and reported R2 had fallen while at the dentist and was sent to the emergency room via ambulance. At 12:38 PM, a nurse's note documented the hospital called regarding R2 with a [DIAGNOSES REDACTED]. On [DATE] at 11:15 AM, an Accident and Incident Report log was presented and the [DATE] incident was not listed on the (MONTH) 2019 log. On [DATE] at 10:20 AM, a revised Accident and Incident Report for (MONTH) 2019 was presented by the V2, Director of Nursing. V2 stated the facility had failed to report this and do an investigation. V2 stated the incident involving R2 had happened outside the facility and was not aware that the log had not been updated and an official investigation had not been completed. R2's Hospital Computed [NAME]ography (CT) scan, dated [DATE], documented There is acute [MEDICAL CONDITION] and a complex skull fracture which extends across the skull from right to left. R2's Hospital History and Physician (H&P), dated [DATE], documented the CT scan showed an extensive subarachnoid hemorrhage, subdural hemorrhage and complex skull fracture. The H&P documented the family was notified of the findings and documented They have agreed to keep patient in the hospital with comfort measures only, with the understanding that patient will likely soon pass related to the [MEDICATION NAME] hemorrhage. R2's State of Illinois Certificate of Death Worksheet, dated [DATE], documented R2 expired on [DATE]. The cause of death documented [MEDICATION NAME] force trauma due to falling and striking head on ground. On [DATE] at 3:20 PM, V5, CNA stated he had worked on the locked unit for years and remembered working with R2. He stated R2 was at first mostly independent with needing only cues during care or direction to activities or meals. He stated toward the end before R2's death, R2 required more cueing and assistance with care and more supervision. He stated she wandered throughout the unit without assist mostly but did have to have hand holding assistance while walking at times and did not know how to use her call light for assistance. He stated R2 complained of dizziness at times, especially during showers which was twice weekly. He stated he would not leave R2 unattended outside. On [DATE] at 3:30 PM, V6, CNA stated R2 was at first independent with cueing from staff. She stated R2 was unable to use her call light or remember what it was for. She stated just before her death, R2 needed more assistance with care, was incontinent at times, required more assistance with ambulating (hand holding) and complained more often of headaches and dizziness. V6 stated R2 needed extra hygiene assistance with toileting and would frequently take herself to the bathroom unassisted. On [DATE] at 4:05 PM, V4, CNA/Facility Transportation Driver, stated she had transported R2 to the dentist on [DATE] and witnessed her fall. V4 stated she arrived at work that morning and was informed that R2 needed to be transported to the dentist. She stated R2 was taken via wheelchair by V8, CNA from the locked unit to the front entrance to the facility and then ambulated without a gait belt to the van with assisting R2 by grasping R2's hand to help keep her balance as she stepped into the bus and buckled her seatbelt. V4 described the van as having a double door in which R2 could step down onto the roadway next to the sidewalk of the dentist's office. When they arrived at the dentist office, the front entrance was not available, so she had to park parallel to the building. She opened the side double doors, assisted R2 with unbuckling seatbelt and with grasping R2's hand to assist step down the step of the van to the edge of the sidewalk. V4 then stated she continued to hold R2's hand while assisting her up two steps to the sidewalk and then turned to close the double doors and around the back to the driver's side door to park the van when she said she saw R2 fall to the ground through the van window. V4 described the van as having full windows on each side, double doors on the right side with a chair lift, an emergency door at the end and a driver's side and passenger side doors. She stated she immediately ran to R2 who was attempting to sit up and saw that her head was bleeding. She stated she called 911 because she knew the injury to the head was enough to go to the emergency department. She went to turn off the van and put on gloves and held pressure to R2's head. She stated she was not sure if R2 had hit her head on the van or the concrete. She stated the county sheriff arrived, then the ambulance and R2's daughter. She stated R2 was confused and not making sense. V4 stated she did not know R2 had a history of [REDACTED]. V4 stated V8, CNA told her R2 could walk to the van, but needed help