Every finding on record at Serenity Estates at Morris

Based on interview and record review, the facility failed to ensure that a resident's transfer status was reevaluated according to resident's condition to ensure safety during transfer. This failure resulted in the resident sustaining an acute mildly displaced and slightly angulated distal femoral fracture.This applies to 1 of 1 resident (R2) reviewed for injury of unknown origin in the sample of 7. The findings include:Face sheet showed that R2 was 87 years-old who had multiple medical diagnoses including Alzheimer's disease, chronic kidney disease, presence of right artificial hip joint, poly-osteoarthritis, disorders of bone density and structure, vitamin D deficiency, and vitamin B12 deficiency anemia. R2's Minimum Data Set (MDS) dated [DATE], showed severe cognitive impairment and requires total assistance from staff with bed mobility and chair/bed-to-chair transfer.Nurse's notes dated July 10, 2026, showed that R2 was reported to have less function in her right leg and was complaining of pain. V6 (Nurse) assessed R2 and noted that R2's right leg was not in a neutral position and had pitting edema to bilateral lower extremities. Both legs had a light purple hue to them. R2 was unable to verbally describe her pain but R2 yelps when she was being moved. V5 notified V4 (Nurse Practitioner/NP), who ordered urinalysis, x-ray to right knee and ankle, and doppler to right lower extremity. Progress notes dated July 11, 2026, at 6:39 PM, showed that x-ray was done to R2's right ankle and knee and she tolerated the procedure.V4's (Nurse Practitioner/NP) notes that were entered on July 12, 2026, at 7:10 PM (a late entry for the service date on July 10, 2026), showed V4 was informed that R2 was favoring her right leg. V4 saw R2 and noted R2 having pain behind the right knee. R2 has no pain in the right lower leg upon examination. V4 ordered ultrasound to rule out baker cyst as there was a knot behind the right knee. V5's (Nurse Practitioner/NP) notes dated July 12, 2026, at 7:26 AM, showed V5 assessed R2 and noted bruising and swelling in R2's right knee. R2's right lower leg was internally rotated, wild lateral collateral ligament swelling. There was no calf tenderness. Nurse's Notes dated July 12, 2026, at 8:15 AM, showed V13 (Nurse) received result of R2's x-ray, indicating R2 had a fracture in the right femur. At 8:30 AM, V13 notified V5 of R2's x-ray result. V5 ordered to send R2 to the hospital. At 11 AM, hospital staff confirmed that R2 had a fracture in the right femur. R2 was admitted to the hospital. X-Ray result dated July 12, 2026, showed there was a severe skeletal osteopenia. There was an acute, comminuted fracture of the distal femur. There was mild foreshortening and approximate one half bone with posterior displacement of the dominant distal fragments. Hospital Record dated July 12, 2026, showed R2 was brought in by family due to abnormal positioning and swelling of her right leg. R2 was found to have a distal femur fracture as well as a DVT (Deep Vein Thrombosis). R2 was unable to give history and was unable to say if she was in pain but seemed to be in discomfort when moved due to her leg. R2's mobility care plan that was initiated on March 5, 2026, showed R2 was at risk for developing an impairment in functional joint mobility due to her generalized weakness related to polyarthritis, and other specified disorders of the bone density and structure. This care plan has interventions which include maintaining good body alignment. R2's other mobility care plan that was initiated on February 7, 2022, showed that R2 has impaired physical mobility requiring assistance with mobility related to weakness, ARF (Acute Renal Failure), Alzheimer's Dementia, polyarthritis, and other specified disorders of the bone density and structure. This care plan showed interventions which includes R2 needing total assistance from staff with turning and repositioning in bed, to encourage R2 to get out of bed and into a chair daily and as tolerated. The Physical Therapist's (PT) evaluation for R2's transfer status dated January 28, 2025, showed R2's assistance required 2 staff assistance and mechanical lift as needed. On August 17, 2026, at 10:24 AM, R2 was sleeping in bed. Bilateral lower extremities were elevated with a pillow. R2's right leg had an immobilizer. On august 17, 2026, at 2:52 PM, V1 (Administrator) stated everyone (staff) informed her that R2 did not have any fall or any incident that could have resulted to a fracture. The staff all denied any sign of abuse or neglect. R2's transfer status was a 2 staff assistance; R2 was able to stand and pivot. R2 always displayed anxiety and moaning behavior whenever ADL (activities of daily living) care was provided, that's why it was hard to determine if there was something wrong with R2. On August 17, 2026, at 3:04 PM, V14 (Certified Nursing assistant/CNA) stated R2 always complaint of everything in general she always had an anxious look on her face when staff provided care. R2's transfer required 2 staff assistance via stand and pivot. There were days that R2's knees would buckle and they supported her by holding on to the gait belt that was wrapped around her torso. R2 used to walk while sitting in her wheelchair. On August 17, 2026, at 3:14 PM, V15 (CNA) stated that before the incident, R2 required 2 staff assistance when being transferred by stand and pivot. Currently, R2 requires mechanical lift. R2 was very hard to understand, her behavior changes constantly one moment she could be fine, next she could cry, and next she could be asking for food or drink. Often during transfer, her knees would buckle and they would support her by holding on to her gait belt. R2 used to be good with her transfer status of stand and pivot, but lately her condition has been deteriorating. On August 18, 2026, at 9:56 AM, V17 (CNA) stated she worked on July 10, 2026. V17 and another CNA staff (V19) assisted R2 to get up for breakfast. They assisted R2 with transferring via stand and pivot with use of a gait belt. R2 stood up crying and moaning, which was her normal behavior on a daily basis. Whenever they assist R2 to stand up, R2 was always hunched forward with knees slightly bent. After they transferred R2 to her wheelchair, they propelled her to the dining room. R2 always cries whenever she gets up and that was her normal behavior. But that day on July 10, 2026, V17 noticed that while in the dining room, R2 kept rubbing her right thigh just above her knee and was crying. That was unusual for R2, so she notified V6 (Nurse) about R2's behavior and action. On August 18, 2026, at 10:58 AM, V19 (CNA) stated on July 10, she helped V17 to transfer R2 to the wheelchair. R2 displayed her usual behavior. R2 made noises during transfer. V19 could not remember details of R2's transfer. V19 only recalled that R2 was making a bunch of noises like moaning during transfer. On August 18, 2026, at 1:39 PM, V18 (CNA) stated R2 required 2 staff assistance. R2's legs usually buckled during transfer. R2 was not a good candidate for a stand and pivot, because she couldn't stand. R2 was anxious all the time. V18 couldn't tell the difference with R2 if she was more anxious because that was R2's normal demeanor. On August 18, 2026, at 2:16 PM, V8 (CNA) stated R2 needed 2 staff assistance for transfer. R2's weight bearing was not the best. R2 was being transferred via stand and pivot, R2 had little weight bearing. They (staff) did more of the lifting for R2 because her legs buckled. Sometimes R2 does not bear weight at all, and they had to lift her with use of gait belt. On August 18, 2026, at 2:27 PM, V20 (Rehab Director) stated R2 was seen by PT in December 2024 to January 10, 2025. According to the PT notes R2 was recommended for 2 staff transfer assistance for stand and pivot and/ or dependent transfer, which means using the mechanical lift from bed to wheelchair. R2 was unable to ambulate, and she refused to participate in physical therapy, that was why she was discharged from physical therapy. R2 had reached her maximum potential. The recommendation for the use of mechanical lift was for safety reasons. On August 18, 2026, at 1:15 PM, V5 (NP) stated she examined R2 prior to being sent to the hospital and noted that her leg looked internally rotated. It looked misaligned. V13 (Nurse) later notified V5 of R2's x-ray result, V5 then ordered to send R2 to the hospital. V5 said, if she was notified that a resident's legs kept buckling when being transferred via stand and pivot, V5 would order the physical therapist to reassess the resident's transfer status. On August 19, 2026, at 3:15 PM, V5 (NP) also stated that R2's buckling episodes during transfer from bed to chair and chair to bed, plus R2's co-morbidities including diagnosis of osteopenia put her in a higher risk of injury. The constant buckling could have contributed to the fracture or injury. They should have referred R2 for a therapy evaluation to determine the appropriateness of her transfer status.R2's x-ray result showed an acute mildly displaced and slightly angulated distal femoral fracture and severe osseous demineralization. Facility's conclusion with regards to R2's injury of unknown origin indicated that the contributing factors include R2's diagnoses of osteopenia, Vitamin D deficiency, polyarthritis, anemia, and dementia, which increased the risk of injury and fracture. These underlying conditions likely decreased bone strength and increased susceptibility to fracture. The facility's investigation found no evidence of abuse, neglect, environmental hazards, or equipment malfunction. However, upon interviews with several CNA staff, they were all aware that R2's weight-bearing was poor, and her legs often buckled during stand and pivot transfer. There was no evidence of documentation that any of the staff reported R2's mobility status to the nurses or restorative staff that may result to a referral to physical therapist for screening or re-evaluation. R2's mobility care plan with initiated date of March 5, 2026, showed R2 was at risk for developing impairment in functional joint mobility, this care plan has interventions which include maintaining good body alignment. V17 said in the interview that whenever they assist R2 to stand up, R2 was always hunched forward with slightly bent knees. There was no evidence that R2 was referred to physical therapy for re-evaluation or screening to determine the appropriateness of her transfer status. R2 was last evaluated by PT on January 28, 2025, for her transfer status.On August 19, 2026, around 3:30 to 3:45 PM, V1 (Administrator) and V2 (Director of Nursing) both stated that they gave in-services to all nursing/CNA staff regarding appropriate transfer with return demonstration, facility wide audit to determine the transfer status of residents, to evaluate whether a resident requires one person assistance for stand and pivot or 2-person assistance for mechanical lift. However, there was no evidence that staff were in-serviced regarding observation, notification/reporting when a resident is displaying a change in the mobility condition that may require evaluation or screening from physical therapists.

Based on interviews and record reviews, the facility failed to ensure a resident was properly secured in their wheelchair while being transported by facility staff in the facility's van. This failure resulted in R2 falling from his wheelchair and sustaining a subdural hematoma (brain bleed) and fracture. This applies to 1 of 3 residents (R2) reviewed for supervision and accidents. The findings include: R2's electronic medical records show he is an [AGE] year-old male with diagnoses including chronic congestive heart failure, chronic kidney disease, chronic peripheral venous insufficiency, metabolic encephalopathy, anxiety disorder, and need for assistance with personal care and was admitted to the facility 7/23/2025. R2's current care plan-initiated August 01, 2025, shows he receives a blood thinner due to atrial fibrillation (irregular heartbeat). R2's June 2026 medication administration record shows R2 was receiving a blood thinning medication twice daily from June 01, 2026, to June 19, 2026. On July 10, 2026, at 4:50 PM, R2 said he was hospitalized due to a fall from his wheelchair while he was being transported by the facility's staff in the facility's van. R2 said he was heading back to the facility after an appointment when his wheelchair went backwards and he fell, hitting his head. R2 said he must have passed out because when he woke up, he was in an ambulance being transported to the hospital. R2 said he has had head and neck pain since the fall that requires him to take pain medication daily. R2 rates his pain at a 7 out of 10 on a scale of 1-10 with 10 being the worst pain. R2 said since the fall, he has had episodes of dizziness and cannot do much except go to therapy and that includes not being able to participate in activities. R2 said he had to be transported in the facility's van today for a medical appointment and the experience made him feel dizzy and sick. R2's fall incident report dated June 20, 2026, shows he was observed on the floor of a van during return transportation from an appointment, he was taking a blood thinner, and 911 was called. The facility's final incident report dated June 25, 2026, shows on June 20, 2026, R2 was being transported back to the facility from a scheduled medical appointment, was seated in a wheelchair, and secured in the transport vehicle. During the trip, R2's wheelchair became unstable, shifted backward, and R2 came into contact with the floor of the vehicle. On July 10, 2026, at 2:50 PM, V7 (Medical Director) said R2 did sustain a brain bleed after his fall on June 20, 2026. V7 said she believes R2 may have been on blood thinners during that time which increases the risk of bleeding from an injury. V7 said she believes nursing reported that R2 did hit his head when he fell on June 20, 2026. V7 said it sounded like R2's fall was pretty bad, and he was out of the facility for a while afterwards. V7 said she talked to R2 after his fall, and he still has some pain and headaches. V7 said if a resident is not secured while being transported in a vehicle it could increase risk of injury or fall. On July 10, 2026, at 12:45 PM, V5 (Activities Aide) said on June 20, 2026, while she was transporting R2 back to the facility from an appointment in the facility's van, she heard R2 say who, and she checked behind her to find out what happened. V5 could not see R2 and when she asked R2 where are you? He responded that he was on the floor. V5 said she pulled over and examined R2. V5 said R2 was lying on his right side facing the back door with his feet over the ramp and his seat belt still fastened. V5 said when R2 was originally positioned in the van, his wheelchair was strapped down with the built in hooked straps. V5 said she rode in the facility's bus a couple of times with V8 (Former Activities Aide) and once with V9 (Former Maintenance Staff) and observed the process of transporting residents but never received formal training. V5 said the hooked straps that were used to secure R2's wheelchair when transported don't have a locking mechanism but will tighten when you tug on them. On July 10, 2026, at 1:15 PM, V5 demonstrated on the facility's van how she secured R2's wheelchair on June 20, before R2's fall. V5 placed four of the van's built-in hooked straps on the wheels of an empty wheelchair. On July 10, 2026, at 1:45 PM, V1 (Administrator) said V8 (Former Activities Aide) and V9 (Former Maintenance Staff) were responsible for training staff on resident transportation procedures. On July 10, 2026 at 4:28 PM V1 (Administrator) said training for transportation of residents includes reviewing the safety transport checklist and reviewing a transport book with action items such as checking the bus for safety, checking wheelchairs for safety, ensuring the seat belt is on securely, ensuring residents are comfortably and securely positioned in their wheelchairs, and placing four hooks on the wheelchair with two in the front and back, and ensuring the hooks are secured to the frame of the chair by tugging on the hooks to confirm they're locked in position. V1 said the expectation is that when being trained to transport residents' staff would observe these procedures then perform a return demonstration. V1 said if staff did have any concerns with training, it would be expected that staff would ask questions or express any concerns they had with their understanding of the training. V1 said the trainer would educate the staff on proper procedures. V1 confirmed if staff are not trained properly it may contribute to residents being injured while transported. V1 said she would expect staff to inform the facility if they felt they weren't adequately trained. V1 agreed if staff don't follow training instructions residents could get injured. On July 11, 2026, at 9:02 AM, V1 (Administrator) said a safety checklist has always been in place for the facility's transportation van but V1 was not able to provide a copy of the safety checklist that was completed on June 20, when R2 was transported by V5 (Activities Aide) in the facility's van. R2's physician progress note dated June 20, 2026 shows nursing reported that R2 had an incident in the van while returning to the facility from an appointment. Apparently, R2's wheelchair tipped over while in the van resulting R2 falling and hitting his head. The van driver notified the facility and was advised to call 911 to transport R2 to the emergency room for further evaluation as R2 receives a blood thinner for atrial fibrillation. The ambulance report dated June 20, 2026, shows 911 responded to a report of a fall, upon arrival, the responders found R2 lying on his right side in the back of a transportation bus. The driver of the van states that the patient fell backwards while secured in his wheelchair and hit his head, The paramedics noted all four wheels are strapped down and the patient was thrown backwards out of the wheelchair with one shoulder strap still secured around his shoulder. R2 complained of head, neck, back and right shoulder pain. R2's hospital report dated June 20, 2026, shows he arrived to the emergency department with complaints of head, right shoulder, and low back pain after a fall. R2 was reportedly in the transportation van when the harness became loose, and he fell backwards and hit his head. R2 reported he was experiencing pain in his right shoulder when he moved. R2 experienced a mechanical fall when the fasteners became loose on the wheelchair and fell backwards. R2's diagnoses include a subdural hematoma, closed head injury, fracture, and contusion. The facility's Skilled Nursing Facility Transportation Protocol: for Resident Transportation Using Company Vehicles received July 10, 2026, shows:The purpose of the policy is To ensure the safe transportation of residents by facility employees through resident safety procedures. Secure wheelchairs using approved tie-down systems and occupant restraints. Ensure all residents are safely seated and secured before vehicle movement. The facility's sample transportation safety checklist received on July 10, 2026 includes the following tasks:. Wheelchair secured by frame.Resident seatbelt secured.

