Every finding on record at Prairie Manor NRSG & Rehab CTR

Based on observation, interview, and record review, the facility failed to ensure food served to two residents (R80, R116) was palatable. This affected two (R80, R116) residents reviewed for palatability in a sample of 28 residents. Findings include: R116's face sheet documents R116 is a [AGE] year-old resident with diagnoses including: atherosclerotic heart disease, congestive heart failure, pyelonephritis, chronic obstructive pulmonary disease, rheumatoid arthritis, type 2 diabetes mellitus, dysphagia, and fibromyalgia. R116's minimum data set (6/30/2026) documents a brief interview of mental status summary score of 15, indicating R116 is cognitively intact. On 8/10/2026 at 10:40 AM, R116 expressed complaints about the food being overcooked. R116 recalled food's texture is often very hard from the food being burnt and tastes burnt. R116 stated Even the coffee is burnt! Everything is just cooked way too long. R80's face sheet documents an admission date of 1/13/25 and diagnoses that include but are not limited to post-traumatic stress disorder, dementia, severe protein-calorie malnutrition, and muscle wasting and atrophy. R80's BIMS (brief interview for mental status), dated 6/25/26, is 8 which indicates R80's cognition is moderately impaired. R80's care plan, dated 1/17/25, documents, in part, (R80) benefits from a liberalized diet R/T (related to) po (by mouth) intakes, advanced age, hx (history) wt (weight) changes and underweight BMI status, with interventions that document, in part, Provide and serve supplements as ordered; Provide, serve diet as ordered. Monitor intake and record q (every) meal. On 8/10/26 at 1:04pm, R80 said, See, look. This isn't the first time they (facility) burnt the grilled cheese. I can't even eat this (grilled cheese sandwich). Just gross. A grilled cheese sandwich was observed that appeared significantly burnt on one side, with extensive dark brown to black discoloration across substantial portions of the exterior surface one side of the bread. The surface of R80's bread demonstrated areas of heavy charring and blackened crust, particularly across the center and lower portions of one side of the grilled cheese. The bread was markedly darker than the normally golden-brown appearance expected of toasted bread (observed on R80's other piece of bread), with multiple areas appearing heavily scorched. R80 proceeded to partially separate the 2 pieces of bread, revealing the cheese filling between the slices of bread. The interior portion of the sandwich showed melted yellow cheese intermixed with areas of dark brown to blackened bread and visibly charred material. Portions of the bread surrounding the cheese appeared excessively browned, hardened, and scorched. R80 said, At least it's (grilled cheese) warm, but this burnt side is not edible. Just too burnt and hard. I can't do it (eat the grilled cheese). On 8/10/26 at 1:06pm, V21 (R80's Family Member #2/Rabbi), who was at the bedside with R80, said, Why don't we just ask them (staff) to make one (grilled cheese) that's not burnt? R80 replied, They (staff) think I'm a troublemaker. I'll just eat the half that's not burnt. R80 then ate the half of the grilled cheese that was not burnt and left the other half on the plate to be disposed of. On 8/12/26 at 1:27pm, V7 (Dietary Manager) said, When residents first get here (facility), I meet with them (residents) to get 'likes and dislikes.' R80 calls and complains a lot. Calls all the time. Upon observation of a picture taken of the grilled cheese R80 was served for lunch on 8/10/26, with V7, V7 stated, No, I don't think it's (grilled cheese) burnt. I like my grilled cheeses like that. It's (grilled cheese) probably darker because it's wheat bread. Surveyor showed V7 a picture of part of the bread on the other side of R80's grilled cheese that was not charred, had a golden-brown appearance, and was partly eaten by R80. V7 replied, We (kitchen staff) could have made her (R80) another one (grilled cheese). I was here Monday (8/10/26). I would have made a new grilled cheese myself. I'm not going to give anyone food here that I wouldn't eat. I don't play about food. They (residents) look forward to a good meal. Some (residents) just have a good meal to look forward to. On 8/14/26 at 10:36am, upon observation of a picture taken of the grilled cheese R80 was served for lunch on 8/10/26, with V2 (Director of Nursing/DON), V2 said, Oh, It's (grilled cheese) a little dark. I do like mine (grilled cheese) nice and toasted though. I mean, it (grilled cheese) might be okay to eat. Record review of facility policy titled, Food Palpability Policy: Resident-centered standards for taste, appearance, temperature, texture, choice, and meal satisfaction, dated August 2026, documents, in part, 1. Purpose: To ensure every resident receives meals and beverages that are nourishing, palatable, attractive, properly prepared, and served at safe and appetizing temperatures, while honoring the resident's assessed needs, preferences, culture, choices, and plan of care. 2. Policy: The facility will provide food and beverages that support nutrition, hydration, dignity, and enjoyment. 42 CFR 483.60 requires a nourishing, palatable, well-balanced diet that meets daily nutritional and special dietary needs while considering resident preferences. 42 CFR 483.60(d) requires food to conserve nutritive value, flavor, and appearance; be palatable and attractive at a safe and appetizing temperature; meet individual needs; accommodate allergies, intolerances, and preferences; and include appealing alternatives of similar nutritive value. 4. Definitions: Palatable: Pleasant and acceptable in taste, aroma, seasoning, texture, moisture, temperature, and overall eating quality for the intended resident and diet. Attractive: Presented neatly with appropriate color contrast, portioning, plate arrangement, garnishing when appropriate, and clean service ware. 6.3 Meal Service and Resident Choice: Meals will be plated attractively on clean, intact service ware and delivered without avoidable delay. Record review of facility policy titled, Resident Rights Guideline, dated 10/2023, documents, in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times.; Responsible Party: Interdisciplinary team. Safe Environment: The right to a safe, clean, comfortable, and home-like environment that allows independence as possible.

Based on interview and record review, the facility failed to follow policy/protocols and failed to document on the treatment administration record for providing pressure ulcer preventative measures for one resident (R138) in a sample of 28 residents reviewed for pressure ulcer prevention documentation.R138's Face Sheet documents in part that R138 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include infection and inflammatory reaction due to internal left knee prosthesis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, atrial fibrillation, rheumatoid arthritis, type 2 diabetes mellitus, obstructive sleep apnea, atrial flutter, and acute on chronic combined systolic and diastolic heart failure.R138's Minimum Data Set (MDS) on 5/21/2026 documents in part that R138 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R138 is cognitively intact, and that R138 is dependent for toileting, bathing, and dressing. R138's Care Plan includes the resident has potential/actual impairment to skin integrity related to trauma wounds (surgical incision - left trochanter/hip, Skin stripping - Left Hallux, Abrasion - Left Foot 2nd digit, Right hallux, Right Foot 2nd digit) with interventions including in part Follow facility protocols for treatment of injury.R138's Order Summary report includes in part Pressure relieving cushion to chair every shift (5/16/2026), Peri area/buttock - may apply moisture barrier cream with each incontinence episode very shift, may keep at bedside for CNA (Certified Nursing Assistant) to apply (5/16/2026).R138's Braden Score on 6/5/2026 is 17, indicated R138 is At Risk for acquiring pressure wounds.R138's Treatment Administration Record for June 2026 reviewed for documentation of pressure relieving cushion to chair every shift. 22 occurrences are not documented out of 90 opportunities. (January 2017)On 8/14/2026 at 12:34PM, V22 (Wound Care Licensed Practical Nurse/LPN) affirmed that R138 was at risk for skin breakdown and that pressure relieving cushion was ordered for pressure injury prevention. R138 had wounds but not pressure related during his stay. When asked about the blank entries on R138's treatment administration record, V22 (Wound LPN) confirmed If it is blank, then technically it is not done.Facility Policy Pressure/Skin Breakdown - Clinical Protocol (January 2017) documents in part that In addition, the nurse shall assess and document/report the following: .Current treatments, including support surfaces.

Based on observation, interview, and record review, the facility failed to follow policy and procedure and failed to document the administration of ordered nutritional supplements for one resident (R80), with a known history of weight loss. This failure affected one (R80) resident reviewed for weight loss in a sample of 28 residents. Findings include:R80's face sheet documents an admission date of 1/13/25 and diagnoses that include but are not limited to post-traumatic stress disorder, dementia, severe protein-calorie malnutrition, and muscle wasting and atrophy.R80's BIMS (brief interview for mental status), dated 6/25/26, is 8 which indicates R80's cognition is moderately impaired.R80's Order Summary Report, dated 8/12/26, documents, in part, Ensure three times a day 1 can (237mL); Health Shake with meals for failure to thrive.R80's care plan, dated 1/17/25, documents, in part, (R80) benefits from a liberalized diet R/T (related to) po (by mouth) intakes, advanced age, hx (history) wt (weight) changes and underweight BMI status, with interventions that document, in part, Provide and serve supplements as ordered; Provide, serve diet as ordered. Monitor intake and record q (every) meal.On 8/10/26 at 2:11pm, V16 (R80's Family Member) said, they (facility staff) let her (R80) fall to 57 pounds. They (facility staff) don't bring her (R80) ensure on a regular basis.On 8/10/26 at 10:02am, R80 said, My ensure sometimes I get it (ensure), sometimes I don't. I get another kind too, but I don't know what it's called. The food is terrible here, so I need my ensure. I might have refused the ensure a handful of times, but I usually take it (ensure).On 8/14/26 at 10:36am, upon observation of R80's Medication Administration Record (MAR), dated August 2026, with V2 (Director of Nursing/DON), revealed blank entries for R80's ensure administration on 8/1/26 at 5:00pm, 8/2/26 at 5:00pm, and 8/9/26 at 1:00pm as well as blank entries for R80's health shake administration on 8/1/26 at 5:30pm, 8/2/26 at 5:30pm, and 8/9/26 at 12:00pm. There was no indication whether the nutritional supplements were administered, refused, or not administered due to the resident being out of the facility. V2 affirmed that the MAR (R80) should not be left blank. V2 stated that there is no way to determine whether the resident received the medication. V2 stated that V2 will follow up with staff regarding proper MAR documentation.Record review of facility policy titled, Medication Administration, dated 10/25/2014, documents, in part, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medication refusal must be reported to the prescriber after (XX) number of doses are refused and there must be documentation of prescriber notification of such. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration. Initials on each MAR are cross referenced to a full signature in the space provided. 6) If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time (e.g. the resident is not in the facility at scheduled dose time, or a starter dose of antibiotic is needed), the space provided on the front of the MAR for that dosage administration is [initialed and circled]. An explanatory note is entered on the reverse side of the record. If [XX consecutive doses] of a vital medication are withheld, refused, or not available the physician is notified. Nursing documents the notification and physician response.Record review of facility policy titled, Resident Rights Guideline, dated 10/2023, documents, in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times.; Responsible Party: Interdisciplinary team. Safe Environment: The right to a safe, clean, comfortable, and home-like environment that allows independence as possible.

Based on observation, interview, and record review, the facility failed to ensure one resident's bathroom call light was readily accessible and functioning properly. This failure affected one (R80) resident out of a sample of 28 residents, reviewed for call lights.Findings include:R80's face sheet documents an admission date of 1/13/25 and diagnoses that include but are not limited to unsteadiness on feet, difficulty walking, post-traumatic stress disorder, dementia, severe protein-calorie malnutrition, and muscle wasting and atrophy.R80's BIMS (Brief Interview for Mental Status), dated 6/25/26, is 8 which indicates R80's cognition is moderately impaired.R80's care plan, dated 1/17/25, documents, in part, (R80) is at high risk for falls r/t (related to) her diagnosis of hypotension, disorientation, anemia, osteoporosis, dementia, CAD, HTN, malnutrition, adult failure to thrive, weakness, with interventions that document, in part, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.On 8/10/26 at 10:02am, R80 said, My call light has been broken in the bathroom awhile. I told the nurses about it. I don't remember their names. I told my sons too. R80's call light in R80's bathroom was observed without a string/cord attached to activate the call light.On 8/10/26, upon observation of R80's bathroom call light with V3 (Licensed Practical Nurse/LPN), V3 said, The call light needs a string. No, the call light doesn't work without a string.On 8/12/26 at 1:40pm, V8 (Maintenance Director) said, I was not notified of R80's bathroom call light not working until Monday (8/10/26). The whole cord was pulled out. I had to put a new cord in. No, the call light will not work without the cord. They (staff) usually put that (call lights not working) in TELS. No, it (R80's call light not working) was not put in the work order system. I fixed the call light on Monday (8/10/26).On 8/14/26 at 10:36am, V2 (Director of Nursing/DON) said, My expectation for call lights is that they should be in reach, response in a timely manner, and properly functioning. Call lights are needed so we (staff) can tend to their (residents) needs.Record review of facility policy titled, Answering the Call Light, dated August 2008, documents, in part, The purpose of this procedure is to respond to the resident's requests and needs. 4. Be sure that the call light is plugged in at all times. 7. Report all defective call lights to the Maintenance Department promptly. 10. Call lights must be accessible to residents from their bed or other sleeping accommodation. Call lights must be accessible to residents from each toilet and bath or shower facility. The call system should be accessible to a resident lying on the floor.Record review of facility policy titled, Resident Rights Guideline, dated 10/2023, documents, in part, Purpose: It is the practice of this facility to provide for an environment in which residents may exercise their rights, each day. Our residents have certain rights and protections under Federal law. Our facility meets and provides these rights through care and related services at all times.; Responsible Party: Interdisciplinary team. Safe Environment: The right to a safe, clean, comfortable, and home-like environment that allows independence as possible.

Based on Observation, Interview, and Record Review, the facility failed to follow policy/procedures for wound monitoring and treatment, failed to properly monitor and document wound vac therapy, failed to consistently document alternate dressings consistently while wound vac therapy was suspended, and failed to follow the recommended intravenous antibiotic causing a delay in therapy. This failure affected one resident (R138) in the sample of 28 residents reviewed for quality of care/wound treatments.R138's Face Sheet documents in part that R138 is a [AGE] year-old male admitted to the facility on [DATE]. Diagnoses include infection and inflammatory reaction due to internal left knee prosthesis, acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, atrial fibrillation, rheumatoid arthritis, type 2 diabetes mellitus, obstructive sleep apnea, atrial flutter, and acute on chronic combined systolic and diastolic heart failure.R138's Minimum Data Set (MDS) on 5/21/2026 documents in part that R138 has a Brief Interview for Mental Status (BIMS) score of 15, indicating R138 is cognitively intact, and that R138 is dependent for toileting, bathing, and dressing. R138's Care Plan includes The resident is on antibiotic therapy related to infection of left prosthetic knee infection with interventions including in part Administer antibiotic medications as ordered by physician. Care Plan also includes the resident has potential/actual impairment to skin integrity related to trauma wounds (surgical incision - left trochanter/hip, Skin stripping - Left Hallux, Abrasion - Left Foot 2nd digit, Right hallux, Right Foot 2nd digit) with interventions including in part Follow facility protocols for treatment of injury.R138's Order Summary report includes in part If Wound Vac becomes dislodged before next MD (Medical Doctor) appointment, apply wet-to-dry dressing BID (twice a day) to left hip (6/11/2026), Monitor Wound Vac to left thigh for drainage and functioning properly every shift (5/26/2026), and Left Hip - Clean with Normal saline, pat dry, apply wet-to-moist saline dressing BID and as needed (6/26/2026).R138's Progress Notes Reviewed from May 2026 through July 2026. Contents include in part:5/22/2026 - Infectious Disease consult note - .Medication list reviewed and resident noted on Intravenous (IV) Cefazolin 2grams every 8 hours till 5/25/2026 while Keflex 1000 milligrams is to start after completion of intravenous antibiotics.5/26/2026 - Nurse note -- Resident returned from Hxxx Pxxx Orthopedics with wound vac and return appointments for 6/2/2026 and 6/9/2026.6/2/2026 - Nurse note - Received call from Infectious disease RN (registered nurse) to start cefazolin 2 grams IV every 8 hours until 6/30/2026.6/9/2026 - Nurse note - During patient care, resident's wound vac to left thigh dislodged. Wound cleansed with NSS (Normal Saline Solution), wet-to-dry dressing applied.6/10/2026 - Nurse Note - Call placed to (Ortho Doctor) related to wound vac dislodged, requesting further orders.6/10/2026 - Nurse Note - .Returned call. New orders for dry dressing to left hip wound site. Appointment for 6/11.6/11/2026 - Nurse Note - Resident returned with the following directions: Wound vac placed on today and needs to stay in place for 1 week (until next appointment). If wound vac becomes dislodged, please initiate wet-to-dry dressings BID. 6/24/2026 - Nurse Note - .has dressing dry/intact to left hip, wound vac off, seeing surgeon tomorrow.6/25/2026 - Nurse Note - .Wound vac on draining and charging.6/26/2026 - Nurse Note - Informed that the Wound VAC dressing has been reinforced with Tegaderm related to bloody drainage leaking out of the dressing. Also informed that (facility) has a Wound VAC available. Per (ortho), continue to reinforce dressing with Tegaderm and call Monday and update the office. A PRN (as needed) wet-to-dry dressing order is in place if Wound Vac fails.6/26/2026 - Nurse Note - Resident seen to assess the Left hip Wound VAC with another Nurse. Observed bloody drainage leaking out of the dressing. Observed small blood clots in the VAC tubing creating a blockage. Wound VAC removed, wet to moist dressing applied.6/30/2026 - Nurse Note - Wound Care: Left hip: Cleanse with Normal Saline, pat dry, apply Wet to Moist Saline dressing BID, and as needed. Per: (Ortho Surgeon).R138's Treatment Administration Record for Monitoring Wound Vac every shift May 2026 - 1 occurrence with no documentation out of 16 opportunitiesR138's Treatment Administration Record for Left Hip Wound Wet to Dry Dressing June 2026 - 2 treatments not documented out of 8 opportunitiesR138's Treatment Administration Record for Monitoring Wound Vac every shift June 2026 - 11 occurrences with no documentation out of 90 opportunitiesR138's Treatment Administration Record for Left Hip Wound Wet to Dry Dressing July 2026 - 1 occurrence not documented and 1 refusal out of 5 opportunities R138's Orthopedic after visit summary on 5/26/2026 documents in part Ongoing wound drainage managed with antibiotics. Continue Cefazolin 2 gram IV every 8 hours per infectious disease recommendation; communicated need for ongoing IV antibiotics to facility.Review of medication administration orders and audit demonstrates that Cefazolin Sodium Injection Solution Reconstituted 2 GM (Cefazolin Sodium) Use 2 gram intravenously every 8 hours until 06/30/2026 was ordered on 6/2/2026 through 6/30/2026, despite request from orthopedics to resume on 5/26/2026. This delay in order caused a lapse in IV antibiotic therapy from 5/26/2026 till 6/2/2026.On 8/11/2026 at 4:30PM, V54 (Orthopedic Registered Nurse) confirmed the timeline of orders, and relayed the expectation was that the IV antibiotics were to be continued as per verbal notification and written on after visit summary. There was also an instance where the wound vac had become dislodged, and ortho wasn't notified till the following day, causing a delay in alternate treatment orders (referring to 6/9/2026, with no notification till 6/10/2026).On 8/14/2026 at 12:34PM, V22 (Wound Care Licensed Practical Nurse/LPN) affirmed that R138 was receiving wound vac therapy during his stay, and that the wound vac was to be checked by nursing at minimum each shift. V22 (Wound LPN) stated that the floor nurses do not have training in wound vacs, so when they leak or malfunction, then they would be expected to do a wet to dry dressing. When asked about the blank entries on R138's treatment administration record, V22 (Wound LPN) confirmed If it is blank, then technically it is not done. 'Yes, orders are to be carried out as ordered by the physician. I am not sure why there were delays, as I (V22) was not the covering wound nurse at that time.Facility Policy Pressure/Skin Breakdown - Clinical Protocol (January 2017) documents in part The physician will authorize pertinent orders related to wound treatments, including pressure redistribution surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents and In addition, the nurse shall assess and document/report the following: Full assessment of skin condition including but not limited to location, stage or partial/full thickness, length, width and depth, presence of exudates or necrotic tissue, Pain assessment, Resident's mobility status, Current treatments, including support surfaces, All active diagnoses.

