Every finding on record at Seminary Manor

Based on interview and record review the facility failed to notify the Health Care Power of Attorney of a change of condition for one (R1) of three residents reviewed for notification of changes. Findings include:On 6/20/26 at 10:15 AM V4 (R1's Health Care Power of Attorney) stated that he was not notified of R1's wounds on his heels. I had to find them myself on 5/13/26 when I was clipping his toenails. Someone should have called me and let me know that he had wounds. R1's Medical Record documents that R1 had bogginess (physical finding where tissue feels soft, spongy, or mushy upon palpation) noted to his left heel on 4/17/26.R1's Medical Record documents that he had an intact blister to his right heel discovered on 4/25/26. R1's notes included physician notification and new treatment orders for each wound.R1's Medical Record did not contain any documentation that V4 (R1's Health Care Power of Attorney) was notified of either wound finding (4/17/26 and 4/25/26.) On 6/22/26 at 9:00 AM V2 (Director of Nursing) confirmed that R1's Medical Record did not contain any documentation that V4 (R1's Health Care Power of Attorney) was notified that he had wounds. If they (nurses) did not document it, then it was not done. It should be documented in his notes and his Power of Attorneys should always be notified of wounds.The Facility's Change in a Resident's Condition policy dated 07/1998 documents Unless otherwise instructed by the resident the nurse will notify the resident's representative when b. there is a significant change in the resident's physical, mental or psychosocial status. Except in medical emergencies, notification will be made within twenty four hours of a change occurring the resident's condition or status.

Based on interview and record review the facility failed to prevent employee to resident mental abuse for one (R1) resident out of seven reviewed for abuse. This failure caused R1 to feel blindsided, dumbfounded, and embarrassed. Findings include:The facility policy, Abuse Prohibition and Reporting (elder Justice Act), revised 11/28/19, documents not in its entirety, To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms.Shift coordinators and shift nurses, will be instructed to be aware of inappropriate staff behavior and take the necessary procedure for correction of these behaviors. They would include, but not limit to derogatory language, rough handling, ignoring resident requests, and not observing appropriate safety measures that would endanger resident.Facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator then the facility employee or agent should immediately report the matter to the facility DON (Director of Nursing).The administration shall notify the resident's representative of the alleged abuse.If the incident involves alleged abuse and evidence indicates that an employee is the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident.Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident.The following will be documented in the resident's medical record: a. The nature and extent of any injuries sustained or the condition resulting from the alleged incident. B. Whether the resident was sent to the hospital. C. Whether the resident's physician was called. R1's resident face Sheet documents that R1 admitted to the facility on [DATE] and R1's diagnoses on admission include but are not limited to Acute respiratory Failure with Hypoxia, Peripheral Vascular Disease, General Anxiety Disorder and Benign Prostatic Hyperplasia. R1's current plan of care shows no documentation regarding psychosocial well-being or interventions. On 4/24/26 at 3:00pm, R1 stated that on the morning of April 15th around 5:30am he had placed his call light on because he had to use the bathroom. A CNA (Certified Nursing Assistant) came in and asked him what he needed and he told her he needed to use the bathroom so the CNA grabbed the bedside urinal and threw it at his groin, then grabbed his penis and pushed it down toward the urinal but it didn't feel right but the CNA would not listen and just yelled, it's in, go! R1 went on to tell the CNA that it (penis) was not in the urinal and the CNA yelled again, It's in, use it! So R1 proceeded to urinate at which time R1 felt urine go all over him and the bed. R1 stated that the CNA was not happy about the mess and proceeded to forcefully close the curtain between his bed and his roommates and forcefully sat R1 up on the side of the bed at which time a second CNA, not sure of her name, came in to help. The second CNA saw how angry the first CNA was about the mess and told the first CNA that she would clean it up and so the first CNA left the room. R1 stated that the CNA who was rough with him was an older lady, late 50's, and heavy set but not sure of her name. R1 stated the whole thing blindsided me; I was dumbfounded but not afraid. I was concerned and embarrassed by the whole mess. R1 also stated, No one from this facility has come to talk to me about what occurred, they have talked to my son and (R2) but not me. On 4/28/26 at 11:00am, V3 (Assistant Director of Nursing) stated that she did not speak with R1 or follow-up with him after the incident was reported to see how he was doing. On 4/28/26 at 11:15am, V4 (Social Service Director) stated that she has not spoken with R1 regarding the allegation and she has not followed up with R1 at all to check on his well-being. On 4/28/26 at 11:20am, V5 (Social Service/admission Director) confirmed that she had not personally been able to speak with R1 regarding the incident, so she does not know how he feels or what his account of the story is but V16 (Manager of assisted living) had come over and attempted to speak with R1. R1 had told V16 that he was advised not to talk. V5 also stated, I'm not sure if anyone else in our facility was able to talk with him (R1). On 4/28/26 at 11:35am, V6 (Licensed Practical Nurse), when asked about checking on R1's psychosocial well-being, stated, When I work, I talk to him and all of my residents to see how they are doing but I did not talk to R1 about anything specific related to the incident. On 4/28/26 at 2:15pm, V2 (Director of Nursing) verified that R1's Care Plan had not been revised to address R1's psychosocial well-being after the incident. On 4/28/26 at 3:45pm, V1 verified that there is no documentation in R1's medical record or investigation to prove attempts were made by the facility to speak with R1. When asked if there was any follow up to check on R1's psychosocial well-being after the allegation V1 stated, I did not see any reason to, he was showing no signs of distress. When asked if R1 not wanting to speak with facility staff could be seen as distress, V1 stated, In my mind he did not want to talk with us because the family is talking about litigation, it had nothing to do about his psychosocial well-being. The facility's investigation file documents V20 CNA was terminated at approximately 8:45 AM on the morning of 4/16 for poor quality of care, being discourteous and failure to perform job duties.

Based on interview and record review the facility failed to report an allegation of abuse to the Abuse Coordinator for one (R1) of seven residents in a sample of seven reviewed for abuse. Findings include:The facility policy, Abuse Prohibition and Reporting (elder Justice Act), revised 11/28/19, documents not in its entirety, To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms.Shift coordinators and shift nurses, will be instructed to be aware of inappropriate staff behavior and take the necessary procedure for correction of these behaviors. They would include, but not limit to derogatory language, rough handling, ignoring resident requests, and not observing appropriate safety measures that would endanger resident.Facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator then the facility employee or agent should immediately report the matter to the facility DON (Director of Nursing).The administration shall notify the resident's representative of the alleged abuse.If the incident involves alleged abuse and evidence indicates that an employee is the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident.Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident.The following will be documented in the resident's medical record: a. The nature and extent of any injuries sustained or the condition resulting from the alleged incident. B. Whether the resident was sent to the hospital. C. Whether the resident's physician was called. R1's resident face Sheet documents that R1 admitted to the facility on [DATE] and R1's diagnoses on admission include but are not limited to Acute respiratory Failure with Hypoxia, Peripheral Vascular Disease, General Anxiety Disorder and Benign Prostatic Hyperplasia. On 4/24/26 at 2:00pm, V15 (R1's son) stated he told V1 (Administrator) that he was not notified by the facility of the abuse allegation and had to find out about the incident from his dad, R1, and roommate R2 when he arrived at the facility on 4/15/26. V15 stated that V1 told him she had just heard about this situation and to give the facility time to investigate the situation. V15 also stated that the following day when R1 and R2 were being interviewed by local police, V1 came to the room and R2 pointed at V1 and told the police that he had reported to her the morning of the incident. On 4/24/26 at 3:00pm, R1 stated, No one from this facility has come to talk to me about what occurred, they have talked to my son and (R2) but not me. On 4/28/26 at 9:50am, R2 stated around 6am on 4/15/26, he told the CNA (Certified Nursing Assistant), unknown to R2 but verified later as V8/CNA, that he wanted to report an abuse complaint on a third shift CNA so V8 got V6 (Licensed Practical Nurse) who came to R1 and R2's room and told R1 and R2 that she would need to get someone else for them to talk to. On 4/28/26 at 11:53am, V8 (Certified Nursing Assistant/CNA) stated that approximately 9:00am on 4/15/26, R2 approached her asking who worked third shift last night and he appeared upset. V8 told R2 she was not sure because she did not see them that morning. R2 went on to tell her he thought his roommate, R1, had been abused. R2 told V8 that there were two girls one of them was nice the other one was not, ripped curtain closed. R2 stated that his roommate, R1, told him what happened, third shift CNA was very rough with him and something with a urinal. V8 stated that she went to the nurse, V6 (Licensed Practical Nurse), and told her that R2 stated he thought his roommate was abused by third shift and asked her to go to the room with her. V8 stated that she and V6 went down to the room and when they got there, V6 asked R1 to hold on she was going to go get Social Service, so he did not have to repeat himself. When V8 was asked who the Abuse Coordinator is and who do you report abuse to V8 stated, I don't know who the Abuse Coordinator is but would report to the nurse and maybe the Administrator about it. When asked if she reported the allegation of abuse to the Administrator, she stated she did not. On 4/28/26 at 11:35am, V6 (Licensed Practical Nurse) stated that V8 (Certified Nursing Assistant) came to her around 10:00am, may be 11am give or take on 4/15/26 and reported that R1 had a complaint about third shift but did not elaborate. V6 stated she went down to R1's room and asked him what she could help him with and R1 stated he had a complaint about a third shift CNA (Certified Nursing Assistant). V6 told him she would go get Social Services, so he did not have to repeat himself. V6 stated that she called V5 (Social Service/admission Director) and told her R1 had a complaint and was told she would come and talk with R1. V6 also stated that she became aware that it was an abuse allegation when she took R1's son, V15, down to talk with Social Services and V15 stated to them, This is elder Abuse. On 4/28/26 at 11:20am V5 (Social Service/admission Director) who stated that she was told by V6 (Licensed Practical Nurse) around 11:00am on 4/15/26 that R1 had a complaint but did not state what the complaint was so V5 went down to R1's room to speak with him but R1 was sleeping and his roommate R2 had a visitor. V5 stated she attempted again but R1 was at lunch the second time. V5 stated before she could attempt to go speak with R1 again, V6 brought R1's son, V15, to her office around 3:45pm. V5 stated that she and V4 were in the office and V15 came in stating, This is Elder Abuse. This was the first time I heard anything about abuse. On 4/28/26 at 2:15pm, V2 stated that it is the policy of the facility that if staff hear the words abuse or suspect abuse they are to go directly to the Administrator who is the Abuse Coordinator to report it and if Administrator is not available then they would come to me (Director of Nursing) and if I am not available they are to go to Human Resources. They are to keep calling or looking until one of us is available. On 4/28/26 at 3:45pm, V1 (Administrator) who stated she became aware of the allegation between 3-4pm on April 15th. V1 stated, it is the expectation of staff to report any allegation of abuse to the Administrator, Me in this instance, immediately.

Based on interview and record review the facility failed to thoroughly investigate an allegation of abuse for one (R1) of seven residents in a sample of seven reviewed for abuse. Findings include:The facility policy, Abuse Prohibition and Reporting (elder Justice Act), revised 11/28/19, documents not in its entirety, To protect residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms.Shift coordinators and shift nurses, will be instructed to be aware of inappropriate staff behavior and take the necessary procedure for correction of these behaviors. They would include, but not limit to derogatory language, rough handling, ignoring resident requests, and not observing appropriate safety measures that would endanger resident.Facility employee or agent who becomes aware of alleged abuse or neglect of a resident should immediately report the matter to the facility Administrator or designee. If allegation involves the Administrator then the facility employee or agent should immediately report the matter to the facility DON (Director of Nursing).The administration shall notify the resident's representative of the alleged abuse.If the incident involves alleged abuse and evidence indicates that an employee is the perpetrator of the abuse, then the Administrator shall immediately suspend the employee suspected to be involved in the alleged abuse without pay pending investigation of the incident.Interviews with all involved parties or potential witnesses will be completed. If possible, at least two interviewers shall be present for each witness interview. At least one interviewer shall take notes. Signed statements from those persons who saw or heard information pertinent to the incident shall be obtained. Statements shall be taken from the suspect, the person making the accusations, the resident abused or neglected (if cognitive level permits), other staff or residents who may have witnessed the incident, and any other person who may have information related to the incident.The following will be documented in the resident's medical record: a. The nature and extent of any injuries sustained or the condition resulting from the alleged incident. B. Whether the resident was sent to the hospital. C. Whether the resident's physician was called. R1's resident face Sheet documents that R1 admitted to the facility on [DATE] and R1's diagnoses on admission include but are not limited to Acute respiratory Failure with Hypoxia, Peripheral Vascular Disease, General Anxiety Disorder and Benign Prostatic Hyperplasia. On 4/24/26 at 3:00pm, R1 stated, No one from this facility has come to talk to me about what occurred, they have talked to my son and (R2) but not me. R1's electronic medical record or the facility reported incident investigation dated 4/15/26 has no documentation that the facility spoke with R1 regarding the allegation of abuse reported on 4/15/26. On 4/28/26 at 2:15pm, V2 (Director of Nursing) verified that there is no documentation in R1's medical record or the investigation that the facility attempted to interview R1 regarding the allegation. On 4/28/26 at 3:45pm, V1 verified that there is no documentation in R1's medical record or investigation to prove attempts were made by the facility to speak with R1.

Based on interview and record review, the facility failed to ensure a resident was free from sexual harassment by another resident, for one of three residents (R2), reviewed for abuse, in a sample of three.Th facility policy, Abuse Prohibition and Reporting, dated (revised) 11/28/19 directs staff that the facility prohibits abuse. The purpose of the policy is to protect residents from any kind of abuse such as verbal, sexual, mental, physical. The facility's definition of sexual abuse includes, but is not limited to, sexual harassment, sexual coercion or sexual assault.R1's current Physician Order Sheet, dated March 2026 documents that R1 was admitted to the facility on [DATE].R1's current Minimum Data Seat Assessment, dated 11/29/25 documents R1's cognitive status as 10 out of 15 (moderate impairment).R1's current Care Plan includes the following Problem Areas: (R1) has a history of displaying multiple behaviors including exit seeking, physical and verbal behaviors directed towards others and rejection of care, specifically showers, and use of sunscreen in the summer. Verbal and physical behaviors are directed towards staff and are frequently the result of redirection from rejection of care, or as a result of delusions. At times, verbal behaviors will be inappropriate comments towards female staff during cares. He frequently displays delusions related to needing to find family members, his car, calling the police, etc. Delusions cause him to be agitated, which does contribute to behavioral symptoms. R2's current Physician Order Sheet, dated March 2026 documents that R2 was admitted to the facility on [DATE].R2's current Minimum Data Set Assessment, dated 2/4/26 documents R2's cognitive status as 11 out of 15.A review of R2's current Care Plan, as of 3/17/2026 does not include any Problem areas to indicate that R2 makes false allegations against staff or other residents.The facility form, Final Submission of Alleged Resident to Resident Inappropriate Comment documents, On January eighth at five thirty in the morning, (V7/Certified Nursing Assistant/CNA) made a report to (V3/Agency Nurse) that she was advised by (R2) that (R1) had made an inappropriate comment to her in the facility (North) dining room. (V3) reported the incident to (V21/Licensed Practical Nurse/LPN). (R1 and R2) were no longer in contact when (V21/LPN) reported the issue to V7/Certified Nursing Assistant/CNA). (V21/LPN) advised (R1) that making inappropriate comments to other residents is not acceptable. (V3/Agency Nurse) escorted (R1) to the south side of the building where (R1's) room and dining room are located. (V21/LPN) advised (V2/Director of Nurses/DON). (V2/DON) advised (V1/Administrator). An investigation was initiated immediately. The POAs (Power Of Attorneys) and physician for both were notified of the situation. The initial report was sent to the (State Agency) within two hours of occurrence. No staff members or other residents witnessed the incident per (R2) and staff working in the area. On 1/8/2026, (V2/Registered Nurse Supervisor) interviewed R2. (R2) stated that (R1) told her he would like to see her breast and touch them in a sexual manner. (R2) stated she told (R1) to stop talking to her that way and (R1) did stop immediately. (R2) stated she reported the incident to keep other women from receiving similar comments from (R1). On 1/12/26, (V1/Administrator) interviewed (R1). (R1) stated that he had no memory of the incident. (R1) stated that he knew that speaking to a woman in a sexual manner would be inappropriate and stated he would never talk to a woman that way. (R2) has trouble remembering events which makes educating him on these manners difficult. Based on review of the situation that occurred on 1/8/26 and both resident's condition, it was founded that abuse was not substantiated due to (R1) not having the capacity to understand his actions.On 3/12/26 at 10:55 A.M., R1 was seated in a wheelchair at the nurse's station, requesting a can of soda. R1 was alert and oriented to person and place. R1 was able to answer questions appropriately. R1 stated he was unable to recall an incident between himself and R2. R1 stated he knows better than to make sexual comments to others.On 3/12/26 at 11:03 A.M., R2 stated she was able to recall the events of 1/8/26. R2 stated it was early morning and both she and R1 were in the dining room waiting for the morning meal. R2 stated R1 told her he wanted to touch her breasts and made other graphic remarks. R2 states she was upset by R1's comments, and told the nurse about it immediately, as she didn't want any other female residents to be spoken to by R1, as she was. R2 states she makes a point to stay away from R1 and goes out of her way to avoid him.On 3/17/26 at 9:11 A.M., V7/Certified Nursing Assistant (CNA) stated she has been an employee of the facility since June 2022. V7/CNA stated R1 often times gets up early and goes over to the facility North dining room for coffee, early in the morning. States at the time of the incident, R2 hadn't been sleeping well and was often up in the facility North dining room also. V2 stated she was working with another staff member down the hall on the date of the incident and heard R2 yelling for staff. V2 stated R2 was wheeling her wheelchair with her feet, looking for staff and R2 was very upset and wanted to report to staff that R1 was making inappropriate comments to her, and she didn't want other female residents to be harassed by R1. V7/CNA stated she and V3/Registered Nurse (RN) immediately went to R1 and V3/RN escorted R1 back to his nurse's station on the facility south side. V7 states at that time, she no longer had any contact with R1 for the remainder of her shift. V7 states both R1 and R2 are oriented to time, place and purpose.On 3/18/26 at 1:01 P.M., V1/Administrator stated she arrived at the decision that the incident between R1 and R2 was not substantiated abuse due to R1 not having the capacity to understand his actions. When asked how she arrived at that decision, V1 stated by reviewing R1's medical chart and based on her interview with R2 and R2's reaction to it all. When asked if R1 understood basic social rules, was able to recognize that certain comments were inappropriate and if R1 was able to follow simple directions or redirections, V1/Administrator agreed R1 was able to do all of those things. V1 verified that R2 has not made any false allegations against staff or residents while residing in the facility. At that time V1/Administrator also confirmed the facility has a responsibility to ensure R2's resident rights to not be sexually harassed, were maintained.

