Every finding on record at Sharon Health Care Elms

Based on interview and record review the facility failed to investigate an injury of unknown origin for one (R1) of three residents reviewed for incidents/accidents.Findings include:The facility policy, Resident Accident/Incident, revised 5/20/15, documents not in its entirety, Residents that end up with an unexplained bruise or skin tear will be investigated to ensure there has been no abuse.The facility policy, Abuse Prevention Program, undated, documents not in its entirety, For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. If the cause of an injury of unknown, the person gathering facts will document the injury, the location and time it was observed, any treatment given and whether the physician, responsible party and/or the Department of Public Health were notified. If the injury is classified as an injury of unknown source, the procedures and time frames for reporting and investigating abuse will be followed.R1's resident face sheet documents R1's date of admission to the facility was 1/6/26 and R1's diagnoses include but are not limited to Iron Deficiency Anemia, Clicking Hip, Generalized Anxiety Disorder, Chronic Venous Hypertension (Idiopathic) with Inflammation of Bilateral Lower Extremity, and Age-Related Osteoporosis without current Pathological Fracture.R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact, occasional pain, and requires partial to moderate assistance with transfers and ambulation.R1's Physical Therapy Notes dated 7/1/26 documents, LLE (Left Lower Extremity) bruising noted, and nursing notified.R1's progress note dated 7/2/26 at 11:26am documents R1 had bruising behind her L knee and edema to her left foot which was reported to the physician with no new orders obtained.R1's hospital records dated 7/3/26 at 09:30 documents R1 has a displaced fracture of the left femoral neck with subsequent documentation on discharge report dated 7/9/26 documenting that R1's primary hospital diagnosis was Pathological Fracture of the Left Femoral Neck.On 7/16/26 at 2:20pm, V13 (Director of Rehab) stated on 7/1/26 she reported to V4 (Registered Nurse) that R1 had bruising to her left inner leg from mid-thigh to mid-calf, it was very discolored and I was concerned. I wasn't going to stand her or do exercises to that leg until I knew what was going on because she was complaining of pain as well. V13 stated on 7/2/26 she again mentioned it in the morning department head meeting and I told them I was not going to do therapy until we got some sort of x-ray. V13 stated she had some swelling to the top of her left foot on 6/30/26 but there was no bruising at that time, It just came on all of a sudden, that's what was concerning.On 7/16/26 at 12:00pm, V4 (Registered Nurse) stated on 7/2/26 V13 (Director of Therapy) showed her R1 had light, gray colored bruising behind her left knee approximately the size of a quarter and R1 was not complaining of any pain or discomfort to the area. V4 denied other staff reporting the bruise to her. V4 stated she had notified the doctor and asked for testing which the doctor did not feel was necessary.7/16/26 at 11:50am, V12 (MDS Coordinator) stated that the morning of 7/2/26 V13 (Director of Therapy) brought concerns to morning department head meeting that R1 had bruising and swelling to her left leg. It was portrayed as a purple color under the skin not a bruise, so we assumed vascular type problem and had nursing contact the doctor to get orders for a doppler and x- ray which the doctor refused because he didn't feel it was necessary. When asked what the protocol on finding bruises of unknown origin is, V12 stated that the nursing staff would fill out an injury of unknown origin form that comes to V12 to initiate an investigation. When asked if nursing should have filled out the injury of unknown origin form V12 stated, I would say yes they should have but I'll be frank with you, did it happen, No.7/16/26 at 11:30am, V1 (Administrator) stated she believes that there was mention of something regarding R1's leg in morning meeting and doctor was called and didn't want to do anything about it. When asked what the facility protocol was for bruising of unknown origin V1 stated, Notify the doctor and that's it. V1 verified that facility policy, Resident Accident/Incident, states that unexplained bruising will be investigated to rule out abuse and verified that an investigation was not initiated and was not reported to state agency.

Based on interview and record review the facility failed to report an injury of unknown origin for one (R1) of three residents reviewed for incidents/accidents.Findings include:The facility policy, Abuse Prevention Program, undated, documents not in its entirety, For resident injuries not involving an allegation of abuse or neglect, the administrator will appoint a person to gather further facts to make a determination as to whether the injury should be classified as an injury of unknown source. An injury should be classified as an injury of unknown source when both of the following conditions are met: The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; and The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. If the cause of an injury of unknown, the person gathering facts will document the injury, the location and time it was observed, any treatment given and whether the physician, responsible party and/or the Department of Public Health were notified. If the injury is classified as an injury of unknown source, the procedures and time frames for reporting and investigating abuse will be followed.R1's resident face sheet documents R1's date of admission to the facility was 1/6/26 and R1's diagnoses include but are not limited to Iron Deficiency Anemia, Clicking Hip, Generalized Anxiety Disorder, Chronic Venous Hypertension (Idiopathic) with Inflammation of Bilateral Lower Extremity, and Age-Related Osteoporosis without current Pathological Fracture.R1's Minimum Data Set (MDS) assessment dated [DATE] documents R1 is cognitively intact, occasional pain, and requires partial to moderate assistance with transfers and ambulation.Facility Incident report dated 5/1/26-7/16/26 documents that R1 had unwitnessed falls on 5/25/26, 5/27/26, 5/29/26, 5/30/26, 6/12/26, and 6/23/26.R1's Physical Therapy Notes dated 7/1/26 documents, LLE (Left Lower Extremity) bruising noted, and nursing notified.R1's hospital records dated 7/3/26 documents R1 has a displaced fracture of the left femoral neck.On 7/16/26 at 2:20pm, V13 (Director of Rehab) stated on 7/1/26 she reported to V4 (Registered Nurse) that R1 had bruising to her left inner leg from mid-thigh to mid-calf, it was very discolored and I was concerned. I wasn't going to stand her or do exercises to that leg until I knew what was going on because she was complaining of pain as well. V13 stated on 7/2/26 she again mentioned it in the morning department head meeting and I told them I was not going to do therapy until we got some sort of x-ray. V13 stated she had some swelling to the top of her left foot on 6/30/26 but there was no bruising at that time, It just came on all of a sudden, that's what was concerning.On 7/16/26 at 12:00pm, V4 (Registered Nurse) stated on 7/2/26 V13 (Director of Therapy) showed her R1 had light, gray colored bruising behind her left knee approximately the size of a quarter and R1 was not complaining of any pain or discomfort to the area. V4 denied other staff reporting the bruise to her. V4 stated she had notified the doctor and asked for testing which the doctor did not feel was necessary. V4 also stated, (R1)'s daughter, V3, came in later in the morning and stated she was going to take her out for the day because she hadn't been out for a while, I thought to myself I can't believe she wants to take her out because it was really hot that day in the 90's with a heat index of 107 but I didn't say anything. Later another nurse, I don't recall who, took a phone call from V3 stating that she was taking R1 to the emergency room for heat stroke. I found out later that she (R1) was admitted with a broken hip and was told it wasn't from a fall it was pathological, but I don't remember who told me that. Nothing had happened that day prior to her going out and she wasn't complaining of anything.On 7/16/26 at 11:50am, V12 (MDS Coordinator) stated that the morning of 7/2/26 V13 (Director of Therapy) brought concerns to morning department head meeting that R1 had bruising and swelling to her left leg. It was portrayed as a purple color under the skin not a bruise, so we assumed vascular type problem and had nursing contact the doctor to get orders for a doppler and x- ray which the doctor refused because he didn't feel it was necessary. When asked what the protocol on finding bruises of unknown origin is, V12 stated that the nursing staff would fill out an injury of unknown origin form that comes to V12 to initiate an investigation. When asked if nursing should have filled out the injury of unknown origin form V12 stated, I would say yes they should have but I'll be frank with you, did it happen, No.7/16/26 at 11:30am, V1 (Administrator) stated she believes that there was mention of something regarding R1's leg in morning meeting and doctor was called and didn't want to do anything about it. When asked what the facility protocol was for bruising of unknown origin V1 stated, Notify the doctor and that's it. V1 verified that facility policy, Resident Accident/Incident, states that unexplained bruising will be investigated to rule out abuse and verified that an investigation was not initiated and was not reported to state agency. V1 stated she wasn't aware it should have been reported.

Based on interview and record review, the facility failed to follow their policy for reducing falls and using a portable lifting machine for one (R1) of three residents reviewed for accident/incidents in a sample of four. This failure resulted in R1 sustaining multiple bruises to her face and body, and pain which required R1 to be transferred to the hospital.Findings include: Facility Using a Portable Lifting Machine, dated May 2008, documents The primary purpose of using a portable lifting machine is to help lift residents who may be too heavy to lift. The portable lift is also used to promote comfort and to maintain good body alignment while the resident is being moved. This procedure requires the assistance of two (2) persons.Facility Fall Policy and Procedure, revised 1/2/2019, documents It is the Policy of (nursing home) to provide an environment conducive to reducing risk for falls. (Nursing home) provides interventions to reduce risk factors for falling.Facility medical record for R1 documents R1 was sent to the (local) hospital on 2/24/26. Facility Mobility Assessment for R1, dated 1/13/2026, documents the following: Surface-to-surface transfer (transfer between bed and chair or wheelchair) not steady, only able to stabilize with staff assistance. Extensive assistance with bed mobility. Total dependence on transferring. Transfer support needed two plus person's physical assist.Facility Nursing Note for R1, dated 2/24/2026 at 8:21AM by V5 RN/Registered Nurse documents the following: This Nurse observed (R1's) bruised and swollen area on her L cheek and dried blood on her teeth and L lip. It hurts her to open her mouth, and she was unable to take her medicine. There is a light bruise on her L clavicle and a small bruised know above her L eye. Ice applied to L cheek.Facility Nursing Note for R1, dated 2/24/26 at 9:20AM by V7 RN Wound Nurse, documents the following: Several bruises noted on assessment this morning per nursing staff. On assessment (R1), this RN observed bruising to the resident's right anterior shoulder, left anterior shoulder, left lateral head, forehead, left eyelid, left eyebrow, left cheek, left inner ear, left jaw, anterior neck, left upper chest, right dorsal hand, left 1st knuckle, left medial wrist, and top lip. Facility Nursing Note for R1, dated 2/24/2026 at 11:37AM by V5 RN, documents the following: (R1) was sent to (local) Hospital for evaluation of facial and clavicle trauma.Ambulance Transport notes for R1, dated 2/24/2026 at 11:59AM, documents the following: Patient relayed that her face and neck are hurting. Hematoma (bruise) center of her forehead. Bruising above patients left ear. Left facial swelling and bruising. Dried blood noted on patients' teeth. Bruising noted on patients' anterior neck and left side. Bruising noted on patients left clavicle.Hospital Nursing Note for R1, dated 2/24/26 at 12:26PM by V4 RN, documents the following: Fall- Nursing home noticed some bruising in the face and dried blood in the mouth, dementia baseline, has bruising in different stages of healing, and pain with movement in face and neck. Bruising in the left clavicle.Hospital Note for R1, dated 2/24/26 at 12:26PM by V14 Physicians Assistant, documents the following: Dried blood in the oropharynx (mouth). Superficial abrasions are appreciated to the internal lips with a large laceration. Pain with palpation to the right elbow, right scapula, left clavicle, superior left orbit, left forehead, and midline cervical spine. Bruising most prominent to the right elbow, and right forearm with bruising consistent with thumb/finger as the cause. Ecchymosis (bruising) also noted to left clavicle, and anterior neck soft tissues. Large hematoma (lump) noted to the left forehead. Ecchymosis appreciated to the left upper orbit/eyelid.R1's hospital Cat Scan, dated 2/24/26 at 3:34PM, documents the following: The patient has pain with movement of the face and neck.On 2/25/2026 at 11:26 AM, V4 Hospital RN stated the following: V4 stated she was the nurse who was caring for R1 when R1 came into the emergency room. V4 stated R1 had a C-Collar (cervical collar) on, and it was on R1 in a manner that looked uncomfortable. V4 stated R1 had visible bruises on the top of her neck on the left side that was a triangle area of spotted bruise that was dark purple and red. R1 had a knot on her left forehead the size of a dime, and a knot on the left cheek the size of a quarter. R1's left arm had purple/red bruising.On 2/25/26 at 10:45AM, V2 RN DON/Director of Nursing stated (R1) had a cracked lip with dried blood on it. She had bruises on her face and chest. There was a full body assessment done by our wound nurse where she had bruising to her neck, numerous areas to her left arm, chest and face. The bruising appeared fresh where some of the bruising was not noticed at first, it was like it was just evolving. She transfers with (portable lifting machine).On 2/25/26 at 1PM, V1 Administrator stated she fired V6 CNA/Certified Nurse Aid for transferring R1 with (portable lifting machine) by herself. Their policy for the (portable lifting machine) is to transfer with two people. Our policy for lifts (portable lifting machine) are always for two people. They (staff) have had a lot of education on this and you are automatically fired because we have drilled this into them with training.On 2/25/26 at 1:45PM, V5 RN stated she works 6AM to 6:30PM, and verified she worked 2/24/26 and was R1's nurse. V5 stated she saw R1 when passing medications around 7:30AM when she was in the dining room. When V5 saw R1, R1 had dried blood on the left side of her lip and on her teeth. R1 told her it hurt to open her mouth, so she refused her medications that were crushed in pudding. I saw her raised bruised on her left cheek about the size of a quarter, and she had a raised bruise above her left eye about a dime size. The bruises were grey. She also had a knot on her forehead and a bruise on her left clavicle that was grey. I put ice on R1's left cheek and notified our (V2).On 2/26/25 at 1:20PM, V6 CNA returned a phone call and stated I worked on 2/24/26 and took care of (R1), and I was terminated this morning for transferring (R1) with a (portable lifting machine) with only one person. We are supposed to use two people with the (portable lifting machine) but I transfer by myself all the time because I don't like to ask for help. (R1) had bruising on her left neck. I transferred her into her wheelchair (manual).On 2/26/26 at 2:28PM, V3 CNA stated, I worked 2/24/26 during the day and I was on (R1's) right side and saw blood in her mouth when she was talking, it was fresh blood because it was not dried.On 2/26/26 at 1:45PM, V11 CNA stated I worked 2/24/26 and when I went into R1's) room, I saw blood first on her mouth and then saw the bump on her left cheek in the dining room around 7:30AM but I did not see it before when in her room. Her injuries look to be in line with a fall.On 2/26/26 at 2:30PM, facility video footage was viewed on V1 Administrator's computer in her office. The video dated 2/24/26 at 6:59AM was viewed and the following was observed: 6:59AM V6 is observed wheeling the (portable lifting machine) into R1's room; 7:01AM R1's door was closed; 7:07AM R1's door was opened; 7:10AM R1's door is slammed shut; 7:15AM R1's door opens and the (portable lifting machine) is put in the doorway of R1's room by V6 and V6 went out of R1's room; 7:17AM V6 went back into R1's room with V3 and V11 both CNA's; and 7:20AM R1's door opens and R1 is pushed down the hallway in her wheelchair by V6 CNA. At that same time, you can see on R1's left side of her cheek a red area.On 2/26/26 at 2:30PM, V2 RN DON stated (R1's) injuries are consistent with a fall. I am not sure why staff was not helping (V6 CNA) with (R1) because on the video it shows staff sitting down on their phone outside of the room and not helping. We are 99.99% sure (R1) was dropped by (V6 CNA) because her injuries on her left side are consistent with a fall.On 2/26/26 at 2:40PM, V13 R1's Physician and Medical Director stated (R1's) injuries are consistent with a fall where they are all on her left side.On 2/26/26 at 3:04PM, V7 RN Wound Nurse stated (R1) had fresh bruising to the left side of her forehead, face, neck, ear, eyebrow, shoulder front and back, and knuckles. It was light blue bruising, so it was fresh. (R1) is solid in her body and weight and when we transferred her out it took four of us to move her. It appears she fell or hit her face/body into the (portable lifting machine) frame.

Based on interview and record review, the facility failed to act quickly to get medical care for one (R1) of three residents reviewed for injuries in a sample of four. This failure resulted in R1 continuing to be in pain at the nursing home after an incident that caused facial and body bruising for four and a half hours before the emergency personnel were summoned to the nursing home.Findings include: Facility Change of Condition Policy and Procedure, undated, documents The Facility shall promptly notify the resident his/her attending physician of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or on-call physician when there has been: An accidents or incident involving the resident; A discovery of injuries of an unknown source; and A need to transfer the resident to a hospital /treatment center.Facility medical record for R1 documents R1 was sent to the (local) hospital on 2/24/26.Facility Nursing Note for R1, dated 2/24/2026 at 8:21AM by V5 RN/Registered Nurse, documents the following: This nurse observed (R1's) bruised and swollen area on her L cheek and dried blood on her teeth and L lip. It hurts her to open her mouth, and she was unable to take her medicine. There is a light bruise on her L clavicle and a small bruised know above her L eye. Ice applied to L cheek.Facility Nursing Note for R1, dated 2/24/2026 at 9:20AM by V4 RN Wound Nurse documents the following: Several bruises noted on assessment this morning per nursing staff. On assessment, this RN observed bruising to the resident's right anterior shoulder, left anterior shoulder, left lateral head, forehead, left eyelid, left eyebrow, left cheek, left inner ear, left jaw, anterior neck, left upper chest, right dorsal hand, left 1st knuckle, left medial wrist, and top lip.Facility Nursing Note for R1, dated 2/24/2026 at 11:37AM by V5 RN, documents the following: Per (V13 R1's Physician) physician order, (R1) is to be sent to (local) Hospital for evaluation of facial and clavicle trauma.Ambulance Transport notes for R1, dated 2/24/2026 at 11:59AM, documents the following: Patient relayed that her face and neck are hurting. Hematoma (bruise) center of her forehead. Bruising above patients left ear. Left facial swelling and bruising. Dried blood noted on patients' teeth. Bruising noted on patients' anterior neck and left side. Bruising noted on patients left clavicle.R1's hospital record, dated 2/24/26 at 12:26PM by V4 RN, documents Fall (Nursing home) noticed some bruising in the face and dried blood in the mouth and pain with movement in face and neck.On 2/25/26 at 1:45PM, V5 RN/Registered Nurse stated she took care of R1 on 2/24/26 from 6AM to 6:30PM. Stated she saw her when passing medications around 7:30AM when she was in the dining room. When she saw R1 she was in the dining room and had dried blood on the left side of her lip and on her teeth; and R1 told her it hurt to open her mouth, so she refused her medications that were crushed in pudding. (V11) Certified Nurse Aid/CNA had asked me about 7AM if I had seen (R1's) cheek and I told her I had not. I saw her raised bruised left cheek about the size of a quarter; and she had a raised bruise above her left eye about a dime size. The bruises were grey. She also had a knot on her forehead and a bruise to her left clavicle that was grey. I put ice on R1's left cheek and notified (V2) RN DON/Director of Nursing. Then (V2) spoke to (V13/R1's) doctor to get the order to send her out. I did not send R1 out right away, there was a delay in her going to the hospital, and she was sent out about lunch time (noon).

Based on interview and record review the facility failed to ensure that a resident received adequate supervision and dietary management to prevent a choking incident for one of three residents (R2) reviewed for choking in the sample of six. These failures resulted in the resident (R2) consuming food inconsistent with his prescribed mechanical soft diet, leading to a fatal choking event at the facility.These failures resulted in an Immediate Jeopardy that began on 7/23/25. While the Immediate Jeopardy was removed on 12/17/25, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits.Findings include: The facility's undated policy titled Food Brought in by Visitors documents that visitors must notify nursing staff prior to providing outside food to a resident. The policy further documents that nursing staff are responsible for confirming whether the food complies with the resident's prescribed diet, allergies, and swallowing precautions.R2's census record documents R2 was admitted to the facility on [DATE].R2's Minimum Data Set (MDS) dated [DATE] documents R2 was cognitively impaired.R2's Hospital After Visit Summary dated 7/23/2025 documents diet instructions of soft-to-digest foods, one-on-one feeding assistance, and aspiration precautions.R2's Physician Orders dated 7/23/2025 documents R2 was admitted with a general diet with regular texture and consistency. This diet order remained unchanged through 10/15/25, the date of R2's death.R2's Care Plan dated 7/23/2025 (R2's Admission) through 10/15/2025 (R2's Death) revealed no documentation identifying R2 as an aspiration risk. The Care Plan did not include documentation that R2 was on a mechanical soft diet or that R2 required staff observation while eating. Additionally, the Care Plan lacked documentation R2 was non-compliant with dietary restrictions and that education had been provided to R2 or family members regarding R2's diet restrictions.R2's Nurse Progress Notes dated 7/23/2025 (R2's Admission) through 10/15/25 (R2's Death) revealed no documentation that staff educated R2's family regarding R2's dietary needs, including permitted or prohibited food items related to swallowing precautions.R2's Nurse Progress Note dated 10/15/2025 by V5 (Wound Nurse) documents, At approx. (approximately) 1840 (6:40 PM) CNA (Certified Nursing Assistant) yelled out that the resident (R2) was choking. All nursing staff present to initiate [NAME] maneuver process. Resident(R2) was sitting in his wheelchair, when nursing staff arrived, the resident appeared bent down, cyanotic, unresponsive with his mouth full of food. 911 called, resident (R2) assisted to the ground; faint pulse verified; CPR (Cardio-Pulmonary Resuscitation) measures initiated by nursing staff. (POA/Power of Attorney/V4) present and stated she had brought the resident a roast beef sandwich from (brand name food chain restaurant.) POA (V4) stated she knows the resident (R2) is on a mechanical soft diet. AMT (Advanced Medical Transport) on scene at approx. 1847(6:47 PM) to take over medical care. AMT call to on-call MD (Medical Doctor) advised medical personnel to stop CPR. Coroner notified at 1855 (6:55PM). Coroner arrived at 2050 (10:50PM). POA (V4) present with expired resident (R2) until Funeral Home arrival per Coroner at 2130 (11:30 PM). Coroner stated there will be no autopsy done due to unnatural death and the Funeral Home will sign certificate. On call notified. Administrator (V1) notified. MD notified.On 12/15/2025 at 11:30 AM, V4 (R2's Family Member) stated V4 brought food to R2 weekly, including a roast beef sandwich and a soda. V4 stated facility staff were aware she brought food weekly and never informed her it conflicted with R2's diet. V4 stated that on 10/15/25, an unknown nurse assisted V4 in carrying the food to R2's room and told R2 she would return later to take him outside to smoke. V4 stated the unknown nurse observed V4 placing sauce on the sandwich and told R2, I'll be back. V4 stated R2 took several bites, appeared to struggle, and V4 instructed R2 to slow down and drink. V4 stated R2's eyes became wide, he crushed the cup in his hand, and V4 yelled for help. V4 stated staff immediately responded and initiated emergency interventions. V4 stated staff asked who brought the roast beef sandwich, and V4 informed them she brought food weekly to R2. V4 stated staff then informed her R2 was on a mechanical soft diet and should not have eaten the sandwich. V4 further stated R2 had difficulty communicating as R2 had garbled speech and was confused, so R2 would have not been aware of any dietary restrictions or could communicate that with V4.On 12/15/2025 at 11:00 AM, V3 (Registered Nurse) stated that on 10/15/25 V4 arrived at the facility with a container V3 believed contained soda. She stated V4 had concealed a folded (fast food restaurant) bag inside the container and stated V4 frequently brought food and snacks to R2. V3 stated R2 was a very fast eater and drinker and would consume food and beverages quickly. V3 stated V4 went into R2's room and V3 left the room. V3 stated that approximately five minutes later, an unknown CNA (Certified Nursing assistant) began yelling that R2 was choking. V3 and V5 (Wound Nurse) initiated the Heimlich maneuver. V3 stated R2 began turning blue, at which point staff assisted R2 to the floor and initiated CPR (Cardiopulmonary Resuscitation) until emergency medical services arrived. V3 stated staff performed repeated mouth checks in attempts to clear R2's airway but were unsuccessful.On 12/15/2025 at 11:10 AM, V5 (Wound Nurse) stated that on 10/15/25 V5 arrived at the facility at the start of her shift and heard an unknown CNA yelling that someone was choking. V5 stated she went down the hallway and observed R2 sitting in his wheelchair while staff attempted the Heimlich maneuver. V5 stated R2 turned blue, and staff were unable to locate a pulse, at which time R2 was assisted to the floor and CPR was initiated. V5 stated R2's family member stood in the room during the incident and did not speak. V5 stated an unidentified CNA reported that R2 had choked on a roast beef sandwich.On 12/16/2025 at 11:15 AM, V6 (Dietary Manager) stated that when a resident admits to the facility the nurse fills out a diet slip and gives to V6, so she knows what diet is ordered and then she makes out a diet card for staff to know what meals to serve. V6 stated that R2 was a Mechanical Soft Diet upon admission and during R2's stay at the facility. V6 stated R2 ate in dining room and would eat very fast. V6 verified that R2's Physician orders and Care plan does not match what R2 was being served at the facility and that the only communication V6 was given is that R2 was a mechanical soft diet. On 12/16/2025 at 12:00 PM, V2 (Director of Nursing) stated she never spoke with R2's family during his stay. V2 stated R2 was on a mechanical soft diet and acknowledged it was her error that the physician order was entered incorrectly by V2 on admission. V2 stated R2's aspiration risk and diet should have been included in the care plan and V2 was unaware they were not.On 12/16/2025 at 12:20 PM, V7 (Care Plan Coordinator/MDS) stated dietary care plans are entered by V6 Dietary Manager. V7 stated she relied on the diet order entered in the computer and did not review hospital discharge instructions. V7 stated she never spoke with R2's family regarding R2's diet. V7 stated staff informed her that R2's family brought snacks and fast-food weekly.On 12/16/2025 at 12:40 PM, V8 (Certified Nursing Assistant) stated R2's sister typically came to the facility on second shift, so V8 did not see V4 often. V8 stated R2 was on a mechanical soft diet, however R2 had a bin of snacks in his room that included items such as pretzels, prepackaged breakfast pastries, crackers and soda. V1 (Administrator) was notified of the Immediate Jeopardy on 12/17/2025 at 9:05 AM.The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy:1.R2 is no longer at risk for the alleged deficiencies. R2 expired on 10/15/2025. 2.On 12/17/2025 V2 initiated daily Nursing Huddles to review resident diets and any residents requiring one on one supervision during meals. On 12/17/2025 V17 notified all families of residents of the facilities policy on visitors bringing in outside food as well as what the residents diet restrictions are.3.On 12/17/2025 V2 and V6 completed an audit of all residents' diet orders.4.All resident dietary cards were reviewed and verified by the Dietary Manager and the Director of Nursing on 12/17/2025. 5. The front desk personnel have been in-serviced regarding food that is delivered, or that comes into the facility from friends or family on 12/17/2025 by ADON. The front desk staff must stop the family member or delivery services and notify the nurse in charge of the resident receiving the food, informing that nurse that outside food had been delivered. The nurse will then review the food and ensure that all the items are consistent with resident dietary orders/restrictions6.The IDT (Inter-Disciplinary Team) reviewed the policy on food brought in by visitors and implemented modifications to the policy to address the new review process on 12/17/20257. A mandatory all-staff training was initiated by V19 (Assistant Director of Nursing) on 12/17/2025 to review the revised Policy on food brought in by visitors and resident diets/ restrictions. All staff members were in serviced before start of next shift.8. On 12/17/2025, a copy of the revised policy on food brought in by visitors was mailed by V18 (Social Services Director) to all resident responsible parties/families.9. The new policy on food brought in by visitors has been added to the new admission pack on 12/17/2025 by V18. Completion Date 12/17/2025

Based on observation, interview, and record review, the facility failed to date multi-use medications upon opening, discard expired medications, and double lock controlled substances for seven residents (R7, R8, R9, R10, R11, R12, R13) reviewed for medication storage in a sample of 13. Findings Include:The facility's Storage of Medications policy (not dated) documents, No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with our established procedures governing the destruction of medication. 14. All controlled substances must be stored under double lock and key.The facility's Labeling of Drugs and Medications policy (not dated) documents, All drugs and biologicals must be properly labeled and legible at all times. 11. f. Other as appropriate or necessary.On 12/15/2025 at 11:00 AM, a facility medication cart contained: R7's opened Lantus vial with no documented date of when it was opened; R8's opened insulin garlgine vial with no documented date of when it was opened. R8's insulin garlgine had also expired on 12/12/2025; R8's Latanoprost Ophthalmic eye solution that expired on 10/28/2025; R8's opened insulin aspart vial with no documented date of when it was opened; R9's Breo Ellipta inhaler that expired on 10/28/2025. On 12/15/2025 at 11:15 AM, a facility's medication room contained an unlocked refrigerator. The refrigerator contained drawers to store controlled substances. Each of the drawers were not locked. R9's lorazepam 0.5 mg (milligrams) IM (intramuscular) (Schedule IV) was in the unlocked drawer. On 12/15/2025 at 11:15 AM, V3(Registered Nurse) confirmed the refrigerator drawers were unlocked and contained R9's lorazepam. V3 also confirmed R7 and R8's medications in the medication cart were opened without a documented opened date, and they should have been labeled with an opened date. V3 also confirmed R8 and R9's expired medications should have been discarded.On 12/15/2025 at 11:30 AM, a facility medication cart contained: R10's opened bottle of levetiracetam liquid with no documented date of when it was opened; R11's Anro Ellipta inhaler that expired on 10/25/2025; R12's Anro Ellipta inhaler that expired on 10/25/2025; R13's Breo Ellipta inhaler that expired on 11/22/2025; R8's Basaglar KwikPen that expired on 10/3/2025.On 12/15/2025 at 11:45 AM, V11 (Registered Nurse) confirmed R10's medication was opened without an opened date documented. V11 also confirmed R8, R11, R12, and R13's medications were expired medications, and they should have been discarded.On 12/22/2025 at 1:30 PM, V2 (Director of Nursing) confirmed all multi use medications need to be labeled with a date they were opened, and all expired medications need to be discarded correctly. V2 also confirmed all controlled substances should be double locked.