Based on observations, interviews, and record reviews, the facility failed to follow its enhanced barrier precautions (EBP) policy and don appropriate PPE (personal protective equipment) prior to entering an EBP resident room to provide direct resident care and failed to perform hand hygiene before exiting a resident's room after providing direct resident care. These failures affected four residents (R2, R3, R4, and R5) out of five residents reviewed for infection control in a sample of 6. Findings include: On 12/18/25 at 11:04 AM, V10 CNA (certified nurse aide) was observed entering R3's EBP room and rearranging R3's personal items on bedside table. V10 then exited R3's room with R3's water pitcher and placed it on the counter at the nurses' station. V10 was then observed placing the mechanical lift device in the tub room and return to the nurses' station to wash hands. V10 then filled R3's water pitcher and brought into R3's room. On 12/18/25 at 11:25 AM, V6 CNA entered R2's EBP room to provide incontinence care. V6 did not don a gown prior to entering R2's room. At 11:31 AM, V6 exited R2's room, removed gloves, went to the tub room, opened the door and grabbed a soiled linen rolling cart. V6 brought cart to R2's room and placed soiled linen in cart then brought cart to tub room. V6 did not perform hand hygiene prior to exiting R2's room. V6 was then observed washing hands at sink in nurses' station. On 12/19/25 at 8:20 AM, this surveyor observed V4 (wound care nurse) enter R5's room to provide wound care treatment for R5's right buttock wound. The signage on R5's door notes EBP - wound care - any skin care requiring a dressing. V4 did not don a gown prior to entering R5's room. On 12/19/25 at 8:30 AM, V3 (wound care nurse) stated that R5 is not on enhanced barrier precautions; his roommate, R4, is due to having a colostomy. When questioned if R5 has a wound that requires a dressing, V3 responded yes but he is not on EBP. V3 stated that the facility interpreted the EBP policy to refer to chronic wounds. V3 stated that a resident's wound must be present for 90 days before the resident is placed on enhanced barrier precautions. On 12/19/25 at 10:20 AM, V9 LPN (licensed practical nurse) was observed providing colostomy care to R4. R4 is on EBP. V9 did not don a gown prior to preforming direct resident care. On 12/19/25 at 1:20 PM, V5 (infection prevention nurse) stated that if resident has a wound for 90 days, then we will place the resident on enhanced barrier precautions. V5 stated that this is the facility's EBP policy. V5 stated that she is not aware that the facility's EBP signage notes: wound care -- any skin care requiring a dressing. V5 stated that each resident room has a hand sanitizing dispenser, and a bathroom sink for staff to wash hands. V5 stated that staff are expected to perform hand hygiene prior to exiting any resident's room. V5 stated that staff should not exit the resident's room, go to tub room to grab a cart or return equipment, then perform hand hygiene at the nurses' station. R5's medical record notes R5 with a right buttock pressure ulcer identified on 11/3/25. Wound measures 3.6cm (centimeters) x 3.2cm x 0.1cm.R5 with diagnoses of chronic obstructive pulmonary disease, severe protein-calorie malnutrition, prostate cancer, adult failure to thrive, cancer of kidney, secondary cancer of other parts of the nervous system. These factors may delay or prevent wound healing and may put R5 at risk for further breakdown. On 11/24/25, R5's right buttock wound measured 2.2cm x 1.7cm x 0.1cm. On 12/1/25, V3 noted R5's Left buttock MASD (moisture associated skin damage) area and right buttock wound area have conjoined. On 12/15/25, R5's right buttock pressure ulcermeasured 3.6cm x 3.2cm x 0.1cm. R5's POS, dated 11/4/25, notes wound care: right buttock: cleanse with normal saline, pat dry, apply hydrogel to wound bed, secure with border gauze/dry dressing daily and as needed if soiled or dislodged.The facility's enhanced barrier precautions signage notes everyone must: clean their hands, including before entering and when leavingthe room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities. Dressing,bathing, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use, wound care: any skin openingrequiring a dressing. The facility's enhanced barrier precautions policy, revised 3/21/24, notes, in part, enhanced barrier precautions refer to the use of gownand gloves for use during high-contact resident care activities for residents at increased risk of multidrug resistant organism acquisition (residents with wounds). Initiation of enhanced barrier precautions - implement enhanced barrier precautions for residents with any of the following: wounds. High-contact resident care activities include: dressing, bathing, transferring, providinghygiene, changing linens, changing briefs or assisting with toileting, device care or use, wound care: any skin opening requiring a dressing. On 12/19/25, V1 (administrator) presented the CMS (Centers for Medicare & Medicaid Services) memorandum, dated 3/20/24, enhanced barrier precautions in nursing homes. This guidance notes enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds, not shorter-lasting wounds, such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid(R)) or similar dressing.

Based on observations, interviews, and record reviews, the facility failed to have the low air loss mattress at the correct weight setting for one resident (R2) with a stage 4 pressure ulcer, who is at risk for skin breakdown and requires extensive assistance with turning/repositioning, out of three residents reviewed for wound management in a sample of 6. Findings include:On 12/19/25 at 8:55 AM, this surveyor observed V3 (wound care nurse) provide wound care treatment for R2's sacral pressure ulcer. R2 was observed to have a low air loss mattress with the weight setting at 400 pounds. On 12/19/25 at 9:05 AM, V3 stated that the weight on R2's low air loss mattress is locked and V3 does not know how to unlock it to adjust the weight setting. V3 stated that the machine is set for a person weighing 400 pounds. V3 stated that she knows R2 does not weigh 400 pounds but would have to check R2's medical record to know what R2's current weight is. V3 stated that the weight setting on the mattress should be checked daily. V3 stated that she will have to ask maintenance to come fix the weight setting. V3 stated that the resident's weight determines how much air flows through the mattress. V3 stated that the specialty mattress would be more firm if the weight setting was set higher than the resident's actual weight causing more pressure on the resident's wound. V3 stated that you don't want too much pressure on wound d/t increased setting of weight. R2's medical record, dated 12/4/25, notes R2's weight was 265.8 pounds. R2's wound assessment details report, dated 12/15/25, notes R2 with a stage 4 pressure ulcer left buttock to sacrum to right buttock. Wound was identified on 5/7/24. Wound measures 5.5cm (centimeters) x 4cm x 1cm. R2's MDS (minimum data set), dated 11/7/25, notes R2 requires maximum assistance from staff with bed mobility. R2 is dependent on staff for toileting and transfers. The facility's pressure wound treatment policy, dated 01/2017, notes, in part, the pressure injury treatment program should focus on tissue load. Tissue load refers to the pressure, tension, and mechanical forces on injured skin and underlying tissues. CMS (Centers for Medicare & Medicaid Services) article titled pressure reducing support surfaces - group 2 policy article, dated 4/7/22, notes, in part, that styles of group 2 powered pressure reducing mattresses (alternating pressure, low air loss) which is characterized by all of the following: an air pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress, inflated cell height of the air cells through which air is being circulated is 3.5 inches or greater, height of the air chambers, proximity of the air chambers to one another, frequency of air cycling (for alternating pressure mattresses), and air pressure provide adequate beneficiary lift, reduce pressure and prevent bottoming out, ands a surface designed to reduce friction and shear, and can be placed directly on a hospital bed frame.

Based on interview and record review, the facility failed to develop and implement effective fall interventions related to the root cause of a resident with multiple falls. This affected one of three residents (R1) reviewed for falls. This failure resulted in R1 having six falls in six months with no change in fall interventions. Findings Include: R1 is an [AGE] year old with the following diagnosis: Parkinson's disease, functional quadriplegia, difficulty in walking, and orthostatic hypotension. A Plan of Care note dated [DATE] documents the nurse was called to R1's room by another staff member. The nurse observed R1 on the floor sitting in front of the wheelchair. R1 was assisted back to the wheelchair. The Care Plan dated [DATE] documents R1 is a high fall risk related to diagnosis of Parkinsonism, weakness, syncope, depression, and coronary artery disease. Interventions were added after each fall. The following interventions were documented on [DATE]: anticipate and meet R1's needs, follow facility fall protocol, and be sure R1's call light is within reach and encourage R1 to use it for assistance as needed. R1 needs prompt response to all requests for assistance. The Fall Report dated [DATE] documents a staff member called the floor nurse to R1's room where R1 was observed sitting on the floor in front of R1's wheelchair. R1 reported R1 was trying to get into the wheelchair and slid onto the floor because R1 did not lock the wheelchair. R1 was alert to person, place, and time. There's no documentation of any additional interventions put in place after this fall. A Nursing note dated [DATE] documents the nurse heard R1 calling up for help. Upon entering the room, R1 was on the floor with R1's back against the bed. R1 was in a sitting position. R1 told staff R1 was trying to self-transfer from the bed to the wheelchair when R1 slid to the floor from the bed. The Care Plan from [DATE] had interventions added from after the fall on [DATE]. The following interventions were documented on [DATE]: R1 needs a safe environment with even floors free from spills and/or clutter, adequate/glare-free light, working and reachable call light, bed in the low position, and personal items within reach; R1 needs activities that minimize the potential for falls providing diversion and distraction. The Care Plan dated [DATE] documents R1 is high risk for falls. An intervention dated [DATE] documents physical therapy will evaluate and treat R1. The Fall Report dated [DATE] documents R1 was calling out for help and upon entering the room, R1 was observed sitting on the floor with R1's back against the bed. R1 stated R1 was trying to self-transfer from the bed to the wheelchair and slid to the floor. The level of consciousness or mental status was not documented. There is no documentation of any additional interventions put in place after this fall. A Nursing note dated [DATE] documents R1 was observed in R1's room in a sitting position. R1 stated the dresser fell on R1's right ankle as R1 is trying to open the dresser where the belongings were kept. R1 complained of right ankle pain. The nurse practitioner was informed and ordered an x-ray to the right leg, right ankle, and right upper back. The incident was immediately reported to maintenance and the dresser was replaced with a new dresser. The Care Plan from [DATE] had interventions added from after the fall on [DATE]. The following intervention was documented on [DATE]: encourage R1 to use the call light for assistance with needs. The Fall Report dated [DATE] documents R1 was observed in a sitting position in R1's room. R1 reported trying to reach for a belonging in R1's dresser when the dresser fell on R1's legs. R1 complained of the upper right back and right ankle hurting. The nurse practitioner was notified and ordered x-rays. Maintenance was notified and made immediate corrective action. The old dresser was replaced with a new one. There is no documentation on R1's mental status or level of consciousness. There is no documentation any additional interventions were put in place after this fall. A Nursing note dated [DATE] documents R1 was found on the ground on the side of the bed during rounds. R1 stated R1 was trying to get into bed and slid out of the wheelchair. When asked why R1 didn't use the call light for help, R1 stated, I thought I could do it. The area was free from spills or objects. R1 had gym shoes on R1's feet. R1 denied all pain or discomfort. The Care Plan from [DATE] had interventions added after the fall on [DATE]. The following interventions were documented on [DATE]: anticipate and meets R1's needs; follow facility fall protocol; and be sure R1's call light is within reach and encourage R1 to use it for assistance as needed. R1 needs prompt response to all requests for assistance. These are the exact same interventions that were documented after the fall on [DATE]. Other interventions for this care plan include ensure that R1 is wearing appropriate footwear when ambulating or mobilizing in a wheelchair and educate R1 and family about safety reminders and what to do if a fall occurs. It is documented R1 had on appropriate footwear during this fall. The Care Plan from [DATE] had interventions added from after the fall on [DATE]. The following intervention was documented on [DATE]: physical therapy to evaluate and treat as ordered. The Fall Report dated [DATE] documents R1 was found sitting on the floor on the side of the bed. R1 reported trying to get R1 into bed from the wheelchair and slid. R1 thought R1 could do this unassisted so R1 did not call for help. The area remains free from spills and R1 had on gym shoes during the fall. R1 was alert to person, place, and situation. There's no documentation of any additional interventions were put in place after this fall. A Nursing note dated [DATE] at 8:03 PM documents R1 fell and had no injury. R1 was attempting to go to the bathroom unassisted and fell . A new order was put in place to encourage fluids. The Care Plan from [DATE] had interventions added from after the fall on [DATE]. The following interventions were documented on [DATE] and [DATE]: move R1 closer to the nurse's station and encourage R1 to participate in activities that promote exercise and physical activity for strengthening/improved mobility. The Fall Report dated [DATE] documents R1 was observed on the floor on the side of the wheelchair and R1's room. R1 reported R1 attempted to go to the bathroom. R1 was alert to person, place, and situation. No injuries were noted at the time of the fall. There's no documentation of any additional interventions were put in place after the fall. A Nursing note dated [DATE] documents the CNA notified the nurse R1 was found sitting on the floor mat. R1 stated R1 was going to the bathroom unassisted. R1 was educated on the importance of putting on the call that when needed. A full body assessment was completed, and no visible injuries were noted. The Care Plan from [DATE] had interventions added from after the fall on [DATE]. The following intervention was documented on [DATE]: offer toileting assistance after meals and activities/before bedtime. The Fall Report dated [DATE] documents R1 was found sitting on the floor on the floor mats beside the bed by the CNA. R1 reported R1 was going to the washroom. No visible injuries were noted. R1 was alert and oriented to place. There's no documentation of any additional interventions were put in place after this fall. A Nursing note dated [DATE] documents this is post fall documentation. Bruising was noted to R1's mid forehead, right eyebrow, and around the right eye. The right side of the forehead had a closed scab near the upper head. The nurse practitioner was notified and assessed on face. No new orders at this time. On [DATE] at 12:55PM, V1 (Nurse) stated V1 was the nurse during the [DATE] fall. V1 reported R1 used to be very independent before R1 started to decline around the beginning of 2025. V1 reported R1 has Parkinson's and kept declining and was getting weaker. V1 stated the fall in ,d+[DATE] was caused by R1 self-transferring to the wheelchair unassisted and the wheelchair was not locked. V1 reported R1 was alert and oriented times 2 to 3 at the time of the fall. V1 stated the restorative nurse put in all fall interventions and the staff nurses make sure the fall interventions are in place. V1 denied knowing how fall interventions are chosen. On [DATE] at 1:23PM, V2 (Restorative Aide/CNA) stated R1 was ambulatory when R1 arrived to the facility. V2 stated R1 was in the walking and transferring restorative program at this time. V2 reported as R1 was declining the restorative programs changed to bed mobility and dressing. V2 confirmed the changes in the program were made at the beginning of 2025. V2 reported R1 began getting weaker and more confused as the decline continued. V2 stated since R1 was ambulatory in the beginning, no physical interventions were put in place, but R1 was educated on using the call light and not getting up without help. V2 reported new interventions are put in place after each fall. V2 reported the interventions are documented in the care plans so staff can reference them when needed. V2 stated all of R1's falls were due to R1 trying to self transfer or walk alone. V2 could not recall any other interventions for falls. On [DATE] at 3:18PM, V3 (Nurse) stated V3 was the nurse during the [DATE] fall. V3 reported R1 fell because R1 was reaching out for a personal belonging, and the dresser fell on top of R1's leg, knocking R1 out of the wheelchair. V3 reported R1 was found on the floor. V3 stated the staff nurse, or the restorative nurse can put in a new intervention after a fall. V3 denied remembering what intervention was put in place after this fall. V3 stated R1 was alert and oriented times three at the time of the fall. V3 was not able to recall R1's functional status or if R1 was a high fall risk. On [DATE] at 3:32PM, V4 (Nurse) stated V4 was R1's nurse on [DATE]. V4 stated V4 last saw R1 during dinner time and a CNA called V4 about 30 minutes later to let V4 know R1 was found on the floor. V4 reported R1 told V4 that R1 was going to the washroom unassisted. V4 stated telling R1 that R1 had to use the call light before getting up. V4 denied R1 had any injuries. V4 stated R1 was confused, but still able to communicate R1's needs. V4 stated the floor nurse can put in fall interventions, but management can alter the fall interventions. V4 stated interventions are chosen based on what the cause of the fall is before reported, this is done to stop any other falls from happening in the same manner. V4 denied remembering what fall intervention was put in place after the fall on [DATE]. On [DATE] at 4:22PM, V5 (Nurse) stated while doing hourly rounds R1 was found on the floor near R1's wheelchair. V5 reported R1 was trying to self-transfer either to the bed or to the wheelchair unassisted on [DATE]. V5 denied R1 used the call light for assistance. V5 confirmed R1 had a habit of getting up without using the call and trying to take care of R1's needs alone. V5 stated R1 was alert and oriented times two at the time of the fall. V5 reported V5 reminding R1 to use the call light before transferring due to R1 being unsteady. V5 was unaware of R1's decline but was not able to answer any other questions due to only taking care of R1 two times. V5 denied knowing R1's transfer needs. V5 stated interventions were put in place for R1 after the fall. V5 couldn't remember what interventions were put in place in the care plan. V5 stated the restorative nurse will put in the fall interventions that best fit the resident to prevent any other falls from reoccurring in the same manner. On [DATE] at 6:03PM, V6 (Nurse) stated V6 was the nurse during the fall on [DATE]. V6 reported R1 kept getting up unassisted, but R1's health was declining. V6 stated R1 was getting weaker. V6 reported R1 was found on the floor in R1s room. V6 stated R1 was trying to use the bathroom alone. V6 reported all nurses have to put in a new intervention after a fall. V6 denied remembering what was put in place for R1 and denied remembering any other fall interventions. V6 did report that R1's room was moved closer to the nurse's station. V6 reported R1's was a high fall risk due to being weaker. V6 stated restorative sees the resident after a fall to see if any other interventions can be put in place to prevent further falls. V6 reported all interventions are documented on the care plan. V6 denied being aware if fall interventions were assessed after being implemented for residents. When asked how the facility determines if a fall intervention is appropriate for a resident, V6 said, I don't know. On [DATE] at 12:53PM, V7 (Nurse) stated V7 was the nurse for R1 during the fall on [DATE]. V7 reported R1 was found sitting on the floor next to R1's bed. V7 stated R1 was alert oriented times three at the time the fall. V7 stated R1 was attempting to transfer from the bed to the wheelchair unassisted and couldn't make it to the wheelchair. V7 reported R1 slid onto the floor. V7 reported R1 normally transferred to the chair without assistance and then self-propelled around the facility. V7 stated R1 just missed the chair that time. V7 reported after this fall is when R1 began to get weak. V7 reported R1 knew how to put on the call light and ask for help but R1 refused to call for assistance. V7 stated staff were encouraged to increase monitoring for R1 for three days. V7 denied remembering what other interventions were put in place after this fall. V7 reported restorative will update the care plan with new interventions and floor staff are told in report or can also access the care cards for more information. V7 stated residents are assessed by restorative to see if they have the appropriate fall interventions in place. V7 was not able to answer how often residents are assessed for appropriate fall interventions. V7 reported fall interventions should mirror the type of fall and no intervention should be repeated if the same fall has happened more than once because this indicates it is not an intervention that is working for this resident. On [DATE] at 2:47PM, V9 (Restorative/Fall Nurse) stated R1 had multiple falls (V9 was unable to remember the exact number) due to R1 attempting to get up unassisted. V9 reported R1 was alert and oriented up until the last couple falls but could not say when R1's mental status decline happened. V9 stated R1 needed partial/moderate assistance with transfers. V9 reported R1 had Parkinson's disease which was the cause of R1's decline over the past couple months before R1 expired. V9 stated after a resident fall, a new intervention needs to be put in place to prevent the fall from happening again. V9 reported a new intervention has to be put in after each fall and match the cause of the fall so the fall will be less likely to occur again. V9 reported V9 will interview the resident and talk with staff to see if a cause of the fall can be determined. V9 stated each intervention is assessed after it is put in place for about one to two days after implementation. V9 stated V9 will talk with staff to see if the interventions that are in place are effective. V9 was unable to access the care plan, but stated physical therapy evaluations, education on call light use, keeping items within reach, and moving R1 closer to the nurse's station were some of the interventions put in place after the fall. V9 was not able to give dates of what interventions were placed when. V9 stated the floor nurse or V9 can put in an intervention after a fall. V9 denied staff ever bringing any concerns to V9 about R1's interventions not being effective. V9 stated that if staff makes V9 aware that a current intervention is ineffective than a new intervention will be put in place. V9 reported if the resident has had the same fall occur in the same manner, then a different intervention should be used for each fall. V9 stated interventions should never be repeated. When asked why R1 had multiple of the same fall interventions and if R1's fall interventions were effective, V9 reported the interventions were put in place but R1 refused to use the call light and staff were trying to manage R1's decline as best as possible. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status as ten (moderate cognitive impairment). Section GG of the MDS documents R1 is dependent with all ADL care except eating, needs partial/moderate assistance with bed mobility and transfers and substantial/maximal assistance with walking. Section J of the MDS documents R1 has had falls since the previous assessments but the falls did not have any injury. The policy titled, Falls and Fall Risk, Managing, dated ,d+[DATE] documents, Policy Statement: Based on previous evaluation and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: 1. The staff, with the input of the attending physician, will identify appropriate interventions to reduce the risk of fall. If a systematic evaluation of a resident's fall risk, identify several possible interventions, the staff may choose to prioritize interventions .4. If falling recurs, despite initial interventions, staff implement additional or different interventions, or indicate why the current approach regimen remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the fall is identified as unavoidable. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident response to interventions intended to reduce falling or the risks of falling .3. If the resident continues to fall, staff will reevaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusion that specific irreversible factors exist that continue to present a risk factor for falling or injury due to falls.