Based on interview and record review, the facility failed to administer the laxative suppository as ordered by the physician,This applies to 1 of 3 residents (R2), reviewed for administration of laxative medications. The findings include:R2 had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, cerebral infarction due to thrombosis of right middle cerebral artery, diverticulosis of large intestine without perforation or abscess without bleeding and need for assistance with personal care, based on the face sheet.R2's progress notes dated April 24, 2026 at 5:43 PM showed that the resident returned to the facility after her appointment and after visiting the ED (Emergency Department) with the family. The same progress notes showed that according to the nurse from the ED, R2 presented with constipation and urinary retention. The same progress notes showed, Resident also given suppository for constipation with an order to continue with Glycerin 2-gram rectal suppositories for the next 3 days.R2's order details showed an order dated April 24, 2026 for Glycerin (adult) Rectal Suppository 2 GM (grams), insert 1 suppository rectally once daily for constipation x 3 days.R2's Glycerin rectal suppository administration details showed that on April 25 and April 26, 2026, the suppository was not administered because it was not available at the facility, it was ordered at the pharmacy, and the facility was waiting for the delivery.R2's eMAR (electronic Medication Administration Record) showed that the resident received the first Glycerin suppository at the facility on April 27, 2026. However, the same eMAR showed no evidence that R2 received the second and the third doses of the Glycerin suppository as ordered by the physician.On May 19, 2026 at 11:43 AM, V2 (Director of Nursing) stated that she had reviewed R2's Glycerin suppository order dated on April 24, 2026. V2 admitted that R2 did not receive the full ordered doses of the Glycerin suppository because the medication was not available at the facility on April 25 and 26, 2026. V2 confirmed that based on the eMAR, R2 only received one dose of the Glycerin suppository on April 27, 2026 and there was no other evidence to show that it was given for additional two more days to complete the three days order. During the same interview, V2 stated that she expects the nurse to follow the physician's order to administer the Glycerin suppository for three days as ordered and it is also the facility's policy to administer a resident's medication as ordered by the physician.The facility's medication administration policy dated October 21, 2025 showed, Medications are administered by licensed nurses, or other staff who are legally, authorized to do so in this state, as ordered by the physician and in accordance with professional standard of practice, in a manner to prevent contamination or infection.

Based on observation, interview and record review, the facility failed to have enough full body lifts to accommodate residents' needs. This applies to 2 of 2 residents (R1 and R3) reviewed for mechanical lifts. The findings include: 1. On 04/30/26 at 1:00 PM, the surveyor and the administrator toured the facility; one electric full body mechanical lift was on the first floor in use. One manual lift was on the second floor in use. No other full body lifts were seen throughout the facility.On 04/30/26 at 10:40 AM, R1 was sitting in a wheelchair in the room. R1 stated the facility has only one working full body mechanical lift in the facility. R1 stated when she is ready to get out of bed or go back to bed, there is not a mechanical lift available. R1 stated she has to stay in bed or in her wheelchair for extended times. R1 was admitted to the facility on [DATE] with multiple diagnoses which included hemiplegia and hemiparesis affecting left non dominant side, cerebral infarction, diabetes, osteoarthritis, muscle weakness, cognitive communication deficit, and need for assistance with personal care per the admission Record. R1's MDS (Minimum Data Set) dated 03/20/26 showed R1 was cognitively intact. R1 required the use of a wheelchair and was dependent upon staff for transferring. R1's ADL (Activities of Daily Living) self-care performance deficit showed, Transfer: Full body lift machine and two assist.2. On 04/30/26 at 8:45 AM, R3 was sitting in a wheelchair in the room. R3 stated she is transferred via full body mechanical lift. R3 stated there is only one full body mechanical lift in the facility. R3 stated a few days ago, the CNA's (Certified Nursing Assistant) told her she could not lay down because there was no mechanical lift available. R3 stated she likes to eat her lunch while sitting in the wheelchair but prefers to eat dinner in bed. R3 stated she had to eat dinner while sitting in the wheelchair. R3 stated she sat in the wheelchair for six hours that day. R3 stated multiple CNA's told her they were doing the best they could with getting her in bed. On 04/30/26 at 9:43 AM, V4 (CNA) stated the entire facility has two full body mechanical lifts, one electric and one manual. V4 stated both of the lifts were on another unit. V4 stated there are times when the residents cannot get out of bed or lay down because they do not have lifts available at that time.On 04/30/26 at 10:20 AM, V6 (CNA) stated on 04/27/26 or 04/28/26, the facility was down to one full body mechanical lift. V6 stated it delays care when there are not enough mechanical lifts. V6 stated R1 asked to lay down. V6 stated R1 was informed that the lift was upstairs and that it might be a while before she could lay down. V6 stated she was not able to put R1 in bed by the end of her shift, and she reported it to second shift. On 04/30/26 at 12:30 PM, V8 (CNA) stated on 04/28/26, R1 had her call light on and wanted to go back to bed. V8 stated she had a hard time finding a mechanical lift to put R1 back in the bed. V8 stated she checked a few units and did not find the lift. V8 stated she went to another unit, and the lift was charging. V8 stated when the lift is charging, they cannot use it. V8 stated it was endorsed to the next shift that R1 wanted to go to bed. On 05/02/26 at 1:15 PM, V1 (Administrator) stated one of the lifts was in the maintenance office due to safety concerns. V1 stated all units, first and second floor are sharing the full body mechanical lifts right now. V1 stated it is expected that residents needs are met timely, and they should be able to lay down as soon as they ask. R3 was admitted to the facility on [DATE] with multiple diagnoses which included polyneuropathy, megaloblastic anemias, diabetes, major depressive disorder, hypertension, osteoarthritis, intervertebral disc degeneration per the admission Record. R3's MDS dated [DATE] showed R3's cognition was intact. The same MDS showed R3 was dependent upon staff for transfers.The facility's Safe Resident handling/Transfers Policy, revised 10/01/25, showed 14) Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on interview and record review, the facility failed to administer prescribed medications as ordered. This applies to 1 of 1 resident (R1) reviewed for medications. The findings include: R1 was admitted to the facility on [DATE] with multiple diagnoses which included hemiplegia and hemiparesis affecting left non dominant side, cerebral infarction, diabetes, osteoarthritis, muscle weakness, cognitive communication deficit, and need for assistance with personal care per the admission Record. R1's Order Summary for April 2026, showed an active order for Alprazolam (Xanax) 0.25 mg (milligrams) at bedtime. R1's MAR (Medication Administration Record) for 04/01/26-04/30/26 showed Alprazolam 0.25 mg at bedtime a scheduled medication. The same MAR showed for the dates of 04/11/26, 04/12/26, and 04/13/26, there was a code with the number 11 in those boxes along with the administering nurse initials. The MAR's Chart Codes showed that the number 11 code meant Med not available.On 05/01/26 at 10:15 AM, V13 (Psych Nurse Practitioner) stated the pharmacy informed her that the nurses could get Xanax from the convenience box/emergency medications until her shipment arrives to the facility. On 05/01/26 at 2:45 PM, V10 (RN/Registered Nurse) stated on 04/11/26 she signed on R1's MAR (Medication Administration Record) that the Xanax was not available. V10 stated she did not call the doctor, nurse practitioner, or the pharmacy to inform them that R1 did not have the medication available. V10 stated the nurses are supposed to call the doctor and inform them if a resident did not receive a medication. On 05/02/26 at 3:29 PM, V11 (RN) stated on 04/12/26 she signed on R1's MAR that the Xanax was not available. V11 stated she did not call the pharmacy to see what was going on with the medication. V11 stated she should have called the doctor to let them know that R1 had not received Xanax, and if they wanted to do something else. V11 stated she did not try to get the Xanax from the emergency supply of medications at the facility. On 05/02/26 at 3:00 PM, V2 (DON/Director of Nursing) stated she was unaware that R1 had missed three doses of Xanax. V2 stated the nurses had not called her to inform her of the medication not being in the facility. V2 stated the nurses are aware if medications are not available, they could get it from the Nexus (emergency stock). V2 stated R1 should not have missed three doses of Xanax, the pharmacy and the providers should have been called. V2 stated benzodiazepines should not be stopped abruptly, withdrawal symptoms or worse could occur.The facility's Medication Administration Policy, revised 10/01/25, showed Policy Explanation and Compliance Guidelines: 12) b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. 23) Correct any discrepancies and report to nurse manager.

Based on interview and record review, the facility failed to provide a residents POA (Power of Attorney) notification of end of therapy services. This applies to 1 of 1 resident (R6) reviewed for notification of end of therapy. The findings include: R6 was admitted to the facility on [DATE] with multiple diagnoses which included hemiplegia and hemiparesis, muscle disorders, difficulty in walking, cognitive communication deficit, diabetes, Alzheimer's Disease, unspecified visual disturbance, depression, hearing loss, and dementia per the Face Sheet. On 04/08/26 at 9:30 AM, R6 stated her daughter is her POA. R6 stated she used to be in therapy and does not know why it ended. R6 stated she did not remember receiving or signing a letter stating therapy would be ending. R6 stated if the facility had given her a letter stating that therapy was ending, she would have given it to her daughter. R6 stated she makes decisions with her daughter. On 04/07/26 at 1:00M, V11 (Social Services Director) stated she issued a NOMNC (Notice of Medicare Non-Coverage) to R6 when her skilled therapy ended in December 2025 by her. V11 stated a NOMNC was not issued to R6 when her Part B therapy ended in March 2026. V11 stated she did not send a NOMNC to R6's POA to notify her of therapy ending. V11 stated she did not take into consideration that R6 had a diagnosis of Alzheimer's Disease.R6's EMR (Electronic Medical Record) showed a signed NOMNC by R6 on 12/16/25. The EMR showed no notification of R6's POA being notified of the last covered day of skilled services. The EMR showed no documentation of a NOMNC being given to R6 or R6's POA for the end of therapy, last covered dates 03/06/26 and 02/24/26. The facility was unable to show that R6's POA had been notified of either end of therapy services. My Power of Attorney for Health Care dated 09/16/16 showed R6's daughter (Name) as the POA. The form showed R6's initials next to a box stating, I Authorize My Agent to make decisions for me starting now and continuing after I am no longer able to make them for myself. While I am still able to make my own decisions, I can still do so if I want to. R6's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage dated 12/16/25 was signed by R6. The notice showed Medicare does not pay for everything, even some care that you or your health care provider think you need. The Skilled Nursing Facility (SNF) or its Utilization Review Committee believes that the care listed below does not meet Medicare coverage requirements. Beginning on 12/19/25, you may have to pay out of pocket for this care if you do not have other insurance that may cover these costs. The care(s) you have been receiving during the Inpatient Skilled Nursing Facility stay includes Physical Therapy and Occupational Therapy. The Notice of Medicare Non-coverage form dated 12/16/25 and signed by R6 showed, Medicare coverage of your current skilled nursing services will end on 12/18/25. R6's Impaired cognitive function/dementia or impaired thought process r/t Alzheimer/dementia care plan dated 12/03/25 showed interventions: monitor/document/report to MD any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficult understanding others. Impaired cognitive function r/t Alzheimer's, impaired decision-making, short-term memory loss care plan dated 01/04/26 showed communicate with the resident/family/caregivers regarding residents capabilities and needs.The facility was unable to provide a NOMNC for the end of Part B therapy in March 2026.The facility's Advance Beneficiary Notices Policy dated 10/21/25 showed, A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility. Delivery requirements: The notice shall be written legibly in a language and/or format that the resident/representative understands. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). For part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN). For Part B items and services, the facility shall use the Advance Beneficiary Notice of Non-Coverage (ABN).

Based on interview and record review, the facility failed to protect residents right to privacy and confidentiality. This applies to 2 of 2 residents (R7 and R8) reviewed for resident's rights. The findings include:1. R7 was admitted to the facility on [DATE] with multiple diagnoses which included central cord syndrome of cervical spinal cord, congestive heart failure, quadriplegia, anxiety, major depressive disorder, and benign prostatic hyperplasia per the admission Record. On [DATE] at 9:15 AM, the surveyor and V1 (Administrator) viewed a 53 second video posted on V28's (CNA/Certified Nursing Assistant) Tik Tok social media account. The video showed R7 wearing a gown and being lifted by a mechanical lift. R7 was seen on the video in the washroom, clothed, performing personal hygiene activities. R7 was seen on another occasion in his room, sitting in a wheelchair, and organizing his personal items on the bedside table. On another day, R7 was sitting in the wheelchair, catching and throwing a ball. R7 and R8 were seen trying to grab a ball with a reach extender device. Another clip in the video showed a resident, wearing a gown, with his left arm across the right arm, holding a rosary and a death notice with a picture of a female. The last clip of the video showed an In Loving Memory card with R7's date of birth , date of death , and the name of the funeral home. The end of the video showed the name of the social media site, along with V28's (CNA) username for the site. On [DATE] at 10:00 AM, V1 identified the two residents seen in the social media video as R7 and R8. V1 stated V28 was employed at the facility until [DATE]. V1 stated R7 was a long-time resident of the facility until he died, and R8 was still a resident in the facility. V1 stated posting residents on social media is a violation of their policy, resident's rights, and it is the facility's responsibility to protect the residents. V1 stated the facility did not have permission from R7 or the family to take videos, pictures, or post on social media. On [DATE] at 10:45 AM, V2 (DON/Director of Nursing) stated it was wrong for V28 to share videos of residents and it should not have happened. V2 stated V28 violated the facility's social media policy and HIPAA (Health Insurance Portability and Accountability Act). V2 stated her expectations for the staff are no videos or pictures of residents.On [DATE] at 11:15 AM, V27 (Activity Director) stated she obtains consents from the families or residents for videos and pictures to be taken of the residents. V27 stated she had never obtained any written consents from R7 and R8, or their families for pictures and videos to be taken of them. V27 stated the employees are not allowed to post residents on their personal social media. On [DATE] at 2:49 PM, V28 stated she worked at the facility for almost two years. V28 stated she resigned on [DATE] and her last day of employment at the facility was [DATE]. V28 stated she posted a collage of videos of R7 on her social media account on [DATE] and deleted it on [DATE]. V28 stated she knew it was not right to post R7 on her social media account. V28 stated she did not have permission or written consent to take pictures, video recordings, or post on social media. V28 verified that her username on Tik Tok was the same as the username at the end of the posted video. R7's Census List showed R7 was admitted to the facility on [DATE] and expired on [DATE]. R7's Progress Notes dated [DATE] at 6:33 AM, showed Patient is now on hospice care. Patient is in the bed resting comfortably. Will continue to monitor. Progress Notes dated [DATE] at 11:18 AM, showed POA (Power of Attorney) in room with patient. Patient ending near of life and having pain and terminal agitation. Progress Notes dated [DATE] at 10:30 PM, showed Resident expired at 6:45 PM. Resident on hospice. Picked up by (Funeral Home) at 9:30 PM, on [DATE].R7's Audio, Video and Photographic Release Form was signed by R7's POA. The form stated Please do not use my name or photograph within the facility in the following circumstances. Please do not release my name or photograph outside the facility without my specific written authorization.2. R8 was admitted to the facility on [DATE] with multiple diagnoses which included hemiplegia and hemiparesis, major depressive disorder, anxiety, hypertensive chronic kidney disease, aphasia, and dysphasia. R8's EMR (Electronic Medical Record) contained no written consents for R8 to be photographed, video recorded, or to be on any employees social media site. The facility was unable to provide written consent for audio, video, and photographic. The facility's Social Media Use Policy, revised [DATE], showed Policy: It is the policy of this facility to protect residents, staff, visitors, volunteers and practitioners against misuse of social media content. Taking, keeping, or distributing unauthorized photographs or audio/video recordings of residents through multimedia messages or on social media networks is a violation of the resident's right to privacy and confidentiality. Staff members must recognize that they have an ethical and legal obligation to maintain resident privacy and confidentiality at all times. Policy Explanation and Compliance Guidelines: 1. Employees are strictly prohibited from transmitting by way of any electronic media any resident-related image or information that may be reasonably anticipated to violate resident rights to confidentiality or privacy. This includes information that could degrade or embarrass the resident. 2. Photographs or recordings of a resident and or his or her private space without the resident or designated representative's written consent, is prohibited. Examples include taking unauthorized photographs/videos of: d. taking unauthorized photographs or recordings of residents in any state of dress or undress using any type of equipment.