with the steps and seatbelt. She stated this was the first time she had transported R2. On [DATE] at 11:01 AM, V3, R2's Physician, stated R2's condition upon admission to the facility was guarded due to advanced end stage [MEDICAL CONDITION] resulting in debility and decline in mental and physical abilities. He stated the admission was after a lengthy period where the family was caring for R2. He stated R2 was admitted due to increased debility, weakness, falling, wandering and eloping from home. He stated R2 was alert to self only and was not be able to remember simple directions and had poor safety awareness. He stated R2 was ambulatory, but at times not steady due to physical decline and dizziness and did require staff supervision. He stated R2 had fallen at home and the facility several times with some injuries, mostly skin tears, bruising and abrasions. He stated that the fall on [DATE] certainly contributed to R2's death due to skull fracture with brain hemorrhage. He stated he had been told that R2 had fallen in the community at a dentist appointment and was left unattended while the facility van driver was parking the van. On [DATE] at 6:15 PM, V1, Administrator, stated the facility did not have a specific policy and procedure on transporting residents regarding resident's special needs, history of falls or whether direct physical contact during assist was required. On [DATE] at 12:35 PM, V9, Registered Nurse (RN), stated she was working on [DATE] and recalls telling V4, CNA that R2 should be taken by wheelchair from the unit to the front lobby to get on the van due to it being such a long walk and R2 may become too tired. V9 stated she did not specifically tell V4 of R2's falls history, dizziness or transfer requirements. On [DATE] at 2:00 PM, V1, stated the facility does not have a specific policy and procedure regarding how staff notify facility van drivers transporting residents of their required needs for ,[DATE] staff during transport, wandering residents or special needs during transport. V1 stated that staff rely on nursing assessments and the [NAME]'s Hopkins Fall Risk Assessment Tool for ADL care and assistance needs for each resident. On [DATE] at 12:50 PM, V1, Administrator, and V2, Director of Nurse's, were notified of the Immediate Jeopardy. On ,[DATE] and [DATE], the surveyor confirmed through interview and record review, the facility took the following actions to remove the immediacy: 1.A complete audit of all residents' care plans and RCIS to ensure supervision and assistive devices are consistent with resident's assessed needs, goals and care plan by the Director of Nurse's (DON) and her designee. To be started on [DATE] and completed on [DATE]. 2.The DON or her designee will create a transportation assistance roster based on the audit, which will include all residents who have been assessed as requiring assistance with transfers or ambulation. This roster will be reviewed and updated on a weekly basis. This roster will be provided to the administrator to be shared with all drivers and transportation aides to ensure that appropriate assistance is provided for residents identified as requiring assistance when being transported. To be started on [DATE] and completed on [DATE]. 3.The DON and her designee will review with all nursing staff how to locate care plans and RCIS prior to their next scheduled shift, including supervision and assistive devices need for each individual resident's goals including assistance required during transportation. Training will be ongoing with existing staff and all new hires. To be started on [DATE] and completed on [DATE]. 4.The Administrator will in-service all nursing staff on proper communication when sending a resident to an appointment via facility transportation. Communication shall include but not limited to resident transfer status, ambulation status, assistive devices, diagnosis, and any medical condition the transportation driver should know about. Staff will not be allowed to work without having received this training. Training will be ongoing with existing staff and all new hires. To be started on [DATE] and completed on [DATE]. 5.The Administrator or DON or her designee will in-service all transportation drivers on supervision and assistive devices needed with completing facility transports and retraining completed. Special emphasis was placed on review of the transportation assistance roster and ensure that appropriate assistance is provided for residents identified as requiring assistance when being transported. No transportation was done until the training was completed. Training will be ongoing with existing staff and all new hires. To be started on [DATE] and completed on [DATE].