Based on observation, interview, and record review the facility failed to assess and monitor for pressure ulcers for a resident who is at high risk for pressure ulcers. This deficiency affects one (R2) of three residents reviewed for Pressure Ulcer Prevention Program. Findings include: On 2/13/25 at 11:25 AM, V4 (Wound Care Nurse) said that R2 was sent to the hospital on 1/24/25 for change in condition, R2 was observed unresponsive and abnormal vital signs. V4 said R2 only had scar tissue to the sacral area but no open skin. When R2 returned to the facility on [DATE], R2 returned with an unstageable wound that the hospital did debridement. V4 said that R2's son and husband were made aware of resident change of condition and hospital transfer. V4 said that R2's wound care is done weekly, and measurements are also done on a weekly basis and weekly wound rounds with MD. On 2/13/25 at 1:45PM, V2 (Director of Nursing) said that weekly skin assessments are completed during wound care treatments and are documented on shower sheets. V2 said she was unaware of R2 having a sacral wound, no staff verbalized any concerns for R2. On 2/13/25 at 1:45 PM, V11(Licensed Practical Nurse) said she was the nurse that sent R2 to the hospital at the start of her evening shift. R2 was observed with a change in condition, not her normal self. V11 notified Nurse practitioner and obtained orders to transfer to hospital. V11 said that she did wound treatment to bilateral lower extremities, but did not do a full body assessment before R2 left to hospital. V11 notified R2's son and husband of transfer. V11 said that skin assessments are done weekly and also when she has a shower a skin assessment is done and documented on the shower sheets. On 2/14/24 at 12:27 PM, V16 (Nurse Practitioner) said that on 1/24/25 when R2 was transferred to the hospital she was unaware of any wounds to the sacral area. R2 had multiple wounds on her legs, but not sacral area, V16 said that her expectations of the facility generally should be doing skin assessments on residents that are high at risk for developing ulcers more frequently than weekly skin assessments. R2 was initially admitted on [DATE] and was readmitted on [DATE] with diagnosis listed in part but not limited to: CVA with left hemiparesis, Cognitive Communication deficit, muscle weakness with atrophy, PVD, epilepsy, dysphagia, metabolic encephalopathy, GERD, pulmonary nodule, anemia, T2DM, protein calorie malnutrition, Vit D deficiency, hyperlipidemia, hypertension, CKD, Encounter for change or removal of surgical wound dressing. Admission and current Braden/skin assessment indicated that she is at high risk for developing pressure ulcers/skin impairments. Active physician order sheet indicated: Peri area/Buttocks: May apply Barrier cream after each incontinence episode. May keep at beside, CNA may apply. Pressure redistribution mattress, ProStat 30ml twice a day, Reposition as needed, Skin assessment weekly on shower days. Wound Care: Sacrum: Cleanse with Normal Saline, pat dry, apply Medi Honey with gauze to wound bed, gently fill wound space with fluffed gauze; apply Medi Honey gauze to open Peri wound areas, cover with Border gauze daily and as needed one time day. Comprehensive care plan indicates that she has pressure ulcer which increases her potential for additional pressure ulcer development. Intervention: Follow facility policies/protocols for the prevention/treatment of skin breakdown. R2 wound care observation made with V4 and V11. R2 medical record reviewed, Wound measurements, skin assessments, dietary notes, Progress notes, and Care plan. Wound Report from 7/2024 to 2/11/2025, Prevention of Pressure Wounds Policy, Accidents/Incidents logs from 10/2024 to 1/2025 and Shower Sheets from 11/01/24 to 1/25/25. Facility's policy on Prevention of Pressure Wounds. Effective March 2024.Purpose: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. 9. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. 3. For those unable to change own position, change position at least every 1 hour. 9. A healed injury. The history of a healed pressure injury and its stage (if known) is important, since areas of healed Stage III or IV pressure injuries are more likely to have recurrent breakdown. 1. Tools for assessing skin and pressure injury risk: a. Braden Risk Assessment Form b. Intervention Prevention Measures.

Based on observation, interview, and record review, the facility failed to adequately supervise residents assessed as being at risk for falls and in the dementia unit, failed to make sure that fall interventions were implemented for 2 residents (R2 and R3) and failed to have any base line fall intervention/ adequate supervision for a newly admitted resident with history of falls (R1). These failures affected three (R1, R2 and R3) of five residents reviewed for falls/injury. These failures resulted in R1 having a fall in the dining that resulted in a right femur fracture, requiring surgery; R2 had a fall in her room and sustained a femur fracture requiring a surgical procedure; and R3 had a fall in her room and sustained a right distal clavicle fracture, which required treatment at a local hospital. Findings include: 1. R1 is [AGE] years old admitted to the facility on [DATE], past medical history includes, but not limited to other specified sepsis, fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing, muscle wasting, other lack of coordination, dementia cognitive communication disorder, dysphagia oropharyngeal phase, insomnia, unsteadiness on feet, etc. On 9/10/2024 at 10:20AM, R1 was observed in the dining room in a wheelchair with peers, awake and alert with some confusion not able to answer any questions but was asking if his wife is here. Minimum Data Set (MDS) assessment dated [DATE] section C (cognitive patterns) score R1 with a BIMs of 2, section GG (functional abilities) of the same assessment coded R1 as requiring partial/moderate assistance to substantial/maximal assistance for all Activities of Daily Living (ADL) needs. Progress note dated 8/10/2024 at 14:19:49, documented that R1's wife informed a staff that R1 has had 5 falls in the past, this information was communicated to a nurse practitioner. Physician progress note dated 8/9/2024 documented that R1 was in the hospital for low blood pressure and has been experiencing bradycardia for some months, plan of care indicated fall precautions. Base line care plan dated 8/9/2024 indicated that R1 is cognitively impaired, needed assistance with ADLs, incontinent of bowel and bladder, but did not have any provision for supervision or fall precaution. Facility reportable incident dated 8/10/2024 stated that resident was in the dining room with family, approximately 5 minutes after family left, R1 was noted lying on the floor in the dining room on his right side. R1 was sent to the hospital, diagnostic test at the hospital revealed a right femur fracture. On 9/9/2024 at 3:11PM, V5 (LPN) said that the day R1 had a fall, the family was visiting with him in his room, they got ready to go and wheeled resident to the dining room because it was close to dinner time. V5 was passing medications, left for a few seconds to get something from the medication room and heard a sound, she ran out from the medication room and saw R1 on the floor, V5 said that he did not see when the family members left. On 9/10/2024 at 10:38AM, V10 (Family member) said that she was not present when R1 had a fall and did not push him to the dining room. She visited R1 with her daughter. They were there all day. V10 received a call about an hour after they left the facility informing her that R1 fell , one of the aides pushed him to the dining room for dinner to the table, R1 got up and fell . V10 said that she does not recall being in the dining room at all. R1 was previously in an assisted living and kept on falling, he came to this facility for rehabilitation due to frequent falls. On 9/10/2024 at 11:27AM, V11 (C.N.A) said that she is familiar with R1 and was assigned to him the day he had a fall. It was dinner time, R1 got his tray, V11 went to go pass a tray in the hallway. There was no other C.N.A in the dining room, V11 did not see R1's family members at all. There were about 5 other residents in the room, V11 was informed by the nurse that R1 was on the floor. On 9/9/2024 at 4:31PM, V9 (C.N.A) said that he is familiar with R1 but did not witness resident's fall. V9 was passing trays in the hallway when the nurse called him to assist in getting resident up from the floor. V9 said that R1 was in the dining room, there were other residents also. There should have been another C.N.A in the dining room but V9 is not sure. On 9/11/2024 at 11:39AM, V14 (LPN/Restorative Nurse) said that when the facility gets a new resident, herself and the three restorative CNAs will assess the resident to determine what type of interventions they need and will put it in the care card in the resident's room. The assessment is usually done the same day or the following day depending on when the resident arrives at the facility but is done as soon as possible. V14 said that R1 came on a weekend and fell the following day, she did not even see him before he went to the hospital, V14 is not sure if they placed a wheelchair and floor mat in R1's room but stated that R1 could have been monitored closely until his activity level is determined. For the second floor (dementia unit), V14 said that all the residents are out of the room and in activity, the fall incidents on that floor all boils down to supervision. 2. R2 is a [AGE] year-old female who has resided at the facility since 2022 with past medical history of Fracture of unspecified part of neck of left femur, encounter for other orthopedic aftercare, dysphagia oropharyngeal phase, muscle wasting and atrophy, unspecified fall sequela, difficulty walking, shortness of breath, dementia, Alzheimer's disease, need for assistance with personal care, unsteadiness on feet, etc. Facility reported incident dated 8/23/2024 documented that resident was observed on the floor in her room and complained of pain to the left lower extremity, X-ray revealed a left femur fracture, R2 was sent to local hospital for further evaluation. Hospital record dated 8/18/2024 states in part, [AGE] year-old female .presents to ED from nursing home after sustaining a mechanical fall. Per nursing home staff, resident was walking to the bathroom, this morning, patient did not want to bear weight on the left lower extremity and staff noticed that the left lower extremity was externally rotated and shortened. During the Facility Reported Incident investigation on 9/9/2024 at 11:40AM, R5 was observed in bed, bed was noted to be very high, resident stated that he does not know where his call light is, surveyor observed the call light on the floor, behind resident's head of bed. At 11:50AM, Surveyor presented this observation to V3 (LPN) who said that resident's bed is not supposed to be that high, V3 let the bed down to the lowest position and picked up resident's call light from the floor behind his bed. On 9/11/2024 at 10:45AM, R6 was observed in bed sleeping, bed was very high, wheelchair at bedside. At 12:00PM, surveyor presented this observation to V14 (LPN) who went and lowered resident's bed to the floor .adding that resident's bed is supposed to be lowered to the floor when she is in bed. Fall risk assessment dated [DATE] scored R2 as 15, indicating high risk for falls, MDS assessment dated [DATE], section C (cognitive) scored R2 with a BIMs of 2, section GG (functional abilities) of the same assessment indicated that R2 is dependent on staff for all ADL cares, including rolling from left to right, sit to lying, transfers and ambulation. Section H (bowel and bladder) documented that R2 is frequently incontinent of bowel and bladder. Fall care plan dated 7/25/2024 indicated that R2 is a high risk for falls, interventions include, R2 needs a safe environment, a working and reachable call light, bed in low position, slide rails as ordered, handrails on walls, etc. Per record review, R2 had a fall on 7/24/2024 in the dining room while walking to find a seat for breakfast. R2 was readmitted to the facility on [DATE] post ORIF related to left femur fracture, R2 had another fall in her room on 8/28/2024 while going to the bathroom. Physiatry note dated 9/8/2024 documented that R2 was noted to have functional decline because of the hospitalization . Fall care plan dated 7/25/2024 states that R2 is a high risk for falls related to her diagnosis of low back pain, dementia, Alzheimer's, etc. Interventions includes, R2 needs a safe environment with even floors free from spills, clutter, bed in low position, call light within reach, slide rails as ordered, handrails on walls, etc. On 9/10/2024 at 10:50AM, V15 (LPN) said that she works afternoon and night shift, she is familiar with R2, resident is confused, was assigned to her the day she had a fall. The C.N.A changed the resident who was in bed, later she was found on the floor by the door, her call light was within reach, and her bed was low. R2 walks and eats by herself, does not use wheelchair or walker and not able to use the call light, V15 is not sure if the resident has a floor mat, R2 could not explain what happened, just nodded no to pain assessment. 3. R3 is [AGE] years old and has resided at the facility since 2021, past medical history includes Metabolic encephalopathy, other intervertebral disc degeneration thoracic region, fracture of unspecified part of right clavicle, complete rotator cuff tear or rupture of right shoulder, fall from bed, essential primary hypertension, weakness, cognitive communication deficit, hypotension, etc. Facility Reported Incident dated 7/25/2024 stated in part that at approximately 5am, R3 was observed on the floor in her room, next to her bed, R3 was noted with a laceration to the right side of face and complained of right shoulder pain. R3 was sent to the hospital and an X-ray showed a right distal clavicle fracture. MDS assessment dated [DATE] scored R3 with a BIMs score of 6, section GG of the same assessment indicated that R3 uses a walker for ambulation, independent for eating but requires substantial to maximal assistance from staff for most ADL cares, and requires partial to moderate assistance for transfers, including rolling from left to right, lying to sitting and sit to stand, R3 requires supervision to touching assistance for all ambulation. Section H of the same assessment indicated that R3 is always incontinent of bowel and bladder. Care plan dated 7/2/2024 indicated that R3 is at high risk for falls related to confusion, gait/balance problems, incontinence, unaware of safety needs, etc. Interventions include bed in low position, call light within reach. Bilateral floor mats while in bed and wing mattress was initiated on 7/26/2024, after resident's injury. On 9/11/2024 at 3:26PM, V18 (LPN) said that she is familiar with R3 and was assigned to her the day she had a fall. V18 responded to resident yelling for help, she does not use her call light, none of the residents on the second floor uses their call light. V18 said that R3 gets up and goes to the bathroom by herself with her walker, V18 cannot tell exactly how the resident got the injury, she documented that the bed was low, but maybe it was not to the lowest for the resident to sustain a fracture. V18 is not sure the last time resident was seen prior to the fall; she was passing medication at the time. A document presented by V1 (Administrator) titled Fall- clinical protocol (undated) stated in part that as part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling. a. Staff will ask the resident and the caregiver or family about a history of falling. b. The staff and physician should document in the medical record a history of one or more recent falls. Under monitoring and follow-up, the document states in part that the staff and physician will document the individual's response to interventions intended to reduce falling or the consequences of falling. If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling.

Based on observation, interview, and record review the facility failed to monitor and record daily freezer and refrigerator temperatures for food safety. This deficiency may potentially affect all 123 residents receiving food from the facility. Findings include: On 7/9/2024 at 10:02AM, Rounds made to kitchen with V5 Dietary Manager (DM). Observed Freezer and Cooler/Refrigerator temperature were not monitored today. V5 said that the cook should monitor and record the temperature today at 5am. It was not done because they were short this morning. V5 read the current temperature of freezer at -3F (Fahrenheit) and Cooler/Refrigerator at 32F. Daily Freezer/Refrigerator temperature log July 2024. No temperature recording made for 7/9/24. Instruction: This log will be maintained for each refrigerator and freezer (both walk in and reach in units) in the facility. A designated food service employee will record the time, air temperature and their initials. The food service supervisor for each facility will verify that the food service employees have taken the required temperatures by visually monitoring food service employees and reviewing, initialing, and dating a sample of logs each month. Maintain this log for minimum of three years and until given permission to discard it. If corrective action is required on any day, circle the date in the first column and explain action taken on back of the chart or an attached sheet of paper. Refrigerators should be between 36F and 41F. Freezer should be between -10F to 0F. On 7/11/24 at 1:10PM, V5 DM said that they have only 1 resident on NPO (nothing by mouth). On 7/11/24 at 2:30PM, Informed V1 Administrator and V2 Director of Nursing of above concerns. On 7/12/24 at 10:35AM, Informed V12 [NAME] President of Culinary Services of concerns identified in kitchen that Freezer and Refrigerator temperature were not monitored and recorded on 7/9/24. The Refrigerator temperature was at 32F and it was not within the acceptable range per facility's policy. V12 said that refrigerator temperature should be between 36F to 40F, he will have maintenance look at it. Facility's policy on Food storage revised June 2023 indicates: It is the policy of Extended Care LLC that all food products will be stored under proper conditions of sanitation, temperature, light, moisture, ventilation, and security. Purpose: To meet all federal and state guidelines and protecting the safety of the resident from any cross contamination and food born illnesses. Process: 6. All readily perishable foods or beverages shall be maintained at temperatures of 7 degrees C (41 degrees F or below or at 60 degrees C (140 degrees F) or above, at all times, except for very short times during necessary periods of preparation or service. 7. Frozen foods shall be stored at minus) degrees or below at all times. (There is an accurate thermometer in each refrigerator and freezer)

Based on observation, interview, and record review the facility failed to ensure coordinated care was implemented by failure to document hospice services rendered to resident's medical record that is available and accessible to interdisciplinary team (IDT). This deficiency affects two (R22 and R45) of three residents in the sample of 25 reviewed for Hospice care Management. Findings include: On 7/9/2024 at 11:00AM, V8 LPN (Licensed Practical Nurse) and V9 LPN said that R22 and R45 are both on hospice care. V9 showed the hospice binder/charts for both residents. Reviewed both hospice binder charts with V9. Noted no documents found for R22. The folder is empty, only visits log from 6/12/24 to 7/4/24. No IDT progress notes found. Noted R45 hospice documents in binder but missing IDT progress notes. Noted R45's hospice visit log from 6/10/24 to 7/9/24. V9 said usually when hospice care staff comes to visit hospice resident, they document in the hospice binder. V9 said that usually Social Services coordinate with hospice care management. On 7/9/24 at 11:33AM, V10 Social Service said that she is only responsible for referral to hospice vendors/services, the Social Service Director is the one responsible for making sure all hospice documents for coordinated care are in the hospice binder. On 7/9/24 at 11:48AM, V11 Hospice Social Service (HSS) said that he comes to see both R22 and R45. He said that the last time she visited both was last month but cannot remember the date. He said he did not log in and did not document his visit and services provided last month. He said that he cannot find the hospice binder and he cannot find a nurse from the unit to ask. He added that only the hospice nurses are required to document, he is social service, and he does not need to document in the hospice progress notes. V9 LPN overheard what V11 HSS told the surveyor, and she denied that there is no nurse available in the unit. V9 said that the binder is placed in the nursing station desk and there are always staff available in the unit if he needs assistance. On 7/9/24 at 11:53AM, V6 Medical Record said that she is responsible to make sure all hospice coordinated care documents are in place and updated in the hospice binder. She should be monitoring it weekly and uploading it in resident electronic chart. She said that she has not been doing it for a while. Reviewed R22 and R45 hospice records with V6. Noted no hospice documents/assessments/IDT progress notes in R22's folder. R45 does not have IDT progress notes, last progress notes dated 6/12/24 done by RN. On 7/11/24 at 10:00AM, Reviewed R22's hospice medical records with V9 LPN and noted that all documents were faxed by hospice provider dated 7/9/24 after the surveyor found out that there are no hospice documents in chart. R22 was admitted on [DATE] with diagnosis listed in part but not limited to History of Malignant neoplasm of breast, Chronic obstructive pulmonary disease, Vascular dementia with psychotic disturbance, history of transient ischemic attack and cerebral infarction. Active physician order sheet indicates she was admitted to hospice care on 4/24/24. Care plan indicates that she is admitted to hospice care due to overall decline in health. Hospice binder does not have hospice record documents except for IDT visit log from 6/12/24 to 7/4/24. R45 was admitted on [DATE] with diagnosis listed in part but not limited to Alzheimer's disease, Dementia with behavioral disturbance, Oral phase dysphagia, Acute Kidney disease, Peripheral vascular disease. Active physician order sheet indicates she was admitted to hospice care on 1/10/24. Care plan indicates that she is admitted to hospice care due to overall decline in health. Hospice binder does not have IDT progress notes documentation except for visit log dated from 6/10/24 to 7/9/24. Facility's policy on Hospice services indicates: Policy: It is the policy of this facility to honor the advance directives and care alternatives residents may desire when terminally ill and to afford residents with care that allows for dignity and comfort during the end of their lives. The facility will provide hospice services either directly or through arrangements with a qualified service provider. Standards: 6. All hospice service staff will write a progress note for each resident visit indicating treatment provided and pertinent information related to the resident's condition which is available in the medical record for all interdisciplinary staff to access. Hospice provider single patient agreement for residential hospice services provided in the nursing facility for R22 and R45 indicates: 7. Communications concerning hospice patient: The parties will communicate pertinent information with each other either verbally or in the hospice patient's record at least weekly or at each hospice patient visit to ensure that the needs of each hospice patient are addressed and met 24 hours per day. 11. Clinical Record.Each clinical record shall completely, promptly, and accurately document all services provided to and events concerning, the hospice patient (including . progress notes) as required by this agreement.