Based on observation, interview and record review the facility failed to provide staff supervision during toileting for a resident that was assessed as requiring toileting assistance (R2), one of three residents reviewed for falls, in a sample of 3. This failure resulted in R2 being left unsupervised, falling from a toilet resulting in a head laceration, extensive bruising and fractured ribs. FINDINGS INCLUDE:R2's facility Resident Face Sheet documents that R2 was admitted to the facility on [DATE] with the following diagnoses: History of Falls, Displaced Fracture of Greater Trochanter of Left Femur, Need for Assistance with Personal Care, Weakness, Generalized Anxiety Disorder, Exudative Age-Related Macular Degeneration, right eye, Osteoarthritis, Asthma and Chronic systolic (congestive) heart failure.R2's Hospital History and Physical Transfer Notes document, (R2) has a past medical history significant for congestive heart failure (CHF), a fall, hypertension (HTN), hyperlipidemia, atrial fibrillation (a-fib), urinary incontinence, takotsubo syndrome, macular degeneration, and a history of an anterior wall myocardial infarction (MI) resulting in weakness. The patient fell and sustained a left femur fracture, for which an open reduction and internal fixation (ORIF) procedure was performed. (R2) admitted to Skilled Nursing Facility on 07/17/2025 for skilled nursing and rehab. (R2) asked to be seen by primary team to optimize therapy, pain control and discharge planning. (R2)'s plan and progress were discussed with nursing staff and therapy. Frequent monitoring and management by trained clinicians are essential to safeguard patient well-being, enhance recovery, and prevent clinical decline. The complexities of rehabilitation, chronic conditions, and individualized treatment plans necessitate regular assessments for early detection of complications, frequent adjustments of treatment plans and to promote patient safety. R2 becomes very anxious and starts to panic making her very unsafe at times.R2's Care Plan, dated 7/18/25 includes the following Problem Areas: (R2) is at risk for falling related to recent illness/hospitalization and new environment. (R2) has increased confusion and does attempt to get up (as desired) without using call light, despite numerous education attempts. (R2) has voiced to staff that she does not like to turn her call light on because she doesn't want to bother anyone. (R2) needs encouragement to utilize staff for help.R2's Fall Risk Assessment Tool, dated 7/18/25 documents, (R2) has a history of falls, is incontinent of bowel and bladder, receives opiates, diuretics, hypnotics, sedatives and psychotropic medication and requires assistance for mobility, transfers or ambulation. Score is 17: High Risk for Falls.R2's Occupational Therapy Screen, dated 7/18/25 documents, Toileting hygiene = Substantial/maximal assistance.R2's Minimum Data Set Assessment, dated 7/24/25 documents: Section GG: Toileting Hygiene/admission Performance - The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, include wiping the opening but not managing equipment: 02- Substantial/Maximal Assistance and Toilet Transfer/admission Performance - The ability to get on and off a toilet or commode: 01-Dependent.R2's Physician Progress Notes, dated 7/21/25 document, (R2) fell walking down some steps (and) did sustain a fracture of the left hip. (R2) is Non weight bearing and is Non ambulatory at this time. Diagnosis: Closed Fracture of Left Hip.R2's Nursing Progress Notes, dated 9/09/2025 at 10:19 A.M. document, This nurse was standing outside (R2's) room when a loud noise was heard and (R2) started to yell. This nurse entered the room and (R2) was noted to be laying on the bathroom floor with gait belt around waist. (R2) had her walker under her legs. (R2) was laying on her back. (R2) had a gash to bridge of her nose, her glasses were in place. (R2) had a laceration to her forehead and to her right upper arm. Cold compresses were applied to (R2's) forehead and to bridge of nose to help stop the bleeding. (R2) was (complaining) of leg pain. (R2's) right leg did have external rotation noted. (R2) denied any head or neck pain. Blanket was placed under her head. 911 was called for transport to Emergency Room. Emergency Medical Transport placed a sling under (R2) and manually lifted (R2) onto the stretcher. (R2) was alert and orientated and talking with staff the entire time.R2's Nursing Progress Notes, dated 9/09/2025 at 1:33 P.M. document, (R2) being admitted to hospital for multiple broken ribs at this time.R2's (Hospital) admission History and Physical, dated 9/9/25 documents, (R2) arrived at the emergency room from (the facility). (R2) was sitting on (the) toilet when she lost her balance and fell onto the floor. In this fall, (R2) suffered a laceration to her right forehead. (R2) has some skin tears to her left knuckle and right elbow. There is an abrasion to her chin. There is some bruising and swelling over her right clavicle and an abrasion and bruising on her nose. (Computerized Tomography/CT) of (R2's) head showed soft tissue thickening consistent with contusion of the scalp. CT of (R2's) facial bones showed contusions and hematomas. CT Angiogram of (R2's) chest showed right supraclavicular contusion and hematoma and nondisplaced fractures of the posterior left 8th and 9th ribs.R2's (facility) Nursing Progress Notes, dated 9/16/25 document that R2 was returned from the hospital. On 9/17/25 at 10:05 A.M., R2 was up in a wheelchair in her room. R2 was alert and able to answer questions appropriately. Extensive bruising was present no to (R2's) entire face, neck, hairline and visible arms and legs. A healing laceration was present to (R2's) right front forehead. At that time R2 stated, 'I'm in so much pain. They left me in the bathroom. They weren't supposed to, and I fell and broke my ribs. I can't hardly move anymore.On 9/17/25 at 11:07 A.M., V6/Certified Nursing Assistant (CNA) stated she was the CNA the day that (R2) fell. V6/CNA stated that R2 had been (in the facility) for a couple of months and we were trying to get (R2) to do more for herself. V6/CNA stated that (R2) had been in therapy and she thought R2 she was getting stronger. V6/CNA stated she walked R2 from just outside of her bathroom, with a gait belt and set her on the toilet and left. V6/CNA stated she walked down the hall to (another hall) and was standing there charting. V6/CNA stated she heard a yell and when she got to (R2's) room that (V3/Licensed Practical Nurse) was already in the room. V6/CNA stated that (R2) was bleeding pretty bad and was complaining of a lot of pain. V6/CNA stated she usually stayed with (R2) when she was in the bathroom, or stood right outside of the bathroom door, with the door cracked. V6/CNA stated (R2) had been in therapy and gotten so much stronger, I thought (R2) would be okay if I walked away.On 9/17/25 at 2:33 P.M., V2/Director of Nurses verified that R2 required extensive staff assistance for toileting, was very anxious and required frequent staff encouragement to use the call light for staff assistance. At that time V2/Director of Nurses stated that since R2's recent fall from the toilet, upon return to the facility, staff had updated her care plan to include not leaving R2 alone on the toilet.

Based on record review and interview, the facility failed to: (1) return resident trust fund balances for 46 residents (R1, R5-R49) reviewed for trust fund balances after being discharged /expired 30 days; and, (2) provide notification or trust fund balances reaching $200 less than the SSI/Supplemental Security Income resource limit for three residents (R2, R3, and R4), of 111 residents, reviewed for trust fund account balances, in a total sample of 111 residents. FINDINGS INCLUDE: 1) The facility admission Contract document: V. Deposits and Refunds: The Facility hereby acknowledges receipt of the deposit, if any, noted at the beginning of the contract. Any refund owed to the Resident for advance payments shall be paid by the Facility within forty-five (45) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid residents, any such refund will be paid within thirty (30) days of the Facility's receipt of the final Medicaid payment for care of the Resident or as directed by the Department of Public Aid. The facility policy, entitled Resident Trust Fund Account, document: 10. All facilities should dispose of any remaining resident's funds in accordance with State, Medicaid and Federal specific regulations within 30 days of discharge or expiration; and Uncashed Checks: Payees will be contacted regarding checks issued to close a resident trust account that have not be cashed within 2 months of being issued. Checks will be voided and reissued as necessary. If unable to contact payees within 6 months of issuing a check that has not yet been cashed, the check will be voided and turned over to the State Unclaimed Property Division.On [DATE], at 9:00 a.m., V8/Complainant-R1's daughter confirmed money in R1 Resident Trust Fund has not been returned, within 30 days of R1's discharge on [DATE].R1's Electronic Medical Record/EMR document, R1 was admitted , to the facility, on [DATE] and discharged on [DATE].R1's admission Contract was signed, by R1, on [DATE].R1's Resident Trust Fund Current Balance Report, as of [DATE], indicates a balance of $69.00. There is no evidence in R1's record that indicates R1's remaining balance was refunded.In addition, the EMR's for R5-R49, document the following dates of discharge [or expiration/death] and the Current Balance Report dated [DATE], document the balances remaining in their trust fund account: R5-[DATE] $61.87; R6-[DATE] $52.00; R7-[DATE] $39.60; R8-[DATE] $98.01; R9-[DATE] $105.00; R10-[DATE] $37.00; R11-[DATE] $708.30; R12-[DATE] $78.00; R13-[DATE] $26.00; R14-[DATE] $10.00; R15-[DATE] $35.00; R16-[DATE] $9.00; R17-[DATE] $30.00; R18-[DATE] $10.00; R19-[DATE] $100.00; R20-[DATE] $169.00; R21-[DATE] $66.00; R22-[DATE] $36.00; R23-[DATE] $6.00; R24-[DATE] $6.00; R25-[DATE] $8.00; R26-[DATE] $120.08; R27-[DATE] $54.02; R28-[DATE] $26.00; R29-[DATE] $0.87; R30-[DATE] $40.00; R31-[DATE] $103.46; R32-[DATE] $3.00; R33-[DATE] $0.25; R34-[DATE] $47.00; R35-[DATE] $153.27; R36-[DATE] $37.00; R37-[DATE] $29.00; R38-[DATE] $1,797.00; R39-[DATE] 288.00; R40-[DATE] $150.01; R41-[DATE] $2.00; R42-[DATE] $100.00; R43-[DATE] $10.00; R44-[DATE] $48.00; R45-[DATE] $12.00; R46-[DATE] $40.00; R47-[DATE] $39.00; R48-[DATE] $46.00; and R49-[DATE] $9.97 On [DATE], at 12:00 p.m., V1 confirmed refunds are needed to be made for the residents discharged /expired. On [DATE], at 9:00 a.m., V1/Administrator confirmed V1 and V5/Corporate Accounts Receiving verified the Current Balance Report, dated [DATE], which documents resident trust fund balances. 2)) The facility policy, entitled Resident Trust Fund Account, document: 9. Notification of Responsible Party for SSI Resource Limit / Personal allowance. When a Medicaid Resident's RTF [Resident Trust Fund] account reaches $200.00 less than the SSI resource limit, the RTF Custodian will notify the Resident, Legal Representative, and Social Services. The Social Security Administration website, document the individual resource limit is $2000.00 The facility document, entitled Current Balance Report, dated [DATE] document the following individual balances which exceed the SSI resource limit: R2 $2925.88; R3 $4450.68; and R4 $3449.00. On [DATE], at 12:00 p.m., V1/Administrator confirmed R2, R3, and R4's trust fund accounts exceed the SSI resource limit. During this interview, V3/Business office Manager confirmed V3 started in V3's position four months ago; V3 is still training/learning; and V3 was unaware of the SSI resource limit. On [DATE], and 10:47 a.m., V1 confirmed there is no written documentation that R2, R3, and R4, were notified that their accounts reached the $200.00 less than the SSI resource limit.

Based on interview and record review, the facility failed to conduct quarterly QAPI/Quality Assessment Plan Improvement meetings. This has the potential to affect all 97 residents living in the facility. Findings include: Facility QAPI Plan, dated 3/31/25, documents The Committee is responsible for meeting on a quarterly basis. Facility provided QAA sign in sheets dated 3/6/25 and 4/24/25. No other QAA sign in sheets were available to review after the previous survey date of 8/7/24. On 5/13/25 at 12:53PM, V1 Administrator provided two QAA sign in sheets for the past year of QAA meetings. At that same time, V1 stated she cannot find any QAA sign in sheets prior to March 2025. V1 stated when V1 temporarily left in July 2024, QA meetings were not being held in her absence. Centers for Medicare and Medicaid Services (CMS) form 671 Long-term Care Facility Application for Medicare and Medicaid, dated 5/13/2025, signed by V1, document 97 residents reside in the facility.

Based on interview and record review, the facility failed to identify, monitor and review antibiotic use for five of five residents (R25, R40, R47, R74, R297) reviewed for antibiotic stewardship in the sample of 44 residents. This failure has the potential to affect all residents who reside in the facility with a current census of 97 residents. Findings include: The Infection Control policy revised 12/17/19 documents the Infection Control Committee shall be responsible for surveillance or known nursing home potential infections, the review and analysis of actual infections, the promotion of a preventative and corrective program designed to minimize infection hazards. Follow the Antibiotic Stewardship Program and develop a practical system of reporting, evaluating and keeping records of infections in order to provide an indication of an outbreak level of nosocomial infections and trace the source. The Infection Control Committee reviews the system for reporting, evaluation and keeping records of infections among residents in order to provide an indication of the endemic level of all nosocomial infections to trace the source of infection and to identify epidemic or potential epidemic situations. Nursing staff will develop weekly reports on antibiotics including a review to ensure appropriate use of antibiotics. The Antibiotic Stewardship policy revised 12/18/19 documents the purpose of the program is to reduce inappropriate use of antibiotics, improve resident outcomes and lessen adverse events. The facility will track antibiotic use daily. The facility will ensure the pharmacy reviews all antibiotic usage appropriateness. Centers for Medicare and Medicaid Services [CMS] Form 671 [Long-term Care Facility Application for Medicare and Medicaid], dated 5/13/2025, signed by V1/Administrator, document 97 residents reside in the facility. 1. R25's Medication Administration Record (MAR) dated May 2025 documents Macrodantin (antibiotic) was ordered on 9/24/24 for a Urinary Tract Infection and continues to be administered daily. R25's Progress Note dated 9/18/24 documents a response to an inquiry regarding the stop date of the antibiotic made on 9/17/24 was that the antibiotic was a maintenance dose for a history of Urinary Tract Infections and no stop date was ordered. The Infection Tracking Log dated January, February, March, April and May 2025 did not include R25's antibiotic or indication for use. The Pharmacist's Summary of Recommendations dated January, February, March, April and May 2025 did not include an evaluation for R25's Macrodantin prophylactic antibiotic appropriateness. 2. R40's Medication Administration Record (MAR) dated May 2025 documents Macrobid (antibiotic) was ordered on 2/21/25 for preventative use for Urinary Tract Infections and was administered daily until discontinued on 5/15/25. The MAR documents Levofloxacin (antibiotic) was ordered on 5/12/25 - 5/14/25 and 5/15/25 - 5/21/25 for a Urinary Tract Infection. R40's Progress Note dated 12/2/24 documents R40's physician ordered Macrobid daily for preventative use for frequent Urinary Tract Infections. The Infection Tracking Log dated February, March, April and May 2025 did not include R40's Macrobid antibiotic or indication for use. The Infection Tracking Log documents R40 had a Urinary Tract Infection on 5/10/25 and 5/15/25 and indicated a Culture, Laboratory Test or Radiology Exam was conducted although did not identify the test results/organism (results of the culture) and/or appropriateness of the antibiotic. The Pharmacist's Summary of Recommendations dated March, April and May 2025 did not include an evaluation for R40's Macrobid antibiotic appropriateness. 3. The Pharmacist's Summary of Recommendations dated March 2025 documents an evaluation of R47's Cephalexin (antibiotic) 3/6/25 - 3/13/25 for a diagnosis of Cough. The Infection Tracking Log dated March, April and May 2025 did not include an entry for R47's infection. 4. R74's Progress Note dated 3/20/25 documents to obtain a urinalysis and start Keflex for seven days until urine culture and sensitivity results come back; and 3/22/25 documents to start Cipro for three days for Pseudomonas Aeruginosa. The Infection Tracking Log dated March 2025 indicated a Culture, Laboratory Test or a Radiology Exam was conducted although did not identify the test results/organism and/or the appropriateness of the antibiotic nor the antibiotic ordered on 3/31/25. The Pharmacist's Summary of Recommendations dated March, April and May 2025 did not include an evaluation for R74's Keflex or Cipro antibiotic appropriateness. 5. R297's Medication Administration Record (MAR) dated April 2025 documents Fluconazole (antifungal) was ordered 4/4/25 - 4/9/25 for a rash and nonspecific skin eruption; Azithromycin (antibiotic) was ordered 4/10/25 - 4/14/25 for Atelectasis; Cefpodoxime (antibiotic) 4/15/25 - 4/19/25 for Acute Cystitis; and Levofloxacin (antibiotic) 4/21/25 - 4/27/25 for Acute Cystitis. R297's Progress Note documents on 4/4/25 Fluconazole (anti-fungal) was ordered for four days due to redness and tenderness in the peri-area; on 4/10/25 received order for Azithromycin (antibiotic) received per chest x-ray results; on 4/13/25 completed antibiotic for Pneumonia; on 4/14/25 a new order for Vantin/Cefpodoxime (antibiotic) was ordered for Acute Cystitis; on 4/18/25 remains on antibiotics for Upper Respiratory Infection; on 4/24/25 was treated for a Urinary Tract Infection for Extended Spectrum Beta-Lactamase (ESBL/antibiotic resistant bacteria/organism); and on 4/25/25 a chest x-ray was conducted. The Infection Tracking Log dated April 2025 documents on 4/10/25 and 4/14/25 a Culture, Laboratory Test and/or Radiology Exam was conducted although did not identify the test results/organisms nor the antifungal on 4/6/25 and antibiotic ordered for treatment on 4/10/25. The Pharmacist's Summary of Recommendations dated April and May 2025 did not include an evaluation for R297's antifungal or Levofloxacin appropriateness. On 5/15/25 at 1:30 PM, V3 (Assistant Director of Nursing/Infection Preventionist) stated she only reviews and monitors residents on prophylactic antibiotics when they are first initiated and does not continue monitoring. V3 agreed the Infection Tracking Log did not track the Culture, Laboratory Test or Radiology Exam results, the log was not complete and the Pharmacist's Summary of Recommendations was not inclusive of all antibiotics or antifungals ordered. V3 agreed tracking the source of infections to identify epidemic or potential epidemic situations was not being conducted. On 5/15/25 at 2:15 PM, V1 (Administrator) stated the Infection Prevention Program has struggled with getting the required infection information in the new tracking system and ensuring it's accuracy.

