Every finding on record at Prairieview Lutheran Home

Based on Observation, Interview and Record Review the facility failed to properly install foot pedals (R58), identify oxygen tubing and call light cord as trip hazards resulting in a fall (R1) and properly transfer R1 following a fall. These failures affect two of six residents (R1, R58) reviewed for accidents in the sample list of 29. These failures resulted in R58's left leg fracture and R1's right hip and right arm fracture. Findings include: The facility's Fall and Fall Risk Management policy documents that staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. This policy also documents fall risk factors, including environmental factors that contribute to the risk of falls, such as improperly fitted or maintained wheelchairs and unsafe or absent footwear. 1.) On 9/5/2025, R58's nursing progress notes state: While (V25, R58's Power of Attorney) was pushing resident (R58) in wheelchair outside during fall [NAME], when resident (R58) went from cement lot to grass, R58's foot caught on ground and (V25) was unaware and continued to push wheelchair per resident. Resident (R58) denies any pain or discomfort while sitting still. (R58) states discomfort with movement. Local 2–3+ edema noted below knee. Dr. (Doctor) notified and POA (Power of Attorney) made aware. Orders received to send resident to hospital. Management made aware. On 9/29/25 at 11:05 AM, R58 was in the dining room in R58's wheelchair with foot pedals on. R58 stated that she was outside at the fall festival when V25 was pushing her wheelchair without foot pedals, and V25 pushed R58 from the pavement to the grass because there were a lot of people. R58 stated the wheelchair got stuck in the grass and her leg was caught under the wheelchair. R58 stated that no staff were outside to help. R58 was brought inside and sent to the emergency room and returned with a diagnosis of left tibial fracture in two places and small joint effusion. R58's Left Knee X-ray dated 9/5/25 documents frontal view suggesting an impaction fracture of the medial tibial plateau, and the lateral view indicates a comminuted proximal tibial fracture (shinbone near the knee). Further imaging such as computed tomography (CT) was recommended. R58's Left Knee CT dated 9/5/25 documents evaluation due to left knee pain and swelling following fall from wheelchair. CT indicated fracture of the posterior tibial plateau involving medial and lateral aspects extending anteriorly into tibial metadiaphysis. On 9/30/2025 at 1:45 PM, V15, Certified Nursing Assistant, stated R58 did not have foot pedals on when her husband took her out to the fall festival, and that R58 is supposed to have foot pedals on. On 12/2/25 at 11:00 AM, V2, Director of Nursing, stated R58 should have had foot pedals on appropriately, and if someone saw them incorrectly used, they should have stopped and helped/educated V25. On 12/2/2025 at 1:37 PM, V19 (Nurse Practitioner) stated R58's foot pedals should be on appropriately. V19 stated that when R58's POA was pushing R58 in her wheelchair, R58's foot being caught contributed to R58's fracture. V19 stated facility staff should have helped V25 when observing R58 being pushed with the foot pedals incorrectly placed. On 9/30/2025 at 2:15 PM, video footage of R58's incident on 9/5/2025 was viewed with V1, Administrator. The video showed R58's wheelchair foot pedals were on but were off to the side of the wheelchair, with R58's legs out in front of her. V25 attempted to place the foot pedals in proper position but was unable to and left them on the side of the wheelchair while pushing R58 outside to the fall festival. Staff walked past R58 and V25 and did not offer assistance or adjust R58's foot pedals prior to V25 taking R58 outside. V1 confirmed staff should have provided education or assistance with R58's foot pedals. 2.) On 9/29/2025 at 11:04 AM, R1 stated she thought she fell in the facility around July when she got up to go to the bathroom around 2:00 AM. R1 stated she took herself to the bathroom and did not call for staff until after she fell, and the fall caused a broken arm and hip that required surgery. R1 was unable to recall additional information regarding the fall. R1 was sitting in a recliner in her room, which was next to the bathroom wall. R1 was wearing oxygen via nasal cannula. R1's admission Minimum Data Set, dated [DATE] documents R1 as cognitively intact and requiring supervision/touch to partial/moderate assistance from staff with transfers, and supervision/touch assistance with walking. This assessment documents R1 had not had any falls since admission on [DATE]. R1's Care Plan revised 9/11/25 documents R1 has memory impairment and is forgetful; R1 is at risk for falls related to deconditioning, gait/balance problems, history of falls, and psychotropic medications. R1's Nursing Note dated 8/13/2025 at 3:41 AM documents that Certified Nursing Assistants (CNAs) were rounding and heard R1 calling for help. R1 was found lying on the floor with her head toward the foot of the bed, on her back with her feet straight out. R1 had a skin tear to the right upper forearm, left wrist, and above the right eyebrow, and had a contusion to the right upper forehead. R1 complained of right hip and right elbow pain. R1 reported she was trying to go to the bathroom and tripped on her oxygen tubing. R1 left by ambulance at 3:35 AM. The Investigation Report for Falls dated 8/13/25 documents R1 reported she was trying to go to the bathroom and environmental safety issues listed include cords—oxygen and call light. R1's fall investigation file, provided by V2, Director of Nursing (DON), included interview statements dated 8/13/25 with V10 CNA and V12 Licensed Practical Nurse (LPN). These statements describe R1's fall as documented in the 8/13/25 nursing note. R1's Hospital admission and Physical dated 8/13/25 at 4:18 AM documents evaluation for fall. R1 reported she attempted to get out of bed on her own, tripped on her oxygen tubing, and fell, hitting the right side of her head. R1 was found to have a right nondisplaced femoral neck fracture and a nondisplaced distal right humeral fracture, and Orthopedic Surgery was consulted. R1's Orthopedic Surgery Operative Report dated 8/13/25 at 2:03 PM documents a partial right hip replacement and application of a right long-arm cast. R1's Physician Progress Note dated 8/19/25 at 9:34 AM, recorded by V19, Nurse Practitioner, documents R1 recently admitted for long-term care and fell on 8/13, resulting in right humeral fracture and right hip fracture, post-surgical repair. R1 now requires two staff for transfers and reports that transfers are not going well, but is working with therapy on strength and tolerance. On 9/30/25 at 4:58 PM, V10 CNA stated V10 found R1 on the floor early on 8/13/25, tangled in oxygen tubing. V10 stated R1 liked to sleep in the recliner, and the call-light cord and oxygen tubing had to stretch across the room, and possibly R1 tripped over one of these, causing the fall. V10 stated R1 complained of right hip pain while on the floor, and V10 was surprised how the nurses transferred R1 into bed. V10 stated they scooped under R1's shoulders and legs, which caused R1 to scream out in pain. V10 stated a full mechanical lift should have been used or R1 should have remained on the floor until emergency services arrived. V10 stated if R1's room setup had been changed prior to the fall, it could have prevented the cords from being a trip hazard. V10 stated R1's room was changed after the fall, placing the recliner near the wall with the call-light box. On 12/1/25 at 9:29 AM, V11 LPN described R1's fall according to the 8/13/25 nursing note. V11 stated it was not in R1's best interest to have cords draped across the floor. R1 had to go over the oxygen tubing and call-light cord to get to where she was found between the foot of the bed and the recliner. R1 was found lying on her back toward her right side, and V11 questioned whether R1 had fractures based on her position and her complaints of right arm and hip pain. On 12/1/25 at 2:30 PM, V18 LPN stated R1 reported she went to stand and tripped over her oxygen tubing. V18 stated the oxygen tubing was across the floor from the bathroom to R1's recliner. V18 stated R1 was transferred off the floor with three people—one lifting R1's shoulders, one her legs, and one her waist/bottom. V18 stated a full mechanical lift was not used because R1 was lightweight and did not have complaints of pain or signs of impaired range of motion, external rotation, or leg shortening. V18 confirmed R1 did not bear weight during this transfer. V18 agreed that oxygen tubing caused the fall and stated R1's room was rearranged afterward. On 12/1/25 at 1:50 PM, V2 DON stated V2 investigated R1's 8/13/25 fall and the root cause was R1 tripping over her oxygen tubing. A new intervention was rearrangement of R1's room. On 12/2/25 at 10:31 AM, V2 stated that after a fall, a resident should be transferred off the floor either by using a full mechanical lift or by using a gait belt with two-staff assist if the resident can bear weight. On 12/1/25 at 2:42 PM, V19 Nurse Practitioner stated R1's fall caused R1's right hip and humerus fractures. V19 stated staff should have used a full mechanical lift or left R1 on the floor until emergency services arrived. V19 stated it would not be appropriate to arm-and-leg lift R1 from the floor into bed.

Based on interview and record review the facility failed to report low blood glucose levels to the physician for one of one resident (R49) reviewed for physician notification in the sample list of 29. Findings include: The facility's undated Change in a Resident's Condition or Status Policy documents the nurse is responsible for notifying the physician of changes in a resident's condition, including adverse reactions to medications, a need to significantly alter treatment, and when there are specific instructions to notify the physician. This policy documents to record information related to the change in the condition in the resident's medical record. R49's Order Summary Report dated 9/30/25 documents R49 has Type 1 Diabetes Mellitus and an order dated 2/17/25 to notify V24 (R49's Endocrinologist) for blood sugars less than 70 or more than 250. R49's September 2025 Medication Administration Record documents Humalog (short acting insulin) 100 units per milliliter (u/ml) give 4 units before meals if blood sugar is over 90 or 3 units when less than 90, Humalog 1-10 units before meals per blood sugar based sliding scale and Lantus (long acting insulin) 100 u/ml increased from 12 units daily to 15 units daily on 9/16/25. This record documents R49's 6:00 AM blood sugar was 63 on 9/22/25, 59 on 9/27/25 and 57 on 9/28/25. There is no documentation in R49's medical record that V24 was notified of R49's low blood sugar levels that began on 9/22/25. On 9/30/2025 at 4:30 PM V2 Director of Nursing stated if it is after hours, V24 doesn't really help us so we often fax R49's blood sugar results to V24. V2 stated the nurses should document physician notification in the nursing notes, but V2 will also check to see if there was an electronic facsimile. On 12/01/2025 at 12:11 PM V2 stated there was no documentation that R49's low blood sugars were reported to the physician.

Based on observation, interview and record review the facility failed to provide a homelike environment by failing to repair a damaged wall for one of one resident (R2) reviewed for homelike environment in the sample list of 29. Findings include: On 9/29/2025 at 11:01 AM the wall behind R2's bed had several long linear gouges near each side of the head board. On 9/30/25 at 3:30 PM R2 was lying in bed. There were gouges on the wall behind the head of R2's bed. R2 stated the wall has been like that for months and the bed causes this damage when the staff lower/raise the bed. On 12/01/2025 at 8:45 AM the gouges were still on the wall behind R2's bed. On 12/01/2025 at 8:47 AM V15 Certified Nursing Assistant (CNA) stated the damage to R2's wall is from the head of the bed and V15 was unsure how long it had been like that. V15 stated maintenance usually repairs the wall, but V15 was unsure if or when it was last repaired. On 12/01/2025 at 10:33 AM V16 CNA stated V16 was unsure how long R2's wall has been like that and staff are suppose to let maintenance know or fill out a work order request. V16 was unsure if anything had been done to address R2's wall. V16 confirmed the damaged wall would not be considered very homelike. On 12/01/2025 at 10:39 AM V17 Maintenance Supervisor entered R2's room. V17 stated maintenance was not aware of the condition of R2's wall until staff reported it this morning. V17 stated staff should report things like this. V17 stated the damage was caused from the brackets on the back of R2's bed, which is a hospice bed, and the facility owned beds have something on the back that prevents the bed from touching the wall. V17 stated this is bad and it will need to be patched and painted.