Based on interviews and records reviewed the facility failed to prevent an incident of resident-to-resident physical assault. This affected two of three residents (R1, R2) reviewed for physical abuse. This failure resulted in R2 attacking R1 unprovoked with a belt to R1's leg. R1 being a severely cognitive resident it is reasonable to conclude this resulted in R1 suffering psychological feelings of fear after being attacked by R2. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. R2's cognitive assessment dated [DATE] is a 0, severely impaired. On 8/15/23 at 10:49AM R1 observed in the dining room but did not provide statement. On 8/15/23 at 11:28AM V1, Licensed Practical Nurse (LPN), said during the night shift in the morning hours, V7, Certified Nursing Assistant (CNA), called me I was passing medications. V7 said R2 is on the floor. She said R2 was in the room of another patient. V1 said R2 was agitated. V1 said R2's lip was bleeding, and she was trying to administer care and R2 grabbed my hand and twisted it backwards and he was twisting my legs around his. V1 said R2 is very strong he just kept bending my right hand. V1 said this is the second time he attacked me. V1 said the first time he pulled down my pants. He had been refusing to get out of a patient room. I was trying to get him out and he grabbed my pants and pulled them down. V1 said R2 twisted my right wrist. V1 said the first time he attacked me was earlier this year. V1 said R2 gets confused around 5:00 or 6:00PM. V1 said in the mornings he was very combative, and it seems like the medicine has worn off and you can't control and reason with him. V1 said R2 needs constant redirection because he goes into others' rooms and lays in other peoples' beds. V1 said all I saw was R2 was on the floor on his side talking gibberish. V1 said I didn't see him with anything in his hands. V1 said the male CNA was still in the room when she entered. V1 said R1 was in bed sleeping and she woke up when R2 was in the room. V1 said one of the CNAs had said R1 was screaming ahh, someone is in my room. On 8/15/23 at 12:44PM V2, Social Services, said I don't know if R2 ever physically harmed any resident or staff in the facility. On 8/15/23 at 1:20 PM V3, Director of Social Services, prior to this (incident 7/17/23) I did not know R2 had been aggressive in the past. I should know because I am the director of social services. On 8/15/23 at 4:01PM V4, CNA, said V4 said I went into another resident's room and then I heard R1 screaming. V4 said the last time he saw R2 before the incident R2 was in his room. V4 said I heard R1 screaming, loud like someone was hurting her. V4 said I saw R2 hit R1 on the leg with the belt one time. V4 said I saw R2 swinging the belt over R1 to hit her again. On 8/17/23 at 10:29AM V5, R1's family, said the facility called me the day it happened (7/17/23). V5 said I went to see R1 the following day. V5 said R1 told me a man was in her room and he was swinging a belt. V5 said R1 said she was sleeping when he came in. V5 said R1 said she got hit with the belt. On 8/17/23 at 11:45AM V6, Administrator, said I completed the investigation for R1 and R2. I spoke with V4 and V7, CNA. V6 said V7 said she was in a room and V4 had walked out of the room and heard a yell. V6 said V7 said V4 went to see what was going on. V7 said she did not see anything but got the wheelchair to get R2 out of the room. V6 said R2 was R1's room. V6 said R2 should not be in R1's room. V6 said V4 said he heard the yell and went to see what was happening. V6 said V4 said when he got to R1's room he saw R2 in the room standing at the side of R1's bed and R2 was swinging a belt. V6 said V4 had her arms up. V6 said the men do have belts. V6 said during the investigation abuse was substantiated. V6 said R2 has a belt hitting someone, I would say yes that is abuse. On 8/17/23 at 12:05 PM V8, Nurse Practitioner, was asked if it is reasonable to conclude that R1 would have felt fear when she woke up to see a man swinging a belt at her. V8 said it is reasonable to think R1 felt fear, they are feeling threatened in that situation. V8 said R1 may not remember the situation but at that moment it would be reasonable for R1, even with Dementia, to feel fear. R1's Abuse Risk Review dated 7/14/23 states R1 has the following risk factors Frailty or total dependence. R1's progress notes dated 7/17/23 at 4:50PM states R1 had an altercation with another resident. R2's progress notes dated 6/22/23 written by V8 state R2 seen for Complaint: sundowning. R2 still having periods of agitation and hard to redirect once a month. Assessment and plan: Dementia with Psychotic Disturbances. R2's care plan dated 12/26/22 states R2 grabbed at the uniform of a nurse. Interventions include redirect and intervene during periods of increased agitation. Separate resident from others as needed. Social Services to assess for aggression. The facility Abuse Prevention Policy Dated 10/24/2022, in part, states the facility affirms the right of our residents to be free from abuse. Physical Abuse includes hitting.

Based on interviews and records reviewed the facility failed to supervise and monitor a resident with a history of aggression and agitation to prevent a resident to resident assault. This affected 2 of 3 (R2, R1) resident reviewed for supervison. This failure resulted in R2 wandering into R1's room and physically assaulting R1 with a belt. The Findings include: R1 has diagnosis including but not limited to Dementia, Major Depressive Disorder, Alzheimer's Disease, Generalized Anxiety Disorder, and Weakness. R1's cognitive assessment dated [DATE] is a 6, severely impaired. R2 has diagnosis including but not limited to Unspecified Dementia and Alzheimer's Disease. R2's cognitive assessment dated [DATE] is a 0, severely impaired On 8/15/23 at 10:49AM R1 observed in the dining but did not provide statement. On 8/15/23 at 11:28AM V1, Licensed Practical Nurse (LPN), said V7, Certified Nursing Assistant (CNA), called me I was passing medications. V1 said R2 was in the room of another patient. V1 said R2 was agitated. V1 said this is not first time she has had to take R2 out of another resident's room. V1 said R2 gets confused around 5:00 or 6:00PM. V1 said R2 needs constant redirection because he goes into others' rooms and lays in other residents' beds. V1 said R1 was in bed sleeping and she woke up when R2 was in the room. V1 said one of the CNAs had said R1 was screaming ahh, someone is in my room. V1 said neither she, V7 or V4 saw R2 walk towards and into R1's room. 8/15/23 1:07PM V10, Certified Nursing Assistant (CNA), said R1 is pleasant, soft spoken, never seen her upset, nice. V10 said R1 is alert and oriented and most of the time she knows what's going. I have not seen her be afraid. V10 said R2 was hard, his dementia would go in and out, and he can be violent at times. V10 said R2 would grab at me. V10 said I just kept redirecting him. V10 said R2 was confused the majority of time. On 8/15/23 at 4:01PM V4, CNA, said I went into another resident's room and then I heard R1 screaming. V4 said before the incident the last time I saw R2 he was in his room. V4 said I heard R1 screaming, loud like someone was hurting her. V4 said I saw R2 in R1's room and R2 hit R1 on the leg with the belt one time. V4 said I saw R2 swinging the belt over R1 to hit her again. On 8/17/23 at 10:29AM V5, R1's family, said the facility called me the day it happened (7/17/23). V5 said I went to see R1 the following day. V5 said R1 told me a man was in her room and he was swinging a belt. V5 said R1 said she was sleeping when he came in. V5 said R1 said she got hit with the belt. On 8/17/23 at 11:45AM V6, Administrator, said I completed the investigation for R1 and R2. V6 said R2 was in R1's room. V6 said R2 should not be in R1's room. V6 said V4 said he heard the yell and went to see what was happening. V6 said V4 said when he got to R1's room he saw R2 in the room standing at the side of R1's bed and R2 was swinging a belt. V6 said V4 had her arms up. On 8/17/23 at 12:05 PM V8, Nurse Practitioner, was asked if it is reasonable to conclude that R1 would have felt fear when she woke up to see a man swinging a belt at her. V8 said it is reasonable to think R1 felt fear, they are feeling threatened in that situation. V8 said R1 may not remember the situation but at that moment it would be reasonable for R1, even with Dementia, to feel fear. R1's Abuse Risk Review dated 7/14/23 states R1 has the following risk factors Frailty or total dependence. R1's progress notes dated 7/17/23 at 4:50PM states R1 had an altercation with another resident. R2's progress notes dated 6/22/23 written by V8 state R2 seen for Complaint: sundowning. R2 still having periods of agitation and hard to redirect once a month. Assessment and plan: Dementia with Psychotic Disturbances. R2's care plan dated 12/26/22 states R2 grabbed at the uniform of a nurse. Interventions include redirect and intervene during periods of increased agitation. Separate resident from others as needed. Social Services to assess for aggression.

Based on observation, interview and record review the facility failed to maintain dignity and respect during dining observation for one of one resident (R99) reviewed for resident rights in a sample of 25. Findings include: On 8/1/2023 at 12:15pm V20 (Certified Nursing Assistant-CNA) was observed standing over R99 assisting with feeding a meal. On 8/1/2023 at 12:18pm V20 said we don't have any chairs in this dining room, yes, I should be sitting down while assisting with meals. On 8/1/2023 at 2:30pm V3 (Director of Nursing-DON) said I expect all staff to respect the residents and have a seat while assisting with meals. A Care-plan dated 10/31/2022 R99 requires a mechanical soft diet. Facility Policy: Resident Rights Protocol for all Nursing Procedures 1. Prior to having direct-care responsibilities for residents, staff have appropriate in-service training on resident rights including: a. Resident dignity and respect:

Based on observation, interview and record review the facility failed to develop individualized comprehensive care plan to resident to meet his medical, nursing, and physiological needs in the facility. This deficiency affects one (R232) of three residents in the sample of 25 reviewed for Resident's comprehensive care plan. Findings include: On 8/1/23 at 10:50am, V15 LPN and V16 LPN said that R232's has indwelling catheter, biliary drainage, and on contact isolation for Clostridium difficile (C. Diff) infection. Observed R232's lying in bed. On 8/2/23 at 12:33pm, Review R232's medical record with V5 MDS (Minimum Data Set)/Care plan Coordinator. R232 is admitted on [DATE] with diagnosis listed in part but not limited to Calculus of gallbladder status post cholecystectomy, Urinary retention, Diabetes Mellitus type 2, Clostridium Difficile colitis. Physician order sheet indicated: Insulin lispro 4 units subcutaneous with meals four times a day to manage blood glucose. Heparin solution 5,000 units subcutaneous three times a day for clot management. Indwelling catheter care every shift. Change for blockage or leaking. Biliary drain: cleanse site with soap and water, apply split sponge dressing every 48 hours and PRN. Flush with 10ml of normal saline every 48 hours. Do not aspirate. Review R232's comprehensive care plan with V5 MDS/Care plan Coordinator. V5 said that there is no care plan for R232 regarding his contact isolation for C. diff, indwelling catheter usage, insulin usage, biliary drainage care and heparin injection usage. V5 said that they overlook in formulating comprehensive care plan for R232's addressing his medical needs. V5 said that interim care plan is formulated within 24 hours upon admission and comprehensive care plan is formulated within 14 days upon admission. Facility's policy on Comprehensive Care plan indicates: Policy: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and or psychological needs is developed for each resident. Policy specification: 3. Each resident's comprehensive care plan has been designed to: a. Incorporate identified problem areas b. Incorporate risk factors associated with identified problems e. Identify the professional services that are responsible for each element of care f. Aid in preventing or reducing declines in the resident's functional status or functional levels g. Enhance the optimal functioning of the resident by focusing on a rehabilitative program as needed i. Reflect the resident's needs and preferences and align with the resident's cultural identity.

Based on observation, interview and record review the facility failed to follow its policy on medication safety by finding medications without physician order at resident's bedside. This deficiency affects one (65) of three residents in the sample of 25 reviewed for Resident's safety. Finding include: On 8/1/23 at 12:38pm, Observed R65 lying in bed. Observed the following medications at R65's bedside tray table in front of him namely: Diaper rash ointment (Desitin cream), Zinc oxide ointment, hemorrhoidal ointment, Hydrocortisone cream ([NAME] eczema cream), Neuropathy cream, and Diaper rash cream (Riley's butt cream) labeled for another resident's name. R65 said that these are all his medications, and he is using it. He said that his daughter brought these medications several weeks ago and applied when she comes to visit. Called V16 LPN to R65's room and showed the medications at bedside tray table. V16 said that medications probably brought by his family. V16 said that R65 should not have medications at bedside without order from the physician. V16 said that Diaper rash cream (Riley's butt cream) belongs to a discharged resident. V16 said that she will remove all the medications and will give it to V3 DON. On 8/1/23 at 2:10pm, Informed V3 DON of above observation. V3 said that R65 cannot have medication at bedside without physician order. V3 said that R65 cannot use treatment medication of another resident. Facility's policy on Medication administration indicates: Policy: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the medication management system in the facility. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures: B. Administration 2) Medications are administered in accordance with the written order of the prescriber 14) Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 15) Medication supplied for one resident are never administered to another resident.

Based on observation interview and record review the facility failed to monitor the low air loss mattress is functioning properly on a resident who has multiple stage 4 and unstageable of pressure ulcers. The facility also failed to follow the manufacturer recommendation of avoiding multiple layers of linens over the Low Air Loss mattress. This deficiency affects one (R122) of three residents in the sample of 25 reviewed for Pressure ulcer Management. Findings include: R122 is readmitted on [DATE] with diagnosis listed in part but not limited to Hemiplegia and Hemiparesis following Cerebral Infarction affecting left non-dominant side, Metabolic Encephalopathy. Physician order sheet indicated: Pressure reducing mattress continuous. Care plan indicated: R122 has pressure ulcers noted at re-admission, and is at risk for slow, no healing of wound and further breakdown related to immobility, CVA (cerebrovascular accident) with left hemi, Diabetes, Anemia, Chronic Kidney disease and Protein calorie malnutrition. Wound report dated 7/31/23 indicated: 1) Left thumb- stage 2 Pressure Ulcer (PU), dated identified-7/26/23, 1.5x1.5x0.1cm. 2) Sacrum- stage 4 PU, date identified-7/19/23, present on admission, 12.8x7.5x0.3cm. 3) Left thigh posterior ischial- stage 2 PU, date identified-7/19/23 , present on admission 0.2x0.2x0.1cm. 4) Left top of foot lateral foot- necrotic PU , date identified -7/19/23, present on admission, 5x2cm. 5) Left ankle- necrotic PU, dated identified-7/19/23, present on admission, 3x3cm. 6) Left lateral heel- necrotic PU, date identified-7/19/23, present on admission, 5x6.8cm. 7)Right top of foot bunion area- PU, date identified-7/19/23, present on admission, 1.5x1cm. 8) Right top of medial foot-PU, date identified-7/19/23, present on admission, 2x2cm. 9) Right ankle medial malleolus-PU, date identified-7/19/23, present on admission, 1x2.5cm. On 8/2/23 at 11:05am, Observed R122 lying in Low Air Loss mattress with booster on each side of the bed attached. Noted Low Air Loss mattress control unit located at the foot part of the bed is off. V9 Wound Care Nurse (WCN) and V19 Wound Care Physician (WCP) preparing for wound dressing of R122 while V18 CNA is preparing R122 for wound care. On 8/2/23 at 11:15am, Before V9 WCN and V18 CNA trying to reposition R122 for wound care, informed them of Low Air Loss mattress control unit is off. V9 checked on the control unit and the cord connected to the mattress. The control unit does not have lit on. V9 said that the cord is not properly connected. V9 corrected it and the Low Air Loss mattress control unit turns on. V9 and V18 repositioned R122 to his side, observed bath blanket folded in quarter underneath R122. Informed V9 of observation made. V9 said that R122 should only be on flat sheet over the Low Air Loss mattress. V9 educated V18 that only flat sheet is placed for resident on Low Air Loss mattress, no multiple layers of linen. V9 WCN provided wound care to R122 assisted by V19 WCP and V18 CNA. On 8/2/23 at 11:47am, V9 WCN said that she expected the staff - nurses and CNAs to monitor residents on Low Air Loss mattress control unit is on and it's functioning properly. V9 said that no multiple layer of linens is placed on Low Air Loss mattress, only flat sheet. On 8/2/23 at 11:50am, V18 CNA said that she is did not check this morning if R122's Low Air Loss mattress control unit is on and it's functioning properly. On 8/3/23 at 9:50am, V9 WCN said that she did gave in-services to staff regarding: monitor function of low air loss mattress and proper linen on low air low mattress yesterday and gave copy of the in-service meeting done. Facility's policy on Pressure /Skin Breakdown-Clinical Protocol indicates: Policy specification: 7. The physician will authorize pertinent orders related to wound treatments including pressure redistribution surfaces, wound cleansing and debridement approaches, dressing (occlusive, absorptive etc.) and application of topical agents. Facility's policy on Support Surface Guidelines indicates: Purpose: To provide guidelines for the assessment of appropriate pressure reducing and relieving devices for the residents at risk of skin breakdown. General Guidelines: 1. Pressure-reducing and pressure-relieving devices are to promote comfort for all bed-or chair bound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Assessment: 1. Any individual at risk for developing pressure injuries should be placed on a pressure-reducing device such as foam, static air or alternating air when lying in bed. Intervention/Care strategies 1. Any individual at risk for developing pressure injuries should be placed on a pressure-reducing device such as foam, static air or alternating air when lying in bed. Facility provided copy of Low air loss mattress manufacturing guideline indicated: Step 2. Cover the mattress with a cotton sheet.

Based on observation, interview and record review the facility failed to complete smoking assessment of resident upon admission who has history of conviction of arson. This deficiency affects one (R87) of three resident reviewed for Smoking Safety management. Findings include: On 8/1/23 at 11:00am V15 LPN and V16 LPN said that R87 is a smoker. On 8/1/23 at 1:22pm, Observed R87 propelling himself in the 1st floor unit. He said that he smokes without supervision. On 8/3/23 at 11:36am, Review R87's medical records with V11 Director of Social Services. R87 is admitted on [DATE]. Care plan indicated that he is identified offender. He was convicted of Arson in 1983 and retailed theft in 1987. Resident was assessed to be at risk for aggression based on this facility's aggression assessment. V11 said that she did not complete R87's smoking assessment upon admission. She completed it only when requested for it on 8/1/23. She said it was not done because she was on vacation when R87 was admitted . Facility's policy on Resident's smoking indicates: Purpose: To establish guidelines to prohibit smoking by residents and visitors in the building except in designated areas. To establish guidelines for the specific circumstances I which residents may smoke in the designated areas and when increased supervision is required. Policy Specifications: 1. All residents who desire to smoke will be assessed by the interdisciplinary team to determines if the individual is appropriate for independent smoking.

Based on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one (R70) out of seven residents reviewed for accommodation of needs in a sample of 25. Findings Include: On 08/02/23 at 11:15 AM, R70 was observed sitting in her wheelchair. Her call light was on the floor and not within her reach. On 8/2/2023 at 11:20 AM, V24 (CNA) observed that R70 call light was on the floor and not within the reach of R70. V24 said that the call light should be within R70's reach. On 8/2/2023 at 11:22 AM, V16 (Licensed Practical Nurse) said that call light should be within R70 reach. On 8/3/2023 at 12:00 PM, V3 (Director of Nursing) said that the call light within the resident's reach. R70 is an [AGE] years female admitted on [DATE] with diagnosis not limited to acute or chronic diastolic (congestive) heart failure, difficulty in walking, major depressive disorder, and acute kidney failure. R70 care plan dated 6/20/2022 documents: Keep call light in reach at all times. Facility Call Light Policy Purpose: The purpose of this procedure is to respond to the resident's requests and needs. General Guidelines: 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