Based on interview and record review the facility neglected to implement their policies on Tracheotomy and Tracheal Suctioning and provide 15 minute checks for 1 of 2 residents (R2) reviewed with a [MEDICAL CONDITION] in a sample of 5. This failure resulted in R2 being sent to the hospital and expiring. This resulted in Immediate Jeopardy. While the immediacy was removed on 6/20/2014 at 6:20 PM, the facility remains out of compliance at Severity Level 2 as the facility continues to educate staff, evaluate and monitor the effectiveness of the facility policy and procedures and provide inservice training on tracheal suctioning and tracheotomy care. Findings include: R2's Hospital Consult dated 5/19/2014, documents that R2 was admitted to the hospital on [DATE] with an intracranial bleed. R2's Critical Care Progress Note dated 6/10/2014, documents that R2 had a [MEDICAL CONDITION] placed on 6/7/2014 due to [MEDICAL CONDITION]. On 6/20/14 at 9:30am, E2, Director of Nursing, DON, was interviewed. E2 stated when the hospital gave report to the facility, E4, Registered Nurse, RN received report from the hospital discharge planner and the hospital reported they kept R2 restrained so she would not pull tubes off. R2's Physician order [REDACTED]. R2's Resident Progress Notes dated 6/14/2014-6/16/2014 documented suctioning and secretion color on one shift on 6/15/2014. Oxygen saturation documented one time on 6/16/2014 at 1:08 am. R2's Physician order [REDACTED]. E14 Licensed Practical Nurse, LPN was interviewed on 6/20/2014 at 11:00 am. E14 stated she does not document in the clinical nursing notes, E14 stated she just signs on the Medication Administration Record [REDACTED] R2's Resident Progress Notes dated 6/15/2014 at 6:31 PM documents that nurse was called to R2's room, due to R2 appeared short of breath, respirations labored, facial skin color dark red-blue, oxygen saturation at 83%, connections [MEDICAL CONDITION] and secured, lungs sounds assessed no audible congestion noted,. Oxygen saturation at 90-, skin color improved, resting in bed. E4, Registered Nurse (RN) was interviewed on 6/19/2014 at 3:20 PM in regards to incident on 6/15/2014. E4 stated that R2's tubing and mask over tracheotomy was off twice. E4 stated that the first time it happened speech therapy found and hooked back up, and E4 stated that she checked R2 and everything was fine. E4 stated it happened a second time on 6/15/2014 when E4 was on supper break. E4 stated she implemented 15 minute checks after the second incident, because of R2 trying to pull tube out. Resident Progress Notes dated 6/16/2014 documents at 9:00 AM Certified Nursing Assistants (CNA) called nurse to room. R2 was observed without blood pressure, pulse or respiration. Called code white. Nurse immediately got assistance went into room, starting compressions and respirations with ambu bag. Ambulance arrived at 9:15 am. Intubated by ambulance staff and transported to hospital. On 6/20/2014 E2, DON was interviewed in regards to 15 minute checks for R2. E2 stated that in regards to 15 minute checks she would expect staff to go in R2's room and observe that R2's oxygen is on and that she had not pulled any tubes off. E2 stated they have sheets for staff to mark 15 minute checks on. E2 stated the facility had received report from the discharge planner at the hospital and that E4, RN had reported to her that they had kept R2 restrained at the hospital so R2 would not pull tubes off. Documentation on Trying To Pull Tubes Out Behavior Monitoring dated 6/15/2014, the facility failed to document 15 minute checks at 7:45 PM, 8:00 PM, 8:15 PM, 9:30 PM and 10:00 PM. On 6/16/2014 the facility failed to document 15 minute checks at 5:00 am. 5:15 AM. Last documented 15 minute check on 6/16/2014 was 8:00 am. R2's Treatment Administration History dated 06/01/2014-06/18/2014 [MEDICAL CONDITION] every shift, the nursing staff put their initials each shift. The Treatment Administration History fails to document the status of the ostomy site, breath sounds and vocal sounds, respiratory functions, skin color, pulse oximetry and drainage and secretions. The facility's procedure Tracheal Suctioning documents that prior to suctioning, auscultate the resident lungs to serve as baseline data and to auscultate resident's lungs after suctioning to assess the procedure's effectiveness. The procedure states documentation to be done in the nursing notes for date and time, amount, color and consistency of secretions. Amount of saline instilled, if Ambu bag is used, [MEDICAL CONDITION] inner cannula care is done. Document in nurse's notes any unusual findings and status of ostomy site. The facility's procedure Tracheotomy documents that tracheotomy care is to be provided every shift and documented in the clinical nursing record. The status of the ostomy site is to be documented on each shift to include breath and vocal sounds, respiratory functions, skin color, pulse oximetry and drainage and secretions. Facility's procedure Tracheotomy documents all licensed personnel must receive in-servicing on proper tracheotomy care prior to providing that care. In-servicing will be done by an experienced nurse and subsequent in-servicing will continue. On the job observation and supervision will be given by the nursing supervisor. The Immediate Jeopardy situation was identified to have began on 6/14/2014 when the facility failed to follow their policy assess and monitor R2. E1 and E2 were notified of Immediate Jeopardy on 6/20/2014 at 3:20. On 6/20/2014, through interview, observation and record review, the facility took the following actions to remove the Immediacy; 1. Assess and revise the Care Plan of all residents with tracheotomies to ensure that they properly address adequate monitoring of the resident's tracheotomy by nursing staff. 2. Review and revise the facility policy on Tracheotomy to ensure that the policy properly addresses the monitoring of residents with tracheotomies, including situations when additional monitoring may be required. 3. Inservice all nursing staff on the new Tracheotomy policy before being allowed to return to work. 4. All direct care staff will be inserviced on what a resident 15 minute check consists of and what to document when 15 minute checks have been ordered or put in place for a resident. 5. The Director of Nursing (DON) will review the orders for all residents with a tracheotomy for the next three months on a weekly basis to ensure that the orders provide for appropriate monitoring of the tracheotomy given the resident's condition.