Based on interview and record review, the facility failed to provide a care plan conference for a resident and their representative. This applies to 1 of 1 resident (R6) reviewed for care planning. The findings include: R6 was admitted to the facility on [DATE] with multiple diagnoses which included hemiplegia and hemiparesis, muscle disorders, difficulty in walking, cognitive communication deficit, diabetes, Alzheimer's Disease, unspecified visual disturbance, depression, hearing loss, and dementia per the Face Sheet. On 04/08/26 at 9:30 AM, R6 stated neither she nor her POA had attended a care plan meeting since being admitted to the facility. On 04/07/26 at 1:00 PM, V11 (Social [NAME] Director) stated care plan conferences have not been done as they should have been. Stated if a care plan conference had been done for R6, she would have documented the progress notes. V11 stated she was unable to provide documentation of the care plan conference being conducted. On 04/09/26 at 2:55 PM, V1 (Administrator) stated she was not able to find a documented record of a care plan conference being held for R6. V1 stated care plan conferences should be held for residents at a minimal of every 90 days or with significant change. V1 stated if conferences are not conducted, it could result in a communication breakdown between the resident, family, and facility.R6's EMR (Electronic Medical Record) showed no evidence of a care plan conference being conducted. The facility was unable to provide documentation that a care plan conference with R6 or R6's POA (Power of Attorney) had been conducted. The facility's Comprehensive Care Plans Policy dated 10/21/25, showed It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be prepared by an interdisciplinary team, that includes but is not limited to the resident and the resident's representative, to the extent practicable.

Based on observations, interview, and record review, the facility failed to provide safe medication storage and labelling practices for residents receiving prescription and narcotic medications.This applies to 4 residents (R1, R5, R12, and R105) sampled for medication storage and labeling in a sample of 26.The findings includes:1. According to the face sheet, R1 was admitted to the facility on [DATE], and had multiple diagnoses including (COPD) chronic obstructive pulmonary disease with acute exacerbation, acute kidney failure, and hypertensive heart disease with heart failure.R1's POS (Physician Order Sheet), dated November 14, 2025, showed an active order for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated inhaler to be administered one time a day for COPD.On December 16, 2025, at 9:25 AM, V19 (Nurse) administered Trelegy Ellipta Inhalation Aerosol Powder Breath Activated inhaler, which had no pharmacy label, to R1. V19 said the medication was probably brought by R1 when admitted to the facility. V19 also said R1 had an unopened Trelegy Ellipta Inhalation Aerosol Powder Breath Activated inhaler sent by the facility pharmacy which had a label, but the nurses have been administering the inhaler without the pharmacy label to R1.On December 17, 2025, at 10:21 AM, V2 (Director of Nursing/DON) said the unlabeled Trelegy Ellipta Inhalation Aerosol Powder Breath Activated inhaler medication the facility nurses had been administering to R1 was brought with R1 from another hospital upon admission. V2 also said it was not safe to administer medications that do not have the facility's pharmacy labelling on the packet to residents. V2 also added that the facility's pharmacy does not send medications without labeling for the residents, and the facility should have sent the medication home with R1's family. In addition, V2 said the medication should not have been administered to R1 to ensure the resident is receiving the correct medications sent by the pharmacy.2.On December 17, 2025, at 10:20 AM, a narcotic medication card containing 30 tablets of Dipen/Atrop tablet 2.5 (MG) milligrams belonging to R105 was in the facility's locked narcotic medication box. The narcotic medication card showed that two medications (pocket 10 and 20) were opened and re-taped with a paper tape. V21 (Nurse) said the medication has had the tape on the medication card for a long time, although nurses are supposed to discard opened and unused narcotic medications with two nurses.3. On December 17, 2025, at 10:38 AM, a narcotic medication card containing 22 tablets of tramadol HCL 50 MG belonging to R12 was in the facility's locked narcotic medication box. The narcotic medication card showed that two medications (pocket 20 and 27) were opened and re-taped with a paper tape. V20 (Nurse) said nurses are supposed to discard opened and unused narcotic medications with two nurses and should not them to the narcotic card.4. On December 17, 2025, at 11:57 AM, during medication cart check with V19 (Nurse), a narcotic medication card containing 15 tablets of Alprazolam tablet 0.5 MG belonging to R5 was in the facility's locked narcotic medication box. The narcotic medication card showed that one medication (pocket 1) was opened and re-taped with a paper tape. On December 17, 2025, at 3:07 PM, V2 said the facility should have had two nurses witnessed and disposed unused residents' narcotic medications appropriately. V2 also said nurses should not have returned unused narcotic medication by applying paper tapes to seal the medication cards for infection control, risk of narcotics diversion, and ensuring the residents receive the correct medication as ordered by the physician, prepared, and packed by pharmacy.The facility's Medication Administration Policy, revised on November 13, 2025, showed, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observation, interview, and record review, the facility failed to provide foods at a palatable temperature acceptable to the residents. This applies to 13 of 13 residents (R3, R7, R23, R27, R31, R35, R48, R73, R105, R107, R111, R118, R123) reviewed for dining in the sample of 26. The findings include: Facility Fall/Winter menu (Week 3, Tuesday) for lunch included (hot) Italian Beef Sandwich, Potato Wedges, and 3 Bean Salad. During initial tour the following residents stated the food is cold: On December 15, 2025, at 11:00 AM, R105 stated, I eat in the room and dining room. The food is not really hot. On December 15, 2025, at 11:23 AM, R73 stated, Food is high quality, but they have trouble keeping it warm.On December 15, 2025, at 11:39 AM. R111 stated, I eat in the room. Food is not very edible and is cold.On December 15, 2025, at 11:55 AM, R35 stated the food is ice cold. R35 stated she eats in her room and remarked she does not understand why her food is cold, as her room is closer to the kitchen. On December 15, 2025, at 12:17 PM, R23 was eating in dining room and stated the food is usually served cold.On December 16, 2025, at 9:04 AM, R118 stated the food is sometimes served cold. On December 16, 2025, at 9:53 AM, R3 stated the food is sometimes served cold. On December 16, 2025, at 1:30 PM, during Resident Counsel Meeting, R7, R27, R31, R48, R107, R111, R123 stated the food is usually served cold. On December 16, 2025, starting at 11:25 PM, during meal service, the plates were noted heated by a heating lamp above the steam table. Once the food was plated, it was placed on a tray and covered by a metal lid for room trays. These trays were then loaded onto a free-standing cart, and then covered by a plastic liner and rolled unto the unit. On December 16, 2025, at 12:13 PM, the meal temperatures tested by V3 (Dietary Manager) after last meal tray was served and showed Italian roast beef sandwich 104.5 degrees Fahrenheit, potatoes wedges 134.9 degrees Fahrenheit. Other item served was cold item of 3 bean salad. When asked, V3 responded the facility does not have heating pellets for each plate and has only one insulated enclosed cart for the C-Wing. On December 17, 2025, at 9:26 AM, V18 (Dietitian) state the palatability of foods should be between 110-120 degrees Fahrenheit. V18 added the facility does not have a policy for palatability of food.

Based on observation, interview, and record review, the facility failed to provide pureed consistency foods to residents that have a diet order for the same. This applies to 4 of 4 residents (R21, R39, R80, R129) reviewed for pureed diets in the sample of 26. The findings include: Facility Fall/Winter menu (Week 3, Tuesday) for lunch included Italian Beef Sandwich and 3 Bean Salad. On December 16, 2025, at 10:52 AM, during pureed meal prep of Italian Beef in facility kitchen, V4 (Cook) stated she is preparing for 4 residents. V4 placed unmeasured amount of ground Italian beef, that was noted to have charred portions, into the blender along with 4 ounces of beef broth and a tablespoon of thickener. V4 blended the product in the food processor for about 2 minutes and then opened the container and scaped down the sides and processed it again for another minute. V4 then taste tested the product and stated it was ready for service. On taste testing, the pureed beef had coarse particles of charred bits and hardened pieces of meat. V3 (Dietary Manager) was called to the area and notified of the same, and she agreed the item needs to be pureed more. V4 stated she has already pureed the 3-bean salad and placed it in the refrigerator for service. On taste testing the same, the item had pieces of beans that were also visible floating in the pureed mixture. V4 and V3 were notified the item was not safe to serve. V3 agreed that the item needed to be pureed further. On December 17, 2025, at 9:26 AM, V18 (Dietitian) stated the pureed food should be smooth with no texture, like mash potato consistency, and should have no lumps or chewing required. V18 added she will revise the menu to exclude 3 bean salad for the pureed consistency as the kidney beans will be difficult to puree. Facility (undated) policy titled Pureed Food Preparation included:Guideline: Pureed foods will be prepared using standardized recipes to ensure quality, flavor, palatability and maximum nutritive value.Procedure: 6. Pureed foods will be the consistency of applesauce or smooth, mashed potatoes . Pureed Meat Protocol: To ensure proper consistency and nutritional value when pureeing meat.Procedure: 4. If the product is too runny, add thickener; if the product is too thick, slowly add more liquid. The desired consistency should be smooth and should be able to stand alone on the plate. Recipe for Pureed Italian Beef Sandwich included to process until fine in consistency. If thickener is needed, combine thickener and beef broth to obtain pudding like consistency. Facility Diet order listing showed that R39, R80 and R129 were on pureed diets and R21was on pureed meat.