Based on interview and record review, the facility failed to have effective fall interventions in place and failed to provide adequate supervision to ensure the safety of a resident assessed to be at risk for falls. This failure applied to one (R5) of one resident reviewed for accidents and supervision. This failure resulted in R5 having a fall with injury that resulted in a subdural hematoma and subsequently died . Findings include: R5 is a [AGE] year-old male admitted to the facility on [DATE] with the diagnosis of but not limited to abnormalities of gait and mobility, restlessness and agitation, unsteadiness on feet, and Alzheimer's disease. On [DATE] R5 had a fall in the facility during which R5 hit his head and sustained a laceration to the right brow. Record review of R5's death certificate documents cause of death for R5 as Subdural Hemorrhage (Due to or as a consequence of) Fall. Death certificate also documents the following: Manner of death: Accident Date of Injury: [DATE] Place of Injury: Nursing Home Description of How Injury Occurred: Subdural Hemorrhage Due to Unwitnessed Fall Further review of R5's medical record, includes note that R5 had a fall on [DATE] at 6:30am where on-coming staff for the day shift noted R5 in room laying on his back with his legs in the air. Record review of R5's Progress Notes include multiple entries from different nurses on different days and shifts reporting that R5 walks at a fast pace with unsteady gait, with the need to be redirected. Record review of R5's Progress Notes on [DATE] reads: R5 left the unit and was observed on the first floor. On [DATE] V1 (Administrator) submitted a schedule of staff working on [DATE] noted is two nurses and one CNA at the time of R5 fall in the floor dining room. Staff redirected R5 back to the second floor. On [DATE] at 9:15am V1 administrator submitted a new schedule with V8 CNA handwritten into the second-floor schedule for the date of [DATE]. On [DATE] at 10:20am Interview with V2 DON (Director of Nursing) said R5 was very busy he would ambulate quickly up and down the hallways very impulsive no safety awareness and difficult to redirect at times. He had 4 falls in the facility the last fall he did go to the hospital they sent him back with all negative X-rays and CT (Computerized tomography) scans. Vitals should be taken daily unless something is going on or there is a change in condition then they will be taken more often. Long term residents are charted on by exception if something is going on if not then monthly. On [DATE] his behavior was as usual he was running in and out or resident's room, getting aggressive with staff. I believe the subdural hematomas was from the fall he had on [DATE] I believe it was from that week because he has not had any more falls since that one. I don't recall him running into walls or any doors. On [DATE] at 10:30am V2 DON said, I need to correct myself R5 only had 3 falls in the facility not 4, I was mistaken. On [DATE] at 1:06pm interview with V8 CNA (Certified Nursing Assistant) said, I was working on [DATE] but R5 was not my patient. He was seen coming and going in and out of residents room a little unsteady, but he didn't have any falls that day that I know of. He would walk really fast that's when he became unsteady then we will try to get him to sit down. The only thing they told us was to watch him and to make sure he was steady while walking. I know they got him a helmet but before that last fall I don't know what precautions they just said keep an eye on him. I only know of that one fall I'm not sure if they had him on 1:1 monitoring at that time. I know he would get like very anxious a lot I would redirect him to sit in the dining room or I will walk with him to the dining room he did not fall or hit his head this day. On [DATE] at 1:42pm Interview with V6 CNA said Yes I worked [DATE] second shift, I'm familiar with R5 he did a lot of moving running, stumbling, moving extra fast he was hard to redirect. I know they gave him a helmet and floor mats. He can walk but he would get extra hyper then we would try to redirect him. It was hard trying to take care of him. The nurse would sometimes assign one CNA to him when we had the staff to walk with him and monitor him. It's supposed to be 4 CNAs it may have been 2 or 3 that day. Yes, we would ask for him to be put on 1:1 if we have the staff if not everybody had to help out with him. On [DATE] at 2:08pm Interview with V7 LPN said Yes I worked [DATE] day shift. He was normal nothing abnormal. That morning he was difficult to redirect earlier but I was able to redirect him. No, he did not have any falls as far as I know of. I kept him by my side a lot to monitor him Yes more like a 1:1. No, the facility didn't put it in place I did as being his nurse. Well, he would ambulate at a fast pace so I would try to be with him because he has an unsteady gait he would just take of at a fast rate of speed. No, he didn't have any falls on my shift. No, I never requested extra help because we had ,d+[DATE] CNAs and activities was there. I think at the beginning R5 was easy to redirect but as it got towards the end no, I don't think he was a fit for the facility. On [DATE] at 2:34pm Interview with V4 CNA said Yes I remember R5 yes I worked [DATE] on day shift, yes, I was the only CNA working on that day. It doesn't happen often maybe once every three or four weeks. The most they try to have are ,d+[DATE] CNAs. I am supposed to be in restorative, but I have been working as a CNA on the floor for months. It's no one in restorative we all been working the floor. Well, we don't know how many CNAs working until we get here sometimes people call off and they will try to replace them, but you just never know. I can't recall off hand but if he is up walking, he would walk really fast most of the time I believe he was steady. They told us to monitor his shoes or nonskid socks we needed to remind him to slow down. I was not aware of him falling because I was doing my rounds at that time. I was doing rounds toileting people. Yes, sometimes I believe he was on 1:1, that day I had 30 something residents and its hard trying to watch everybody. Sometimes it's only two CNAs and that will give us like 21 residents. Yes, we would let the nurse know and if they not busy, they will help us, or we would try to keep him in activities, but he was very impulsive and just jump up and start running. On [DATE] at 2:58pm Interview with V5 LPN said Yes I was the nurse for R5 the day he fell . He was being his usual self, walking around I kept him in activities that day. As long as he in activities he was doing okay. After lunch he came out the dining room walking really fast, and I couldn't get to him, and he lost his balance and fell . I believe he did need more monitoring. It was discussed I can't remember when that we can use more help for him. Since he's been here, I had to put him on 1:1 that day after he fell . I can't remember off top I just use to try to keep him next to me for his safety. I did everything I could that day to keep him safe. On [DATE] at 10:12am interview with V3 ADON said Yes, I knew R5 I didn't know his medical history as far as dealing with his medication regimen or his care. I didn't deal with him as much. I think it was a weekend the nurse on second floor called to ask me for help with R5. They needed help monitoring him he was restless he was grabbing other residents food I went to provide extra help. I know he was a pacer at times I went to help he was trying to open doors he would be redirected. On his floor the doors are lock because of the unit so he would just twist the knobs. We had people that would walk with him to try to keep him safe it was very difficult, and it was hard to have 1:1 or people for extra monitoring we would discuss in morning meetings about his medication regimen, ask if anyone has time to go to the floor and walk with him. I do recall when he would fall, we would send him out to the hospital, and they would send him back. I guess we didn't fill out the paperwork correctly so they had to send him back here because they could find placement. We were looking for placement for him. He needed the extra monitoring that's why we would ask if anyone had extra time to come walk with him. We talked to the Psych Nurse Practitioner, and she gave an as needed order it was liquid and that help get him to bed, I sat in the room with him until he fell asleep. Everyone in the building knew he was all hands-on deck with him. I think we was doing the best we could with the resources we had. We would even ask the family if they could come in and help with mealtimes or just monitoring. Usually, the second floor get priority because of the level of acuity of care they need. They should have ,d+[DATE] CNAs we don't do 1:1 but they would get an extra CNA when he needed extra monitoring. Yes, if I was working, he would have been safe with one or Two CNAs because I would have isolated him with me. Review of R5's care plan did not show that the facility modified the resident's plan of care based on the increase needs of the resident in regard to falls and safety. Interventions were not individualized to meet the resident's needs. Care plan has a problem start date of [DATE]: (R5) has a behavior of running in hallway which may be r/t his DX of dementia. Interventions dated [DATE] are to ensure proper footwear, redirect as needed, and review medications (adjust as needed). Evaluation Notes dated [DATE] documents Quarterly reviewed care plan. Continue with goal and approaches. No additional interventions added after [DATE]. Care plan with problem start date [DATE]: (R5) is at risk for falling Dx/Hx of dementia, Alzheimer Disease, constipation, Weakness and [CONDITION(S)]. Interventions added [DATE] do not address resident ambulation while in hall until after gall occurred on [DATE], although resident has a history of unsteady gait and difficulty ambulating per staff interviews and medical record review. On [DATE] interventions were added: walk scheduled with one person assist in the afternoons and safety helmet ordered. R5's MDS (Minimum Data Set) dated [DATE] documents that R5 required extensive assistance, two + persons physical assist with bed mobility, transfers, walking in room, and walking in corridor. MDS dated [DATE] documents that R5 required extensive assistance, two + persons physical assist with bed mobility and transfers; required limited assistance, one-person physical assist when walking in room and walking in corridor. Facility did not provide documentation of improvement in resident condition to explain decrease from two + to one staff assist. On [DATE] at 11:23am interview with V9 Medical Director said Yes I seen R5 two to three times since he was here. If his facility can't get a doctor to follow a patient by default, I see them. When the resident first come to the facility they do interviews and assessments to see if they are a fit for the facility. When he first came, I believe he just needed to get settled in because this was a new place for him. When I saw him one time he was in his room, one time he was at the nursing station and one time he was pacing up and down the hallway. If he fell , they should do an assessment and put precautions in place based on what they decide that patient need it could be 1:1. But dementia patient can't always be on 1:1 it's on a day-to-day basis. I can't make that decision it's up to the staff and nurses to decide on what monitoring a patient may need. It's their decision amongst themselves. Of course, extra monitoring is always better. (Reviewing R5 progress notes) He was aggressive, unsafe judgment, walking quickly unsteady they should have had someone with him gait unsteady. Yes, if they would have reported this behavior to me, I would have told them to get more supervision for him. They have a Nurse Practitioner that was working with him so they would report behaviors and things like that to them. When he had a fall or change in condition, they would call me. A subdural hematoma can take one to several days to show up. It depends on if it is a slow bleed or huge trauma, a huge trauma will show bleeding right away a slow bleed can take two -three days to show. One possibility is that he fell again but they say he didn't fall again so the other possibility is that it was a slow bleed from the last fall he had. So, possibility that it was a slow bleed that progress and got worst or new fall that no one seen. Record review of document submitted by the facility Titled Falls-Clinical Protocol with the revised date of [DATE] on page FA-2 next to monitoring and follow up states: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have bleed ruled out or resolved. a. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall.