Based on interview and record review the facility failed to follow Registered Dietician recommendations to obtain weekly weights to monitor for and prevent further weight loss for one (R1) of four residents reviewed for nutrition in a sample of six. Findings include:R1's Care Plan, dated 12/22/2025 documents, R1 has had a significant weight loss 6.1% (percent) in one month weight 153.3 lbs. (pounds), R1 eats 50% sometimes less. R1 will get up from table before completing his meals. R1's significant weight loss 10.7% (percent) in three out of six months (December 2024-March 2025).R1's Registered Dietician note dated 1/24/2025 documents, Weight on 12/16/2024, 163 lbs. (pounds), weight on 1/10/2025, 153 lbs. Weight change: weight loss of 10 lbs/6.1% (percent) in one month. Recommendation: weekly weight.R1's Weight Summary, dated 1/2025, documents R1's weight was only obtained once during the month of January on 1/10/2025 (153.3lbs (pounds)).R1's Registered Dietician note dated 2/26/2025 documents, Nutritional weight change note, weight 145.8 lbs. (pounds), more than 30-day weight of 1/10/2025: 153.3 lbs. (5% (percent) weight loss), Recommendation: continue weekly weights.R1's Weight Summary, dated 2/2025, documents R1's weight was only obtained once during the month of February on 2/19/2025 (145.8lbs).R1's Registered Dietician note dated 3/14/2025 documents, Nutritional weight change, recommendation: continue weekly weights X (times) four weeks.R1's Weight Summary, dated 3/2025, documents R1's weight was only obtained twice during the month of March on 3/13/2025 (156 lbs.) and 3/21/2025 (155 lbs.).R1's Registered Dietician note dated 4/3/2025 documents, Nutritional wound note, recommend continuing recording weekly weights X four weeks.R1's Weight Summary, dated 4/2025, documents R1's weight was only obtained once during the month of April on 4/5/2025 (153 lbs.).On 12/17/2025 at 1 PM, both V8 and V16 (Certified Nurse Assistants) stated they thought R1 was only monthly weights. They have not obtained weekly weights on R1 because they were not aware R1 was on weekly weights.On 12/17/2025 at 1:15 PM, V11 (Registered Nurse) confirmed weekly weights were not performed on R1. V11 stated she was not aware he needed them weekly.On 12/17/2025 at 11:38 AM, V12 (Registered Dietician) confirmed she puts her recommendations in dietary notes, nursing staff is to refer to notes and place orders per medical doctor. V12 stated she recommended R1 to be on weekly weights due to his significant weight loss to monitor his weight loss or gain.

Based on interview and record review the facility failed to follow Physician ordered wound treatments and implement Registered Dietician recommendations for wound healing for one (R1) of three residents reviewed for pressure ulcers in a sample of 13. Finding Include:The facility's Physician's Order Policy (not dated) documents, The purpose of this policy is to establish guidelines for the ordering, processing, and management of physician's orders in a long-term care facility, ensuring compliance with State and Federal regulations, and promoting the health and safety of residents. Order implementation, orders must be implemented promptly by licensed nursing staff according to the facility's protocols. The facility's Pressure Ulcer Preventive Measures policy (not dated) documents, Residents at risk for the development of pressure ulcers receive interventions to reduce the risk of pressure ulcers. Procedure: 26. Maintain adequate intake of protein, calories, and fluids by offering support with eating. 27. Provide nutritional support and/or food supplements (protein, calories, vitamin C, and zinc) for nutritionally compromised residents. R1's Wound Physicians note, dated 2/12/2025, documents, Stage three pressure wound of the right, lateral foot. Wound size: 2.5 cm (centimeters) x 4 cm x not measurable, depth is unmeasurable due to presence of nonviable tissue and necrosis. Procedure note, surgically excised 10 cm of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm (centimeters). R1's Wound Physicians note, dated 2/19/2025, documents, Stage three pressure wound of the right lateral foot, wound size, 2 cm x 1 cm x not measurable due to presence of nonviable tissue and necrosis. Procedure note, surgically excised 1.4 cm of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm. R1's Wound Physicians note, dated 2/26/2025, documents, Stage four pressure wound of the right lateral foot, wound size, 2.2 cm x 1.5 cm x not measurable due to presence of nonviable necrosis. Procedure note, surgically excised 2.31 cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.6 cm. R1's Wound Physicians note, dated 3/12/2025, documents, Stage four pressure wound of the right lateral foot, wound size 2 cm x 1.5 cm x not measurable due to presence of nonviable tissue and necrosis. Procedure note, surgically excised 2.10 cm of devitalized tissue and necrotic muscle level tissue were removed at a depth of 0.7 cm. R1's Registered Dietician note, dated 3/14/2025, documents, Recommendation, 30 ml (milliliters) protein liquid BID (twice daily) x (times) 30 days (wound healing). R1's current medical record no documentation of facility addressing the Registered Dietician's recommendation on 3/14/25 of implementing protein liquid for wound healing. R1's Wound Physicians note, dated 3/19/2025, documents, Stage four pressure wound of the right lateral foot, wound size 2.3 cm x 1.5 cm x not measurable due to presence of nonviable tissue necrosis. Procedure note: surgically excised 2.42 cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.7 cm.R1's Wound Physicians note, dated 3/26/2025, documents, Stage four pressure wound of the right lateral foot, wound size 1.8 cm x 1.5 cm x not measurable due to presence of nonviable tissue and necrosis. Procedure note, surgically excised 1.89 cm of devitalized and necrotic muscle tissues were removed at a depth of 0.6 cm.R1's TAR (Treatment Administration Record), dated 3/1/2025-3/31/2025, has no documentation of R1's physician ordered wound care being performed on R1's right lateral foot three out of 31 days (3/9, 3/16, 3/23). R1's Registered Dietician note, dated 4/3/2025, documents, Recommendation, 30 ml protein liquid BID x 30 days (wound healing). R1's current medical record has no documentation of the facility implementing the Registered Dietician's recommendation on 4/3/25 of implementing protein liquid for wound healingR1's Wound Physicians note, dated 4/9/2025, documents, Stage four pressure wound of the right lateral foot, wound size 1.8 cm x 1.5 cm x not measurable due to presence of nonviable tissue and necrosis. Procedure note, surgically excised 1.62 cm of devitalized tissue and necrotic muscle level tissues were removed at a depth of 0.7 cm. R1's Treatment Administration Record, dated 4/1/2025-4/30/2025, has no documentation of R1's physician ordered wound care being performed on R1's right lateral foot two out of 30 days (4/2, 4/3).On 12/18/2025 at 2:01 PM, V2 (Director of Nursing) confirmed there was no documentation of R1's wound care being done on 3/9, 3/16, 3/23, 4/2, and 4/3/25. On 12/18/2025 at 2:00 PM, V1 (Administrator) confirmed days were missing on R1's TAR and stated, If it wasn't documented, it didn't happen. On 12/17/2025 at 2:00 PM, V14 (Wound Doctor) stated not following the Registered Dietician recommendation to give liquid protein, and not following the physician ordered wound treatments would most definitely contribute to R1's wounds worsening.

Based on interview and record review the facility failed to maintain an Infection Control log for June, July, August and September of 2025. This failure has the potential to affect all 69 residents residing in the facility.Findings include:The facility's Resident Roster dated 9/16/25 was provided by V1/Administrator and documents 69 residents reside in the facility at the time of the survey.The facility's undated Infection Control Protocol and Antibiotic Stewardship policy documents, The Infection Control Preventionist/Antibiotic Stewardship Leader will track all Facility Infections, monthly laboratory organism reporting . On 9/18/25, V2 Infection Preventionist and DON/Director of Nursing could not provide a complete list of residents currently on isolation precautions including Enhanced Barrier Precaution/EBP, Contact or Droplet isolation, or an Infection Control Log for June, July, August, or September 2025. On 9/16/25 at 2:45pm V2 stated she was the facility's Infection Preventionist and produced the certificate of completion of the Infection Prevention Program Training dated 2023.On 9/17/25 at approximately 3:00pm V2 stated, she did not have Infection Control and tracking Logs for the months of June, July, August, or September of this year. V2 stated she knew the monthly tracking logs should have been completed in accordance with the Infection Control and Prevention Protocol and Infection Preventionist's role.

Based on interview and record review, the facility failed to ensure weights were obtained and the physician was notified of weight gains per Physicians Order. The facility also failed to monitor weights for discrepancies for one of three residents (R19) with daily weights in a sample of 28. Findings include:The facility's Weight policy, revised 5/18/25, documents the purpose of this policy is to monitor the residents' weights, and track weight changes as they occur.The facility's Documentation Guidelines policy, revised 3/14/17, documents, Not documented, not done, and document facts.R19's Physician Order, dated 2/27/25, documents to weigh R19 daily related to R19's diagnosis of congestive heart failure and to notify the physician if R19's weight gain is greater than three pounds (lbs.) in a day or five pounds in a week.R19's Weight Summary, dated 6/1/25 to 9/17/25, has no documentation of R19's daily weights being obtained for 28 out of the 59 days during the time span of 6/1/25 through 9/15/25. R19's Weight Summary also documents daily weight gain fluctuations varying from 13.6 lbs to 36.9 lbs (6/21/25 through 6/22/25-36.9 lbs; 6/23/25 through 6/24/25-35.5 lbs; 7/10/25 through 7/11/25-32.6 lbs; 7/18/25 through 7/23/25 16.1 lbs; 8/22/25 through 8/23/25 13.6 lbs). R19's current medical record has no documentation of R19's physician being notified of R19's weight gains of more than three pounds in a day and/or five pounds in a week.On 9/18/25 at 2:40 PM, V7 (Care Plan Coordinator) confirmed R19's daily weights were not obtained as ordered, the physician was not notified of R19's gains of more than three pounds in a day or five pounds in a week per R19's physicians order, nor were R19's weights monitored for discrepancies.

Based on interview, observation, and record review the facility failed to initiate Enhanced Barrier Precautions for two residents (R66, R2) out of five residents reviewed in a total sample of 28. Findings include: The facility's undated Enhanced Barrier Policy documents, Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents at increased risk of MDRO (Multidrug-resistant organism) acquisition (e.g., residents with wounds or indwelling medical devices). 1. R2 was admitted on [DATE] with diagnoses of Encephalopathy, Lymphedema, Sepsis, Cellulitis Right lower Limb, Protein-Calorie Malnutrition and Failure to Thrive. R2's current Care Plan documents R2 has actual impairment to skin integrity of the (bilateral) legs related to lymphedema. R2's Hospital records documented on 8/24/25 R2 was admitted to the hospital from the facility with diagnoses of right lower leg cellulitis resulting in Sepsis (Life-threatening condition to an infection which can cause widespread inflammation, organ failure and/or blood clots.) R2 was treated with Intravenous Antibiotics, discharge back to the facility on 8/26/26 and continued oral antibiotics until 9/2/25. R2 Physician's Order dated 9/5/25 documents to cleanse pubis area with Normal Saline and pat dry, apply Hydrocolloid dressing every Monday, Wednesday and Friday and was last conducted on 9/17/25. R2's Progress Notes dated 9/10/25 documents R2 had a traumatic injury resulting in an acquired wound of the Pubis, documented measurements, continue with ordered dressing changes and on 9/17/25 R2 refused for the wound doctor to evaluate her continued wounds. Throughout the survey on 9/16/25 through 9/18/25, R2 did not have an Enhanced Barrier Precaution sign posted on her door or available Personal Protective Equipment (PPE) available for use. On 9/16/25 at 9:40 AM, V16 (Certified Nurse Aide/CNA) and V17 (CNA) were observed to transfer R2 from her bed to a reclining wheelchair via a mechanical lift. V16 and V17 did not don PPE during the mechanical lift. R2 had a Physician's Order for EBP initiated on 3/19/25 and discontinued on 7/1/25. The record lacked a current EBP order. The EBP log last updated 9/12/25 did not indicate R2 was on EBP. On 9/17/25 at 2:30 PM, V8 (Registered Nurse/Wound Nurse) confirmed R2 had a wound. On 9/18/25 at 1:00 PM, V2 (Director of Nursing/Infection Preventionist) stated residents with wounds should be placed in Enhanced Barrier Precautions and was unsure if R2 had an order for EBP or not. 2. R66's medical record documents R66 was admitted to the facility on [DATE] with the following diagnoses: Multiple Sclerosis, Gastrostomy, Heart Failure, and endocarditis. R66's Physician's orders dated 8/5/25 documents, Enhanced Barrier Precautions. On 9/17/25 at 11:41 AM V5 (Licensed Practical Nurse) performed hand hygiene and applied gloves. V5 assessed and gave water flush for R66's feeding tube. V5 confirmed R66 is on Enhanced Barrier Precautions (EBP). V5 then put gown on to finish R66's cares. On 9/17/25 at 12:40 PM V2 (Director of Nursing) provided R66's urine culture results dated 9/7/25. Culture results document, Vancomycin screen is positive. This is VRE (Vancomycin Resistant Enterococcus). On 9/17/25 at 12:45 PM V2 confirmed R66's culture results indicate VRE. V2 stated, I went ahead and placed R66 on contact isolation even though it is only two more days. On 09/18/2025 at 9:15 AM V2 stated a physician's order is placed in the EHR (Electronic Health Record) when a resident is placed on contact isolation. V2 confirmed there was not a physician's order in R66's chart for contact isolation at this time.

Based on observation and interview, the facility failed to maintain one resident's (R23) room in good repair of 24 residents' rooms observed during the initial tour for maintenance in a sample of 28. Findings include:R23 was admitted on [DATE] with a diagnosis of Malignant Neoplasm of the Right Lung.R23's Minimum Data Set (MDS) dated [DATE] documents R23 has a Brief Interview for Mental Status (BIMS) score of 14, no cognitive impairments.On 9/16/25 at 9:40 AM, R23's window ledge was broken off, had sharp hard edges and had exposed wood. Heat from the outdoors could be felt through the broken area.R23 stated she can feel the wind come through the window and the ledge had been broke since admission approximately nine months ago. R23 stated her room would get cold in the wintertime due to the broken window ledge.On 9/18/25 at 11:30 AM, V20 (Maintenance Director) stated he was unaware of R23's broken window ledge. V20 stated the residents' rooms had been renovated and windows had been replaced over the past year or so. V20 agreed housekeeping, nursing staff or any other employee that provided care to R23 should have identified and reported the broken window ledge.

Based on observation, interview, and record review the facility failed to adequately supervise a resident (R1) to prevent resident-to-resident physical abuse for five of five residents (R1-R5) reviewed for abuse in the sample of five. These failures resulted in R1 punching R2 in the left eye, causing a hematoma under R2's left eye and bruising surrounding R2's left eye, and R1 punching R5 in the right arm, causing R5 right arm pain for three days. Findings include: The facility's Abuse Prevention Program policy undated documents, Policy: The facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. This facility therefore prohibits mistreatment, neglect, or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect, or abuse of our residents. This will be done by: Establishing an environment that promotes resident sensitivity, resident security, and prevention of mistreatment and identifying occurrences and patterns of potential mistreatment. This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultations, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals. Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting in physical harm, pain, or mental anguish. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. 1. R1's admission Record documents R1 was a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Drug-Induced Subacute Dyskinesia, Schizoaffective Disorder Bipolar Type, Psychotic Disorder with Delusions, Anxiety Disorder, and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. R1's MDS (Minimum Data Set) assessment dated [DATE] documents R1 is severely cognitively impaired, displays physical symptoms directed towards other daily (e.g. (for example) hitting, kicking, pushing, scratching, grabbing, abusing others sexually), displays verbal behaviors directed towards others daily (e.g. threatening others, screaming at others, cursing at others) and wanders daily significantly intruding on the privacy or activities of others. R1's current Care Plan documents, (R1) has potential to be verbally and physically aggressive and resistive to cares. Poor impulse control. (R1) will physically fight when staff (are) trying to provide care. (R1) will attempt to physically hit (R1's) peers if they are not able to move out of (R1's) way when (R1) is trying to get by somewhere. (R1) has potential to be physically aggressive to other residents. (R1) displays anger, history of harm to others, and poor impulse control. R1's Progress Notes dated 3-3-25 and signed by V8 (LPN/Licensed Practical Nurse) document, (R1) started hitting on (R2), sitting in a wheelchair and minding (R2's) own business. (R1) started hitting on (R2) causing a hematoma to (the) left lower eye and a scratch to (R2's) left cheek. (R1) and (R2) both separated. (R1) started the incident who is dangerous to staff and other residents. (R1's) behavior is toxic to this facility. R1's Progress Notes dated 3-3-25 and signed by V9 (LPN) document, (R1) kicked and scratched (R3) which made (R3) bleed on (R3's) right upper arm. (R3) has about four scratches that are one cm (centimeter) long. R1's Progress Notes dated 3-16-25 and signed by V3 (RN/Registered Nurse) document, (R1) violent and aggressive towards staff and (R4). R1's Progress Notes dated 4-7-25 and signed by V3 (RN) document, (R1's) wheelchair got caught up with (R5's) wheelchair in the dining room. (R5) stuck her tongue out at (R1) and (R1) slapped (R5) on the right side of the neck. R1's Progress Notes dated 5-28-25 document R1 was admitted to the hospital for treatment of hypoglycemia. On 5-30-25 at 9:30 AM R1 remains in the hospital. 2. R2's admission Record documents R2 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Dementia without Behavior Disturbance, Visual Loss, and Difficulty Walking. R2's MDS assessment dated [DATE] documents R2 is severely cognitively impaired, has no behaviors, and is dependent on staff for ADL's. R2's Accident/Incident Report and Progress Notes dated 3-2-25 at 8:15 PM and signed by V8 (LPN) document, (R2) physically attacked by (R1) causing (R2) a left black eye and a small scratch on (R2's) left cheek and hematoma under (R2's) left eye. On 5-31-25 at 10:15 PM V11 (Agency LPN) stated, On 3-2-25 after suppertime I saw (R1) go up to (R2) and punch (R2) several times in the face. (R1) gave (R2) a black eye to the left eye and a knot (hematoma) under the left eye. (R2) is helpless and cannot defend herself. I got in between (R1) and (R2) and was able to take (R1) to her room. (R1) is very abusive and we (facility) staff never know when (R1) is going to get mad and hit someone. 3. R3's admission Record documents R3 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Hemiplegia and Hemiparesis affecting the right dominant side, Generalized Osteoarthritis, Rheumatoid Arthritis, Aphonia (total loss of voice), Anxiety Disorder, and Major Depressive Disorder. R3's MDS assessment dated [DATE] documents R3 is cognitively intact, has no behaviors, and is dependent on staff for ADL's. R3's Accident/Incident Report and Progress Notes dated 3-14-25 at 3:15 PM and signed by V10 (LPN) document, Observed Physical Assault/Altercation. This writer (V10) heard (R3) yell. (V10) walked around the corner and (R1) was swinging (R1's) arms and kicking (R3). After incident (R3) showed (V10) his arm and four skin tears were noted. On 5-30-25 at 11:00 AM R3 was sitting in his room in a wheelchair. R3 was non-verbal and communicated by pointing with his hands and writing on a piece of paper. V3 (RN) was in the room and helped this surveyor to interpret (R3's) handwriting. When this surveyor asked about the altercation between (R1 and R3), (R3) wrote the following on a piece of paper, (R1) is sick in the head. (R1) came up to me for no reason and punched me in both eyes. I tried to block (R1), but (R1) was able to hit me in the eyes. It was painful. When I tried to block (R1), (R1) scratched and pinched both my arms. That hurt worse than the hit to the eyes. When this surveyor asked (R3) if he felt abused by (R1), (R3) shook his head yes.: 4. R4's admission Record documents R4 is a [AGE] year-old admitted to the facility on [DATE] with the diagnoses of Major Depressive Disorder, Delusional Disorders, Mood Disorder, Dementia with Psychotic Disturbance, Visual hallucinations, and Alzheimer's Disease Early Onset. R4's current Care Plan documents R4 is currently receiving hospice services, is totally dependent on staff for ADLs, and is confused. R4's MDS assessment dated [DATE] documents R4 is severely cognitively impaired. R4's Accident/Incident Report and Progress Notes dated 3-16-25 at 12:40 PM and signed by V4 (RN) document, Observed Physical Assault/Altercation. Alleged altercation between another resident (R1) where (R4) was hit in the arm. No apparent injury. On 5-30-25 at 10:15 AM R4 was sitting in a high back fully padded wheelchair. R4 was pleasantly confused and unable to talk. R1 and R4's Witness Statement dated 3-16-25 and signed by V7 (CNA/Certified Nursing Assistant) documents, I was feeding, and I heard (V6/CNA) yelling stop. I (V7) looked up and (R1) was hitting (R4) on the head area and like chest area. On 5-30-25 at 10:35 AM V6 (CNA) stated, (R1) and (R4) were eating in the dining room. (R1) rolled up in her wheelchair to (R4) and (R1) was yelling and mad about something. (R1) punched (R4) in the right arm. I removed (R1) to her room. (R4) had no visible injuries. 5. R5's admission Record documents R5 is a [AGE] year-old that was admitted to the facility on [DATE] with the diagnoses of Adjustment Disorder with Depressed Mood, Insomnia, Vascular Dementia without Behavioral Disturbance, and Mood Disorder. R5's MDS assessment dated [DATE] documents R5 is cognitively intact and is dependent on staff for ADL's. R5's Accident/Incident Report and Progress Notes dated 4-7-25 at 7:45 AM and signed by V3 (Registered Nurse/RN) document, Observed Physical Assault/Altercation. (R5's) wheelchair got locked up with (R1's) wheelchair in the dining room. (R5) stuck her tongue out at (R1) and (R1) slapped (R5) on the right side of the neck. No apparent injury. On 5-30-25 at 11:00 AM R5 was sitting in a wheelchair in the dining room. R5 stated, (R1) hit me over a month ago. (R1's) wheelchair tire got hooked on my tire and (R1) got mad and hit me in the right arm three times. I was in pain for three days after that. I have arthritis all over. (R1) should not be able to hit me. That is abuse. On 5-30-25 at 2:00 PM V3 (RN) stated, (R1) is out of control and needs supervised by staff at all times. On 4-7-25 (R1) and (R5's) wheelchairs got locked together and (R1) hit (R5) for no reason. On 5-30-25 at 2:10 PM V1 (Administrator) stated, All of the altercations from R1 to R2, R3, R4, and R5 are physical abuse.

Based on observation, interview, and record review, the facility failed to ensure resident safety after a transfer and failed to keep a resident free from injury for one of three residents (R1) reviewed for accidents/injuries in a sample of four. This failure resulted in R1 sustaining pain, bruising and a hospital visit with fractures to the left ankle and foot. Findings include: The facility's undated Residents' Rights for People in Long-Term Care Facilities documents Your rights to safety: The facility must provide services to keep your physical and mental health, at their highest practical levels. The facility's Resident Accident/Incident Policy, revised 5/12/15, documents It is the Policy of (named facility) to provide a safe environment for all residents. We understand there will be a time when our best efforts will not be enough. Accidents will happen. Residents will fall. The facility's Fall Policy and Procedure, revised 1/2/19, documents It is the Policy of (named facility) to provide an environment conducive to reducing risk for falls. (Named facility) provides interventions to reduce risk factors for falling but cannot guarantee or maintain a fall-free environment. R1's current clinical record documents R1 is alert and oriented times three (person, place, and time), dependent on staff for all ADLs (Activities of Daily Living) except eating, utilizes a wheelchair, and has diagnoses including but not limited to Dementia with agitation, Peripheral Vertigo, Alzheimer's Disease, Hypertension, Congestive Heart Failure, Anxiety, and Muscle weakness (generalized). R1's Accident/Incident Report, dated, 2/28/25 at 6:15pm, documents R1 had an unobserved fall from a (reclining) wheelchair while in her room. R1's Progress note, dated 2/28/25, documents CNA (Certified Nursing Assistant/V8) notified staff that he went to get bed linens and when (V8) came back to room (R1) was on the floor lying on her side. On 3/26/25, at 1:14pm, R1 was resting in a (reclining) chair in her room. On 3/27/25, at 11:06am, V8 CNA stated I took (R1) to her room then went to the linen closet to put her to bed. When I came back, she had fallen out of the (reclining wheelchair). All four wheels were in the air. She was against the mattress which was leaning on the wall. R1's butt (buttocks) was on the foot pedal and rest of her body was up against the mattress against the wall. The chair fell forward. (R1's) (reclining chair) was in the upright position. I think if I would have reclined it (the chair), I could have prevented it (R1's fall). R1's current Care plan documents R1 is totally dependent on staff for transferring and is at risk for falls related to decline in health. This Care plan includes an intervention dated 2/12/25 for nursing staff to ensure R1's (reclining)wheelchair is reclined when sitting in (reclining) wheelchair and not eating. R1's Skin Tear/Bruise of Unknown Origin Investigation, dated 3/7/25 at 4:15pm, documents R1's left lower leg foot/ankle swollen and bruised. List of resident equipment in use: wheelchair/(reclining) wheelchair/mechanical lift. Internal Risk Factors identified as Mobility deficit or immobility, History of fall and partial falls, and restless behavior. R1's Unusual Occurrence Report Form, dated 3/7/25, documents R1 with complaints of pain to the bridge of her left foot. The bedside X-ray Results for R1, dated 3/7/25, documents there is an oblique fracture of the distal third of the fibula. Impression: Non articular fracture of the distal fibula. R1's Progress note, dated 3/8/25, documents Resident showing signs of excruciating pain and discomfort. Per Nursing judgement, this nurse made an educated decision to send resident out to ER (emergency room ) to be further evaluated. Resident agrees with treatment plan stating her 'foot hurts really bad.' The local hospital radiology report of R1's left ankle x-ray, dated 3/8/25, documents: History: Left ankle pain after falling out of chair. Impression: 1. Acute nondisplaced fracture of the distal fibula. 2. Acute displaced fracture of the fourth metatarsal neck. 3. Acute nondisplaced fractures of the base of the second and third metatarsals. R1's Hospital After Visit Summary, dated 3/8/25, documents Reason for Visit: Fall; Ankle Injury. The facility's Final Report to the State Agency for R1, dated 3/14/25, documents resident (R1) subsequently went out to hospital on 3/8/25 related to increased swelling observed by RN (Registered Nurse). Imaging showed the distal fibula fracture as well as several metatarsals. Resident (R1) returned to the facility with lower extremity in protective wrap. An appointment is scheduled with (Orthopedics) on the 17th of this month. An extensive investigation was complete per the Administrator with staff interviews and review of the cameras. On 3/27/25, at 2:10pm, R1 was transferred into bed via mechanical lift. Staff removed the splint/boot from her left foot/ankle. R1 was now lying in bed with a bandage noted to her left foot/ankle. At this time R1 stated the following: It happened when I was in a chair. I turned my head because I heard someone, I thought I knew. When I turned back, I fell to the right and out of my chair. My left foot hit the wall. It hurt. Four staff got me back up. It was a few days later that they sent me out to the hospital and found out it was fractured. On 3/28/25, at 1:50pm, V15 R1's Family Member stated When I asked (R1) how she hurt her foot she told me the same thing. She had said that she was in a chair, heard people talking to her, turned to look towards them and fell out of the chair. R1's Progress note, dated 3/10/25 and signed by V19 Nurse Practitioner/NP, documents INTERVAL HISTORY: Pt (patient) is up in her WC (wheelchair). She has some pain to her LLE (left lower extremity). Was noted to be sore, bruised and swollen. Did have an XR (x-ray) that showed: Closed left ankle fracture and multiple closed fractures on metatarsal bone of left foot. Splint in place and referred to podiatry. On 4/1/25, at 11:28am, V19 Nurse Practitioner/NP confirmed that (R1's) fracture is most likely from a previous fall. On 4/1/25, at 1:34pm, V2 Director of Nursing/DON stated, I was notified about (R1's) foot when (V15 R1's Family Member) came in and asked about it on Friday March 7th. I went to (R1's) room. I saw edema, significant bruising to ankle, top of foot and posterior aspect of foot/ankle. On 3/28/25, at 2:50pm, V1 Administrator confirmed that R1 did have a fall on 2/28/25 and confirmed R1's fractures to her ankle/foot. As of 3/28/25, R1's medical record did not document any further falls/accidents/incidents between R1's fall on 2/28/25 and 3/7/25.