Based on observation, interview, and record review, the facility failed to follow transmission-based precautions for COVID-19 positive residents. The facility also failed to follow standard infection control practices while handling contaminated medical devices. This applies to 6 of 26 residents (R3, R20, R25, R98, R103, R118) reviewed for infection control in the sample of 26. The findings include: 1. On December 15, 2025, at 10:10 AM, R20 and R98 were sitting in the common area without PPE (Personal protective equipment). R20 was coughing while seated at the table with residents (R6, R63, R64, R76, R84 and R98). V10 (Licensed Practical Nurse/LPN) was in the common area wearing only a surgical mask and stated, The ones with masks have COVID. I can watch them out here versus in the rooms. At 10:12 AM, V31, CNA (Certified Nurse Assistant), entered the common area, donning only a surgical mask. At 11:25 AM, V32 (CNA) entered the common area, donning only a surgical mask with unmasked R93. V19 assisted unmasked residents (R10, R21, R28, R79, R91, R112, and R125) at a table situated across from the table with R20 and R98. On December 16, 2025, at 9:35 AM in the common area, unmasked R20 asked V9, ADON/IP (Assistant Director of Nursing/ Infection Preventionist) for something to eat. V9 stated to R20, Yes, let me get you something to eat. V9 affixed a surgical mask to R20. V13 (CNA) entered the common wearing a surgical mask. At 9:48 AM, V9 brought a box of surgical masks to the common area. V13 and V12 were donning a gown and surgical mask as they applied surgical masks to residents in the common area. On December 16, 2025, at 9:50 AM, V9 (Assistant Director of Nursing /Infection Preventionist) verbalized, Patients with COVID-19 should be wearing a N95 mask; at the very least a surgical mask. The staff should wear a gown, PPE and are encouraged to wear a N95. V9 stated residents who are COVID-19 positive have transmission base precautions signage (contact precautions, droplet precautions and respiratory precautions) placed on the door to alert staff and visitors. V9 provided a document titled Respiratory Line List used for tracking residents and staff who tested positive for COVID-19. V9 states the initial COVID-19 positive case was a staff member on November 14, 2025. The residents are tested twice a week on the night shift. The nurses record the positive results and affix the signage to the residents' doors. R20's EMR (Electronic Medical Record) showed R20 was admitted to the facility on [DATE], with diagnosis of Alzheimer's disease, hypertensive chronic kidney disease, type II diabetes, mood disorder, major depressive disorder, anxiety, difficulty walking and osteoarthritis. The MDS (Minimum Data Set), dated October 10, 2025, showed R20 is severely cognitive impaired and dependent with activities of daily living. The EMR showed an infection note on December 9, 2025, at 1:55 PM, R20 tested positive for COVID-19 and therefore placed on droplet and contact isolation and visitors will wear an N95 mask, gown and gloves. R20's care plan, dated December 10, 2025, showed R20 required Transmission Based Precautions (TBP). The resident requires contact and droplet isolation due to COVID-19 diagnosis. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces, an effort will be made to place resident in private room, isolation precautions will be discontinued per policy, maintain precautions to minimize the risk of transmission to other residents, remove gloves before leaving the room and wash hands immediately, wear gloves when entering the room if you will have any contact with residents or resident's infected area, and while caring for the resident change gloves and wash hands after contact with infection material. EMR (Electronic Medical Record) showed R98 was admitted to the facility on [DATE], with diagnoses of chronic kidney disease, vascular dementia, repeated falls, hypothyroidism and hyperlipidemia, hypertension, and COVID-19. R98's MDS, dated [DATE], showed R98 is severely impaired of cognitive skills for daily decision making and dependent for activities of daily living. The care plan, dated December 8, 2025, showed R98 required Transmission- Based Precautions (TBP). The resident requires contact and droplet isolation due to COVID-19 diagnosis. After removing gloves and washing hands, do not touch potentially contaminated environmental surfaces, an effort will be made to place resident in private room, isolation precautions will be discontinued per policy, maintain precautions to minimize the risk of transmission to other residents, remove gloves before leaving the room and wash hands immediately, wear gloves when entering the room if you will have any contact with residents or resident's infected area, and while caring for the resident change gloves and wash hands after contact with infection material The facility provided their TBP signage posted outside door of R20's and R98's room. The signage had Stop. droplet precautions everyone must: clean their hands, including before and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry or remove face protection before room exit. Stop N95 plus eye protection and contact precautions: Everyone must: . Put on a fit -tested N-95 respirator before room entry, (visitors wear a mask).Put on gown before room entry and discard before room exit. Put on eye protection before entry to the room and remove after exit.Stop contact precautions everyone must: clean their hands, including before entering and when leaving the room . Providers and staff must also: Put on gloves before room entry, discard gloves before room exit, put on gown before room entry. discard gown before room exit, do not wear the same gown and gloves for the care of more than one person. The facilities policy titled Transmission-Based (Isolation) Precautions, with a revisions date of October 1, 2024, showed, It is our policy to take appropriate precautions to prevent transmission of pathogens, based on pathogens' modes of transmission. residents on transmission-based precautions should remain in their rooms except for medically necessary care. All staff receive training on transmission-based precautions upon hire and annually. nursing staff receive training on signs and symptoms of infection, common organisms that require additional control measures, and considerations for residents who are colonized with infectious organisms.healthcare personnel caring for residents on contact precautions wear a gown and gloves for all interactions that involve contact with the residents or potentially contaminated areas in the resident's environment. A private room is preferential. when one resident is infected with a pathogen that is transmitted by the droplet route, maintain at least 3 feet of separation between beds. Residents on droplet precautions who must be transported outside the room should wear a facemask and follow respiratory hygiene/cough etiquettes described in the facility's Standard Precautions Infection Control Policy. The Infection Surveillance policy, with a revision dated of October 1, 2024, showed, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections.observations of staff including the identification of ineffective practices. 2. R3's EMR showed R3 was admitted to the facility on [DATE], with diagnoses that included Parkinson's Disease, generalized muscle weakness, and unspecified abnormalities of gait and mobility. R3 tested positive for Covid-19 on December 12, 2025, per the facility line list of Covid positive staff and residents. R3's POS (Physician's Order Sheet) showed Contact/Droplet Isolation Covid-19 every shift for 11 days. The order date showed December 12, 2025, and completion date is December 23, 2025. R118's EMR (Electronic Medical Record) showed R118 was admitted to the facility on [DATE], with diagnoses that included intervertebral disc disorder with radiculopathy, lumbar region, acute respiratory failure with hypoxia, generalized muscle weakness, other chronic pain, dizziness and giddiness. R118 tested positive for Covid-19 on December 6, 2025, per the facility line list of positive staff and residents. On December 15, 16, and 17, 2025, intermittent observations were made of V16 (CNA/Certified Nurse Assistant), V17 (CNA), V19 (LPN/Licensed Practical Nurse), V21 (LPN), and V35 (RN/Registered Nurse) entering R3's and R118's rooms to provide direct patient care without wearing eye protection. Both residents were positive for Covid-19. The signs on the doors indicated they were on Contact and Droplet Transmission Based Precautions. The Droplet precautions signs clearly stated eye protection was to be worn. On December 16, 2025, V36 and V37 (Family member) were in the hallway. Neither was wearing any PPE (Personal Protective Equipment). V37 said her family member was admitted to the facility last night and no one had told them they had to wear a mask when in the facility and moving about the unit. On December 16, at 9:46 AM, V38 (POA/Power of Attorney) and V39 (friend) were visiting R118 in his room. Both visitors were wearing surgical masks only. V39 said no one made them aware they should be wearing gown, gloves, N95 mask, and eye protection before entering the room of a Covid positive resident. V39 said they just put on the mask they were given when they entered the facility by the receptionist. On December 16, 2025, V16 (CNA) was wearing an N95 mask on the unit. She stated no one told her she had to wear a N95 mask except when going into Covid positive rooms. V16 said she chooses to always wear an N95 to protect herself and her family members at home. On December 17, 2025, at 12:02 PM, survey team was made aware that R35 had tested positive for Covid-19 on the midnight shift. Surveyor went to R35's room and V9 (Infection Prevention Nurse) was in R35's room wearing only a N95. The curtain in between the beds was open so both residents were visible from hallway. There was nothing separating R35 and her roommate, who tested negative on the night shift. There were no isolation signs on the door, or isolation cart with PPE (Personal Protective Equipment) outside the room. V17 (CNA) entered the room wearing only a surgical mask and it was pulled down below her nose. V9 exited the room, and she had V17 come out with her. V9 was heard telling V17 that R35 had tested positive for Covid last night so they needed to move the roommate to another room. V9 left and returned with the one sign and put it on the door, it was the Stop everyone must wear N95 plus gown, gloves, and eye protection sign. V17 called over V16 (CNA) and told her R35 had tested positive for Covid on the night shift. V16 and V17 both said no one told them that during the morning shift report. V16 said this is why she wears the N95 mask all the time. At 12:07 PM, V9 said the roommate had tested negative for Covid last night, but was now symptomatic, so V9 said they will not be moving the roommate to another room. V9 said when in the hallway, the staff only need to wear a surgical mask. When going into the Covid rooms, they must wear the gown, gloves, and N95; she did not mention eye protection. Once a resident tests positive for Covid, V9 said she calls the family to let them know and discourages them from visiting. They are told if they come into the facility and enter the Covid positive room, they need to wear the gown, gloves, and N95. If they stay in hallway, they only wear a surgical mask. V9 said even though they have several residents currently positive for Covid-19, she didn't think they could have a separate Covid positive unit. 3. According to the face sheet, R103 has multiple diagnoses including, type 2 (DM) diabetes mellitus, chronic kidney disease, and hypertensive heart disease. R103's POS (Physician Order Sheet) dated November 27, 2024, showed an active order for blood glucose check to be done for R103 before meals. On December 16, 2025, at 11:15 AM, V22 (Nurse) had the medication cart parked in front of R103's door. V22 had gloves on and was performing blood glucose check for R103 in the R103's room. V22 cleaned R103's finger with an alcohol pad, punctured the finger using a lancet (finger stick device), and placed the used lancet on a paper towel on R103's table. V22 squeezed the blood from R103's finger onto the blood glucose meter test strip to obtain R103's blood glucose result. V22 placed the blood glucose meter on the paper towel. V22 then removed the glove from her right hand, picked up the lancet which was used to puncture R103's finger with her right hand without wearing gloves, and held the blood glucose meter with her left-hand as she walked out of R103's room. V22 dropped the used lancet in the trash bag attached to the side of the medication cart and immediately removed the lancet from the trash bag which had other disposed items in it with the same hand without wearing gloves. V22 said the lancet was accidentally dropped into the trash bag. V22 then disposed the lancet in the sharps container above the trash can on the side of the medication cart. V22 performed hand hygiene using hand sanitizer gel, wore gloves, sanitized the glucose meter, removed her gloves, sanitized her hands with hand sanitizer and proceeded to wheel the medication cart to another resident during the medication pass. 4. According to the face sheet, R25 has multiple diagnoses including, type 2 (DM) diabetes mellitus with hyperglycemia, Parkinson's disease, and hypertensive heart disease. R25's POS (Physician Order Sheet), dated June 22, 2025, showed an active order for blood glucose check to be done for R25 before meals and at bedtime. On December 16, 2025, at 11:35 AM, V22 (Nurse) had gloves on and was performing blood glucose check for R25. V22 removed gloves from her right hand after performing blood glucose check for R25 and then picked up the used lancet (finger stick device) used to puncture R25's finger to obtain blood for testing without wearing gloves. V22 then disposed the used lancet in the sharp's container on the side of the medication cart parked outside R25's room. V22 performed hand hygiene using hand sanitizer gel and proceeded to another resident during the medication pass. On December 16, 2025, at 2:33 PM, V2 said V22 should have used a gloved hand to pick up a sharp object such as a lancet that has been contaminated with blood. V2 also said V22 should not have reached into the trash bag without wearing gloves to grab a sharp object contaminated with blood due to the risk of accidental finger stick or puncture. V2 also added V22 should have performed hand hygiene using soap and water after using the hand sanitizer due to possible exposure to blood. The facility's Hand Hygiene Policy, revised on November 3, 2025, showed, Policy: all staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.

Based on interview and record review, the facility failed to provide dignity to a resident during provisions of care.This applies to 1 of 26 residents (R118) reviewed for dignity in the sample of 26.The findings include: R118's EMR (Electronic Medical Record) showed R118 was admitted to the facility on [DATE], with diagnoses that included intervertebral disc disorder with radiculopathy, lumbar region, acute respiratory failure with hypoxia, generalized muscle weakness, other chronic pain, dizziness, and giddiness. R118's MDS (Minimum Data Set), dated October 27, 2025, showed R118 was cognitively intact and was dependent on staff for showering.On December 16, 2025, at 9:04 AM, R118 said there was an incident, he thinks it was maybe two weeks ago, when the CNA (Certified Nurse Assistant), whose name he said he could not remember, took him to the shower room and turned on the water. The CNA told R118 she would be right back; she had to go to the other shower room for another resident. R118 said it was around 15 minutes later when the CNA returned, and he was shivering cold. R118 said he was not able to wash himself, so he was just sitting there naked, waiting, and it was cold. On December 16, 2025, at 2:16 PM, V2 (DON/Director of Nursing) said when giving a resident a shower, the resident should never be left alone in the shower room or left naked. On December 16, 2025, at approximately 3:30 PM, V1 (Administrator) said she spoke with R118, and he pretty much told her the same thing. V1 said it was common sense that the staff member should not have left [R118] in the shower room by himself.

Based on observation, interview, and record review, the facility failed to provide services to prevent further contractures for a resident and failed to apply recommended devices to treat a resident's contractures.This applies to 2 of 3 residents (R14 and R15) reviewed for range of motions in the sample of 26. The findings include: 1.R14's face sheet included R14 was admitted on [DATE], with multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, hypomagnesemia, dysphagia following cerebral infarction, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, and ataxia following cerebral infarction. R14's quarterly MDS (Minimum Data Set), dated October 31, 2025, showed R14 was moderately impaired in cognition. R14's functional limitation in range of motions showed impairment on one side. On December 15, 2025, at 12:29 PM, R14 was seated in dining room. R14's left arm appeared flaccid with his palm closed in a fist. When asked if he can open his fist, he stated he could not. R14 stated he had a stroke and not able to use left arm. R14 stated he does not receive therapies, and staff does not do any range of motion exercises with him for his left arm/hand. On December 16, 2025, at 10:45 AM, V5 (Certified Nursing Assistant) stated she has never seen R14 with any device on his left hand since she worked at facility in past ten months. On December 16, 2025, at 1:15 PM, when asked if therapy has seen R14 related to his left arm, V6 (Director of Therapy) stated he knows that PT (Physical Therapy) saw him but does not think he was seen by OT (Occupational Therapy). V6 stated he will check his records and give updated information. On December 16, 2025, at 1:53 PM, V6 returned and stated R14 was seen by PT in December 2024 and July 2025, as R14 had a functional decline related to a fall. V6 stated R14 has not been seen by OT earlier and he had asked V7 (Occupational Therapist) to assess him. V6 stated based on V7's assessment, he was told R14 will be appropriate for a wrist and arm splint before the arm/hand gets into a further contracture. V6 stated it was good that it was caught today, or it would have progressed into a contracture. V6 stated he does not know how soon the hand progressed to current state. On December 16, 2025, at 1:53 PM, V7 stated R14 has had PT before but not had OT requested before. V7 stated, It came to my attention today and I got orders from the Nurse Practitioner and went ahead and screened him. I was able to complete the screen and recommended a WHO (wrist hand orthotics) focusing on wrist/hand/digit. He had a neuromuscular palsy from the stroke, and all his flexor muscles are shrinking. If that was not assessed, it will get worse and develop into a flexor contracture. So, since we caught it today in the early stage, we were able to apply a splint with a good fit and no pain. We will monitor everything from hygiene to skin integrity and make sure that it doesn't become a further problem. V7 added, He (R14) was keeping his hand fisted without the device. If he had the splint earlier, it would have prevented that. He does not have any active range of motion now. Occupational Therapy Evaluation and plan of treatment, dated December 16, 2025, included: Clinical impressions/reasons for Skilled Services: Patient presents with impairments in balance, gross motor coordination, dexterity, use of environmental modification strategies, strength, follow through, self-modification, mobility and interpersonal care and mobility which requires skilled OT services to assess and modify environmental barriers, restore cognitive and perpetual abilities, provision pain management techniques, improve rehab potential, increase safety awareness, increase functional activity tolerance, facilitate sitting tolerance and postural control assess and modify environmental hazards, assess safety with adaptive equipment, assess the need for adaptations/assistive devises, develop and instruction on adaptation techniques, design and implement Restorative Nursing Program Additional Analysis: Left hand WHO to left hand to prevent contracture (hand weakness). Order details: OT splint schedule for left hand/wrist. Left resting hand splint to be applied in AM (morning) for 3 hours, removed during meals, reapplied in PM (evening) for 3 hours and to monitor hand splint use for proper fit and hygiene to reduce skin breakdown. On December 17, 2025, at 1:05 PM, V2 (Director of Nursing) stated the facility does not have a restorative program and are just about to start one. 2. R15's admission record showed R15 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, weakness, need for assistance with personal care, epilepsy, chronic pain, and fusion of the spine. R15's Minimum Data Set, dated [DATE], showed her to be cognitively intact. R15's occupational therapy (OT) evaluation and plan of treatment notes showed R15's reason for therapy was to address left upper arm flexion contracture R15 started occupational therapy on September 9, 2025 and the goal was R15 would achieve normal anatomical alignment of the left hand for 4 hours using a resting hand splint in order to improve skin integrity and hygiene, and achieve proper joint alignment, and prevent contracture. At that time, they recommended elbow extension orthosis and a resting hand orthosis during night hours. R15 had a point of care task that showed the following: ensure resident Os Calcis Stiffness index (OCSI) brace is applied to her left arm every evening, and off every morning. OCSI symbol should be at the top of her arm. R15 discharge OT summary, dated October 17, 2025, showed the following recommendations: Restorative program Establish/Trained=restorative range of motion program, restorative splint and brace program. 1. Range of motion program established trained: passive range of motion to left shoulders, elbow, wrist, digits to increase range of motion and decrease contractures. 2. Splint and brace program establish/trained splint and brace program 3. Splint and brace program established/trained: R15 is currently able to care for and clean device and apply brace one person assistance. On December 15, 2025, at 11:35 AM, R15 observed with a left-hand closed contracture and a left elbow contracture with left hand at her chest. R15 did not have any splint, brace, or any device on her left arm or left hand. On December 16, 2025, at 10:05 AM, R15 stated she has a brace for her left hand/wrist but no one puts it on because they can't open her hand wide enough to put it on (long arm brace). R15 does not have a brace or anything on her contracted left hand or arm. On December 16, 2025, 11:58 AM, V23(Director of Rehab) stated he believes R15 has had occupational therapy and he does not believe she is on any restorative program. On December 16, 2025, at 12:48 PM, V23 stated upon discharge from occupational therapy, R15 should be wearing a hand brace and arm brace daily per their recommendations. V23 stated the staff were trained on how to apply resident splint. V23 stated the staff were aware she needed the brace. On December 16, 2026 at 2:20 PM, V23 stated R15 had received OT starting September 9, 2025, and they were working to increase her range of motion (ROM) in her left hand, establish an exercise program, and she was to have splints placed with one assistance from staff. On December 16, 2025, at 12:25 PM, V33(Certified Nursing Assistant/CNA) and V34 (CNA) both stated they do not assist R15 with any splints or devices for R15's left hand or arm. V33 and V34 both stated they have not had any direction or education to do so. On December 16, 2025, at 2:26 PM, R15 stated she had 3 splints; no one assists her with putting them on, and she cannot do it by herself. R15 stated her left elbow brace should have been placed every night. R15 stated she is supposed to sleep in it, and no one has put it on her for months and months. R15's resting hand roll splint device for her left hand has a tie to keep it in place. R15 stated she needs assistance to put on because she can't tie/secure it with one hand. R15 had a hand second splint that runs down the dorsal part of her arm (wrist splint) that she stated she is also not wearing because her hand can't open enough to put in on. R15 had third elbow/arm brace that she stated she should be sleeping in it, but no one puts it on. R15 stated she kept asking people to help her to put it on. R15 would have to go looking for them to assist her. R15 stated the staff never approached or asked if she needed assistance and then she just stopped asking. R15 stated they were not putting the elbow brace on correctly and it was cutting off her circulation in her left hand. R15 stated she does not get therapy, and no one works with her doing any range of motion. On December 16, 2025, at 1:55 PM, V23 stated R15's wrist splint was an older one and came into the facility with it. V23 stated R15was no longer able to use it and not able to get her range to use it, so they gave her a new resting hand splint. V23 stated R15 used the new resting hand splint/log device during therapy, and it was to continue after OT stopped. V23 stated they in-service staff to place, but there is normally an order for it to be placed. V23 stated he was not sure when it should be placed it the hand splint. He would ask OT. She is supposed to be wearing both the elbow brace with resting hand brace/splint together. On December 16, 2025, at 2:48 PM, V26, Certified Nursing Assistant/CNA, stated she was not aware R15 had a resting hand/log splint and has never assisted resident in placing it. V26 stated she was never educated on how to assist R15 on putting on either the hand or the elbow brace, and no staff has directed her to put R15's braces on at night. V26 stated once in a while, R15 had asked her to put the elbow brace on. V26 stated the elbow brace is hard to put on. V26 stated she familiar with the task in their point of care charting that refers to placing R15's brace and she does not recall ever clicking on it. On December 17, 2025, at 1:00 PM, V27 (CNA) stated she does not do anything with R15s' splint or brace for her left hand and elbow. On December 17, 2025, at 1:04 PM, R15 stated no one put either of her braces on yesterday or last night. As of December 16, at 11:38 AM, there was no task or order for placing or assisting in the placement of R15's left hand resting-hand brace/log. R15 had no care plan for her left arm or left-hand contractures. On December 17, 2025, at 2:56 PM, V2 (Director of Nursing) stated they do not have a restorative program. V2 stated she expects the staff to follow therapy recommendations. V2 stated she expects staff to follow therapy recommendation because they are important for the resident's quality of life, to maintain resident range of motion, and enhance their quality of life. V2 stated the CNAs are responsible for the Point of Care tasks including the one for R15's brace placement. The facility's Prevention of Decline in Range of Motion, dated December 4, 2025, showed based on the comprehensive assessment, the facility will provide interventions, exercises and/or therapy to maintain or improve range of motions. b. the facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to: i. appropriate serves (specialized rehabilitation, restorative, maintenance). ii. Appropriate equipment (braces or splints). Iii. Assistance as need (active assisted, passive, supervision).