Based on interview and record review, the facility failed to discontinue a PRN/as needed medication for one resident (R237) of 20 residents reviewed for unnecessary drugs in a sample of 44. Findings include: Facility Pharmaceutical Procedures, revised 1/5/23, documents It is the policy of the facility to review resident's medication on a regular basis in order to provide residents with only the necessary medication for their health needs. Facility Behavior Management Committee, revised 6/1/22, documents To ensure that each residents medication regimen is free of unnecessary medications. R237's current May 2025 physician orders documents Alprazolam 0.5 mg/milligrams tablet twice a day PRN for generalized anxiety with an order date of 3/12/25. R237's medical record documents the last time R237 received Alprazolam was on 4/9/25. On 5/15/25 at 2:45 PM, V2 DON/Director of Nursing verified R237's medical record had Alprazolam ordered PRN and needed to be discontinued.

Based on interview and record review, the facility failed to develop a Care Plan to include a blood thinner and Insulin for one resident (R235) of 20 residents reviewed for Care Plan development in a total sample of 44. Findings include: Facility Care Plan Policy, revised 6/1/22, documents It is the policy of this facility to develop a Comprehensive Person-Centered Care Plan as appropriate for each resident to meet a residents medical and nursing needs. R235's May 2025 Physician Orders include orders for Eliquis 5 mg/milligrams twice a day for Atrial Fibrillation, and Humalog Insulin per sliding scale four times a day for Diabetes. R235's May 2025 Medication Administration Record/MAR documents R235 is currently receiving his Eliquis and Humalog Insulin. R235's current Care Plan for May 2025 does not include R235's Atrial Fibrillation diagnosis or Eliquis, and does not include R235's diagnosis for Diabetes or Insulin. On 5/15/25 at 1:35 PM, V13 Care Plan Coordinator stated if the Eliquis and Atrial Fibrillation along with the Insulin and Diabetes was not on the Care Plan then she missed it. At that same time, V13 verified R235's Care Plan did not include the Insulin and Diabetes diagnosis or Eliquis and Atrial Fibrillation diagnosis and should.

Based on observation, interview, and record review, the facility failed to apply leg compression stockings for one resident (R69) of one residents reviewed for compression stockings in a sample of 44. Findings include: Facility Staff Nurse job description, revised 6/2012, documents Responsible for working in a team approach with the nurse aides to ensure residents are receiving said services. Prepares and documents treatments which are administered to residents as prescribed by the residents physician. R69's May 2025 Physician orders documents Tubi Grips (compression stockings) BLE/bilateral lower extremities on in the AM, and off at HS/bedtime. R69's May 2025 Treatment Administration Record documents R69 has her Tubi Grips on. On 5/15/25 at 1:35 PM, R69 was up in the activity area with her bilateral pant legs pulled up with no Tubi Grips, socks, or shoes on. At that same time, V11 CNA/Certified Nurse Aid stated they got R69 up today, are responsible for putting on R69's Tubi Grips, and verified R69 did not have on her Tubi Grips and should have them on her legs. V11 then went to R69's room and verified R69's Tubi Grips were in her top dresser drawer for use.

Based on interview and record review, the facility failed to identify potential triggers, triggers for a past trauma-related incident, or emotional support needed for one resident (R237) of one resident reviewed for trauma informed care in a sample of 44. Findings include: Facility Social Services Director policy, revised 9/2019, documents Provide social support for residents as needed. Assist with mood and behavior programming processes as needed. R237's medical record documents the following diagnoses: Generalized Anxiety Disorder, Psychotic Disturbance, Mood Disturbance, Major Depressive Disorder, and Hallucinations. R237's Social Assessment, dated 3/18/25, documents When a young child (R237's) parents separated and she went into an orphanage for awhile. Eventually, (R237's) parents got back together and took her back, then forced her to go back to school when she didn't want to. R237 was also Sexually Assaulted and experienced a Tornado. This form does not document any potential triggers or emotional support needed for R237. R237's current Care Plan for May 2025 and medical record does not document R237's potential triggers or emotional support needed for her past trauma. On 5/15/25 at 1:25 PM, V12 Discharge Planner stated social services was off work this week but confirmed (R237's) Care Plan and medical record did not address (R237's) potential triggers, or emotional support needed to prevent re-trauma. On 5/15/25 at 4:04 PM, V7 Administrator sent an email to indicate the facility did not have a policy on trauma informed care.

Based on observation, interview, and record review the facility failed to develop and implement pressure relieving interventions to prevent pressure ulcer development and worsening, conduct a pressure ulcer risk assessment once a week for four weeks after admission, obtain a treatment for a newly identified pressure ulcer, and accurately and thoroughly assess pressure ulcers weekly for two of three residents (R1 and R2) reviewed for facility acquired pressure ulcers in the sample of five. These failures resulted in R1 developing an unstageable pressure ulcer to the left heel six days after admission to the facility and R2 developing a stage three pressure ulcer to the right heel and an unstageable pressure ulcer to the inner ankle that required autolytic debridement (using own body's enzymes to remove dead tissue) and caused R2 severe pain. Findings include: The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol dated 10-24-22 documents Objective and Purpose: To ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of any pressure injury or pressure ulcer that might develop. Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure injury will present as an open ulcer. The appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Principles: 1. A skin assessment is completed on all residents upon admission and weekly for the first four weeks after admission, quarterly, and whenever there is a change in the resident's condition. 2. An individualized plan of care will be developed for the resident following the guidelines of the assessment. 3. All high and moderate risk residents will be assessed for the needs of the items below. If the intervention is initiated, it will be added to the care plan. A. Special mattress and wheelchair cushions. B. PROMS (Passive Range of Motions). C. Protein and/or Nutritional Supplements. D. Turning and positioning schedule. E. Skin Checks. F. Elbow/heel protectors/bridging of heels. 6. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size, wound bed, drainage, odor, tunneling, undermining or sinus tract, wound edges/surrounding tissues, and pain at site. B. Determine the injury's current stage of development: Stage One Pressure Injury: Non-blanchable erythema of intact skin. Stage Two Pressure Ulcer: Partial thickness skin loss with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not viable. Granulation tissue, slough, and eschar are not present. Stage Three Pressure Ulcer: Full thickness loss of skin, in which subcutaneous fat is visible in the ulcer and granulation tissues are epibole (rolled wound edges) are often present. Slough and or/eschar may be visible but does not obscure the depth of tissue loss. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/pressure injury. Unstageable Pressure Ulcer: Full-thickness ski and tissue loss in which the extent of tissue damage with the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (dry, adherent, intact without erythema or fluctuance) should only be removed after careful consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue, this area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue, This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. C. Notify the physician of the above assessment and obtain orders for treatment of pressure ulcer/injury. If pressure ulcer/injury is showing no improvement, Physician will be notified so change of treatment may be obtained, E. Care plan will be established for treatment of existing pressure ulcers/injuries. G. For pressure ulcer with drainage the physician will be notified, and culture obtained if ordered. Pressure Injury and Treatment Protocol: H. Weekly measurements will be conducted and entered in the chart under wound management. J. Turning and repositioning assistance will be given to those residents that are unable to reposition themselves. K. Special devices will be used to relieve pressure, L. All treatment and charting of pressure ulcers/injuries will be done by licensed staff. R1's Admission Record documents R1 was a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of a Left Femur Fracture, Abnormalities of Gait and Mobility, Lack of Coordination, and Weakness. R1's Procedure and Surgeon Notes dated 12-2-24 document R1 received a left hip open reduction internal fixation with intramedullary implant repair to repair R1's left hip fracture. R1's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) and 12-31-24 document R1 was at risk of developing a pressure ulcer. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 was cognitively intact and had no pressure ulcers on admission (12-5-24). This same MDS Assessment documents R1 developed a facility acquired stage II pressure ulcer. R1's Medical Record does not include evidence of a Braden Scale being completed every week for four weeks after R1's admission, as instructed by the facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol. R1's Progress Notes dated 12-11-24 and signed by V5 (Prior Director of Nursing) document, While dressing (R1) for the day (CNA/Certified Nursing Assistant) notified this nurse of area to (R1's) left heel. Area is a 3.5 cm (centimeter) by 3.7 cm fluid filled blister, not draining, surrounded by pink normal skin. Area cleansed, skin prepped, and border foam applied for protection. Foot floated while CNA finished dressing (R1). Recommendation to continue above treatment and apply moon boot forwarded to (Clinic). R1's Hospital Discharge Summary dated 12-31-24 documents, (R1) was noted to have a left heel blackish blister upon admission (hospital admission 12-23-24). Likely 2/2 deep tissue injury (full-thickness deep tissue injury) causing some localized bleeding resulting in a blood blister. ABI (Ankle-Brachial Index) normal to left lower extremity. R1's Progress Notes dated 1-12-25 and signed by V6 (Wound Nurse) document, (R1's) wound measurement area to (R1's) L (left) heel. Area is a 4 cm x 5 cm fluid filled blister, not draining, surrounded by pink normal skin. Area cleansed, skin prepped, and border foam applied for protection. Foot floated while CNA finishes dressing (R1). The facility's Weekly Wound Reports dated 12-18-24, 12-25-24, and 1-8-25 document R1's wound to the left heel as a stage one Pressure Injury. The facility's Weekly Wound Report and R1's Medical Record/Progress Notes do not include a weekly assessment of R1's wound to the right heel for the week of 1-1-25 through 1-7-25. R1's Care Plan dated 12-5-24 (Admission) through 1-14-25 (Discharge) documents, Problem: (R1) is at increased risk for pressure ulcers related to decreased mobility and generalized muscle weakness following recent illness and hospitalization . Goal: (R1) will have decreased risk for skin breakdown during this quarter. Interventions: Assist (R1) with turning and re-positioning. Pressure reducing device in wheelchair and bed. Provide incontinence care after each incontinent episode. Therapy as ordered. This same care plan does not include R1's new onset of a pressure ulcer to the left heel with goals or interventions to treat and prevent the left heel pressure ulcer from declining or prevent further pressure ulcer development. R1's Progress Notes dated 1-15-25 document R1 was discharged to another long-term care facility per the family's request. On 1-28-25 at 9:37 AM V8 (R1's Family Member) stated, Anytime I would visit (R1) when she was admitted to the facility, she would not have a heel boot on. On 1-29-25 at 9:10 AM R1 was living in another long-term care facility and was interviewed by phone. R1 stated, I broke my right hip and could not move my leg on my own while in bed. I could not feel my heels at all due to the swelling. The staff never elevated my feet off the bed, and I did not get those jelly filled (heel protection) boots until after I got the sore to my left heel. I did not wear shoes while in bed or while in the recliner. When I was in the recliner my heels would be lying on the footrest. On 1-29-25 at 9:45 AM V6 (Wound Nurse) stated, I categorized (R1's) left heel pressure ulcer as a stage one throughout (R1's) stay here. I did not know if a pressure ulcer was black or purple that it was considered unstageable. I have not had a lot of wound training. There were a lot of staff off around Christmas, so no wounds got assessed from 12-25-24 through 1-7-25. On 1-29-25 at 1:50 PM V16 (Care Plan Coordinator) stated, I am sorry. I am behind a month on care plans. (R1's) Care Plan was never updated to include pressure relieving interventions to prevent pressure ulcers to (R1's) heels and was never updated once (R1) developed a new pressure ulcer to the left heel with goals to prevent the pressure ulcer from worsening and prevent further pressure ulcers. On 1-29-25 at 2:10 PM V7 (Nurse Practitioner) stated, (R1's) pressure ulcer to the left heel was probably caused by pressure when (R1) would be sitting in her recliner. When sitting in the recliner, (R1's) heels would by lying on the footrest. On 1-29-25 at 2:18 PM V15 (Prior DON/Director of Nursing) stated, (R1) was in bed quite a bit and did not have a wound to her heel on admission. (R1's) heels would be on the bed and that is what caused the pressure ulcer to (R1's) right heel. (R1) had a broken left hip. On 12-11-24 a CNA found a wound to (R1's) left heel and reported it to me. I assessed the wound and noted the wound to be a 3.5 cm by 3.7 cm fluid filled unstageable blister caused by pressure. On 1-29-25 at 2:30 PM V10 (MDS Coordinator) stated, I am responsible for completing the Braden Scale Assessments and I have been behind. (R1) was supposed to have a Braden Score completed on admission and every week for four weeks after admission. (R1) only had a Braden Scale Assessment completed on admission and did not have one completed for the next three weeks after admission. On 2-3-25 at 10:00 AM V17 (Therapy Director) stated, When (R1) had admitted here the beginning of December 2024 (R1's) legs were so heavy from the fluid build-up. (R1) could not lift her legs or feet up off the bed by herself. (R1) also had groin pain whenever trying to lift her legs up. (R1) needed moderate assistance of staff to raise her legs and feet off the bed and turn and re-position while in bed. 2. R2's current Physician's Orders document R2 has the diagnoses of Chronic Congestive Heart Failure and Cerebrovascular Disease. R2's MDS Assessments dated 11-25-24 and 12-5-24 document R2 is severely cognitively impaired and had no pressure ulcers. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] (Admission) documents R2 was not at risk of developing pressure ulcers. R2's Braden Scale for Predicting Pressure Sore Risk assessment dated [DATE] documents R2 was at high risk of developing pressure ulcers. R2's Care Plan dated 11-18-24 (Re-admission to facility) through 12-12-24 (date of pressure ulcer development to right heel) does not include pressure ulcer relieving interventions to prevent pressure ulcer development once R2 was identified by the Braden Scale for Predicting Pressure Sore Risk Assessment (dated 11-18-24) as being at high risk of developing pressure ulcers. R2's Event Details and Progress Notes dated 12-12-24 and signed by V6 (Wound Nurse) documents, Pressure Injury to Right Heel. Orders: Right heel cleanse area, apply Medi-honey and mepilex to be changed daily. (R2) has an area on his right heel that measures by 5 cm x 4 cm. R2's Medical Record dated 12-12-24 only includes a measurement of R2's newly developed right heel pressure ulcer and does not include any further description of the pressure ulcer's wound bed, drainage, odor, tunneling, undermining or sinus tract, or wound edges/surrounding tissues. The facility's Weekly Wound Report and R2's Medical Record/Progress Notes do not include a weekly assessment of R2's wound to the right heel for the week of 1-1-25 through 1-7-25. R2's Wound Management Progress Notes dated 1-22-25 and signed by V6 document, (R2) has an area on his right heel that measures 2.4 cm by 3.4 cm and an area to his right medial ankle measuring at 2.4 cm by 2.0 cm. Both have serosanguinous (drainage of blood and serum) drainage between minimal and moderate. Both Stage II. R2's Medical Record does not include documentation of V4 (R2's Physician) being notified of R2's pressure ulcers having drainage or an order to treat the newly developed pressure ulcer to R2's right inner ankle on 1-22-25. R2's Physician's Order and Treatment Administration Records dated 1-22-25 through 2-4-25 do not include a physician's order to treat R2's right inner ankle pressure ulcer or evidence of a treatment being performed to R2's right inner ankle pressure ulcer. R2's Wound Visit Notes dated 2-5-25 and signed by V19 (Clinical Wound Care Nurse) document, Wound Right, Medial Heel is a Stage Three Pressure Ulcer acquired on 12-12-24 and had received a status of not healed. Initial wound encounter measurements are 2 cm length by 1.2 cm width, by 0.3 cm depth. There is a moderate amount of drainage noted. Wound bed had 76-100 percent granulation (healing tissue), 1-25 percent slough (dead tissue). Debridement Performed: Autolytic. Wound Right, Medial Ankle is an Unstageable Pressure Injury obscured full-thickness skin and tissue loss. Pressure ulcer acquired on 1-22-25 and had received a status of non-healed. Initial wound measurements are 2 cm length by 1.5 cm width by 0.3 cm depth. There is a moderate amount of serous drainage noted. Wound bed had 1-25 percent granulation, 76-100 percent slough, Debridement performed: Autolytic. On 1-29-25 at 9:50 AM R2 was lying in bed with a cushioned heel protecting boot to R2's right foot. R2's left foot was lying directly on the bed. R2 had an uncovered pressure ulcer to the right inner ankle and a dressing dated 1-28-25 to the right heel. V6 (Wound Nurse) removed the dressing to R2's right heel and measured both pressure ulcers to R2's right heel and right inner ankle. R2's right inner ankle pressure ulcer measured 2.3 cm by 2.7 cm and was covered in 100 percent slough with a moderate amount of serosanguinous drainage. R2's right heel pressure ulcer measured 1.6 cm x 2 cm with 50 percent granulation tissue and a moderate amount of serosanguinous drainage. V6 proceeded to cleanse both pressure ulcer with normal saline, applied Medi honey, and covered with gauze. During the treatment R2 was hollering out in pain stating, My foot hurts! My foot hurts! On 1-29-25 at 10:00 AM V6 (Wound Nurse) stated, I noticed (R2) had a new pressure ulcer to the right inner ankle last week (1-22-25). The right inner ankle wound had drainage last week but did not look this bad and I do not remember the wound having slough last week. (R2) usually always has pain when I change his dressings. I do not recall if the physician was notified of (R2's) wounds to the right heel and right inner ankle having drainage. I have caterogorized both of (R2's) pressure ulcers to the right foot and right inner ankle as stage two's. On 2-10-25 at 9:20 AM V6 stated, There is no documentation of a treatment order being obtained to (R2's) right ankle pressure ulcer or documentation of a treatment being performed to (R2's) right ankle pressure ulcer on (R2's) treatment administration record. On 2-10-25 at 11:00 AM V4 (Physician) stated, Both of (R1) and (R2) heels should have had off-loading to prevent the pressure ulcers from developing. That is basic to prevent pressure ulcers. Around three months ago the wound nurse was very active there about letting me know if there were changes to wounds. For the past three months I have not had a lot of communication with the facility about the residents' pressure ulcers. (R1's) pressure ulcer should not have been categorized as a stage one. (R1's) pressure ulcer to the heel would have been an unstageable pressure ulcer. (R2's) pressure ulcer to the right inner ankle should have been categorized as unstageable.