Based on observation, interview and record review, the facility failed to perform hand hygiene and glove changes during pressure ulcer treatments. The facility also failed to ensure pressure ulcer treatments were completed as ordered. These failures effect three of three residents (R2, R3, R4) reviewed for pressure ulcers in a sample of four. Findings include: The facility's undated Wound Care policy documents Purpose: To provide guidelines for the care of wounds and soiled dressings to decrease the potential for nosocomial infections. Steps in the Procedure: 1. Wash your hands thoroughly before beginning the procedure. 11. Put on exam glove. Loosen tape and remove dressing. 12. Pull glove over dressing and discard into appropriate receptacle. Wash hands. 13. Put on disposable gloves. 14. Use no-touch technique. Use tongue blades and applicators to remove ointments and creams from their containers. 15. Pour liquid solutions directly on gauze sponges. 17. Cleanse wound with solution. 20. Dress wound. [NAME] tape with initials, time, and date and apply to dressing. 21. Pick up soiled items. Discard into designated container. Remove gloves and discard into trash bag/container. Wash hands. The facility's undated Using Gloves policy documents Purpose: To provide guidelines for the use of gloves. Objectives: 1. To prevent the spread of infection and disease to residents and employees; 2. To protect wounds from contamination. Miscellaneous: 1. When gloves are indicated, disposable single-use gloves should be worn .4. Nonsterile gloves should be used primarily to prevent the contamination of the employees' hands when providing treatment or services to the resident and when cleaning contaminated surfaces. 5. Wash hands after removing gloves. Gloves do not replace handwashing. The facility's undated Handwashing policy documents When to Wash Hands: 6. After handling used dressings, specimen containers, contaminated tissues, linen, etc. 8. After handling items or work surfaces potentially contaminated with a resident's blood, excretions, or secretions. 12. Upon completion of duty. The facility's undated Treatment of Pressure Ulcers (Bedsores) policy documents Purpose: The purpose of this procedure is to provide guidelines for the treatment of pressure ulcers to facilitate healing. This policy includes to 19. Dress the pressure sore with the prescribed dressing. The facility's undated Physician's Order Policy documents Purpose: The purpose of this policy is to establish guidelines for the ordering, processing, and management of physician orders in a long-term care facility, ensuring compliance with State and Federal regulations, and promoting the health and safety of residents. Procedures: 3. Order Implementation - All medications and treatments shall be administered as per the orders, with documentation in the resident's medical record. 1. R2's Wound Evaluation and Management Summary, dated 3/19/25, documents R2 has a Stage II p/u (pressure ulcer) to right buttock measuring 7 x (by) 4 x 0.1cm/centimeters; Stage III left buttock measuring 2 x 1 x 0.1cm; and Stage III p/u to coccyx measuring 2 x 1 x 0.2cm. R2's current Physician Order Sheet/POS documents Right Buttocks, Left Buttocks and Coccyx - cleanse with normal saline solution, apply hydrocolloid 3 times per week, Monday, Wednesday, Friday on Day Shift every day. R2's current Physician Order Sheet/POS documents an order for Right Buttocks - cleanse with Normal saline solution and apply hydrocolloid three times per week, on Day Shift every Monday, Wednesday, Friday; Start Date: 2/28/25. D/C (Discontinue Date): 3/20/25. R2's March 2025 Treatment Administration Record/TAR documents this treatment was not completed on Friday 3/7/25. On 3/26/25, at 11:04am, R2 is sitting in a wheelchair in her room. V4 Registered Nurse/RN/Wound nurse prepared supplies of Normal Saline/NS and a hydrocolloid dressing to perform wound care on R2's coccyx. V4 donned gloves and gown. R2 stood up while V4 removed R2's dressing soiled with light serosanguinous drainage. R2's buttocks and coccyx had pink open areas with exposed dermis and granulation noted. With the same soiled gloves V4 RN cleansed the wound with saline soaked gauze and applied the hydrocolloid dressing. V4 removed gown/gloves, left R2's room, then used hand sanitizer out in hall and walked into R3's room to perform wound care. V4 did not perform hand washing. On 4/1/25, at 1:34pm, V2 Director of Nursing/DON stated There was a concern brought to (V4 Wound Nurse) after a weekend about a wound not being dressed. This was for (R2). I discussed with the nurses about orders and supplies and that we had both. Not sure what happened. One of the nurses, an agency nurse (V22 RN) indicated she didn't know what the treatment was. It is inappropriate to miss a treatment. They are in the residents' records. 2. R3's Wound Evaluation and Management Summary, dated 3/26/25, documents R3 has a Stage IV pressure wound of the right lateral foot (1.8 x 1.5 x not measurable cm/centimeters) and a Diabetic wound of the right distal first toe (2.5 x 3.5 x not measurable cm). R3's current POS documents Right Lateral Foot and Right Foot First Digit - cleanse areas with Normal saline solution and apply calcium alginate with silver cover with bordered gauze on Day Shift every day. On 3/26/25, at 11:15am, R3 is lying in bed. V4 RN/wound nurse prepared supplies of Normal Saline/NS, Calcium alginate with silver and bordered gauze to change the dressing on R3's right lateral foot. V5 RN assisted. V4 donned gloves and gown. With gloved hands V5 RN removed the outer bordered gauze. V4 RN removed the calcium with silver dressing which was soiled with moderate serosanguinous drainage. R3 had an open area with necrotic tissue to his right lateral foot. With the same soiled gloves V4 cleansed the wound with saline soaked gauze, applied the Calcium with silver dressing, then applied an outer bordered gauze dressing. V4 RN changed gloves without any hand sanitizing then performed the same physician ordered treatment in the same manner to R3's diabetic wound of the right first toe. V4 RN removed gown/gloves, left R3's room, then used hand sanitizer out in hall and walked into R4's room to perform wound care. V4 did not perform hand washing. 3. R4's Wound Evaluation and Management Summary, dated 3/26/25, documents R4 has a non-pressure wound of the left anterior knee; etiology trauma/injury (1.8 x 1.5 x not measurable cm/centimeters) and Stage IV pressure wound of the left lateral ankle (1.5 x 1.5 x not measurable cm). R4's current Physician Order Sheet/POS documents Left Ankle and Left Knee - cleanse area with Normal saline solution and apply hydrocolloid every three days on Day Shift. On 3/26/25, at 11:25am, R4 was lying supine in bed. V4 RN gathered supplies of Normal Saline and a hydrocolloid dressing to perform wound care on R4's left ankle and knee. V4 donned gloves and a gown then removed R4's dressing from his left knee that was soiled with moderate serosanguinous drainage. V4 stated it is abscess drainage. With the same soiled gloves, V4 RN cleansed the open wound with saline soaked gauze and applied the hydrocolloid dressing to R4's left knee. V4 removed her gloves then donned a new pair of gloves without sanitizing in between glove change. V4 RN removed the dressing from R4's left ankle which was soiled with light serosanguinous drainage. With the same soiled gloves, V4 cleansed the open wound with saline soaked gauze and placed a hydrocolloid dressing over it. V4 RN removed her gloves, left R4's room and used hand sanitizer out in the hallway. V4 RN did not perform hand washing. On 3/26/25, at 11:35am, V4 RN/Wound nurse stated that she does not use hand sanitizer in between glove changes if her hands are clean. V4 stated that she should have changed her gloves after the dirty task and before going to clean. V4 confirmed V4 should have also changed gloves after cleansing the wound. V4 stated Normally I wash my hands, use hand sanitizer before and after then wash my hands after that since my hands get sticky and break out from the hand sanitizer. I did not do that. I was trying to hurry for you. On 4/1/25, at 1:34pm, V2 Director of Nursing/DON stated that during wound treatments nurses are to change gloves after removing old dressing, put new gloves on, cleanse the wound then put new gloves on before putting new dressing on. Should use hand sanitizer between glove changes and wash hands in between residents.

Based on observation, interview, and record review, the facility failed to transfer a resident with the required mechanical lift, for one of three residents (R1) reviewed for falls in a sample of 3. This failure resulted in R1 falling twice and during the second fall sustaining a periprosthetic distal left femur fracture, ongoing pain, and psychosocial fear of being transferred with a mechanical lift. FINDINGS INCLUDE: The facility policy, Fall Policy and Procedure directs staff, It is the policy of (the facility) to provide an environment conducive to reducing risk for falls. (The facility) provides interventions to reduce risk factors for falling .Should the resident be observed sitting on the floor or being assisted by staff to sit down on the floor, the nurse will be notified and a fall report will be completed R1's current facility Face Sheet documents that R1 was admitted to the facility on [DATE] after a fall with a Left Hip Fracture. This same form includes the following diagnoses: Cerebral Palsy, Blindness of One Eye, History of Cerebral Infarction, Paraplegia, Depression with Psychotic Features and Anxiety. R1's (current) Care Plan, dated 6/16/2023 includes the following Focus Areas: (R1) is at risk for falls related to history of cerebral palsy, left hip fracture and left-sided paraplegia. Also included are the following Interventions: Transfers: (R1) requires extensive assistance by two staff to move between surfaces using a (mechanical) lift. R1's Minimum Data Set Assessment, dated 11/14/2024 documents, ADL's (Activities of Daily Living): Impairment on one side of lower extremity; requires use of wheel chair; requires substantial/max (maximum) assistance for bathing, dressing, and bed mobility and is dependent for all transfers. Requires extensive assistance of 2 staff members and (mechanical) lift for all transfers. R1's Fall Risk Evaluation, dated 11/24/2024 documents, One to two falls past 3 months, Intermittent confusion, Chairbound/Incontinent, 1-2 Predisposing Diseases, Gait/Balance- not able to perform function and Takes 1-2 (High Risk) Medications. Risk For Falls: (R1) is at risk for falls. R1's Nursing Progress Notes, dated 1/9/2025 at 3:51 P.M. document, CNA (Certified Nursing Assistant) was behind (R1) holding (R1) at the shower bar while attempting to transfer from (R1's) w/c (wheelchair) to the shower chair, for a shower. (R1) thought her phone had fell out of her belongings onto the floor and turned around suddenly and fell on her buttocks. No apparent injury. The facility Fall Investigation form, dated 1/9/2025 documents,(V5/Certified Nursing Assistant) was behind (R1) holding her while (R1) held shower bar. (R1) jerked around and fell on her buttocks. Recommendations/Interventions: Staff Member (V5/Certified Nursing Assistant) was educated on (correct) transfer for (R1) and the use of a shower bed. R1's Nursing Progress Notes, dated 1/24/2025 at 3:48 P.M. document, This Nurse (V4/Registered Nurse) had a conversation with (V6/Certified Nursing Assistant) (who) stated (R1) only told me her leg hurt and that (R1) didn't didn't know why. (V6/Certified Nursing Assistant) stated I transferred (R1) and (R1) started shaking and buckled and I lowered (R1) to the floor. There was no fall, I lowered (R1) to the floor. R1's Nursing Progress Notes, dated 1/24/2025 at 4:00 P.M. document, Certified Nursing Assistant came to Nurses' Desk and (stated) (R1) needed something for pain. (Nurse) went to (R1's) room and asked (R1) what was wrong and what hurt. (R1) stated her L (left) upper thigh hurt. (I) asked (R1) what type of pain, aching, sharp and (R1) replied deep aching. (Nurse) gave (R1) (Acetaminophen) (Analgesic) at (3:50 P.M.). R1's Nursing Progress Notes, dated 1/24/2025 at 6:41 (P.M.) document, Upon coming on shift, (V4/Registered Nurse) reported that (V6/Certified Nursing Assistant/CNA) had lowered (R1) to the floor. CNA indicated that (R1) is complaining of pain in the left leg, describing it as excruciating. (R1) also stated that she is unable to move her left leg. Upon assessment, the nurse observed swelling to (R1's) right ankle. The physician has been notified of the situation. R1's Nursing Progress Notes, dated 1/24/2025 at 6:56 P.M. document, MD (Medical Doctor) states send (R1) to the ER (emergency room ). (R1) to be further evaluated. The facility Fall Investigation form, dated 1/24/2025 documents, (R1) stated her left thigh hurt and she didn't know why and (R1) had pain when nurse tried to lift her leg. Later, (V6/CNA) stated she transferred (R1) and (R1) began shaking and buckled and (V6) lowered (R1) to the floor. Recommendations/Interventions: (V6) was disciplined and all the other staff will be inserviced to use (mechanical) lift only with (R1). R1's (hospital) History and Physical documents, admitted : 1/25/25. (R1) with past medical history for depression with anxiety, seizure disorder, and left-sided hemiplegia due to cerebral palsy who presented to the hospital after a fall at (facility). (R1) was reportedly being transferred by the staff when (R1) was dropped, landing on her left side. Imaging in the ED (Emergency Department) showed questionable left hip injury as well as a distal periprosthetic femur fracture on the left. (R1) reports significant discomfort in her left leg at this time, more in the distal thigh but has some pain in the hip. ASSESSMENT AND PLAN: Closed fracture of distal end of femur. Orthopedic surgery has been consulted. On 2/10/2025 at 10:45 A.M., R1 was seated in a wheel chair in the (facility) Dining/Activity Room with other residents, at a table for coffee and donuts. (R1) recalls falling two times, once when staff dropped me. R1 becomes visibly upset, crying when talking of incident. Repeats over and over, I hurt. I'm afraid of the lift. Refused to answer further questions surrounding incidents. On 2/10/2025 at 10:59 A.M., V4/Registered Nurse (RN) stated, I have been a nurse here for the past ten years and three weeks. (R1) had a history of a previous fall with a fracture, left-sided paraplegia, and a history of cerebral palsy. (R1) was supposed to be a two person, lift for all transfers. V6/Certified Nursing Assistant (CNA) came to me and asked if (R1) had anything for pain. (V6/CNA) said (R1's) leg hurt. I went to see (R1) and she told me that (V6/CNA) had dropped her and hurt her leg. When I questioned (V6/CNA), she told me she was transferring (R1) by herself from the bed to (R1's) wheelchair and (R1's) leg buckled and (V6/CNA) lowered (R1) to the floor. (V6/CNA) kept repeating that she only lowered (R1) to the floor. I didn't do a fall report right away, call the doctor, or R1's family or the DON (V2/Director of Nurses). I didn't consider it a fall. It wasn't until later that (V2/DON) told all of us that even when you lower someone to the floor, it's considered a fall. (R1) has always been a (mechanical) lift for all transfers. (V6/CNA) should not have been trying to transfer (R1) by herself. On 2/10/2025 at 12:25 P.M., V3/Care Plan Coordinator stated she was responsible for all the facility fall investigations. States (R1) is at risk for falls due to history of CP (Cerebral Palsy), paraplegia and blindness to (the) left side and history of falls with a fracture. States (R1) does not stand and has been a (mechanical) lift for the past two years. States facility policy is for all mechanical lift transfers to be performed with two staff members present. States (R1's) care plan addressed (R1's) interventions including the use of a mechanical lift for all transfers. States (R1's) facility care cards, addressed (R1's) need for a mechanical lift for all transfers. States care cards are used to inform the CNAs (Certified Nursing Assistants) what specific care each resident requires. States she investigated both of (R1's) falls in January. States on 1/9/25 at 3:00 PM, (V5/CNA) was attempting to transfer (R1) by herself, without using a mechanical lift, from (R1's) wheel chair to a shower chair. Confirmed that (R1) fell on her buttocks. States (V5/CNA) was educated on the need to use a mechanical lift to transfer (R1) from her wheelchair onto the facility shower bed, for (R1) to receive a shower. Also confirms that (R1) fell again on 1/24/25 at 3:40 PM when (V6/CNA) transferred (R1) by herself, without the use of a mechanical lift from (R1's) bed to (R1's) wheelchair, when (R1's) leg gave out and she lowered (R1) to the floor. States (V6/CNA) was disciplined for failure to use a mechanical lift and another staff assistance for all of (R1's) transfers and all other nursing staff were educated on the need to use a mechanical lift to transfer (R1). On 2/10/2025 at 1:12 P.M., V5/Certified Nursing Assistant (CNA) confirmed on 1/9/25 she attempted to transfer (R1) from the wheelchair to a shower chair, while in the shower room. (V5/CNA) states (R1) thought she had dropped her phone and turned around suddenly to look for it and fell on to (R1's) buttocks. (V5/CNA) states she didn't know she was supposed to transfer (R1) at all times with a mechanical lift, states she hadn't worked with (R1) very often. On 2/10/2025 at 1:18 P.M., V6/Certified Nursing Assistant verified on 1/24/25 she attempted to transfer (R1) from the bed into (R1's) wheelchair, when (R1's) leg gave out and she lowered (R1) to the floor. (V6/CNA) states she wasn't aware she was supposed to transfer (R1) with a mechanical lift and additional staff assistance, at all times. On 2/10/2025 at 1:26 P.M., V7 and V8/Certified Nursing Assistants prepared to transfer (R1) from the wheelchair to bed for incontinence care via a mechanical lift. (R1) began yelling out and was tearful with any movement of her left leg.

Failures at this level required more than one deficient practice statement. A. Based on observation, interview, and record review the facility failed to conduct a resident assessment to determine the resident's degree of mobility, physical impairment and the proper transfer method needed once a resident experienced increased weakness. The facility also failed to maintain an adequate working electrical supply to adjust an electric bed into the lowest position prior to a transfer for one resident (R9) and failed to implement appropriate fall interventions for one resident (R8.) These failures affect two of three residents (R8, R9) reviewed for falls in the sample of 27. These failures resulted in R9 losing grip of the sit-to-stand mechanical lift handles and falling to the floor, sustaining a coccyx fracture and severe pain that required hospitalization . B. Based on observation, interview, and record review the facility failed to assess the smoking safety yearly for one of five residents (R40) reviewed for smoking in the sample of 27. Findings include: a.) The facility's Job Description for CNA's (Certified Nursing Assistants), undated, documents Illustrative Examples of Work: Care delivery to include, but not limited to: Bathing a minimum of two times weekly, daily oral hygiene, shaving, changing clothes, nail care, toileting feeding, ambulating, transferring, room care, hair care. Recognizing and reporting changes in condition to the nurse (example: health problems, eating problems, changes in skin or incontinence behavioral problems, unstable vital signs.) Maintain a safe environment for the residents and other staff. Follow safety practices (example: keeping resident areas hazard free, follow good body mechanics, wear proper footwear, use lifting devices according to manufacturer's directs, wear gait belt, etcetera.). General Employee Guidelines: Immediately report defective equipment, hazardous conditions, or supply shortages. The facility's Fall Policy and Procedure, dated 1/2/2019, documents It is the Policy of (the facility) to provide an environment conducive to reducing risk for falls. (The facility) provides interventions to reduce risk factors for filling but cannot guarantee or maintain a fall-free environment. The facility's Transfer Between Surfaces policy, dated 3/2000, documents Purpose: To improve or maintain the resident's self-performance in moving between surfaces or planes either with or without assistive devices. Procedure: 1. Explain and demonstrate procedure. 5. Bed should be flat and level with wheelchair seat. The facility's Fall Prevention Practice, dated 1/10/2016, documents Below is a list of things that can help reduce the risk for falls: 8. Report changes in mental status to nurse immediately. 1. R9's Admission Record documents R9 is a [AGE] year-old male admitted to (the facility) on 5/14/2012 with the following, but not limited to, diagnoses: Chronic Obstructive Pulmonary Disease, Difficulty in walking, Frontotemporal Neurocognitive Disorder, Dementia, Schizoaffective Disorder, Extrapyramidal and Movement Disorder, and Cerebral Infarction. R9's Minimum Data Set (MDS) assessment dated [DATE], documents R9 has severe cognitive impairment, and requires substantial assistance for activities of daily living, toileting, and transfers. R9's current Care Plan documents, (R9) has the potential for falls due to increased weakness. The facility's Maintenance Work Order dated 9/19/24 and signed by V7/CNA, documents R9's room had no electricity. R9's Progress Note, dated 9/19/24 and signed by V15/RN (Registered Nurse), documents (R9) was observed on the floor, lying on right side. Per two aides (Identified as V8/CNA (Certified Nursing Assistant) and (V9/CNA), they were attempting to get (R9) into bed. After a couple minutes, it was indicated that (R9) was to be moved back into chair due to the bed being unavailable for use. Throughout all of this, (R9) was in a mechanical stand lift and was already up at the highest position. Per (V8 and V9), (R9) began to drift down. (V8 and V9) stated that they pulled chair under (R9) but at that point (R9) was too low to get into his chair. Then (V8 and V9) stated that (R9) quickly slid through the straps due to him lifting his arms up, where (R9) then hit the floor at fast and unexpected speed where (V8 and V9) were unable to slowly lower (R9). Different reports of if (R9) hit head or not, so per the physician, we (the facility) called emergency services to send (R9) out to the emergency room to be evaluated due to nature of fall. Per (V8 and V9) (R9) was lethargic. No signs of lethargy when this nurse assessed (R9). During assessment, (R9) stated that he was in extreme pain on right side of arm. R9's Electronic Medical Record does not include evidence of a nursing assessment being performed when R9 was lethargic prior to be transferred from the wheelchair. R9's Local Emergency Record, dated 9/19/24, documents CT (Computed Tomography) pelvis for bone detail without contrast final result: Impression:1. Acute or subacute mildly displaced comminuted inferior coccyx fracture. This same form documents Clinical Impression: Fall, Urinary Tract Infection, and Hyponatremia (low sodium level.) On 10/06/24 at 9:02 AM R9 was in self-propelling wheelchair around R9's room. R9 had nonskid socks on. R9 was unable to answer questions appropriately at this time. On 10/7/24 at 12:04 PM V8/CNA stated, (V9/CNA) and I were transferring (R9) from his wheelchair to the bed with a mechanical stand lift machine. (R9) was weak when (V9) and I were lifting him, so (V9) and I tried to get (R9) to the bed quickly. When (V9) and I attempted to transfer (R9) to the bed we realized the bed was too high. I then tried to use the controller to lower the bed while (R9) was trying to hold on and slipping from the sit-to-stand machine at the same time. I realized the controller was not working to the bed, so (V9) and I attempted to turn him back around and put him in the wheelchair. By that time (R9) had let go of the sit-to stand and had fell to the ground. V8 verified at this time, that she should have not attempted to transfer (V8) when she realized he was weak and should have ensured the bed was working and in the proper position prior to transferring R9. On 10/7/24 at 12:14 PM V9/CNA stated, (R9) was not a resident on my group the night of 9/19/24, but I was asked to help lay (R9) down. (R9) had been outside at a party, and when he came inside, (R9) was found lopped over the side of his wheelchair in the television room. (V15/RN) called (V8/CNA) and I up to the nurse's desk and asked for us to lay (R9) down. I pushed (R9) to his room with (V8). I asked (V8) how she wanted to transfer (R9) since (R9) seemed weak and was lopped over. (V8) just stated we would transfer (R9) with the stand mechanical lift and get him to his bed. (V8) and I strapped (R9) to the mechanical stand lift machine and started lifting (V8) up in the air. As (V8) and I were lifting him up, (R9) started slipping and was barely hanging on to the (stand lift machine.) (V8) and I attempted to hurry and put (R9) in bed before (R9) fell just to notice the bed was too high. (V8) and I tried to use the controller to lower the bed and the controller wasn't working. (V8) and I attempted to turn (R9) back around to get (R9) in his wheelchair, but (R9) kept getting lower and lower and then let go of the (hand bars of the mechanical stand lift) machine. When (R9) let go of the (stand lift machine) (R9) fell quickly to the ground. If (R9) was on my group that night, I would have not transferred him to the bed when he was visibly weak. I would have gone and notified (R9's) nurse to have (R9) assessed. I should have done that anyway, but I felt like that was (V8's) responsibility. V9 verified she should have notified R9's nurse prior to transferring R9 when R9 was lethargic and should have ensured the bed was working and in the proper position prior to transferring R9 to the bed. On 10/7/2024 at 12:30 PM V6/Maintenance Assistant stated, I get work orders for no electricity all the time for rooms. The staff will move the resident's beds and hit the plug, which breaks a prong off in the outlet. When the staff went to plug the bed back in, the plug-in hits the prong and blows the circuit breaker. I received the work order for (R9) not having electricity in his room on 9/20/24. The staff laid it on my desk on 9/19/24, but I don't usually get to work orders in the same day, it's always the next day I am at the facility. No staff member got ahold of me to let me know (R9) did not have electricity in his room on 9/19/24. On 10/7/24 at 12:47 PM V7/CNA stated, I filled out a work order on 9/19/24 around 2:30 PM regarding (R9) not having electricity in his room. (R9's) television was not working. I put the work order on (V6/Maintenance Assistance) desk. I did not tell anyone else or try to get ahold of (V6) to fix it right then. On 10/8/24 at 1PM V2/Director of Nursing stated, If any staff notices a change in condition with a resident, they should immediately notify the nurse prior to transferring especially if the resident seems weaker. Also, the staff should have everything positioned correctly prior to transferring any resident. V2 verified no nursing assessment had been performed prior to V8/CNA and V9/CNA transferring R9 from his wheelchair. On 10/8/24 at 1:09 PM V3/Assistant Director of Nursing stated Staff should go to the nurse or myself prior to transferring a resident if they notice a change in the resident's condition or if they notice the resident is weaker. They should never transfer someone to a bed with the bed in high position, they should always ensure the bed is at appropriate position prior to transferring. 33975 2. R8's Fall Investigation Worksheet/Worksheet, dated 5/25/24 at 8:56 pm, documents that R8 slid out of the wheelchair in R8's room, while transferring self to bed. The Worksheet documents no injuries and fall interventions for a gripper pad to be placed in R8's wheelchair and to utilize a nightlight. R8's Fall Investigation Worksheet, dated 7/1/24 at 4:00 pm, documents a fall in R8's bathroom. The Worksheet documents that R8's decision making is impaired and has unsteady gait. The Worksheet describes that R8 hit the side of R8's head on R8's bathroom door jamb/frame while trying to get up from the toilet. The Worksheet documents no injuries and fall interventions for staff to intervene when they see her going down the hall and ask her is she needs to go to the bathroom and take her as much as possible. R8's Fall Investigation Worksheet, dated 7/27/24 at 3:00 pm, documents a fall from R8's wheelchair, in R8's room. The Worksheet documents that R8 has impaired memory, impaired decision making and is impaired physically. The Worksheet documents no injuries and fall interventions to educate R8 on the proper use of R8's call light. R8's Fall Investigation Worksheet, dated 9/8/24 at 10:08 am, documents a fall from R8's wheelchair in R8's room. The Worksheet documents no injuries and that R8's gripper pad be replaced in R8's wheelchair. On 10/8/24 at 12:50 pm, V2 (Director of Nursing) stated (R8) is confused and self transfers a lot. (R8) is frequently taking herself to the bathroom and she always slides to the end of R8's wheelchair seat all the time too. On the first fall, we put a gripper pad on (R8's) wheelchair to help to grip (R8) in the wheelchair but (R8) does not like it on there and removes it all the time. R8's MDS (Minimum Data Set) documents that (R8's) cognition score is ten out of fifteen, which is moderately impaired. We have educated (R8) and we just changed (R8's) gripper pad again. Now that I think about it, we probably should use some different interventions since (R8) is confused and keeps removing the gripper pad from (R8's) wheelchair. We do not have (R8) on a toileting schedule. 32875 b.) On 10/7/24 at 9:15 AM, R40 was sitting in front of the facility in his wheelchair with two other residents and had just finished smoking a cigarette. There were no staff present for supervision. On 10/8/24 at 11:55 AM, V4/MDS/Minimum Data Set Coordinator stated that R40 is an independent smoker and does not need to be monitored. On 10/8/24 at 2:20 PM, V2/Director of Nursing stated that the smoking assessments are to be done at least yearly by V14/Activity Director. R40's Face Sheet documents R40 was admitted to the facility on [DATE] with diagnoses which included Schizoaffective Disorder, Mild Cognitive Impairment, Emphysema, and Chronic Obstructive Pulmonary Disease. R40's Care Plan dated 3/23/22 documents (R40) is an independent smoker. The Resident Smoking List for October 2024 documents that R40 is an independent smoker. R40's facility Smoking -Safety Screen dated 3/1/23 at 3:23 PM, documents that R40 has cognition loss, dexterity problems, is an independent smoker, keeps his own smoking materials, and lights his own cigarettes. The Smoking Safety Policy and Procedure revised 7/18/2019 documents Policy In order to provide the residents of (the facility) the opportunity to use tobacco products and do so in a safe environment and manner, the following procedures/rules/regulations shall be followed by all residents. Procedure Those that wish to use tobacco products will be assessed upon admission, yearly, and as needed as to the resident ability to smoke safely and to ascertain other needs the resident may have in which using tobacco products would be an issue, i.e. (example), ability to manage/ budget tobacco products. Based upon this assessment the resident will be placed in one of three groups as described below (full independence, managed independence, or supervised). A copy of the rules and regulations pertaining to smoking is given to each resident and further discussed with the SSA (Social Service Assistant). A Smoking Contract is then executed indicating the resident's understanding of smoking rules and his/her agree compliance.

Based on interview and record review the facility failed to provide a bed hold notification to the resident or resident representative for four of four residents (R6, R9, R11, R46) reviewed for hospital transfers in the sample of 27. Findings include: The facility's Bed Reserve policy, undated, documents Notification Process: All residents will be provided notification of bed reserve policy upon admission. In addition, a copy of the policy will be provided upon hospitalization along with other pertinent documents. Responsible parties will be notified by phone of the bed reserve policy within 24 hours. 1. R6's Census List, dated 10/8/2024, documents R6 was discharged to the hospital on 3/6/24, 3/9/24, and 5/13/24. There was no evidence in R6's medical record of a bed hold notification given to R6 or R6's representative for 3/6/24, 3/9/24, and 5/13/24. 2. R9's Census List, dated 10/8/2024, documents R9 was discharged to the hospital on 7/9/24, 7/19/24, 9/8/24, 9/16/24, and 9/19/24. There was no evidence in R9's medical record of a bed hold notification given to R9 or R9's representative for 7/9/24, 7/19/24, 9/8/24, 9/16/24, and 9/19/24. 32875 3. R11's Face Sheet documents R11 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease, Personal History of Urinary Tract Infections, Constipation, Chronic Kidney Disease, Stage 2, and Type 2 Diabetes Mellitus. R11's Emergency Department to Hospital Admission Report documents that R11 was sent to the hospital on 9/2/24 due to R11 not having urine output for three days. A bedside ultrasound showed 1500 cc/cubic centimeter of urine retained in R11's bladder. R11 was admitted to the hospital for Urinary Retention and Constipation. R11 discharged back to the facility on [DATE]. R11's Census List printed 10/8/24 at 10:27 AM documents that R11 transferred out to the hospital on 9/2/24 and transferred in from the hospital on 9/5/24. There was no evidence in R11's medical record of a bed hold notification given to R11 or R11's representative for 9/2/24. 4. R46's Census List, dated 10/8/24, documents R46 discharged to the hospital on 12/23/23, 3/11/24 and 8/19/24. On 10/7/24 at 9:50 am, V4 (Minimum Data Set Nurse/MDS Nurse) stated, The nurses on the floor are supposed to be giving a Bed Hold Policy and written notification to the Residents when they go to the hospital. I cannot find any documentation of a bed hold being given to R6, R9, R11, and R46 for the dates above. On 10/8/24 at 10:00 am, V1 (Administrator) stated, I do not have any documentation or copies of bed holds for R6, R9, R11 or R46 for the dates above. On 10/8/24 at 10:40 am, V1 (Administrator) stated, I did find a few copies of signed written notifications for some of the Residents when they discharged , but we do not seem to have a specific routine on doing these. Surveyor: [NAME], [NAME] 33975

Based on interview and record review the facility failed to develop a Care Plan for pain for one resident (R4) of 24 residents reviewed for pain in the sample of 27. Findings include: The Care Plan Policy dated 6/1/23 documents Residents admitted to the facility will have a care plan initiated within 48 hours of admission and completed no later than 21 days after admission. Care plans are revised at least quarterly, whenever there is a significant change in the patient's condition and on an as needed basis. Patients receive care and treatment based on an assessment of their needs, the severity of their disease, condition, impairment, or disability. The data obtained from the assessment is used to determine and prioritize the patients plan of care. The development, implementation, and maintenance of a patient's plan of care is an interdisciplinary process. All disciplines involved in the care of a patient collaborate to develop the care plan. Each healthcare team member provides input based on comprehensive assessments. The patient/family/responsible party is included in the development, implementation, maintenance, planning and evaluation of the care provided. The patient goals and plan of action are updated by the individual who identified the problem area or by other healthcare team members according to their area of expertise. Multiple care team members may have input to and document on a plan of action for any health care concern. R4's Face Sheet documents R4 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Muscle Wasting and Atrophy, Abnormal Posture, Presence of Right Artificial Hip Joint, Vascular Dementia, Severe, without Behavioral Disturbance, Age-Related Cognitive Decline, and Disorganized Schizophrenia. R4's Physician Order Summary printed 10/8/24 at 12:57 PM, documents that R4 takes Acetaminophen with Codeine 300-30 mg/milligrams two times a day for pain. Start date is 9/4/24 with no end date documented. R4's Care Plan printed 10/8/24 at 12:57 PM does not document a care plan for pain. On 10/8/24 at 11:58 AM, V4 (Minimum Data Set/Care Plan Coordinator) stated that R4 does not have a care plan for pain. On 10/8/24 at 2:20 PM, V2/Director of Nursing stated that R4 takes scheduled Tylenol with Codeine twice a day for lower back pain and general body pain. R4 has taken the medication about a month and there is not a care plan for R4's pain. V4 does the care plans and there was a communication problem that caused V4 not to know that R4 needed to have a pain care plan.