Based on observation, interview, and record review, the facility failed to ensure that recommended fall preventive measures were put in place at all times for residents who were identified as high risk for falls. This applied to 2 of 3 residents (R2, R4) reviewed for falls in the sample of 5. The findings include: Findings Include: 1. R2's face sheet documents R2 is 82 years-old who has multiple medical diagnoses including repeated falls, unsteadiness on feet, lack of coordination, and Alzheimer's disease. R2's Minimum Data Set, dated [DATE], shows R2 is cognitively impaired. Facility's fall incident log, dated May 8 to August 12, 2025, shows R2 had multiple fall incidents on May 31, June 13, June 16, June 19, July 3, and July 13, 2025. R2's fall care plan with initiated date of May 30, 2025, shows: R2 is at risk for falls in relation to poor safety awareness, history of falls, and dementia. This same care plan shows multiple interventions which include wheelchair cushions with non-skid mat (Dycem) to chair. On August 7, 2025, from 2:50 PM to 3:28 PM, R2 was observed in the unit D dining room. R2 was sitting in her wheelchair, she was restless and was attempting to stand up. There was no sign of non-skid mat on the wheelchair seat. At 3:28 PM, V13 (Certified Nursing Assistant/CNA) assisted R2 to stand up with use of gait belt, however, there was no non-skid mat on the wheelchair seat. On August 11, 2025, R2 was observed multiple times. At 9:35 AM, R2 was sitting in her wheelchair in the dining room, and at 12:00 PM, she was eating in the dining room. Both times R2 does not have non-skid mat on her seat. On August 11, at 1:44 PM, V8 and V9 (Both CNAs) assisted R2 to the toilet with the assistance of V6 (Nurse). V8 and V9 assisted R2 to transfer from wheelchair to toilet seat. There was no non-skid mat in the wheelchair. 2. R4's face sheet shows R4 is 78 years-old who has multiple medical diagnoses including specified disorders of muscle, lack of coordination, repeated falls, and vascular dementia. Facility's fall incident log, dated May 8 to August 12, 2025, shows R4 had multiple fall incidents on May 27, June 8, June 13, June 14, August 6, and August 10. R4's care plan with revision date of August 6, 2025, shows R4 is at risk for falls in relation to poor safety awareness, use of an anti-depressant, use of a diuretic, dementia diagnosis, vertigo, and history of falls. This same care plan shows multiple inventions which include non-skid mat to wheelchair. On August 7, 2025, at 3:06 PM to 3:24PM, R4 was observed sitting in her wheelchair in the day room with other residents. There was no sign of non-skid mat on her seat. At 3:24 PM, V13 assisted R4 to stand up with the use of gait belt, however, there was no non-skid mat on her wheelchair. On August 11, 2025, R4 was observed multiple times. At 9:40 AM, R4 was in the hallway sitting in her wheelchair. At 1:20 PM, R4 was in the hallway socializing with R5. Both times R4 did not have the non-skid mat on her wheelchair seat. On August 11, 2025, at 1:28 PM, V8 and V9 (Both CNAs) assisted R4 to the bathroom. There was no non-skid mat on her wheelchair seat. V8 stated she had never seen R4's wheelchair seat with a non-skid mat. On August 12, 2025, at 10:51 AM, V15 (Nurse) stated, To prevent fall incidents one needs to find the root cause of the fall such as catching UTI (urinary tract infection) early, keeping the residents busy with activities, and regular toileting, understanding reason for falls and following recommended fall interventions. On August 12, 2025, at 11:37 AM, V2 (Director of Nursing/DON) stated she places multiple interventions for fall preventions such as hourly monitoring and non-skid chair mat on the wheelchair for people who have poor safety awareness and high-risk for fall. V2 also said she expects the staff to follow these interventions.

Based on interview and record review, the facility failed to ensure medications were readily available to newly admitted residents. This applies to 2 of 3 residents (R1, R2) reviewed for medications in the sample of 3. The findings include: 1. R1's Face Sheet showed he was admitted to the facility on [DATE]. R1's 4/24/25 Minimum Data Set (MDS) showed he is cognitively intact. R1's Face Sheet showed his diagnoses include COPD (chronic obstructive pulmonary disease) with acute exacerbation, depression, emphysema, chronic respiratory failure, asthma, sciatica, hyperlipidemia, and a rib fracture. On 4/29/25 at 12:50 PM, R1 stated he waited a long time to get all of his medications after he was admitted . On 4/28/25 at 5:35PM, V3, LPN (Licensed Practical Nurse), stated she worked on 4/19/2025, and worked a double shift. V3 stated she assisted with R1's admission, but she was not his assigned nurse. V3 stated the cut-off time for the pharmacy ordering is between 4:00-5:00 PM for medications to be filled, but some medications are available in the facility's (medication storage). V3 stated it is a case-by-case scenario if a STAT delivery is needed. V3 stated she would take everything that was needed and available from the (medication storage) and then call the pharmacy for a STAT delivery. V3 stated a STAT delivery is supposed to deliver within three hours. V3 stated R1 came to the facility on [DATE], after 4:00 PM and he was assigned to V4 (LPN). On 4/29/25 at 11:51AM, V4 (LPN) stated she was assigned to R1 and R2 on 4/19/25, and she has worked at the facility for only three weeks. V4 stated she had 30 residents and two admissions on 4/19/25 and it was difficult. V4 stated she did not have access to the (medication storage), and was not aware that she could call the pharmacy to gain access. On 4/29/25 at 9:28AM, V5 (Pharmacist) stated deliveries are twice a day, around 8:00 AM and 4:00 PM. V5 stated if they get the orders after the cut off time, the meds will go to the following delivery. R1's Discharge paper from the hospital showed he was discharged at 4:01 PM from the hospital. R1's 4/19/25 discharge orders for his scheduled doses of atorvastatin and montelukast showed next dose: today (4/19/25) at bedtime. R1's April 2025 MAR (Medication Administration Record) showed his 4/19/25 doses of atorvastatin and montelukast scheduled at 8:00 PM simply had an X. R1's 4/19/25 discharge orders for five other medications (meloxicam, pantoprazole, sertraline, tamsulosin and an Incruse inhaler) showed next dose: tomorrow (4/20/2025) morning. R1's April 2025 MAR showed a 5 or a 9 for his 6:00 AM pantoprazole ad sertraline doses and his 8:00 AM doses of his Incruse inhaler, meloxicam, tamsulosin, Symbicort inhaler, and his buprenorphine/naloxone. Per the legend on the MAR, a checkmark indicates a medication was administered, and a 5 or 9 is a referral to a progress note. R1's 4/20/25 MAR progress notes from 8:53 AM showed meds not delivered yet, on way and 9:22 AM showed .will call pharm to see when delivery of narcotics and any missing meds . Notes from 11:57 for R1's Symbicort inhaler showed not available; at 12:04 PM for meloxicam n/a; 12:06 PM for pantoprazole n/a; and 3:51 PM for sertraline not done. The pharmacy medication delivery sign-in sheet showed R1's medications were delivered on 4/20/2025 at 2:26 PM, and were received by V4, LPN. 2. R2's Face Sheet showed she was admitted to the facility on [DATE]. R2's MDS showed she was cognitively intact. R2's Face Sheet showed her diagnoses include diabetes, peripheral vascular disease, congestive heart failure, stage 4 kidney disease, cerebral infarction, transient ischemic attacks, and pulmonary hypertension. On 4/28/25 at 12:45PM, V7 (R2's family) stated when she asked about R2's medications on Sunday 4/20/25, staff told her R2's medications were discontinued until Monday (4/21), and R2 did not get her medications. V7 stated R2 had been living in an Assisted Living and they had called her because they got a fax about R2's medication and she was no longer there. V7 stated she went to the Assisted Living and got all R2's medications to bring to the skilled care. V7 stated around 4:00 PM on Monday, she was told R2's medication arrived from the pharmacy, and the facility no longer needed the medications from the Assisted Living. On 4/28/25 at 1:37 PM, V8, RN (Registered Nurse), stated as soon a new admission comes in, staff look at the medication list that come from the hospital with the discharge instructions. V8 stated nurses enter the medications one at a time into the computer in the physician orders, then then pharmacy takes over. R2's hospital discharge orders from 4/19/25 showed she was to receive clopidogrel and Lasix next dose: today (4/19/25) evening, her Humalog insulin next dose: today (4/19/25) evening with meal, and her hydralazine next dose: today (4/19/25) at bedtime. The discharge orders also showed R2 was to receive six other medications (famotidine, fluoxetine, Farxiga, losartan, metolazone, and prednisone) next dose: tomorrow (4/20/25) morning, and levothyroxine next dose: tomorrow (4/20/25) morning before meal. R2's progress notes showed her medication orders were not entered in the computer until 4/20/25, starting at 6:39 PM, on Sunday. R2's Physician Order Sheet showed the orders were put in on the 4/20/25, and medications were to start being administered on Monday, 4/21/25. The pharmacy medication delivery manifest showed ten of R2's medications were delivered on Monday 4/21/25, and signed for by facility staff at 3:33 PM. R2's April MAR showed she missed twelve doses of various oral medications, three scheduled doses of insulin, and potentially five doses of sliding scale insulin. R2's progress note from 4/20/25 at 9:49 PM showed, Patient was admitted to (facility) at [4 PM] on 4/19/25. On 4/29/25 at 2:38 PM, V1 (Administrator) verified there was no documentation showing the physicians were notified about the medication administration delays. The facility's March 2023 Pharmacy Hours and Delivery Schedule policy showed, New orders and refill requests may be faxed or sent electronically at any time Facility-specific fax cut-off times are arranged between the facility and pharmacy New orders communicated to the [name] pharmacy after the cut-off time will automatically go into the next regular delivery for the facility . If .the resident is in need of medication as a STAT order, the medication should be started from the emergency dispensing kit if applicable, and/or an emergency delivery must be requested An emergency delivery can be requested by sending the order to the [name] pharmacy, contact the pharmacy by phone to alert them that you sent a STAT order . The facility's Unavailable Medications policy (implemented 8/1/24) showed, .4. Staff shall take immediate action when it is known that the medication is unavailable determine what efforts have been attempted by the facility or pharmacy provider to obtain the medication Notify Physician of inability to obtain medication medication .obtain alternative treatment orders and/or specific orders for monitoring . 5. Staff shall follow procedures for medication errors, including physician/family notification .

Based on observation, interview, and record review, the facility failed to ensure a resident was safely transferred with a mechanical lift for 1 of 4 residents (R1) reviewed for falls in the sample of 4. The findings include: R1's Physician Order Sheet, printed on 1/17/25, shows R1 has diagnoses that include dementia, weakness, meniers disease, and hearing loss. R1's fall risk assessment, dated 1/8/25, shows R1 is high risk or falls. R1's careplan, dated 4/6/24, shows R1 is a risk for falls due to vision, hearing, weakness, gait balance problems with intervention to include transfer status, mechanical lift with 2 staff. On 1/17/25 at 10AM, R1 was lying in bed. Through communication board, he was able to say he was ok and was not in pain. V3 (License Practical Nurse-LPN) checked R1's head. A diffuse bruise, reddish black in color, was noted at the back of his head. R4 (R1's wife and roommate with a BIMS of 14-no cognitive impairment) said she was not in the room on 1/8/25 when the incident happened. She went to the dining room to get coffee. When she came back, R1 was noted lying on the floor. I came in, knelt down by him and put my hand beneath his head, I felt a big goose egg at the back of his head. He (R1) was alert but was just staring straight up, he looked shocked. He was sent to the hospital and came back. He has bruising at the back of his head. R4 said she was told R1 was being lifted from his wheelchair to bed. R1 fell backwards with his wheelchair with him, hitting his head on the floor. R4 said there should always be a staff behind R1 during transfers. On 1/17/25 at 10:15 AM, V7 (Certified Nursing Assistant-CNA) said she was one of the CNAs on 1/8/25 who transferred R1 using the mechanical lift. V7 said she was in front of R1 doing the controls, while V6 (CNA) was on R1's side. V7 said when R1 was being lifted via the mechanical lift, R1's wheelchair was also being lifted with him. V7 said they put R1 back down and checked what was going on; if any of the slings were being caught. Then they tried again. As R1 was being lifted via the mechanical lift the 2nd time, R1's wheelchair tipped backwards with R1 in the wheelchair, hitting his head on the floor. The mechanical lift sling was not securely attached to the metal hook. V7 said it happened so fast, we tried to grab him but he was already on the floor. V7 also said they were so focused on why the wheelchair was going up with R1, and were not able to ensure all the hooks/slings were secured. On 1/17/25 at 10:51 AM, V6 (CNA) said she was with V7 (CNA) on 1/8/25 transferring R1 from wheelchair to bed. As R1 was being raised via mechanical lift, the wheelchair was going up with R1. R1 was lowered down. As R1 was being lifted back up again, the mechanical sling on the right side came off. R1 tilted backwards with his wheelchair to the floor. V6 stated, (R1's) a heavy-set guy, we tried to grab him, but he still fell backwards. (R1) hit his head on the floor. V6 said she was on R1's left side, and not behind the wheelchair, so she was not able to stop the wheelchair tipping backwards. On 1/17/25, at 9:40 AM, V3 (License Practical Nurse- LPN) said she was the Nurse working on 1/8/25 when the incident happened. V7 and V6 (CNA's) were transferring R1 from his wheelchair to bed via mechanical lift. As R1 was being raised up, the wheelchair tilted backwards with R1 in it. The part of the loop (sling) came off. R1 fell backwards with his wheelchair hitting his head on the floor. V3 said fall assessments show no injury except redness at the back of his head. R1 was sent out via 911 and came back the same day. All tests were negative. R1's hospital records, dated 1/8/25, show R1 was diagnosed with scalp hematoma (bruise) and was discharged back to the facility same day (1/8/25) On 1/17/25 at 12:30 PM, V8 (Physical Therapist) said, When transferring a resident via mechanical lift, the resident should be positioned well under the pad. Make sure all straps (slings) were not getting caught on the wheelchair, all 4 slings securely placed in all the hooks and checking the sides and back to ensure resident is safe during the transfer. On 1/17/25 at 9:18 AM, V1 (Administrator) said all staff have been re-trained (including V6 and V7) regarding safe transfers using the mechanical lift. The facility policy entitled Safe Resident Handling/Transfers (undated) states, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and and provide and promote a safe, secure and comfortable experience for the resident while keeping the employee safe in accordance with current standards and guidance.