Based on record review and interview, the facility failed to monitor the level of Oxygen in a portable Oxygen tank for a resident diagnosed with Congestive Heart Failure, ensure a continuous Oxygen supply was administered as ordered by the Physician, and failed to perform an assessment after a resident went without Oxygen and experienced respiratory distress and a low pulse oximetry reading for one of three residents (R1) reviewed for Oxygen use in the sample of five. These failures resulted in R1 being without oxygen for 20 minutes on one occurrence and 10 minutes on second occurrence, which caused R1 to experience chest pain, shortness of breath, feelings of being smothered and imminent death. Findings include: The facility's Oxygen Therapy and Safety policy dated 4-9-20 documents Area: Nursing. It is the policy of this facility to provide a safe environment for residents, staff, and the public. Purpose: To provide a source of oxygen to persons experiencing an insufficient supply of same and to address the use and storage of oxygen and oxygen equipment. Staff responsible: Director of Nursing, Staff Nurse, Nurse Aides. Oxygen Therapy: M.D. (Medical Doctor) will provide: When to use, how often, liter flow, and whether to use cannula or mask. Document date, time, flow rate, frequency, and results of oxygen therapy in medical record. Address use of oxygen in care plan. Oxygen in Use: Licensed staff using oxygen equipment will be trained in its operation, safety precautions, and manufacturer's instructions for using equipment. R1's Admission Record documents R1 was a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of a Congestive Heart Failure, Weakness, Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure with Hypoxia, Dependence on supplemental oxygen, Atrial Fibrillation, and Chronic Fatigue. R1's MDS (Minimum Data Set) Assessment documents R1 was cognitively intact. R1's Physician's Orders dated 12-5-25 through 12-7-24 document, Oxygen at five liters per nasal cannula continuously for Shortness of Breath. R1's Physician's Orders dated 12-7-25 through 12-23-24 document, Oxygen at four liters per nasal cannula continuously for Shortness of Breath. Oxygen Saturation every shift-titrate oxygen to maintain above or equal to 90% (percent). R1's Physician's Orders dated 1-3-25 through 1-10-25 document, Oxygen at five liters per nasal cannula continuously. R1's Physician's Order dated 1-10-25 and signed by V14 (Pulmonologist) document, Keep (R1) at six liters of oxygen. May titrate to keep oxygen saturation above 89%. R1's Nephrology Physician's Progress Notes dated 1-6-25 and signed by V8 (R1's Nephrologist) documents, (R1) has not been brought in with her required amount of supplemental oxygen with oxygen saturations around 80 percent. R1's Care Plan from admission (12-5-24) to discharge (1-14-25) does not address R1's oxygen needs or goals. R1's Progress Notes do not include any documentation of an assessment performed after R1 went without oxygen on 1-6-25 or any other occurrences of R1 going without her physician ordered oxygen. R1's Progress Notes dated 1-15-25 document R1 was discharged to another long-term care facility per the family's request. On 1-28-25 at 9:37 AM V13 (R1's Family Member) stated, On 1-6-25 I met (R1) and (V12/Transport) at (V8's) office. Upon arrival, I questioned how much oxygen was available. The driver (V12) replied they had one oxygen unit. I expressed this was inadequate for (R1's) needs. (V12) told me to call if (R1) needed more oxygen. When in (V8's) office I noticed (R1's) oxygen tank was empty. The staff came in and (R1's) pulse oximetry was 80 percent and (R1) was cyanotic, slurring her words, and complaining of back and arm pain. (V8's) instructions were to take(R1) to prompt care. (V8's) secretary stated that she had called (V12) and was told (V12) was filling an oxygen tank right then. From the time (V8's) secretary called for more oxygen to when (V12) came with the oxygen was 20 minutes. During dinner on 1-12-25 (R1's) oxygen tank again went empty. It was empty for more than ten minutes. (R1) started to become symptomatic. Another resident's family member (V9) noticed (R1) in distress and went to get a nurse. The nurse returned without an oxygen tank. After what was described as what seemed like a long time an unknown CNA returned with a replacement oxygen tank. No vital signs were recorded in (R1's) medical record and no progress or assessment was made about the occurrence. I was scared for (R1's) life while she was at that facility, and we decided to move (R1) to a different facility. On 1-28-25 at 2:15 PM V12 (Transport) stated, I am not certified. On 1-6-25 I took (R1) to her appointment with (V8). (V13/R1's Family Member) road with me in the van to the appointment. I took one portable oxygen tank with us to the appointment. (V13) told me I should take two tanks. I spoke to a nurse, and she told me I only needed one oxygen tank. I do not remember what nurse I spoke to. I filled (R1's) tank before the appointment. I dropped (R1) off for her appointment and went back to the facility. Around an hour to an hour and a half later, I got a call from the receptionist at (V8's) office saying I needed to get to their office fast because (R1) ran out of oxygen and was having a hard time breathing. I got a new oxygen tank and went to (V8's) office. (V13) was outside and waiting on me. I disconnected (R1's) oxygen tubing from the empty tank and attached the oxygen to the new tank. I turned the dial to five liters as that is what (V8) said (R1) needed. I brought (R1) back to the facility and a CNA took (R1) to her room. Some of the portable oxygen tank's gauges do not work. On 1-29-25 at 9:10 AM R1 was living in another long-term care facility and was interviewed by phone. R1 stated, I ran out of oxygen three or four times while living at that nursing home (the facility). One time at suppertime, I started to feel funny and checked my oxygen tubing. No oxygen was coming out. No staff were in the dining room, so I asked a visitor who was in there to go get me help. I felt like I was going to pass out and started having chest pain. It is the worst feeling when you cannot breathe. I was short of breath and felt like I was being smothered. It felt like forever before someone got me an oxygen tank. I was lucky the visitor was there to help me. When I went to the doctor (1-6-25) I was in the office and my oxygen tank ran out. I started turning purple and my eyes were twitching. I had chest pain. My son (V13) kept telling me to deep breath. I don't know what it feels like to die, but I know I felt close to it that day. It took 30 minutes for the facility to get me oxygen. The staff did not make sure I always had oxygen. On 1-29-25 at 10:40 AM V9 (Visitor) stated, I was in a private dining room on 1-12-25 with my parents and another resident (R1). (R1) was the only other resident in this dining room. There were no staff present in this dining room. (R1) told me, I need help! (R1) was panicked and having a hard time breathing. I went and found a staff member and told them (R1) needed oxygen. (R1) was trying to deep breath and it looked like (R1) was struggling to breath. It took a nurse around ten minutes to get (R1) oxygen. It really scared me. On 1-29-25 at 11:05 AM V20 (Oxygen Supply Company Representative) stated, The portable oxygen tanks are older and some of the gauges do not work properly and the tanks do not have the volume to fill completely, making them not last as long as they should. If a patient is on five liter of oxygen, an oxygen concentrator should really be used to prevent a patient from running out of oxygen. On 1-29-25 at 2:10 PM V7 (Nurse Practitioner) stated, (R1) should not have run out of oxygen with her diagnoses. Running out of oxygen would cause (R1) to become short of breath and her pulse oximetry to drop. (R1) should have been on an oxygen concentrator and not on a portable oxygen tank. On 1-29-25 at 2:18 PM V15 (Prior DON/Director of Nursing) stated, I was not aware of (R1) running out of oxygen or experiencing shortness of breath or other symptoms from running out of oxygen. If (R1) went without oxygen a nurse should have done an assessment of (R1) and documented the occurrence in (R1's) progress notes. On 1-29-25 at 2:40 PM V21 (CNA/Certified Nursing Assistant) stated, We (facility staff) really do not have a set schedule on when to check residents to make sure their oxygen tanks are full. I just check periodically, and if the oxygen tanks are empty I fill them. The portable oxygen tanks do not last long. On 1-30-25 at 11:55 AM V14 (Pulmonologist) stated, I saw (R1) in my office and (R1) was very upset and said she ran out of oxygen several times. (R1) is [AGE] years old and requires supplemental oxygen at all times. (R1) has multiple heart concerns and has Chronic Obstructive Pulmonary Disease, Valvular Heart Disease, and Congestive Heart Failure. At absolutely no time should (R1) have ran out of oxygen. There is no excuse that the facility could have for (R1) to go without oxygen at any time. Any amount of time that (R1) would go without oxygen could result in (R1's) oxygen levels dropping and would be devastating and detrimental to (R1's) health. It could result in (R1's) death. (R1's) oxygen saturations should never drop below 89 percent.

Based on observation, interview and record review, the facility failed to ensure a nebulizer mask and nebulizer tubing was changed every seven days and stored in a bag between uses for two residents (R2 and R18) and failed to ensure Oxygen tubing was changed every seven days for two of four residents (R2, R34, and R62) reviewed for respiratory care in a sample of 30. Findings include: The facility's Nebulizer Treatment Administration, dated 01/2003, documents Purpose: 1. For delivery of liquid aerosol medication, as prescribed by a physician. 2. To aide in expectorations of secretions. Equipment: 1. Nebulizer unit. (Consists of (1) Medication container, (2) Nebulizer T-piece, and (3) Mouthpiece.) 2. O2 (Oxygen) tubing. Procedure: 15. O2 tubing used only for intermittent nebulizer therapy must be changed weekly. If used more often, such as for receiving O2, replace tubing every 48 hours. 16. Disposable nebulizers must be replaced every 15 days. The facility's Oxygen Therapy, dated 3/16/17, documents Objective: 1. To provide a source of oxygen to persons experiencing an insufficient supply of same. Procedure: 7. Oxygen set-up (cannula/mask, tubing) must be exchanged every seven days. Documentation: 1. Date, time, flow rate, frequency, and results of oxygen therapy in Medical Record. 1. R18's current POS (Physician Order Sheet) documents a Physician order for Albuterol Sulfate Solution 0.62 milligram/3 milliliter one vial inhalation orally four times a day as needed. On 8/4/24 at 9:30 AM R18's nebulizer tubing and nebulizer mask was lying on R18's nightstand un-bagged and dated 6/20/2024. On 8/4/24 at 9:23 AM V4/Registered Nurse confirmed R18's nebulizer tubing and nebulizer dated 6/20/24 and un-bagged. V4 stated, Nebulizer masks and nebulizer tubing should be changed at least every seven days and bagged after use. 33970 2. 08/04/24 08:00AM R2's oxygen tubing was coiled up on bedside chair and attached to nebulizer machine dated 5/28. 3. On 8/4/24 at 8:05 R34's Oxygen tubing and nasal cannula were on the floor in his room with no date on the oxygen tubing. R34 was not in his room at the time and the tubing was connected to an oxygen tank inside of his room and it was running. On 08/04/24 at 8:30 AM R34 was in the dining room with a small oxygen tank on the back of his wheelchair with oxygen tubing that had no dates on it. 4. On 08/04/24 R62's Oxygen tubing and nasal cannula were on the floor in her room with no date on the oxygen tubing. R62 was not in her room at the time and the tubing was connected to an oxygen tank inside of his room and it was running. On 08/04/24 at 8:30 AM R62 was in the dining room with a small oxygen tank on the back of her wheelchair with oxygen tubing that had no dates on it.

Based on interview observation and record review the facility failed to ensure that wound care supplies were disinfected after each resident's wound cares. This failure has the potential to affect residents (R34, R57, R62, R67, R80, R199) that receive wound cares in the facility. Findings include: The facility's Standard Precautions policy facility's Wound Care policy, dated 08/2009, documents Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious agents. On 08/06/24 at approximately 1:00pm, V2 DON (Directed of Nurses), provided a Wound Summary Report, dated 08/05/2024, listing residents receiving wound care in the facility. The facility's Wound Care policy, dated 03/2004, documents, **Standard Precautions Must Be Followed During Care of Wounds. ** R80's medical record documents diagnoses including Insulin Dependent Diabetes and Chronic Kidney Disease Stage three. R80's Treatment Administration Record documents. Wound Care to Upper Gluteal Region: 1) Clean and dry area well. 2) Apply thin layer of zinc paste over open areas. 3.) Place bordered foam dressing. 4) Change daily and as needed. R80s Physicians Progress Note by resident's physician (V9), dated 8/5/24, documents under Chief Complaints: Pressure Ulcer and Assessment includes: Pressure Ulcer Left Buttock. V9 Dr. Wagner's Plan documents, I would put a moisture barrier this wound followed by a (bordered foam dressing). On 8/5/24 at approximately. 10:05am, R80 was laying on their left side and R80's waterproof, bordered dressing, dated 8/4/24, was intact to R80's coccyx and left buttock area. On 8/5/24 at 10:25am V3, Wound Nurse and ADON, Assisted Director of Nurses, gathered wound supplies and completed R80's daily wound care as ordered, to include cleansing R80's wound with an eight-ounce spray bottle of wound cleanser, using spray at close proximity to R80's open wound. After completion of R80's wound care, V3, ADON, returned wound cleanser spray bottle to the top treatment cart in the Medication Room without disinfecting the wound cleanser bottle. V3 stated that the multi-use spray wound cleanser is used for multiple residents' wound cared treatments and returned to the treatment cart. On 8/6/24 at 10:45am V6, LPN (Licensed Practical Nurse), verified that spray wound cleanser bottles are used for multiple residents' wound care and stored in the Medication Room or on the top of the treatment cart. On 8/7/24 at approximately 8:30am, V2, DON (Director of Nurses), stated that the wound cleanser bottles used for wound care throughout the facility, are considered community property and used for multiple residents' wound cares.