Based on observation, interview and record review the facility failed to provide monitoring and documentation of dialysis access site observations, failed to provide communication with the dialysis center, failed to identify type of dialysis access site/device, failed to provide a current/valid dialysis contract and failed to develop and implement a policy and procedure for residents receiving offsite dialysis for one resident (R60) of one resident reviewed for Hemodialysis in the sample of 27. Findings include: No Policy and Procedure for the care of a Dialysis resident residing at the facility was provided during the survey. On 10/6/24 at 10:30am V1, Administrator confirmed only one resident (R60) in the facility received dialysis. R60's Current Physician Orders indicate R60 was admitted to the facility on [DATE] with diagnoses that included End Stage Renal Disease, Cardiac Arrest and Diabetes Mellitus. R60's orders include One time a day every Monday, Wednesday and Friday related to End Stage Renal disease. R60's orders do not include dialysis or details including the type of dialysis R60 was to receive (on Monday, Wednesday, Friday). R60's Comprehensive assessment dated [DATE] indicates R60 is alert and fully oriented to persons, time, and situations. On 10/6/24 at 10:15am R60 was sitting in his room and refused to speak about anything. At that time, a large visible dialysis access device was visible in R60's left arm. R60 did acknowledge that the shunt in his left arm was for dialysis and responded Nobody does anything here when asked about how the nurses care for his access site. On 10/8/24 at 11:45am V10, RN (Registered Nurse) stated they do not send any type of communication sheet to dialysis with R60 or receive anything back. V10 stated We don't keep any type of communication sheets or have a dialysis communication book. They might let us know about labs or something if we need to know. On 10/8/24 at 11:50am V11, RN (R60's assigned nurse) and V12, LPN (Licensed Practical Nurse) stated there were no dialysis communication sheets for R20. Both V11 and V12 stated they check R60's shunt for bruit and thrill and identified R60's shunt in left arm. V12 stated We have to put Lidocaine (topical anesthetic) on his arm before he leaves. No physician orders or instructions from dialysis were found or presented to indicate Lidocaine was to be applied to R60's arm. Review of R60's MAR/TAR's (Medication and Treatment Administration Records) from admission 8/19/24 through 10/8/24 did not document monitoring of R60's dialysis access device or checking for bruit and thrill. R60's current Care Plan indicates (date initiated 8/26/24): R60 goes to dialysis on Monday, Wednesday and Friday related to renal failure. R60 will have immediate intervention should any signs/symptoms of complications from dialysis occur through the review date. R60 will have no signs/symptoms of complications from dialysis through the review date. Check and change dressing daily at access site. Document. Do not draw blood or take Blood Pressure in arm with graft. Encourage R60 to go for the scheduled dialysis appointments. R60 receives dialysis 3 times a week. Monitor labs and report to doctor as needed. R60's Care Plan does not indicate location of dialysis access device, specific complications, or interventions to monitor or provision of medications on dialysis days. R60's MAR/TAR's (Medication and Treatment Administration Records) from admission 8/19/24 through 10/8/24 did not document monitoring of R60's dialysis access device. R60's Progress Notes from admission 8/19/24 to 10/8/24 did not document monitoring of R60's shunt pre or post dialysis. On 10/9/24 at 9:26am V1, Administrator stated before R60, they had not had a dialysis resident for a long time. V1 stated she was aware the Dialysis Contract provided during the survey was not the current Company that was providing dialysis for R60. V1 stated they need to review the requirements to care for a resident with dialysis. V1 acknowledged they did not have the necessary communication with dialysis, a valid dialysis contract or policy and procedure for caring for a dialysis resident. The dialysis contract provided by the facility was dated 2001/2007 and was not the contract for the company currently providing dialysis to R60. On 10/9/24 at 9:26am V1 confirmed she was still waiting for the current dialysis company to send a contract for her to sign.

Based on interview and record review, the facility failed to provide supervision to a resident with severely impaired cognition and a history of falls, failed to implement fall interventions, and failed to document a thorough investigation of a fall for one of three residents (R1) reviewed for falls in the sample of three. These failures resulted in R1 falling, hitting his head, and sustaining a Subarachnoid hemorrhage (brain bleed) on 5/3/23. Findings include: The facility's Resident Accident/Incident policy dated 8/27/21, states Those individuals identified at risk for falls, will be identified for staff to monitor more closely. On a daily basis incidents/accidents will be investigated and reviewed by the facility administrative staff. Necessary intervention changes will be made in the resident's care plan. The facility's Fall Policy and Procedure dated 1/2/19 states, The nurse will complete the necessary documentation: A. Enter a complete description of the incident including, who was notified, any orders received, vital signs, description of any injury, any treatment administered, witnesses, and/or transportation to (emergency room ) information. R1's electronic medical record documents R1 was admitted to the facility on [DATE] with diagnoses which included, Cerebral Infarction with right sided hemiparesis, Alcohol induced Dementia, and Anxiety Disorder. R1's Minimum Data Set assessment dated [DATE], documents R1 had severely impaired cognition and was unable to ambulate independently. R1's electronic Physician Orders dated 5/2023, document R1 was taking Eliquis (blood thinner) 5 mg (milligram) daily. R1's Fall Evaluations dated 2/3/23, 2/17/23, and 5/16/23, document R1 was at risk for falls. R1's Care Plan dated 2/14/23, states (R1) is at risk for falls due to weakness, poor balance, and confusion. (R1) has had falls prior to his admission. R1's Fall Investigation dated 2/24/23 at 2:05 p.m., documents R1 had an unwitnessed fall in his room trying to get out of bed without assistance. R1 did not sustain any injuries. This same Investigation documents Recommended steps to prevent recurrence: Make sure (R1) is not in the (wheelchair) in his room unsupervised and remove wheelchair from room when he is in bed. R1's Fall Investigation dated 4/25/23 at 4:23 p.m., documents R1 was observed standing up from his wheelchair and slid down to the floor. R1 did not sustain any injuries. This same Investigation states Recommended steps to prevent recurrence: Monitor (R1) and remind to not get up when seen trying to get up. R1's Fall Investigation dated 5/3/23 at 10:50 p.m., documents R1 had an unwitnessed fall in his room. R1 hit his head on the floor causing a quarter sized laceration to right eye area and a bruise to his left lower back area. R1 was sent to the local hospital and was admitted with a diagnosis of Subarachnoid Hemorrhage. R1's Hospital CT (Computed Tomography) of the head or brain report dated 5/4/23, documents R1 sustained a post traumatic acute Subarachnoid Hemorrhage in the left frontal lobe. On 6/8/23 at 10:21 a.m., V10 (Registered Nurse) stated I took care of (R1) on 5/3/23 and one of the (Certified Nurse Aides) had put (R1) to bed not too long before I found him on the floor. He was on the floor closer to the bathroom. I can't remember exactly where his wheelchair was, but it was in his room. I can't say whether he had tried to get in the wheelchair at any point since he is confused and could not tell me what happened. I think he was trying to use the restroom alone due to his diagnosis of Dementia. He can't ambulate alone very far, if at all, without falling. He has a habit of trying to continually get up without assistance. We (the facility) don't use fall alarms anymore, so I know he didn't have one. I had a Certified Nurse Aide in the room with me, but I cannot remember who it was. I should have had her document a statement of what she observed after the fall. On 6/9/23 at 3:00 p.m., V2 (Director of Nursing) stated R1's fall interventions did include to not leave his wheelchair in his room. V2 stated after his first fall that intervention was implemented hoping he would not visualize the wheelchair and try to get out of bed alone. V2 stated R1 had a habit of trying to stand/get up without assistance. V2 stated R1's wheelchair should not have been in his room on 5/3/23 once he was put to bed. V2 stated V10 should have had the Certified Nurse Aide that assisted her write a statement, so we know who else was involved after the fall. V2 stated he was unable to determine who the Certified Nurse Aide was that assisted V10 after R1 was found on the floor on 5/3/23.

Based on interview and record review, the facility failed to act on and obtain a physician response to a Pharmacist's Drug Regimen Review which documented a clinically significant medication issue for one of four residents (R1) reviewed for physician orders in the sample of four. This failure resulted in R1 incorrectly receiving extra doses of an anti-diabetic medication. R1 was found unresponsive, hypoglycemic and required transfer to the hospital via ambulance. Findings include: The facility's Medication Regimen Review Policy, undated, states, The consultant pharmacist performs a comprehensive review of each resident's medication regimen and clinical record at least monthly. The Medication Regimen Review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. The MRR also involves a thorough review of the resident records and may include collaboration with other members of the interdisciplinary team, collaboration with the resident, family members or other resident representatives. The MRR also involves reporting of findings with recommendations for improvement. All findings and recommendations are reported to the Director of Nursing and the Attending Physician, the Medical Director and Administrator. Procedure: 2. The consultant pharmacist reviews the medication regimen of each resident at least monthly. a. A more frequent review may be deemed necessary i.e., if the medication regimen is thought to contribute to an acute change in status or adverse consequence, or the resident is not expected to stay 30 days. b. Upon admission or re-admission to the facility, the consultant pharmacist performs a MRR in accordance with CMS (Centers for Medicare and Medicaid Services)-N2001. The consultant pharmacist will provide a notice of the MRR having been performed with a Code 0 (no discrepancy) or Code 1 (discrepancy noted), along with a clinical recommendation for each discrepancy noted on admission or re-admission. 6. Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the director of nursing, medical director, and prescriber as appropriate. 7. Recommendations are acted upon and documented by the facility staff and/or the prescriber. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's Census Report documents R1 admitted to the facility on [DATE] and was discharged to the hospital on 5/8/23. R1's After Visit Summary (AVS), dated 5/5/23, documents Discharge Medications with an order for Glipizide 2.5 mg/milligram tab (tablet)-sr/sustained release-24 hr/hour. Commonly known as Glucotrol XL (Extended Release). Take two tablets by mouth daily. R1's Order Summary Report, 5/5/23-5/8/23, documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications with a start date of 5/6/23. R1's Drug Regimen Review/DRR from the facility's Pharmacy Company states, Attention Required: Discrepancies Noted. CMS (Centers for Medicare and Medicaid Services) N2001: Drug Regimen Review This form states, In compliance with CMS-N2001: Drug Regimen Review, upon admission/readmission, the resident's medication regimen was reviewed for clinically significant medication issues. After clinical review, the following was noted: Hospital paperwork showed patient (R1) is using Glipizide 2.5 mg 2 (two) tabs (tablets) daily. Order needs to be reviewed and updated per (name of electronic charting system) says 2 (two) tabs (tablets) BID (twice a day). This DRR documents R1's admitted to the facility as 5/5/23 and documents V11 as R1's Physician. The physician/prescriber response section is blank. This form states, In accordance with CMS-N2001, prescriber response must be received by midnight the next calendar day. R1's CMS-N2001 Drug Regimen Review, dated 5/6/23 by V13 (Pharmacist) states, In compliance with CMS-N2001: Drug Regimen Review, upon admission/readmission the resident's medication regimen was reviewed to assess whether any clinically signification medication issues were present. After review it was noted that: Code One, Yes. One or more clinically significant medication issues were identified during the DRR This DRR is electronically signed and dated by V13 (Pharmacist) on 5/6/23 at 11:49 AM. DRR Conversation Records documents the DRR communication was faxed to the facility's nursing station, emailed to V2 (Director of Nursing) and emailed to V12 (Care Plan Coordinator) on 5/6/23 at 11:58 AM and was re-faxed to the facility's nursing station on 5/8/23 at 1:30 PM. On 5/9/23 at 1:27 PM, V13 documents R1 is back at the hospital. R1's Medication Administration Record (MAR) dated 5/1/23-5/31/23 documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications. This same MAR documents two Glipizide ER 2.5 mg tablets were given two times a day on 5/6/23 and 5/7/23 at 9:00 am and 5:00 PM. Another dose of two Glipizide ER 2.5 mg tablets is documented as being given again on 5/8/23 at 9:00 AM, 16 hours after the previous dose. R1's Skilled Nursing Facility to Hospital Transfer Form, signed by V4 documents on 5/8/23, R1 was transferred to the local area hospital with lethargy and low blood sugar. On 5/25/23 at 11:27 AM, V10 (Pharmacist) stated that after a review of R1's admission medications were completed a discrepancy noted R1's Glipizide order was entered as 2.5 mg ER two tabs two times a day and the hospital order was ordered for only once a day. V10 stated requests for a clarification were sent to V2 and V12 via electronic mail and a request was sent to the facility nursing station fax number as well on 5/6/23. V10 stated a fax was sent to the nursing station fax number again on 5/8/23. V10 stated no response was received from the facility regarding the discrepancy. V10 stated R1's extra doses of Glipizide could have caused R1's hypoglycemia. On 5/25/23 at 3:51 PM, V2 (Director of Nursing) stated, The minute the nurses got the fax (R1's Drug Regimen Review), it should have been addressed. The faxes are not supposed to sit. We are still investigating this to see what happened. V2 stated since it was a weekend, V2 did not see the electronic mail correspondence from the pharmacy. On 5/25/23 at 3:29 PM, V11 (R1's Physician) stated V11 does not recall receiving notification regarding pharmacy's request for clarification regarding R1's Glipizide medication order. V11 stated that V2 (Director of Nursing) made V11 aware today (5/25/23) that the Glipizide order was ordered incorrectly and that R1 had received more than the ordered dose. V11 stated R1's hypoglycemia on 5/8/23 could have been from the extra doses of Glipizide that was given. On 5/26/23 at 12:10 PM, V9 (Assistant Director of Nursing) stated R1's Drug Regimen Review fax that indicated there were issues with R1's medication orders should have immediately been addressed by the nurses when it was pulled from the fax. V9 stated, Addressing this right away could have prevented a medication error from occurring. V9 stated all nurses are going to be re-educated on the fax machine and the importance of responding to received faxes at huddle at shift change today. As of 5/26/23, R1's medical record did not document a physician response to V13's Drug Regimen Review.

Based on interview and record review, the facility failed to accurately transcribe physician orders resulting in a significant medication error of an anti-diabetic medication and failed to order and administer an emergency glucose replacement when a resident's blood glucose levels were critically low for one of four residents (R1) reviewed for physician orders in the sample of four. These failures resulted in R1 incorrectly receiving extra doses of an anti-diabetic medication. R1 was found lethargic, unresponsive and with critically low blood glucose levels. R1 was transferred to the local area hospital via ambulance. Findings include: The facility's Medication Pass Guidelines, dated 3/00, states, Purpose: To assure the most complete and accurate implementation of physicians' medication orders and to optimize drug therapy for each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Physician's Orders-Medications are administered in accordance with written orders of the attending physician. The nurse who receives the order is responsible for transcribing to the chart. The facility's Ordering and Receiving Medications Policy, dated 3/00, states, Purpose: To ensure that medications are available for administration at the correct time, in the correct form and quantity. Procedure: New Orders 1. All new orders must be written on a physician's order sheet. 2. Transcribe written physician orders appropriately to the Medication Administration Record (MAR) and treatment sheets. V11's (R1's Physician) Standing Orders and Guidelines for Patient Care and Reasonable Expected Reviewer's Criteria, signed and dated by V11 on 1/21/16, states, VI. Emergency e. If a known diabetic patient becomes lethargic or shows signs and symptoms of Insulin reaction or hypoglycemia, BGM (Blood Glucose Monitor) the patient. If below 60 and symptomatic, give 1 (one) cc (cubic centimeter/one milliliter) Glucagon and send notification. If unable to BGM patient and symptomatic, give 1 cc Glucagon and send to emergency room . The facility's First-Dose and Emergency Medication Kit Policy, undated, states, Policy: Emergency needs for medication are met by using the facility's approved emergency medication supply or by special order from (name of the facility's Pharmacy). The facility's (Name of Automated Dispensing System) Item List documents Glucagon 1 mg (One Milligram) Kit is contained inside. The facility's Registered Nurse/Licensed Practical Nurse Job Description, undated, states, Position Purpose: Provide Nursing Care to residents in accordance with clinically accepted practice, governmental regulations, accreditation standards, and consumer wishes and needs. Responsibilities: Requires the ability to apply general nursing techniques and practices, Requires the ability to maintain accurate records, charts and report observations, Requires the ability to follow and give oral and written directions in exact detail and to administer therapeutic prescriptions. Provides routine nursing care in accordance with the physician's orders in conformance with recognized nursing techniques and procedures established standards, and the administrative policy of the facility to which assigned. Maintains clinical charts; reports on the conditions of residents; accepts appropriate telephone communications with the physicians. Assists residents with nursing care problems. R1's Facesheet documents R1 admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus. R1's Census Report documents R1 admitted to the facility on [DATE] and was discharged to the hospital on 5/8/23. R1's After Visit Summary (AVS) documents R1 was being discharged to the facility after an inpatient hospital stay from 4/15/23-5/5/23. This AVS documents the following: Discharge Medications with an order for Glipizide 2.5 mg/milligram tab (tablet)-sr/sustained release-24 hr/hour. Commonly known as Glucotrol XL (Extended Release). Take two tablets by mouth daily. and Recommendations for your Diabetes: Follow directions for your medicine, meals and exercise, Check your blood sugars often, Stay within your safe blood sugar levels; Treat a low blood sugar right away, and Tell all doctors about your diabetes. R1's Order Summary Report, 5/5/23-5/8/23, documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24 hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications with a start date of 5/6/23. R1's Drug Regimen Review/DRR from the facility's Pharmacy Company dated and timed 5/6/23 at 11:49 AM by V13 (Pharmacist) documents the following: Code One, Yes. One or more clinically significant medication issues were identified during the DRR; R1's admitted to the facility as 5/5/23; and V11 as R1's Physician. The DRR states, Attention Required: Discrepancies Noted. CMS (Centers for Medicare and Medicaid Services) N2001: Drug Regimen Review This form states, In compliance with CMS N2001: Drug Regimen Review, upon admission/readmission, the resident's medication regimen was reviewed for clinically significant medication issues. After clinical review, the following was noted: Hospital paperwork showed patient (R1) is using Glipizide 2.5 mg 2 (two) tabs (tablets) daily. Order needs to be reviewed and updated per (name of electronic charting system) says 2 (two) tabs (tablets) BID (twice a day). R1's Medication Administration Record (MAR) dated 5/1/23-5/31/23 documents an order for Glipizide ER (Extended Release) Oral Tablet Extended Release 24-hour 2.5 mg/milligrams. Give two tablets by mouth two times a day related to Type 2 Diabetes Mellitus without complications. This same MAR documents two Glipizide ER 2.5 mg tablets were given two times a day on 5/6/23 and 5/7/23 at 9:00 am and 5:00 PM. Another dose of two Glipizide ER 2.5 mg tablets is documented as being given again on 5/8/23 at 9:00 AM, 16 hours after the previous dose. The facility's Packing Slip from the Pharmacy, dated 5/5/23, documents Glipizide ER 5 mg tablets were delivered for R1. R1's Nursing Note on 5/8/2023 at 4:35 PM, signed by V4 (Licensed Practical Nurse) states, (R1) presents as lethargic. Upon assessment bs (Blood Sugar) 46, unable to arouse. (R1) sent to (name of local area hospital) for eval (evaluation) and treat (treatment). All appropriate parties notified. R1's Skilled Nursing Facility to Hospital Transfer Form, signed by V4 documents on 5/8/23, R1 was transferred to the local area hospital with lethargy and low blood sugar. R1's (Name of Ambulance Company) Patient Care Report documents on 5/8/23 paramedics were dispatched Emergency to the facility. This report documents the following: Chief Complaint: Diabetic-Hypoglycemia (Primary); Primary Symptom: Altered Mental Status; Primary Impression: Hypoglycemia; and a blood glucose level of 27. This report states, EMS (Emergency Medical Service) Unit arrived on scene to find (R1) unconscious laying in his bed. (V4/Licensed Practical Nurse) relayed that she came to give the patient (R1) his nightly medications and found him to be in his current state. (V4) relayed that (R1) has a history of Diabetes Type 2 and is only on oral medication. (V4) could not relay the last time (R1) was at his normal and stated she does not usually work over here. (R1) is unable to confirm or deny any pertinent negatives due to being altered. (R1) is being transferred to (name of local area hospital) for further medical care and evaluation. (R1) was unresponsive to all stimuli Post treatment, (R1) was noted to respond to verbal stimuli. Assessment: Hypoglycemia. (R1) was assessed, BGL (Blood Glucose Level) obtained and noted to be 27. On 5/25/23 at 10:33 AM, V2 (Director of Nursing) stated, I definitely would have expected Glucagon to be given if a resident's blood sugar is less than 60. There should have been orders for it (Glucagon). On 5/25/23 at 10:45 AM, V9 (Assistant Director of Nursing) stated that on 5/8/23, V4 (Licensed Practical Nurse/LPN) had yelled for help because R1 was unresponsive to sternal rubbing. V9 stated R1's blood sugars were low and that V4 was trying to get into the box to give Glucagon. V9 stated V4 did not give Glucagon to R1. On 5/25/23 at 2:22 PM, V4 (LPN) stated, On 5/8/23, I entered (R1's) room and he was asleep, snoring. I did a sternal rub and there was no response (from R1). It was a sudden change. I immediately thought of his blood sugar. I checked his blood sugars with the glucometer, and it said it was 46. Someone was calling the ambulance and I went to get the Glucagon. Glucagon didn't pull up on (R1's) list of medications because there was not an order for it. If the Glucagon had pulled up right away on R1's profile, I would have been able to give a dose before (the Ambulance Company) arrived instead of looking around for one. They (Ambulance Company) arrived quick. (R1's) blood sugar had dropped down to 27 by the time (Ambulance Company) came. V4 verified V4 did not administer Glucagon to R1 on 5/8/23 prior to R1 being sent to the hospital. On 5/25/23 at 3:29 PM, V11 (R1's Physician) stated, It's normal procedure that R1's discharge medication orders from the hospital are to be followed and implemented at the facility as ordered. V11 stated, With a blood sugar in the 40s, I would have expected Glucagon to be given (to R1) as an emergency medication (on 5/8/23). V11 stated that V2 (Director of Nursing) made V11 aware today (5/25/23) that the Glipizide order was ordered incorrectly and that R1 had received more than the ordered dose. V11 stated R1's hypoglycemia on 5/8/23 could have been from the extra doses of Glipizide that was given. On 5/24/23 at 1:11 PM, V5 (Licensed Practical Nurse) stated that V5 entered R1's medication orders into the electronic charting system based off of the orders R1 came to the facility with when R1 was discharged from the hospital. V5 stated V5 also faxes the hospital discharge orders to the pharmacy so they can be verified. V5 verified R1's medications were not double checked by another nurse after V5 entered them into the computer. On 5/25/23 at 11:27 AM, V10 (Pharmacist) stated that after a review of R1's admission medications were completed a discrepancy noted R1's Glipizide order was entered as 2.5 mg ER two tabs two times a day and the hospital order was ordered for only once a day. V10 stated the reports were sent to the facility requesting clarification with no answer received. V10 stated R1's extra doses of Glipizide could have caused R1's hypoglycemia. On 5/25/23 at 3:51 PM, V2 (Director of Nursing) verified that R1's Glipizide medication order was transcribed incorrectly by V5 (LPN) and that R1 received more of the Glipizide medication than R1 should have. V2 stated, A reasonably prudent nurse would have double checked the orders with another nurse before submitting them. As of 5/26/23, R1's medical record did not document Glucagon was administered to R1 by facility staff.

Based on observation, record review and interview the facility failed to assess the need for increased psychosocial cares for one resident (R7) with PTSD (Post Traumatic Stress Disorder) after two physical attacks by another resident (R1) of four residents reviewed for abuse. This failure has caused R7 to be fearful of leaving her room or interacting with other residents and has caused emotional distress for R7. Findings Include: R7's Medical Record documents she was admitted on [DATE] with diagnosis of Dementia, Anxiety, history of suicidal behavior, Delirium due to a known physiological condition, Psychosis not due to a substance or known physiological condition. R7's BIMS (Brief Interview for Mental Status) Score was a 5/15 on admission, indicating severe cognitive impairment for R7. R1's Medical Record documents he was admitted on [DATE] with diagnosis of Vascular Dementia with behavioral disturbances after a CVA (Cerebral Vascular Accident) and Depression. R1's BIMS score on 2/9/2023 was 3/15, indicating severe cognitive impairment for R1. An Abuse Investigation Report dated 3/9/23 documents at 12:30 P.M.(V8/RN) heard a scream from down the hallway and ran down the hall to the room (R7's room) and saw (R1) strike (R7) in the face. An Abuse Investigation Report dated 3/12/13 documents at 1:30 P.M. V14 (RN) saw R1 enter R7's room, R7 began screaming Get out! V14 heard R1 state Shut the f*ck up and saw him strike her right cheek with a closed fist and then began fighting with staff when they intervened. On 3/16/23 at 10:30 A.M. R7 stated I am so scared. R7 tearful and crying. Repeatedly stating I don't know why when asked anything regarding R7 striking her. R1 mimed being punched in the face and said, kept doing it, three times. R7 did articulate that R1 had chased me down in my own place (room) twice. R7 stated she did not want to come out of her room just in case he's out there. I go places only with other people. R7's Medical Record does not include documentation of a psychosocial assessment or R7 being offered any counseling or behavioral health services. On 3/21/23 at 9:15 AM V4 (Social Services Director) stated I spoke to (R7) after both incidents of being hit, she was very unclear about what she wanted. V4 confirmed that there has been no counseling or behavioral health services offered to R7 after being hit by R1. I think (V16/Assistant Administrator) has talked to her some about it (incidents on 3/9/23 and 3/12/23). On 3/21/23 at 9:20 A.M. V6 (Assistant Administrator) stated I spoke to (R7) once about her feelings regarding incidents (being hit by R1 two times.) (R7) was confused and couldn't seem to recall details regarding being hit by (R1) either time. V6 confirmed that no increased monitoring, counseling, or behavioral health services have been provided for R7 since the first incident on 3/9/23. On 3/21/23 at 10:00 AM, V17 (Medical Director) stated For anyone with PTSD (Post Traumatic Stress Disorder) being hit could remind them of their original trauma. (R7) would benefit from some sort of behavioral health or group counseling sessions now that she has been retraumatized.

Based on interview and record review the facility failed to ensure two residents (R7 and R6) of four residents reviewed for abuse were free from physical abuse. This failure caused R6 to sustain facial fractures. Findings Include: The Facility's Abuse Prevention Program dated 2011 documents This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of resident property, corporal punishment, and involuntary seclusion This facility is committed to protecting our residents from abuse by anyone including, but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to the individual, family members or legal guardians, friends or any other individuals. The Facility's Abuse Prevention Program dated 2011 defines physical abuse as the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention. Physical abuse includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment. An Abuse Investigation form dated 3/9/23 documents (R7) was heard screaming (V8/LPN/Assistant Director of Nursing) ran down the hall and saw (R1) strike (R7) across the face. On 3/16/23 V8 (LPN/ADON) stated When I entered the room (R1) had (R7)'s shirt grabbed up in his left hand and he struck her closed fist with his right. An Abuse Investigation form dated 3/12/23 documents a written and signed statement from V18 CNA (Certified Nursing Assistant) I was sitting in the breakroom, and I heard (R7) screaming loud yelling 'stop'. I ran into her room and witnessed (R1) hitting her and yelling shut the f*ck up. A Final Abuse Investigation Report dated 3/6/23 documents that on 3/3/23 at 10:24 PM (R6) wandered into (R5)'s room. (R5) pushed (R6) and closed the door. (R6) had fallen to the ground, got herself up and opened (R5)'s door again and (R5) slammed the door in (R6)'s face causing her to stumble backwards and grab the right side of her face. This Abuse Investigation Report documents On 3/4/23 (R6) had increased bruising to eye and jaw area and was sent to the emergency room for evaluation. emergency room reported a mildly depressed fracture of the right nasal bone and a nondisplaced fracture of the right zygomatic arch. Mildly displaced fractures involve anterior and lateral walls of right maxillary sinus and the lateral wall of the right orbit as well as the right orbital floor. An Abuse Investigation form dated 3/3/23 documents a written and signed statement from V19 (CNA) (R6) entered (R5)'s room and (R5) pushed (R6) by the upper body then she fell , she got herself back up to enter his room again and he slammed the door on her and it her in the face. On 3/16/23 at 2:00PM V15 (Insurance Representative) stated (R5) called our office and wanted to make it clear that whatever happened on 3/3/23 was an accident, that he just wanted (R6) to get out of his room and leave him alone, he did not mean for her to get hurt. V15 stated (R5) told me that he pushed a lady and she fell then he shut his door in her face.