Based on observations, interviews, and record reviews, the facility failed to honor the residents' right to choose to be a resident of the facility by not honoring the residents' request to return home after completion of rehabilitation therapy. This failure applied to one of one (R93) resident reviewed for resident rights and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year-old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. R93 has a hearing deficit and when communicating with R93 you must speak directly in her ear. On 08/22/2022 at 12:00pm during resident interview, R93 said, I have a problem that they will not let me go home. I have not seen a doctor or talked to anyone about why I'm still here; no one will explain to me. I have a house in (city) that I own. The only thing I must do is pay taxes once a year and they will not let me go home. I have been here since November 2021. I called 911 because I was not feeling good, and they took me to (local) hospital then I was railroaded here. They told me I had to do therapy before I could go home. I completed it and they still are not letting me go home. I tried to talk to them, but no one will talk to me. On 08/23/2022 at 10:55am interview with V22 Assistant administrator said, R93 has a court date next month for guardianship. She was living in her home by herself, I believe the house had code issues. She is confused and she is at risk for safety. We petitioned for guardianship because she has limited support in the community, she doesn't have family nearby to help her make sound decisions because she is not able to make decisions on her own. Once the guardian is appointed, then they will help her with placement for living. I'm not sure why they would need to help her with placement; yes, we do that here. She signed her own admission paperwork. On 08/23/2022 at 4:49pm interview with V20 Admission Director said, R93's Power of Attorney resigned in late January. I faxed the admission paperwork to him to sign. When we gave her the guardianship paperwork, she said she wanted to get a lawyer because she felt she doesn't need a guardian. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator told me to reach out to the guardianship office to take responsibility. The MDS coordinator is responsible for placing the diagnosis. She didn't sign her paperwork because she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I know that's used for dementia. (V20 was giving resident transfer paperwork from the hospital and ask did she see the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/23/2022 V20 Admission Director presented R93's admission packet. Record review of the admission packet noted that R93 had not signed the admission packet and the POA at that time had not signed the admission packet. On 08/24/2022 V20 Admission Director said R93 did sign her admission packet. V20 presented an updated admission packet with R93's signatures. On 08/24/2022 at 11:26am, R93 said, Months ago they handed me a stack of papers and asked me to sign them, they didn't explain anything to me about the papers, what they were about. They are trying to say I am not able to care for myself, but I've been taking care of myself for [AGE] years. They gave me these papers on July 23rd about court. I've been living on my own, I know what I can do and what I can't. I was paying all of my bills on time. I know I can't cut my grass, so I hired someone to do it. I know I'm not a plumber so if I need pluming work done, I will call a plumber. Right now, I am looking for someone that can demolish my house I will not let them get it. I work hard for my house. I worked two, three jobs to pay for my house for someone to just come and take it from me. This is extremely stressing me out. I worked [AGE] years to pay off that house. I am the one that called 911 because I was not feeling well, they told me I had a severe urinary tract infection, which they treated me for in the hospital. They asked me my next of kin and I gave them my cousin's name. They wanted me to come here to do therapy, I did it. I didn't want to come here. I wanted to go home. I feel they railroaded me into this prison. That's what it feels like, a prison. I can't do anything anymore. I used to go shopping with my friends, I can't anymore. I am trying to have my friend become over my health care now, I don't need anyone over my finances, I pay all of my bills. When I first came here, my friend that lives across the street from me would get my mail and bring it to me and I would then pay them. Now I have put all bills on auto pay to make sure they are getting paid. No, they have not told me why I am still here. They know I have problems with my blood pressure by looking at my records from my primary doctor; that's all I can think of. They are trying to put two diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They have not given me one test to medically say that I have those diseases. Yes, they've given me a bill, it was in June some time. We were in a function in the dining room, and they handed me a yellow envelope and like four other people got one too. It was a bill for like $7,000 and some odd dollars. I feel very angry, upset, and helpless because it's hard to get help on the outside while they got me locked up in here. I have a house that is dwindling because no one is living in it. My friend will go and cut the lights on and off and has set a timer for the lights to come on at night, so someone thinks someone is there. I have a new car in the garage. I can't drive. They have taken part of my life away from me that I can't get back. I am [AGE] years old. I should not be going through this. I can't see my friends or nothing. This is like I am a prisoner. On 08/24/2022 at 1:18pm V23 Ombudsman said She is able to go home with care. The facility is doing this because they want to be paid. I will run this by my supervisor and see what we are able to do on our end. On 08/25/2022 at 9:39am V22 assistant administrator said, Residents are able to sign paperwork with a BIMs (Brief Interview for mental status) of 11 and up. They are unable to sign for a score of 10 or under. They are not required to have a guardianship, but it depends on each individual case and what information was provided. BIMS of 11 and up depends. She had another BIMS assessment yesterday. She was on the calendar if there are any change in condition, MDS will send out an e-mail letting us know that there is a change in the resident's condition, and we will discuss the change in the interdisciplinary team meeting. I didn't do the last one. On the new assessment, she scored a 9. Based on the assessment that was done yesterday, she needs help with making decisions. 08/25/22 10:24 AM V22 (Assistant Administrator/Social Services) said, yesterday during the MDS/BIMS assessment R93 exhibited some depressed symptoms and was quiet and did discuss her situation regarding next steps for guardianship. R93 does wish to leave. Primary goal is for her to have a safe discharge. Admissions is speaking with the guardian's office regarding her discharge plans. V22 stated, admissions would be better able to explain why a resident with the BIMS score of 11 was referred to the guardian's office. V22 said she returned from medical leave in March 2022. V22 said if R93 had any questions regarding the guardianship process she would answer them. V22 stated she was not here during the process of applying for guardianship for V22. V22 said, to my knowledge R93 has not exhibited anymore psychotic behaviors while here in the facility. 08/25/2022 at 11:03 am, V20 said, We allowed her to sign the admission and financial paperwork because she wanted to, and she had a BIMs score of 11. She is considered border line; we allow them to sign when their BIMs score allows them to. In January she had a BIMs of an 8 but she was in her right mind, so she was able to sign. 08/25/2022 surveyor requested documentation of R93's house not being up to code and utilities not being connected. A document was submitted by V22 from the public guardian office stating that the guardian handling R93's case is out the office. 08/25/2022 at 12:50pm V22 said, V19 Social worker for R93 is on bereavement leave, she recently lost her husband. I will provide her number and you can try to reach her. V19's number was provided but surveyor was unable to reach for interview. 08/25/2022 at 3:26pm, V40 CNA said, (R93) is confused. Sometimes she won't let you take care of her; she will say I can do it myself. No, she makes sound decisions most of the time. She will always tell me she is working on some paperwork. I believe she can make some decisions. When I talk to her, she will start crying saying she wants to go home. She is depressed and tells me she doesn't deserve to be here, and she should be at home. No, she has not complained to me about seeing ghosts. 08/25/2022 at 3:48pm, V27 (Nurse Practitioner) said, R93 came from the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had been calling 911 for over a year reporting she sees ghosts. She was unable to care for herself. She couldn't pay her bills. Her water was off and other utilities as well. She was a hoarder and was not keeping up with her house. I got this information from her cousin who was her power of attorney, but he resigned in January because he said he has dementia, and his wife has problems, so he was unable to care for or take care of R93's issues. Yes, according to R93's hospital records a brain scan was done and it was normal. I got the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I completed the exam, and she could not spell world backwards. She was not able to follow three-stage commands and she was not able to draw intersecting pentagons. In this state, I don't work under a doctor. I completed my assessment. I didn't need to do a clinical diagnostic test. I did my assessment (V26 Psychiatrist) didn't have to complete the full assessment, I did it. I can't prove it clinically, but the MMES assessment demonstrates she has dementia and is unable to make decisions. Record review of R93's hospital records document that she was admitted to the hospital with a severe [CONDITION(S)] and was exhibiting hallucinations and [CONDITION(S)]. On page two of her medical records dated 11/23/2021 from the hospital under Assessment notes R93 may have [CONDITION(S)] secondary to an underlying medical issue. It also notes that R93 has not had any neurocognitive testing completed. On page three, under assessments, it states that R93's hallucinations and delusions are resolved. Record review of a social service progress note dated 02/04/2022 notes that R93 was anxious about going home because her house is unattended. Record review of R93's Section C MDS Cognitive Patterns documents the following BIMS (Brief Interview of Mental Status) scores: (scores 8 - 12 = moderately impaired) 11/30/21 - 08 2/4/22 - 08 5/7/22 - 10 8/7/22 - 11 Review of R93's care plan noted there was plan to discharge R93 home. Record review of R93's Report of Physician, dated 01/28/2022 and dated 05/04/2022 V26 signature is noted on the form as having completed a full evaluation of R93 and finding her unfit to make decision on her own. 08/25/2022 at 2:15pm, contact was made with V25 (Physician Secretary) and V25 stated, V26 (Psychiatrist) has not seen R93. R93 is not on his list of patients to be seen. V26 is V27's (Nurse Practitioner) supervisor. Facility submitted a progress note noted 12/03/2021 stating that R93 is unable to make any financial or medical decisions for herself. On 01/28/2022 a progress note written by V27 Nurse Practitioner, stated that R93 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Included in the progress note is R93's MMSE (Mini-Mental State Examination). On 08/24/2022 record review of R93's power of attorney forms noted to only cover health care and not financial. On 01/20/2022 R93's Power of attorney resigned from being her POA for health care. Record review of R93's admission packet dated 1-12-2022 noted R93 has signed the facility contract for admission to the facility. Record review noted R93 was presented and signed the Advance Beneficiary Notice of Non-coverage on 02/6/2022. Record review noted R93 was presented and signed the Notice of Medicare Non-Coverage form on 02/6/2022. Record review of R93 Progress noted dated 08/25/2022 note R93 requested a voice enhancer to help her hear better. Record review of documents submitted by the facility titled Dementia- Clinical Protocol with a revised date of April 2007 under Assessments and recognition. Number 4 states the staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Number 5 states the staff, and the Physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about health care treatment choices, including life-sustaining treatments. Under Cause Identification number one states. As needed (for example, when the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Individuals with dementia can also have a personality disorder, mental illness, [CONDITION(S)], [CONDITION(S)], depression, adverse drug reactions (ADRs) or other conditions causing or contributing to impaired cognition and problematic behavior. B. As needed, the physician will verify or reconsider the diagnosis, treatment selection, monitoring of responses to treatment and adjustment of medications. Number 3 states the physician will order any diagnostic tests indicated to clarify the nature or causes of dementia and identify other co-existing or alternative causes of cognitive impairment and problematic behavior, for example, [CONDITION(S)] dysfunctions, adverse drug reaction, [CONDITION(S)], etc. A document provided by the facility titled Transfer and Discharge policy with the effective date of June 2017. Under policy states: To ensure residents transfers and discharges will be conducted in accordance with residents' rights, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record reviews, the facility failed to keep a resident free from mental abuse by not providing the resident with an explanation of why the facility is requesting a court appointed guardian for the resident. This failure applied to one of one (R93) resident reviewed for mental abuse and has resulted in R93 suffering extreme stress and feeling symptoms of depression due to not being able to discharge from the facility. Findings include: R93 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. R93 has a hearing deficit and when communicating with R93 you have to speak directly in her ear. On 08/22/2022 at 12:00pm during resident interview, R93 said, I have a problem that they will not let me go home. I have not seen a doctor or talked to anyone about why I'm still here; no one will explain to me. I have a house in (city) that I own. The only thing I have to do is pay taxes once a year and they will not let me go home. I have been here since November 2021. I called 911 because I was not feeling good and they took me to (local) hospital then I was railroaded here. They told me I had to do therapy before I could go home. I completed it and they still are not letting me go home. I tried to talk to them but no one will talk to me. On 08/23/2022 at 10:55am interview with V22 Assistant administrator said, R93 has a court date next month for guardianship. She was living in her home by herself, I believe the house had code issues. She is confused and she is at risk for safety. We petitioned for guardianship because she has limited support in the community, she doesn't have family nearby to help her make sound decisions because she is not able to make decisions on her own. Once the guardian is appointed, then they will help her with placement for living. I'm not sure why they would need to help her with placement; yes we do that here. She signed her own admission paperwork. On 08/23/2022 at 4:49pm interview with V20 Admission Director said, R93's Power of Attorney resigned in late January. I faxed the admission paper work to him to sign. When we gave her the guardianship paper work she said she wanted to get a lawyer because she felt she doesn't need a guardian. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator told me to reach out to the guardianship office to take responsibility. The MDS coordinator is responsible for placing the diagnosis. She didn't sign her paper work because she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I know that's used for dementia. (V20 was giving resident transfer paperwork from the hospital and ask did she see the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/23/2022 V20 Admission Director presented R93's admission packet. Record review of the admission packet noted that R93 had not signed the admission packet and the POA at that time had not signed the admission packet. On 08/24/2022 V20 Admission Director said R93 did sign her admission packet. V20 presented an updated admission packet with R93's signatures. On 08/24/2022 at 11:26am, R93 said, Months ago they handed me a stack of papers and asked me to sign them, they didn't explain anything to me about the papers, what they were about. They are trying to say I am not able to care for myself but I've been taking care of myself for [AGE] years. They gave me these papers on July 23rd about court. I've been living on my own, I know what I can do and what I can't. I was paying all of my bills on time. I know I can't cut my grass so I hired someone to do it. I know I'm not a plumber so if I need pluming work done I will call a plumber. Right now I am looking for someone that can demolish my house I will not let them get it. I work hard for my house. I worked two, three jobs to pay for my house for someone to just come and take it from me. This is extremely stressing me out. I worked [AGE] years to pay off that house. I am the one that called 911 because I was not feeling well, they told me I had a severe urinary tract infection, which they treated me for in the hospital. They asked me my next of kin and I gave them my cousin's name. They wanted me to come here to do therapy, I did it. I didn't want to come here. I wanted to go home. I feel they railroaded me into this prison. That's what it feel like, a prison. I can't do anything anymore. I used to go shopping with my friends, I can't any more. I am trying to have my friend become over my health care now, I don't need anyone over my finances, I pay all of my bills. When I first came here, my friend that lives across the street from me would get my mail and bring it to me and I would then pay them. Now I have put all bills on auto pay to make sure they are getting paid. No, they have not told me why I am still here. They know I have problems with my blood pressure by looking at my records from my primary doctor; that's all I can think of. They are trying to put two diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They have not given me one test to medically say that I have those diseases. Yes, they've given me a bill, it was in June some time. We were in a function in the dining room and they handed me a yellow envelope and like four other people got one too. It was a bill for like $7,000 and some odd dollars. I feel very angry, upset, and helpless because it's hard to get help on the outside while they got me locked up in here. I have a house that is dwindling because no one is living in it. My friend will go and cut the lights on and off and has set a timer for the lights to come on at night so someone thinks someone is there. I have a new car in the garage. I can't drive. They have taken part of my life away from me that I can't get back. I am [AGE] years old. I should not be going through this. I can't see my friends or nothing. This is like I am a prisoner. On 08/24/2022 at 1:18pm V23 Ombudsman said She is able to go home with care. The facility is doing this because they want to be paid. I will run this by my supervisor and see what we are able to do on our end. On 08/25/2022 at 9:39am V22 assistant administrator said, Residents are able to sign paperwork with a BIMs (Brief Interview for mental status) of 11 and up. They are unable to sign for a score of 10 or under. They are not required to have a guardianship but it depends on each individual case and what information was provided. BIMS of 11 and up depends. She had another BIMS assessment yesterday. She was on the calendar if there are any change in condition, MDS will send out an e-mail letting us know that there is a change in the resident's condition and we will discuss the change in the interdisciplinary team meeting. I didn't do the last one. On the new assessment, she scored a 9. Based on the assessment that was done yesterday, she needs help with making decisions. 08/25/22 10:24 AM V22 (Assistant Administrator/Social Services) said, yesterday during the MDS/BIMS assessment R93 exhibited some depressed symptoms and was quiet and did discuss her situation regarding next steps for guardianship. R93 does wish to leave. Primary goal is for her to have a safe discharge. Admissions is speaking with the guardian's office regarding her discharge plans. V22 stated, admissions would be better able to explain why a resident with the BIMS score of 11 was referred to the guardian's office. V22 said she returned from medical leave in March 2022. V22 said if R93 had any questions regarding the guardianship process she would answer them. V22 stated she was not here during the process of applying for guardianship for V22. V22 said, to my knowledge R93 has not exhibited anymore psychotic behaviors while here in the facility. 08/25/2022 at 11:03 am, V20 said, We allowed her to sign the admission and financial paperwork because she wanted to and she had a BIMs score of 11. She is considered border line, we allow them to sign when their BIMs score allows them to. In January she had a BIMs of an 8 but she was in her right mind so she was able to sign. 08/25/2022 surveyor requested documentation of R93's house not being up to code and utilities not being connected. A document was submitted by V22 from the public guardian office stating that the guardian handling R93's case is out the office. 08/25/2022 at 12:50pm V22 said, V19 Social worker for R93 is on bereavement leave, she recently lost her husband. I will provide her number and you can try to reach her. V19's number was provided but surveyor was unable to reach for interview. 08/25/2022 at 3:26pm, V40 CNA said, (R93) is confused. Sometimes she won't let you take care of her, she will say I can do it myself. No, she makes sound decisions most of the time. She will always tell me she is working on some paperwork. I believe she can make some decisions. When I talk to her, she will start crying saying she wants to go home. She is depressed and tells me she doesn't deserve to be here and she should be at home. No, she has not complained to me about seeing ghosts. 08/25/2022 at 3:48pm, V27 (Nurse Practitioner) said, R93 came from the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had been calling 911 for over a year reporting she sees ghosts. She was unable to care for herself. She couldn't pay her bills. Her water was off and other utilities as well. She was a hoarder and was not keeping up with her house. I got this information from her cousin who was her power of attorney but he resigned in January because he said he has dementia and his wife has problems so he was unable to care for or take care of R93's issues. Yes according to R93's hospital records a brain scan was done and it was normal. I got the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I completed the examine and she could not spell world backwards. She was not able to follow three-stage commands and she was not able to draw intersecting pentagons. In this state, I don't work under a doctor. I completed my assessment. I didn't need to do a clinical diagnostic test. I did my assessment (V26 Psychiatrist) didn't have to complete the full assessment, I did it. I can't prove it clinically but the MMES assessment demonstrates she has dementia and is unable to make decisions. Record review of R93's hospital records document that she was admitted to the hospital with a severe [CONDITION(S)] and was exhibiting hallucinations and [CONDITION(S)]. On page two of her medical records dated 11/23/2021 from the hospital under Assessment notes R93 may have [CONDITION(S)] secondary to an underlying medical issue. It also notes that R93 has not had any neurocognitive testing completed. On page three, under assessments, it states that R93's hallucinations and delusions are resolved. Record review of a social service progress note dated 02/04/2022 notes that R93 was anxious about going home because her house is unattended. Record review of R93's Section C MDS Cognitive Patterns documents the following BIMS (Brief Interview of Mental Status) scores: (scores 8 - 12 = moderately impaired) 11/30/21 - 08 2/4/22 - 08 5/7/22 - 10 8/7/22 - 11 Review of R93's care plan noted there was plan to discharge R93 home. Record review of R93's Report of Physician, dated 01/28/2022 and dated 05/04/2022 V26 signature is noted on the form as having completing a full evaluation of R93 and finding her unfit to make decision on her own. 08/25/2022 at 2:15pm, contact was made with V25 (Physician Secretary) and V25 stated, V26 (Psychiatrist) has not seen R93. R93 is not on his list of patients to be seen. V26 is V27's (Nurse Practitioner) supervisor. Facility submitted a progress note noted 12/03/2021 stating that R93 is unable to make any financial or medical decisions for herself. On 01/28/2022 a progress note written by V27 Nurse Practitioner, stated that R93 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Included in the progress note is R93's MMSE (Mini-Mental State Examination). On 08/24/2022 record review of R93's power of attorney forms noted to only cover health care and not financial. On 01/20/2022 R93's Power of attorney resigned from being her POA for health care. Record review of R93's admission packet dated 1-12-2022 noted R93 has signed the facility contract for admission to the facility. Record review noted R93 was presented and signed the Advance Beneficiary Notice of Non-coverage on 02/6/2022. Record review noted R93 was presented and signed the Notice of Medicare Non-Coverage form on 02/6/2022. Record review of R93 Progress noted dated 08/25/2022 note R93 requested a voice enhancer to help her hear better. Record review of documents submitted by the facility titled Dementia- Clinical Protocol with a revised date of April 2007 under Assessments and recognition. Number 4 states the staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Number 5 states the staff and the Physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about health care treatment choices, including life-sustaining treatments. Under Cause Identification number one states. As needed (for example, when the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Individuals with dementia can also have a personality disorder, mental illness, [CONDITION(S)], [CONDITION(S)], depression, adverse drug reactions (ADRs) or other conditions causing or contributing to impaired cognition and problematic behavior. B. As needed, the physician will verify or reconsider the diagnosis, treatment selection, monitoring of responses to treatment and adjustment of medications. Number 3 states The physician will order any diagnostic tests indicated to clarify the nature or causes of dementia and identify other co-existing or alternative causes of cognitive impairment and problematic behavior; for example, [CONDITION(S)] dysfunctions, adverse drug reaction, [CONDITION(S)], etc. A document provided by the facility titled Transfer and Discharge policy with the effective date of June 2017. Under policy states: To ensure residents transfers and discharges will be conducted in accordance with residents rights, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observations, interviews, and record reviews, the facility failed to follow their policy by not completing a comprehensive assessment after a resident's change in medical condition and when adding new diagnoses' to residents' plan of care. This failure applied to one of one (R93) residents reviewed for comprehensive assessment and has resulted in R93 being deemed unfit to make decisions without thorough documentation that the physician verified or reconsider underlying causes of cognitive impairment (including recent urinary tract infection, known to cause [CONDITION(S)]) and/or failing to include diagnostic tests and collaboration with other physician specialists (such as neurology) when giving the resident a new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Findings include: R93 is an [AGE] year old female admitted into the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/22/2022 surveyor observed R93 sitting up in her chair making phone calls. R93 was able to communicate to the surveyor and make needs and concerns known. R93 has a hearing deficit and when communicating with R93 you have to speak directly in her ear. On 08/22/2022 at 12:00pm during resident interview, R93 said, I have a problem that they will not let me go home. I have not seen a doctor or talked to anyone about why I'm still here; no one will explain to me. I have a house in (city) that I own. The only thing I have to do is pay taxes once a year and they will not let me go home. I have been here since November 2021. I called 911 because I was not feeling good and they took me to (local) hospital then I was railroaded here. They told me I had to do therapy before I could go home. I completed it and they still are not letting me go home. I tried to talk to them but no one will talk to me. On 08/23/2022 at 10:55am interview with V22 Assistant administrator said, R93 has a court date next month for guardianship. She was living in her home by herself, I believe the house had code issues. She is confused and she is at risk for safety. We petitioned for guardianship because she has limited support in the community, she doesn't have family nearby to help her make sound decisions because she is not able to make decisions on her own. Once the guardian is appointed, then they will help her with placement for living. I'm not sure why they would need to help her with placement; yes we do that here. She signed her own admission paperwork. On 08/23/2022 at 4:49pm interview with V20 Admission Director said, R93's Power of Attorney resigned in late January. I faxed the admission paper work to him to sign. When we gave her the guardianship paper work she said she wanted to get a lawyer because she felt she doesn't need a guardian. She has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The administrator told me to reach out to the guardianship office to take responsibility. The MDS coordinator is responsible for placing the diagnosis. She didn't sign her paper work because she had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I know that's used for dementia. (V20 was giving resident transfer paperwork from the hospital and ask did she see the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/23/2022 V20 Admission Director presented R93's admission packet. Record review of the admission packet noted that R93 had not signed the admission packet and the POA at that time had not signed the admission packet. On 08/24/2022 V20 Admission Director said R93 did sign her admission packet. V20 presented an updated admission packet with R93's signatures. On 08/24/2022 at 11:26am, R93 said, Months ago they handed me a stack of papers and asked me to sign them, they didn't explain anything to me about the papers, what they were about. They are trying to say I am not able to care for myself but I've been taking care of myself for [AGE] years. They gave me these papers on July 23rd about court. I've been living on my own, I know what I can do and what I can't. I was paying all of my bills on time. I know I can't cut my grass so I hired someone to do it. I know I'm not a plumber so if I need pluming work done I will call a plumber. Right now I am looking for someone that can demolish my house I will not let them get it. I work hard for my house. I worked two, three jobs to pay for my house for someone to just come and take it from me. This is extremely stressing me out. I worked [AGE] years to pay off that house. I am the one that called 911 because I was not feeling well, they told me I had a severe urinary tract infection, which they treated me for in the hospital. They asked me my next of kin and I gave them my cousin's name. They wanted me to come here to do therapy, I did it. I didn't want to come here. I wanted to go home. I feel they railroaded me into this prison. That's what it feel like, a prison. I can't do anything anymore. I used to go shopping with my friends, I can't any more. I am trying to have my friend become over my health care now, I don't need anyone over my finances, I pay all of my bills. When I first came here, my friend that lives across the street from me would get my mail and bring it to me and I would then pay them. Now I have put all bills on auto pay to make sure they are getting paid. No, they have not told me why I am still here. They know I have problems with my blood pressure by looking at my records from my primary doctor; that's all I can think of. They are trying to put two diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They have not given me one test to medically say that I have those diseases. Yes, they've given me a bill, it was in June some time. We were in a function in the dining room and they handed me a yellow envelope and like four other people got one too. It was a bill for like $7,000 and some odd dollars. I feel very angry, upset, and helpless because it's hard to get help on the outside while they got me locked up in here. I have a house that is dwindling because no one is living in it. My friend will go and cut the lights on and off and has set a timer for the lights to come on at night so someone thinks someone is there. I have a new car in the garage. I can't drive. They have taken part of my life away from me that I can't get back. I am [AGE] years old. I should not be going through this. I can't see my friends or nothing. This is like I am a prisoner. On 08/24/2022 at 1:18pm V23 Ombudsman said She is able to go home with care. The facility is doing this because they want to be paid. I will run this by my supervisor and see what we are able to do on our end. On 08/25/2022 at 9:39am V22 assistant administrator said, Residents are able to sign paperwork with a BIMs (Brief Interview for mental status) of 11 and up. They are unable to sign for a score of 10 or under. They are not required to have a guardianship but it depends on each individual case and what information was provided. BIMS of 11 and up depends. She had another BIMS assessment yesterday. She was on the calendar if there are any change in condition, MDS will send out an e-mail letting us know that there is a change in the resident's condition and we will discuss the change in the interdisciplinary team meeting. I didn't do the last one. On the new assessment, she scored a 9. Based on the assessment that was done yesterday, she needs help with making decisions. 08/25/22 10:24 AM V22 (Assistant Administrator/Social Services) said, yesterday during the MDS/BIMS assessment R93 exhibited some depressed symptoms and was quiet and did discuss her situation regarding next steps for guardianship. R93 does wish to leave. Primary goal is for her to have a safe discharge. Admissions is speaking with the guardian's office regarding her discharge plans. V22 stated, admissions would be better able to explain why a resident with the BIMS score of 11 was referred to the guardian's office. V22 said she returned from medical leave in March 2022. V22 said if R93 had any questions regarding the guardianship process she would answer them. V22 stated she was not here during the process of applying for guardianship for V22. V22 said, to my knowledge R93 has not exhibited anymore psychotic behaviors while here in the facility. 08/25/2022 at 11:03 am, V20 said, We allowed her to sign the admission and financial paperwork because she wanted to and she had a BIMs score of 11. She is considered border line, we allow them to sign when their BIMs score allows them to. In January she had a BIMs of an 8 but she was in her right mind so she was able to sign. 08/25/2022 surveyor requested documentation of R93's house not being up to code and utilities not being connected. A document was submitted by V22 from the public guardian office stating that the guardian handling R93's case is out the office. 08/25/2022 at 12:50pm V22 said, V19 Social worker for R93 is on bereavement leave, she recently lost her husband. I will provide her number and you can try to reach her. V19's number was provided but surveyor was unable to reach for interview. 08/25/2022 at 3:26pm, V40 CNA said, (R93) is confused. Sometimes she won't let you take care of her, she will say I can do it myself. No, she makes sound decisions most of the time. She will always tell me she is working on some paperwork. I believe she can make some decisions. When I talk to her, she will start crying saying she wants to go home. She is depressed and tells me she doesn't deserve to be here and she should be at home. No, she has not complained to me about seeing ghosts. 08/25/2022 at 3:48pm, V27 (Nurse Practitioner) said, R93 came from the hospital with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She had been calling 911 for over a year reporting she sees ghosts. She was unable to care for herself. She couldn't pay her bills. Her water was off and other utilities as well. She was a hoarder and was not keeping up with her house. I got this information from her cousin who was her power of attorney but he resigned in January because he said he has dementia and his wife has problems so he was unable to care for or take care of R93's issues. Yes according to R93's hospital records a brain scan was done and it was normal. I got the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . I completed the examine and she could not spell world backwards. She was not able to follow three-stage commands and she was not able to draw intersecting pentagons. In this state, I don't work under a doctor. I completed my assessment. I didn't need to do a clinical diagnostic test. I did my assessment (V26 Psychiatrist) didn't have to complete the full assessment, I did it. I can't prove it clinically but the MMES assessment demonstrates she has dementia and is unable to make decisions. Record review of R93's hospital records document that she was admitted to the hospital with a severe [CONDITION(S)] and was exhibiting hallucinations and [CONDITION(S)]. On page two of her medical records dated 11/23/2021 from the hospital under Assessment notes R93 may have [CONDITION(S)] secondary to an underlying medical issue. It also notes that R93 has not had any neurocognitive testing completed. On page three, under assessments, it states that R93's hallucinations and delusions are resolved. Record review of a social service progress note dated 02/04/2022 notes that R93 was anxious about going home because her house is unattended. Record review of R93's Section C MDS Cognitive Patterns documents the following BIMS (Brief Interview of Mental Status) scores: (scores 8 - 12 = moderately impaired) 11/30/21 - 08 2/4/22 - 08 5/7/22 - 10 8/7/22 - 11 Review of R93's care plan noted there was plan to discharge R93 home. Record review of R93's Report of Physician, dated 01/28/2022 and dated 05/04/2022 V26 signature is noted on the form as having completing a full evaluation of R93 and finding her unfit to make decision on her own. 08/25/2022 at 2:15pm, contact was made with V25 (Physician Secretary) and V25 stated, V26 (Psychiatrist) has not seen R93. R93 is not on his list of patients to be seen. V26 is V27's (Nurse Practitioner) supervisor. Facility submitted a progress note noted 12/03/2021 stating that R93 is unable to make any financial or medical decisions for herself. On 01/28/2022 a progress note written by V27 Nurse Practitioner, stated that R93 was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Included in the progress note is R93's MMSE (Mini-Mental State Examination). On 08/24/2022 record review of R93's power of attorney forms noted to only cover health care and not financial. On 01/20/2022 R93's Power of attorney resigned from being her POA for health care. Record review of R93's admission packet dated 1-12-2022 noted R93 has signed the facility contract for admission to the facility. Record review noted R93 was presented and signed the Advance Beneficiary Notice of Non-coverage on 02/6/2022. Record review noted R93 was presented and signed the Notice of Medicare Non-Coverage form on 02/6/2022. Record review of R93 Progress noted dated 08/25/2022 note R93 requested a voice enhancer to help her hear better. Record review of documents submitted by the facility titled Dementia- Clinical Protocol with a revised date of April 2007 under Assessments and recognition. Number 4 states the staff and physician will review the current physical, functional, and psychosocial status of each individual with dementia to formulate an accurate overall picture of the individual's condition, related complications, and functional impairments. Number 5 states the staff and the Physician will jointly define the decision-making capacity of someone with dementia, including the extent to which the individual can participate in making everyday decisions and considerations about health care treatment choices, including life-sustaining treatments. Under Cause Identification number one states. As needed (for example, when the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. Individuals with dementia can also have a personality disorder, mental illness, [CONDITION(S)], [CONDITION(S)], depression, adverse drug reactions (ADRs) or other conditions causing or contributing to impaired cognition and problematic behavior. B. As needed, the physician will verify or reconsider the diagnosis, treatment selection, monitoring of responses to treatment and adjustment of medications. Number 3 states The physician will order any diagnostic tests indicated to clarify the nature or causes of dementia and identify other co-existing or alternative causes of cognitive impairment and problematic behavior; for example, [CONDITION(S)] dysfunctions, adverse drug reaction, [CONDITION(S)], etc. A document provided by the facility titled Transfer and Discharge policy with the effective date of June 2017. Under policy states: To ensure residents transfers and discharges will be conducted in accordance with residents rights, physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on interviews and records reviewed the facility failed to safely assist a resident while providing incontinence care to prevent an avoidable accident for 1 of 3 (R1) residents reviewed for safe care, the facility also failed to ensure fall prevention interventions were in place to include bed bolsters and floor mats to reduce the risk of fall with injury for 1 of 3 (R5) resident reviewed for fall prevention interventions. These failures resulted in R1 falling to the floor while being assisted by staff sustaining a laceration to the head requiring 2 sutures, and R5 falling from the bed to the floor and sustaining an acute right superior and inferior pubic ramus fractures. Findings include Review of incident report dated 7/6/2022 and documents R1 with diagnosis that include Unsteadiness on feet, [CONDITION(S)] and collapse, Weakness, Unspecified dementia, unspecified [CONDITION(S)], and [CONDITION(S)]. Description of Occurrence: R1 was adjusting incontinence brief, lost balance and fell . Aide present when R1 was pulling up briefs-lost balance but aide could not stop the fall. V5's nursing note dated 7/6/2022 at 3:50 AM documents the following: While staff member assist resident with pulling up her pullup resident lost her balance falling to her right side on to the floor. Resident has hit her head causing laceration to site. Controlled bleeding currently. Writer and staff member assist resident to bed. Site cleansed with normal saline and gauze then steri-strips applied. On 8/12/2022 at 10:18AM V5 (LPN) states, what her note says is most accurate to what happened that day. 8/12/2022 at 9:39 PM V6 (CNA) I was trying to help her pull up a diaper. R1 was sitting on the bed. close to edge. I was putting on diaper. V6 states He was in front of R1 trying to pull up her pull up and she tilted over and hit her head on the side of the bed. She fell to the right side. V6 states, R1 was always dizzy so made sure she set on the bed. V6 states, When she stands the balance isn't always there. Never see her flop over like that before. V6 states, he thought maybe she was kind of sleepy. V6 states, that when looking back he could have made sure R1 was always fully in the bed and lying down when changing her. The objective when helping with incontinence is to make sure they don't fall. V6 states, looking back I could have left her in bed, that is the way I'm doing it now. On 8/11/2022 at 2:18 PM V3 (Restorative Nurse) states she does investigations for fall. Surveyor asked what V3 thought the cause of R1's fall was after her investigation. V3 states, It could be improper aid or weakness. V3 states she expects staff to keep them [residents] safe and not drop them. I don't understand how she fell because she doesn't have increased weakness. V3 states, she thought it more educational issue with staff. V3 states V6 told her R1 just fell , and he didn't have time to catch her. On 8/16/2022 at 5:20 pm V11 (ADON) states when helping someone with incontinence care, first check care plan and supplies ready, skin check, safety check, wheelchair locked. transfer mode known, make sure every in place to prevent falls, not leaving person unattended. you must be attentive most importantly you want to prevent falls. Reviewed facility's in-service with V6 (CNA) with date of 7/6/2022 and documents a 10-minute in-service with topic of Supporting Resident's during incontinent care. Review of R1's fall care plan dated 2/17/2022 documents: resident at risk for falling related to diagnosis of history of altered mental status, [CONDITION(S)], Dementia, DM < [CONDITION(S)]. Review of R1's ADL care plan dated 6/23/2022 documents: R1 is limited in ability to transfer self-related-to decreased strength and balance and requires a restorative transfer program. Care plan also documents the following: R1 is limited in ability to move independently in bed related to decreased mobility and weakness and requires restorative a bed mobility program. Review of Hospital records document the following on page 15: History: Laceration. Patient sent to ED for evaluation after fall with head injury. Patient had a witnessed fall from wheelchair and sustained scalp laceration. Fall: The accident occurred 1 to 2 hours ago. Fall occurred: from wheelchair. She fell from a height of 1 to 2 ft. She landed on a hard floor. Review other hospital records dated 7/6/2022 page 21 documents: laceration repair with 2 sutures. Review of Falls and Fall Risk, managing policy documents: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. R5's MDS dated [DATE] section G documents R5's bed mobility requires extensive two+ person's physical assist. R5's MDS section C documents R5's Brief Interview for Mental Status (BIMS) of 6/15. Review of R5's 5/29/2022 fall report documents the fall report. 1) Root cause determination documents resident: rolled out of bed. 2) Based on the above assessment and direct observation at the location of the fall, the fall management team (FMT) determines the following new interventions and recommendations need to be implemented: Bolsters, UA and CS. R5's fall care plan start date 9/27/2016 and documents: bilateral Bolsters at rest. Approach start 5/29/2022. On 8/11/2022 at 3:34 PM V9 (CNA) states she found R5 on the floor on the 7/21/2022 fall and R5 said she didn't know how she got on the floor and V9 states she then told the nurse. V9 states R5 is bedridden. V9 states, R5 had bolsters on and they weren't tightened properly. V9 states when she checked the straps, they were loose. V9 states, I told the nurse it was loose. It wasn't done the proper way and it was loose. Surveyor asked her to clarify what she meant by loose. V9 states, the bolster was sitting there loose without being attached to the bed. V9 states after the fall the staff got in-serviced on how to properly apply the Bolsters. Surveyor asked V9 if she checked the bolsters to see if attached correctly and she said, No She assumed it was done correctly. V9 states she didn't know until the resident fell that it wasn't attached. V9 states, Now we check all the time because we don't want anyone falling. On 8/6/2022 at 10:40 AM V10 (LPN) states a CNA called her to the room and R5 was on the floor on floor. V10 states, she asked R5 what happened and if she was okay or in pain. V10 states R5 said her back hurt. V10 states she and three CNA's put R5 back in the bed. V10 states, at the beginning of the shift, they must make sure the bolsters are tight. V10 states, When it is tight it would be difficult for her to role. V10 states they knew before the last in-service to check the bolsters and then got the in-service about it. V10 nurse's progress note dated 7/21/2022 at 8:45 PM documents: Writer called to the room by CNA to come to resident's room. On getting there, resident was observed on the floor on her back. Resident was asked if she was okay and what happened. Resident told writer My Back is hurting me but could not tell writer what happened or how she got on the floor. Writer obtained vital signs. See Matrix. Writer and other staff assisted resident back to bed. Resident was able to move extremities per usual. No bruising or open area observed. Nurse Practitioner made aware of fall and order received for a stat x-ray to back hip and pelvic are. Order received and carried out. Resident POA called and made aware. All questions and concerns addressed. Resident assisted with needs and made comfortable in bed with bin in lowest position and head of bed elevated and call light in reach. Review of R5's fall report Event Audit documents the following: 1) Root cause determination documents resident: rolled out of bed unable to determine how per resident. 2) Based on the above assessment and direct observation at the location of the fall, the fall management team (FMT) determines the following new interventions and recommendations need to be implemented: 1) Bolsters replaced, 2) staff education on bolsters. 3) In-service dated 7/22/22 documents V9 and V10 getting in-serviced on the following: Dimensions of bolsters-comfort/condition/function/placement. On 8/16/2022 at 5:20 pm V11 (ADON) states the restorative aids educate how to put on the bolsters. They are a little tricky. V11 states Resident has to be taken out of the bed to adjust the bolsters. V11 states, that bolsters are there so resident doesn't roll out of bed. V11 states, every staff member going in the R1's room should be checking that the bed low, oxygen on, bolsters are secure and call light within reach. R5's radiology report dated 7/27/2022 documents the conclusion of bilateral hips X-ray as follows: Acute right superior and inferior pubic ramus fractures. The facility's fall risk, managing Policy: 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview and record review, the facility failed to modify the resident's plan of care to have effective interventions in place to keep a dependent resident free from repeated falls. This failure applied to one of one (R2) residents reviewed for accridents and supervision and resulted in R2 having five documented falls in a period of three and a half months with injuries including a fractured clavicle, scalp laceration that required sutures, and a left [CONDITION(S)]. Findings include: R2 is an [AGE] year-old female who was admitted to the facility on [DATE], with the following past medical history: [CONDITION(S)], unspecified dementia without behavioral disturbance, Enthesopathy unspecified, dysphagia oral phase, laceration without foreign body of other parts of head, unspecified injury of head, weakness, generalized anxiety disorder, fracture of unspecified part of right clavicle, repeated falls, etc. R2's Minimum Data Set (MDS) assessment dated [DATE] Section C (Cognition) documented a BIMs score of 2 (severe cognitive impairment); Section E (Behaviors) documented no behaviors, and section G (Functional Status) coded R2 as extensive assist with 2-person physical assist for bed mobility and transfers, extensive with one-person physical assist for dressing, eating, toilet use, and personal hygiene. R2's medical record documents the following falls since admission into the facility: 11/06/2021: R2 fell in her room; x-ray of right hip and pelvis was negative for fracture. 11/22/2021: R2 sustained a clavicle fracture from a fall in her room. 12/24/2021: R2 had a fall in her room with no injuries. 1/04/2022: R2 had a fall in the dining room with no injuries. 2/24/2022: R2 was observed on the floor in the dining room and was sent to the hospital for bleeding to the forehead; hospital record documented the clinical impression as fall, head injury due to traumatic scalp laceration; R2 returned to the facility on [DATE] with 4 sutures to her forehead. 3/16/2022: R2 sent to the hospital for complaint of left leg pain and facility's l hip x-ray report that was positive for left femoral neck subcapital fracture with overriding displacement; hospital record from 3/16/2022 showed that R2 underwent a surgical procedure of left hip hemiarthroplasty on 3/19/2022; resident did not return to the facility. R2's current fall care plan did not show any revision or update in her fall interventions after these falls. R2's care plan dated 10/13/2021states that resident is unable to make daily decision without cues/supervision related to dementia. The goal is that resident will not injure self-secondary to impaired decision making, interventions include provide cues and supervision for ADLs, redirect resident when potential for injury is evident, determine if decisions made by resident endanger the resident or others, intervene if necessary. 5/4/2022 at 3:22PM, V4 (RN) said that she remembers R2, she was confused and needed a lot of redirections, she was a very high fall risk some of the interventions she had was bed to the lowest position, floor mat and tapers to wheelchair, never had an alarm. V4 said that R2 fell in the evening (most recent fall) after dinner, she was sitting in a wheelchair in her room and was yelling out for help, V4 added that resident sometimes stays in her room by herself to calm her down, she does not recall any new interventions after the fall because resident was moved to another floor. 5/4/2022 at 3:32PM, V5 (LPN) said that R2 came to their floor from the first floor, she was confused, wanted to stand up and ambulate with an unsteady gait. R2 was a fall risk but she cannot remember what was in her care card. V5 said that on 2/24/2022, she responded to the dining room and observed R2 on the floor, she assessed resident and noticed that she was bleeding from her forehead, she called 911, they came immediately, and resident was sent out to the hospital. 5/4/2022 at 3:50PM, V7 (LPN) said that she did not witness the fall on 1/04/2022 but was informed by the Director of Nursing (DON) that R2 fell , she did her vitals and passed it on to the next shift. Resident always try to get up and walk and she sundowns quickly. V7 said that she was not sure if anything changed as far as resident's care plan or interventions after the fall, she was moved to the second floor. 5/9/2022 at 11:38AM, V11 (OTA) stated that she had a session with R2 and the session was sitting in the sink. R2 was complaining that her leg was hurting, and this was the resident's first session after she came back to therapy. V11 said that the session was completed, but maybe not for too long, she reported to the nurse that resident is continuously stating that she does not feel good and that her leg hurts. The nurse was already aware, there was no report of R2 falling that day or since she came back from the hospital. 5/9/2022 at 11:51PM, V12 (OT), said that after the fall, R2 was very weak, and had a decline, she could not follow command and needed cues for everything. V12 added that she had only one session with R2 after the fall, she was restarted on therapy, she was not really participating, but did not complain of any pain during assessment. 5/9/2022 at 12:01PM, V13 (PT) said that she evaluated resident in February after the fall, she came back from the hospital and had shuffling gait, required moderate assist with transfer, did not complain of any pain during walking. V13 said that she only evaluated resident, she never had any therapy session with her. 5/9/2022 at 1:15PM, V15 (Nurse Practitioner) said that the nurse called her and said that resident was having pain at therapy, R2 had a fall in February, went to the hospital and came back with sutures. As far as she can recollect and according to staff, resident did not have another fall, during assessment after R2 was reported having some pain. V15 said that she assessed her (R2) and she would not let her touch her left lower leg, that's when she ordered the X-ray that came back positive for fracture. 5/10/2022 at 1:47PM, V19 (Attending physician/Medical Director) said that R2 has tremors, was confused, tends to fall and was wheelchair bound. V19 was asked if it is possible for R2 to have this fracture to her left hip from the fall that occurred on 2/24/2022 without any signs and symptoms and he said that under normal circumstances he will say no, but based on the resident's history, he really doesn't know. V19 said that this is probably a new fracture, and since the resident is dependent on staff for all her ADL care, someone could have noticed some abnormalities. V19 added that the facility was very short staffed during the pandemic, now that the pandemic is over, he has told them that they need more staff and more supervision for the residents to reduce the number of falls and injuries. A document provided by V1 (Administrator) titled, Falls and Fall Risk Managing (undated), states as its policy statement that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Under policy interpretations and implementation, the policy states in part that if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Under monitoring for subsequent falls and fall risk, the policy also states in part that if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on observations, interviews and records reviewed the facility failed to ensure there were effective fall prevention interventions in place to prevent/reduce the risk of falling for 1 of 5 residents reviewed for fall prevention protocol and procedures. This failure resulted in R1 having multiple falls incidents subsequently falling and sustaining a fracture to the left distal femur. Findings include: Review of R1's face sheet documents a [AGE] year that was admitted to the facility on [DATE] with diagnoses that includes: cerebral ischemia, [CONDITION(S)] and collapse, bilateral primary [CONDITION(S)] of hip, contracture, left hand, encounter for other orthopedic aftercare, unspecified fracture of unspecified femur, minimally displaced zone II fracture of sacrum, and other abnormalities of gait and mobility, and unspecified Altered Mental Status. R1's Brief Interview for Mental Status Score (BIMS) dated 11/22/21 documents a score of 4/15 which indicates severe impairment. R1 MDS Section G dated 11/22/21 documents R1 requires extensive 2 person assist with toileting and transfers. R1's fall risk assessment dated [DATE] documents R1 as a high risk for falls. MDS documents Walking was not attempted and R1 is not able to stabilize self without staff assistance. Record review of R1 events log and root cause analysis of falls since 11/20/20 documents 7 of 9 falls were related to R1 trying to go the restroom: 11/20/20 observed on the floor in bedroom. R1 stated I'm going to the bathroom. Care plan documents intervention added as follows: U/A and C&S with labs r/t frequent c/o need to urinate 1/10/21 resident was going to the restroom. She started walking towards the restroom and fell . Resulting in R1 complaining of coccyx pain. Care plan documents intervention added as follows: floor mats at bedside while resident in bed. 2/26/2021 unwitnessed fall. Resident observed with black eye told staff she fell 2 weeks ago. R1's Fall root cause analysis documents resident was trying to go to the bathroom. Attend/supervise resident during toileting needs every 2hrs/PRN while in bed. 3/9/2021 R1 was found crawling on the floor in her room. 3/18/2021 R1 observed with her knee on the floor kneeling on the chair in her room. R1's Fall root cause analysis documents resident was trying to go the bathroom. Care plan documents intervention added as follows: observe frequently and lace in supervised are when out of bed. 3/28/2021 R1 found crawling to the bathroom. R1 was assisted to the toilet. Brief damp and resident voids moderate amount of yellow urine. 7/19/2021 R1 found with a fracture to her left arm. Resident states she had fallen but not sure when. 11/6/2021 R1 found on the floor laying on right side on the floor near the bathroom. V2 states I was at the facility and she said she was going to the restroom. Care plan documents intervention added as follows: Obtain PHYSICAL THERAPY consult for strength training, toning, positioning, transfer training, gait training, mobility devices, etc. 12/8/2021 R1 found on the floor mat next to bed. As of 1/27/2022 at 10:34 AM there were no new interventions for this fall that occurred on 12/8/2021. V2 stated no R1's care plan had not been updated for the 12/2021 fall. The Root cause analysis dated 12/8/2021 documents R1 needed to use the restroom. Review of facility reported incident dated 11/8 /2021 documents R1 was found near the bathroom where she complained of knee pain and sent to the hospital. Hospital report of xray of left knee and left femur documents the following impression: Acute, oblique fracture through the distal left femoral metaphysis with mild medial displacement/angulation of the distal fracture fragment. On 1/27/2022 at 1:30 PM V2 (DON) V2 states, I'm at a lost with what to do with her (R1). Surveyor asks, if V2 believes Physical therapy/occupational therapy is appropriate intervention to address the cause of someone who keeps trying to get out of bed to urinate. V2 states I guess we can round more frequently on her. Every hour. On 2/4/2022 at 1:55 Pm V2 states when R1 needs assistance she yells out that she needs help and her room is not next to the nurse's station. On 1/27/2022 10:50 AM V4 (LPN) states R1's is fall precaution and 2 person assist with ADL. Cast on leg from fall 2 months ago. R1 call light comes on as just before we enter the room. R1's room observed to be near the end of the hall away from the nurses station. R1 in the room and no staff present. R1 is observed in a wheelchair scooting herself forward. Half of call light tied to the left side of her wheelchair, the other half is hanging from the wall. It appears that R1's pull herself forward which triggered the light to come. On 1/27/2022 at 11:00 AM 2nd floor V3 CNA worked here 11. V3 states R1 tries to get out of the chair all the time. We have to keep an eye on her. They have to stay in their rooms right now. Normally everyone in the dining room and watch them. 2/4/2022 at 1:14 V3 states R1 doesn't like being by herself. V3 states when R1 is alone she tries to go to bathroom by herself. V3 states, when R1 is with staff she will always let us know she has to go to bathroom. We physically take her to the restroom and try to have 2 people to do that. R1 is a fall risk. I have told the nurses in the past that she tries to get out of the chair. I've told the nurse plenty of times. On 2/4/22 at 12:48 PM as surveyor approaches R1's room and as get to room here R1 screaming help. find it to R1 and go in room. Everyone in rooms today. V11 states, she sees R1 trying to get out of chair or trying to maneuver herself to the restroom in her wheelchair. V11 states, Yes, I've seen her [NAME] to lift herself out of chair. When I see that I try to redirect her. I tell her she could hurt herself. I've told the nurse when I've seen her trying to lift out of the chair. V11 lets us know when she needs to be changed. She calls out. She doesn't use call light. Surveyor asks, how can R1 tell you she needs something if she doesn't use her call light. V11 states she always just calls out. V11 states when she hears R1 screaming, she goes to her room and see what she needs. V11 states, since she has worked at the facility R1 calls out. On 2/4/2022 at 12:58 PM V17 (LPN) states R1 is confused, alert to self. At one point, she was a high fall risk, but has not fallen lately. She has fallen trying to go to the rest room. She does not want to urinate in her depends. She prefers physically go to the rest room. When I've seen her up or trying to get up she says I'm going to bathroom. V17 states she has never found her on the floor but has assisted other nurses in assessing her after R1 was found on the floor. V17, states, yes, I have seen her trying to lift herself up out of bed. I help put her back to bed. Sometimes I just catch her up or attempting to get up. I redirect her back to her bed or chair. To prevent her falls we have floor mats, bed low, and call lights but she doesn't use the call light. CNA's are toileting her every 2 hours. Since Covid outbreak we keep residents in their rooms. On 2/4/2022 at 1:55 PM V2 states when R1 needs assistance she yells out that she needs help and her room is not next to the nurse's station. The facility's falls and fall risk managing policy dated August 2008 documents the following: Policy Interpretation and implementation 4. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. 5. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. 6. Staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