Based on interview and record review, the facility failed to document justification for the use of duplicative antidepressant therapy for one of five residents (R18) and failed to document the justification for reinstating an antipsychotic for one resident (R60) reviewed for psychotropic medications in the sample of thirty. Findings Include: The facility's Psychopharmacologic Drug Usage Procedure, dated 10/18/17, documents Definition: A psychopharmacologic Drug is any medication used for managing behavior, stabilizing mood, or treating psychiatric disorders. This includes the following types of drugs: antipsychotic, antidepressants, anti-anxiety medications, and sedatives/hypnotics. Procedure: Use of psychopharmacological medications requires assessment by the attending physician, and specific orders must be written by the attending physician with supporting diagnoses. 2. Psychopharmacological medication usage must be reassessed at least every 90 days and include rationale for continuing the medication. 7. Documentation of behaviors and conditions requiring the use of these mediations must be done on routine basis, as well as medication response and adverse consequences. 1.) R60's Admission Physician Order Sheet dated 5/10/2021 documents that R60 was admitted to the facility on the anitpsychotic medication Olanzapine 5 mg (milligrams) every night for Dementia with Delusions and Agitation. R60's Medication Regime Review from Pharmacy dated 8/3/23 documents a recommendation for the doctor to discontinue the use of the antipsychotic medication Olanzapine due to no documented behaviors to justify the use of it. The Physician accepted the recommendation so the medicine was discontinued. R60s nurse notes document that on 5/8/24 R60's daughter stated that when (R60) stayed the weekend with her that she was argumentative with her and accusatory. Daughter states that is what happens when they try to reduce their medication. R60's nurse's notes document that on 5/4/24 at 1:40 PM R60 was standing in the front entry telling staff she was going on a walk she was reminded that she needs staff to assist her that she became agitated with staff. She offers statements of missing clothing items. R60's Nurse Notes on 5/4/24-5/29/24 document several episodes of R60 yelling at staff regarding missing clothing, becoming angry and agitated with staff. There is no documentation of R60 having delusions or halluciantions. R60's Physican Order Sheet for June 2024 documents that R60 was put back on antipsychotic medication Olanzapine 2.5 mg (milligrams) every 12 hours as needed for agitation and delusions. R60's Physican Order Sheet for June 2024 documents that R60 was put back on antipsychotic medication Olanzapine at 5 mg every night for failed gradual dose reduction with return of agitation and delusions. On 8/6/24 at 10:00 AM V3 (Licensed Practical Nurse/ Care Plan Coordinator) confirmed that R60 was upset about laundry that indeed was missing and some were ruined by the laundry dpartment and replaced by facility. V3 stated that R60 was obsessed about her missing clothes and was very angry and upset. V3 stated The daughter also wanted her back on her regular dose of medicine. On 8/6/24 at 10:15 AM V2 (DON) also confirmed that R60's clothes that she accused people of stealing were missing, that they were at the daughters house after a home visit. V2 also confirmed that the facility had ruined some of R60's clothes and she became very upset and was yelling at staff. V2 confirmed that the things that R60 was upset about were actually happening, therefore would not be considered delusions or hallucination. 49187 2. R18's POS (Physician Order Sheet) documents the following: Mirtazapine (antidepressant) 30mg (milligrams) by mouth daily, Bupropion HCL (hydrochloride) (antidepressant) 300mg by mouth daily, and Sertraline (antidepressant) 150mg by mouth daily. On 8/7/24 at 10:00AM V2/Director of Nursing stated she is the individual responsible for managing psychotropic medications for the residents in the facility. V2 stated R18 is not a harm not herself or others. V2 stated she is not sure why R18 is taking three antidepressants, and verified that this information was not documented in R18's medical record.

Based on interview and record review the Facility failed to reasonably accommodate one of three Residents (R1) reviewed for Resident cares in a sample of three. Findings include: Facility Resident Rights for People in Long-Term Care Facilities, dated 11/2018, documents: you have the right to make your own choices; your Facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life; the Facility must provide equal access to quality care regardless of diagnosis condition or payment source; the Facility must provide services to keep your physical and mental health, at their highest practical levels; and you have the right to complain to your Facility. R1's current Care Plan, documents that R1 admitted to the facility on [DATE]. R1's Care Plan also documents diagnoses including: Urinary Tract Infection, Congestive Heart Failure, Dyspnea, Weakness, Need for Assistance for Personal Care, Muscle Weakness, Abnormal Gait and Mobility, Pain and Anxiety; R1 is on Hospice Care; and that R1 requires substantial maximum assistance of one staff member for bed mobility and transfers. R1's Minimum Data Set/MDS, Section GG (Functional Abilities and Goals) dated 10/21/23, documents that R1 requires partial to moderate staff assistance with lying and sitting on the bed. The Facility local State Agency Report (State of Illinois/Illinois Department of Public Health), dated 12/22/23, documents an incident with R1 and V3 (Certified Nursing Assistant/CNA). The Report documents that R1 stated that V3 (CNA) was upset with R1 for requesting that the R1 asked the girls to boost me up in the bed and they did but then I slid back down so I had to call them again and I could tell she (V3) was upset. R1 stated that V3 (CNA) told R1 that they cannot just keep coming in here every two minutes to help you. R1 stated that V3's (CNA's) attitude needed to be addressed. The Facility local State Agency Report (State of Illinois/Illinois Department of Public Health), dated 12/22/23, documents V3 (CNA) stated way before dinner time, V3 Told (R1) that (R1) would stop sliding down in bed if (R1) kept (R1's) knees up and would be easier because she was on top of everything and could not help scoot (R1) up. R1 also stated, that was the third time I had boosted (R1) up in 20 minutes and I told (R1) that it was getting harder for me to pull (R1) up because I was losing strength and that I had been here since 5:30 am. (R1) got mad because I asked (R1) to help as much as (R1) could when rolling and (R1) yelled at me. I asked (R1) to please not yell at me. (R1) got nasty with me and was telling me I needed to do a bunch of things and I told her that I was getting to them one at a time. I told (R1) that I understood (R1's) pain. I asked (R1) what was going on with (R1) today and why she was talking to me that way, and other than today (R1) has always made jokes and laughed with me and (R1) told me she did not really care and that I got paid as a CNA to do what (R1) wanted me to do. I told (R1) that was partly true. I asked (R1) if (R1) needed anything else while I was still in the room. I told (R1) that I get paid to help take care of my residents but that I do not get paid to be treated like crap and to be yelled at, (R1) told me to get out. (R1) was just being mean to me and yelling at me to do things, but rather than ask me and talk to me like I was a human being too, it hurt my feelings. The Facility local State Agency Report (State of Illinois/Illinois Department of Public Health), dated 12/22/23, documents V4 (CNA) stated, I went in to (R1's) room to help (V3/CNA) with (R1) and (V3) was being extremely rude and R1 was shaken and upset. The Report also documents that when leaving R1's room, R1 requested more cares, and V3 (CNA) told R1 what did you fucking say to me. On 1/20/24 at 12:16 pm, V3 (CNA) stated, I never said the 'F word' to (R1) (V4/CNA) and I do not get along that great and she was making stuff up. I had told that nurse that (R1) was not being herself all day and that something was off, because (R1) was being mean all day to me. We usually got along really well. I had to move (R1) up in bed like three times within 15 minutes, so I asked (R1) to please keep (R1's) knees up while in bed and it would help (R1) from sliding down. I had been at work since 5:30 am and this happened a little before dinner time, so I was getting tired and may have been a little short, but I never cursed at (R1). (R1) was getting mad at me and I did not feel like I deserved to be talked that way, so I was trying to make (R1) understand that, and told her. On 1/20/24 at 2:00 pm, V1 (Administrator) stated, I terminated (V3/CNA) over the way that (V3) talked to (R1) during cares. I have no tolerance for any employee being short with any Resident. I do know that when I interviewed with (R1) regarding this situation, (R1) did tell me that (V3) was not abusive to (R1), but (R1) did not like the way that (V3) talked to (R1) during cares. (R1) did state that there were normally not any problems with (V3), but that (V3) was extra short tempered that day.

Based on observation, interview, and record review the facility failed to immediately notify the physician to obtain a treatment for a UTI (Urinary Tract Infection) for one of three residents (R1) reviewed for UTI's in the sample of three. These failures resulted in R1's UTI being left untreated for 12 days and R1 experiencing increased moaning, pain, and discomfort. This resulted in R1 being sent to the emergency room and admitted to the local hospital for four days to receive treatment with intravenous antibiotics for the diagnosis of Sepsis secondary to a UTI. Findings include: The facility's Lab/Diagnostics Policy dated 11-28-17 documents, Policy: It is a policy of the facility to provide means of quality diagnostic lab services for the residents. Purpose: To provide residents a means of diagnostic service promptly and conveniently. Procedure: 1.Provision for Diagnostic Services: d. Any abnormal lab results upon receipt by the facility nurse will be promptly reported to the to the ordering Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist. Any new orders received as a result will be referred to on the lab slip, orders and in the nurse's notes; g. the lab result will have on it the ordering Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist's name, date and time and the notifying Facility Nurse's signature. The facility's Change in a Resident's Condition Policy dated 12/02 documents, Purpose: Our facility shall promptly notify the resident, and/or resident's representative, and his or her attending physician of changes in the resident's condition and/or status. Procedure: 1. The nurse will notify the resident's attending physician when: b. There is a significant change in the resident's physical, mental, or psychosocial status; e. Deemed necessary or appropriate in the best interest of the resident. On 1-2-24 at 10:03 AM R1's door had a sign indicating R1 was in contact/droplet precautions. R1 was lying in bed with the head of bed raised. R1 was grimacing in pain holding her stomach and stated she needed to use the bathroom. R1 had a brief on, her pants were around her ankles, and R1 appeared restless. R1's current Face Sheet documents R1 has the following diagnoses: Dysuria, Retention of Urine, and UTI. R1's BIMS (Brief Interview of Mental Status) dated 1-2-24 documents R1 is severely cognitively impaired. R1's Nurses Note dated 11-21-23 and signed by V7/RN (Registered Nurse) documents, (R1) yelling out, crying and moaning in pain. (R1) reports all over general discomfort, PRN (as needed) tramadol administered this am (morning). R1's Nurses Note dated 11-23-23 and signed by V6/LPN (Licensed Practical Nurse) documents, This nurse (V6) collected the urine specimen that was needed due to dysuria (painful urination). R1's Urinary Culture and Sensitivity final result dated 11-25-23 documents R1 had greater than 100,000 CFU (Colony-Forming Units)/ML (Milliliters)/Klebsiella Aerogenes (bacterial infection of the urine). R1's Nurses Notes dated 11-25-23 (date of final urinary culture and sensitivity) through 12-6-23 do not include any documentation of the facility notifying the physician or obtaining a treatment regarding R1's urinary culture and sensitivity results, dated 11-25-23, indicating R1 had a urinary tract infection. R1's Nurses Note dated 12-7-23 and signed by V5/LPN documents, Per (V8/R1's Primary Physician) N.O. (New Order) for Septra-DS (Double Strength/antibiotic) one tab BID (Twice a Day) PO (by mouth) times 10 days for UTI. R1's Nurses Note dated 12-8-23 and signed by V10/LPN documents, (R1) appears anxious- moaning and crying out. When (R1) asked if she is in pain- (R1) points to her stomach and states her hips hurt. PRN Tramadol administered with little effect. Resident refused dinner tonight and would not sit appropriately for staff to assist with eating. PO fluids encouraged. R1's Nurses Note dated 12-9-23 and signed by V10/LPN documents, (R1) started to get restless and agitated at approximately 9:30 AM. (R1) sliding herself down in wheelchair and holding her knees. Appears to be in pain. (R1) stated that she has pain all over. (R1) would not sit in chair to eat lunch and did not have any intake at lunch. (R1) assisted to bed and PRN Tramadol administered. R1's Nurses Note dated 12-9-23 and signed by V10/LPN documents, (R1) up in chair for supper and started moaning and crying out. (R1) sliding down in her wheelchair. (R1) stated that her back is hurting and she has pain all over. (R1) assisted back to bed for comfort. R1's Nurses Note dated 12-9-23 and signed by V7/RN documents, (R1) moaning, crying and thrashing around in bed. Upon entering room (R1) observed with clothing removed, blankets on floor, and water pitcher on floor. (R1) restless. Face red/flushed. Unable to follow commands. (R1) does report generalized discomfort. T (Temperature) 102.2 P (Pulse) 42 O2 (Pulse Oximetry) 87% (percent) RA (Room Air) BP (Blood Pressure) 142/87. PRN tramadol and Tylenol administered. (R1) continues on antibiotic therapy for UTI. (V8) notified with verbal orders received to send (R1) to ER (emergency room ) for evaluation. R1's Hospital Note dated 12-9-23 documents R1 was admitted to the local hospital to treat Sepsis secondary to UTI with intravenous antibiotics given 12-9-23 through 12-12-23. This same form documents, (R1) is an [AGE] year-old female with a history of UTI, sleep apnea, hypertension, GERD (Gastroesophageal Reflux Disease), Hyperlipidemia, Parkinson's disease with underlying Dementia, Asthma being admitted to (Local Hospital) on 12-9-23 with a chief complaint of altered mental status. (R1) came from (The Facility) where she was diagnosed with a UTI on 11-23-23. Unfortunately, facility lost the paperwork and did not start treatment until 12-7-23. In the ER (R1) was noted to be septic and sepsis protocol was started. On 1-2-24 at 11:15 AM V4 (Infection Preventionist) stated, (R1) had a history of UTI's. (R1) started to have dysuria on 11-23-23 and we got orders to obtain a UA. The UA final culture came back to the facility on [DATE] as (R1) having a UTI with greater than 100,000 colonies of Klebsiella (bacteria of the urine). There is no documentation of the physician being notified or a treatment order being obtained for (R1's) UTI from 11-25-23 through 12-6-23. The physician should have been notified immediately on 11-25-23 to obtain an order to treat (R1's) UTI. I do not know how it slipped through the cracks. On 12-7-23 (V8) called the facility and ordered Septra DS to treat (R1's) UTI. On 1-2-24 at 11:30 AM V8 (R1's Primary Physician) stated, When the facility got (R1's) final UA culture results on 11-25-23, I should have been notified of the results immediately so I could have given an order to start (R1) on antibiotics immediately for a UTI. I am available 24 hours a day, seven days a week. The nurses could have called me anytime to report (R1's) UA results. I noticed (R1) had a UTI according to the UA culture on 12-7-23 and called the nursing home immediately to give an order to start (R1) on Bactrim DS (Septra DS) to treat (R1's) UTI. (R1's) UTI should have been treated immediately on 11-25-23. I cannot deny that if (R1's) UTI was treated immediately it would have kept (R1) from developing further symptoms, becoming septic, and needing hospitalization to treat (R1's) urinary sepsis. The problem is continuity of care.