Based on record review and interview the facility failed to accurately assess/monitor and provide tracheotomy care for 1 of 2 (R2) with a tracheotomy in a sample of 5. This failure resulted in the facility finding R2 unresponsive and sending R2 to the hospital. R2 expired at the hospital. This resulted in Immediate Jeopardy. While the immediacy was removed on [DATE] at 6:20pm, the Facility remains out of compliance at Severity Level 2 as the facility continues to educate staff and evaluate the effectiveness of the facility policies and procedures for providing care to residents with a tracheotomy. Findings include: R2's Hospital Consult, dated [DATE], documents that R2 was admitted to the hospital on [DATE] with an intracranial bleed. R2's Hospital Critical Care Progress note dated [DATE] documented R2 had a [MEDICAL CONDITION] on [DATE] for [MEDICAL CONDITION]. R2's hospital transfer documentation dated [DATE] at 10:00 AM documents that R2 had a [DIAGNOSES REDACTED]. On [DATE] at 9:30 AM, E2, Director of Nursing, DON, was interviewed. E2 stated when the hospital gave report to the facility, E4, Registered Nurse, RN received report from the hospital discharge planner and the hospital reported they kept R2 restrained so she would not pull tubes off. R2's admission sheet documents that R2 was admitted to the facility on [DATE] at 12:30pm. R2's Medication Administration History dated [DATE]-[DATE] documents physician's orders [REDACTED]. On [DATE] at 4:00PM, 8:00 PM and 12:00 AM on [DATE] R2's Medication Administration History documented: Not administered/ item not available. On [DATE] at 10:00 AM, E3, Registered Nurse (RN) was interviewed in regard to availability of medications. E3 stated that R2's medication should have came in on [DATE] between 8:00 and 10:00PM. E3 stated that if medications do not come in, the nurse could call the pharmacy and they would bring as a stat order. R2's PO dated [DATE] documents that R2 was to have humidity to [MEDICAL CONDITION] site continuous and oxygen to be set at 40% or 6 liters because of [DIAGNOSES REDACTED]. R2's PO dated [DATE] documents that R2 was to have [MEDICAL CONDITION] care every shift and check oxygen saturation every shift. R2's Resident Progress Notes, dated [DATE]-[DATE], documented suctioning and secretion color on one shift on [DATE]. Oxygen saturation documented one time on [DATE], and one time on [DATE] at 1:08 AM. R2's Physician order [REDACTED]. Per interview with E14 Licensed Practical Nurse, LPN was interviewed on [DATE] at 11:00 am in regards to tracheotomy care and suctioning. E14 stated she does not document in the clinical nursing notes, E14 stated she just signs on the Medication Administration Record [REDACTED] Pulmonary Progress Notes dated, [DATE] 3:,[DATE]:30pm by E9, Certified Respiratory Therapy Technician (CRTT) documents that R2 frequently tries to rub neck to relieve itch. R2's Resident Progress Notes dated [DATE] at 6:31PM documents that nurse was called to R2's room, due to R2 appeared short of breath, respirations labored, facial skin color dark red-blue, oxygen saturation at 83%, connections [MEDICAL CONDITION] and secured, lungs sounds assessed no audible congestion noted,. Oxygen saturation at 90-, skin color improved, resting in bed. E8 was interviewed on [DATE] for clarification of the statement dated [DATE]. E8 stated he had seen R2 on [DATE] to do part of R2's evaluation. E8 stated that he went into R2's room around 5:,[DATE]:00 PM on [DATE]. E8 stated that the blue tube that was supposed to be connected to [MEDICAL CONDITION] in the floor. E8 stated he picked up off the floor and placed on the bed and went and got E4, RN. E8 stated R2 looked tired. E8 stated that E4 RN hooked the tube up. E8 stated that R2 responds by nodding her head and would try to open her mouth. E8 stated that R2 would point to her nose and head when asked. E4, Registered Nurse (RN) was interviewed on [DATE] at 3:20 PM in regards to incident on [DATE]. E4 stated that R2's tubing and mask over tracheotomy was off twice. E4 stated that the first time it happened speech therapy found and hooked back up, and E4 stated that she checked R2 and everything was fine. E4 stated it happened a second time on [DATE] when E4 was on supper break. E4 stated she implemented 15 minute checks after the second