Based on interview, and record review, the facility failed to monitor and supervise a high fall risk resident while in the dining room for 1 of 4 residents (R2,) reviewed for falls, and failed to develop a plan to prevent a fall incident for a high risk for falls resident for 1 of 4 residents (R3) reviewed for falls. These failure resulted in R2 being left unmonitored in the dining room and R2 fell from the wheel chair onto the floor, sent to the local hospital and diagnosed with [REDACTED]. Findings Include: R2 is an [AGE] year old with the following Diagnosis: [REDACTED]. R2 admitted to the facility on [DATE]. A note dated 3/9/20 documents R2 observed lying on the floor in a supine position. R2 alert and oriented times 1 which is baseline. Bleeding noted from the back of R2's head. Pressure was applied and bleeding was controlled. Swelling also noted to the back of the head and ice applied. R2 sent to the hospital for further evaluation. The Fall Event dated 3/9/20 documents R2 was sitting in the dining room and had an unwitnessed fall. R2 noted to be calm right before the fall. The Hospital Records dated 3/9/20 documents R2 apparently fell at the nursing home and the outside imaging showed an acute subarachnoid hemorrhage as well as a subdural hygroma with a 2 millimeter midline shift. R2 admitted to the intensive care unit. The Minimum Data Set ((MDS) dated [DATE] does not document any Brief Interview Mental Status (BIMS) score. Section G of the 3/9/2020 MDS documents R2 is an extensive assist for all activities of daily living. The Incident Report dated 3/13/20 documents R2 was sitting at the dining room table with others waiting for the activity to start. V8 was present in the room at the time of the fall. V8 was setting up for the activity and had V8's back turned for a moment and suddenly heard a noise. V8 turned toward the noise and saw R2 lying on the floor in front of the wheelchair. Staff and the Nurse Practitioner provided first aid. R2 sent to the hospital and admitted with a laceration to the back of the head and subarachnoid hemorrhage. R2 returned to the facility on hospice per R2's family request. On 10/28/20 at 118AM , V7 (Nurse) stated, I dropped R2 off in the dining room for R2's morning activity. I believe there was 2 activity aides in there and 2 CNAs. I wasn't in there so I didn't see what happened but I heard a noise and someone call for the nurse, so myself and the nurse practitioner went in the dining room and R2 was on the ground. I think what they told me was they were going to help another resident and had their backs turned for a second and R2 stood up and fell . R2 was pushed up against the end of the table and if looked like R2 tried to get up and walk away but tripped over the wheelchair. We assessed R2 and R2 was bleeding from the back of R2's head. R2 wasn't having any aggressive behaviors that day. We were trying to having people watch R2 more because R2 was unsteady and was aggressive toward staff. Yes, R2 was a high fall risk from the beginning. R2 was high fall risk because R2 was unsteady and R2's behaviors. R2 was very impulsive. On 10/28/20 at 1:29PM, V8 (Activity Aide) stated, I was setting up my activity and the nurses and CNAs were bringing in people who were going to participate. There was maybe like 7 residents in there total. I was in there by myself. The CNAs will usually drop the residents off and go do their work or chart. They will tell me who is high fall risk and I just try to keep them engaged. If I can't handle someone, I call for the nurse or a CNA to come help me. I was setting up the tables for a game called table ball. I was pushing the tables together and I had my back turned to R2. It was turned for maybe 2-3 minutes while I was setting up. I can't remember what the CNAs told me about R2 when he was dropped off. On 10/28/20 at 2:06PM, V9 (Fall Coordinator) stated, For dementia residents, we try to manage their behaviors more. It can vary from day to day depending on what behavior they are having. It's really up to the nurse what to do but we walk with them in the hall to tire them out some, we sit with them at the nurse's station, and we try to keep them in activities. We just cluster them in supervised areas during the day. There is usually 1-2 activity aides in the dining room and 1 CNA. They should be constantly moving from resident to resident checking on them. Residents shouldn't be in the room during set up because the activity person can't really watch them and set up. They can't be left unsupervised if the aide leaves the room to get things for the activity. I know for that fall, V8 turned V8's back for a second and R2 got up and fell . On 10/29/20 at 12:36PM, V11 (Medical Director) stated, All the residents are on the second floor to be monitored better. The second floor are residents are confused and usually do have the ability to walk all over without some kind of help. Residents with behaviors and that are high fall risks are brought out into areas where they can be monitored better by all the staff. I know they keep them at the nurse's station and then they do activities in the dining room with them too. If they are in the dining room doing activities, then they should be monitored appropriately. The Care Plan dated 3/4/20 documents R2 has a [DIAGNOSES REDACTED]. R2 is unable to make daily decisions without cues/supervision. R2 is at risk for falling related to [MEDICAL CONDITION], dementia, history of falls, hypertension, anxiety, dysphagia, weakness, and high cholesterol. Interventions in place include: provide environment free of clutter and observe frequently and place in supervised areas when out of bed. R3 is a [AGE] year old with the following Diagnosis: [REDACTED]. R3 admitted to the facility on [DATE]. A note dated 3/6/2020 documents R3 admitted to the facility and is a limited to extensive assist with most ADLs. The Minimum Data Set ((MDS) dated [DATE] documents R3's Brief Interview for Mental Status Score (BIMS) as 2 (severely cognitively impaired). Section G of the MDS dated [DATE] documents R3 needs limited to extensive assist with walking and transfers. R3 needs a 2 person assist for walking and transfers. The Fall Risk Observation Sheet dated 3/18/20 documents R3 is a high fall risk. A note dated 3/21/20 documents the CNA found R3 with lower extremities hanging out of the bed. R3 educated that hanging legs out of the bed can lead to falls. R3 expressed understanding. The Fall Event dated 3/29/20 documents R3 found on the ground around 1:20PM. R3 calm and confused. R3 noted with laceration to the nose. Pain assessed and R3 denied pain at this time. R3 put back in bed. A note dated 3/29/20 documents R3 found on the floor by the bathroom. R3 reported being ok and put back to bed. R3 with a cut to the nose. The nurse notified the nurse practitioner and orders received. STAT labs drawn at around 4:30PM. At 8:30PM, a critical lab result was reported to the facility and R3 was sent out to the hospital for evaluation. R3 left the facility around 9:20PM. The Laboratory report dated 3/29/20 documents the specimen was collected at 4:20PM and the results were reported to the facility at 8:08PM. The Hospital Records dated 3/29/20 documents R3 arrived to the emergency department at 9:42PM. R3 presented to the emergency department for a ground level fall and abnormal labs. R3 does not remember the fall. R3 reported pain around the nose area but has no other complaints. A laceration over the bridge of the nose and bruising around the left eye noted. The CT scan of the facial bones showed nasal fractures. R3 admitted to the intensive care unit. The Incident Report dated 4/2/20 documents R3 fell while walking to the bathroom and was found down during rounds. STAT orders for x-ray and labs received by the nurse practitioner. R3 sent to the hospital for abnormal lab values. Record review revealed bilateral nose fractures. On 10/28/20 at 2:06PM, V9 (Fall Coordinator) stated, Everyone on the second floor is a high fall risk. R3 was specifically a fall risk because of dementia, weakness, and altered mental status. R3 should not have been ambulating alone. We go verbal reminders to make sure R3 was calling before getting up for help. R3 should not have been getting up alone. For resident like R3 I would say they probably would be doing more frequent checks on R3. No it's not in R3's care plan. I don't know why R3's room was moved. It may have been the only room available. On 10/28/20 at 2:48PM, V10 (Nurse) stated, R3 was found on the floor by the bathroom. The CNA found R3. She came to get me and I went to assess R3. I called the NP and an x-ray and labs were ordered. R3 did have a little cut that was bleeding on R3's nose. It didn't looked deformed. R3 could tell you R3's needs but R3 was confused. R3 knew his name, R3 could tell you if R3 needed to use the bathroom or something like that but R3 didn't really know what was happening. R3 was a high fall risk. R3 was very unsteady when R3 walked. R3 always was trying to get out of bed. R3 would have his legs out and we would have to tell R3 to get back in bed. We got around in a wheelchair all the time. R3 never really walked. They normally would be in the hallway or at the nurse's station with us but they had to stay in their rooms then because of COVID. We do rounding on them every hour. No, it was still every hour during COVID. Some residents were every 30 minutes. I don't remember if R3 was every 30 minutes. On 10/29/20 at 12:36PM, V11 (Medical Director) stated, Residents were all supposed to be in their rooms but you had some residents that didn't understand so they were having behaviors. They were getting up before anyone could get to them. Everyone was more focused on COVID and managing that during that time period. R3 made a room change on 3/23/20 from room [ROOM NUMBER] (a room directly across from the nurse's station) to room [ROOM NUMBER] (a room that is second to last room down the hall). Room change much further away from the nurse's station than the previous room. The Care Plan dated 3/9/20 documents R3 is at risk for falls due to dementia, weakness, hypertension, [MEDICAL CONDITION], anxiety, and altered mental status. Interventions include: give verbal reminders not to ambulate/transfer without assistance, keep call light in reach, provide an environment free of clutter, and encourage resident to stand slowly. The Policy titled, Fall and Fall Risk, Managing, dated 08/2008 documents, Staff will identify and implement relevant interventions (e.g., hip padding or treatment of [REDACTED].