Based on interview and record review, the facility failed to provide safe transfer assistance. This applies to 1 resident (R1) of three reviewed for safe transfers. This failure resulted in R1 incurring a acute nondisplaced bimalleolar fracture and a nondisplaced oblique fracture of the distal fibula. Findings include: 1. R1's Medical diagnosis from the electronic record documents R1 as a [AGE] year old, with diagnoses to include Aphasia, Hemiplegia and Hemiparesis following a Cerebral Infarction. The Final Report to Illinois Department of Public Health, dated 10/17/2/2024, documents, On 10/11/2024, The resident was lowered to the ground after becoming weak during a transfer from her electric wheelchair to her bed via pivot transfer. A (mechanical lift) was used to lift the resident from the floor to the bed after a head to toe assessment revealed no obvious injury and subsequent assessments had not indicated any observable abnormalities to the right lower leg/ankle area. The resident later expressed pain to her right lower extremity during the early morning hours of 10/12/2024 and was sent to the ER (emergency room ) for evaluation and sent back later that morning with no fractures or dislocation noted and norco for pain management as needed. The resident continued to have pain to the right leg with repositioning in bed and 10/14/2024 Dr ordered X-rays to the right hip/right femur/and right knee with no fracture of dislocation indicated. Dr. rounded on 10/15/2024 to evaluate the resident and ordered another set of X-rays to the right tibia/fibula, right ankle and right foot with the results sent to the facility on [DATE] with an acute non-displaced bimalleolar fracture and a non-displaced oblique fracture of the distal fibula. Dr. was notified and gave orders to send the resident back to the hospital for evaluation which confirmed the bimmalleolus fractures which appear to be minimally displaced and a soft cast was applied to the right lower extremity. A chronic fracture deformity of the right humeral neck and deformity of the right distal humerus which may require an elbow series if acute symptoms are present. A right arm sling was placed and resident was transferred back to the facility. Resident currently with Tylenol ordered for pain per family request. The Radiology Results Report for R1, dated 10/15/2024, documents under Findings: Right Tibia and Fibula~ An acute nondisplaced bimalleolar fracture is noted. The Radiology Report for R1, dated 10/16/2024, documents under impression Right Ankle~Displaced fractures through the lateral malleous and medial malleous. The care plan for R1 documents, The resident is risk for falls r/t (related to) Deconditioning, Gait/balance problems. Resident will have 2 cna assist to bed from scooter. Will use sit to stand or Hoyer transfer to and from the bed to motorized wheel chair. On 10/24/2024 at 10:45 AM, V2, Director of Nursing, stated, That was (V8, CNA) first shift in the building. She will not be back to work here. The one person transfer was not appropriate. On 10/24/2024 at 2:07 PM, V7, Licensed Practical Nurse, stated, None of us had never worked with (V8, Certified Nurse Aide/CNA) before. It was her first assignment from the staffing agency. At the beginning of the shift, we made it clear that if she needed anything to come and tell us. Everyone is more than willing to help with whatever you need. That why I couldn't believe what she did. She transferred (R1) by herself. The transfer is a two person transfer with (R1). (V8, CNA) told me she was doing a pivot transfer from the scooter to the bed when (R1's) leg buckled and (V8, CNA) lowered the resident to the floor. She should've asked us to help her with the transfer. On 10/25/2024 at 10:53 AM, V11, CNA, stated, (R1) is a two person assist for transfer, always. She's a sit to stand (mechanical) transfer. We always use a gait belt, the machine and two people. On 10/26/2024 at 2:22 PM, V4, Medical Director, stated, Yes I expect the staff to follow safe transfer procedure. That includes two to transfer for residents that require the support. I have already spoken to (V1, Administrator) regarding this. The policy titled Safe Resident Handling/Transfers, dated 10/01/2024, documents under #10. Two staff members must be utilized when transferring residents with a mechanical lift.

Based on interview and record review, the facility failed to employ sufficient staff to carry out the functions of the Food and Nutrition Services, including meal preparation. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On Wednesday 10/8/24 at 11:45 AM, R205 said on the previous Monday they were supposed to have tuna salad on toast, but it was not served on toast, it was just white bread. On 10/10/24 at 11:27 AM, R205 said there had been multiple occasions when the meals served did not match the menu, and that made R205 feel like her ability to choose had been taken away from her. On 10/8/24 at 10:27 AM, V9 said the facility does not have sufficient Dietary staff. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said she switched the meals this week on Monday and Wednesday because they were short staffed on Monday. V9 said the Monday lunch meal was supposed to be chicken enchiladas, but chicken enchiladas have a long preparation time, and she only had 2 staff in the kitchen, herself and the cook. V9 said she is supposed to have at least 4 staff in the kitchen not including herself, the Dietary Manager. V9 said they should always be staffed with 1 Cook, 3 Dietary Aides, and 1 Dietary Manager. V9 said because she did not have enough staff on Monday, she prepared Wednesday's lunch on Monday, which was pulled pork, pasta salad, and pea salad. V9 said she does not want the resident's to suffer because the kitchen is short staffed. V9 said the facility has been short staffed for at least 2 months, and she ends up having to [NAME] sometimes. V9 said they are currently short a morning part time Cook, a part time Dietary Aide in the afternoon, a full time Dietary Aide in the morning, and an afternoon part time [NAME] position will be opening up on 10/20, when a staff member has their last day. On 10/9/24 starting at 10:57 AM, lunch service was observed, and the residents were served chicken enchiladas, street corn, and cheesecake. The facility's Spring Summer Menus 2024, Week 3 shows on Wednesday for Lunch the residents should be served Hawaiian Pork Sliders, pasta salad, pea salad, and cheesecake for dessert. The facility's Spring Summer Menus 2024, Week 3 shows on Monday for Lunch the residents should be served Chicken Enchiladas, Mexican Street Corn, and Dulce De Leche Cupcakes. The Monday Dinner shows the residents are supposed to be served an English Muffin Tuna Melt as their entree. On 10/9/24 at 3:20 PM, V9 (Dietary Manager) said she did not know how often or when, but there had been other occasions besides Monday and Wednesday of this week that she had to switch meals around or substitute meals due to insufficient staff. V9 said she just wants the residents to get fed on time. V9 said she tries not to switch meals around because the residents don't like change, and the littlest change disrupts them. V9 said that V1 (Administrator) has had to help her in the kitchen before because of lack of staff. V9 said she was not present for dinner service on Monday, but she was not aware that residents were served regular bread instead of toasted bread for their English Muffin Tuna Melts on 10/7/24. V9 said there should be 4 staff in the kitchen at any given time, not including the Dietary Manager: 1 Cook, 3 Aides and herself. V9 said on the weekends they only have 2 Aides and a [NAME] for breakfast and then an Aide comes in at 11 before Lunch service. V9 then provided the staffing schedule from 7/8/24 through 10/27/24 and highlighted all of the days they had/will have insufficient staff. These days include: 7/8/24, 7/9/24, 7/10/24, 7/12/24, 7/13/24, 7/14/24, 7/18/24, 7/19/24, 7/28/24, 7/29/24, 7/30/24, 7/31/24, 8/1/24, 8/2/24, 8/8/24, 8/9/24, 8/19/24, 8/20/24, 9/2/24, 9/7/24, 9/8/24, 9/17/24, 9/23/24, 9/24/24, 9/25/24, 9/26/24, 9/30/24, 10/1/24, 10/2/24, 10/5/24, 10/6/24, 10/7/24, and 10/15/24. Out of 111 days, they had insufficient staff on 33 days. The facility provided Facility Assessment Tool, dated 12/13/2022, states, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies .Staffing Plan 3.2 Based on your resident population and their needs for care and support, describe your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time .Example 1. Evaluation of the overall number of facility staff needed to ensure a sufficient number of qualified staff are available to meet each resident's needs . Dietician or Dietary Manager: 1 Dietician and 1 Dietary Manager, Food and Nutrition Staff: 3-4/3-4 . Example 2. Describe your general staffing plan to ensure that you have sufficient staff to meet the needs of the residents at any given time .Dietary Staff: 4 AM and 4 PM .

Based on observation, interview, and record review the facility failed to follow their menus. This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen. Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671), dated 10/8/24, documents the total census was 90 residents. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said all residents eat from the facility kitchen; there are no NPO (Nothing by Mouth) residents. On Wednesday 10/8/24 at 11:45 AM, R205 said on the previous Monday they were supposed to have tuna salad on toast, but it was not served on toast, it was just white bread. On 10/10/24 at 11:27 AM, R205 said there had been multiple occasions when the meals served did not match the menu, and that made R205 feel like her ability to choose had been taken away from her. On 10/8/24 at 10:27 AM, V9 said the facility does not have sufficient dietary staff. On 10/8/24 at 10:58 AM, V9 (Dietary Manager) said she switched the meals this week on Monday and Wednesday because they were short staffed on Monday. V9 said the Monday lunch meal was supposed to be chicken enchiladas, but chicken enchiladas have a long preparation time, and she only had 2 staff in the kitchen, herself and the cook. V9 said she is supposed to have at least 4 staff in the kitchen not including herself, the Dietary Manager. V9 said they should always be staffed with 1 Cook, 3 Dietary Aides, and 1 Dietary Manager. V9 said because she did not have enough staff on Monday, she prepared Wednesday's lunch on Monday, which was pulled pork, pasta salad, and pea salad. V9 said she does not want the resident's to suffer because the kitchen is short staffed. On 10/9/24 starting at 10:57 AM, lunch service was observed, and the residents were served chicken enchiladas, street corn, and cheesecake. The facility's Spring Summer Menus 2024, Week 3 shows on Wednesday for Lunch the residents should be served Hawaiian Pork Sliders, pasta salad, pea salad, and cheesecake for dessert. The facility's Spring Summer Menus 2024, Week 3 shows on Monday for Lunch the residents should be served Chicken Enchiladas, Mexican Street Corn, and Dulce De Leche Cupcakes. The Monday Dinner shows the residents are supposed to be served an English Muffin Tuna Melt as their entree. On 10/9/24 at 3:20 PM, V9 (Dietary Manager) said she did not know how often or when, but there had been other occasions besides Monday and Wednesday of this week that she had to switch meals around or substitute meals due to insufficient staff. V9 said she just wants the residents to get fed on time. V9 said she tries not to switch meals around because the residents don't like change, and the littlest change disrupts them. V9 said that V1 (Administrator) has had to help her in the kitchen before because of lack of staff. V9 said she was not present for dinner service on Monday, but she was not aware that residents were served regular bread instead of toasted bread for their English Muffin Tuna Melts on 10/7/24. The facility's undated policy titled, Menu Substitution Policy states, . Procedure: 1. Menu substitutions are necessary when a product is unavailable, residents request a substitution such as for Meal of the Month; or to take advantage of special pricing . This policy does not mention menu substitutions or switches are appropriate due to lack of sufficient kitchen staff.

Based on observation, interview, and record review, the facility failed to ensure the safety of a resident who is known to wander. This failure resulted in the resident falling down a stairwell with her wheelchair and sustaining fractures to her clavicle and ribs. This applies to 1 of 3 residents (R1) reviewed for fall with significant injury. The findings include: R1's Electronic Medical Record (EMR) shows diagnoses of [CONDITION(S)] with behaviors, generalized anxiety disorder, and repeated falls. R1's September 7, 2021 Minimum Data Set (MDS) shows R1 has severe cognitive impairment and requires one staff physical assistance for locomotion on the unit. The same MDS shows R1 was not steady on her feet, had functional impairment of both legs, and requires the use of a wheelchair. R1's care plan for wandering (revised 01/07/2021) shows R1 is a wanderer related to impaired safety awareness and wanders aimlessly . Interventions for the same date on the care plan include Identify pattern of wandering: Is wandering purposeful, aimless, or escapist? Is resident looking for something? . Another intervention on the care plan showed disguise exit: cover doorknobs and handles, tape floor . R1's risk for falls care plan (revised 06/20/2019) shows she is at risk for falls related to confusion, an intervention dated 09/17/2018 shows to encourage resident to stay in high visible areas . R1's care plan from an actual fall on 03/03/2020 (initiated 03/03/2020) related to poor balance, poor communication/comprehension, and unsteady gait showed an intervention from the same date as observe for unsafe situations . R1's November 13, 2021 fall/incident note from 4:51 PM showed R1 reported she was looking for [husband's name] . I thought he was down here. R1's Vitals note from November 13, 2021 at 7:56 PM shows R1 was admitted to the area hospital with an observational diagnosis of left distal clavicle fracture and left rib fracture. On November 29, 2021 at 12:01 PM, V5, CNA (Certified Nurse Assistant), reported V5 was working on Saturday November 13, 2021, when R1 fell down the stairs. V5 stated around 3:30 PM, V5 helped another resident to her room and asked V4, RN (Registered Nurse), to help her with cares. V5 stated when V5 left that resident's room, V5 noticed one pole from the makeshift covid unit doorway was on the floor, and a second pole was also on the floor past the doorway, in the middle of hallway. (The makeshift doorway separated the current resident rooms from what would be covid rooms, if there had been residents with covid.) V5 stated V4 checked all those empty covid rooms and bathrooms, even though all the doors were closed, to see if there was a resident in any of the rooms. V5 stated V5 did not find anyone, but then could not find R1 when she checked on V5's residents. V5 stated V5 checked the other unit for R1 because R1 liked to wheel herself all over. V5 stated R1 was kind of a wanderer, but the staff there reported they had not seen R1. V5 stated R1 would at times wander over to the other unit, and during covid, R1 would open the heavy door to leave her unit, and then open the heavy door to enter the other unit, and R1 was able to do it all by herself. V5 stated V5 rechecked all the rooms and bathrooms again on the empty covid unit hall. V5 stated when V5 came all the way to the very end, V5 noticed the green light on the egress bar was flashing green (meaning the door was not armed). There was no alarm going off, but V5 opened the stairwell door and she saw R1 laying on the landing. R1's wheelchair was tipped forward, but had stopped on the second or third step of the stairs. V5 stated V5 called for the nurse (V4). On November 29, 2021 at 1:57 PM, V4, RN (Registered Nurse), stated V4 was finishing some charting on R1's unit around 3:30 PM on November 13, 2021. V4 stated V4 assisted V5 with another resident, then stayed with the resident and talked after V5 left. V4 stated a short while later, V4 heard V5 screaming something like, Help she fell down the stairs! V4 stated V4 left the room and saw the covid unit curtain was collapsed and a pole in the middle of the floor. V4 stated when V4 got to the emergency door at the far end of the hall, R1 was holding on to the stairway railing while lying on the stair landing. V4 described V4's assessment of R1, and stated R1 told V4 R1 was looking for R1's husband. V4 stated when paramedics arrived, they placed R1 on a stretcher and R1 was transported to an area hospital. The facility's November 19, 2021 Final Reportable of R1's fall showed R1 was admitted to a local hospital with diagnoses of a left clavicle fracture and a left rib fracture. On November 29, 2021 at 1:57 PM, V4 stated R1 on any day can be seen wheeling herself independently on the unit. R1 will even go to the end of the hall towards the nurses' station, leave the unit, and enter the other unit on R1's floor. R1 could open the heavy metal doors by herself. V4 stated if they needed R1 and R1 wasn't in R1's room or on R1's unit, R1 could be found on the other unit. R1 was a very determined individual, and most days R1 thought R1's husband was on the other unit. V4 stated R1 was admitted to the hospital and diagnosed with a left fractured clavicle and left side fractured 8th and 9th ribs. On November 24, 2021 at 4:29 PM, V10 (RN) reported R1 seemed to be obsessed with the plastic curtain, describing it as two poles that went from the ceiling to the floor with a zipper in the middle. V10 reported R1 was strong enough and capable of getting past the curtain and being able to open the door. R1 would go to the other end of unit past the nurses' station, open the heavy metal door, and enter the other unit on this floor. On November 29, 2021 at 12:13 PM, V3 (Maintenance Director) reported every morning Monday through Friday, either V3 or V6 (Maintenance Personnel) will go door to door and press the egress bar, listen, ensure the door beeps for 15 seconds, open the door to trigger the alarm, then close the door. V3 stated, We have to use a key and turn it to the left to turn the alarm off, and then turn the key to the right to reset alarm. V3 stated a steady green light means the alarm is armed (on), and a flashing green light means the alarm has been disarmed. If someone opened the door without entering the code, and the door closes, but no one resets alarm, the alarm will at some point turn off, and the light will flash green until someone uses the key to reset it or turn on the door alarm. If the alarm is disarmed, the door can be pushed open without having to hold the bar down for 15 seconds. To reset the alarm, you have to turn the key to the right and then you will see a solid green light; if you turn it to the left, the alarm will be turned off and the light would flash green. On November 24, 2021 at 1:02 PM, V1 (Administrator) reported the egress bar alarms on the emergency exit doors should sound if someone goes through the door without entering the keypad code next to the door. On November 29, 2021 at 2:47 PM, V1 (Administrator) reported the doors were checked every morning by maintenance Monday through Friday, and there was not anyone assigned to check the doors on the weekends.