incident, because of R2 trying to pull tube out. Resident Progress Notes dated [DATE] documents at 9:00 AM Certified Nursing Assistants (CNA) called nurse to room. R2 was observed without blood pressure, pulse or respiration. Called code white. Nurse immediately got assistance went into room, starting compressions and respirations with ambu bag. Ambulance arrived at 9:15AM. Intubated by ambulance staff and transported to hospital. A typed statement dated [DATE] in regards to incident [DATE] by E8, Speech Language Pathologist (SLP), Registered Dietitian (RD) documents that E8 responded to the code white (emergency). E8's statement documents that an air pump was requested. E8 documented there was not one on the cart so E8 went to another resident's room to get one. E8 was interviewed on [DATE] for clarification of the statement dated [DATE]. E8 stated that he did not know the technical term for the air pump, but the blue thing you squeeze. E8 stated there was not one in the room so he went to R1's room and got one. On [DATE] E2 was interviewed in regards to 15 minute checks for R2. E2 stated that in regards to 15 minute checks she would expect staff to go in R2's room and observe that R2's oxygen is on and that she had not pulled any tubes off. E2 stated they have sheets for staff to mark 15 minute checks on. During the interview E2 was asked as Registered Nurse would she not expect nursing staff to have assessed R2 more frequently? E2 stated that she thought nursing staff were in R2's room more frequently than they documented. E2 stated the facility had received report from the discharge planner at the hospital and that E4, RN had reported to her that they had kept R2 restrained at the hospital so R2 would not pull tubes off. Documentation on Trying To Pull Tubes Out Behavior Monitoring dated [DATE], the facility failed to document 15 minute checks at 7:45PM, 8:00PM, 8:15PM, 9:30PM and 10:00PM. On [DATE] the facility failed to document 15 minute checks at 5:00am. 5:15AM. Last documented 15 minute check on [DATE] was 8:00am. R2's Treatment Administration History dated [DATE]-[DATE] [MEDICAL CONDITION] every shift, the nursing staff put their initials each shift. The Treatment Administration History fails to document the status of the ostomy site, breath sounds and vocal sounds, respiratory functions, skin color, pulse oximetry and drainage and secretions. On [DATE] at 2:13 PM Z1, Physician was interviewed by telephone. Z1 was informed that R2's Medication Administration History documented that R2 did not receive nebulization treatments as ordered by the Physician on [DATE] at 4:00 PM, 8:00 PM and 12:00 AM on [DATE]. Z1 was asked if lack of nebulization treatments could have contributed to R2's death. Z1 stated "yes". Z1 stated that R2 had a new tracheotomy and R2 required good [MEDICAL CONDITION] care, suctioning, and breathing treatments. Z1 stated that positioning is also very important. The facility provided documented training All About Tracheostomies. Training was provided on [DATE] by a Registered Respiratory Therapist. The facility failed to provide documented training for E4 RN, E10 LPN, and E11 LPN. The facility's procedure Tracheal Suctioning documents that prior to suctioning, auscultate the resident lungs to serve as baseline data and to auscultate resident's lungs after suctioning to assess the procedure's effectiveness. The procedure states documentation to be done in the nursing notes of date and time, amount, color and consistency of secretions. Amount of saline instilled, if Ambu bag is used, [MEDICAL CONDITION] inner cannula care is done. Document in nurse's notes any unusual findings and status of ostomy site. The facility's procedure Tracheotomy documents that tracheotomy care is to be provided every shift and documented in the clinical nursing record. The status of the ostomy site is to be documented on each shift to include breath and vocal sounds, respiratory functions, skin color, pulse oximetry and drainage and secretions. facility's procedure Tracheotomy documents all licensed personnel must receive in-servicing on proper tracheotomy care prior to providing that care. In-servicing will be done by an experienced nurse and subsequent in-servicing will continue. On the job observation and supervision will be given by the nursing supervisor. The Immediate Jeopardy situation was identified on [DATE] with R2 was identified to have began on [DATE], when the facility failed to assess and monitor R2. E1 and E2 were notified of the Immediate Jeopardy on [DATE] at 3:20pm. On [DATE], through interview, observation and record review, the facility took the following actions to remove the Immediacy; 1. Assess and revise the Care Plan of all residents with tracheotomies to ensure that they properly address adequate monitoring of the resident's tracheotomy by nursing staff. 