Based on observation, interview and record review, the facility failed to follow their policy and perform safe mechanical lift or two person transfers for 3 of 4 residents (R1,R2,R3) reviewed for falls. This failure resulted in R1 slipping during the transfer and sustaining a fractured left arm. Findings include: On 10/28/14 at 3pm, E3(Nurse) stated R2 will be transfered back to bed by mechanical lift, but the transfer is done with 2 people. At 3:05pm, R2 sat in the wheelchair at the side of the bed. E4(Nurse Aide) and E5(Nurse Aide) placed the sling for the lift on the left side of R2 and pulled it back behind and under R2. To position the sling, E4 and E5 had to lift R2's upper body forward, then lift R2's legs and pelvis up off the wheelchair seat. E4 and E5 attached the sling to the lift and as E4 operated the machine, E5 guided R2 in the sling. Once R2 was up in the air and without the support of the wheelchair, R2 tilted to the left side and the sling was not under the right side of his body. As E4 and E5 continued the lift and were moving R2 away from the wheelchair, they were prompted by the surveyor to stop the transfer. R4 and R5 stopped the transfer and verified that the sling was not placed properly around R2. R4 and R5 continued to adjust and reposition the sling under R2 for 6 more minutes before reattaching the sling to the lift and proceeding with the transfer. Facility Incident Report Form 8/1/14 11pm Description of Occurrence R1 verbalized left shoulder pain, physician notified and received an order for [REDACTED]. Statement of Events 8/5/14 E6(Nurse) cared for R1 on 8/1/14 6am-2pm shift. R6 was told by E8(Social Service) that R1 had left shoulder pain, rating 5 out of 10 on the pain scale, and E8 reported to E6 and the oncoming nurse (2pm-10pm shift) that R1 reported almost falling in the bathroom while being transfered with the standing lift. Statement of Events 8/5/14 E7(Nurse Aide) cared for R1 on 8/1/14 6am-2pm shift. E7 transfered R1 alone using the standing lift. R1 complained of pain to the left arm during the transfer, R1 did not fall. Typed interview 8/5/14 with E8 documents that on 8/1/14, R1 told E8 that her left shoulder hurt and that R1 almost fell during a transfer. E8 reported it to the nurse in charge. Progress Note 8/6/14 documents E1(Administrator) spoke with Z2 about the evnet on 8/1/14. E1 told Z2 that R1 almost fell during the transfer, and E8 reported this to the nurses. On 10/29/14 at 11:25am, E6 stated E8 came to the nurse's station on 8/1/14 and said that R1 told her that she almost fell in the bathroom when being transferred and complained of pain in the left shoulder. E6 stated she was leaving for the day, and expected E8 to follow up with the doctor. If a resident said that they almost fell and now had pain, E6 would have called the doctor. On 10/29/14 at 11:45am, E8 stated that on 8/1/14, R1 told her that she nearly fell during a transfer and now had pain in the left shoulder. E8 told 2 nurses at the change of shift. On 10/29/14 at 12:20pm, E7(Nurse Aide) stated that on 8/1/14 approximately 11am, during a standing lift transfer, R1 told her she felt like she was slipping. E7 stated she did not tell the nurse. E7 stated she performed R1's transfer by herself when it should have been done with 2 people. On 10/29/14 at 1:30pm, Z1(Physician) stated that R1 fractured the left arm during the transfer and Z1 did not receive a call from the nurse until later that night on 8/1/14. Z1 stated an x-ray would have been ordered sooner if he knew about the change in pain in R1's left arm and the near fall during the transfer. During the fall on 8/18/14, R3 was transfered by one staff member. R3 was changed to a 2 person transfer with a gait belt after the fall on 8/18/14 because R3 refused the mechanical lift for transfers. Event on 8/21/14, R3 was transfered by one person. Restorative Nursing Assessment 7/30/14, R3's transfer status is a two person transfer. Care Card (undated) documents R3 as a two person transfer with a gait belt. On 11/19/14 at 1:20pm, E12(Restorative Nurse) stated R3 refused the mechanical left for transfers, so she was assessed as a 2 person transfer with a gait belt as on the care card. Fall Care Plan is not updated after the fall on 8/18/14. Using a Protable Lifting Machine policy - The protable lift should be used by two staff member. Place the sling along the back of the resident. Be sure the top of the sling is at the head of the resident and the bottom at the resident's knees. Investigating and Reporting Accidents/Incidents/Events policy - Regardless of how minor an accident or incident may be, including injuries of an unknown source, it must be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. The Nurse Supervisor/Charge Nurse must be immediately informed of accidents or incidents so that medical attention can be provided.

Based on interview and record review, the facility failed to assess a new onset of pain for 1 of 4 residents (R1) reviewed for pain. This failure resulted in R1 having pain in the left arm, rating it 10 out of 10 on the pain scale, after a known near fall with new complaints of left arm pain 11 hours earlier. Findings include: On 10/28/14 at 9:45am, Z2(Family) stated they were not notified that R1 almost fell during a transfer and started having pain in the left arm until late at night on 8/1/14. Facility Incident Report Form 8/1/14 11pm Description of Occurrence R1 verbalized left shoulder pain, physician notified and received an order for [REDACTED]. Statement of Events 8/5/14 E6(Nurse) cared for R1 on 8/1/14 6am-2pm shift. E6 was told by E8(Social Service) that R1 had left shoulder pain, rating 5 out of 10 on the pain scale, and E8 reported to E6 and the oncoming nurse (2pm-10pm shift) that R1 reported almost falling in the bathroom while being transfered with the standing lift. Statement of Events 8/5/14 E7(Nurse Aide) cared for R1 on 8/1/14 6am-2pm shift. E7 transfered R1 alone using the standing lift. R1 complained of pain to the left arm during the transfer, R1 did not fall. E7 did not report the complaint of pain to a nurse because R1 was already getting pain medicine for a headache. Typed interview 8/5/14 with E8(Social Service) documents that on 8/1/14, R1 told E8 that her left shoulder hurt and that R1 almost fell during a transfer. E8 reported it to the nurse in charge. Progress Note 8/6/14 documents E1(Administrator) spoke with Z2 about the event on 8/1/14. E1 told Z2 that R1 complained of left shoulder pain after a transfer with the standing lift. E1 told Z2 that R1 almost fell during the transfer, and E8 reported this to the nurses. Statement of Events from staff caring for R1 the 2 days before the transfer on 8/1/14, 7/30/14 and 7/31/14, all document R1 did not complain of any pain in the left shoulder. E2(Director of Nursing) Investigation Summary 8/6/14 documents R1 verbalized left shoulder pain, physician was notified, an order was received for an x-ray, and x-ray results revealed a left humerus fracture. R1 began to complain of increased left shoulder pain on 8/1/14. Accoring to E7, R1 complained of pain to the left shoulder during a transfer. Nurse Notes 7/29/14 through 7/31/14 document R1 was not medicated for left arm or shoulder pain. Nurse Note 8/1/14 9:49pm documents R1 complained of pain in the left arm rating 10 out of 10 on the pain scale. Pain Scale on the Medication Administration Record [REDACTED]". The physician was notified and an x-ray of the left shoulder was ordered. July 2014 Medication Administration Record [REDACTED]. Admission Pain Observation 4/25/14 documents R1 has a history of left shoulder pain due to a dislocation. There are no other Pain Observations upon the new left arm pain after the transfer on 8/1/14 or at 9:49pm at the time of severe pain. Controlled Substance Proof of Use April - July 2014 document R1 was last medicated with [MEDICATION NAME] (pain medication) on 7/26/14, 5 days before the transfer on 8/1/14. On 10/29/14 at 11:25am, E6 stated E8 came to the nurse's station on 8/1/14 and said that R1 told her that she almost fell in the bathroom when being transferred and complained of pain in the left shoulder. E6 stated she was leaving for the day, but medicated R1 with Tylenol and expected E8 to follow up with the doctor. If a resident said that they almost fell and now had pain, E6 would have called the doctor. E6 stated R1 did not complain of pain in the left shoulder prior to 8/1/14. On 10/29/14 at 11:45am, E8 stated that on 8/1/14, R1 told her that she nearly fell during a transfer and now had pain in the left shoulder. E8 told 2 nurses at the change of shift. On 10/29/14 at 12:20pm, E7(Nurse Aide) stated that on 8/1/14 approximately 11am, during a standing lift transfer, R1 told her she felt like she was slipping. E7 stated she did not tell the nurse about R1's pain because R1 was already being medicated. On 10/29/14 at 1:30pm, Z1(Physician) stated that R1 fractured the left arm during the transfer and Z1 did not receive a call from the nurse until later that night on 8/1/14. Z1 stated an x-ray would have been ordered sooner if he knew about the change in pain in R1's left arm and the near fall during the transfer. Pain Clinical Portocol - Identify individuals who have pain or are at risk for having pain. Such assessments should occur on admission to the facility, at each quarterly review, whenever there is a significant change in condition and at any time pain is suspected. Resident's physician and family/responsible party should be notified of significant changes pertaining to resident's pain level.

Based on interview and record review, the facility failed to implement safety measures to prevent 1 of 3 residents (R1) reviewed for elopement risk, from leaving the facility without supervision from a total sample of 24. The facility also failed to implement fall precautions, provide adequate supervision, and devices to prevent falls and accidents for 3 of 11 residents (R10, R8, and R13) reviewed for falls from a sample of 24. This failure resulted in R1 eloping from the facility and sustaining a fracture while out of the facility. Findings include: 1) R1's [DIAGNOSES REDACTED]. R1 transferred from another long term care facility. On 4/19/13, at 3:00 PM, admission records show that E4, Nurse, assessed R1 to be alert and oriented to person and place and independent with ADL's (Activities of Daily Living). The Elopement Risk assessment did not identify R1 at risk for elopement at that time. E5, Nurse noted on the following day, 4/20/13 that R1 had a resident alarm device to the right wrist. On 5/02/13 at 10:43 PM, E2, Director of Nursing (DON) stated that the resident alarm device was placed by another facility. On 5/02/13 at 10:10 AM, E5, Nurse stated that R1 was redirected several times, by the second day, because of wandering into other resident's rooms. On 5/01/13 at 2:53 PM, E6, Nurse said that, between 6:00 and 6:30 PM on 4/23/13, R 1 walked out of the dining room towards the elevator and attempted to enter it. E6 said he was able to verbally redirect R1 from entering the elevator. E6 stated that he intercepted R1 from leaving by the elevator multiple times that evening. On 5/01/13 at 2:35 PM, E7, Certified Nurse Assistant, (CNA ) stated that R1 tried to exit the elevator on the first floor at about 7:30 PM on 4/23/13 but was escorted back to the third floor. E7 stated that about an hour later, the intercom made an announcement about R1's elopement. On 5/03/13 at 10:50 AM, E8, Nurse stated that she was R1's nurse on 4/23/13 at the time of the elopement. E8 stated that R1 was very restless on 4/23/13, around 8:15 PM and was medicated with Ativan. Review of the Medication Administration Record ( MAR ) for that date and time is not signed off for Ativan while the other 8 PM medications, Aricept and Desyrel, have been signed off. E8 stated that R1 was so restless that she would not stay in her room. E8 said that at 8:45 PM, E10, CNA was assigned to monitor R1. E8 said that E10, CNA sat at the nurse's desk facing R1. E8 said that at 8:50 PM, she noticed that R1 was no longer sitting across from the nurse's station and the emergency code was activated for elopement. E8 said that after all able staff searched the building and grounds, R1 was not located. A missing person report was filed with the police. The police report shows that R1 was reported missing at 9:21 PM and was found sitting in a driveway of a home .82 miles away at 10:40 PM. The Weather Underground History Report (www.wunderground.com) showed that the weather in that area on 4/23/13 was rainy with a mean temperature of 49 degrees Fahrenheit and wind gusts up to 26 miles per hour. According to the emergency room report, E1 arrived at 11:02 PM accompanied by emergency ambulance service. Upon arrival, R1 was confused, skin cold to touch, clothes completely saturated with mud and water due to rain and wore an incontinence brief which was wet and covered in mud. R1 had abrasions to both knees. R1 was diagnosed to have a fractured left fibula (the smaller of the two bones of the lower leg). On 5/01/13 at 9:55 AM, E2, DON stated that R1 left the building via the first floor main entrance door between 8:45 PM and 9:10 PM. E2 stated that the door alarm was programmed to engage at 9:00 PM every night. On 5/03/13 at 3:00 PM, E11, Receptionist, stated that she left the facility at 8:00 PM on 4/23/13; the time sheet stated 8:02 PM. On 5/3/13 at 3:00 PM, E1, Administrator did not show that the front entrance of the building was monitored between 8:02 PM and 9:00 PM on 4/23/13, including the time R1 was thought to leave the building. On 5/03/13 at 3:10 PM, E12, Maintenance Director stated that the alarm is now scheduled to trigger at 8:00 PM, when the receptionist leaves. 2) R8's face sheet shows a resident admitted to the facility on [DATE]. R8 is hard of hearing and legally blind. [DIAGNOSES REDACTED]. R8 is described as confused, physically aggressive and at times combative. Nursing progress notes date 4/16/13 states R8 was observed on the floor. Notes dated 4/24/13 states R8 slid from her wheelchair on 4/19/13 with new intervention for use of a thin, rubberized pad to be applied to the wheelchair cushion. Additional interventions include bed and chair alarms and low bed with mats while in bed. On 5/8/13 R8 was observed in her wheel chair in her room with no rubberized pad on the wheelchair. Again on 5/9/13 at approximately 11:40am, R8 was in bed, asleep with bed not in lowest position and floor mats not in place. 3) The facility's event report documents on 3/24/2013 at 6:00 PM, R10's wheelchair alarm sounded causing R10 to turn around in his wheelchair to shut off alarm. R10 fell out of the wheelchair. R10's wheelchair contained a wheelchair alarm and a thin non-slick rubberized pad under and above the wheelchair seat cushion to prevent falls. Event report documents on 4/19/2013 around 5 PM, R10 became violent and hit three staff members. R10 was given an injection for agitation per as needed order. R10 fell out of wheelchair attempting to transfer self to bed at 6:17 PM on 4/19/2013. R10 received an abrasion to his forehead. Event report documents on 4/24/2013 at 9:47 PM, R10 slid out of wheelchair with no apparent injury. R10 wheelchair contained a wheelchair alarm and thin non-slick rubberized pad above and below seat cushion. In addition, R10 was provided with mats to floor and a bed alarm. Another event report on 5/1/2013 at 6:45 PM, R10 fell to the floor attempting to transfer to bed. R10 had bruising to back of his head. On 5/9/2013 at 6:50 am R10 fell transferring self to the toilet. On both 5/1 and 5/9 of 2013, R10 had thin non-slick rubberized pad above and below cushion and wheelchair alarm. Wheelchair alarm and thin non-slick rubberized pad initiated months prior to above incidents. Facility fall review on 5/9/2013 shows order for laboratory workups and review of medications. Prior to 5/9/2013 no previous orders for fall prevention interventions were noted. On 5/9/2013 at 2:15 PM, E2, DON and E3, Corporate Nurse stated "R10 falls discussed and interventions reviewed." E2 states "Morning after a fall, the care plans are updated and interventions for falls reviewed, fall risk assessment done, and restorative nurses discuss interventions." Physical Therapy screen indicates no need for evaluation or treatment, does not qualify. No further interventions noted to prevent injuries from falls. 4) On 5/7/13 at 1:15 PM in R13's room, E16, CNA attempted to transfer R13 out of the wheel-chair and into the bed. E16 failed to cue R13 as to where to place her hands and to push off using her hands. E16 grabbed the back of R13's pants and adult brief with her right hand and pulled up as E16's other arm was under R13's left armpit. E16 did not use a gait belt. R13 was weak and bent over and unable to stand so E16 placed R13 back into the wheel-chair and stated she needs help. E16 and E17, CNAs are back in the room with one on each side of R13. Neither use a gait belt. E16 and E17 each grab the back-side of R13's pants and adult brief and place their other hand under R13's armpit and pull R13 upward out of the wheel-chair. R13 is dead weight and weak. Neither E16 nor E17 gave cues for R13 as to where to place her feet and hands. As they pull R13 out of the wheel-chair, R13's feet are barely touching the floor and her hands are not holding on to anything. The facility's current policy labeled Lifting/Transfers documents under item #5, "when appropriate, the resident should assist with transfer" and under item #8, "explain the procedure to the resident before beginning". The policy documents for a 2 person assist transfer to : "Place a gait belt snugly around the resident's waist but loose enough to put two fingers between the belt and the resident. Position one person on each side of the resident. Using one person's arm closets to the resident, securely grasp the gait belt. Your arm will be between the resident's arm and body. Cue the resident, to scoot to the edge of the (surface), lean forward and assist by pushing from the (surface). Reach behind the resident with the opposite arm holding onto the belt at the resident's back. Count to three and lift together."