Based on observation, interview, and record review, the facility failed to implement fall interventions and complete neurological assessments following an unwitnessed fall for two of three residents (R1, R2) reviewed for falls in the sample of three. These failures resulted in R1 getting up from her wheelchair and sustaining a displaced fracture of greater trochanter of right femur, closed nondisplaced fracture of 7th cervical vertebral body, and transverse minimally displaced/impacted fracture of eight proximal humeral metaphysis. Findings include: The facility's Emergencies policy, dated 4/3/18, documents, Falls: If a fall is unwitnessed, notify physician and initiate neuro checks. A blank facility Neuro Vital Signs for 72 hours form, no date available and provided by V2 Director of Nursing on 4/17/23, documents, Every 15 minutes for one hour; Every 30 minutes for one hour, Every one hour for four hours, every four hours for 24 hours, every shift for 72 hours. 1. R1's Event Report, dated 3/10/23 at 12:47 p.m., documents that R1 had a fall by scooting off of her wheelchair while in the day room participating in activities. The report has no documentation of immediate measures taken and/or interventions put into place following R1's fall. R1's Fall Care plan, dated 2/24/23, documents, R1 at risk for falling related to recent illness/hospitalization and new environment. Last reviewed/revised: 3/3/23. This care plan has no revision following R1's fall on 3/10/23. R1's Event Report, dated 3/23/23 at 2:24 p.m., documents that R1 had an unwitnessed fall in her room, and R1 was observed on the floor by (V5 Activity aide) and nurse was called. R1 was trying to get up by herself and walk. Nurse assessed R1. R1 did not have any wounds and did not complain of pain at this time. R1 was placed back in wheelchair per facility policy. The report has no documentation of immediate measures taken and/or interventions put into place following R1's fall. R1's current medical record has no documentation of neurological checks being completed following R1's unwitnessed fall that occurred at 2:24 p.m. On 4/13/23 at 12:10 p.m., V12 (CNA) stated, For lunch, (R1) had a caregiver (V4 R1's Private caregiver) that came in to help her eat. She had finished up lunch and (V4) had just finished up and left. I saw (R1) up in her wheel chair and then I went to break. When I came back from break, I heard that she had fallen. I didn't know of her having any dycem (non slip material) in her wheelchair, and they didn't ask me to put anything in her wheel chair. On 4/13/23 at 12:17 p.m., V13 (CNA) stated, I was in another resident's room. Then, when I came out, I walked by her room and she was on the floor. She could slip out of that chair like nothing. We got her up off of the floor with the mechanical lift and she was smiling. She never complained of anything. We got her up into the wheelchair and brought her out of her room. She should have already had the nonslip pad in her wheel chair, but honestly I don't know if it was there or not. R1's Event Report, dated 3/23/23 at 5:15 p.m., documents, Location of fall: Dining room. R1 was sitting in her wheelchair waiting for dinner to be served. R1 got up out of her wheelchair and was trying to move sign out of the way. Was fall witnessed: Yes-CNA (Certified Nursing Assistant) was in the dining area. Pain Assessment: Right hip and right arm severe horrible intense pain. The investigation also includes written staff interviews including: V8 (CNA)-I was down on 400 hall getting resident ready to go for dinner when the fall took place. I was told by a coworker that (R1) fell . I told the nurse about it.; V7 CNA-I was in the dining room when I noticed (R1) on the ground. I went to get (V6) and (V3 Licensed Practical Nurse-LPN) to let them know (R1) had fallen.; V6 (CNA)-I was pushing a resident into dinner room when (V7) told me (R1) had fallen so I sat with (R1) while (V7) went and got nurse. R1's Nurses' notes, dated 3/23/23 at 5:19 p.m., document, Nurse calls 911 for ambulance to be sent over to hospital for further evaluation. R1's ED Provider notes, dated 3/23/23 at 7:49 p.m., document, Chief Complaint: R1 presents with fall. R1 arrives from nursing home with (V11 R1's Power of Attorney) for complaints of two falls today. (V11) states she is usually in a wheelchair and thinks she can get up, but he states she is too weak to stand on her own. It is difficult to get any answers out of R1 due to her Alzheimer's. (V11) states she had originally complained of right hip pain. (V11) is unsure if this was witnessed or not. Clinical Impression: Displaced fracture of greater trochanter of right femur. Closed nondisplaced fracture of seventh cervical vertebra. R1's Nurses' notes, dated 3/24/23 at 12:16 a.m. and signed by V9 (LPN), document, R1 returned to facility via ambulance with diagnosis of displaced fracture of the greater trochanter of right femur, and closed non-displaced fracture of seventh cervical vertebra. PRN (as needed) order for Norco received. Cervical collar in place. R1's current medical record has no documentation of neurological checks being completed upon R1's return from the hospital following her fall that included head involvement. R1's Nurses' notes, dated 3/24/23 at 10:51 a.m. and signed by V10 (Registered Nurse-RN), document, R1 was not swallowing this am, would not respond to any commands, unable to give pain medication for recent fractures. Due to condition, Physician notified and would like (R1) evaluated in the ED again. Ambulance called to transport resident. R1's ED Provider Notes, dated 3/24/23 at 12:41 p.m., document, Chief Complaint: R1 presents with Concussion altered since yesterday. R1 fell has increasingly weakness today's slow to respond. She fell and has a right hip fracture nondisplaced C7 fracture. Is increasingly weak today. Clinical Impression: General weakness. Falls Frequently. Humeral head fracture, right, closed. R1's Nurses' notes, dated 3/26/23 at 2:30 p.m., document, R1 arrived to facility by stretcher. Transferred from hospital for recent falls with fractures to C7 vertebrae, right shoulder, and right trochanter. R1 will be admitted to hospice for comfort measures. The facility report to the State Agency, dated 3/27/23, documents, (R1) observed lying on right side on floor in main dining area near doorway. R1 last noted siting up in wheelchair, at assisted feed dining table with wheelchair brakes locked. R1 wheelchair noted pushed back though remained positioned at dining table. R1 with report of increased discomfort to right hip and right arm. Sent to ED (Emergency Department) for further evaluation 3/23/23 and returned to facility with diagnosis as follows: 1) Displaced fracture of greater trochanter of right femur 2) Closed non-displaced fracture of 7th cervical vertebral body. R1 returned to hospital ED 3/24/23 for noted change in condition with request for further follow-up. R1 admitted to hospital at that time for diagnosis as follows: Weakness, Falls with injury: 1) Displaced fracture of greater trochanter of right femur 2) Closed non-displaced fracture of 7th cervical vertebral body 3) Transverse minimally displaced/impacted fracture of eight proximal humeral metaphysis with no dislocation. R1's Fall care plan, dated 3/26/23, documents that R1's previous fall care plan was discontinued on 3/27/23, and the care plan was revised to include R1's fall interventions related to all three of R1's on 3/26/23. On 4/13/23 at 11:00 a.m., V3, stated, (R1's) first fall on that day (3/23/23) was in her room. She was really antsy in her room. I don't know what she was trying to do that day. Afterwards she was agitated, so we brought her out to the nurses' station. She didn't hurt anything with that first fall. With her 2nd fall, residents were still getting wheeled into the dining room when it happened. The meal had not started. (V6) told me (R1) had got up out of her chair to move a wet floor sign. She turned to pick up the sign and fell on her right side. (V6) is who I thought witnessed the fall. (V8) came and got me letting me know that (R1) had fell . When I went in to initially assess her. She was laying on her right side. I asked her if she was in pain and she said her right side was hurting. I told them not to move her and I immediately called 911. On 4/13/23 at 2:35 p.m., V6 stated, I never witnessed (R1) fall. I was pushing another resident into the dining room and (V7) came and got me and said (R1) was on the floor. I didn't see her fall. I went over and sat with (R1). I didn't touch her because I can't do that. She said her arm and her hip both hurt. She complained the most of her arm and she was laying on it. When we start putting residents into the dining room, the Activity Aide is supposed to be in there to supervise the residents for this purpose. I didn't see an Activity Aide anywhere. When I got to work that day, I got report that (R1) had fallen, but I wasn't told anything to do different with (R1). I don't even know who took (R1) to the dining room, but I know her wheelchair was up to the table and the wheels were locked. I don't know how she got out of that wheel chair she would have had to climb over it somehow or something. I honestly do not remember her having any type of dycem in her wheelchair. On 4/17/23 at 10:10 a.m. V8 stated, I did not witness (R1) fall. I was helping a resident in the bathroom when (V7) came and told me that (R1) had fallen in the dining room. I went to (V3) and told her that (R1) was on the floor. After telling (V3), I went to sit with (R1). She was sad laying there on her right side in lots of pain. The last time I had saw (R1) she was sitting by the nurses' station. I'm not sure who even took her to the dining room. Staff are bringing residents into the dining room, but no one was directly supervising that assisted dining room. No one stayed with the residents. When I came onto shift, no one told me that (R1) had fallen earlier in the day. I didn't know until V6 told me when we were sitting with (R1). Her wheelchair was pushed up to the table locked, and there was nothing in the wheelchair. There wasn't any cushion or any of that sticky stuff. On 4/17/23 at 2:30 p.m., V5 (Activity Aide) stated, Prior to (R1's) incident (3/23/23) my responsibility during meal times was to push residents to the meal, help serve trays, and then help residents back to their rooms. We were not responsible for staying with the residents to make sure they were supervised. I pushed (R1) down to the dining room, but no one told me she couldn't be left unattended. On our way to the dining room, a CNA stopped me and said to make sure I pushed (R1) up to the table and locked her wheels that was it. So that is what I did. Then, I left to help other residents. I did not witness (R1) fall. Her wheel chair was still at the table but turned out a little ways after she fell . On 4/17/23 at 9:30 a.m., V9 (LPN) stated, When (R1) came back from the hospital and was transferred to the bed, she said 'oh' when they moved her arm and that was it. I pulled Norco from our back up box to give to her and by the time I got back down there she was asleep. So, I didn't wake her. She slept the rest of my shift. Normally, if a resident has an unwitnessed fall we start neurological checks, but since she went to the hospital, I didn't start any when she came back. I didn't get anything in report of what we should do different to prevent her from falling again when she came back from the hospital. She was fine until (V10) got here that morning, and (V10) sent her out to the hospital. On 4/13/23 at 2:45 p.m., V10 stated, I came in the morning after she returned and immediately went down at 6 am to assess her. I couldn't believe they sent her back because she was not doing well. She was out of it and couldn't even swallow to take her pain medication. When (V2) got here I got her opinion and sent her back out to the ED. We normally have a neurological check sheet for the checks but we didn't have one when I got here that morning. I just assessed her on my own. On 4/17/23 at 10:20 a.m., V2 (Director of Nursing) stated, After the first couple days of being in the facility, (R1) started trying to get up out of the wheelchair independently. The fall on 3/10/23 she was in activities in the day room scooting around and slid to the floor. It was witnessed. At that time, we initiated dycem to her wheel chair seat. It should have been in her wheelchair after that fall. I can't find it on the careplan. On 3/23/23, (R1's) first fall was she attempted to stand up from wheelchair and fell . It was an unwitnessed fall. I do not have any observations (documentation) of neurological checks being documented after the initial fall vitals. Neurological checks should be started when a fall is unwitnessed. The frequency is according to the neuro vital signs sheet. The intervention for this fall was to assist to common areas while in wheelchair to be supervised. The nurse is also responsible for reporting the new intervention to the staff. Later in the day, she was in the door way of the assisted dining room area lying on her right side. There was no one who actually witnessed the fall. The event report is not correct by saying the fall was witnessed. Activities has someone who stays in the dining room while residents are brought in. There was educational needs with the activity staff because they didn't stay in the dining room to supervise the residents. They were actually assisting in transporting residents to the dining room. The intervention was to be in a supervised area. The intervention after this fall was to not leave unattended while up in wheelchair. There was no documentation of any type of neurological assessment when she returned from the hospital after the 2nd fall on 3/23/23 because again there is no event in the computer where they would have documented it. (V10) obviously did a neurological check when she came on shift because she noticed a change in her mental status and sent her to the ED. V2 confirmed that all of the new fall interventions were not on R1's care plan until 3/26/23. 2. On 4/13/23 at 11:53 am, R2 was pleasantly confused sitting at the dining room table feeding herself with her wheeled walker at her side. R2's Fall Event form, dated 1/2/23 at 12:50 p.m., documents that R2 had a fall in her bathroom resulting in a laceration to her left temple. R2's Nurse's notes, dated 1/2/23 at 12:41 p.m., document, CNA notified nurse that R2 was on the floor in restroom near the toilet. Upon entering restroom, R2 was in a supine position with her head against the door. When asked what happened R2 stated 'I have to use the bathroom.' 2 cm (centimeters) laceration to left forehead. R2's current medical record has no documentation of neurological checks being completed following R2's fall with head involvement. On 4/17/23 at 10:20 a.m., V2 (Director of Nursing) confirmed that neurological checks were not done on R2 following her fall on 1/2/23.

Based on observation, interview and record review, the facility failed to ensure resident's bed was in low lying position for one (R1) of three residents reviewed for falls. This failure resulted in R1 sustaining a right-sided subdural hematoma and scattered subarachnoid hemorrhages and subsequently death. Findings Include: R1's care plan dated [DATE] documents, Problem: Resident (R1) at risk for falling r/t (related to) recent illness/hospitalization and new environment. (R1) has hx (history) of falls. (R1) has a dx (diagnosis) of dementia, poor safety awareness and is impulsive. Res (resident) has impaired balance and mobility related to weakness and confusion Goal: Resident will have decreased risk for injury related to fall this quarter. Approach: Low bed and scoop mattress. R1's fall risk assessment dated [DATE] documents R1 as a high fall risk. On [DATE] at 10:00 AM, V6, Care Plan Coordinator, stated One of the fall interventions for (R1) was for the bed to be in a low position. (R1) has a history of getting up from his bed and walking without assistants or calling for help R1's medical record documents R1 fell four times with two falls, [DATE] and [DATE], resulting in serious injuries. R1's medical record dated [DATE], documents (R1) fell hitting face. Laceration, broken teeth and bruising with skin tear. Sent to emergency room for evaluation and sutures. R1's hospital records dated [DATE] documents Imaging report: computerized tomography (CT) scan brain. Impressions: No evidence of acute [CONDITION(S)]. R1's medical record dated [DATE] documents At 7:15 PM, Certified Nursing Assistant (CNA) called this nurse to (R1)'s room. When entering the room, (R1) was noted to be laying on his left side on the floor by his bed. Bed was up in a normal position and call light was not on. (R1) stated I fell out of my bed. (R1) noted to have laceration to back side of left head. Pressure applied and bleeding did slow down. On call doctor notified and new order to send to emergency room for treatment. R1's hospital record dated [DATE] at 9:36 PM documents Imaging report: CT scan brain. Findings: Scattered subarachnoid hemorrhages are seen within the right temporal lobe and frontal lobe. Hemorrhagic contusions in the right temporal parietal lobe are visualized. There is a small right-sided subdural hematoma measuring up to seven millimeters. Bilateral periventricular white matter changes are seen suggesting microangiopathic ischemic changes. R1's hospital records dated [DATE] documents (R1) presents as a transfer from outside hospital after unwitnessed fall at the nursing home. He was found to have a subdural hematoma as well as subarachnoid hematoma. during transfer, he had two seizures. On [DATE] at 9:00 am, V2, Director of Nursing (DON), stated Mobile x-ray came in to get an x-ray of (R1)'s hand and left his bed in the raised position. (R1) fell out and sustained a subdural hematoma. On [DATE] at 12:25 AM, observation of R1's bed appeared approximately six inches from floor. V2, DON, stated That's the low-lying position. (R1)'s bed was in a raised position at the time of the fall. Observation of bed in raised position is approximately three feet off the floor. On [DATE] at 12:35 PM, V1, administrator, stated The x-ray tech took an x-ray of R1's right hand, exited the room and left R1's bed in the raised position. R1 wound up falling out of the bed causing a head injury. On [DATE] at 11:09 AM, V3, CNA, stated I was working on [DATE] assigned to (R1)'s group. That evening I got (R1) cleaned up and placed him in bed. The mobile x-ray technician came in to take an x-ray of (R1)'s hand and asked me to raise the bed to a high position, so I raised (R1)'s bed up for the X-ray. It's not mandatory to stay in the room with them, but I always do. During the x-ray, a call light in another room went off and so I asked the x-ray technician if it was ok to answer the call light. He said yes. So, I left the room to answer another call light. When I came out of the room from answering the call light, I heard (R1)'s roommate hollering We need help. When I entered (R1)'s room, the x-ray technician was gone, (R1) was lying on the floor between the beds, and the bed was still in the raised position. On [DATE] at 1:55 PM, V5, x-ray technician, stated I was called in to take an x-ray of (R1)'s hand. When I got there a nurse told the CNA to give me a hand. We walked into the room and the bed was in a low position, I didn't know where the controls were, so I asked the CNA to raise the bed in order for me to get my machine under the bed. The CNA raised the bed. I told the CNA I was good because I only had three x-rays to get. She left the room; I finished the x-ray and left the room. I did not put the bed back down because it wasn't that far off the floor. When I left, the CNA that was in the room with me, was in the hallway, so I told her I was all done and needed let off the unit because it's a locked unit. She let me out and I left. On [DATE] at 9:00 AM, V1, Administrator stated We don't have a fall prevention or fall risk policy. We do the fall assessment and put the fall interventions on the care plan. V1 also stated that there currently is no policy addressing x-ray technicians while on site. R1's medical record dated [DATE] documents that (R1) expired in the hospital. R1's death certificate lists date of death [DATE]; cause of death a. Traumatic Subdural Hematoma with Subarachnoid Hemorrhage b. Fall.