Based on observation, interview and record review the facility failed to develop and implement individualized supervision interventions to prevent falls for 2 residents (R1 and R5). This failure resulted in one resident falling and sustaining multiple fracture injuries (R1). This applies to 2 of 5 residents (R1 and R5) reviewed for fall incidents in the sample of 22. The findings include; 1) R1 admitted to facility February 29, 2016 with [DIAGNOSES REDACTED]. R1's March 7, 2016 minimum data set assessment (MDS) include severe cognitive deficits with a BIMS (brief interview of mental status), score of only 3 out of possible 15. R1 is also described as requiring extensive assistance with transfers, ambulation and toileting activities, have loss of range of motion (ROM), to one lower extremity and have frequent urinary incontinence. R1 is also assessed to be unable to communicate needs. R1's medical records included a physician statement dated July 31, 2015 stating R1 is unable to make informed decisions due to underlying dementia. R1's March 7, 2016 fall care plan states at risk due to poor safety awareness and impulsive at times. The care plan also includes R1 is incontinent of bowel and bladder, can ambulate with hands on assistance, is receiving psychotropic medications, has hallucinations and is resistive to care. The care plan interventions included monitor closely. The intervention did not specify R1's individualized supervision needs. R1's physician orders, physician progress notes [REDACTED]. R1 was hospitalized [DATE] through 21, 2016 with urosepsis infection. During November 3, 2016, 2:20 PM interview, E20 (nurse aide), stated R1 is very confused and frequently attempts to stand and walk unassisted. R1 is very impulsive and is a fall risk. E20 stated on April 8, 2016 there were 3 nurse aides working on the D-wing (where cognitively impaired residents reside). Just prior to R1's fall incident all 3 of the nurse aides (including E20), were bringing residents into the dining room from their rooms to get ready for dinner. R1 was placed in the dining room with other residents and the nurse aides left the dining room to get other residents when E20 heard a chair alarm sounding. E20 went out of a residents room to assess the alarm and observed R1 falling from a standing position and strike her face against one of the tables. R1's pants leg was observed tangled up on another residents recliner chair. E20 stated there was no staff in the dining room when R1 stood up from her wheel chair. E20 also stated R1 was always impulsive and had a history of [REDACTED]. E20 said R1 was always very restless, felt like she always had to get up and had to keep moving. During November 3, 2016, 3:15 PM interview, Z1 (R1's attending physician), stated R1 was a fall risk due to dementia and requires supervision. R1's April 8, 2016 incident report and nursing progress notes include at 4:30 PM, an alarm sounded in the D-wing dining room. E20 went to evaluate the sounding alarm and observed R1 walking unassisted in dining room and then to trip on another residents wheel chair. E20 was unable to prevent R1's fall. R1's face hit against a table and fell on to the floor. R1 observed with facial discoloration, swelling and bleeding. R1 sent to the hospital for evaluation and diagnosed with [REDACTED]. R1's April 8, 2016 hospital records document presence of a current UTI. R1's April 8, 2016 fall investigation include a care plan update as a result of this fall. The new approaches only included evaluate for alternative alarm, offer busy work and discontinue previous intervention for a therapy screening. 2). R5 ' s Face Sheet documents that he is [AGE] years old and was admitted to the facility on [DATE]. R5 ' s Past Medical History from the local hospital documents that he has a history of fall on May 10, 2016 and was found to have left intracerebellar bleed. The patient reported to have left cerebellar intraparenchymal hemorrhage with intraventricular extension and [DIAGNOSES REDACTED] status [REDACTED]. Subsequently, the patient had impaired cognition, expressive aphasia, impaired mobility and impaired activities of daily living. R5 ' s POS (physician's order [REDACTED]. On November 1, 2016 during tour of the facility, R5 was sitting in the doorway of his room in his wheel chair alone. R5 had multiple steri strips and reddened purplish areas on his arms. The facility ' s fall reports documents the following falls for R5 since being admitted : July 9, 2016 fell in room alone, trying to get into bed at 6:00pm. August 20, 2016 fell in room while visiting spouse. August 28, 2016 got out of bed, unable to stand. September 1, 2016, found on floor next to bed in his room, trying to go to bathroom, no witnesses October 15, 2016, slid out of chair in dining room, scrape to left rib cage. October 31, 2016, in his room alone, observed on floor. Injury-skin tears and bump to left forehead, skin tears to left elbow, left forearm, right wrist, and right forearm. R5 ' s MDS (Minimum Data Set) dated September 22, 2016 documents that he requires staff assistance for toileting, and transfers. The Brief Interview for Mental Status (BIMs) documents a score of 6/15 indicating cognitive impairment. R5 ' s MDS also documents that he had a fall within 2-6 months prior to admission to the facility. R5 ' s initial Care Plan presented on November 2, 2016 by the facility for high risk for falls did not document interventions for the falls R5 sustained on October 15, 2016 or October 31, 2016. The Care Plan was dated July 12, 2016 with a goal date of October 12, 2016. The care plan did not include revisions for the falls R5 sustained in October 2016. On November 2, 2016, E2 (Director of Nursing) stated that R5 had falls prior to being admitted to facility and was a high fall risk when he arrived to the facility. E2 stated that the facility had given R5 chair alarm but it was removed because R5 fidgeted with it. R5 ' s care plan did not document him having had an alarm or interventions for him fidgeting with it. E2 also stated that R5 requires supervision but is allowed to sit in his room alone. E2 stated that on October 31, 2016, R5 was in the dining room. E2 stated there was no staff in the dining room and R5 propelled himself to his room where he fell . E2 stated that E7 (Nurse) had passed by and saw R5 in his room by himself. R5 sustained injuries to his forehead and skin tears to his arms when he fell . On November 2, 2016 at 2:00pm, E7 stated that R5 requires supervision. E7 stated she is aware of all the falls R5 has had. E7 stated that on October 31, 2016 she passed by R5 ' s room and saw him in his chair looking out the window alone. E7 stated she did not enter the room, attempt to bring R5 out with supervision or ask staff to go supervise him. E7 stated that when she came back past R5 ' s room she noticed the wheel chair but R5 wasn ' t in the chair. E7 stated she then noticed R5 on the floor. On November 3, 2016 from 10:00am-11:40am, R5 was sitting in his room alone. There was no staff in R5 ' s room or in the lounge area outside of R5 ' s room. R5 propelled himself outside of his room and sat in the doorway. No staff stopped to check on R5. There was no one supervising R5. The facilitys Fall Prevention and Management Policy documents: Upon completion and review of the fall risk assessment, a fall safety care plan will be initiated with fall safety intervention(s) based on the resident's risk factors and individual needs. All residents will be supervised a minimum of every 2 hours and PRN (as needed) depending on their potential fall risk- if specific supervision intervals are needed this will be reflected on the fall risk care plan. The care plan will be updated with the new individualized fall safety prevention interventions(s).

Based on interview and record review the facility failed to notify the physician a of fall with head injury, for one resident (R1) out of three residents reviewed for falls. This caused R1 a delay in immediate care and treatment for [REDACTED]. The findings include: R1 was admitted to the facility on [DATE]. The physician order [REDACTED]. The sheet also showed that R1 had [MEDICATION NAME], a blood thinning medication ordered. On [DATE], a nursing note timed 1:31am was documented as a late entry for [DATE] at 4:45pm. The note showed that R1 was observed by the Certified Nursing Assistant on the floor in the bathroom. E5 (Licensed Practical Nurse) wrote an assessment at that time. The assessment showed that R1 had a large hematoma on the left forehead. The note showed that R1 had pain and received 500 milligrams of Tyelenol from E5. The note also showed that E10 Medical Doctor was paged times two. E10 was on call for E9 (Medical Doctor/Director). The note then shows that a fax will be sent in the morning to notify the doctor. A Neurological Flow Sheet dated for [DATE] showed that around 4:45pm R1 was transferred by two assists to the bed and then to the chair. The Neurological Sheet showed that around 7:45pm the resident had no change. The sheet is not complete and is not signed or timed. An Incident report, dated for [DATE], showed that at 8:15pm R1 was lethargic and responsive to tactile stimulation only. R1 was then sent out to the community hospital and expired. On [DATE] at 9:50am, via telephone interview, E5 (Licensed Practical Nurse) stated that R1 was fine. E5 stated, " When I first saw R1 she was on the bathroom floor. There was a large hematoma on her head and she complained of pain and dizziness. Her Blood pressure and other vital signs were normal. I told my charge nurse about it and I called the Doctor but there was no return call. On [DATE] at 3:00pm, E8 (Registered Nurse) stated, " I was in charge that night. E5 called me down to check on R1. R1 had swelling on the forehead and was complaining of pain. I anticipated that R1 would have gone out to the hospital for a check. I told E5 to put a call out the physician. If I didn't hear back from the doctor I would have called the emergency room physician to see if he could page the doctor " . On [DATE] at 1:45pm, E9 (Medical Doctor and Medical Director) stated, " I just found out today that R1 fell and expired. If we are not answering our pages the staff is to call the hospital emergency room physician. There are also two other doctors that could have been called. Even so I was on vacation and had my cell phone with me and on. They know they could have called me. I would have wanted to know right away if R1 fell and I would have sent R1 out to the hospital for evaluation " . Facility policy updated [DATE] entitled, "Post Fall Assessment Policy" documents "If there is any head involvement or the resident unsure if head involvement occurred neurological checks will be initiated for an assessment period of 72 hours." "The nurse will notify the resident's physician and responsible party in an appropriate time frame."

Based on interview and record review the facility failed to monitor, complete the neurological assessment, notify the physician and obtain emergency medical care for one resident R1 who was on blood thinning medication and fell with injury to the head. This applies to one of four residents (R1) reviewed for falls. This failure caused a delay in the evaluation and treatment of [REDACTED]. The findings include: R1 was admitted to the facility on [DATE]. On [DATE], R1 was readmitted to the facilities long term care unit after being hospitalized . The admission physician order [REDACTED]. The physician order [REDACTED]. On [DATE], a note was written at 1:38am by E5 (Licensed Practical Nurse). E5 wrote a late addendum regarding a fall R1 had on [DATE] at 4:45pm. The note showed that R1 was found on the bathroom floor at 4:45pm. R1 was conscious and complaining of head pain. The note showed that R1 had a hematoma to the forehead. The note showed only one set of vital signs. There was no time documented. The vital signs in the nursing note match the vital signs done at 4:45pm on the Neurological flow sheet. The neurological flow sheet dated [DATE] instruct the nurse to assess neuro status every 15 minutes times one hour, then every 30 minutes times one hour, then every hour for four hours, then every four hours for 24 hours. The sheet for R1 dated [DATE] showed only seven sets of vital signs. The vital signs are not timed nor signed by the examiner. R1 fell at 4:45pm. The nursing note for [DATE] at 1:30am showed that R1 was sent out to the hospital at 8:25pm on [DATE]. On [DATE] at 2:30pm, E4 (Certified Nursing Assistant) stated, " I took vital signs every 15 minutes until I left at six o ' clock. I did them five times. I gave report to the next shift to continue to monitor " . The Neurological Flow sheet showed only two more sets of untimed vital signs after the ones taken by E4. The sheet does not show all of the vital signs that were to be done per the instructions on the sheet. The incident report generated for R1,by E5 (Licensed Practical Nurse) on [DATE] at 4:45pm show only one set of vital signs. At 6:30pm, E5 wrote R1 continues with a headache and neuro checks are within normal limits. At 8:15pm, E5 wrote that R1 was found lethargic and responsive to tactile stimulation only. There are no vital signs or neurological checks documented. The note showed that R1 was being sent to the community hospital emergency room . The Nursing progress note dated [DATE] at 1:39am, showed that at 8:25pm R1 was sent out to the hospital. The clinical record showed no documentation of the neurological checks or vital signs prior to transfer. On [DATE] at 9:50am, via telephone interview, E5 (Licensed Practical Nurse) stated that she knew R1 was on [MEDICATION NAME] therapy. E5 stated, " R1 had swelling to the forehead. R1 complained of headache and dizziness. The vital signs and neurological checks were normal " . The interview process with E5 was difficult due to a language barrier. E5 was unable to understand all of the questions asked and had difficulty expressing answers that could be understood. On [DATE] at 1:40pm, E1 (Administrator) stated that E5 had not performed an investigation of the fall or followed the facility policy regarding head injuries. E1 said that she became aware of the incident the morning of [DATE]. E1 said that if E5 was unable to reach the doctor there were many other options including calling E1. On [DATE] at 1:45pm, E9 (Medical Doctor and Medical Director) stated, " I just found out today that R1 fell and expired. If we are not answering our pages the staff is to call the hospital emergency room physician. There are also two other doctors that could have been called. Even so I was on vacation and had my cell phone with me and on. They know they could have called me. I would have wanted to know right away if R1 fell and I would have sent R1 out to the hospital for evaluation right away " . Facility policy updated [DATE] entitled, "Post Fall Assessment Policy" documents "If there is any head involvement or the resident unsure if head involvement occurred neurological checks will be initiated for an assessment period of 72 hours." "The nurse will notify the resident's physician and responsible party in an appropriate time frame."