Based on interview and record review the facility failed to report an injury of unknown origin for one resident (R51) of one resident reviewed for abuse in a sample list of 29Findings Include:R51's Care Plan revised 9/23/25 lists the following diagnoses: Dementia, Psychotic Disturbance, Mood Disturbance, and Anxiety. This Care Plan also documents (R51) is on anticoagulant therapy (Eliquis) Related to Atrial Fibrillation and history of Deep Venous Thrombus.R51's Minimum Data Set (MDS) dated [DATE] documents R51 is severely cognitively impaired.R1's progress note dated 9/13/25 at 12:43PM documents large bruise was noticed to Rt. arm and hand of (R1). Bruise approximately 20cm x 7cm to Rt. antecubital area, and 18cm x 8cm to Rt. distal anterior area of arm and hand. Wound care nurse notified. Waiting for orders. On 9/30/25 at 2:30PM V1, Administrator verified the injury of unknown source discovered 9/13/25 had not been reported to the state agency. The facility's Abuse, Neglect, Exploitation, Misappropriation Program updated April 2021 documents: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. 9. Investigate and report any allegations within timeframes required by federal requirements.

Based on observation, interview and record review the facility failed to provide a physician ordered nutritional supplement for one of four residents (R1) reviewed for nutrition in the sample list of 29. Findings include: On 9/29/2025 at 11:12 AM R1 stated R1 has lost weight since admitting to the facility and her most recent weight was around 80 pounds (lb). There was a bottle of (nutritional supplement) on R1's overbed table. R1 stated R1 is suppose to get one bottle three times per day, but R1 is lucky to get one. R1 was thin, with bony prominences visible. On 9/30/25 at 12:01 PM R1 had lunch in her room. R1 ate half of a pork burger sandwich, peach gelatin, and dessert. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact. R1's MDS dated [DATE] documents R1 scored on the higher end of moderate cognitive impairment. R1's active care plan documents R1 has malignant neoplasm of right lower lung and small cell B-cell lymphoma, types of cancer. R1's Physician Order dated 8/25/25 documents to give 237 milliliter (ml) bottle of (nutritional supplement) three times daily. R1's Care Plan Meeting Note dated 8/26/2025 at 3:15 PM documents the interdisciplinary team met with R1's family due to significant change. This note documents R1's weight was 83.6 lbs. down from 93 lbs. in July and R1's intakes have been poor. R1's nutritional supplement was increased to three times per day yesterday. R1's weight log documents R1's weights as follows:94 on 7/6/2597 on 7/23/2593.2 on 8/4/2583.6 on 8/25/2585 on 9/7/2586.6 on 9/10/2585.4 on 9/17/2583 on 9/24/25 R1's Nutrition Note dated 9/29/2025 at 7:39 AM documents R1 had a 10 lb weight loss in one month, current body mass index is 14.2, and R1 has malnutrition. R1 is on a regular diet with (nutritional supplement) three times daily which exceeds R1's estimated needs. R1's Nursing notes dated 9/29/25 at 11:41 AM and 9/30/25 at 8:33 AM and 11:31 AM documents (nutritional supplement) 237 ml was not available to be given as ordered. There is no follow up communication with the physician or dietitian to obtain orders for alternative supplement to give. On 9/30/25 at 2:20 PM V4 Licensed Practical Nurse stated the facility has been out of (nutritional supplement) since yesterday and V4 was unsure when the supply was suppose to arrive. V4 stated V6 Ancillary Clerk is responsible for ordering the supplement. V4 stated there isn't an order to give anything in place of that supplement. V4 stated the facility has other supplements available, but nothing has been given in it's place since there isn't a physician's order.On 9/30/25 at 2:30 PM V6 stated V6 orders two cases of (nutritional supplement) every two weeks, which is 48 bottles, and V6 placed an order today that should arrive tomorrow. The storage room was viewed with V6 that contained other nutritional supplements, but there was no supply of R1's ordered supplement. V6 stated V6 was not aware that the facility was out of this supplement. 9/30/25 at 2:43 PM V2 Director of Nursing stated if a supplement is unavailable then the nurses should contact the doctor to get an order for something else to give in it's place until the supply arrives.

Based on observation, interview, and record review the facility failed to change nebulizer equipment for one of three residents (R61) reviewed for respiratory care in the sample list of 29. Findings include: The facility's undated Administering Medications through a Small Volume (Handheld) Nebulizer policy documents to change equipment and tubing every seven days. On 9/29/2025 at 10:52 AM R61 stated R61 uses nebulizer treatments as needed, sometimes once per day. R61 stated R61 already had one treatment today. R61's nebulizer tubing and mask was on top of R61's dresser and was labeled with a date of 9/11/25. R61's physician orders did not include an order to routinely change nebulizer equipment. R61's September 2025 Medication/Treatment Administration Records (MAR/TAR) document R61 received Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) milligrams per 3 milliliters nebulizer treatments on 9/12/25 at 7:06 AM, 9/16/25 at 6:12 AM and 9/29/25 at 5:52 AM. There is no documentation that R61's nebulizer equipment is routinely changed. On 9/29/2025 at 4:13 PM V4 Licensed Practical Nurse stated nebulizer tubing is changed weekly on Thursdays on dayshift and documented on the TAR, even if there are as needed nebulizer treatment orders. At 4:19 PM V4 entered R61's room and confirmed R61's nebulizer tubing was dated 9/11/25. V4 stated V4 usually changes the nebulizer tubing on Thursdays, V4 works on R61's hallway every other Thursday, and V4 did not work on R61's hallway last Thursday.

Based on observation, interview and record review the facility failed to ensure hand hygiene was performed prior to insulin administration for two of 12 residents (R9, R49) reviewed for medication administration in the sample list of 29. Findings include: The facility's undated Handwashing/Hand Hygiene policy documents hand hygiene is considered a primary means in preventing the spread of infection. This policy documents to use an alcohol based hand sanitizer or wash hands with soap and water before/after direct resident contact, before handling medications, and before performing noninvasive procedures. On 9/30/25 at 10:49 V8 Registered Nurse administered R49's oral Carafate 1 gram tablet. V8 returned to the medication cart and pushed it down the hall to R9's room. At 11:00 AM V8 applied gloves and administered Humalog 100 units/milliliter 8 units into R9's abdomen. V8 did not perform hand hygiene after giving R49's oral medications or prior to administering R9's insulin injection. On 9/30/25 at 11:35 AM V8 stated hand hygiene should be performed before/after each resident's medication administration. V8 confirmed V8 did not perform hand hygiene after giving R49's oral medication or prior to giving R9's insulin injection.