Based on observation, interview and record review the facility failed to ensure physician ordered pressure relief boots to prevent skin breakdown were in use for one of three residents (R3) reviewed for pressure ulcers in a sample of four. This failure resulted in R3 developing a stage four pressure ulcer to the right ankle. Findings include: A Skin Assessment Policy and Procedure dated 2005 states, It is the policy of this facility to monitor the skin integrity for signs of injury and irritation. In addition to ongoing assessment of the skin, the facility will implement measures to protect the resident's skin integrity and to prevent skin breakdown. R3's Minimum Data Set (MDS) assessment dated [DATE] documents R3 is severely cognitively impaired and is totally dependent on staff for all care including bed mobility, transfers, dressing, toilet use and personal hygiene. R3's Braden Scale for Predicting Pressure Ulcer Risk assessment dated [DATE] documents R3 only responds to painful stimuli, cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over one-half of R3's body. R3's pressure ulcer risk assessment documents that R3's skin is kept moist almost constantly by perspiration or urine and dampness is detected every time R3 is moved or turned. R3's pressure ulcer skin assessment documents R3 is chairfast and does not make even slight changes in body or extremity position without assistance and requires moderate to maximum assistance in moving. This assessment also documents that complete lifting of R3 without sliding against the sheets is impossible and R3 frequently slides down in the bed or chair, requiring frequent repositioning with maximum assistance. In addition, this assessment documents R3 has [CONDITION(S)], contractures or agitation leading to almost constant friction. R3's Treatment Administration/Medication Administration Records (TAR/MAR) document R3 has been receiving skin assessments every day. R3's current care plan dated as created on 12/1/14 documents, (R3) is at risk for pressure ulcers due to immobility and [CONDITION(S)] and has a history of right ankle and right foot pressure ulcer. This same pressure ulcer care plan intervention dated 7/09/2019 documents, Protective Boots as ordered by MD (physician). On 10/20/22 at 11:30a.m. V7 (Licensed Practical Nurse/LPN) stated that she is R3's floor nurse. V3 stated that the floor nurses do not assess residents' skin. V7 stated that skin assessments are only performed by V11 (Wound Nurse) on a weekly basis. A Skin Only Evaluation dated 10/13/22 documents R3 was assessed to have a friction wound to R3's right medial ankle measuring 1.5 centimeters (cm) long by 1.5 cm wide with an undetermined depth on that date. R3's Wound Physician Evaluation and Management Summary dated 10/18/22 documents that R1 had a new stage four pressure wound to the right medial ankle which was a full thickness wound measuring 1cm long x 0.8 cm wide with the depth not measurable and with a wound bed which was 50% (percent) slough (dead tissue). R3's Wound Physician also documented that R3 required a surgical excisional debridement to remove necrotic tissue (nonviable tissue) to aide in healing of viable tissue around the wound. This physician's summary also documented that at the time of R3's wound evaluation, R3 was only using socks and a pillow around R3's feet. On 10/20/22 at 1:05p.m V11 (Wound Nurse) stated that she assesses residents at risk for pressure ulcers for skin breakdown on a weekly basis. V11 stated that the floor nurses are supposed to assess residents' skin daily. V11 stated that she assessed R3's skin on 10/13/22 and found a wound to R3's right lateral ankle. V11 stated that R3 did not receive pressure relieving boots to prevent her ankles and feet from developing pressure ulcers until after R3's wound was found on 10/13/22. V11 stated that V12 (Wound Physician) assessed R3's right lateral ankle wound on 10/18/22, at which time, V12 called R3's right ankle wound a stage four pressure ulcer. On 10/20/22 at 1:20p.m. V11 (Wound Nurse) entered R3's room to assess R3's right ankle pressure ulcer. R3's upper and lower extremities were contracted towards R3's chest with R3's lower legs crossed at the ankles making R3's right outer ankle bone rest against the bed. V11 had some difficulty visualizing R3's wounds because R3's legs were stiff and fixed in their contracture position. V11 proceeded to remove the dressing from R3's right ankle to reveal a round open wound over R3's right outer ankle bone which appeared to be approximately 1.5 cm long x 1.5 cm wide with a red/brown wound bed and with white tissue bordering the wound. On 10/20/22 at 2:35p.m. V2 (Director of Nurses/DON) stated that residents developing pressure ulcers has been a problem in the facility. V2 stated that the facility no longer has their floor nurses perform many resident assessments, including skin assessments. Instead, V2 stated, the floor nurses are supposed to take a good look over each resident's skin every day. V2 stated this good look is not the same as a full skin assessment but basically just a look during cares to see if there are any concerns. When asked why R3 would not have had pressure relief boots in place when R3 is contracture with constant pressure against her feet and ankles, and because pressure relief boots are an intervention documented on R3's care plan, V2 replied that the facility is working to get their nursing staff to implement pressure relief interventions as they are ordered, or care planned to prevent residents from developing pressure ulcers.

Based on observation, record review and interview, the facility failed to ensure a resident was transferred in a safe manner, for one of three residents (R1) reviewed for transfers in a sample of three. This failure resulted in R1 being transferred independently by V3 (Hospice Certified Nursing Assistant) to a high back reclining chair and R1's foot becoming entrapped, causing an Acute Proximal Left Tibia and Fibula fracture. Findings include: The facility policy, titled Transfer Between Surfaces (3/2000), documents Purpose: To improve or maintain the resident's self-performance in moving between surfaces or planes, either with or without assistive devices. Fundamental Information: It is better to have another staff member assist with a transfer than to risk injury. The policy also instructs staff to Determine the required sequence of the activity and determine when and how the client will require physical assistance. The Electronic Medical Record documents R1 was admitted to the facility on [DATE] with the diagnoses of Left Sided [CONDITION(S)], History of Cerebral Infarction and Dementia with Behavioral Disturbances. Minimum Data Set assessments dated 6/15/22 and 9/14/22, each document that R1 is totally dependent on two or more staff during transfers. R1's current Plan of Care documents, (R1) is unable to perform her ADL's (Activities of Daily Living). She is dependent on staff. She uses a (high back reclining chair) and is propelled by staff. She has bilateral arm and leg contractures. (R1's) left side contractures are worse than her right and (R1) is at risk for falls due to immobility, dementia, and stroke. R1's 9/14/2022 Lift/Transfer Evaluation Observation documents R1 is not able or partially able to assist with transfers. A Nursing Note dated 9/22/2022 at 10:50 am, documents At approximately 10:10 a.m V3 - (Hospice Certified Nursing Assistant) approached (V5 - Registered Nurse) and asked her to come assess (R1's) leg. (V3) stated to (V5) that she was transferring the resident by herself, and the resident's leg got stuck in the chair. The resident's leg was observed to have a bulge on the upper shin. (V5) asked (V6 - Licensed Practical Nurse) to assess (R1's) leg. He observed the same bulge on the upper shin, and he called upon (V2 -Director of Nursing) to assess the leg as well. All of the assessing nurses determined that the leg needed to be imaged as it was outside of the normal limits for the resident. STAT x-ray orders were placed by (V5). R1's Left Leg X-ray report, dated 9/22/22, documents Impression: Acute fracture proximal tibia and possible fracture proximal fibula. Recommend orthopedic follow-up. An Initial Reportable Investigation, dated 9/22/22, by V2 (Director of Nursing) documents, At approximately (10:10 am) today (V3) notified (V5) that she thought something was wrong with (R1's) shin. (V3) further stated that she was transferring (R1) and (R1's) foot got stuck on the (high back reclining) chair. (V4 - Certified Nursing Assistant) states she overheard (V3) state 'It snapped.' Upon examination there was slight [CONDITION(S)] to the anterior left shin area of the left leg without broken skin, bruising or redness. Bony prominence to the left shin area seems malformed or injured and suspicious for possible injury. The Initial Reportable later documents R1 was sent to the emergency room for further evaluation and treatment of an Acute Fracture of the Left Proximal Tibia and possible fracture of the Left Proximal Fibula. A Five Day follow up to the Initial Reportable of 09/22/2022 confirms that additional imaging revealed R1 did sustain a Left Tibia and Fibula Fracture and R1 was returned to the facility with a leg splint. The follow up Initial Reportable also documents, (V3) has been reeducated on transfers, sit to stand transfers, (mechanical lift) transfers, asking for assistance when needed and to taker her time during transfers. She has also been reeducated on the use of a gait belt. On 9/26/22 at 11:28 am, R1 was in bed, with her legs contracted at the knees and hips. R1's left leg was wrapped and splinted for stability. On 9/27//22 at 12:37 pm, V3 stated she was by herself putting R1 into bed from her (high back reclining) chair on 9/22/22 to give her a bath. V3 stated she picked (R1) up and her foot got stuck in the footrest of the (high back reclining) chair, so I got her foot out of the open slat and put her in bed. V3 stated she noted the injury as she started bathing R1 and alerted staff. V3 stated there was nothing outlined in R1's medical record specifying what R1's actual transfer status was, and she had transferred R1 in that manner before. On 9/26/22 at 11:30 am, V4 (Certified Nursing Assistant) stated R1 has always required a mechanical lift and two staff to transfer. On 9/26/22 at 12:20 pm, V2 stated he conducted the investigation into R1's left leg fracture. V2 stated it was determined that V3 was alone and attempting to transfer R1 into her high back reclining chair when the injury occurred. V2 stated, (V3) was never able to clearly explain how R1's foot got caught in the chair, but obviously this was an unsafe transfer (for R1). V2 indicated that V3 should have had additional staff assisting the transfer of R1 and V3 should have been using a mechanical lift.

Based on observation, interview and record review the facility failed to investigate and prevent multiple injuries for one resident (R44) of three residents reviewed for wounds from injury in the sample of 26. This failure resulted in an infection of an elbow wound requiring antibiotics and isolation precautions. The facility also failed to use the assessed number of individuals needed to transfer residents for two residents (R57 and R322) of eight residents reviewed for falls in a sample of 26. Findings include: 1) Facility Policy/Resident Accident/Incident Policy dated/revised 8/22/21 documents: It is the policy of (the facility) to provide a safe environment for all residents. Residents that end up with an unexplained bruise or skin tear will be investigated to ensure there has been no abuse. On a daily basis incidents/accidents will be investigated and reviewed by the facility administrative staff. Necessary intervention changes will be made in the resident's care plan. The ADON (Assistant Director of Nursing) will discuss, instruct, supervise and/or inservice the staff or residents' plan of care (interventions) in an effort to improve the safety of our residents. Changes will be made as often as necessary to keep our residents as safe as possible. Current Physician's Order Report indicates R44 was admitted to the facility on [DATE] with diagnoses that include [CONDITION(S)]. Physician's Order dated 9/5/22 indicates R44 is on Contact Isolation due to [CONDITION(S)] ([CONDITION(S)]) infection right elbow. Physician's Order indicate antibiotics were initiated on 8/18/22 and completed on 8/29/22 for [CONDITION(S)] right elbow wound. Current Care Plan indicates R44 has risk for skin injury to due abnormal movements and identifies right elbow wounds from 7/12/22 and left elbow wounds from 7/31/22. Care plan indicates interventions identified on 12/11/19 include elbow protectors and (fabric protective arm sleeves) ordered by the MD (Medical Doctor). Intervention dated 12/11/19 also include to pad bed rails, wheelchair arms or any other source of potential injury if needed. On both 9/13/22 and 9/15/22 R44 was sitting in a recliner style-high back wheelchair with legs stretched out fully on the bed. R44's recliner chair was pushed up completely to the side of the bed to allow R44's legs to be supported. R44's door had posted signs indicating R44 was on Contact Precautions. R44 had a gauze wrap wound dressing on both elbows - no elbow or fabric arm/skin protectors. On both days R44 was wearing a short sleeve T-shirt with exposed skin from mid upper arms to fingertips. Both of R44's exposed upper arms were noted to be resting directly on the metal portion of the arm rest on both sides of the chair. The non-metal portion of the arm rest was made of a hard rubberized material. R44's head rested on plastic support straps and not on the cushioned headrest due to R44's position in the chair. R44 had severe frequent uncontrolled jerking movements of bilateral arms, legs and torso. During these movements R44's arms were noted to jerk and flail against various surfaces of the chair including the unpadded arm rests. On 9/15/22 at 10:15 am V4, Wound Nurse stated that R44's chair should have padding to cover the exposed hard surfaces especially over the metal on the armrests. V4 stated Even the non-metal part of the armrest isn't really cushioned. V4 stated that R44 has a new (injury) wound on his left leg that she assumes happened the night before last. V4 stated she did not know what R44 hit his leg on or if an incident report was done. At that time a gauze wrap dressing was noted to R44's left mid shin. V4 stated it would be helpful to know what (R44) actually caused the wound. Nurse Note dated 9/15/22 at 6:55 am indicates R44 has a new area to left lower leg measuring 2 cm (centimeter) x 1.4 cm. Wound Physician Notes dated 9/13/22 indicates R44 has five different wound sites: Site #2: right upper elbow partial thickness wound; etiology infection Site #3: non-pressure wound of left elbow; etiology trauma/injury Site #4: non-pressure wound of right anterior elbow due to traumatic injury; etiology trauma/injury Site #5: Stage 3 pressure wound right hip Site #6: non-pressure wound of right lower elbow due to trauma/injury Each of the elbow wound sites list the wound physician's recommendations as Off-load wound, reposition per facility protocol and Elbow protector. Current facility wound log indicates R44's right upper elbow wound type as friction.' On 9/15/22 at 11:45 am V3, ADON (Assistant Director of Nursing) and V4, Wound Nurse stated that R44's Site #2 etiology is friction and friction would be classified as trauma/injury. On 9/16/22 at 1:18 pm ADON acknowledged that R44's chair should be padded better, and no incident/accident reports were done for the injuries R44 sustained. On 9/16/22 at 2:00 pm V1, Administrator stated, (R44's) whole environment needs to be reviewed for safety. The facility's Transfer Between Surfaces policy dated 3/00, documents It is better to have another staff member assist with a transfer than to risk injury. Determine the required sequence of the activity and determine when and how the client will require physical assistance. 2. R57's minimum data set (MDS) dated [DATE] documents Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Two plus person physical assist. R57's X-ray results dated 9/9/22 documents Chronic proximal fibula fracture. On 9/13/22 at 9:45 AM, R57 observed sitting in wheelchair with her right leg propped up with an immobilizing brace on it. On 09/13/22 at 9:46 AM, R57 stated I was dropped during a transfer last week. They wound up fracturing my right knee. (V11, Certified Nursing Assistant (CNA)) was transferring me when I fell . It happened last Monday or Tuesday. They had a mobile X-ray come in on Friday to X-ray my knee and come to find out, my knee is fractured. So now I have to wear this knee brace. On 09/14/22 at 1:32 PM, V11, CNA, verified he was transferring R57 last week and had to lower her to the floor. V11, CNA, stated I was transferring her (R57) by myself when she lost her balance and I had to lower her to the floor. I reported it to the nurse. On 9/14/2 at 1:40 PM, V3, Assistant Director of Nursing (ADON) verified R57's MDS documents she is a two person assist with transfer and stated, There should have been two people helping her. On 9/15/22 at 12:35 PM, V12, CNA stated (V11, CNA) reported to me that (R57) fell . I reported it the nurse. (V11, CNA) was the only one in the room when (R57) fell . On 9/15/22 at 3:10 PM, V18, Physician, stated (R57)'s fracture is not from the fall. She had a pre-existing fracture that was exacerbated from the fall. 3. R322's fall report dated 2/8/22 documents CNA to this nurse stating when transferring residents to wheelchair, resident leaned forward and went to knees. Resident did not hit head. Resident to be transferred with two for assist in the future. R322's MDS dated [DATE], documents Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Two plus person physical assist. On 9/14/22 at 1:42 PM V3, ADON, stated (R322) required two staff members for transfers during his fall on 2/8/22. However, only one staff member was transferring him. It's in the fall investigation and we put the intervention in the care plan to insure there's always two people when transferring him.

Based on observation, interview and record review the facility failed to treat, monitor, and prevent new and worsening pressure ulcers that required surgical debridement for one (R69) of five residents reviewed for pressure ulcers in a sample of 26. This failure resulted in house acquired pressure ulcers and worsening pressure ulcers, that required surgical debridement for R69. Findings include: Facility Pressure Ulcer and Skin Care Management Policy, effective 3/2000, documents: a resident who enters the facility without pressure ulcers does not develop pressure ulcers; a resident having pressure ulcers receives treatment and services to promote healing, prevent infection and reduce the risk of new pressure ulcers developing; a licensed nurse checks the resident's body for the presence of pressure ulcers, wounds and other skin conditions on admission and weekly; the presence of any pressure ulcer, wound or other skin condition is documented weekly on pressure ulcer or skin report forms in the progress notes and care plan; implements treatment procedures in accordance with professional standards of practice; nursing staff reviews the pressure ulcer prevention and treatment procedures with resident physician; a licensed nurse completes a pressure ulcer or skin report when a pressure ulcer, wound or other skin condition is identified and weekly until healed; and the interdisciplinary team considers and includes interventions for pressure ulcer prevention and treatment to provide an aggressive program of consistent interventions by all staff involved. R69's Nursing Evaluation/Data Collection Form, dated 7/27/22 at 3:30 pm, documents that R69 readmitted to the facility from the local hospital. The Nursing Evaluation Form, skin condition, documents that R69 admitted with a fissure to the coccyx, reddened bilateral heels and a left 5th toe area. The Nursing Evaluation Form does not document measurements or descriptions of the wounds. R69's Treatment Administration Records/TAR, dated 7/27/22 through 8/31/22, documents that R69's bilateral heels treatment was not initiated until 7/29/22, two days after admission and documents a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . R69's coccyx wound treatment was not initiated until 7/29/22, two days after admission, and documents to cleanse with normal saline and gauze, apply a thin layer of ointment ([MEDICATION(S)]) to the wound bed three times a day and as needed and leave open to air every shift for the fissure. R69's TAR does not document a completed treatment to R69's coccyx on 8/6/22 and 8/7/22 (day shift) and 8/8/22 (night shift). The TAR does not document a completed bilateral heel treatment on 8/6/22 and 8/7/22. R69's TAR, dated 9/1/22 through 9/12/22, documents an order that was started on 8/3/22, for an ointment (Santyl/[MEDICATION(S)]) to R69's left heels, and does not document a completed treatment on 8/6/22, 8/7/22 and 8/23/22. The TAR also does not document a completed coccyx treatment for 9/1/22 and 9/5/22, left heel treatment on 9/1/22 or 9/5/22. The TAR also documents a new treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] R69's Nursing Progress Note, dated 8/30/22 at 3:39 pm, documents that R69 has a new area on left ankle, called wound clinic, waiting on call back. R69's Nursing Progress Note, dated 8/30/22 at 4:38 pm, documents that the facility received a call back from the wound clinic and they will evaluate resident when they see him next week. A dry dressing was applied at that time until R69 seen at wound clinic. R69's Nursing Progress Note, dated 9/9/22, documents that R69 has a new area to the left hip (1.5 centimeters/cm by 1.0 cm). R69's Nursing Notes, dated 8/2/22, document that R69 has a new pressure ulcer to the left posterior heel (2.0 centimeter/cm X 2.5 cm) and is unstageable. Facility Wound Report, dated 9/5/22 through 9/11/22, does not document the measurement or description of R69's left heel/left foot, coccyx or left hip wound. The computer generated Report does document, in handwriting, that R69's left hip was house identified as house acquired on 9/9/22 (no measurements), left lateral ankle blister was identified as house acquired on 9/5/22 (4.0 cm x 4.0 cm, unstageable deep tissues) and a blister was identified as house acquired on 9/2/22 to the fifth toe (unidentified left or right foot and no measurements or wound description). R69's Wound Clinic Notes, dated 9/2/22 through 9/15/22, document that R69 has an unstageable pressure ulcer injury of the left heel. The Notes also document a conversation on 9/15/22 at 9:22 am with V4 (Wound Nurse) requesting something else and they do not have orders to the left hip. The Clinic Notes also document that a pressure reducing mattress is recommended. R69's Wound Clinic Notes, dated 9/2/22, documents the size of R69's left heel wound as 2.6 cm x 6.5 cm x 0.2 cm and black eschar (moderate serous drainage) and the left lateral ankle wound size is 3.2 x 2.5 x 0.1 (moderate serous drainage). On 9/15/22, at 1:20 pm, V4 (Wound Nurse) was changing R69's wound dressings. When V4 removed R69's left heel soiled dressing it was undated and not signed by a nurse. R69's entire heel was completely covered with black eschar (approximately 2.5 inches by 2.5 inches, with scant brown drainage). V4 verified that a new scabbed area to R69's right outer heel was identified (approximately 1.0 cm x 1.0 cm) and needed a treatment order. R69's coccyx peri-wound area was reddened and open, measuring approximately 2.0 X 1.0 cm, with no drainage, and did not have a treatment/dressing in place. R69 had an area to the left outer 5th toe, that was black with eschar and no treatment/dressing was in place. R69's right hip was open and did not have a dressing in place. R69 was not on an air mattress. On 9/15/22, at 1:20 pm, V4 (Wound Nurse) stated, I am brand new at the facility. I just saw this new area on (R69's) right outer heel just now. I will have to get a treatment order for that. It is about the size of a dime and is scabbed. (R69's) wounds were getting treated here in the facility, but because they have all gotten worse, now we have to send him to the wound clinic for treatment. He just started going there towards the end of August. His wounds have gotten worse. Every time I contact the wound clinic, for help, they just tell me to wait until his next visit, so I have not always put treatments in place, but recently I have started just calling our Medical Director for advice. I think (R69) was sent to the Wound Clinic to rule our vascular issues, but (R69's) left hip, heel and outer foot are all pressure ulcers. I think that left 5th great toe is not pressure, but the others probably are due to the location. On 9/15/22, at 1:42 pm, V3 (Assistant Director of Nursing/ADON) stated, (R69) admitted back to the facility on [DATE], with just reddened bilateral heels that were not open, a fissure on his coccyx and an area on the 5th left toe. (R69's) areas have gotten worse and now he goes to the wound clinic for treatment. We did not have a wound nurse and our wound documentation is not very good and does not document all of (R69's) weekly measurements or wound description information, as we should have been doing. We have a new wound nurse now that just started a week or so ago. On 9/15/22, at 9:22 am, V18 (Wound Clinic/Registered Nurse) stated, (R69's) first visit here was on 8/19/22 and has only been seen three times. Some of R69's wounds did worsen, and some did require surgical debridement.

Based on observation, interview and record review, the facility failed to provide supervision for a resident identified as a high risk for falls and implement and follow fall interventions for two residents of (R5, R43) of four reviewed for falls in a sample of 35. This failure resulted in R43 experiencing an unwitnessed fall, subsequently sustaining a Subarachnoid hemorrhage and a well-circumscribed compression deformity of the anterior superior C7 vertebral endplate requiring hospitalization . These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 7/29/21, the facility remains out of compliance at a Severity Level 2 as the facility establishes the next Quality Assurance and Quality Assessment and Performance Improvement meeting to ensure the procedures are being followed. The facility will also monitor procedures through observation and verbal communication to ensure compliance. The facility's Smoking Safety Policy and Procedure, revised 7/18/19, documents that Supervised individuals have demonstrated that they are incapable or unwilling to use tobacco products safely, and/or have had significant or repeated violations of the rules/regulations concerning tobacco use. These individuals will be given 1 cigarette at a time during the designated smoke time. Smoking times for supervised smokers are: 9:30am, 11:00am, 1:30pm, 3:00pm, 5:00pm, 7:00pm and 8:30pm. These residents may obtain tobacco products from activities on an as needed basis provided there is a staff member available to supervise the individual. During the spring and summer months, independent smokers are allowed to go outside at any time during the day. The door to the patio area will be left unlocked until 10:30pm. If residents want to go outside to smoke after 10:30pm a staff member will unlock and supervise the door. Supervised smokers will only be allowed to go outside and smoke when staff is available to go outside and sit with them. The facility's supervised smoking times are 9:30am, 11:00am, 1:30pm, 3:00pm, 5:00pm, 7:00pm, and 8:30pm. The facility's Fall Policy and Procedure, revised 1/2/19, documents that the resident is not to be moved until the Nurse has had the opportunity to assess the resident. 1. R43's Fall Risk Evaluation, dated 6/22/21 documents that R43 is at risk for falls with a score of 20. R43's Smoking-Safety Screen dated 3/23/21, documents that (R43) requires supervision while smoking due to her impaired safety awareness. R43's current Care Plan documents that R43 is a smoker. This form documents that R43 will be on supervised smoking for staff supervision. The Care Plan documents R43's intervention include staff to monitor (R43) while smoking to ensure she does not receive injury or harm. R43 needs assistance at times due to confusion, poor vision, and tremors. This form documents that (R43) is at risk for falls and R43 has poor vision and will run into things and trip over things. R43 will also sit down thinking a chair is there and fall. R43's interventions are to have staff assist R43 when trying to sit on the bench outside and redirect back inside until staff are available. R43's Accident/Incident Report, dated 11/12/20, at 6:45pm, R43 fell on the patio. R43 was in the sitting position and assisted up, no injuries were noted during the assessment. R43 was assisted up and remained on the patio, smoking, unsupervised. This form documents that no new interventions due to confusion, cognition and visual impairment. R43's Accident/Incident Report, dated 4/25/21 at 4:00pm, documents that (R6) reported that R43 was going to sit down on the bench on the patio, unsupervised, when R43 tripped and landed on both knees. R43 rolled over to her buttocks, in a sitting position. Upon assessment, R43 had abrasions to her bilateral knees. This report documents that the new intervention put into place is for staff to assist R43 when trying to sit on a bench on the patio, and for staff to redirect R43 to go back inside the building. R43's Accident/Incident Report, dated 5/12/21 at 9:45pm documents that R43 was outside, on the patio, smoking unsupervised, and went down (fall) between the table and the bench. This report documents that there were no injuries noted during the assessment. R43's new intervention is to follow up with the eye doctor. R43's Accident/Incident Report, dated 7/22/21 at 11:25pm documents that R43 was on the patio, unsupervised, sitting on the ground, bleeding noted from R43's left elbow. This report documents that R28 reported that R43 was attempting to sit on the bench, missed and landed on the ground. The report documents the new intervention in place is to lock the patio door at 10:00pm. R43's Accident/Incident Report, dated 7/27/21 at 6:35am, documents that (R5) reported that R43 had fallen on the patio. R43 was up in the chair, when staff arrived, R28 assisted R43 up into the chair. During assessment, R43 had a laceration on right eye, abrasions to bilateral knees, and abrasion on her right cheek and temple. This report documents that R43 was sent to the emergency room for an evaluation and treatment. This form also documents that R43 was being transferred to another hospital due to a brain bleed. R43's Medical-Neurological assessment dated [DATE], documents the reason for the assessment is R43 tripped over landscaping and fell and hit her knee and head. R43 has epistaxis (bleeding) present from the right nostril, an abrasion on her left anterior knee. R43's CT (Computed Tomography) test of R43's head, showed a Subarachnoid hemorrhage within the right sylvian fissure. R43's CT of the spine showed a well-circumscribed compression deformity of the anterior superior C7 vertebral endplate. On 7/27/21 at 2:00pm, V1, Administrator, stated that R43 was on the patio unsupervised. V1 stated that R43 tripped over the landscaping and fell . V1 stated that the facility cannot have staff on the patio at all times. V1 verified that R43 is not allowed to smoke unless staff are present. V1 stated that she is unsure why R43 was on the patio at that time in the morning. On 07/28/21 at 12:45 PM, V24 LPN stated, (R15) is the one who came to me and said that (R43) had fallen (on 7/27/21). The smoke patio doors are unlocked at 6:00am and they close at either 10:00 p.m. or 12:00 a.m. We only had four CNAs (Certified Nursing Assistants) working that morning when the fall happened. By the time I got out to the patio, (R43) was already up in a chair. (R43) had a laceration above her right eye and abrasions on her face. I got her back into the building and set her in a chair to assess her. The bleeding wouldn't stop so I called 911. On 07/28/21 at 1:49 PM, V1 (Administrator) stated, I'm not really for sure of the exact times of the patio doors to be locked. The times on the smoking policy are conflicting. I believe the staff open it at 6:30 a.m. and it's locked at 10:30 p.m. On 7/29/2021 at 11:50am, R28 stated that he was in the TV room, when R15 came in and said that (R43) fell on the patio. R28 stated that R43 always followed R15 on to the patio, to attempt to smoke. R28 stated that when he got out to the patio, R43 was on all fours attempting to get up. R28 stated that he assisted R43 up to a chair. At that time, R28 pointed to a chair about 10 feet from where R43 fell . R28 stated that R43 tripped over the same flower bed edging last week but at night. R28 stated, (R43) told me she is going blind. R28 stated that R43 should not be on the patio without staff. R28 stated that the last supervised smoke time is 8:30pm, but residents are allowed to go onto the patio any time. R28 also stated that the facility does not have enough staff to keep an eye on residents in general, let alone while they are out sitting on the patio. On 7/29/21 at 11:55 am, R15 was alert and oriented smoking on the patio. R15 stated, (R43) followed me out to the patio, and was asking me for a cigarette like she always does. (R43) has to have staff with her when she smokes. (R43) was walking towards me when she tripped on this flower bed edging (pointing to the edging along the sidewalk that was raised approximately six inches). (R43) fell down to her knees first, but she fell so hard that then she hit her head, and was bleeding. No staff were outside, so I ran inside to tell someone. I saw (R28) in the TV room so I told him first, then I went to the Nurses' desk to let them know. (R43) has fallen out here before with no staff. The facility doesn't ever have enough staff here to take care of all of us let alone supervise people out here on the patio. The doors are locked at midnight and open back up at 6:00 a.m. 2. R5's Fall Risk Assessment, dated 7/18/21, documents that R5 is at risk for falls. R5's Smoking Assessment, dated 7/20/21, documents that R5 is safe to smoke with supervision. R5's current Care Plan documents that R5 is smoker and must be monitored during smoking for staff supervision. This form also documents that R5 has weakness in both legs at times, which makes him at risk for falls. R5's Accident/Incident Report, dated 4/2/21 at 7:15pm, R5 was found outside on the ground with his eyes rolled back in his head. R5 could not get up, R5 continued to smoke and refused to go the hospital. R5 got up independently after a few seconds, continued to smoke. R5's new intervention was to use oxygen on a regular basis to keep pulse oxygenation above 92%. On 7/28/21 at 10:00am, V3, Assistant Director of Nursing, stated that there were no staff on the patio at the time of R5's fall (on 4/2/21). V3 stated that R5 is used to doing what he wants, but has had a recent decline. On 7/28/21 at 1:00pm, R15 was on the patio smoking and there were not staff in the area. On 7/29/21 at 10:00am, R28 was on the patio smoking, standing by the wall, under an awning. R28 was not visible from inside the building. R28 re-entered the building and the patio door stayed open for 15 seconds. There were no staff in the area to observe the door. The immediate Jeopardy was identified on 7/28/21 at 3:00pm. The Immediate Jeopardy began on 4/25/21, when the facility failed to implement supervision and established fall interventions for R43 while on the patio. V1, Administrator and V2, Director of Nursing were notified of the Immediate Jeopardy on 7/29/21 at 11:35am. On 8/2/21, the surveyor confirmed through observations, interview and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On 8/2/21 at 10:00am, V1, Administrator stated that the patio doors are locked at all times except during smoking times. V2 (Director of Nursing) in serviced every employee on the new smoking and patio policy. This was completed 7/29/21. 2. On 8/2/21, V1 verified that every smoking Care Plan has been updated with interventions. This was completed 7/29/21. 3. On 8/2/21, the patio door remained locked, and no one was allowed on the patio without staff supervision, 4. V25, Activity Director, verified that a Resident Council Meeting was held on 7/29/21, to explain the new smoking/patio policy. V25 stated that all smoking residents signed a new facility smoking contract. 5. On 8/2/21 at 10:30am, V3, Assistant Director of Nursing, verified the in-services given concerning the new smoking/patio policy. V3 verified that any new information is shared at each change of shift huddle.