Based on observation, interview and record review the facility failed to apply gait belt and failed to train staff to safely transfer a resident using a slide board. This applies to 1 of 3 residents (R1) reviewed for fall. This failure resulted in R1 sustaining a laceration on the forehead that required suturing after a fall on 10/7/13. The findings include: R1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R1's initial MDS (Minimum Data Set) dated 5/28/13 shows that the resident is oriented and requires extensive assistance x 2 persons, physical assist with transfers and bed mobility. R1's weight record shows that on 10/2/13, the resident weighed 228 pounds. R1's fall assessments dated 5/28/13 and 8/13 both shows a score of 19, indicating that the resident is at risk of falling. R1's incident report dated 10/7/13 (6:00 AM) shows that the resident fell on the floor while the CNAs (Certified Nursing Assistance) were transferring the resident from bed to the wheelchair using a sliding board without a gait belt. R1 fell forward and sustained a skin breakdown on the right brow and nose area. R1 was sent to the emergency room . Further review of the same incident report showed that R1's weight and improper transfer were the environmental factors for the fall and the possible cause of the fall was the CNA not using assistive device. R1's hospital records dated 10/7/13 shows that, the resident was diagnosed with [REDACTED]. R1's incident report/staff statement report dated 10/7/13, both signed by E4 (CNA) and E5 (CNA) shows, "I was transferring R1 from bed to chair using the slide board. When he was half on the slide board and half on the chair, his feet became caught underneath the chair as we were still in the process of sliding him, didn't know it so when lifting him after getting in the chair, he fell , face first on the floor. We didn't grab him in time." On 10/16/13 at 2:05 PM, R1 was inside his room, up in the wheelchair, alert oriented and verbally responsive. R1 was observed with sutures intact above his right eye brow area and bruising below the right eye by the cheek area. R1 stated during interview that when he fell on [DATE] during the slide board transfer, the 2 CNAs did not apply a gait belt on him. According to R1, 1 CNA was in front of him, holding the slide board and the other CNA was positioned behind him, "No staff was in front to hold and guide me to break or prevent my fall." R1 stated that more training of the staff would have helped for better understanding of the transfer procedure using the slide board. On 10/16/13 at 1:00 PM, E4 during interview stated that on 10/7/13 at around 6:00 AM, she and E5 were assisting to transfer R1 from bed to the wheelchair using a slide board. Per E4, she was positioned behind the resident towards R1's right side, while E5 was positioned in front of the resident. According to E4 they did not apply a gait belt to R1 before attempting to transfer the resident using the slide board. E4 stated that during the slide board transfer, R1's feet got caught on the wheel of the wheelchair because, "his feet were not positioned properly, so resident fell forward on his face." Per E4, R1 sustained a skin tear on the right side of the forehead. E4 stated that she have not seen and have not used a slide board to transfer a resident and that she does not know how to use it. E4 further stated that she did not have any training from the CNA school and/or from the facility with regards to the use of the slide board to transfer the resident. On 10/16/13 at 2:45 PM, E5 stated that on 10/7/13 between 6:00 AM and 6:10 AM, she and E4 were assisting to transfer R1 from bed to the wheelchair using a slide board, without a gait belt. Per E5, she was positioned in front of the resident towards R1's left side, while E4 was positioned behind the resident. According to E5, R1 slide from the bed to the wheelchair successfully using the slide board. However, when she (E5) attempted to remove the slide board from underneath R1 (while in the wheelchair), the resident fell forward because his feet were caught underneath the wheelchair. Per E5, it happened so fast that they were not able to stop the fall because the resident was heavy. E5 stated that when R1 fell to the floor, the resident sustained [REDACTED]. According to E5 she did not receive any formal training or instruction from the facility with regards to the use of the slide board to transfer the resident. On 10/16/13 at 11:30 AM, E3 (Rehab Director) stated during interview that, "for slide board transfer, definitely use a gait belt for safety. If the resident loose their balance, the staff has something to hold on to without physically grabbing a limb to stop the fall." "Staff are suppose to hold on to the gait belt during the entire transfer, to ensure safety in-case resident loses balance." According to E3, the therapy department gave an in-service with regards to the use of the slide board transfer. However, there was no documentation provided to verify if E4 and E5 received the educational training/in-service with regards to the safe use of the slide board. Review of the undated policy and procedure regarding Slide Board Transfer shows, "To ensure safety of resident and staff during transfer. This type of transfer is to be done with at least 2 people and staff must be trained prior to transfer." The same policy and procedure also showed, "Assemble a gait belt around the patient for extra support. Make sure the gait belt is snug, but not too tight. Grasp each side of the gait belt with an underhanded grip." On 10/17/13 at 11:30 AM, Z1 (Medical Director) stated that he had approved the policy and procedure regarding slide board transfer on 1/3/13 and that the facility staff are expected to follow it to ensure safe transfers of the resident.

Based on observation, record review and interview the facility failed to: - Develop and implement specific and individualized interventions to monitor R16 from falling. - Conduct a comprehensive assessment for the use of assistive devices including total mechanical lift and chair and bed alarm for R16. - Ensure the staff was proficient when transferring R16 with a total mechanical lift. R16 is confused and disoriented, incontinent, unsteady to ambulate independently, has a history of multiple falls and dependent on staff for her activities of daily living. As a result: - R16 had fallen 13 times between 8/3/11 and 11/4/11. On 8/23/11 when R16 fell for the 5th time she sustained right ankle fracture. R16 also fell seven times after she sustained the right ankle fracture. - R7 sustained left hip fracture on 11/24/11 when she had fallen in dining room. On 1/3/12 R7 sustained left orbital contusion when she was transported in wheel chair by a transporter. This is for three of six residents (R16, R7 and R17) in the sample of 22 residents who are risk for falls. Findings include: 1. R16's admission record documented she is an [AGE] year old female admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R16's 10/14/11 Minimum Data Set (MDS) indicated she is incontinent of bowel and bladder, dependent on staff for her activities of daily living, unstable in balance to ambulate and has a history of multiple falls. R16's 7/5/11 fall risk assessment scored 14 and it was indicated a score greater than '10' is high risk for falls. The facility did not analyze the risk factors or if the risk factors could be modified. The plan of care interventions for falls is not individualized for the use of bed and chair alarm. The facility documented between 8/3/11 and 11/4/11 13 accidents and incidents showing R16 had fallen: 8/3/11 10:05 am resident sitting on floor, removed bed alarm, got out of bed. The interventions added were to add a tamper poof alarm and educate resident to call for help. R16 is confused and has unstable balance. It is not clear as to how these interventions will prevent R16 from falling again. 8/5/11 1:00 am alarm sounded, found resident on floor in front of bathroom, resident stated she slid out of her wheel chair and intervention added was to have non-skid pad in wheel chair in place. The investigation did not comment as to why R16 was in her wheel chair at 1:00 am un-attended. 8/7/11 2:54 am resident sitting next to bed, resident stated she reached for call light. The intervention was to clip call light to blanket. R16 has short term memory impairment, it is not clear how the facility will ensure R16 will follow the education. 8/8/11 2:50 pm found resident on floor with sheet under her. The intervention was to keep R16 in wheel chair at the foot of the bed. No intervention noted who will monitor R16 to ensure she is safe in her room unattended. 8/23/11 12:40 pm resident (R16) was found on the floor out side the bathroom in her room by a visitor; she stated she tripped over a rug, but there was no rug. R16 toileted self independently and attempted to ambulate back to wheel chair and fell . R16 is unsteady in balance to ambulate self. The facility failed to monitor R16 in her wheel chair, even though the facility was aware of R16 got up from wheel chair, ambulated and fell multiple times prior to this incident. As a result R16 fell and on the floor and sustained right ankle fracture. After R16 returned from the hospital on [DATE] 10:45 pm she was found on floor next to her bed. On 9/10/11 at 9:35 am staff heard alarm sounding in R16's room and found her on floor in a sitting position on the floor in front of wheel chair by her bed. The facility evaluated and implemented; (i) 9/10/11 to use a bed enclosure (bed enclosed with a tarpaulin and net) when she is in bed and (ii) to use a seat belt when she is in wheel chair. Even after these interventions were in place the facility continued to monitor R16 is safe when she was in bed and when she was in her chair. The examples of unsafe situations are: (i) on 9/17/11 5:35 am R16 sustained a cut on her great toe from wedging into webbing of the bed enclosure; (ii) on 9/27/11 12:50 pm alarm sounded, staff found R16 sitting on floor in front of wheel chair in room, R16 took shoe off of left foot and slid out of wheel chair. (iii) 10/1/11 10:50 am R16 was found on floor at room mate side of room with her back against the wall, R16 was in her wheel chair. (iv) 11/4/11 12:30 pm R16 was found on floor in her room with wheel chair beside her, resident stated she tried to get off from wheel chair to toilet. It is unclear to explain these instances of R16 landing on the floor from her wheel chair if a seat belt was applied while she was in the wheel chair. R16 also had an incident of falling to the floor in the bath room with two staff being present on 10/5/11 at 8:15 am. The incident report noted two staff took R16 to the toilet. When the staff got R16 of the toilet her knees gave out and fell on the floor on her buttocks. The investigation report indicated the facility discipline the staff for their failure to use a total mechanical lift to transfer R16. 2) Incident report of 11/24/11 indicates that R7, a [AGE] year old female, was in the D-wing dining room at 6:00 pm when she was found on the floor sitting next to her wheel chair. Resident stated she was trying to get up and fell on her let and hit her head as well. R7 said she had a shooting pain to left leg from knee to thigh. The injury listed is redness to the left side of her head and cannot move left leg with normal range of motion. R7's physician ordered an Xray that was done in the facility that evening. R7 was sent to the hospital with [DIAGNOSES REDACTED]. The report indicates this fall was not witnessed and no staff was in the dining room. The last time R7 was seen was 10 minutes prior to this fall. R7's last full annual assessment prior to this fall dated 11/7/11. The cognitive status section of this assessment indicates that R7 is severely impaired. The care area assessment indicates that R7 is alert and oriented to person only. She is confused and forgetful. She needs cues and reminders from staff. [DIAGNOSES REDACTED]. R7's care plan of 11/11/2011 indicates R7 has the potential for trauma-falls and injury. The approach includes to observe and report all unsafe conditions and situations, encourage to ask for assistance, anticipate fall times, monitor closely. The interventions listed on the incident report are to re-educate staff on having staff present in the dining room for supervision until all residents are done. R7 was readmitted from the hospital at 11/29/11 according to nursing notes. R7 has surgical wound 19 1/2 cm with 25 staples intact. On 1/9/12 R7 was observed seated in the the D wing dining room at the breakfast meal at 7:45am. R7 had ecchymosis around both eyes and a scrape on her face. R7 said she did not remember how this happened. E1 administrator said at 1:45 pm on 1/9/12 that R7 was involved in an incident on 1/3/12 when she was being transported to an appointment. 3. Review of R 17's admission face sheet showed R17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R17's CAA (care area assessment) for cognition dated 6/2/11 showed R17 had poor short term memory and poor decision making and safety sense. The CAA also showed R17 had difficulty focusing attention and had disorganized thinking. R17's CAA addressing functional status showed R17 was hard of hearing and had macular degeneration. R17's fall assessment showed R17 was assessed at high risk for falls. Review of the facility's incidents from 8/2011 to 12/2011 showed R17 had 11 incidents. Of the 11 incidents 8 were incidents of falls. Of the 8 falls, five occurred on the night shift (11:00 p.m. - 7:00 a.m.). With these incidents R17 was usually found on the floor. Review of the eight fall incidents showed with five of the incidents R17 was found on the bathroom floor or found on the bedside floor mat with with wet linens. R17's physician's orders [REDACTED]. On 8/19/11 a bladder diary was initiated for R17 for 10 days (8/19 to 8/29/11). Review of the bladder diary documentation showed the documentation was very sparse. Two days (8/20 and 8/26/11) had no documentation. On the remaining days (8/19, 8/21, 8/22, 8/23, 8/24, 8/25, 8/27, and 8/29/11) there was sparse documentation with no documentation on all shifts. Review of documentation on the night shift showed only 1 day of documentation (8/27/11). Review of all incident documentation showed no analysis of trends and patterns of R17's falls in an attempt to determine why R17 was having falls. There was also no noted evaluation or follow up review of the sparsely documented/incomplete bladder diary. Further review of R17's incidents noted on 8/22/11 R17 was found with a bruise to her left arm and elbow and a skin tear to the left posterior hand. On 12/1/11 at 5:40 a.m. R17 fell out of her wheel chair hitting her head on the floor and was noted with a bruise to the right forehead measuring 4 x 4 cm. Interviews with E2 (Director of Nurses) and E3 (Assistant Director of Nurses) on 1/11/11 at 11:55 a.m. noted both to admit no analysis for trends, patterns, etc. had been initiated to identify why R17 was having falls.

Based on interview and record review the facility failed to: (1) develop and implement interventions for the operation of electric recliner for R3. (2) monitor and supervise R3 to prevent her from operating electric recliner/remote in an unsafe manner. As a result: R3 got hold of the remote control for electric chair and fell forward onto the floor. R3 sustained a six centimeter scalp laceration that required sutures and administration of two units of packed red blood cells. This is for one of three residents (R3) in the sample. Findings include: Review of the incident report for R3 on 7/18/11 was done with E1 (administrator) and E2 (director of nurses) and E4 (assistant director of nurses) on 8/12/11. E2 and E4 recall being told by E3 that R3 was seated in the electric recliner chair before the fall. The reclining chair has a remote that operates the position of the chair. The remote can position the chair at different heights. The incident report completed by E4 read, " the recliner chair was tilted all the way forward when E3 entered R3's room after the fall." The report documented R3 was, " found face down with large amount of blood under her head...last time seen sitting in her recliner resting...large laceration observed right side of her forehead about 3 centimeters in size, actively bleeding." E3 stated she usually tucks the remote in between the armrest and seat. E3 said this is done to prevent R3 from reaching to use the remote. E1 stated the reclining chair with remote belonged to R3. E1 said this was brought to the facility by the family for R3's use. E2 and E3 were queried if R3 should have access to the remote. E2, E3 and E4 agreed that the staff position the remote to the recliner to prevent R3 from reaching to use it. E3 stated strongly R3 was seen on several occasions playing with the remote for the chair. During these times the remote would be removed from her reach and repositioned. E3's interview on 8/12/11 indicated R3 was found by E3 CNA (certified nursing assistant), face down on the floor after falling from a reclining chair on 7/18/11. E3 stated she heard R3's call light go off and she yelled. E3 stated she walked into R3's room to find the reclining chair completely straight up. E3 said R3 must have gotten hold of the remote. E3 stated R3 would sometimes be seen playing with the remote, pushing it and making it go up and down. E3 said she usually tucks the remote out of the way of R3's reach so she can't use it. R3 was transferred to the emergency roiagnom on [DATE] after the fall. Z1 (primary care physician) dictated the following in the admitting history: "was found face down on the ground with a large right frontal, six centimeter scalp laceration... there was apparently a pool of blood on the floor...there was no recollection of the episode by R3." The dictated impression summarized an acute unresponsive episode probably secondary to new onset seizure, status [REDACTED]. Z1 stated on 8/16/11 R3," is alert and oriented and has her wit about herself." Z1 said R3 had a new onset seizure on 7/18/11. Z1 said R3 had a six centimeter scalp laceration and required two units of packed red blood cells due to the amount of bleeding caused by the fall. Z1 stated R3 cannot ambulate, has right side hemiparesis and can use of her left side of body. The care plan was reviewed on 8/12/11. This review was done with E1, E2 and E4. The facility did not have a plan developed to prevent R3 from making the chair operational when staff were not present. There is no documentation to show R3 had received any orientation or education on the operation of the chair independently. The restorative assessment dated [DATE] shows R3 being totally dependent in the upper and lower right extremities, unable to ambulate, requires repositioning, totally dependent in transfers from moving to sitting. The fall assessments scored at 15 points for high risk for falls.