Based on interview, and record review the facility failed to assess, monitor for appropriate mode of mechanical lift of four residents reviewed for injury and transfer in a sample list of ten. This failure caused delay of treatment for R1's arterial bleed which required multiple transfusions and emergency surgical repair which eventually led to R1's death.The Immediate Jeopardy began on [DATE] when R1 fell and was not adequately assessed for injury or appropriateness of initiation of sit-to-stand lift. V1, Administrator was notified of the Immediate Jeopardy on [DATE] at 2:27PM. The surveyor confirmed by observation, record review, interview that the Immediate Jeopardy was removed on [DATE], but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. Findings include: R1's Hospital documentation dated [DATE] includes the following diagnoses: Generalized Anxiety Disorder, Major Depression, Alzheimer's Disease, Psychotic Disturbance, Morbid Obesity, Osteoarthritis Right Shoulder, History of Cerebral Vascular Accident with Hemiparesis and Hemiplegia, Ataxia, History of Falls, Bilateral Knee Replacement, Right Rotator Cuff Repair, Anticoagulant Use, and Right Total Hip Replacement. R1's Minimum Data Set (MDS) dated [DATE] documents R1 was totally dependent on staff for all Activities of Daily Living (ADLs). This MDS documents R1 was severely cognitively impaired. R1's Progress Note dated [DATE] at 9:29 AM documents Staff stated resident (R1) lost her balance walking to the bathroom. Stated she (R1) fell into her wheelchair and fell to the floor on her right side and turned herself to sit on her bottom. Staff stated she did not see her hit her head. Gait belt was in use. Resident was complaining of right hip pain. Full head-to-toe assessment completed. When staff assisted resident off the floor and laid her down on her bed she complained of left hip pain. Family, physician, DON (Director of Nursing) and Unit director notified of fall. Physician ordered two-view x-ray of bilateral hips and pelvis stat. (contracted in house Xray Company) was called for x-ray.R1's Progress Note dated [DATE] at 10:15AM documents Staff notified this nurse that resident (R1) had a bruise to her right ear and jaw line, also bruise to right elbow. Physician, Power of Attorney (POA), Director of Nursing (DON), and Unit Director notified.R1's Progress Note dated [DATE] at 9:32PM by V18 Restorative Nurse documents Updated transfer status as follows: Transfers with use of stand lift and two (staff) assistance. Updated the following NURSING REHAB/RESTORATIVE: Transfer Program: (R1) transfers with use of stand lift stand two staff assist PRECAUTIONS: Risk for falls, Shortness of Breath, Fatigues Easily.No measurements of the bruise are documented following the [DATE] fall and a complete baseline assessment of the injury is not documented. An assessment for safe appropriate use of the sit-to-stand lift is not documented. The Weekly Skin Assessments dated [DATE], [DATE] ,[DATE], and [DATE] make no mention of the progression of the bruise first noted [DATE]. The Weekly Skin Assessments dated [DATE] and [DATE] document only scattered bruising. No sites are documented, and no measurements are documented. The right elbow bruise is only mentioned in the [DATE] skin assessment.No progress notes are documented assessing the bruising until [DATE] at 7:09PM by V15, Licensed Practical Nurse (LPN) CNAs were putting resident to bed and noted bruising to sternum and under and across right breast and under right arm that matches up with the strap of stand lift. (R1) does have some pain 5/10 and has limited ROM to right arm. V25 Medical Director was notified and was told of bruising and that (R1) also takes blood thinners. (V25) stated that as long as there is no bleeding it's ok just to monitor area. POA (Power of Attorney) and unit director notified.On [DATE] at 5:00PM, V15 stated When I called V25, I reminded V25 (R1) was on Apixaban (anticoagulant) but he did not give me an order to hold it. V25 just said monitor and as long as there is not bleeding there are no other orders.R1's Progress Note dated [DATE] at 8:52AM documents This nurse observed more bruising to residents upper left and right chest above ribcage. Resident short of breath with activity. PRN Tylenol given, and resident requested to lay down. (V21) unit director, and V2 DON (Director of Nursing), notified. (V2) requested x-ray to be done. Notified (V25) Medical Director for order. Waiting for reply.On [DATE] at 1:02PM, documents Resident had a change of condition from this morning. She (R1) became very pale, shortness of breath, and dry heaves. More bruising was starting to appear from this morning from the sit to stand sling. (V25) notified and agreed to send her to hospital. Resident POA (Power of Attorney) notified agreed to send (R1) to hospital. Ambulance arrived at 1pm and (R1) left facility at 1:05pm. Multiple bruises to R1s right side wrapping around to her mid back, bruising to right arm and into her right armpit. Bruising starting to appear to right upper shoulder by her neck, over left shoulder, and above both ribcages. T 97.4, B/P 114/83, P 143, R 18, 98% on room air. Report given to emergency room doctor. Bed hold form went with resident to (local) hospital. On [DATE] at 9:25 AM, V16 LPN stated it was passed on in morning report on [DATE] by V15 that the CNAs had found bruising the night prior while assisting (R1) for bed, and the bruising looked consistent with the stand lift. V16 stated V15 reported there was little bruising to R1's right side, breast and back. V16 stated V16 went in to assess R1 prior to breakfast and the bruise extended midline chest to midback and right armpit down the right arm. V16 stated V16 immediately notified V25 Physician, who said he had already put Eliquis on hold and asked what more V16 wanted him to do. V16 stated V16 asked for a chest x-ray and he (V25) told her (V16) to do what she wanted. V16 stated V16 ordered a portable chest x-ray but before they got here R1's condition changed. V16 stated R1 was regurgitating, dry heaving, and short of breath, and the bruising had grown in size now extending up R1's chest along bra strap. V16 stated V16 notified R1's POA multiple times and they decided to send R1 to the hospital. V16 stated V16 watched the cameras and could see that R1 was playing balloon toss prior to the bruise being found, and R1 had no signs of pain or injury at that time. V16 questioned whether R1 bumped something while playing balloon toss. V16 stated the bruising was consistent with the sit to stand sling and staff were baffled by how the injury could have happened. V16 stated V16 had not observed R1's transfers but knows that it took two to three staff for her sit to stand lift transfers due to prior reports that R1 would not stand fully upright, knees bent and slouched putting weight on R1s armpits. V16 stated R1 had to be close to the object transferring to, such as the toilet, as R1 could not withstand distance to transfer from the toilet to the bed, so R1 had to transfer back to the wheelchair and then use stand lift to put R1 in bed. V16 stated V16 was unsure if R1 had fallen, and no falls had been reported to her. V16 stated V16 speculates that R1 fell forward while using the sit to stand lift but does not know that for sure. R1's Medication Administration Record dated [DATE] documents the 8:00AM dose of Eliquis was administered. On [DATE] at 10:13AM, V16 stated V16 went into (R1's) room and gave (R1's) medication including the Eliquis before breakfast. (R1) was still in bed then and V16 didn't see the extent of the bruises until the CNA's got (R1) out of bed.R1's CAT (Computerized Axial Tomography) report dated [DATE] states Significant soft tissue contusion and a large subcutaneous hematoma extending from lateral aspect of right shoulder into upper arm and right lateral chest wall. R1 was admitted to the hospital on [DATE] related to the results of this scan and an order for Interventional Radiology consult was written. Per [DATE] hospital record upon arrival R1's Hemoglobin was documented as 5.9 grams per deciliter with the normal range being 11.6 to 15 grams per deciliter. R1 received multiple transfusions and underwent a two vessel embolization with coils and Gelfoam to stop the bleeding into R1's chest and arm. R1's progress notes document R1 returned to the facility on [DATE] at 7:24PM. (R1) was placed on hospice and expired on [DATE]. R1's death certificate documents R1's cause of death as Metabolic Encephalopathy due to Blood Loss Amenia due to Chest Wall Hematoma. This death Certificate was signed by V25, Medical Director.On [DATE] at 2:25PM, V26 Interventional Radiologist who performed R1's procedure to stop the arterial bleeding stated I believe the injury to (R1's) chest wall was consistent with an injury caused by a sit to stand lift. I don't think there is any possibility it was caused by a foam pool noodle. The injury was caused by significant blunt force trauma to R1's chest wall. I think if I were doing a root cause analysis, I would say what could have been done sooner was (R1) could have been sent to the emergency room the night before prior to (R1) losing so much blood. I do not believe (R1) would have died quite so soon were it not for the Arterial bleed.On [DATE] at 1:49PM, V25 was interviewed by phone. V25 stated that if he had known about the extent of R1's bruise he might have held the blood thinner and had R1 sent to emergency room. V25 stated I did not see the patient. V25 stated if he states to monitor, he expects more than one assessment per 12-hour shift.R1's progress noted document R1 was discharged from the hospital [DATE] at 3:00PM. R1 expired at the facility on hospice services on [DATE]. On [DATE] at 8:55 AM, V21 Memory Care Director stated V21 was not working on [DATE] and received a message from V15 LPN that night after supper, informing V21 of R1's bruising. V21 was not aware at that time of the extent of the bruising. V21 stated no one had seen anything happen and staff were unsure what caused the bruise. V21 stated V15 said the bruise aligned with the stand lift sling, so V21 assumed that was the cause of R1's bruising. V21 confirmed V15 should have documented a measurement of the bruise. V21 stated that is something we will need to do education on. On [DATE] at 9:35 AM, V2 DON stated V15 LPN should have checked on R1 once more during the night and re-measured the bruising at that time.On [DATE] at 4:51 PM, V27 CNA stated R1's bruising was found by V28 and V27 on the evening of [DATE]. V27 stated V28 had worked the night before and it wasn't there, so something must have happened during the dayshift the day we found it. V27 stated initially R1 was a stand pivot transfer but then she started using the sit to stand lift a few weeks prior to her passing away. V27 stated R1 disliked the stand lift, and would tell us that she was hurting and didn't like the lift. V27 stated R1 would tell us to put her down. V27 stated R1 couldn't stand in the lift for very long, so staff had to move her quickly.On [DATE] at 4:43 PM, V28 CNA stated V27 and V28 found R1's bruising prior to transferring R1 to bed. V28 stated the bruising was purple, almost black, and extended from R1's neck to the bottom of the abdomen, across from mid chest to right under arm just before the elbow. V28 stated it was a pretty large bruise and V28 had not noticed the bruising when she had previously cared for R1 prior to the evening of [DATE].On [DATE] at 8:15 AM, V30 Housekeeper stated before R1 was sent to the hospital ([DATE]), it was a Sunday morning. V30 stated V30 would often give back rubs and noticed that morning that R1 had purple/red/pink bruising to the right side of her neck/collar bone area, right side of face, and left wrist. V30 stated V30 did not report this to anyone since she is just a housekeeper. V30 stated an unidentified CNA told her that R1 had fallen out of the stand lift that morning. At 10:08 AM, V30 clarified V30 was off work after [DATE] and stated the date previously mentioned must have been during the first week of September or late [DATE].On [DATE] at 12:20 PM, V44 CNA stated R1 transferred with the sit to stand lift and would complain to staff that R1 didn't like it. V44 stated staff had to tell R1 to cooperate and stand up, and sometimes R1 would not cooperate. V44 stated then we would wait for R1 to push herself up, but sometimes R1 would have her butt sticking out, knees bent slightly, and the sling underneath her armpits bearing weight. V44 stated R1 was only able to tolerate standing in the lift for short duration. V44 stated V44 had not mentioned this to any nurses or restorative nurse. V44 stated V44 had only heard that R1 had a bruise on her left side/armpit area following the August fall, but V44 did not see this bruise. V44 stated R1 would complain of R1's side hurting when the stand lift belt was tightened.On [DATE] at 10:30AM, V18 Restorative Nurse stated R1 was not assessed by therapy to ensure the safety of the sit-to-stand lift. R1 stated I observed one transfer with (R1) and the sit-to-stand lift. I don't have an assessment to determine when a sit-to-stand or other lift is appropriate and the only documentation I have is an Endurance-Functional Ability Assessment. This assessment was provided and does not include safety assessment for sit-to-stand lift.On [DATE] at 8:13 AM, V20 Physical Therapist stated R1 was last on therapy caseload in 2024. At that time R1 was one or two assist and was walking. R1 was not on therapy after that as she refused whenever they would try to pick her up. V20 did not work with R1 on sit to stand lift transfers.On [DATE] at 1:51 PM, V2 DON stated V2 had nothing to provide that therapy assessed/evaluated R1's use of sit to stand lift.Facility submitted abatement plan at 9:26 PM on [DATE]. Abatement plan returned to the facility at 10:21 AM on [DATE] for revision. Received revised version at 11:53 AM. Returned for revisions 12:13 PM. Received final revised version 12:32 PM. Notified facility that abatement plan was accepted 1:08 PM.The Immediate Jeopardy that began on [DATE] was removed on [DATE] when the facility took the following actions to remove the immediacy: 1. For those residents found to have been potentially affected by the alleged deficient practice, the following corrective action was implemented:a. Nursing leaders and Administration met on [DATE] to review a plan to remediate the Immediate Jeopardy as was placed on the Facility on [DATE] at approximately 14:15. Completed [DATE].b. A Lift Assessment (Attachment A) will be conducted on all residents who require the use of a mechanical lift. This will be completed by the Restorative Nurse and Therapy Staff by the end of [DATE]. completed [DATE]c. Education will be provided to the nursing staff regarding the use of mechanical lifts and the new assessment process. This will be initiated by the Nurse Educator by the end of [DATE] and completed by [DATE]; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete this in- service by the end of the week. [DATE] Initiated [DATE]. Ongoing. On [DATE] at 2:08PM, V2 verified through review of sign-in sheet and staff schedule all staff scheduled for night shift [DATE] were not in-serviced. V1 and V2 also verified going forward all staff will receive the training as the removal plan states prior to working on the floor. d. If a CNA is performing a mechanical lift process and feels that the lift process is unsafe, the CNA will report this to the charge nurse. The charge nurse will then immediately assess and may downgrade the mechanical lift at that point in time. This will then be reviewed by DON / ADON / Restorative Nurse / and Therapy. This education will be provided by the Education Nurse and initiated on [DATE] and completed by [DATE]; all staff working the floor will be required to sign off on the in-services and staff not in attendance will be contacted to complete this in-service by the end of the week. Initiated [DATE].On [DATE] at 2:08PM, V2 verified through review of the sign-in sheet and staff schedule all staff scheduled for the night shift on [DATE] were not in-serviced. V1 and V2 also verified going forward all staff will receive the training as the removal plan states prior to working on the floor. e. The Restorative Nurse will seek to obtain her Certification of Restorative Nursing by the [DATE]. Therapy Staff will oversee the Restorative Nursing programs until this certification has been obtained. Initiated [DATE].f. Policies are being updated regarding the monitoring of bruising for all residents on anti- coagulant therapy medication that if a new bruise is identified, the MD will immediately be notified and then the nurse on duty will monitor and reassess the bruise hourly times four hours, then every four hours for the remaining initial 24 hours, then every shift for six days. Measurements will be taken and recorded. Any signs of the bruise increasing in size within this immediate time frame will be reported to the MD by the attending nurse. A Progress Note will be completed by the attending nurse to include measurements, vital signs, and a description of the bruising and/or change of condition. This policy revision will be completed, and nurses will be in-serviced on the policy by the end of the day on [DATE]. Verified [DATE].g. The TAR was updated on [DATE] for all residents who are currently on an anti- coagulant medication: Observe for adverse reactions of ANTICOAGULANT therapy every shift: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath (SOB), loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s). Verified in place [DATE]. 2. The following systematic changes have been implemented.a. The Lift Assessment will be completed for all residents who need a mechanical lift upon admission, quarterly, or as needed if their transfer status is changed. This will be completed by the Restorative Nurse and Therapy Staff by the end of the day on [DATE]. Verified [DATE].b. Following the change in a lift status, DON / ADON / Restorative Nurse or Designee will monitor and reassess three times a week for two weeks. Initiated [DATE]. Ongoing.c. If a resident shows signs of bruising and is on an anti-coagulant, the MD will immediately be notified and then the nurse on duty will monitor and reassess the bruise hourly times hours, then every four hours for the remaining initial 24 hours, then every shift for six days. If bruising increases and/or there are signs of a change in condition, the MD will immediately be notified. Initiated [DATE].d. All above education will be provided by the Education Nurse initially beginning on [DATE], for all new hires, and then monthly for three months. Initiated [DATE]e. Random audits on mechanical lift transfers will be conducted by the Nurse Leadership weekly for 12 weeks. [DATE] the form was provided. Confirmed with V2 she will be completing the audits.f. Random audits on nursing documentation regarding residents who are on anti- coagulant medications will be completed by nursing leaders weekly x 12 weeks, to ensure proper orders are in place and appropriate follow-up for signs/symptoms of adverse reactions are documented. [DATE] form provided. Confirmed with V2 she will be completing the audits.3. The following Quality Assurance Programs have been implemented:a. Lift Assessments and Transfer Status' will be added to the IDT weekly QA reporting for review. This will be presented by the Restorative Nurse and/or Therapy. Verified [DATE].b. Any injuries noted in relation to a transfer with a mechanical device will be reviewed in the daily QA meeting with the IDT. This will be presented by the IDT Nurse Leaders. Verified [DATE]. Confirmed with V2 she will be responsible for this.c. Residents on anti-coagulants and with new bruising will be added to the IDT daily QA reporting for review by the IDT Nursing Leaders. Verified [DATE]. Confirmed with V2 she will be responsible for this.d. Any incidents regarding the monitoring of residents on anti-coagulant medications will be reviewed at the daily QA meeting with the IDT and presented by the IDT Nurse Leadership. [DATE] Confirmed with V2 she will be responsible for this.