Based on interview and record review, the facility failed to administer antiepileptic and anticoagulant medication as ordered by the Physician for one of three residents (R1) reviewed for medication administration in the sample of seven. This failure resulted in R1 having multiple seizures and being admitted to the hospital. Findings include: The facility's Medication Pass Guidelines (effective 3/2000) document physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . If a dose seems excessive considering the resident's age and condition or a medication order seems to be unrelated to the resident's current diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Document the interaction with the physician in the progress notes and elsewhere in the medical record, as appropriate. The nurse who receives the order is responsible for transcribing to the chart. R1's medical record documents diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Progress Notes dated 7/8/21 at 12:48pm document Resident had a 90 second (approximate) [CONDITION(S)] at about 12:30pm. MD (Medical Doctor) notified. Awaiting response. R1's Progress Notes dated 7/8/21 at 5:48pm document Certified Nursing Assistant (CNA) reported [CONDITION(S)] activity-approximately 5 (five) minutes. Resident's (family member, V11) notified and wants resident sent to (hospital). AMT (Advanced Medical Transport) contacted at 5:34pm and MD and management notified at 5:37pm. (R1) left the facility at 5:45pm. R1's AMT transport record dated 7/8/21 documents (R1) had another [CONDITION(S)] as transport was started. [CONDITION(S)] had twitching of the arms and face noted. This lasted for approximately 90 seconds. R1's ED (Emergency department) Provider Notes dated 7/8/21 at 6:55pm document Shortly after labs obtained, (R1) had approximately 92 second of generalized tonic-clonic activity. R1's ED notes document R1 was admitted to the hospital. R1's [MEDICATION(S)] blood level drawn on 7/8/21 at 7:20pm in the Emergency Department (ED) documents a measurement of less than 13 mcg (micrograms)/ ml (milliliter), and the therapeutic range is documented as 50-100 mcg/ml. R1's hospital Neurology Progress Note dated 7/9/21 at 4:01pm documents Assessment/Plan: Seizures secondary to subtherapeutic drug levels. [MEDICATION(S)] ([MEDICATION(S)]) found to be undetectable with dosage at facility reported as 625mg twice daily. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Prescriber written order incorrect, 25ml bid (twice a day), and was written by V10, Registered Nurse (RN). On 7/15/21 at 10:00am, V2, Director of Nursing (DON), provided an investigation dated 7/15/21 for R1's low [MEDICATION(S)] level and hospitalization . This investigation documents ((V10, Registered Nurse (RN)) failed to write the corrected order for [MEDICATION(S)] when correcting the order on 4/30/21. The investigation also documents Upon review with the supply and demand of [MEDICATION(S)] ([MEDICATION(S)]) with Prime Care Pharmacy it was noted that the resident (R1) received and used the appropriate amount of [MEDICATION(S)] as ordered. At this time, V2 confirmed that R1 received no [MEDICATION(S)] from 5/1/21-7/8/21. R1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/16/21 at 12:04pm, V5, Registered Pharmacist/Primary Care Pharmacy, stated R1's [MEDICATION(S)] was dispensed on 5/29/21 and not again until 7/9/21. V5 stated the bottle of [MEDICATION(S)] solution dispensed on 5/29/21 would last for 18 days if properly administered. On 7/16/21 at 10:40am, V3, Assistant Director of Nursing, stated the bottle of [MEDICATION(S)] solution dispensed on 5/29/21 was dated as opened on 6/18/21. On 7/16/21 at 12:04pm, V5, Registered Pharmacist, stated if the bottle of [MEDICATION(S)] solution was opened on 6/18/21, it would be empty by 7/4/21 or 7/5/21. V5 stated there was not enough medication in the bottle to last until 7/8/21. On 7/16/21 at 10:59am, V6, Primary Care Physician (PCP), stated the facility did not notify him that R1's [MEDICATION(S)] had been incorrectly discontinued on 4/30/21, and that R1 had not received it for over two months. V6 stated Not receiving the [MEDICATION(S)] would have lowered R1's [CONDITION(S)] threshold and caused her to have seizures. V6 also stated he was not notified that R1 missed some of her doses of [MEDICATION(S)]. R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There is no order for [MEDICATION(S)] in R1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A Medication Incident and Discrepancy Report dated 6/23/21 documents on 6/23/21 V7, Licensed Practical Nurse (LPN), discovered (R1) did not have an order (for [MEDICATION(S)]) available. Upon further investigation, it was noted the order entered by (V17), Registered Nurse (RN) on 6/9/21 had ended on 6/15/21 and another PT/INR (Pro time/ International Ratio) lab draw had not been ordered. On 7/20/21 at 12:55pm, V2, Director of Nursing, stated V12 (RN) failed to order the PT/INR for R1 to be drawn on 6/16/21, so another [MEDICATION(S)] order was not received by the Physician. V2 confirmed that R1 did not receive any [MEDICATION(S)] from 6/16/21-6/22/21.

Based on observation, record review, and interview the facility failed to implement new fall interventions after a fall, initiate neurological checks and timely report and investigate a fall for two of three residents (R1 and R2) reviewed for falls in a sample of three. This resulted in R1 sustaining a subsequent fall on [DATE] and resulted in R1 sustaining a Parasymphysis and Rami fracture of the pelvis on [DATE]. Findings include: The Facility's Fall Procedure Policy dated [DATE] documents: (The facility) provides interventions to reduce risk factors for falling .each shift is to assess the resident: 72 hour post event assessment including neurological checks if a head injury occurred or is suspected. 1. The Facility's August, September and [DATE] Incident logs did not document any falls had occurred for R1. R1's electronic medical record documents R1 was admitted to the facility on [DATE] and expired on [DATE]. R1's MDS (Minimum Data Set) dated [DATE] section B, documents R1 has unclear speech-slurred mumbled words. The same MDS documents under section C that R1 demonstrates the following behaviors that are present and fluctuate: inattention, disorganized thinking, altered level of consciousness and psychomotor retardation. This same MDS documents under section G: R1 walks in room with supervision and 1 person physical assist. R1's current electronic care plan documents (R1) is at risk for falls r/t (related to) unaware of safety needs, confusion, poor communication/comprehension. R1's Accident/Incident Report dated [DATE] and completed by E3 LPN (Licensed Practical Nurse) documents R1 sustained an unobserved fall on [DATE] at 3:30 a.m. R1 was on bedroom floor fitting in between bed and w/c (wheelchair) .stated he did not hit his head when asked .neurochecks and vs (vital signs) within normal limits .A & O (alert and oriented) x1 .refer to Ortho (orthopedics) . The same form documents R1 is memory impaired and decision making impaired. The same form documents R1 had 1 other fall in the past 30 days. The facility was unable to provide an incident report for R1's fall that occurred 30 days prior. R1's electronic medical record documents a Morse Fall Scale was completed on [DATE] at 4:10 a.m. for post fall. The facility was unable to provide documentation for a fall investigation from [DATE]. Administrative Investigation Notes dated [DATE] document on [DATE] and [DATE] (R1) observed ambulating with unsteady gait and a limp. R1's electronic medical record documented an order on [DATE] ortho consult for difficulty walking, limping . R1's Consultation Report dated [DATE] documents: reason for visit, hip/pelvic pain, parasymphysis fx/Rami fx (fracture.) R1 sustained another unobserved fall on [DATE] at 3:30 a.m. R1's Accident/Incident Report completed by E3 LPN documents: (R1) was sitting on floor between bed and w/c. A & O (alert and oriented) x 1, Neuro checks in normal limits, able to move all extremities equal. No injury noted .Recommended to prevent occurrence: (R1) expired 0530 (5:30 a.m.). R1's electronic medical record did not document Neurological checks were completed for the falls on [DATE] or [DATE]. R1's electronic progress notes document a late entry with a created date of [DATE] for the fall of [DATE] written by E3 LPN that documents: Neuro checks within normal limits .no injury noted. R1's electronic medical record contains another late entry by E3 LPN. The Late entry was created on [DATE] at 8:03 a.m. (after R1's death occurred at 5:30 a.m.) regarding R1's [DATE] fall and documents: continues FVS (fall vital signs), Neuro checks within normal limits .no injury. R1's electronic medical record documents a late entry created on [DATE] at 7:48 AM by E5 LPN regarding R1's [DATE] care. This note documents R1 ambulates to shower several times he appeared to have a limp. E12 (former ADON) created a late entry electronic progress note for R1 that was created on [DATE] regarding R1's [DATE] care. This note documents that (R1) continues to ambulate with a limp. R1's medical record contained an x ray report for right hip, unilateral with pelvis .impression no acute fracture or dislocation dated [DATE]. No additional x ray reports were found in R1's medical record between [DATE] and [DATE]. R1's Certificate of Death Worksheet dated [DATE] by the local coroner documents significant contributing conditions contributing to death .pelvic fracture. On [DATE] at 5:00 a.m. E4 RN (Registered Nurse) stated R1 would not voice that he was in pain, could not voice if he hurt something. On [DATE] at 5:20 a.m. E5 LPN (Licensed Practical Nurse) stated R1 was not a reliable historian in regards to saying if he was having pain or hurt. On [DATE] at 11:15 a.m. E2 DON (Director of Nursing) stated R1's orthopedic consult ordered on [DATE] and completed on [DATE] was obtained due to R1 being unsteady related to falls. E2 stated frequent checks should have been listed as an intervention on R1's [DATE] incident report but were not. E2 was unable to provide documentation that R1's frequent checks were being done following R1's [DATE] fall. E2 stated the only falls E2 was aware of for R1 were on [DATE] and [DATE]. E2 verified R1's medical record did not contain documentation that neurological checks were completed for R1 on [DATE] or [DATE]. E2 also verified R1's medical record did not contain fall vital signs for the fall on [DATE]. 2. On [DATE] at 2:30 PM and [DATE] at 2:25 PM, R2 was lying in R2's bed resting with R2's eyes closed. R2's bed was pushed against the wall and R2's call light was within reach. The facility's Incident Log (dated ,[DATE]) documents that R2 had one fall on [DATE] and two falls on [DATE]. R2's Nursing Progress Notes (dated [DATE]; created date [DATE]) documents the following: Late Entry: It was reported to me (E12, Former Assistant Director of Nursing) by (E10, Registered Nurse) that (R2) had fallen that morning in (R2)'s room and that there were no injuries, states that staff have been keeping an extra close eye on (R2) and that they fed (R2) breakfast after the falls and put (R2) to bed because (R2) had been awake most of the night . the falls had occurred at 7:05 AM and 7:15 AM this morning. R2's Accident/Incident Reports (dated [DATE]) document that R2's [DATE] falls at 7:05 AM and 7:15 AM were not investigated until [DATE]. R2's Accident/Incident Report for R2's [DATE] at 7:05 AM documents the following: Observed (R2) on (R2)'s right side with (R2)'s head at the bottom of the bed. (R2)'s right arm was under (R2)'s body. (R2) was positioned between the bed and the chair. (Neurological checks within normal limits). R2's Accident/Incident Report for R2's [DATE] at 7:15 AM documents the following: Observed (R2) on (R2)'s right side with (R2)'s head at the top of the bed with (R2)'s right arm under (R2)'s body. (R2) was positioned between the bed and the chair. (Neurological checks within normal limits). An untitled document (dated [DATE]) in E10's personnel file completed by E2 (Director of Nursing) documents the following: On [DATE], it was reported to me (E2) by (E12, Former Assistant Director of Nursing) the following issues regarding (E10) during my absence: Failure to complete an incident report on (R2) for multiple falls and initiate (Neurological) checks on [DATE]. Failure to notify (E13, R2's Physician/Medical Director) of the fall On [DATE] at 2:20 PM, E2 (Director of Nursing) verified that R2 had two falls on [DATE] and that E10 did not report those falls, document neurological checks in R2's medical record or complete an incident report for R2's falls on [DATE]. E2 stated that E10 should have reported R2's falls on [DATE], documented neurological checks and completed incident reports for both of R2's falls on [DATE].

Based on observation, record review and interview the facility neglected to follow their mechanical lift policy in relation to proper placement of the lift sheet for one of three residents reviewed for falls in the sample of three. This failure resulted in R1 falling from a mechanical lift and sustaining a subdural hematoma, facial laceration requiring suturing, and a fractured femur. Findings Include: The (undated) Facility Policy, Using Portable Lifting Machine, instructs staff to, Place the sling, fan-folded, along the back of the resident. Make sure the top of the sling is at the head of the resident and the bottom at the resident's knees. On 11/22/2016 at 8:30A.M., R1 was laying in bed with eyes closed. A laceration was noted to R1's mid-forehead with 8 sutures intact present. R1's CT (Computerized Tomography) of the head or brain from the local emergency room , dated 11/21/2016 at 7:20 P.M., documents the following: Impression small acute left cerebral convexity subdural hematoma; Frontal scalp contusion; laceration; and likely containing foreign debris. R1's Imaging exam of the right femur, dated 11/21/2016 at 7:12 P.M., documents, Closed [MEDICAL CONDITION] end of right femur. Z1 Primary physician progress notes [REDACTED].M., documents the following: Recently fell off hoyer lift and sustained Right Femur Fracture and laceration to mid forehead; Patient (R1) was taken to local emergency room ; She (R1) also sustained a subdural hematoma; and Patient (R1) not a surgical candidate and will not have ortho (orthopedic) surgery. On 11/22/206 at 11:10 A.M., E1 DON (Director of Nurses) stated the following: After the investigation the only conclusion that I could come up with is that the mechanical lift sheet was positioned too far up resident's (R1) body, so when the CNA's (Certified Nursing Assistants) (E2 & E4) lifted resident (R1) up to transfer the resident (R1) slipped out of the sling; (R1's) feet touched the floor, then resident (R1) landed on R1's face and the CNA's were unable to catch (R1); and if the mechanical lift sheet was positioned correctly around and below (R1's) hips, and close to (R1's) knees, (R1) would not have slipped out of the mechanical lift sheet. On 11/23/2016 at 11:10 A.M., E2 CNA stated the following: The hoyer lift sheet that was underneath the resident (R1) was positioned too high above the hips and not close to R1's knees; the mechanical lift sheet is to be positioned closer down near the knees; when resident (R1) was being transferred (R1) slipped out of the mechanical lift sheet with feet landing on the floor, then (R1) fell forward hitting (R1's) face on the floor; and I did not check the placement of the mechanical lift sheet because I thought the other CNA had checked for correct placement. On 11/22/2016 at 11:10 P.M., Z1 Primary Physician stated the following: Yes, resident (R1) fell to the floor from the hoyer lift and sustained a [MEDICAL CONDITION] Femur, a Subdural Hematoma, and a laceration to the mid forehead; and this should not have happened, but we are keeping her comfortable.

Based on observation, record review, and interview the facility failed to properly position a resident in a mechanical lift sheet for one (R1) of three residents reviewed for falls in a sample of three . This failure resulted in R1 sustaining a subdural hematoma, a facial laceration, and right femur fracture when R1 fell out of the lift sheet during a transfer. Findings Include: The (undated) Facility Policy, Using Portable Lifting Machine instructs staff to Place the sling, fan-folded, along the back of the resident. (Make sure the top of the sling is at the head of the resident and the bottom at the resident's knees.) On 11/22/2016 at 8:15 A.M., R1 was laying in bed with eyes closed, a laceration and contusion was noted near mid forehead with eight sutures in place, and bilateral lower extremities were contracted. Z1 (R1's Primary Physician) Progress Notes dated 11/22/2016 at 3:34 P.M., documents the following: (R1) recently fell off the hoyer lift and sustained a right femur fracture and laceration to the mid-forehead; patient (R1) was taken to the local emergency room ; she (R1) also sustained a subdural hematoma; patient (R1) is not a surgical candidate and will not have Ortho (Orthoscopic) surgery; (R1) returned to the facility later in the day; and (R1's)laceration was repaired with 8 sutures and on bedrest. R1's local hospital emergency room notes dated 11/21/206, documents the following: Chief Complaint: Fall, Facial Laceration; and Diagnoses: [REDACTED]. R1's CT (Computerized Tomography) of the head and brain from the local emergency room ,dated 11/21/2016 at 7:20 P.M., documents Small acute cerebral convexity subdural hematoma. Frontal scalp contusion, laceration and likely containing foreign debris. R1's Imaging exam of the right femur from the local emergency room ,dated 11/21/2016 documents, Closed fracture of the distal end of the right femur. R1's Accident/Incident report, dated 11-21-16, documents the following: CNA notified me (E3) that resident (R1) was on the floor; when I (E3) walked into room, I observed resident (R1) laying prone (face down) with her head by the foot of the bed; I (E3) rolled resident (R1) over and performed an assessment; MAE (Moves All Extremities) without difficulty; I (E3) observed blood on resident's (R1) face and when I (E3) cleansed resident's (R1) face, I (E3) observed a laceration to the middle of (R1's) forehead; and I (E3) requested the assistance of eight other staff members. E1 DON (Director of Nursing) investigation synopsis, faxed to the local state department undated, documents the following on R1: Please be advised that on 11/21/2016 at approximately 1:42P.M., resident (R1) was being transferred from a recliner chair to the bed via hoyer lift, and resident (R1) slid out of the hoyer sling landing on her (R1's) feet face first on the floor as reported by (E2) and (E4) both CNA's; (E3)LPN (Licensed Practical Nurse) reports that when (E3) entered the room (E3) observed resident (R1) laying in the prone (face down) position with head by the foot of the bed; resident (R1) then was rolled over and an assessment was performed to determine that the resident (R1) had a laceration to the forehead that needed sutured; (Z1) R1's Primary Physician was notified and resident (R1) was sent to the local emergency room ; resident (R1) was found to have a Left Cerebral Subdural Hematoma, frontal scalp contusion, and laceration; resident (R1) also diagnosed with [REDACTED]. incident. On 11/22/2016 at 11:10 A.M., E1 DON (Director of Nurses) stated the following: The mechanical lift sling was positioned too far up on resident's (R1) body; as the CNA's lifted (R1) in the mechanical lift sheet up, R1 slipped out of the sling; R1's feet touched the floor and then R1 landed on R1's face; and if the hoyer sheet was positioned around R1's hips and down near R1's knees, R1 would not have slipped out of the sling. On 11/23/2016 11:12 A.M., E2 CNA stated The hoyer sling that goes underneath (R1) to transfer (R1) was positioned too high up near R1's head and buttocks, and it (hoyer sling) should be positioned close to R1's neck and go down near R1's back of the knees.

Based on interview and record review the facility failed to follow a care plan for fall prevention measures, and failed to follow a Fall Procedure policy for one of three residents (R2) reviewed for falls in a sample of six. These failures resulted in R2 falling ,sustaining a laceration, a fractured right orbit (eye socket), and a subarachnoid hemorrhage. Findings include: A Fall Procedure policy dated 6/08/15 states, It is the Policy (of the facility) to provide an environment conducive to reducing risk for falls Following an observed or suspected fall event .Do not move the resident until the nurse has assessed the resident. R2's fall risk assessment dated [DATE] documents R2 is at high risk for falling. R2's care plan dated 8/17/14 documents R2 is at risk for falls related to confusion and being legally blind. The care plan also documents for staff to ensure R2's bed is kept in the lowest position as a fall prevention measure. R2's Minimum Data Set assessment dated [DATE] documents R2 is severely cognitively impaired with moderate hearing difficulty, has highly impaired vision, and sometimes understands when spoken too. R2's MDS also documents R2 requires extensive assistance for bed mobility, transfers, and incontinence care. R2's fall investigation dated 12/11/15 documents that on 12/11/15 at 7:50a.m. E6 (Certified Nurse Aide/CNA) was assisting R2 with care. E6 had raised R2's bed from the low position in order to provide R2's care. The investigation documents that E6 became distracted by another staff member outside of R2's room at which time E6 turned away from R2 to pull back R2's privacy curtain. The investigation documents that while E6 was turned away, R2 then fell off the bed onto the floor sustaining a laceration. The investigation also documents that R2 was admitted to the hospital, .for right orbital fracture and subarachnoid hemorrhage. R2's fall investigation documents E4 and E6 lifted R2 back into bed after the fall but prior to being assessed by a nurse. An emergency room history and physical of present illness dated 12/11/15 states, The CNA was cleaning the patient when she stepped away from the bed, the patient fell on the floor hitting her head. A hospital Computed Tomography scan result dated 12/11/15 states R2 was diagnosed with [REDACTED].frontal lobe. On 12/16/15 at 2:05p.m. E6 verified that on 12/11/15 while providing care to R2, E6 left R2's bed in the high position while E6 turned away to talk with E4 (CNA Supervisor). E6 stated that while E6 was providing care to R2, E4 called into R2's room multiple times asking to speak to E6. E6 stated, I told E4 just a minute and E4 said E4 needed me to step out. E6 verified leaving R2 unattended with the bed in the high position so E6 could look around R2's privacy curtain to speak with E4. E6 stated that E6 heard a loud sound, turned back toward R2's bed, and saw R2 on the floor. E6 stated R2's head was bleeding around the right eye. On 12/16/15 at 11:20a.m. E4 verified talking to E6 from the hallway on 12/11/15 while E4 was caring for R2. E4 stated that E6 looked around R2's privacy curtain to talk with E4. E4 stated, .then there was a thump and R2 was on the floor. E4 verified that E4 and E6 lifted R2 back into bed before R2 was assessed by a nurse. E4 verified R2 was bleeding from a cut around R2's right eye. E4 stated, I know I shouldn't have picked up R2 off the floor. On 12/17/15 at 8:50a.m. Z1 (R2's Hospital Physician) verified R2's fracture to the right eye socket and subarachnoid hemorrhage were new injuries consistent with the trauma R2 sustained when R2 fell from the bed at the facility 12/11/15.

Based on interview and record review, the facility failed to notify the physician of a significant weight loss for one of three residents (R1) reviewed for hydration and weight loss in the sample of three. These failures resulted in R1 becoming acutely ill, and requiring hospitalization for Severe Dehydration and [MEDICAL CONDITION] (Increased Sodium Level). Findings include: The facility's Weight Policy dated 10-17-2014, documents a significant weight change is as follows: If being weighed weekly, a 2% (percent) in one week. 5% in one month. 7.5% or more in three months. 10% or more in six months. If a significant weight change persists, the doctor will be notified. The facility's Change of Condition Policy and Procedure (date unknown) documents the nurse will notify the resident's attending physician or on-call physician when there has been a "significant change" in the resident's physical, emotional, or mental condition. R1's Physician order [REDACTED]. R1's Physician order [REDACTED]. Clinical record for R1 documents that from 02/17/15 through 03/13/15 R1 experienced a 5%(percent) weight loss and from 02/17/15 through 04/09/15 R1 experienced a 7.5% weight loss. From 04/23/15 through 04/30/15 R1 experienced a 6.7% weight loss according to the same clinical record. This same record shows no documentation of R1 ' s attending physician being notified of the significant weight losses. R1's Progress Notes dated 5-8-15 from 7:09 a.m. to 7:54 a.m., document R1's skin as pale and warm to touch, bowel sounds hypoactive, heart rate irregular, and a decreased pulse oximetry, requiring R1 to be sent to the emergency department. R1's Hospital Emergency Department Notes dated 5-8-15 and signed by Z2 (R1's Emergency Department Attending Physician), document R1 was admitted to the Emergency Department with Severe Dehydration and [MEDICAL CONDITION]. R1's Complete Metabolic Panel lab dated 5-8-15, documents R1's sodium level at 147 (normal range 135-145). On 5-12-15 at 11:10 a.m., E2 (Director of Nursing) stated,"(R1's) significant weight loss of 134 pounds on 4-23-14 to 122 pounds on 5-17-15, has not been reported to the physician yet. We (facility staff) have our weight meetings monthly, but have not had a meeting this month. We (the facility) have not done any new nutritional interventions for (R1) since (R1's) admission in February." On 5-12-15 at 1:30 p.m., E3 (Dietary Manager) stated, "(R1) weighed 135 pounds in February and was 126.8 pounds in March. That was (R1's) first significant weight loss. On 5-7-15, (R1) had a significant weight loss of 10.3 percent from three months prior. I usually tell (E2/Director of Nursing) or (E7/Assistant Director of Nursing) when a resident has a significant weight loss, and they (E2 or E7) notify the physician. I have never notified the physician of (R1's) weight loss. (R1) has not had any new weight loss interventions since (R1's) significant weight losses in March 2015, and May 7th, 2015." On 5-12-15 at 2:15 p.m., E7 (Assistant Director of Nursing/ADON) stated, "I was off of work the week of 4-30-15, so I did not get (R1's) weight put into the computer system that week. (R1's) weight went from 134 pounds (week of 4-23-15) to 125 pounds (week of 4-30-15) in one week. If the weekly weight of 125 pounds was put into the computer on 4-30-15, we (facility staff) would have known (R1) had a significant weight loss in one week, and the physician, dietician, and family would have been notified, but were not. (R1's) weight the week of 4-23-15 of 134 pounds was a re-admission weight from (R1) being in the hospital." On 5-13-15 at 1:20 p.m., E7 (Assistant Director of Nursing) stated, "Weight meeting are held once a month, and this is when the physician is notified of weight loss. Whoever does the weight charting is responsible for notifying the physician. I did not do (R1's) weight charting or notify (R1's) physician of (R1's) weight loss." On 5-14-15 at 10:40 a.m., Z4 (R1's Primary Physician) stated, "I have not been notified of (R1) having significant weight losses. I would have expected to be notified. Had I been notified, I would have increased (R1's) caloric intake and fluids. (R1's) dehydration could have been prevented. There is no reason a resident fed by a [DEVICE] (gastrostomy tube) should become dehydrated or have a weight loss. Now that weights are on the facility's computer, I no longer see the residents' weight logs when I make rounds." On 5-14-15 at 2:30 p.m., Z5 (Registered Dietician) stated, "(R1) had a significant weight loss from 4-23-15 to 4-30-15. The physician should be notified within 24 to 48 hours of the facility knowing of a weight loss." On 5-14-15 at 1:00 p.m., E1 (Administrator) verified the facility should notify the physician immediately when a resident has a significant weight loss.