2. Review and revise the facility policy on Tracheotomy to ensure that the policy properly addresses the monitoring of residents with tracheotomies, including situations when additional monitoring may be required. 3. Inservice all nursing staff on the new Tracheotomy policy before being allowed to return to work. 4. All direct care staff will be inserviced on what a resident 15 minute check consists of and what to document when 15 minute checks have been ordered or put in place for a resident. 5. The Director of Nursing (DON) will review the orders for all residents with a tracheotomy for the next three months on a weekly basis to ensure that the orders provide for appropriate monitoring of the tracheotomy given the resident's condition.

Based on record review and interview, the facility failed to administer prescribed nebulizer medication to 1 of 2 residents ( R2) with a tracheotomy in the sample of 5. This failure resulted in the facility finding R2 unresponsive and sending her to the hospital. R2 expired at the hospital. Findings include: R2's admission sheet documents that R2 was admitted to the facility on [DATE] at 12:30pm. R2's Medication Administration History dated [DATE]-[DATE] documents physician order [REDACTED]. Resident Progress Notes dated [DATE] documents at 9:00 AM Certified Nursing Assistants (CNA) called nurse to room. R2 was observed without blood pressure, pulse or respiration. Called code white. Nurse immediately got assistance went into room, starting compressions and respirations with ambu bag. Ambulance arrived at 9:15AM. Intubated by ambulance staff and transported to hospital. On [DATE] at 10:00 am E3, Registered Nurse (RN) was interviewed in regard to availability of medications. E3 stated the facility has 2 convenience boxes. E3 stated that if a resident was admitted after hours she would utilize the convenience box. E3, RN stated that if medication was not available in the convenience box the facility has an 800 number that can be called to the pharmacy and medication usually arrives in a couple of hours. E3 stated that if medication is needed prior to 2 hours the nurse can notify the physician and request to get from the local pharmacy. E3 stated there is a resource to get medications in an emergency or after hours. On [DATE] at 10:10AM E2, Director of Nursing (DON) was interviewed. E2 stated that if a resident comes in after hours and needs medication, the nurse would usually put in computer as a stat order. E2 stated that the facility receives medications from the pharmacy every night between 8:00 and 10:00PM. E2 stated that R2's medication should have came in on [DATE] between 8:00 and 10:00PM. E2 stated that if medications do not come in, the nurse could call the pharmacy and they would bring as a stat order. On [DATE] at 11:30am Z2, Director of Pharmacy Operations was interviewed by telephone. Z2 stated that all medications ordered by the facility on [DATE] were delivered at 11:00PM on [DATE]. Z2 stated a fax was received at 1:37PM for R2's medication orders. Z2 stated that medications can be received after hours, the facility can call the 800 number and the pharmacy can call a local pharmacy and have the medications picked up and delivered by a courier. On [DATE] at 2:13PM Z1, Physician was interviewed by telephone. Z1 was informed that R2's Medication Adminisration History documented that R2 did not receive nebulization treatments as ordered by the Physician on [DATE] at 4:00PM, 8:00PM and 12:00AM on [DATE]. Z1 was asked if lack of nebulization treatments could have contributed to R2's death. Z1 stated "yes". Z1 stated that R2 had a new tracheotomy and R2 required good [MEDICAL CONDITION] care, suctioning, and breathing treatments. Z1 stated that positioning is also very important.