Based on interview and record review the facility failed to ensure all staff were trained on the facility's Quality Assurance Performance Improvement Program. This failure affects all 84 residents in the facility. The facility's Facility assessment dated as reviewed 9/26/25 includes staff education/training upon hire and annually through (web-based training and education system), new employee orientation, and in-services. This Facility Assessment does not include QAPI training as one of the topics that staff will be trained on. On 11/4/25 at 10:55 AM, employee education and training were reviewed with V48 Human Resources and V48 was asked about QAPI training. V48 confirmed there was no documentation of QAPI training in the (web-based training and education system) or as part of the facility's new employee orientation training. V48 stated V48 will have to follow up with V33 Nurse Educator to see if there is any training on QAPI. At 12:35 PM, V48 stated QAPI training has not been completed since 2020. On 11/4/25 at 1:16 PM, V33 Nurse Educator confirmed QAPI training has not been completed. V33 stated V33 just added QAPI training in (web-based training and education system) for all staff and the staff have a week to complete it. The facility's Resident Roster dated 10/27/25 documents a census of 84 residents.

Based on interview and record review the facility failed to have the physician document and sign progress notes for each visit for five of six residents (R1, R2, R5, R9, R10) reviewed for physician visits in the sample list of 10. 1.) R1's undated Face Sheet documents R1's primary physician as V25. R1's Progress Notes, recorded by V10 Licensed Practical Nurse, document V25 evaluated R1 on 6/27/25, 8/22/25 and 9/9/25. As of 11/3/25, R1's electronic medical record (EMR) did not include any Physician Progress Notes by V25. 2.) R2's undated Face Sheet documents R2's primary physician as V25. R2's Progress Notes, recorded by V10, document V25 evaluated R2 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R2's EMR did not include any Physician Progress Notes by V25. 3.) R5's undated Face Sheet documents R5's primary physician as V25. R5's Progress Notes, recorded by V10, document V25 evaluated R5 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R5's EMR did not include any Physician Progress Notes by V25. 4.) R9's undated Face Sheet documents R9's primary physician as V25. R9's Progress Notes, recorded by V10, document V25 evaluated R9 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R9's EMR did not include any Physician Progress Notes by V25. 5.) R10's undated Face Sheet documents R10's primary physician as V25. R10's Progress Notes, recorded by V10, document V25 evaluated R10 on 6/27/25, 8/22/25, and 10/24/25. As of 11/3/25, R10's EMR did not include any Physician Progress Notes by V25. On 11/4/25 at 8:10 AM, V2 Director of Nursing stated the physician visit notes are documented under the assessments or uploaded into the resident's EMR in the miscellaneous section. V2 stated sometimes they have to request for the physician to send them to the facility. At this time V25's Progress Notes were requested for R1, R2, R5, R9 and R10. At 9:55 AM, V2 stated V2 had to request V25's Progress Notes. On 11/4/25 at 1:49 PM, V25 stated V25 sees each resident at least every 60 days, tries to open a progress note at the time of each visit and tries to have an office day to complete the visit notes, but that doesn't always happen.

Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for one of four residents (R1) reviewed for accidents in the sample list of 10. Findings include:The facility's undated Final Report documents the following: on 9/21/25 the Certified Nursing Assistants (CNAs) were putting R1 to bed and noted bruising to sternum, under and across the right breast and under right arm. R1 complained of pain and had limited range of motion to right arm. On 9/22/25 more bruising was noted to R1's right chest above rib cage, R1 was short of breath with activity and later complained of chest pain, nausea, and was pale. R1 was sent to the local emergency room where R1's Hemoglobin was 5.9 (normal range 11.6-15 grams per deciliter). R1 was given a reversal agent due to bleeding, and later had a brachiocephalic, right subclavian and right axillary artery angiogram that demonstrated an active bleed in the right anterior lateral chest that required two-vessel embolization with coils and gel foam. There were no reports of a fall or other mechanism of injury that may have directly caused R1's bruising and bleeding. R1 requires the use of a sit to stand lift for transfers, and the affected area is similar to the location of the stand lift sling, and the use of this lift does not cause this type of injury. R1 was playing balloon toss using her right arm and the facility questions if R1 may have torn something while playing and outstretching her arm. As a precaution R1's transfer status was changed from sit to stand lift to full mechanical lift. R1's Progress Note dated 9/21/25 at 7:09 PM, recorded by V15 Licensed Practical Nurse (LPN) documents the CNAs were putting R1 to bed and found bruising to sternum, under and across right breast and under right arm that matches up with the strap of the stand lift. R1 rated pain 5 out of 10 and had limited range of motion to right arm. R1's Nursing Notes document R1 returned to the facility on 9/28/25, admitted to hospice, and passed away on 10/4/25. The facility's September 2025 Housekeeping schedule documents one housekeeper worked on the memory care unit (R1's unit) on 9/21/25. The facility's September 2025 Activity Staff schedule documents three activity staff worked on R1's unit. The facility's Faith Place (memory care unit) Assignment sheets dated week of 9/20/25-9/26/25, document the following assignments: On 9/21/25 two nurses and six CNAs worked dayshift, two nurses and four CNAs worked evening shift. These same staff also worked on 9/20/25, with three of the evening shift CNAs as night shift. The facility's investigative file for R1's 9/21/25 bruising/injury, provided by V2 Director of Nursing, included only four staff Incident/Investigation Interview Forms. V27 CNA and V28 CNA interview forms dated 9/21/25 at 7:00 PM document they found large bruising underneath R1's breast, on the left side of R1's breast, and across R1's right side. These forms are not signed that a staff person interviewed V27 and V28, as indicated on the form. V13 CNA interview form dated 9/22/25 documents during last rounds V13 noticed a small bruise to R1's left arm, thought to be old, and that was the only bruise V13 observed. There is no documentation that these staff were asked the cause of R1's bruising/injury, if R1 had any falls, or how R1 had been standing for transfers in the sit to stand lift. V12 CNA interview form dated 9/22/25 documents V12 only noticed an old bruise to R1's left arm, R1 is anxious during transfers as she does not like the sit to stand lift, but there were no transfer issues during V12's shift. On 10/28/25 at 2:42 PM, V15 LPN stated V15 was alerted to a bruise on (R1's) right chest and arm by the CNAs on 9/21/25. V15 stated V15 felt the bruise lined up with the belt on the stand lift that R1 used to transfer. V15 denied any knowledge of any incidents that could have caused R1's bruising. On 10/28/25 between 4:01 PM and 4:43 PM, V27 and V28 CNAs stated they found R1's bruising on the evening of 9/21/25 prior to transferring her to bed, which was not noted when V28 had last cared for R1 the night before. V27 stated something must have happened during the dayshift. V28 described the bruise as purple, almost black, extending from the base of R1's neck down to the bottom of R1's abdomen, across from mid chest to right under arm before the elbow. V27 stated initially R1 was a stand pivot transfer but then R1 started using the sit to stand lift a few weeks prior. V27 stated R1 disliked the stand lift, R1 would tell us that she was hurting and didn't like the lift, and to put R1 down. V27 stated R1 couldn't stand in the lift for very long, so staff had to move R1 quickly. V27 and V28 were not aware of the cause of R1's injury, or any falls or incidents that could have caused R1's injury. On 10/29/25 at 8:55 AM, V21 Memory Care Director stated V21 did not work on 9/21/25 and received a text message that evening from V15 Licensed practical Nurse reporting R1's bruising. V21 stated no one saw anything happen and staff were unsure what caused the bruising. V21 stated V15 LPN told V21 that the bruise aligned with the stand lift sling, so V21 assumed that was the cause of R1's injury. On 10/29/25 at 1:27 PM, V1 Administrator stated V1 assisted collectively with nurse management for the investigation of R1's 9/21/25 bruising/injury. V1 stated V15 LPN, and the two CNAs were interviewed for this investigation. V1 confirmed no other staff were interviewed. V1 stated the interviewed staff were asked about what happened and how R1 had been that day/evening. V1 stated the staff only talked about R1 in the sling and how she played balloon toss with a pool noodle that afternoon. V1 was asked to clarify what the staff mentioned about the stand lift sling and V1 stated meaning R1 transferred with the stand lift and sling that day. V1 said there were no reported accidents, injuries, or concerns related to the sling use. V1 confirmed staff were not asked if R1 had any falls/incidents or what caused R1's injury. V1 stated the staff report resident falls. V1 stated V1 reviewed video surveillance footage of R1 on the afternoon of 9/21/25 participating in an activity that involved using a pool noodle to strike a balloon.V1 stated based on this observation, V1 questions if R1's stretching and repetitive arm movements during the activity may have contributed to a vascular injury, such as a tear in an artery, which could potentially explain the bruising observed on R1. V1 confirmed no other video surveillance was reviewed. The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the investigation process is used to try to determine the cause of injuries of unknown source and rule out abuse. This policy documents the designated investigator will begin the investigation immediately to implement a root cause investigation and analysis, and the gathered information is given to the administrator. The investigation may include who was involved, resident statements, roommate statements, involved staff and witness statements, a description of the resident's behavior and environment at the time of the incident.