Based on interview and record review, the facility failed to provide supervision to prevent falls, determine root cause analysis of each resident fall, identify trends/patterns of falls, and implement interventions to decrease the risk of future falls for one of three residents (R1) reviewed for resident injury in the sample of three. These failures resulted in R1 falling on [DATE] and fracturing his left clavicle (collar bone) and falling on [DATE] and fracturing his left cheek bone. Findings include: On [DATE] at 2:47 p.m., V1 (Administrator) stated the facility does not have a written policy or procedure for investigating falls. V1 stated when a resident has a fall the nurse creates an Event Report. V1 stated the following morning the IDT (Interdisciplinary Team) discusses any falls (Event Reports) that occurred since the last meeting and makes sure that there is a thorough investigation completed that includes a root cause analysis and new interventions documented on the care plan to reduce the risk of future falls. R1's computer generated census report documents R1 was admitted to the facility on [DATE] with diagnoses which included, [CONDITION(S)] with Behavioral Disturbances, [CONDITION(S)], [CONDITION(S)], Benign [CONDITION(S)] [CONDITION(S)], Repeated falls, Nocturia (urinating frequently at night), Metabolic [CONDITION(S)], Cerebral Infarction, Anxiety Disorder, [CONDITION(S)] of bilateral hips. R1's computer generated census report also documents R1 expired in the facility on [DATE]. R1's Minimum Data Set (MDS) Admission assessment dated [DATE], documents R1 was cognitively intact on Admission. R1's Significant Change MDS dated [DATE], documents R1 had moderately impaired cognition, and R1's Significant Change MDS dated [DATE], documents R1 had severely impaired cognition. R1's Admission Fall Risk assessment dated [DATE], documents R1 was at high risk for falls. The Facility's Fall log dated [DATE] through [DATE], documents R1 had falls on the following dates: [DATE] at 2:30 p.m., [DATE] at 8:10 p.m. , [DATE] 7:53 p.m., [DATE] (2:36 p.m.), [DATE] (10:37 p.m.), [DATE] (5:00 p.m.), [DATE] (5:32 p.m.), [DATE] at 4:30 p.m., [DATE] at 4:48 a.m., [DATE] at 3:24 a.m., [DATE] at 5:21 a.m., [DATE] at 9:07 a.m., [DATE] at 4:30 a.m., [DATE] at 5:45 a.m., [DATE] 8:25 a.m., [DATE] at 7:42 p.m., [DATE] at 3:41 a.m., [DATE] (12:15 a.m.), [DATE] (8:05 p.m.), [DATE] (12:48 a.m.), [DATE] (5:57 a.m.), [DATE] (6:08 p.m.), [DATE] at 7:22 p.m., [DATE] 8:15 a.m., [DATE] at 1:41 a.m., [DATE] at 10:49 a.m. (resulting in fractured left clavicle), [DATE] at 2:56 p.m., [DATE] at 8:15 p.m., [DATE] at 11:30 p.m., [DATE] at 10:17 a.m., [DATE] at 12:30 p.m.(resulting in fractured cheek bone), [DATE] at 5:49 a.m., and [DATE] at 4:31 a.m. R1's falls dated [DATE] through [DATE], documents R1's had 17 falls that occurred between the night time hours of 8:00 p.m. to 6:00 a.m. R1's Event Reports document the following falls occurred in/around R1's bathroom, R1 was incontinent or R1 voiced the need to use the restroom: [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] at 12:15 a.m. and 8:05 p.m., [DATE], and [DATE]. R1's fall investigations for the above dates do not address R1's falls potentially being related to toileting or R1's diagnosis of Nocturia. R1's Care Plan dated [DATE] through [DATE], does not document R1's diagnosis of Nocturia or any interventions to address R1's frequent need to urinate at night. R1's Event Reports dated [DATE], [DATE], [DATE] at 12:53 a.m., [DATE] at 8:05 p.m., [DATE] at 12:48 a.m., [DATE] at 5:57 a.m., [DATE], [DATE], [DATE], and [DATE] do not document a thorough investigation with a root cause analysis and interventions implemented to reduce the risk of future falls. R1's Event Report dated [DATE] at 10:49 a.m., documents R1 fell out of his wheelchair. R1's X-Ray report dated [DATE], documents R1 had a distal left clavicle fracture as a result of R1's fall on [DATE]. R1's Event Report dated [DATE] at 12:40 p.m., documents R1 was found on the floor in his room with two small slits in R1's left cheekbone. R1's X-Ray report dated [DATE], documents R1 had a left cheek fracture. On [DATE] at 2:47 p.m., V1 stated R1 had a lot of falls during his stay and was constantly getting up without assistance. V1 stated the staff tried to keep R1 in areas where staff could keep an eye on him. V1 stated the facility has no documented evidence that R1 was on 1:1 supervision during his stay. V1 stated each one of R1's falls should have been investigated including a documented root cause analysis and appropriate intervention implemented to help reduce the risk of future falls. V1 stated that R1's fall investigations dated [DATE], [DATE], [DATE] at 12:53 a.m., [DATE] at 8:05 p.m., [DATE] at 12:48 a.m., [DATE] at 5:57 a.m., [DATE], [DATE], [DATE], and [DATE] were not thoroughly investigated with an appropriate root cause analysis and new interventions implemented on R1's care plan. V1 stated that neither R1's care plan nor R1's Fall investigations addressed R1's diagnosis of Nocturia or frequent falls involving R1's toileting needs. V1 stated a thorough investigation would include identifying a pattern of falls, such as times, resident needs at the time of the fall, and locations. On [DATE] at 8:45 a.m., V8 (Ombudsman) stated V7 (R1's family member) had requested V8's assistance due to R1 having a very large number of falls during his stay and not getting the supervision he needed to prevent the falls. V8 stated V8 and V7 met with the Care Plan team on two different occasions to discuss what could be done to keep R1 from falling and getting injured so often. V8 stated R1 had approximately 14 falls in October alone. V8 stated R1 had constant skin tears and lacerations but had also had a fractured clavicle and fractured cheek bone. V8 stated the facility did not implement interventions after each fall. V8 stated V8 requested R1 receive 1:1 supervision during the care plan meetings and the facility stated they were not able to provide 1:1 care. V8 stated V1 (Administrator) asked V7 to hire a personal assistant to sit with R1 at all times or have family sit with R1. V8 stated R1's toileting needs seemed to be the biggest reason for R1's falls. V8 stated the staff were not toileting him often enough so R1 would get up by himself and fall. On [DATE] at 9:10 a.m., V7 (R1's family member) stated that the facility failed to implement new interventions after R1's falls and R1 just continued to fall. V7 stated she frequently talked to nursing staff and Administration regarding R1's falls. V7 stated the facility refused to provide 1:1 supervision for R1 and that is what R1 required due to his poor cognition. V7 stated R1 ended up with a fractured clavicle and a fractured cheek bone because of falls due to lack of supervision. V7 stated the facility did not do their due diligence to ensure R1 remained safe and without injuries. On [DATE] at 10:52 a.m., V4 (Certified Nurse Aide) stated R1 was very difficult to keep from getting up without assistance. V4 stated R1 was fast and due to his Dementia, R1 just didn't remember not to get up. V4 stated 1:1 supervision was not provided that V4 was aware of. On [DATE] at 10:55 a.m., V5 (Licensed Practical Nurse) stated R1 was always trying to get up and walk independently. V5 stated the staff would try to keep him in their eyesight when he was awake but as they went to take care of another resident, R1 would be trying to stand and often fall. V5 stated the staff were not able to provide 1:1 care for R1 because there were also other Dementia residents to care for.

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control and Protection guidance and the Facility's COVID-19 policy to identify and prepare a designated space with dedicated staff to care for and monitor residents with confirmed COVID-19, maintain face coverings over the nose and mouth, have isolation signage posted to designate isolation precautions, sanitize/disinfect resident care equipment, and store linens in a COVID negative site, and maintain hand hygiene/glove change. These failures had the potential to affect all 57 residents residing in the facility. These failures resulted in an Immediate Jeopardy. An Immediate Jeopardy situation was identified on 11/10/20 at 9:00 AM. The Immediate Jeopardy was identified to have begun on 10/28/20 when confirmed COVID positive residents were moved to 400 hall. The facility housed COVID exposed residents in quarantine as well as COVID negative residents on 300 Hall. Also, one nurse and two CNAs were dedicated to care for both 300 and 400 halls during their shift. The facility failed to prepare a designated space and dedicated staff to care for residents that had confirmed COVID-19 versus the residents who were COVID negative. The facility also failed to properly don and doff personal protective equipment (PPE), follow correct procedures for wearing PPE and implement Infection Control measures to prevent cross contamination from COVID positive units to COVID negative units. On 11/10/20 at 9:00 a.m., V1 (Administrator) was notified of the Immediate Jeopardy situation. While the immediacy was removed on 11/11/20, the facility remained out of compliance at a Severity Level 2. The facility is in the process of designating specific space with dedicated staff to care for residents with confirmed COVID-19 versus COVID negative residents, and posting isolation precaution signage on resident rooms. The facility is also in-servicing all staff in the following areas: Proper use of Personal Protective Equipment/PPE, keeping face coverings over their nose and mouth, having isolation signage added to resident door to designate isolation precautions, sanitizing/disinfecting resident care equipment, storing of clean linens in an unaffected area, and maintaining hand hygiene/glove change as well as performing random audits of direct patient care. Findings include: The Centers for Disease Control and Protection (CDC) Preparing for COVID-19 in Nursing homes, dated 6/25/20, documents, Identify space in the facility that could be dedicated to monitor and care for residents with COVID-19. Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. Identify HCP (Healthcare Personnel) who will be assigned to work only on the COVID-19 care unit when it is in use. Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive). Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them). The facility's Infection Control Policy, dated 12/17/19, documents, All residents with known or suspected infectious conditions will be cared for using the most appropriate nursing care determined for the benefit and safety of the resident concerned, the other residents in the facility, and the safety of the employees. The policy also documents, Transmission-based precautions: The purpose of isolation techniques is to protect the resident and personnel from infection and to halt the spread of the infectious agent. Emphasis will be placed on isolating the disease-not the resident. All isolation precautions will fall into one of the following categories: Airborne precautions; Contact Precautions; Droplet Precautions. The facility recognizes that the following considerations are applicable in the care of all residents with communicable infections. Handwashing is the foundation of controlling infectious disease. Personnel must wash their hands when coming on duty; when they are visibly soiled; when they are between residents; before and after they blow their nose; after eating or off break; after they handle dressings, urinals, bedpans, needles, or syringes; after toilet use; and when they complete duty. Gowns are worn by all personnel when they enter a strict isolation room and by those coming in direct contact with residents who require airborne, droplet, and contact (if necessary) precautions. Gowns are worn only once and then discarded in appropriate containers before leaving contaminated area. Mask should cover the nose and mouth. Gloves, disposable in nature, will be worn unless sterile gloves are necessary. Gloves will be changed after direct contact with resident's secretions or excretions, even if care of resident has not been completed. The policy also documents, Cleaning/Disinfecting: No alcohol swabs to clean vital sign equipment; Germicidal wipes as disinfectant of choice for medical equipment. The facility profile, dated 10/7/20, documents, Implementation of an Asymptomatic/Transitional Care unit (100 hall) designated as care area for all new admissions/readmissions not currently displaying respiratory symptoms for the 14-day social distancing period; or those who have fulfilled 14-day social distancing on the COVID positive Care unit and not currently displaying respiratory symptoms. Implementation of a Symptomatic Care/COVID positive Isolation unit (600 Hall) designated as care area for all new admissions displaying respiratory symptomology. Any resident (new admission or established resident) diagnosed as having confirmed positive COVID infection will also be placed in this area. The last 8 rooms on this hall, which will remain separated from the respiratory Symptomatic care area rooms by construction of zipper wall, will be designated for these residents. Should the facility identify or observe any resident with new onset respiratory symptoms such as cough, sore throat, shortness of breath or elevated temperature, resident is to be transferred to the Symptomatic care unit (600 hall) where droplet isolation precautions shall be implemented immediately. Resident will be evaluated for need for COVID swab and proceed as per physician order. Should the facility identify any active in-house COVID positive case, resident is to be transferred to the COVID positive care unit (600 hall) and placed in a room behind the zipper wall. Droplet isolation precautions shall be implemented immediately. The facility's Isolation-Set Up and Cleaning Process policy, dated 4/2020, documents, Isolation Room Setup: Determine what type of isolation the resident requires. Leave trash cans in the room being setup for isolation for general garbage. May provide an isolation container for linens in the room. Provide a PPE (Personal Protective Equipment)/Isolation supply cabinet or caddy on door of the room for supplies. Provide alert on door frame to indicate the room is isolation. The facility's Disinfectant List, no date available, documents, Germicidal Wipe: To be used on cleaning equipment including: Glucometers, Lifts, Stand-Aid, Therapy equipment, and etc (Blood pressure cuffs, stethoscopes, and thermometers). The facility's current floor plan, provided by V2 (Director of Nursing) on 10/31/20, documents that the facility currently has five of their six halls open with residents residing in them. The floor plan also documents that a portion of 100 hall (rooms 101-104), 400 hall, and 600 hall are designated for COVID positive residents. The remaining portion of 100 hall (105-115) are designated as residents who have been exposed to COVID however have tested negative and COVID positive residents in transition after their 14 days of quarantine. The facility's 500 hall is designated as a recovered and transition unit. The remaining hallway (300 Hall) is designated as the facility's COVID negative hall. The facility's Daily Census Report (Room Roster), dated 10/31/20 and provided by V2, documents that 57 residents reside in the facility. The Report also documents, 100 Wing: The residents in the following rooms :Rooms 102A , 102B , 103A , 103B , 104A , and 104B are active COVID-19;. Residents in room [ROOM NUMBER]B and 110A have been exposed to COVID, however, they are testing negative; Residng in rooms 106A , 107A , 107B , 108A, 108B , 109A , and 109B are recovered COVID-19 residents in transition. 300 Wing: Rooms 301B , 303B , 309B and 314B residents have been exposed to COVID, however they are testing negative; 310A , 311B , 312B , and 313A are COVID negative residents ; 400 hall: 401A , 402A , 402B , 403B , 407B , and 409A are active COVID-19 residents. 500 hall: Residents in Rooms 500A , 500B, 501A , 503A , 503B , 504A , 504B , 505A , 505B , 506A ,506B ,509A ,509B , 510A ,and 510B are all recovered COVID-19 in transition. 600 Hall: 602A, 603A , 604A ,605A, 606A ,607A , 608A 610A , 611A , 612A , 612B , 613A ,and 614A are residents with active COVID-19. The facility's electronic charting has no documentation of any residents residing in the facility having a comprehensive care plan addressing their COVID positive [DIAGNOSES REDACTED]. On 11/1/20 at 3:00 p.m., V4 (Care Plan Coordinator) confirmed this. On 10/31/20 at 10:15 a.m., the 100 hall wing fire doors were closed. No isolation signage was posted before entering hallway nor any signage on the resident room doors (102-104). V5 (CNA-Certified Nursing Assistant) entered into the COVID positive portion of 100 hallway thru a zippered curtain. V5 had an N95 mask on and goggles, and she was carrying a thermometer and pulse oximetry meter. Then, she applied a gown and gloves in the hallway. V5 entered room [ROOM NUMBER]. V5 exited 102 and immediately entered room [ROOM NUMBER] with the same gloves on and without sanitizing the equipment. V5 exited room [ROOM NUMBER]. With the same gloves, V5 applied hand sanitizer to the pulse oximetry meter. V5 removed her gown and gloves, and using a disinfectant wipe, sanitized the thermometer and pulse oximetry meter. Then, V5 left the unit through the zippered curtain, without sanitizing/washing her hands. On 10/31/2020 at 12:07 p.m., V5 verified that V5 did not remove V5's contaminated gloves, perform hand hygiene and put on new, clean gloves between resident rooms and that V5 should have changed V5's gloves and performed hand hygiene between resident rooms. On 10/31/20 at 10:32 a.m., V6 (CNA) exited room [ROOM NUMBER] with gloves, gown, and surgical mask below her nose carrying a thermometer and pulse oximetry meter. Then, V6 entered room [ROOM NUMBER] without changing her gloves, gown, and/or sanitizing the equipment. V6 exited room [ROOM NUMBER] removing her gown and gloves and performed hand hygiene. V6 did not sanitize the equipment. On 10/31/20 at 10:40 a.m., V6 stated, We are supposed to wear a new gown and gloves for each resident room. I did not do that. I didn't sanitize the pulse oximetry meter or the thermometer. After each resident, we are supposed to sanitize the equipment using a alcohol swab with the contact time of 1-2 minutes. On 10/31/20 at 10:45 a.m., A dry erase board posted at the 300/400/500 hall nurses' desk stated that for day shift V6 and V8 (Both CNAs) were assigned to work 300 (COVID negative hallway) and 400 hall (COVID positive hallway). The board also states that V7 (Licensed Practical Nurse LPN) is working 300/400/500 hall. On 10/31/20 at 11:15 a.m., the 600 hall's (COVID positive) fire doors were closed. The rooms on the 600 hall (601-614) had no isolation precautions signage posted on any of the doors. On 10/31/20 at 11:30 a.m., the 400 hall's (COVID positive) fire doors were closed. No isolation precautions signage was posted on the closed fire doors or any of the resident doors (401-412). V7 stated, This is a COVID positive hall (400). I'm taking care of this hallway, 500 hall, and 300 hall. 500 hall has all had COVID positive and are recovered, and 300 hall is considered our only negative hallway. However, I do have some residents that have been exposed but tested negative on 300 hall. My two CNAs are also working both 400 and 300 hall. No isolation precaution signage is posted on the 400 hall doors nor the resident rooms on 400 hall. On 10/31/20 at 11:45 a.m., V8 (CNA) exited room [ROOM NUMBER] with gloves and gown on. Without removing her gloves, V8 entered room [ROOM NUMBER]. V8 exited the room with V4 (Care plan Coordinator) both still wearing the same gown and gloves. Outside of room [ROOM NUMBER], V8 and V4 removed their gown and gloves, and without washing/sanitizing their hands, applied a new gown and set of gloves and entered room [ROOM NUMBER]. On 10/31/20 at 11:54 a.m., V4 exited the 400 hall wearing the same surgical mask that she wore while on 400 hall. V4 stated that she assisted V8 with a mechanical lift transfer in room [ROOM NUMBER]. On 10/31/20 at 11:54 a.m., V8 (CNA) exited room [ROOM NUMBER] pushing the mechanical lift wearing the same gloves. V8 left the mechanical lift in the hallway, and entered room [ROOM NUMBER]. V8 exited the room still wearing the same pair of gloves. V8 removed gloves and gown, washed her hands, and exited the 400 hall (COVID positive hallway) pushing the mechanical lift. Outside of the fire doors, V8 applied a pair of gloves, and using a disinfectant wipe, disinfected the mechanical lift. Then, wearing the same gloves, V8 pushed the mechanical lift to the 300 hall (COVID negative hallway) and left it in the hallway. On 10/31/20 at 12:45 p.m. V8 exited the 400 COVID positive hallway wearing the same mask that was below her nose, and pushing a kitchen cart out with no gloves on. V8 applied gloves and wiped the cart down with a disinfecting wipe. V8 stated, We are suppose to change our gown and gloves with each room. I didn't do that earlier. We are also supposed to change our mask when switching between 400 and 300 hall. I've been working both hallways all day, and I've worn the same surgical mask the whole time. The mechanical lift I used earlier, I brought it out of the 400 hall, wiped it down with a disinfectant wipe, and with the same gloves on, took it to the 300 hall. Two CNAs are scheduled for 400 and 300 hall. The linens we use for both wings are kept on 400 hall. The linens could be contaminated with being on the COVID hall, but we haven't been told any different. We've always done this. I'm returning this cart to the kitchen. I'm able to go anywhere in the facility while on shift, just because I work the COVID positive hall doesn't limit where I go. With same gloves on, V8 pushed the cart back to the kitchen. On 10/31/20 at 12:05 p.m., No signage was posted on the 100 hall doors that were located on the transition/exposed to COVID hall (Rooms 105-110). V9 (RN-Registered Nurse) stated, R11 and R18 are quarantined from COVID exposure but testing negative. There is no isolation precaution signage on their doors, because we treat this hall as everyone being in isolation. V9 also confirmed that no isolation precaution signage was located on fire doors that enter 100 hall. On 10/31/20 at 12:07 p.m., V5 (CNA) entered room [ROOM NUMBER] with a gown and gloves on pushing the stand aid lift into the room. V9 entered room [ROOM NUMBER] with V5. Then, both staff exited room [ROOM NUMBER] with their gown and gloves on. V9 removed her gown and gloves, and wiped the stand aid lift down with a disinfecting wipe, touching the lift in multiple areas with her bare hands. Once completed, V9 applied a new gown and set of gloves, without sanitizing/washing her hands. V5 stated, We are suppose to be changing our gloves and gown with each room we enter. When we take our gloves off we should be washing or sanitizing our hands. I did not do that earlier when I was working on the COVID positive hall. We are suppose to be wiping the pulse oximetry meter and the thermometer down after each resident. I use the individual alcohol swabs that the nurse has on the cart. I didn't do that as well. Not sure why I used hand sanitizer on the pulse oximetry meter. When I clean the equipment I use the disinfectant wipe, but I don't put gloves on or sanitize my hands afterwards. There are no isolation signs on any of the doors, and it seems like the process is different on every hall. So it's hard to keep things straight of what we are doing. On 10/31/20 at 12:50, V6 (CNA) applied a gown and gloves, already wearing surgical mask and goggles, and entered 400 hall. At 12:55 p.m., V6 exited the 400 hall doors, with the same surgical mask on but sitting below her nose, carrying cloth incontinent pads in her arms. V6 stated, I'm taking these pads to 300 wing. The clean linens for 300 and 400 hall are all stored on 400 hall. On 10/31/20 at 1:15 p.m., V7 (LPN) stated, Residents who tested positive from 300 hall were moved to 400 hall. The residents remaining on 300 hall tested negative, however, some of them were roommates to residents who tested positive. So we are treating them as exposed, and using isolation precautions. No isolation precaution signs are on the doors of 300 hall. The facility's Weekly Nurse Schedule, dated 10/26-11/1/20, documents that on 10/28-11/1/20 one nurse is scheduled to work each shift on the 300 and 400 hall at the same time. The facility's Nursing (CNA) Master Schedule by shift (1st), dated 10/1-10/31/20, documents that from 10/28-11/1/20 the following CNAs were scheduled to work both 300 and 400 hall simultaneously: V5 (10/28/20, 10/29/20); V14 (10/28/20); V15 (10/28/20, 10/29/20); V6 (10/29/20, 10/31/20). The facility's Nursing (CNA) Master Schedule by shift (2nd), dated 10/1-10/31/20, documents that from 10/28-11/1/20 the following CNAs were scheduled to work both 300 and 400 hall simultaneously: V16 (10/28/20, 10/29/20); V17 (10/28/20, 10/31/20); V8 (10/30/20, 10/31/20). The facility's Nursing (CNA) Master Schedule by shift (3rd), dated 10/1-10/31/20, documents that from 10/28-11/1/20 the following CNAs were scheduled to work all hallways facility wide simultaneously during their shift: V18 (10/31/20); V19 (10/28/20, 10/29/20); V20 (10/29/20, 10/30/20, 10/31/20). The schedule also documents that V21 (CNA) was a float between all of the halls from 2:00 p.m. to 2:00 a.m. on 10/30/20. On 11/2/20 at 3:10 pm, V12 (RN) stated that she was currently working 2nd shift in the facility on the 300 and 400 hall. V12 also stated, Two CNAs are working 300 and 400 hall this shift. They go to both halls to help each other with two assist residents. V13 (RN) was the nurse working 300 and 400 hall today on 1st shift. With being the nurse for both 300 and 400 hall, we are caring for COVID positive and residents who haven't tested positive. We are not restricted on our movement throughout the building. On 11/1/20 at 3:00 p.m. V3 (Infectionist Preventionist) stated, We have tried to do staff COVID specific depending on how much staff we have. We try to put the same people with the COVID area. On the South Hall we had one nurse for 400 and 500 and a nurse for 300. When 500 hall became COVID positive we changed to one nurse for 500 and one nurse for 300 and 400. For CNAs we attempt to have two on 300 hall, one on 400, and one on 500. 300 hall CNAs help 400 with two assist residents. V3 also stated, I should be keeping track of all the infections in the building whether they were facility acquired or admitted with to make sure we aren't spreading the infections. With COVID I've increased audits, but only while I'm working the floor. I haven't really been able to be an Infection Preventionist since I've been working the floor so much, since March. I haven't really been able to do this job. I have not been tracking the infections. I don't do the notifications, nor do I speak with the local health department for guidance. On 11/1/20 at 3:25 p.m., V1 (Administrator) stated, 600 hall was split into two with zipper wall. On 10/1/20 our first COVID positive resident went to 600 hall. COVID positive residents went on back side of the curtain, and new admits/symptomatic went on the other side. If a roommate tested positive, they went to a COVID positive hall. If their roommate was negative, that roommate went to the symptomatic hall to be monitored and quarantined for 14 days. On 10/5/20, 500 hall was converted to a COVID positive unit. On 10/14/20, we removed the separation curtain on 600 hall, so it was considered fully COVID positive and 100 hall was then transition along with symptomatic. On 10/20/20, the zippered curtain went up on 100 hall to split it, giving us more COVID positive rooms. On 10/28/20, 400 hall was converted to a COVID positive hallway, and 300 Hall was our COVID free hall. The 300 hall does have residents who are exposed but asymptomatic because we have no open beds on 100 hall. The beds are all open at this time on 200 Hall. We shut that hall down on 10/14/20, but those beds are technically still available. There should be isolation precaution signs posted on the resident doors. The residents that have not been exposed are on the same hall (300 Hall), but we are treating everyone as if they are positive with one and done (new gloves and gown for each room) PPE. A staff member should not enter a room with the same gown or gloves on from a previous room. As soon as they are entering a room they should be applying a clean gown and gloves. 300 hall should have their own linen cart. Linens should not be coming from the 400 hall. We are trying to dedicate the staff to COVID specific hallways during a shift, however, that is not occurring. On 11/4/20 at 8:25 a.m., V1 stated that four new residents (R33, R36, R38, R39) have tested positive during the facility's weekly testing this week. V1 also stated that staff continue to work both 300 (COVID negative) hall and 400 (COVID positive) in the same shift. On 11/2/20 at 4:00 p.m., V11 (Local Health Department) stated, We have talked to the facility about dedicating COVID specific staff. They've been guided to keep like [DIAGNOSES REDACTED]. We don't recommend staff working a COVID positive and COVID negative hallway during the same shift. We tell them to keep staff separate during a shift. We have not recommended that the facility do that (Have staff work COVID Positive and COVID negative hallways simultaneously). On 11/11/20 at 12:15 p.m., the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 11/10/20, V1 (Administrator) confirmed the designation of the 400 hall as a COVID positive, the 300 hall as COVID negative and the 100 as a transitional unit for residents to quarantine upon return from a hospital stay, symptomatic negatives, and new admissions. 600 hall is a COVID positive hall from rooms 611 to 614, and rooms 600-610 are considered a transition area. The two portions of 600 Hall are separated by a plastic zippered wall barrier. As of 11/11/20, 100 hall contained resident who were COVID positive, however, they were in their transition phase; 300 Hall housed residents who have not tested positive for COVID as well as residents who had completed their 28 day COVID positive transition; 400 hall housed residents who are active COVID positive; 500 hall are residents who have completed their 28 day COVID positive transition; 600 hall housed one COVID positive resident and residents in transition. 2. On 11/10/20, V2 (Director of Nursing) ensured isolation precaution signage was placed on the doors of all COVID positive residents to indicate full PPE to be worn per CDC guidance. Signage was also placed on the respective units/halls to indicate the status of the unit (i.e., COVID positive, COVID negative, and Transition) as well as direction regarding the use of PPE while working those hallways. 3. On 11/10/20, V1 and V2 designated staff for COVID positive, COVID negative, and transition areas to be separate and designated for each shift. 4. V2 and V9 (Registered Nurse) initiated in-servicing of staff on 11/3/20 and 11/9/20, concerning the proper use of PPE, keeping face coverings over their nose and mouth, have isolation signage added to resident door to designate isolation precautions, sanitize/disinfect resident care equipment, storing of clean linens in an unaffected area, and maintaining hand hygiene/glove change. The facility plans to have all staff in-serviced by 11/12/20. 5. V3 (Infection Preventionist) and V9 initiated training on 11/3/20 of 1 on 1 in-servicing of direct care staff to educate and observe proper doffing/donning PPE, storage of clean linens, sanitizing/disinfecting resident equipment, and hand hygiene. All facility staff in-servicing/training is to be completed by 11/12/20. 6. On 11/3/20, V2, V3, and V9 initiated random audits observing staff for proper donning/doffing of PPE, storage of clean linens, sanitizing/disinfecting resident equipment, and hand hygiene. The training and education by V2, V3, and V9 continues ongoing daily to ensure compliance.