Based on interview and record review, the facility knowingly failed to follow the plan of care and knowingly failed to follow their policy on significant weight loss for one of three residents (R1) reviewed for falls and weight loss in the sample of three. R1 was not monitored according to the plan of care, fell , and subsequently developed a subdural hematoma. R1 also experienced significant weight loss with no notification of the physician which resulted in hospitalization for Severe Dehydration. Findings include: 1. The Facility's Abuse Prevention Program policy dated 2012, documents that Neglect means the failure to provide, or willful withholding of, adequate medical care, personal care, or assistance with activities of daily living that is necessary to avoid physical harm, mental anguish, or mental illness of a resident. The Facility's Quality Care Practice Fall policy dated 10-23-14, states, "To reduce the risk for resident falls, do not leave residents sitting in their rooms alone in a wheelchair or (high back) wheelchair." R1's Fall Plan of Care dated 2-19-15, documents a fall intervention dated 3-18-15 that staff are to try to keep R1 in an area to be monitored and supervised. R1's Accident/Incident Report dated 3-30-15 at 8:33 p.m., documents R1 was observed on the floor in R1's room, with bleeding and a left eyebrow laceration measuring approximately two cm (centimeters) long. This same report documents that there were no witnesses to the fall, and R1 was sent to the hospital emergency department for evaluation where R1 was admitted with a [DIAGNOSES REDACTED]. R1's Final Report Investigation dated 3-31-15 and signed by E2 (Director of Nursing), documents on 3-30-15 that E8 (Licensed Practical Nurse) had given E10 (Certified Nursing Assistant/CNA) instructions to place R1 at the nurses' station where R1 could be directly observed by the nursing staff due to R1's risk of falls. This same report documents E10 then took R1 to R1's room and placed R1 in a wheelchair with R1's feet propped up on the bed, resulting in R1's fall. This same report documents E10 was suspended from work on 3-31-15 to 4-2-15 due to E10's unsatisfactory performance. R1's Emergency Department Notes dated 3-30-15 and signed by Z3 (Hospital Emergency Department Physician), documents R1 fell from a seated position in R1's wheelchair, at the facility, resulting in a left eyebrow laceration and a moderate sized subdural hematoma. E10's Employee Warning Notice dated 3-31-15 and signed by E2, documents the following: E10 stated E10 left R1 alone in R1's room with R1's legs propped up on the bed. R1 fell and suffered a serious injury. R1 is a high risk for falls and had safety measures in place that were not followed. E10 is suspended from work from 3-31-15 to 4-2-15. On 5-13-15 at 2:20 p.m., E10 (CNA) stated,"They (the facility) suspended me for taking (R1) to (R1's) room where (R1) sustained a fall on 3-30-15. The nurse had told me to leave (R1) at the nurses' station so the nurse could watch (R1), but the nurse was not there, so I took (R1) to (R1's) room. I propped (R1's) feet up on the bed. (R1) was antsy, fidgety, and wanted to get up prior to the fall. I was unable to calm (R1). I went up the hall from (R1), when (R1) fell in (R1's) room." On 5-12-15 at 11:10 a.m., E2 (Director of Nursing) stated, "When (R1) fell on [DATE], the interventions were to keep (R1) some place where (R1) could be supervised and remind (R1) not to get up. (R1) should be somewhere we (the facility) can supervise (R1), anytime (R1) is up in the wheelchair. When (R1) fell on [DATE], (R1) was taken to (R1's) room. That is not what (E10/CNA) was suppose to do. (E10) had been given strict instructions per (E8/Licensed Practical Nurse) to put (R1) at the nurses' station, but (E10) took (R1) to (R1's) room unsupervised, and propped (R1's) feet up on the bed. That is not what (E10) was suppose to do. This resulted in (R1) falling in (R1's) room and sustaining a serious injury of a subdural hematoma. (E10) was suspended for an unsatisfactory performance. (E10) did not follow the direction of the nurse. (E10) knew (R1) was suppose to be placed at the nurses' desk, and was just told prior to (R1's) fall." On 5-14-15 at 10:40 a.m., Z4 (R1's Primary Care Physician) verified that the facility should not have left R1 in R1's room unsupervised. Z4 stated, "I am big about safety of the residents." 2. The Facility's Weight Policy dated 10-17-2014, documents a significant weight change is as follows: If being weighed weekly, a 2% (percent) in one week. 5% in one month. 7.5% or more in three months. 10% or more in six months. If a significant weight change persists, the doctor will be notified. The facility's Change of Condition Policy and Procedure (date unknown) documents the nurse will notify the resident's attending physician or on-call physician when there has been a "significant change" in the resident's physical, emotional, or mental condition. The facility's Nutritional Policy dated 3/2000, documents resident's are to receive sufficient fluid intake to maintain proper hydration. R1's Physician order [REDACTED]. R1's Physician order [REDACTED]. Clinical record for R1 documents that from 02/17/15 through 03/13/15 R1 experienced a 5%(percent) weight loss and from 02/17/15 through 04/09/15 R1 experienced a 7.5% weight loss. From 04/23/15 through 04/30/15 R1 experienced a 6.7% weight loss according to the same clinical record. This same record shows no documentation of R1 ' s attending physician being notified of the significant weight losses. R1's Progress Notes dated 5-8-15 from 7:09 a.m. to 7:54 a.m., document R1's skin as pale and warm to touch, bowel sounds hypoactive, heart rate irregular, and a decreased pulse oximetry, requiring R1 to be sent to the emergency department. R1's Hospital Emergency Department Notes dated 5-8-15 and signed by Z2 (R1's Emergency Department Attending Physician), document R1 was admitted to the Emergency Department with Severe Dehydration and [MEDICAL CONDITION]. This same note documents R1 has suspected elder neglect due to R1 having severe dehydration, poor oral care, and bruises to the arm and legs. R1's Complete Metabolic Panel lab dated 5-8-15, documents R1's sodium level at 147 (normal range 135-145). On 5-12-15 at 11:10 a.m., E2 (Director of Nursing) stated,"(R1's) significant weight loss of 134 pounds on 4-23-14 to 122 pounds on 5-17-15, has not been reported to the physician yet. We (facility staff) have our weight meetings monthly, but have not had a meeting this month. We (the facility) have not done any new nutritional interventions for (R1) since (R1's) admission in February." On 5-12-15 at 1:30 p.m., E3 (Dietary Manager) stated, "(R1) weighed 135 pounds in February and was 126.8 pounds in March. That was (R1's) first significant weight loss. On 5-7-15, (R1) had a significant weight loss of 10.3 percent from three months prior. I usually tell (E2/Director of Nursing) or (E7/Assistant Director of Nursing) when a resident has a significant weight loss, and they (E2 or E7) notify the physician. I have never notified the physician of (R1's) weight loss. (R1) has not had any new weight loss interventions since (R1's) significant weight losses in March 2015, and May 7th, 2015." On 5-12-15 at 2:15 p.m., E7 (Assistant Director of Nursing/ADON) stated, "I was off of work the week of 4-30-15, so I did not get (R1's) weight put into the computer system that week. (R1's) weight went from 134 pounds (week of 4-23-15) to 125 pounds (week of 4-30-15) in one week. If the weekly weight of 125 pounds was put into the computer on 4-30-15, we (facility staff) would have known (R1) had a significant weight loss in one week, and the physician, dietician, and family would have been notified, but were not. (R1's) weight the week of 4-23-15 of 134 pounds was a re-admission weight from (R1) being in the hospital." On 5-13-15 at 1:20 p.m., E7 (Assistant Director of Nursing) stated, "Weight meeting are held once a month, and this is when the physician is notified of weight loss. Whoever does the weight charting is responsible for notifying the physician. I did not do (R1's) weight charting or notify (R1's) physician of (R1's) weight loss." On 5-12-15 at 2:10 p.m., E6 (Certified Nursing Assistant/CNA) stated, "I took care of (R1) frequently. (R1) was very weak one week prior to hospitalization . (R1) seemed dehydrated. (R1) was always asking for food and water. (R1's) lips were cracking. (R1's) mouth was very dry. (R1's) tongue was very dry and had white film on it." On 5-13-15 at 11:00 a.m., E9 (Licensed Practical Nurse) stated, "We (facility staff) would have to clean (R1's) tongue a lot, because it was so dry. (R1) always asked for drinks. (R1) was very pale." On 5-13-15 at 11:30 a.m., Z2 (R1's Emergency Department Physician) stated, "When (R1) came to the emergency department on 5-8-15, (R1) looked like (R1) received poor care in general. (R1's) mouth was dry with lots of dried mucus. The staff (emergency department staff) had to remove lots of dried mucous from (R1's) mouth. (R1) had not been getting enough fluids. (R1's) sodium level was high even after getting fluids in the ambulance. I felt like (R1) was neglected, so I had the hospital make a report of elder neglect." On 5-14-15 at 10:40 a.m., Z4 (R1's Primary Physician) stated, "I have not been notified of (R1) having significant weight losses. I would have expected to be notified. Had I been notified, I would have increased (R1's) caloric intake and fluids. (R1's) dehydration could have been prevented. There is no reason a resident fed by a [DEVICE] (gastrostomy tube) should become dehydrated or have a weight loss. That is neglectful. Now that weights are on the facility's computer, I no longer see the residents' weight logs when I make rounds." On 5-14-15 at 2:30 p.m., Z5 (Registered Dietician) stated, "(R1) had a significant weight loss from 4-23-15 to 4-30-15. The physician should be notified within 24 to 48 hours of the facility knowing of a weight loss." On 5-14-15 at 1:00 p.m., E1 (Administrator) verified the facility should notify the physician immediately when a resident has a significant weight loss.

Based on record review and interview, the facility failed to follow their fall policy, provide supervision, and implement fall interventions to reduce the risk of falls for one of three residents (R1) reviewed for falls in the sample of three. These failures resulted in R1 falling and sustaining a laceration to the left eyebrow and a subdural hematoma on 3-30-15. Findings include: The Facility's Quality Care Practice Fall policy dated 10-23-14, states, "To reduce the risk for resident falls, do not leave residents sitting in their rooms alone in a wheelchair or (high back) wheelchair." R1's Fall Scale dated 5-6-15, documents R1 is at high risk for falling. R1's Fall Plan of Care dated 2-19-15, documents a fall intervention dated 3-18-15 that staff are to try to keep R1 in an area to be monitored and supervised, and a fall intervention dated 2-26-15, that R1 is to have a bed sensor on the bed. R1's Accident/Incident Report dated 3-18-15, documents R1 had gotten out of a wheelchair, tripped over a walker, and was lowered to the floor by another resident. This report documents R1's new fall intervention is to place R1 in an area to be supervised. R1's Accident/Incident Report dated 3-30-15 at 8:33 p.m., documents R1 was observed on the floor in R1's room, with bleeding and a left eyebrow laceration measuring approximately two cm (centimeters) long. This same report documents that there were no witnesses to the fall, and R1 was sent to the hospital emergency department for evaluation where R1 was admitted with a [DIAGNOSES REDACTED]. R1's Final Report Investigation dated 3-31-15 and signed by E2 (Director of Nursing), documents on 3-30-15 that E8 (Licensed Practical Nurse) had given E10 (Certified Nursing Assistant/CNA) instructions to place R1 at the nurses' station where R1 could be directly observed by the nursing staff due to R1's risk of falls. This same report documents E10 then took R1 to R1's room and placed R1 in a wheelchair with R1's feet propped up on the bed, resulting in R1's fall. This same report documents E10 was suspended from work on 3-31-15 to 4-2-15 due to E10's unsatisfactory performance. R1's Emergency Department Notes dated 3-30-15 and signed by Z3 (Hospital Emergency Department Physician), documents R1 fell from a seated position in R1's wheelchair, at the facility, resulting in a left eyebrow laceration and a moderate sized subdural hematoma. E10's Employee Warning Notice dated 3-31-15 and signed by E2, documents the following: E10 stated E10 left R1 alone in R1's room with R1's legs propped up on the bed. R1 fell and suffered a serious injury. R1 is a high risk for falls and had safety measures in place that were not followed. E10 is suspended from work from 3-31-15 to 4-2-15. R1's Accident/Incident Report dated 4-27-15, documents R1 was on the floor in R1's room. This same report documents that facility staff were counseled on making sure the bed sensor is on R1's bed, and staff discipline was taken. E11's (Certified Nursing Assistant) Employee Warning Notice documents E11 received a written notice violation for R1's incident on 4-27-15, in which E11 left R1's bed sensor in the wheelchair and did not place it on R1's bed. On 5-13-15 at 2:20 p.m., E10 (CNA) stated,"They (the facility) suspended me for taking (R1) to (R1's) room where (R1) sustained a fall on 3-30-15. The nurse had told me to leave (R1) at the nurses' station so the nurse could watch (R1), but the nurse was not there, so I took (R1) to (R1's) room. I propped (R1's) feet up on the bed. (R1) was antsy, fidgety, and wanted to get up prior to the fall. I was unable to calm (R1). I went up the hall from (R1), when (R1) fell in (R1's) room." On 5-12-15 at 11:10 a.m., E2 (Director of Nursing) stated, "When (R1) fell on [DATE], the interventions were to keep (R1) some place where (R1) could be supervised and remind (R1) not to get up. (R1) should be somewhere we (the facility) can supervise (R1), anytime (R1) is up in the wheelchair. When (R1) fell on [DATE], (R1) was taken to (R1's) room. That is not what (E10/CNA) was suppose to do. (E10) had been given strict instructions per (E8/Licensed Practical Nurse) to put (R1) at the nurses' station, but (E10) took (R1) to (R1's) room unsupervised, and propped (R1's) feet up on the bed. That is not what (E10) was suppose to do. This resulted in (R1) falling in (R1's) room and sustaining a serious injury of a subdural hematoma. (E10) was suspended for an unsatisfactory performance. (E10) did not follow the direction of the nurse. (E10) knew (R1) was suppose to be placed at the nurses' desk, and was just told prior to (R1's) fall." On 5-14-15 at 10:40 a.m., Z4 (R1's Primary Care Physician) verified that the facility should not have left R1 in R1's room unsupervised. Z4 stated, "I am big about safety of the residents."

Based on observation, interview, and record review, the facility failed to assess significant weight loss and hydration status for one of three residents (R1) reviewed for hydration in the sample of three. These failures resulted in R1 becoming acutely ill, and requiring hospitalization for Severe Dehydration and [MEDICAL CONDITION] (Increased Sodium Level). Findings include: On 5-13-15 at 9:00 a.m., R1 was lying in a hospital bed receiving intravenous fluids. R1 was very pale, thin, and frail. R1's Physician order [REDACTED]. R1's CAA (Care Area Assessment) Worksheet dated 2-24-15, indicates (R1) is dependent upon staff for fluid intake, (R1) is at risk for dehydration, and a dehydration/fluid maintenance care plan should be addressed at risk for dehydration. R1's Dehydration Risk Screener dated 5-7-15, documents R1 is at risk for dehydration. R1's Weights and Vitals Summary documents the following: 2-17-15 weight 136 lbs. (pounds). 3-13-15 weight 126.8 lbs. (-5.0% (percent) change to comparison weight on 2-17-15). 4-9-15 weight 123 lbs. (-7.5% change since comparison weight on 2-17-15). 4-23-15 weight 134 lbs (Re-admission weight from hospital). 4-30-15 125 lbs. (6.7% weight loss in one week as comparison to the 4-23-15 weight). R1's Dietary Note dated 4-15-15 and signed by Z5 (Registered Dietician) documents, "(R1) had a weight loss of 7.5% in two months since admission to the facility. (R1) has a history of [MEDICAL CONDITION]. Recommend weekly weights and monthly labs to monitor progress." R1's Weight Loss Care Plan dated 3-2-15, does not include any further weight loss interventions, since initiated on 3-2-15. R1's Progress Notes dated 5-8-15 from 7:09 a.m. to 7:54 a.m., document R1's skin as pale and warm to touch, bowel sounds hypoactive, heart rate irregular, and a decreased pulse oximetry, requiring R1 to be sent to the emergency department. R1's Hospital Emergency Department Notes dated 5-8-15 and signed by Z2 (R1's Emergency Department Attending Physician), document R1 was admitted to the Emergency Department with Severe Dehydration and [MEDICAL CONDITION]. R1's Complete Metabolic Panel lab dated 5-8-15, documents R1's sodium level at 147 (normal range 135-145). On 5-12-15 at 2:10 p.m., E6 (Certified Nursing Assistant/CNA) stated, "I took care of (R1) frequently. (R1) was very weak one week prior to hospitalization . (R1) seemed dehydrated. (R1) was always asking for food and water. (R1's) lips were cracking. (R1's) mouth was very dry. (R1's) tongue was very dry and had white film on it." On 5-12-15 at 11:10 a.m., E2 (Director of Nursing) stated,"(R1's) significant weight loss of 134 pounds on 4-23-14 to 122 pounds on 5-17-15, has not been reported to the physician yet. We (facility staff) have our weight meetings monthly, but have not had a meeting this month. We (the facility) have not done any new nutritional interventions for (R1) since (R1's) admission in February." On 5-12-15 at 1:30 p.m., E3 (Dietary Manager) stated, "(R1) weighed 135 pounds in February and was 126.8 pounds in March. That was (R1's) first significant weight loss. On 5-7-15, (R1) had a significant weight loss of 10.3 percent from three months prior. I usually tell (E2/Director of Nursing) or (E7/Assistant Director of Nursing) when a resident has a significant weight loss, and they (E2 or E7) notify the physician. I have never notified the physician of (R1's) weight loss. (R1) has not had any new weight loss interventions since (R1's) significant weight losses in March 2015, and May 7th, 2015." On 5-12-15 at 2:15 p.m., E7 (Assistant Director of Nursing/ADON) stated, "I was off of work the week of 4-30-15, so I did not get (R1's) weight put into the computer system that week. (R1's) weight went from 134 pounds (week of 4-23-15) to 125 pounds (week of 4-30-15) in one week. If the weekly weight of 125 pounds was put into the computer on 4-30-15, we (facility staff) would have known (R1) had a significant weight loss in one week, and the physician, dietician, and family would have been notified, but were not. (R1's) weight the week of 4-23-15 of 134 pounds was a re-admission weight from (R1) being in the hospital." On 5-13-15 at 11:30 a.m., Z2 (R1's Emergency Department Physician) stated, "(R1's) mouth was very dry, with lots of mucus. (R1) had not been getting enough fluids when (R1) was sent to the emergency roiagnom on [DATE]. (R1's) sodium level remained high, even after receiving intravenous fluids in the ambulance on the way to the hospital." On 5-13-15 at 11:00 a.m., E9 (Licensed Practical Nurse) stated, "We (facility staff) would have to clean (R1's) tongue a lot, because it was so dry. (R1) always asked for drinks. (R1) was very pale." On 5-13-15 at 1:20 p.m., E7 (Assistant Director of Nursing) stated, "Weight meeting are held once a month, and this is when the physician is notified of weight loss. Whoever does the weight charting is responsible for notifying the physician. I did not do (R1's) weight charting or notify (R1's) physician of (R1's) weight loss. (E3/Dietary Manager) is responsible for notifying the registered dietician of weight loss." On 5-13-15 at 2:20 p.m., E10 (Certified Nursing Assistant) stated, "(R1) had looked like (R1) had lost weight. (R1) was always hungry. (R1) was dehydrated." On 5-14-15 at 10:40 a.m., Z4 (R1's Primary Physician) stated, "I have not been notified of (R1) having significant weight losses. I would have expected to be notified. Had I been notified, I would have increased (R1's) caloric intake and fluids. (R1's) dehydration could have been prevented. There is no reason a resident fed by a [DEVICE] (gastrostomy tube) should become dehydrated or have a weight loss. Now that weights are on the facility's computer, I no longer see the residents' weight logs when I make rounds." On 5-14-15 at 1:45 p.m., E12 (Care Plan Coordinator) stated, "(R1) should have had a dehydration care plan, but does not. I did not do a hydration assessment assessment until 5-7-15. (R1) should have had a hydration assessment done on admission (2-17-15) since (R1) has a gastrostomy tube." On 5-14-15 at 1:45 p.m., E2 (Director of Nursing) verified that R1 did not have a hydration assessment done before 5-7-15, or a dehydration care plan, and should have. On 5-14-15 at 2:30 p.m., Z5 (Registered Dietician) stated, "(R1) had a significant weight loss from 4-23-15 to 4-30-15. An action the facility could have taken was to notify myself or my colleague so we could review (R1's) current diet order, labs, and weight history. I have no record of that happening. When I know of weight loss, I make further recommendations to adjust the tube feeding or the water flushes accordingly. The physician should be notified within 24 to 48 hours of the facility knowing of a weight loss." The facility's Nutritional Policy dated 3/2000, documents resident's are to receive sufficient fluid intake to maintain proper hydration. The facility's Weight Policy dated 10-17-2014, documents a significant weight change is as follows: If being weighed weekly, a 2% (percent) in one week. 5% in one month. 7.5% or more in three months. 10% or more in six months. Within a week, after weights have been received by the nursing department and dietary manager, the weight committee will meet to discuss and recommend the need for any possible dietary interventions or diet order changes. If the dietician is present in the facility, the committee will consult the dietician. If not, the committee will notify the physician for the possibility of new orders.

Based on record reviews and interviews the facility failed prevent one of three sampled residents (R2) from falling out of bed while providing incontinent cares. R2 sustained a left distal impacted femur fracture. Findings include: R2's current Minimum Data Set ((MDS) dated [DATE] notes R2's bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) as needing extensive assistance of two staff. MDS notes R2's weight is 311 pounds. Facility Accident/Incident Report for R2 dated 11/9/14 reads, "Resident (R2) fell out of low air mattress bed onto floor yelling and complaining of left leg pain. Left side [DIAGNOSES REDACTED] from CVA. States she was grabbing for table. Lifted off floor by (Mechanical Lift) and put back to bed. Left leg having more pain and externally rotated." Local Hospital Emergency Department report dated 11/9/14 noted R2 to be oriented to person, place and time. Report reads, "Pt (R2) reports that she fell out of bed this morning while her Aide (E5 Certified Nurse's Aide) was cleaning her up and pushed her a little too hard to one side. fell out of bed onto her left side. Having left hip pain now. Felt like her knee went pop." Emergency report note dated 11/9/14 at 5:07 P.M. reads, "Left Knee xray reviewed showing left distal impacted femur fracture." On 11/18/14 at 1:58 P.M. E5 stated that while performing incontinent care on R2, E5 rolled R2 away from E5 onto R2's right side. E5 said, "I was not paying attention to (R2's) feet while I turned her and that's when she rolled out of bed."

Based on interview and record review the facility failed to follow recommended supervision and verbal cues while eating for one resident (R1) with a history of choking. R1 was found unresponsive after being given a peanut butter sandwich and subsequently died as a result. R1 is one of four residents in the sample and 19 residents in the supplemental sample reviewed for mechanical diets. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the implementation of protocols and oversight visits. FINDINGS INCLUDE: R1's Resident Admission Information sheet documents that R1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. R1 had a documented history of choking as evidenced by nurses notes dated [DATE], when R1 was found sitting in the wheel chair in the hallway, not breathing. R1 was transferred to the local hospital emergency room where it was documented, " (R1) presents for choking episode at nursing home after being given a peanut butter sandwich as an evening snack at 7:30 P.M." R1's current care plan, dated [DATE] includes the following problems: "Swallowing problem: Resident choked on peanut butter sandwich." It also includes the following approaches: " Cut up resident's food in small bites and cue to place on middle of tongue. Cue resident to chew well. Watch for safe swallow before next bite...". R1's Nurses notes dated [DATE] document, " Noted resident ask CNA for a snack and CNA gave resident a peanut butter and jelly sandwich. Up in (R1)'s (wc) wheel chair by the shower room, near the nurse's station. The CNA gave (R1) the sandwich and went down to continue (to) pass snack to other resident. It took approximately 20 (min) minutes to pass and then the CNA had returned and noted resident was blue and gave a sternal rub and rub face. (R1) did not respond.Started CPR (Cardio Pulmonary Resuscitation). 911 called. Police and rescue team arrived and took over CPR.Coroner arrived...(Physician) called.Coroner removed body out of facility." On [DATE] at 4:45 P.M., E9 CNA (Certified Nursing Assistant) stated, " On April twenty eighth, I worked second shift that night. I was assigned the snack cart. (R1) was sitting in (R1)'s wheel chair in B hall, down by the showers. (R1) said 'Can I have a snack?' I gave (R1) a peanut butter sandwich...I went down the hall with the snack cart and when I came back ten or twelve minutes later, (R1) was unresponsive. I yelled for the nurse and she started working on (R1). I feel really bad, Because (R1) had this same problem before with a peanut butter sandwich. No one ever told me (R1) couldn't have a peanut butter sandwich though." On [DATE] at 8:30 P.M., E2 DON (Director of Nurses) stated, "(R1) had two episodes of choking on a peanut butter sandwich, about a year apart. I don't know why the staff kept giving (R1) peanut butter sandwiches." R1's Medical Examiner/ Coroner Certificate of Death (date issued [DATE]) lists cause of death as "aspiration of food bolus." On [DATE] at 3:00 P.M. an Immediate Jeopardy was identified to have begun on [DATE] when staff failed to follow care plan interventions for supervising and assessing R1 while eating a peanut butter sandwich. On [DATE] at 3:05 P.M. E2 (Director of Nurses) was notified of the Immediate Jeopardy. The surveyor confirmed through observation, interview and record review the facility took the following actions to remove the Immediate Jeopardy: 1. Initiated [DATE]. Completed [DATE]. Nursing and Activity staff have received education regarding residents diets. This education was provided by the Dietary Manager and Restorative Nurse. Information covered include: *Resident's diets and snacks will be provided to the nursing department in a notebook at the nurses' station. The diets will be updated immediately following a diet order change. * The activity department will also be provided with a list of diets and snacks updated immediately following a diet change order. * All residents who either receive an activity snack or HS snack are to be given the snack in the dining room under the supervision of staff. If a resident is room bound staff must be present in the room with them until they finish their snack. * A copy of the care plan written for any resident who has been identified as being at risk for having an eating or swallowing deficit will be placed in front of the diet order book at the nurses station. These care plans will be reviewed and updated by the IDT as changes occur. * When a resident begins to show signs of eating or swallowing problems they will be referred to the speech therapist for evaluation. * Facility staff will follow recommendations of the speech therapist and include those interventions on the care plan. 2. Initiated [DATE]. Completed [DATE]. Like residents were identified as those being at risk for having an eating or swallowing deficit. Their care plans were reviewed for accuracy and updated as necessary. 3. The facility Quality Assurance Committee will meet on a quarterly basis and review this protocol and make changes as necessary. 4. The Administrator will be responsible to oversee completion of all the above interventions and assuring that compliance is maintained.