Based on interview and record review the facility failed to safely transfer a resident (R7) resulting in a fall and failed to investigate this fall for one of four residents (R7) reviewed for accidents in the sample list of 10. On 10/27/25 at 10:14 AM, R7 stated R7 had a recent fall while trying to get into bed with staff assistance. R7 stated a gait belt was not used during this transfer. R7's Minimum Data Set, dated [DATE] documents R7 as cognitively intact, R7 requires partial/moderate staff assistance for chair/bed transfers, and R7 had two or more falls without injury since the prior assessment. R7's Care Plan dated 8/26/24 documents R7 is at risk for falls, R7 has a transfer restorative program due to weakness and R7 transfers with one assist, gait belt, and grab bar or walker. R7's Endurance-Functional Mobility assessment dated [DATE] documents R7 transfers with one assist with use of gait belt, grab bar or walker. R7's Nursing Note dated 9/4/2025 at 8:22 PM documents R7 was being assisted into bed from his wheelchair, R7 let go of the bed rail, R7's knees weakened and R7 was assisted to the floor. R7 did not sustain any injuries. The post fall intervention was to use two assist for transfers in/out of bed. The Accident Investigation/Interview Form dated 9/4/25 documents V19 Certified Nursing Assistant (CNA) assisted R7 with transfer from wheelchair to bed, R7 let go of the railing, R7's knees became weak, and R7 was lowered to the floor. This form does not document whether a gait belt was used. There is no documentation that this fall was thoroughly investigated. On 10/27/25 at 1:18 PM, V2 Director of Nursing stated the nurse documented R7's fall in the 9/4/25 nursing note but didn't complete an incident report. V2 confirmed there was no fall investigation packet completed for this fall. On 10/27/25 at 3:09 PM, V19 CNA confirmed V19 assisted R7 during the fall on 9/4/25. In reference to this fall, V19 stated V19 transferred R7 from the bathroom into the wheelchair and V19 was in the process of transferring R7 into bed. V19 stated R7 went to grab the siderail on his bed, R7 let go with one of his hands to grab his pants while standing, R7 lost his balance and fell. V19 stated at that time R7 was a one assist for transfers. V19 stated V19 did not use a gait belt during this transfer. On 10/28/25 at 3:58 PM, V18 Licensed Practical Nurse confirmed V18 completed R7's Endurance-Functional Mobility assessment dated [DATE] and confirmed R7's transfer status at that time was one assist and gait belt. V18 stated staff would also have R7 use the grab bars in his bathroom, on recliner, and on bed, and/or wheeled walker. The facility's undated Managing Falls and Fall Risk policy documents: 1. The staff will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g. (for example), dizziness or weakness) has resolved. 3. 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 observation, interview, and record review, the facility failed to ensure resident safety by not placing foot pedals on a resident's wheelchair while propelling the resident. This failure resulted in R1 experiencing a fall from the wheelchair, facial lacerations to the forehead, eye, and nose requiring eleven sutures to close. The facility also failed to implement fall prevention interventions according to R1's care plan. R1 is one of three residents reviewed for accidents on a sample list of eight. Findings include: 1. R1's Census Detail dated 6/10/25 documents R1 was admitted to the facility 1/19/17. This same Census Detail documents R1 was at the hospital on 5/19/25. R1 Medical Diagnoses List dated 6/10/25 documents R1 experienced health conditions including Dementia, Morbid Obesity, Reduced Mobility, Need for Assistance with Personal Care, Anemia, Chronic Respiratory Failure with Hypoxia, Lumbar Disc Displacement, Difficulty Walking, History of Cerebral Vascular Accident, and Muscle Weakness. R1's Fall Risk Assessments dated 5/6/25, 3/23/25, and 2/10/25 all document R1 is at high risk for falls. R1's Minimum Data Set, dated [DATE] documents R1 received a Brief Interview for Mental Status of three, indicating R1 was severely cognitively impaired. R1 could only repeat two of three words (sock, blue, bed) provided by the tester, could not identify the correct year within 5 years, the correct month, nor the day of the week. R1 could only recall one of the three provided words at the end of this interview. This same Minimum Data Set documents R1 was dependent on staff for toileting, oral, and personal hygiene, as well as lower body dressing, placing on footwear, transitioning from lying to sitting, and for mobility in a wheelchair. R1's Nursing Progress Note dated 4/22/25 at 5:11 AM documents R1 was found by staff face down beside her bed. R1's Nursing Progress Note dated 3/22/25 at 10:57 PM documents R1 was found by staff on her knees beside the bed exhibiting increased signs of confusion. R1's Nursing Progress Note dated 5/15/25 at 11:41 AM documents R1 was very lethargic, was not engaging in conversation nor eating independently and was seated in the assisted dining portion of the dining room to receive staff assistance while eating. R1's Nursing Progress Note dated 5/19/25 at 8:53 AM, documents R1 was being propelled by a staff Registered Nurse (V4) when R1 put her feet on the floor and fell forward out of the wheelchair. This same Note documents staff did not have pedals in place on R1's wheelchair at the time. This Nurses Note documents R1 experienced a facial laceration on the left side of her forehead, around the left eye, and on the bridge of her nose. This note documets R1 was sent to the local emergency room for evaluation. R1's Nursing Progress Note dated 5/19/25 at 1:53 PM documents R1 returned to the facility with an 8.5 centimeter laceration to her left forehead and 11 sutures in place, another 1 centimeter laceration under R1's left eye, and a 0,5 centimeter laceration on the bridge of R1's nose. R1's emergency room Report dated 5/19/25 documents and confirms R1 had experienced facial lacerations of 8.5 centimeters on the left side of R1's forehead, 1 centimeter under R1's left eye, and 0.5 centimeters on the bridge of R1's nose. This same report documents closure of R1's lacerations required 11 sutures. On 6/10/25 at 11:30 AM, V12, Physical Therapist, stated he did work with R1 as part of his skilled therapy case load back in March (2025). V12 stated R1 could propel her own wheelchair at that time but did have fluctuating mental and physical abilities, some good days and some bad days. V12 stated there was not a facility wide policy to place wheelchair pedals on every resident's wheelchair because many residents could still propel their own wheelchairs and the facility wanted to promote independence. V12 then stated there was not a process to evaluate residents for their need to utilize foot pedals on their wheelchairs. On 6/10/25 at 12:08 PM, V4, Registered Nurse, confirmed she was the staff member propelling R1 to breakfast when R1 fell out of the wheelchair. V4 stated she did not put foot pedals on the wheelchair for R1 because R1 would still propel herself in the facility. V4 further stated R1 could move her own wheelchair but could not necessarily locate her own room, or any intended destination, and often would come to the nurses station and ask for someone to take her to her room. V4 stated R1 had not had prior problems holding her legs and feet up while a staff member was propelling the wheelchair for R1. V4 then stated there had been a prior nearly identical incident involving R8 about a year prior to the incident involving R1, where R8 was being propelled by a staff member, put her feet on the floor, and then R8 fell face first out of the wheelchair. R1's Nursing Progress Note dated 6/22/24 at 5:30 PM confirms a kitchen staff member was propelling R1 from the dining room when R1 put her feet down and then tumbled face first onto the floor. On 6/10/25 at 9:10 AM, R1 was lying in bed in her own room. R1 had a pale colored non-pigmented scar on the left side of her forehead approximately 9 centimeters long curving around and beside R1's left eye, with a shape like an inverted V (^) over her left eye. There was an area approximately 1 centimeter long of a dark red scab at the peak shaped area over R1's left eye. On 6/10/25 at 11:15 AM, V6, Certified Nursing Assistant, was propelling R4 through a carpeted hallway into the dining room while R4 was holding his legs and feet up off the floor. On 6/10/25 at 11:25 AM, V5, Spouse of R5, was propelling R5 through a carpeted hallway into the main dining room while R5 was holding his legs and feet off the floor. On 6/10/25 at 11:49 AM, V9, Housekeeper, was propelling R6 through a carpeted hallway from the dining room and to the central nurses station. V9 stated he worked in the housekeeping department and was responsible for cleaning resident rooms, hallways and the dining room. V9 stated he assisted residents out of the dining room so he can get started cleaning the dining room. On 6/10/25 at 11:53 AM, V10, Spouse of R7, was propelling R7 along the carpeted hallway from the main dining room and then outside of the facility while R7 was holding his legs and feet up off the floor. On 6/11/25 at 8:35 AM, V11, Certified Nursing Assistant, was propelling R7 through a carpeted hallway to the main dining room while R7 was holding his legs and feet up off the floor. On 6/11/25 at 9:35 AM, V2, Director of Nursing, stated she had worked at the facility seven and one half years and did have a recollection of the prior incident involving R8. V2 acknowledged there had not been a process implemented after the incident with R8 to evaluate or assess residents for their need to utilize foot pedals on their wheelchairs and stated she had been searching for an assessment tool after this incident involving R1. 2. R1's Care Plan for fall prevention dated as initiated 3/14/22 documents R1 is at risk for falls due to confusion, deconditioning, gait and balance problems, and is unaware of her safety needs. The fall prevention interventions to be implemented by staff include to have R1's bed in the lowest position when R1 is in bed and to have a safety mat (padded floor mat) on the left side of the bed, dated as initiated 8/3/23 with a most recent revision on 3/24/25. These care plan fall prevention interventions were also included on R1's Physician Order Sheets. On 6/11/25 at 9:15 AM, R1 was lying in bed in her own room. R1's bed was not in the lowest position being approximately 16 inches up from the floor. R1's safety mat was folded and leaning against the wall on the opposite side of the room from R1's bed. On 6/11/25 at 9:20 AM, V1, Administrator, observed these findings and simply made an audible growling sound. V1 then instructed an (unidentified) Certified Nursing Assistant to go check R1's room because the bed was not down and the mat was not by the bed. On 6/11/25 at 9:35 AM, V2, Director of Nursing, when informed of the findings of R1's bed not being in the lowest position and the safety mat not being in place, simply stated, Yeah. On 6/11/25 at 1:44 PM, V13, Minimum Data Set Coordinator/ Care Plan Coordinator, confirmed the bed in the lowest position and the safety mat are still current fall prevention interventions for R1.