Based on interview and record review the facility failed to remove old [MEDICATION NAME]es prior to applying a new patch for one (R1) of four residents reviewed for medication errors in a sample of four. This failure resulted in R1 requiring hospitalization for [MEDICAL CONDITION]. Findings include: Facility Admission of A Resident Policy, revised 1/04, documents that: the objective is to facilitate the transition from prior living arrangements to long-term care in a caring, professionally comprehensive manner; to review the resident's personal data with resident and family, to be sure all information on the Admission Notice is correct and current; complete the Nursing Body Assessment in its entirety; and to assess the resident's condition specific to the admitting diagnoses, in addition to the general nursing assessments, and document findings. Facility Medication Administration Policy, revised 2/04, documents the objective to provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified [DIAGNOSES REDACTED]. Facility Medication Errors and Drug Reaction Policy, revised 2/04, documents the objective is to safeguard the resident and that the nurse administering medication should be familiar with the drug reaction, effects and contraindications. The rivastigmine package insert that accompanied the [MEDICATION NAME]es, copyright 2019, documents: to always remove the old patch before applying a new patch and that medication errors resulting in overdose have involved the use of multiple patches at one time. R1's Hospital Discharge Summary Report, dated 8/1/19, documents an order for [REDACTED]. R1's Physician order [REDACTED]. R1's Nursing Progress Note, dated 8/1/19 at 2:10 pm, documents that R1 was admitted to the facility from a local hospital with [DIAGNOSES REDACTED]. R1's Admission Skin Assessment, dated 8/1/19 at 6:46 pm, does not document any [MEDICATION NAME]es. R1's Nursing Progress Note, dated 8/3/19, at 4:05 am, documents that R1 was bleeding from the mouth, unresponsive and pupils were unreactive. R1's Nursing Progress Note, dated 8/3/19, at 10:29 am, documents that R1 was admitted to the local hospital. R1's Hospital Progress Note, dated 8/3/19, at 9:46 am, documents that: R1's [MEDICAL CONDITION] was probable from the postictal phase and that no further bleeding was from the mouth; and that the Poison Center was concerned about the elevated rivastigmine level. R1's Hospital Progress Note, dated 8/5/19, at 6:27 am, and electronically signed by V3 (R1's Physician), documents that R1 presented with a new onset of [MEDICAL CONDITION], in the ER visit they found the patient had three to four [MEDICATION NAME]es on, so the nursing home was applying them without taking off the previous one. Poison Control thought that this could be an etiology. After being admitted to the hospital she had another [MEDICAL CONDITION]. At that point, we treated her with intra-venous [MEDICATION NAME] [MEDICATION]). Facility Notification to the Public Health Agency, dated 8/5/19, documents on the Serious Injury Incident Report (dated 8/2/19 at 1:00 pm), that R1 was admitted to the local hospital on [DATE], at 4:05 am with a [DIAGNOSES REDACTED]. It also documents that R1 was noted in bed with [MEDICAL CONDITION] activity with blood around mouth from biting R1's tongue. R1 had three [MEDICATION NAME]es on with only one dated 8/1/19. R1's Facility Admissions Body Assessment did not reveal any patches in place, however, the facility had only applied the one documented patch on 8/2/19. Facility Medication Error Report, dated 8/3/19, documents the rivastigmine [MEDICATION NAME] error was related to an admission assessment that did not identify two patches in place upon admission and that the nurse applying the patch did not check or remove the outdated patches. On 8/6/19, at 9:40 am, V1 (Administrator) stated, We sent (R1) out to the emergency room for [MEDICAL CONDITION] and blood coming from her mouth from biting her tongue. She was admitted for overdose from having 3 dementia patches on. V1 confirmed that the nurses involved did not follow the protocol for ensuring there is no old patch prior to applying the new one and that the admission nurse did not perform the admission skin assessment. On 8/6/19, at 12:45 pm, V4 (Licensed Practical Nurse/LPN) stated, I admitted her to the facility on [DATE] and did her Admission Body Assessment. I rolled her from side to side and pulled her shirt up, but did not fully remove her shirt to check her skin. I must have overlooked the patches. On 8/6/19, at 1:06 pm, V5 (Licensed Practical Nurse/LPN) stated, She admitted on Thursday, 8/1/19, and her new medicine came in from Pharmacy that night. I worked that night (Thursday 8/1/19 through 8/2/19) and the next morning, on 8/2/19 at 5:00 am, I applied the new rivastigmine patch that had come in the night before. I did not even think to look for an old patch because I thought it was a brand new order. On 8/6/19, at 12:29 pm, V3 (R1's Physician) stated, I have been following her in the hospital and her [MEDICAL CONDITION] activity is exactly related to an overdose of the rivastigmine. [MEDICAL CONDITION] are an overdose side effect. The facility is directly responsible for her medical harm due to the three patches being on.

Based on record reviews and interviews, the facility failed to maintain staff assistance and supervision with one of three sampled residents (R1) with a history of falls. R1 was left unattended fell and sustained a fractured right humerus. Findings include: Hospital Physician's Transcription dated 8/23/10 notes that R1 has [DIAGNOSES REDACTED]. Assessment reads, "This is an [AGE] year old frail appearing female who has a history of falls in the past, who suffered a fall last evening landing on her right arm and shoulder. This resulted in a right comminuted humerus fracture." R1's MDS (Minimum Data Set) dated 8/15/10 notes R1 to be moderately impaired with poor decision making and supervision required. Also notes R1 to need the extensive assistance of one staff person for ambulating and that R1 has fallen in the past thirty days. Document dated 8/23/10 and written by E1 (Administrator) notes that on 8/22/10 R1 was standing at the sink with her walker and the Certified Nurse's Aide (CNA E3) told R1 to stay there while E3 shut the door. When E3 turned back to go to R1, R1 had already started walking and fell before E3 could get back to R1. R1 was sent to the emergency room for an evaluation and was found to have sustained a right shoulder fracture. E3 was disciplined for failure to perform job duties, by not staying with resident with a gait belt which resulted in R1 falling. On 12/15/10 at 9:50 A.M. E3 stated that E3 did leave R1 unattended when E3 went to close the door. E3 said she knew that R1 was not to be left standing unattended, but E3 thought R1 would be all right just for a minute. E3 said she was disciplined for leaving R1 unattended which resulted in R1 falling and sustaining a fractured right shoulder.