Based on interview and record review, the facility failed to identify an electric lift chair as a fall hazard, develop and implement post fall interventions, and thoroughly investigate falls for one of three (R1) reviewed for falls in the sample list of three. This failure resulted in R1 falling and sustaining a left femoral neck fracture requiring surgical repair. Findings include: R1's Minimum Data Set, dated dated dated [DATE] documents R1 had severe cognitive impairment and required substantial/maximal assistance from staff when moving from sitting to standing, for chair/bed transfers, and when walking. R1's Fall Risk assessment dated [DATE] documents R1 was at high risk for falling. R1's Care Plan dated 9/15/22 documents R1 was at risk for falls related to deconditioning, gait/balance problems, psychoactive drug use, and vision/hearing problems. Interventions included silent recliner alarm for poor safety awareness (7/31/23), check function and placement of alarm every shift, nonskid mat in recliner (9/5/23) and transfer/ambulate with standby assist, gait belt and four wheeled walker. R1's Nursing Note dated 4/11/2024 at 11:25 PM documents nurse and Certified Nursing Assistant (CNA) entered R1's room to find R1 sitting on the floor leaning up against the heater in front of the recliner that was in a forward tilt position. R1 was unable to recall how she fell . R1 was sitting in the recliner prior to the fall. R1's Interdisciplinary Team (IDT) Note dated 4/12/2024 at 12:31 PM documents the IDT met to review R1's unwitnessed fall. R1 recently tested positive for COVID-19 with weakness likely. Physical Therapy to evaluate and treat as ordered. R1's Therapy Initiation dated 4/15/24 documents R1's family declined therapy. There are no other documented post fall interventions for this fall in R1's medical record. R1's Nursing Note dated 4/3/2025 at 2:23 PM documents R1 had an unwitnessed fall in her room while attempting to self transfer. R1's call light was within reach. R1 acquired a hematoma (bruising/swelling) to the left side of her head behind her ear and a skin tear to the left thumb. R1 was transferred to the local hospital. The Incident Investigation/Interview Form dated 4/8/25, completed by V5 CNA, documents V5 passed by R1's room and saw R1 on the floor in front of R1's electric recliner/lift chair, which was all the way up. R1's call light was not on. This form does not document a malfunction with R1's chair alarm. The undated Incident Investigation/Interview Form, completed by V9 LPN documents V5 CNA alerted nurse to R1 being on the floor. R1 was on the floor in front of the recliner, the call light was within reach, and R1 was sleeping in the recliner prior to the fall. The Incident Investigation/Interview Form dated 4/3/25, completed by V10 CNA, documents V10 did not witness R1's fall and does not include any additional information. The facility's final report of R1's 4/3/25 fall documents was on 4/3/25 at 2:00 PM. R1 was found on the floor in front of her recliner, and R1 was transferred to the hospital. R1's left hip computed tomography showed a nondisplaced left femoral neck fracture. Surgery was completed on 4/4/25, and the hospital notified the facility on 4/6/25 that R1 passed away. R1's hospital discharge summary documents likely etiology is acute cardiopulmonary arrest given her advanced age and underlying heart disease. This final report does not identify the root cause of R1's fall or any post fall interventions. There is no documentation that the pressure alarm malfunctioned, that the facility identified the lift chair to be a safety/fall hazard, or if a nonskid mat was in R1's recliner. R1's Hospital History and Physical dated 4/3/25 documents R1 admitted after a fall, R1 was found to having bruising to the left hip and radiograph imaging showed a left femoral neck fracture. R1's surgical consult note dated 4/4/25 documents R1 initially presented with left hip pain post fall and shortened/externally rotated left leg with bruising. A computed tomography scan noted a nondisplaced valgus-impacted femoral neck fracture. R1's Operative Note dated 4/4/25 documents R1 received open reduction internal fixation surgical repair of the left femur fracture. On 5/12/25 at 10:39 AM V5 CNA stated V5 walked past R1's room and saw R1 lying on the floor. V5 stated R1's chair pressure alarm was not plugged into the call light box, so the call light did not activate like it was suppose to. V5 stated R1 used an electric lift chair recliner and R1 had a history of using the lift chair remote, so we would try to keep it out of R1's reach. At the time of the fall on 4/3/25, R1's lift chair was in the highest elevated position with the seat all of the way up and the controls were dangling along the side of the chair within R1's reach. V5 was asked what could have been done to prevent the fall. V5 stated making sure all the cords for the alarm were plugged in. At 11:31 AM V5 stated R1 used a nonskid mat in her recliner and V5 was not for sure but thinks the mat was in place when R1 fell . On 5/12/25 at 11:06 AM V10 CNA stated V10 was assigned to R1's hall on 4/3/25. V10 stated R1's fall had something to do with R1's alarm not sounding. V10 confirmed V10 had transferred R1 into the electric lift chair/recliner after lunch. V10 was unsure how often chair alarms should be checked for functioning. V10 stated silenced alarms do not sound, it triggers the call light indicated with a certain color for alarms. V10 stated the sensor pad cord connects into the call light box on the wall of the room. V10 was unsure if R1's sensor alarm was connected to the call light box when V10 transferred R1 on 4/3/25. V10 described R1 as confusing, no ability to recall or retain information and required heavy assistance from staff for transfers. V10 stated V10 was told that R1 has a history of attempting to self transfer and V10 was unsure where she had placed R1's chair remote. V10 was asked what could have been done to prevent the fall. V10 stated checking the alarms, but the alarm doesn't trigger until after the resident has already fallen. At 11:27 AM V10 stated V10 used a nonskid mat in the lift chair, but was unsure if it was in place during R1's 4/3/25 fall. On 5/12/25 at 11:35 AM V8 Director of Rehab stated R1 had not been on therapy caseload within the last year. V8 stated R1 had a prior fall out of the recliner and was suppose to have therapy at that time, but R1's family declined. On 5/12/25 at 11:45 AM V12 Licensed Practical Nurse stated R1 was confused and had a history of prior fall from R1's electric lift chair/recliner, which is why R1 used an alarm in her chair. On 5/12/25 at 11:54 AM V2 Director of Nursing stated therapy was R1's post fall intervention for 4/11/24 fall. V2 confirmed all of R1's 4/3/25 fall investigation documentation was provided. V2 stated the root cause of was R1 attempted to self transfer. V2 stated the CNAs on the floor that day were interviewed regarding the fall and per V5, R1's chair alarm was not working. V2 confirmed nonskid mat and silenced chair alarms were current fall interventions for R1, and information regarding these interventions were not documented as part of R1's fall investigation. V2 confirmed the lift chair was not identified to be a contributing factor in R1's falls. V2 stated the facility does not do any kind of assessment for the use of electronic lift chairs. V1 Administrator and V2 confirmed the facility does not have a policy regarding the use of these chairs. On 5/14/25 at 9:01 AM V2 confirmed R1's family declined therapy, the post fall intervention for R1's 4/11/24 fall. At 9:09 AM V2 stated there were no other interventions that were implemented for R1's 4/11/24 fall. On 5/12/25 between 2:11 PM and 2:25 PM V16, R1's Physician, confirmed R1's fall was the cause of R1's left femur fracture. The facility's undated Managing Falls and Fall Risk policy documents staff will implement a resident-centered fall prevention plan to reduce fall risk factors for resident's at risk for falls or with a history of falls. This policy documents staff will monitor and document response to fall interventions, if the resident continues to fall then staff will re-evaluate whether the intervention remains appropriate or if change is needed. This policy documents the physician will help staff reconsider possible causes that many not have been identified.

Based on interview and record review the facility failed to accurately complete a Minimum Data Set (MDS) Assessment for one of three (R2) residents reviewed for falls in the sample list of three. Findings include: R2's Nursing Note dated 2/20/2025 at 7:35 PM documents V14 Certified Nursing Assistant pushed R2 in a wheelchair into R2's room, R2's feet got caught underneath R2's wheelchair, R2 fell and hit R2's head. R2's Nursing Note dated 2/20/2025 at 8:00 PM documents R2 complained of neck pain and R2's blood pressure was 188/94. R2's family and physician were notified and orders were received to transfer R2 to the local hospital. R2's Nursing Note dated 2/21/25 at 12:27 AM documents the hospital called to report R2 will return to the facility and has spine fracture of dens cervical body. Neurosurgeon consult indicated not eligible for surgery due to complicities, and R2 will need to wear a cervical collar at all times. R2's Computed Tomography scan of cervical spine dated 2/20/25 documents fall with neck pain and R2 has an acute fracture through base of dens. R2's MDS dated [DATE] documents R2 had no falls since the last MDS review, which was 12/18/24. On 5/12/25 at 11:30 AM V3 MDS Coordinator confirmed R2's 3/3/25 MDS was inaccurate and did not document R2's fall with major injury that ocurred on 2/20/25. V3 stated V3 caught the error today and submitted a correction. V3 stated V3 was not sure how this was missed, usually when a resident has a fall with major injury they are admitted to the hospital so that is maybe how this was missed.

Based on interview and record review the facility failed to protect a resident's right to privacy for three of three residents (R1, R2, R3) reviewed for resident rights on the sample of three. Findings Include: The Resident's Rights for People in Long Term Care Facilities dated May 2018 documents residents have the right to privacy. The facility may not give information about residents or their care to any unauthorized person without the resident's permission. 1. R1's Medical Diagnoses list dated February 2025 documents R1 is diagnosed with Alzheimer's Disease. R1's Minimum Data Set (MDS) dated [DATE] documents R1 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. 2. R2's Medical Diagnoses list dated February 2025 documents R2 is diagnosed with Alzheimer's Disease. R2's Minimum Data Set (MDS) dated [DATE] documents R2 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. 3. R3's Medical Diagnoses list dated February 2025 documents R3 is diagnosed with Alzheimer's Disease. R3's Minimum Data Set (MDS) dated [DATE] documents R3 is severely cognitively impaired and requires staff assistance for all Activities of Daily Living. The facility's Final Investigation Report dated 1/24/25 documents on 1/20/25 the facility was alerted by V5 (employee (V4's) ex-boyfriend) that V4 Certified Nurses Assistant (CNA) had shared resident's names and some information about things that happened in V4's workday concerning residents (R1, R2, R3). V4 admitted to V1 Administrator during his investigation that she had shared details about her day with V5 on occasion and did mention resident's first names. V4 was terminated for violating the facility's confidentiality expectations. V4's Record of Counseling dated 1/23/25 documents V4 was terminated related to a violation of the facility's confidentiality policies. On 2/11/25 at 1:20 PM V3 Memory Care Director stated V4 had admitted to venting to her boyfriend about her day and using resident's first names on occasion. V3 stated V4 had crossed a line and should not have been talking to her boyfriend about things going on at work. On 2/11/25 at 2:45 PM V6 Human Resources confirmed V4 admitted to sharing first names of a couple of residents with her boyfriend when venting to him about her day at work. V6 stated V4 was ultimately terminated because she shared first names of residents with an unauthorized person and that is not appropriate and considered a violation of residents right to privacy.

Based on observation, interview, and record review the facility failed to ensure adequate pain management was available, by failing repeatedly to schedule a pain clinic appointment for a medication pump refill. This failure affected one of two residents (R1) reviewed for pain on the sample list of 27. Findings Include: On 11/12/24 at 12:15 pm, R1 was seated in a motorized wheelchair, bedside. R1 stated R1 has a pain pump in her abdomen that has not been filled in months. R1 said R1 is reliant on this pain pump to stop the burning in her feet. R1 stated, I have pain pills but they don't work to relieve the burning pain in feet. My doctor retired and the facility has done nothing to help me find a new doctor to provide refills (surgically implanted pain pump medications). I was going out to my doctor about every six weeks. R1's Medical Device Identification (card) documents R1 had Drug Infusion System implanted on 7/16/24. R1's Physician Order Summary sheet (POS) dated 11/1-11/30/24 documents the following diagnoses: Multiple Sclerosis, Muscle Weakness Generalized, Paralytic Gait, Other Chronic Pain, Presence of Other Devices, Paraplegia, Unspecified, Other Signs and Symptoms, Unspecified Lack of Coordination, Other Reduced Mobility, Dependence on Wheelchair, Other Fatigue, and Contracture Unspecified Joint. R1's same POS documents monitoring as follows: Check pain pump site every day shift notify MD (physician) of any swelling. R1's same POS documents the following medications for pain management Morphine (25.0 mg/ml) infused at 13.552 mg ( milligrams) /day via intrathecal pain pump; managed per (V21, Physician)/Universal Pain Management Institute (clinic), (status Hold), Bupivacaine (3.7 mg/ml) infused at 2.0057 mg/day via intrathecal pain pump; managed per (V21)/Universal Pain Management Institute (status Hold), Hydrocodone-Acetaminophen Oral Tablet 7.5-325 MG (Hydrocodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain management, Acetaminophen 500 mg caplet, Give 1 capsule orally every 4 hours as needed for pain, fever, Gabapentin Capsule 400 MG Give 1 capsule by mouth four times a day for nerve pain, Carbamazepine 100 mg tab Chewable, Give 1 tablet orally two times a day for nerve pain, and Baclofen Tablet 10 MG, Give 1 tablet by mouth three times a day for muscle spasms. R1's Medication Administration Record dated 11/1/24-11/30/24 does not document R1 received PRN Acetaminophen, but did receive Hydrocodone -Acetaminophen PRN for a severe pain level of seven out of ten, one time on 11/10/24. R1's Minimum Data Set, dated dated dated [DATE] documents the following: Brief Interview of Mental Status score as 15 out of a possible 15, indicating no cognitive impairment. Same MDS documents R1 has pain occasionally at four out of ten level (mild-moderate). R1's Care Plan updated 10/29/24 documents the following: (R1) has chronic pain r/t (related to) MS (Multiple Sclerosis) and Arthritis. She has a implanted pain pump. Interventions include: Notify MD PRN (as needed) for increased or uncontrolled pain. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Follow up with pain clinic, (V21, Pain Clinic Physician) as ordered for pain pump refill (delayed refill appointment scheduling, post insertion of pain pump insertion 7/16/24). Evaluate the effectiveness of pain interventions every shift and after administration of PRN medication. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. R1's Social Service note signed by V9, Social Service Director, dated 9/12/24 at 8:24 am, documents the following: 1:1 (one on one) Resident was a little upset this morning, the pain doctor canceled her appointment. She is waiting for her pain pump to be filled. I explained to her that our scheduler (V19, Certified Nursing Assistant) is aware, and she will be making her a new appointment. R1's Appointment Note signed by V19, Certified Nursing Assistant dated 9/12/24 at 9:02 am, documents the following: Contacted (V21, Pain Clinic Physician) office regarding (R1's) follow up appointment. Office staff stated that the nurses (unidentified) and (V21) were in a procedure at this time and a nurse will be calling me back. Awaiting call back at this time. No other documentation of pain clinic notification to schedule appointment for R1 in R1's medical record. On 11/13/24 at 11:30 am, R1 was seated in her motorized wheelchair in the dining room. R1 motioned for this surveyor to come over to her table. R1 stated Are you going to get me an appointment for my pain pump refill. My feet and spine don't burn all the time, but the pills I take only take the edge off. I really need an appointment. No one has said a word to me about getting my pain pump refill. It doesn't matter who I talk to. No one has scheduled an appointment. It has been months and I was getting refills every 6 weeks or so. On 11/13/24 at 2:10 pm, V2 Director of Nursing (DON) confirmed there has not been a pain clinic appointment made for R1's pain medication pump refills. V2 stated R1's pain pump medication was put on hold, and there was no documentation since 9/12/24. V2 also stated she would have followed-up with the the pain clinic had she known there was a delay in getting the appointment. On 11/14/24 at 10:50 am, V19 Certified Nursing Assistant /Ancillary Clerk acknowledged she had not scheduled R1's appointment at the pain clinic for R1's pain pump refill. V19 also confirmed she had not documented any attempts to contact the pain clinic but had left numerous messages. V19 also stated V19 did not tell V2, Director of Nursing, so V2 could follow-up. The facility's undated Pain Management Policy documents: If the resident's pain is complex or not responding to standard interventions, the attending physician may consider additional consultative support. If a consultant is involved in managing pain, the attending physician will maintain an active role by reviewing the consultant's recommendations, addressing medical issues that affect pain, monitoring for complications related to treatment, and evaluating subsequent progress. The physician should not simply defer to the consultant for all pain-related issues.

Based on record review and interview the facility repeatedly failed to follow their policy to maintain complete and accurate medical records for two (R1, R25) of 18 residents reviewed for medical records on the sample list of 27. Findings include: The facility policy Charting and Documentation dated as revised July 2017, documents the following: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Charting and Documentation. The same policy documents: 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. 1.) On 11/14/24 at 1:30 pm, V28 Receptionist provided unsigned R1's SOAP (Subjective, Objective, Assess, and Plan) notes that did not include a full assessment of R1's past medical history, current status, diagnoses, medications, or review of systems. V28 stated V2, Director of Nursing provided the documents and said they were R1's physician progress notes. On 11/15/24 10:10 am, V2 Director of Nursing stated We (the facility) do not have R1's Physician Visit (Progress Notes) documentation, for the last three months. V2 then stated when (V17, Medical Director) assessed (R1) monthly. The nursing (department) just made SOAP (Subjective, Objective, Assess, and Plan) notes. Therefore, there is no full documentation of R1's assessments for the last three months (8/16/24, 9/20/24 and 10/16/24). V2 also confirmed V17 did not sign the nurses SOAP notes of R1's visits (8/16/24, 9/20/24 and 10/16/24), until 11/14/24. 35380 2. R25's Physician Progress Notes dated effective date 8/23/24, 9/27/24, and 10/25/24, all document R25's temperature, pulse, respirations, blood pressure, oxygen saturation, and weights, all having a November 2024 date. There are no current vital assessments documented for the actual vitals that were completed on the actual assessment dates of 8/23/24, 9/27/24, and 10/25/24. On 11/15/24 at 10:32 AM, V11 Administrator stated the Physician Progress Notes dated effective dates are the dates the actual assessment was completed by the physician (V27), and the vital sign information is not correct for the dates of the completed assessments.

Based on interview and record review, the facility failed to accurately obtain weights, obtain daily weights as ordered, and report significant weight changes to appropriate staff for one resident (R25) of one resident reviewed for weight loss in the sample list of 27. Findings include: R25's Physician Order Sheet (POS) dated November 2024, documents an order for daily weights every day shift every Monday, Wednesday, Friday, with an order start date of 9/30/24. R25's Electronic Medical Record (EMR) weight tracking from 9/30/24 through 11/11/24, documents various means of obtaining weights which include standing, sitting, and wheelchair. R25's EMR weights dated 10/4/24 is 107 pounds, and R25's weight documented on 11/11/24 is 96.0 pounds. This is an 11.46% weight loss from 10/4/24 and 11/11/24. There is no documentation in R25's medical record of this weight loss being reported to anyone. On 11/13/24 at 2:48 PM, V13 Licensed Dietician stated weights should be consistent with the same scale, around the same time of day, and with similar clothing on. V13 also stated if there is a weight differential it should be reported to a nurse and then followed through. The facility's Resident Weights Policy dated 2011 Edition, documents residents with significant weight changes or questionable weights will be re-weighed for verification and weight change of 5% in one month should be reported to the physician.

Based on interview and record review the facility failed to protect the resident's right to be free from abuse by failing to prevent misappropriation of a resident's narcotic pain medication. This failure affected one of three residents (R4) reviewed for abuse in the sample of six. Findings Include: The Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy dated 12/23/21 documents the term Abuse can includes misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. The Incident Report for incident of 7/12/24 documents R4 had an order for Hydrocodone (Opioid) to be taken every 6 hours. On 7/12/24, V9 Registered Nurse contacted Hospice to attempt to refill the Hydrocodone. At that time there were only 26 tablets remaining. V12 Hospice Nurse informed V9 that a refill of 60 Hydrocodone was delivered to the facility on [DATE]. Upon an initial investigation, it was determined that 60 tablets of R4's Hydrocodone were missing, along with the corresponding Controlled Drug Received/Record/Disposition Form. Based on the facility's investigation, it is believed that V5 Agency Registered Nurse stole 60 tablets of R4's Hydrocodone and the corresponding Controlled Drug Received/Record/Disposition Form. R4's Physician Order Sheet dated July 2024 documents R4 is diagnosed Alzheimer's Disease, Dementia, Behavioral Disturbance, Mood Disturbance, Anxiety, Seizures, Major Depressive Disorder, Heart Disease, and Muscle Weakness. R4's Physician Order dated 4/24/24 documents R4 was prescribed Hydrocodone-Acetaminophen 5-325 (Opioid) milligrams (mg) by mouth four times a day for pain. R4's Minimum Data Set, dated dated dated [DATE] documents R4 is severely cognitively impaired. R4 receives scheduled pain medication and uses non-verbal sounds to indicate pain. R4's Care Plan dated 7/10/24 documents R4 has the potential to experience pain. R4 is under the care of Hospice Services. R4's Controlled Drug Received/Record/Disposition Form documents on 6/26/24, the facility received 60 tablets of Hydrocodone/Acetaminophen 5-325 mg to be given to R4 four times per day. R4's Controlled Drug Received/Record/Disposition Form documents on 7/3/24, the facility received 60 more tablets of Hydrocodone/Acetaminophen 5-325 mg to be given to R4 four times per day. On 7/24/24 at 4:00 PM, V7 Licensed Practical Nurse (LPN) stated when he worked on the night shift from 7/9/24 to 7/10/24 he completed a narcotic medication count with the oncoming nurse (V5 Agency Registered Nurse) on the morning of 7/10/24. V7 stated the count for R4's Hydrocodone was 84 tablets. V7 stated there was a count sheet for 60 tablets that were delivered early July (none of which had been used yet) and then there was another count sheet that was currently being used for 60 tablets that had been delivered in June (24 tablets left). On 7/30/24 at 11:25 AM, V8 Agency Licensed Practical Nurse stated she completed a narcotic medication count at the start of her shift on the evening of 7/10/24 with V5 Agency Registered Nurse. V8 stated there were 22 tablets of R4's Hydrocodone at the start of her shift. V8 stated there was only one count sheet for R4's Hydrocodone and 22 tablets left. On 7/30/24 at 12:00 PM, V9 Registered Nurse stated she worked on the day shift on 7/12/24. When she started her shift the count for R4's Hydrocodone was 17 pills and V9 stated she called R4's Hospice for a refill. V12 Hospice Nurse informed V9 that a refill of 60 tablets had been sent on 7/3/24 and another refill should not be needed. V9 stated this is when she realized something was wrong and there were 60 tablets of Hydrocodone missing. V9 stated she notified V1 Administrator and V2 Director of Nurses. On 7/30/24 at 2:30 PM, V1 Administrator confirmed 60 tablets of R4's Hydrocodone and the corresponding Controlled Drug Received/Record/Disposition Form went missing on 7/10/24 and the medication hasn't been found. V1 confirmed they believe V5 Agency Registered Nurse is the alleged perpetrator who stole R4's Hydrocodone.

Based on interview and record review, the facility failed to provide safe and effective supervision of R1 during a transfer to prevent a traumatic fall. This failure resulted in R1 falling from a mechanical lift to the floor resulting in a hip fracture requiring emergency medical treatment and surgical repair at the hospital. R1 is one of four residents reviewed for accidents in the sample of four. Findings include: R1's medical diagnosis list (4/25/2024) documents R1's diagnoses include: Muscle Weakness, Paraplegia, History of Cerebral Infarction (partial brain tissue death due to disruption in blood flow), Osteoarthritis, Presence of Artificial Knee Joint, Apraxia (neurological disorder causing difficulty with skilled movements even when a person has the ability and desire to do them), Dementia, Major Depression Disorder, and Anxiety Disorder. R1's quarterly assessment (2/6/2024) documents R1 has severely impaired cognition, upper and lower extremity impairment limiting range of motion, and is completely dependent on staff for all activities of daily living. The same record documents R1 requires staff assistance to transfer from a chair to a bed. The facility Incident Report and Investigation (4/7/2024) documents V3 (Certified Nurse Aide) and V4 (Certified Nurse Aide) were transferring R1 from R1's reclining chair to R1's bed on 4/6/2024 using a sling and mechanical lift. The report further documents when V3 lifted R1's legs, one of the four main straps attaching the sling to the lift slipped free from the lift causing R1 to fall abruptly to the ground striking R1's left hip onto the metal frame of the lift. The same report documents upon assessment, R1's left leg was externally rotated and shortened after the fall and R1 was sent to the hospital emergency department for evaluation and treatment and subsequently was admitted to the hospital for a hip fracture and received surgery on 4/7/2024. The hospital Emergency Department report (4/6/2024) documents R1 presented to the department after a fall from a lift in the nursing home for evaluation of left hip pain and a head injury (hematoma) and received fentanyl (narcotic medication used to treat severe pain) while in the emergency department. The same record documents R1 was diagnosed with a hip fracture and received orthopedic surgery on 4/7/2024. On 4/26/2024 at 11:50 AM, V3 reported, (R1) was kinda shocked at first (after falling from the lift to the ground) then started yelling in pain. (The) EMT (Emergency Medical Technicians) gave (R1) Fentanyl (narcotic medication used to treat severe pain) and (R1) was still screaming afterwards and they were wondering if (R1) was just scared. V3 reported R1 hit R1's head on the floor during the fall and R1 is still experiencing pain when staff move R1's leg. On 4/26/2024 at 1:08 PM, V4 reported V4 and V3 had positioned R1 in the lift sling and R1 had been elevated into the air above R1's chair and when V3 adjusted R1's legs, the top left sling loop attached to the lift became free and R1 fell to the ground. V4 reported R1 continued to yell out in pain after falling from the lift to the ground. V4 reported attending a facility in-service after R1's fall where facility staff were instructed on making sure slings are attached properly when using mechanical lifts to transfer residents. R1's Order sheet (4/26/2024) documents R1 was ordered tramadol (narcotic medication used to treat moderate to severe pain) and daily surgical wound antiseptic treatment upon returning to the nursing home after R1's fall on 4/6/2024. R1's Care Plan (4/26/2024) documents R1 is at risk for falls and was revised on 4/8/2024 with the new fall intervention Staff education on (mechanical lift) use.

Based on interview, and record review, the facility failed to protect a resident from mental abuse by an employee for one (R1) of five residents reviewed for abuse in the sample list of five. R1 was subjected to psychosocial harm by having R1's picture posted on a social media platform by facility staff. Findings include: The facility's Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy revised 12/23/21 documents: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, and mental abuse, including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Mistreatment means inappropriate treatment or exploitation of a resident Mental abuse includes but is not limited to, humiliation, harassment, threats of punishment or deprivation. Taking photographs or recordings of a resident and or his private space without the resident's or designated representative's written consent, is a violation of the resident's right to privacy and confidentiality. If a photograph or recording of a resident, or the manner that it is used, demeans or humiliates a resident, regardless of whether the resident provided consent or regardless of the resident's cognitive status, is considered mental abuse. The facility's First and Final Reportable form dated 12/13/21 documents the following: V1 Administrator was notified on 12/13/21 that V4 Certified Nursing Assistant (CNA) took a photograph of R1 and sent it to a coworker via a social media platform. V1 and V2 Director of Nursing (DON) met with V4, and V4 admitted to taking the photograph and sending it to a coworker. V4 thought R1 looked cute, and meant no harm. V4's actions were considered a terminable offense, and V4's employment was terminated. R1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's 9/5/17 Policy Addendum signed by V4 on 11/17/21 documents: Cell phones are not at any time to be on person when in resident areas, hallways, dining rooms, staff break room, etc (etcetera). Cell phones may only be used outside of the building, and must remain in your pocket until you have exited the building. Upon entering the building, your cell phone must immediately return to your locker or to a designated area where your personal items are kept. At no time should your cell phone remain on your person. V4's payroll form documents the facility terminated V4's employment on 12/13/21. On 12/27/21 at 8:42 AM, V1 stated: On 12/13/21 in the early afternoon, V6 Interim Memory Care Unit Director reported to V1 that V6 had heard a CNA (V4) had taken a picture of R1 and sent the picture to another employee. V1 Administrator, and V2 DON met with V4 that evening, and V4 admitted to taking the photograph and sending it via a social media platform to another CNA (V8). V4 denied sending the photograph to any other staff. V1 wasn't sure when the photograph was taken, and V1 did not see the photograph. V4 told V1 that in the photograph R1 was in the bathtub, and R1 had fallen asleep. R1 was covered, and R1's body was not exposed. V4 told V1 that V4 thought R1 looked cute as V4's rational for taking R1's photograph. Abuse was substantiated, and V4's employment was terminated. On 12/27/21 at 9:50 AM, V6 stated: On 12/13/21 V9 CNA informed V6 that V7 (former CNA) had electronically received a photograph of R1 sitting in a bathtub covered in a blanket. On 12/27/21 at 10:28 AM, V9 stated: On 12/12/21 at an unidentified time V7 told V9 that V7 received a photograph of R1 sent by V4 via a social media platform. V9 did not see the photograph. V7 told V9 that the photograph consisted of R1 sitting in a bathtub, and R1 was covered with a bath towel. On 12/27/21 at 11:22 AM, V4 stated: About two weeks before 12/25/21 around 3:00 AM, V4 was washing wheelchairs in the shower room on the memory care unit. R1 was in the bathtub and covered with a bath towel. V4 took a picture of R1 on V4's personal cell phone and sent the picture via a social media platform to a coworker (V8) who was working on the unit. V4 thought R1 looked adorable since R1 fell asleep in the bathtub. V4 didn't mean any harm and V4 wasn't thinking when V4 took R1's picture. V4 confirmed R1's photograph was also sent to V7 former CNA. On 12/27/21 at 2:04 PM, V14 (R1's Power of Attorney) stated, V1 had informed V14 that an employee had taken R1's photograph, that it was against the facility's policy, and the employee was terminated. V14 was not given specific details of R1's photograph, and was only informed that R1's photograph had been taken. V14 was asked how R1 would have felt if R1 was aware that R1 was photographed while in the bathtub and covered with a bath towel. V14 stated, V14 could only imagine how R1 would have felt. R1 would not have been pleased with the photograph being taken. R1 would have been devastated if R1 knew about that photograph. There is no documentation in R1's medical record that R1's Physician (V23) was notified of R1's abuse allegation

Based on interview and record review the facility failed to implement a physician-ordered breakaway lap cushion for one of three residents (R2) reviewed for falls in the sample of three. This deficient practice resulted in R2 falling from her wheelchair and sustaining a fractured left femur. The findings include: R2's Incident Report states R2 fell on [DATE] at 6:30 PM. Progress Note, dated 4/13/17 at 8:04 PM, states R2 was found sitting on the floor in front of her wheelchair with her left leg bent and looking displaced. R2 was unable to recall how she fell . R2 was assessed by nurse and staff and had pain with movement to her left leg. Z1 (Physician) was notified and gave orders to send R2 to the hospital for evaluation and treatment. R2 left facility at 7PM via ambulance. At 9:27 PM, R2 was admitted to the hospital for fracture to distal end of left femur. On 6/22/17 at 2:00 PM, E2 (Director of Nurses) stated on 4/13/17 about an hour before R2 fell , E4 (Registered Nurse) obtained an order from Z1 for use of a breakaway lap cushion for R2. E2 stated the breakaway lap cushion was never put on because R2 was going to the dining room and it was going to be removed anyway. E2 confirmed that following the meal, R2 left the dining room on her own and fell out of her wheelchair. R2's Physician Telephone Order, dated 4/13/17, states a breakaway lap cushion to wheelchair for positioning and safety as needed. Remove and reposition every two hours. Remove at meals was ordered by Z1 and signed by E4. Radiology/Diagnostics Consultation for Z2 (Radiologist) for lower left leg X-ray completed on 4/14/17 states E2 fell out of her wheelchair and complained of pain to her left knee to mid shaft of the left lower leg. X-ray impression: Minimally displaced comminuted periprosthetis fracture involving the distal left femur. Z2's consultation report dated 4/14/17 states (R1) presents after a fall and noted injury to her left lower extremity. X-rays demonstrate there is a supracondular fracture above the well-fixed femoral component of the left knee.

Based on record review and interview the facility failed to obtain involve the resident's physician and obtain treatment orders timely related to a change in condition after a fall for one of seven residents (R1) reviewed for falls in the sample of seven. R7 sustained a head injury and subsequently died . Findings include: The most recent MDS (Minimum Data Set) prior to discharge date d [DATE] shows R1 cognitively intact (Brief Interview of Mental Status ,[DATE]). The Physicians Orders dated [DATE]-[DATE] shows [DIAGNOSES REDACTED]. The current physicians orders show R1 takes the [MEDICATION NAME] 60 mg (milligrams) at 7:00 am, [MEDICATION NAME] 20 mg at 7:00 and [MEDICATION NAME] 4 mg at 4:30 pm daily. The Nurses Notes on [DATE] at 7:15 pm by E4 (Licensed Practical Nurse) notes: "(R1) found on floor laying on backside at the nurses station. (R1) alert/oriented and verbal states 'I was trying to get (another residents) ice cream'.....Large bump noted to back of head, backside with redness, moves extremities WNL (within normal limits). Hand grasps equal. Bilateral eyes PEARL (pupils equal and reactive to light)...." On [DATE] nursing notes by E5, Licensed Practical Nurse (LPN) at 3:00 pm state: VS (Vital signs) ...(blood pressure) ,[DATE]. Resident complains of headache. Tylenol given. Resident did not recognize son. Resident drowsy, will continue to monitor. During interview with Z1/son of R1 on [DATE] at 9 a.m., Z1 stated that when he arrived at the facility on [DATE] (the day following the fall) "(R1) did not recognize me." Z1 stated that this was unusual for R1. On [DATE] at 10:14 am E2 (Director of Nursing) stated, "I was here then ([DATE] at 3:00 pm)and we thought she (R1) was just tired so we laid her down." E2 stated they did not call the physician at that time regarding the blood pressure, the drowsiness or let the physician know that R1 did not recognize her son. On [DATE] Nursing Notes by E5/LPN at 4:45 pm indicating a change in condition state: Resident has increased lethargy, pupils no reaction, pin point in size, hand grasp unequal, difficulty swallowing, drooling noted. Called (Z2/R1 physician). No answer will continue to monitor. On [DATE] Nursing Notes by E5/LPN at 5:30 pm state: Resident in bed. B/P (blood pressure) ,[DATE], pulse 60....mental status decline continue to (try and) reach (Z2/R1's physician). On [DATE] Nursing Notes by E5/LPN at 6:15 pm state: Called son let him know of mental status decline and elevated B/P (blood pressure) asked if ok to send to (hospital) for CT (computerized tomography) to rule out bleed; permission given. On [DATE] at 9:53 am E5/LPN stated,".......I called the son at 6:15 pm and sent (R1) to the hospital. Day shift told me she was alert and oriented. Compared to what the day girls told me (R1) was very different - very slow and tired......Sometimes (R1) has high blood pressure but it would go down after am (morning) meds. This time it didn't. I just wanted her to be checked out - that's why I finally called the son." Nursing notes show R1 was transferred to the hospital at 6:45 pm on [DATE]. Hospital records indicate that R1's CT scan showed Intra Cranial Bleed. R1 was subsequently transferred to a larger hospital where she died four days later. Death certificate for R1 documents "Cause of Death: Respiratory Arrest due to or as a consequence of : Acute Right Parietal Hemorraghic Right Cerebral Hemorrhage due to or as a consequence of : Fall." On [DATE] at 10:30 am Z2 (Physician) stated (when asked about the delay in medical treatment for [REDACTED]. Three pm to 6:15 pm is a long time to wait before sending her in. They (facility) have sent residents to the ER (emergency room ) before talking to me and I have been fine with it."