Based on observation, interview, and record review the facility failed to identify the physically aggressive behaviors of two residents, R18 and R23, toward other residents as abuse, and failed to put interventions in place to protect the other facility residents from being repeatedly subjected to abusive behaviors by R18 and R23. R18 and R17, a severely cognitively-impaired resident, were roommates. Staff (E16) witnessed R18 hitting R17 in the chest on one occasion, resulting in R17 being sent to the local hospital emergency department and being diagnosed with [REDACTED]." R18 is ambulatory and had a history of [REDACTED]. R18 was witnessed hitting another resident (R39) in the dining room on another occasion. R23 had two incidents of being physically aggressive to other residents, with the second incident resulting in pelvic fracture for R13, after being pushed to the ground by R23. These failures have the potential to effect all 82 residents in the facility. These failures resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 8-14-13, the facility remains out of compliance at severity Level Two. Additional time is needed for the facility to complete staff education on behavioral monitoring, monitor the effectiveness of the implementation of protocols, and for oversight visits. Findings include: 1. A physician's orders [REDACTED]. The POS documents that R18 has medications which include: [MEDICATION NAME] 1 mg (Milligram) intramuscularly injection to be given every six hours as needed for 72 hours dated 8-08-13, [MEDICATION NAME] 2 mg three times daily, [MEDICATION NAME] 100 mg two times daily, Klonopin 1 mg three times daily. The POS also included an order for [REDACTED]. A Minimum Data Set (MDS) Assessment, dated 6-20-13, documents that R18 is moderately cognitively impaired, independently mobile, and displayed verbal behavioral symptoms directed toward others four to six days per week. The MDS documents that R18's behaviors, "Put others at significant risk for physical injury...Significantly disrupt care or living environment." Nurse's Notes, dated 9/2012 through 12/2012, document that the first incident of R18, "trying to hit another resident," was 12-03-12. The remaining Nurse's Notes, dated 12/2012 to 8/2013, document multiple, frequent incidents of R18 hitting or attempting to hit facility staff and residents, entering resident rooms uninvited, throwing dishes, kicking, or attempting to hit others with R18's walker. A facility incident report, dated 12-19-12, documents that R18 was, "hitting and kicking staff with closed hand and other residents." The incident report also indicates that R18 was witnessed kicking E27 (Registered Nurse). The incident report documents that R18 was removed, "from hostile environment to prevent harm from self and others." A facility incident report, dated 3-18-13 documents that, "Another resident (R18) hit R39 on the back of the neck for no reason... R39 was sitting in reclining wheel chair in dining room." The incident report documents that, "Staff (counseled) on keeping R18 away from the other resident (R39) as much as possible and monitor closely when they are in the same room." A second incident report for the same incident, dated 3-19-13, documents that R18 also was attempting to, "kick another staff and resident." The incident report documented E 28 (Certified Nurse Aide), "Was in the dining area and resident hit at me twice and tried to kick me..." A facility incident report, dated 8-12-13, documents that R18, "Entered another resident's room (R21) and struck R21 on the left forearm for an unknown reason. When asked why R18 did it, R18 said, 'I had to,' Neither resident was injured." The incident report indicates that the "recommended steps to prevent recurrence" included, "R18 had recent med increase. R18 is to be redirected when going down hall and kept from going into others rooms without permission. When R18 is having behaviors redirect to R18's room or the nearest quiet place. Resident on 30 minute checks." A facility incident report dated 8-13-13 documents that, "E14 (Assistant Director of Nurses) observed R18 running into another resident (R28) unintentionally with R18's walker pushing R28 up against the wall...(R18) also approached E14 in the medication room and struck E14 on the left wrist with R18's hand." A care plan dated 9-13-12 documents that R18, "...has a history of verbal and physical aggression...R18 does not like to be touched...hits staff, throws trays." R18's behavior care plan interventions include: "explain R18 cannot use physical aggression and the importance of not being verbally or physically aggressive to anyone." The care plan also includes the intervention of providing, "1 to 1" supervision for R18 "Daily and as needed." On 8-13-13 at 11:30 AM. R18 was in the hallway in front of the nurse's station. R18 was yelling unintelligibly while pushing R28 against the wall with a walker. E14 (Assistant Director of Nurses) approached R18 and loudly stated to R18, Don't do that." and led R18 down the hall towards R18's room. On 8-14-13 at 9:05 AM. R21 stated that on 8-12-13 R18 entered R21's room and hit R21 in the arm. R21 stated that R18 has hit R21 at least four to five times in the past. R21 stated, "(R18) just rams me with the walker hard enough that if I was using my cane I would have gone down." R21 stated that, "(R18) is far too dangerous." R21 stated that when R18 hit R21 on the arm facility staff removed R18 from R21's room while at the same time telling R18, "(R18) couldn't get any pudding or something." R21 stated, "I do everything to avoid (R18) but (R18) comes up behind me. (R18) lives right by me and (R18) will see me come out of my room then (R18) will come right out and come after me" R21 stated, "I'm [AGE] years old and I've never been bullied until now." On 8-14-13 at 11:00 AM. E9 (Registered Nurse), E16, and E17 (Certified Nurse Aides) were at the nurses station. E9 stated that R18's behaviors had increased recently but that R18's behaviors were actually just getting back to normal now that R18's medical problems were improving. E17 stated that R18 had hit E2 (Director of Nurses)and E17 on 8-09-13 and had hit E17 also on 8-13-13. E17 stated, "(R18) got E2 last Friday and got me last Friday too. (R18) got me yesterday too." E17 stated, "Back about a month ago (R18) came up behind me and hit me on my back." E16 stated, "(R18)threw a walker at my back and on 8-09-13, (R18) came from behind and tried to hit me on my back." E16 stated, "And he tried to choke me." E16 stated that the incident had not been documented on an incident report because, "I knew that was just his behavior." E9 stated that some of R18's behaviors were because R18 wanted chocolate pudding stating, "I just walk R18 back to R18's room and give R18 what R18 wants." On 8-14-13 at 2:55 PM. E14 ( Assistant Director of Nurse's) stated that when R18 becomes agitated, threatens to hit or kick, or actually hits or kicks staff and residents, R18 is redirected to R18's room. E14 stated that R18, "gets better for awhile then gets aggressive. (R18) doesn't pick his people, it's just anyone who is near. (R18) will say, 'I need to hit you." R17's Nurse's Notes dated 8/12/13 at 5:50 p.m. document "it was brought to my attention a softball size lump had appeared on R17's left upper chest. It was not there during 2:30 p.m. rounds." The Nurse's Note at 7:15 p.m. documents "now bruised and appeared larger." R17's note at 7:15 p.m. documents "now bruised and appeared larger. send to emergency for evaluation, possible fractured rib." R17's Resident Transfer Form from the facility to the emergency room , dated 8/12/13 at 5:50 p.m., documents " injury of unknown origin, left upper chest, soft ball sized bump." R17's Preliminary Field Medical Report, dated 8/12/13, documents "hematoma above left nipple, bruise." R17's Emergency Transport Patient Care Report documents "large hematoma above left nipple, contusions and bruising all over body." The form documents chest, upper left arm and upper left leg as "soft tissue swelling and bruising." This form also documents under the Narrative section "(R17) was found laying in bed in the facility. "large [MEDICAL CONDITION] lump above left nipple up to shoulder about the size of a baseball. Patient (R17) also has bruising to his left upper arm and all across his chest. There is also bruising noted on legs. RN (Registered Nurse) stated being unsure of what happened to the patient but whatever occurred must have happened between 2 PM and 5 p.m. that day (8/12/13)." R17's Summary of Current hospitalization emergency room Note, dated 8/12/13, documents R17 was admitted from the facility with left chest hematoma. It also documents, "The emergency room staff contacted elder abuse hotline due to multiple ecchymotic(bruising) areas to skin and concern for abuse." Under the section of this form titled Assessment it documents "left chest hematoma, uncertain etiology, multiple bruises on body, social services following regarding potential elder abuse." R17's hospital record documents "5 inch diameter hematoma on left anterior chest. Ecchymosis (bruising) in left axillary region. Ecchymosis on right anterior chest wall. Multiple small [MEDICAL CONDITION] over legs." On 8/13/13 at 9:22 AM, Z2 (Admitting emergency room Physician) confirmed that the above-referenced note accurately represents R17's condition on admission to the emergency room . On 8/13/13 at 11:45 AM, R17 was unable to respond appropriately to questions and just repeated "yes." R17 had a softball size raised area on R17's left upper chest. R17 had dark purple bruising in the left axilla which extended down to the elbow. R17's entire left bicep area was bruised. R17 had scattered bruising all the way across the chest just below the nipple line. R17's left foot had purple bruising starting at the left great toe and extending up the length of the foot about 1 1/2-2 inches wide. R17 had a pea sized scabbed area on the left great toe and left knee. On 8/13/13 at 12:45 p.m. E13 (Nurse) stated that on 8/12/13 at 2:30 p.m. R17 was fine but when E15/CNA (Certified Nursing Assistant) got R17 up for dinner is when a red flat areas were discovered on R17's left chest, "don't know what it was, no one heard any noise or commotion from R17 and R18's room." E13 stated E2 (Director of Nursing) instructed E13 to chart the red area as an injury of unknown origin. E13 stated after dinner E13 reexamined R17 and found the red area to be bruised. E13 stated being "at loss as to what happened to R17." On 8/13/13 a signed statement by E15 CNA (Certified Nursing Assistant) documented on 8/12/13 at 5:30 p.m. E15 went to get R17 up for dinner and noticed a large bump on R17's left chest. E15 asked R17 what happened and R17 stated "(R18) been hitting me." On 8/14/13 at 11:00 a.m. E16/CNA stated the following: Last Friday (8/9/13), between 9:45 a.m. and 10:00 a.m., E13 (Nurse) asked for help because R18 was in his room fighting with R17. E16 saw R18 hit R17. E13 (Nurse) directed E16 to get R17 up and out of his room because R18 was hitting R17 in his chest. E16 started getting R17 up and E13 had to hold R18 back so the staff could get R17 up. E13 also saw R18 hit R17. On 8/14/13 at 11:00 a.m. E9/LPN (Licensed Practical Nurse) stated the following: Last Friday (8/9/13) E13 (Nurse) had staff get R17 up and out of is room because R18 was hitting R17 in the chest. E9 saw R18 hit R17. E13 (Nurse) asked for help because R18 was fighting with R17 and E13 had to hold R18 so staff could get R17 up. 2. R23's POS dated 3-1-13, documents R23 had [DIAGNOSES REDACTED]. R23 was discharged from the facility on 7-7-13. R23's Nurse's Notes, dated 12-21-12 at 2:45 a.m., document R23 hit R40 in the mouth because R40 took R23's radio and ate R23's food. The accident report does not include interventions to prevent a recurrence of R23's behaviors. R23's nurse's notes dated 1-8-13 at 8:00 a.m., document R23 was "yelling and telling people to get out of the room." A facility report dated 3-26-13 at 9:43 a.m. and signed by E2 (Director of Nursing), documents on 3-25-13 at 5:45 p.m., R13, who has a [DIAGNOSES REDACTED]. R23 became upset because R13 entered the room and R23 pushed R13 down to the floor. R13 was sent to the emergency room for complaints of right hip pain. R13's pelvis and right hip x-ray dated 3-25-13, documents R13 had two acute fractures of the pelvis. The facility report documents R23 was ticketed for battery and given a notice to appear in court. R23's Nurse's Notes, dated 3-25-13 at 5:45 p.m., document R23 "got mad" because another resident came into R23's room, and R23 pushed the resident (R13) down. The 3-25-13 Nurse's Notes document R23 felt no remorse and R23 stated, "No one should come into my room." On 8-14-13 at 9:15 a.m., E6 (CNA) stated R23 would curse and fight with staff and residents almost everyday. E6 stated the residents were scared of R23. On 8-14-13 at 10:30 a.m., E9 (Licensed Practical Nurse/LPN) stated R23 was physically and verbally abusive to residents and staff. R23 stated if other residents entered R23's room, R23 would push the residents out of the room and throw things at them. On 8-15-13 at 1:15 p.m., E26 (Social Rehabilitation Worker) stated R23's interventions to deal with behaviors were talking with R23 and telling R23 "you can't hurt people." E26 stated "I was unaware of (R23) ever hitting other residents." E26 stated no new interventions were implemented on R23's care plan when R23 was verbally and physically aggressive towards R40 on 12-21-12 or towards R13 on 3-25-13. On 8-13-13 at 2:40 p.m., E1/Administrator stated R23 was known to not like other residents in R23's room or space. On 8-13-13 at 11:10 AM, E1 stated that none of the incidents listed above were reported or investigated as abuse because the incidents were due to "behaviors" On 08/14/13 at 1:00 p.m. an Immediate Jeopardy was identified to have begun on 12-03-12 when R18 was identified as having assualtive behaviors towards other residents. On 08/14/13 at 1:15 p.m. E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1) Amendment of the facility Abuse Policy to reflect throughout the policy that the facility Administrator will be notified immediately if there is a suspected case of abuse. This same policy also includes notification of state agency (IDPH) as soon as possible. 2) Education of staff on policy changes and expectations of all staff members with regard to notifying Administrator and IDPH of suspected abuse. 3) R18 has been removed from the building and admitted for a psychiatric evaluation. A notice of immediate discharge has been given. 4) Facility form to include a mechanism of staff reporting for the person suspecting abuse to fill out and give to the approprate person in charge at the time of the suspected abuse. Education of staff on this form was completed. 5) Establishment of an Abuse Prevention Compliance Committee who will meet after every suspected allegation of abuse and is responsible for gathering all information, interview, investigation and reporting of their findings to the Administrator. Effective 08/14/13. 6) New form for notification of IDPH. One form will be an initial report form that will be used to do the inital notification to the deparment while the other form is for notification of the final results of the investigation.. Effective 08/14/13. 7) Prescreening of all potential residents by the IDT (Interdisciplinary Team) prior to admission to determine the risk to abuse/be abused. 8) Immediate care planning of all residents with the potential to be abused. 9) Risk assessment for abuse is to be done on all current residents. An aggression and violence screening form will also be completed. Any deficits identified in these areas will be addressed on the residents care plan to maintain safety for all residents. Completion date 08/21/13.

Based on interview and record review the facility failed to investigate and report all allegations of suspected abuse and injury of unknown origin immediately to the administrator and state agency as required by facility policy for three of four residents (R13, R17, R21) reviewed for abuse in the sample of 17 and eight residents in the supplemental sample (R28, R31, R33, R34, R37, R38, R39 R40). These failures resulted in immediate jeopardy. While the immediate jeopardy was removed on 8/14/13, the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of the inservices conducted. 1.R23's Nurse's Notes, dated 12-21-12 at 2:45 a.m., document R23 hit R40 in the mouth because R40 took R23's radio and ate R23's food. The accident report does not include interventions to prevent a recurrence of R23's behaviors. A facility report dated 3-26-13 at 9:43 a.m. and signed by E2 (Director of Nursing), documents on 3-25-13 at 5:45 p.m., R13, who has a [DIAGNOSES REDACTED]. R23 became upset because R13 entered the room and R23 pushed R13 down to the floor. R13 was sent to the emergency room for complaints of right hip pain. R13's pelvis and right hip x-ray dated 3-25-13, documents R13 had two acute fractures of the pelvis. The facility report documents R23 was ticketed for battery and given a notice to appear in court. R23's Nurse's Notes, dated 3-25-13 at 5:45 p.m., document R23 "got mad" because another resident came into R23's room, and R23 pushed the resident (R13) down. The 3-25-13 Nurse's Notes document R23 felt no remorse and R23 stated, "No one should come into my room." On 8-13-13 at 2:40 p.m., E1/Administrator stated R23 was known to not like other residents in R23's room or space. 2. A facility incident report, dated 3-18-13 documents that, "Another resident (R18) hit R39 on the back of the neck for no reason... R39 was sitting in reclining wheel chair in dining room." The incident report documents that, "Staff (counseled) on keeping R18 away from the other resident (R39) as much as possible and monitor closely when they are in the same room." A second incident report for the same incident, dated 3-19-13, documents that R18 also was attempting to, "kick another staff and resident." The incident report documented E 28 (Certified Nurse Aide), "Was in the dining area and resident hit at me twice and tried to kick me..." A facility incident report, dated 8-12-13, documents that R18, "Entered another resident's room (R21) and struck R21 on the left forearm for an unknown reason. When asked why R18 did it, R18 said, 'I had to,' Neither resident was injured." The incident report indicates that the "recommended steps to prevent recurrence" included, "R18 had recent med increase. R18 is to be redirected when going down hall and kept from going into others rooms without permission. When R18 is having behaviors redirect to R18's room or the nearest quiet place. Resident on 30 minute checks." A facility incident report dated 8-13-13 documents that, "E14 (Assistant Director of Nurses) observed R18 running into another resident (R28) unintentionally with R18's walker pushing R28 up against the wall...(R18) also approached E14 in the medication room and struck E14 on the left wrist with R18's hand." On 8-13-13 at 11:30 AM. R18 was in the hallway in front of the nurse's station. R18 was yelling unintelligibly while pushing R28 against the wall with a walker. E14 (Assistant Director of Nurses) approached R18 and loudly stated to R18, Don't do that." and led R18 down the hall towards R18's room. On 8-14-13 at 9:05 AM. R21 stated that on 8-12-13 R18 entered R21's room and hit R21 in the arm. R21 stated that R18 has hit R21 at least four to five times in the past. R21 stated, "(R18) just rams me with the walker hard enough that if I was using my cane I would have gone down." R21 stated that, "(R18) is far too dangerous." R21 stated that when R18 hit R21 on the arm facility staff removed R18 from R21's room while at the same time telling R18, "(R18) couldn't get any pudding or something." R21 stated, "I do everything to avoid (R18) but (R18) comes up behind me. (R18) lives right by me and (R18) will see me come out of my room then (R18) will come right out and come after me" R21 stated, "I'm [AGE] years old and I've never been bullied until now." R17's Nurse's Notes dated 8/12/13 at 5:50 p.m. document "it was brought to my attention a softball size lump had appeared on R17's left upper chest. It was not there during 2:30 p.m. rounds." The Nurse's Note at 7:15 p.m. documents "now bruised and appeared larger." R17's note at 7:15 p.m. documents "now bruised and appeared larger. send to emergency for evaluation, possible fractured rib." R17's Resident Transfer Form from the facility to the emergency room , dated 8/12/13 at 5:50 p.m., documents " injury of unknown origin, left upper chest, soft ball sized bump." R17's Preliminary Field Medical Report, dated 8/12/13, documents "hematoma above left nipple, bruise." R17's Emergency Transport Patient Care Report documents "large hematoma above left nipple, contusions and bruising all over body." The form documents chest, upper left arm and upper left leg as "soft tissue swelling and bruising." This form also documents under the Narrative section "(R17) was found laying in bed in the facility. "large [MEDICAL CONDITION] lump above left nipple up to shoulder about the size of a baseball. Patient (R17) also has bruising to his left upper arm and all across his chest. There is also bruising noted on legs. RN (Registered Nurse) stated being unsure of what happened to the patient but whatever occurred must have happened between 2 PM and 5 p.m. that day (8/12/13)." R17's Summary of Current hospitalization emergency room Note, dated 8/12/13, documents R17 was admitted from the facility with left chest hematoma. It also documents, "The emergency room staff contacted elder abuse hotline due to multiple ecchymotic(bruising) areas to skin and concern for abuse." Under the section of this form titled Assessment it documents "left chest hematoma, uncertain etiology, multiple bruises on body, social services following regarding potential elder abuse." R17's hospital record documents "5 inch diameter hematoma on left anterior chest. Ecchymosis (bruising) in left axillary region. Ecchymosis on right anterior chest wall. Multiple small [MEDICAL CONDITION] over legs." On 8/13/13 at 9:22 AM, Z2 (Admitting emergency room Physician) confirmed that the above-referenced note accurately represents R17's condition on admission to the emergency room . On 8/13/13 at 11:45 AM, R17 was unable to respond appropriately to questions and just repeated "yes." R17 had a softball size raised area on R17's left upper chest. R17 had dark purple bruising in the left axilla which extended down to the elbow. R17's entire left bicep area was bruised. R17 had scattered bruising all the way across the chest just below the nipple line. R17's left foot had purple bruising starting at the left great toe and extending up the length of the foot about 1 1/2-2 inches wide. R17 had a pea sized scabbed area on the left great toe and left knee. On 8/13/13 at 12:45 p.m. E13 (Nurse) stated that on 8/12/13 at 2:30 p.m. R17 was fine but when E15/CNA (Certified Nursing Assistant) got R17 up for dinner is when a red flat areas were discovered on R17's left chest, "don't know what it was, no one heard any noise or commotion from R17 and R18's room." E13 stated E2 (Director of Nursing) instructed E13 to chart the red area as an injury of unknown origin. E13 stated after dinner E13 reexamined R17 and found the red area to be bruised. E13 stated being "at loss as to what happened to R17." On 8/13/13 a signed statement by E15 CNA (Certified Nursing Assistant) documented on 8/12/13 at 5:30 p.m. E15 went to get R17 up for dinner and noticed a large bump on R17's left chest. E15 asked R17 what happened and R17 stated "(R18) been hitting me." On 8/14/13 at 11:00 a.m. E16/CNA stated the following: Last Friday (8/9/13), between 9:45 a.m. and 10:00 a.m., E13 (Nurse) asked for help because R18 was in his room fighting with R17. E16 saw R18 hit R17. E13 (Nurse) directed E16 to get R17 up and out of his room because R18 was hitting R17 in his chest. E16 started getting R17 up and E13 had to hold R18 back so the staff could get R17 up. E13 also saw R18 hit R17. On 8/14/13 at 11:00 a.m. E9/LPN (Licensed Practical Nurse) stated the following: Last Friday (8/9/13) E13 (Nurse) had staff get R17 up and out of is room because R18 was hitting R17 in the chest. E9 saw R18 hit R17. E13 (Nurse) asked for help because R18 was fighting with R17 and E13 had to hold R18 so staff could get R17 up. On 8-13-13 at 11:10 AM, E1 stated that none of the incidents listed above in examples 1 and 2 were reported or investigated as abuse because the incidents were due to "behaviors". 3. A facility incident report dated 6/9/13 at 7:30 PM documents R33 was found on the floor unresponsive with a laceration to the left eye. R33 was sent to the hospital and found to have a Intercranial Hemorrhage. E1 did not sign the form until 6/10/13. IDPH was not notified until 6/10/13 at 9:43 a.m. O8-13-13 at 11:10 AM, E1 stated that this injury of unknown origin was not investigated as possible abuse. 4. R31's incident report dated 3/1/13 at 3:45 p.m. documents R31 was noted to have swelling and bruising to the 4th finger on the left hand which was later found to be fractured. The incident report under the section titled "describe exactly what you observed or heard" documented "unable to make statement clear, stated she sleeps and had nightmares and that is how it happened, no witnesses." R31's Physician order [REDACTED]. R31's history and physical documents R31 has [MEDICAL CONDITION], hallucinations, poor judgement, poor memory, verbal aggression and flight of ideas. An abuse investigation was not completed. E1 (Administrator) signed the incident form on 3/4/13. The incident form was faxed to IDPH 3/4/13, 3 days after the injury of unknown origin occurred. On 8/13/13 at 11:10 a.m. E1 (Administrator) stated E1 did not investigate this bruising and swelling as abuse because "you just have to know her (R31)." 5. A facility incident report dated 5/1/13 documents R32 punched R 34 in the head 3 times and then R32 pushed R34's wheelchair causing the wheelchair to propel. R32's history and physical documents R32 has a history of verbal and physical aggression and of making false accusations. R32 ' s care plan includes no documentation of review or new intervention after the 5-1-13 incident. An abuse investigation was not initiated. The incident form was not signed by E1 and IDPH was not notified until 5/2/13, 1 day later. On 8/13/13 at 11:10 a.m. E1 confirmed that the incident was not reported or investigated as abuse and stated "well, they are boyfriend and girlfriend." 6. A facility incident report dated 6/18/13 at 1:00 p.m. documents R38 grabbed R37's walker, R37 then struck R38 in the eye. R38 then threw water on R37. E1 ' s signature on the incident report form is dated 6/19/13. IDPH was notified of the incident via fax on 6/19/13 at 10:10 a.m. The care plan for R38 includes no documentation of review or new intervention after the 6-18-13 incident. On 8/13/13 at 11:10 a.m. E1 confirmed that the incident was not reported or investigated as abuse. On 08/14/13 at 1:00 PM an Immediate Jeopardy was identified to have begun on 12-03-12 when R18 was identified as having assualtive behaviors towards other residents. On 08/14/13 at 1:15PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1) Amendment of the facility Abuse Policy to reflect throughout the policy that the facility Administrator will be notified immediately if there is a suspected case of abuse. This same policy also includes notification of state agency (IDPH) as soon as possible. 2) Education of staff on policy changes and expectations of all staff members with regard to notifying Administrator and IDPH of suspected abuse. 3)R18 has been removed from the building and admitted for a psychiatric evaluation. A notice of immediate discharge has been given. 4) Facility form to include a mechanism of staff reporting for the person suspecting abuse to fill out and give to the approprate person in charge at the time of the suspected abuse. Education of staff on this form was completed. 5) Establishment of an Abuse Prevention Compliance Committee who will meet after every suspected allegation of abuse and is responsible for gathering all information, interview, investigation and reporting of their findings to the Administrator. Effective 08/14/13. 6) New form for notification of IDPH. One form will be an initial report form that will be used to do the inital notification to the deparment while the other form is for notification of the final results of the investigation.. Effective 08/14/13. 7) Prescreening of all potential residents by the IDT (Interdisciplinary Team) prior to admission to determine the risk to abuse/be abused. 8) Immediate care planning of all residents with the potential to be abused. 9) Risk assessment for abuse is to be done on all current residents. An aggression and violence screening form will also be completed. Any deficits identified in these areas will be addressed on the residents care plan to maintain safety for all residents. Completion date 08/21/13.

I. Based on observation, interview and record review the facility failed to recognize the physically aggressive behaviors of four residents, R18, R23, R32 and R38, as abuse, resulting in further failure by the facility to do the following: A.Failure to protect three of three (R13, R17 and R21) residents who were victims of aggression on the sample of 17 and three residents who were victims of aggression (R28, R39 and R40) on the supplemental sample; B.Failure to investigate incidents of aggression or injury of unknown origin for three of three residents (R13, R17 and R21) who were victims of aggression on the sample of 17 and seven residents (R28, R31, R33 ,R34, R37, R39 and R40) on the supplemental sample; and C.Failure to report abuse or injuries of unknown origin to the facility administrator and state agency immediately for three of three residents (R13, R17 and R21) who were victims of aggression on the sample of 17 and seven residents (R28, R31, R33 ,R34, R37, R39 and R40) on the supplemental sample. These failures resulted in immediate jeopardy. While the immediate jeopardy was removed on 8-14-13, the facility remains out of compliance at severity level two. Additional time is need to monitor the effectiveness of the inservices conducted. Based on interview and record review, the facility also failed to report missing narcotic medications to the state agency for one of one incidents involving missing medications. Findings include: 1.R23's POS dated 3-1-13, documents R23 had [DIAGNOSES REDACTED]. R23 was discharged from the facility on 7-7-13. R23's Nurse's Notes, dated 12-21-12 at 2:45 a.m., document R23 hit R40 in the mouth because R40 took R23's radio and ate R23's food. The accident report does not include interventions to prevent a recurrence of R23's behaviors. R23's nurse's notes dated 1-8-13 at 8:00 a.m., document R23 was "yelling and telling people to get out of the room." A facility report dated 3-26-13 at 9:43 a.m. and signed by E2 (Director of Nursing), documents on 3-25-13 at 5:45 p.m., R13, who has a [DIAGNOSES REDACTED]. R23 became upset because R13 entered the room and R23 pushed R13 down to the floor. R13 was sent to the emergency room for complaints of right hip pain. R13's pelvis and right hip x-ray dated 3-25-13, documents R13 had two acute fractures of the pelvis. The facility report documents R23 was ticketed for battery and given a notice to appear in court. R23's Nurse's Notes, dated 3-25-13 at 5:45 p.m., document R23 "got mad" because another resident came into R23's room, and R23 pushed the resident (R13) down. The 3-25-13 Nurse's Notes document R23 felt no remorse and R23 stated, "No one should come into my room." On 8-14-13 at 9:15 a.m., E6 (CNA) stated R23 would curse and fight with staff and residents almost everyday. E6 stated the residents were scared of R23. On 8-14-13 at 10:30 a.m., E9 (Licensed Practical Nurse/LPN) stated R23 was physically and verbally abusive to residents and staff. R23 stated if other residents entered R23's room, R23 would push the residents out of the room and throw things at them. On 8-15-13 at 1:15 p.m., E26 (Social Rehabilitation Worker) stated R23's interventions to deal with behaviors were talking with R23 and telling R23 "you can't hurt people." E26 stated "I was unaware of (R23) ever hitting other residents." E26 stated no new interventions were implemented on R23's care plan when R23 was verbally and physically aggressive towards R40 on 12-21-12 or towards R13 on 3-25-13. On 8-13-13 at 2:40 p.m., E1/Administrator stated R23 was known to not like other residents in R23's room or space. 2. A physician's orders [REDACTED]. The POS documents that R18 has medications which include: [MEDICATION NAME] 1 mg (Milligram) intramuscularly injection to be given every six hours as needed for 72 hours dated 8-08-13, [MEDICATION NAME] 2 mg three times daily, [MEDICATION NAME] 100 mg two times daily, Klonopin 1 mg three times daily. The POS also included an order for [REDACTED]. A Minimum Data Set (MDS) Assessment, dated 6-20-13, documents that R18 is moderately cognitively impaired, independently mobile, and displayed verbal behavioral symptoms directed toward others four to six days per week. The MDS documents that R18's behaviors, "Put others at significant risk for physical injury...Significantly disrupt care or living environment." Nurse's Notes, dated 9/2012 through 12/2012, document that the first incident of R18, "trying to hit another resident," was 12-03-12. The remaining Nurse's Notes, dated 12/2012 to 8/2013, document multiple, frequent incidents of R18 hitting or attempting to hit facility staff and residents, entering resident rooms uninvited, throwing dishes, kicking, or attempting to hit others with R18's walker. A facility incident report, dated 12-19-12, documents that R18 was, "hitting and kicking staff with closed hand and other residents." The incident report also indicates that R18 was witnessed kicking E27 (Registered Nurse). The incident report documents that R18 was removed, "from hostile environment to prevent harm from self and others." A facility incident report, dated 3-18-13 documents that, "Another resident (R18) hit R39 on the back of the neck for no reason... R39 was sitting in reclining wheel chair in dining room." The incident report documents that, "Staff (counseled) on keeping R18 away from the other resident (R39) as much as possible and monitor closely when they are in the same room." A second incident report for the same incident, dated 3-19-13, documents that R18 also was attempting to, "kick another staff and resident." The incident report documented E 28 (Certified Nurse Aide), "Was in the dining area and resident hit at me twice and tried to kick me..." A facility incident report, dated 8-12-13, documents that R18, "Entered another resident's room (R21) and struck R21 on the left forearm for an unknown reason. When asked why R18 did it, R18 said, 'I had to,' Neither resident was injured." The incident report indicates that the "recommended steps to prevent recurrence" included, "R18 had recent med increase. R18 is to be redirected when going down hall and kept from going into others rooms without permission. When R18 is having behaviors redirect to R18's room or the nearest quiet place. Resident on 30 minute checks." A facility incident report dated 8-13-13 documents that, "E14 (Assistant Director of Nurses) observed R18 running into another resident (R28) unintentionally with R18's walker pushing R28 up against the wall...(R18) also approached E14 in the medication room and struck E14 on the left wrist with R18's hand." A care plan dated 9-13-12 documents that R18, "...has a history of verbal and physical aggression...R18 does not like to be touched...hits staff, throws trays." R18's behavior care plan interventions include: "explain R18 cannot use physical aggression and the importance of not being verbally or physically aggressive to anyone." The care plan also includes the intervention of providing, "1 to 1" supervision for R18 "Daily and as needed." On 8-13-13 at 11:30 AM. R18 was in the hallway in front of the nurse's station. R18 was yelling unintelligibly while pushing R28 against the wall with a walker. E14 (Assistant Director of Nurses) approached R18 and loudly stated to R18, Don't do that." and led R18 down the hall towards R18's room. On 8-14-13 at 9:05 AM. R21 stated that on 8-12-13 R18 entered R21's room and hit R21 in the arm. R21 stated that R18 has hit R21 at least four to five times in the past. R21 stated, "(R18) just rams me with the walker hard enough that if I was using my cane I would have gone down." R21 stated that, "(R18) is far too dangerous." R21 stated that when R18 hit R21 on the arm facility staff removed R18 from R21's room while at the same time telling R18, "(R18) couldn't get any pudding or something." R21 stated, "I do everything to avoid (R18) but (R18) comes up behind me. (R18) lives right by me and (R18) will see me come out of my room then (R18) will come right out and come after me" R21 stated, "I'm [AGE] years old and I've never been bullied until now." On 8-14-13 at 11:00 AM. E9 (Registered Nurse), E16, and E17 (Certified Nurse Aides) were at the nurses station. E9 stated that R18's behaviors had increased recently but that R18's behaviors were actually just getting back to normal now that R18's medical problems were improving. E17 stated that R18 had hit E2 (Director of Nurses)and E17 on 8-09-13 and had hit E17 also on 8-13-13. E17 stated, "(R18) got E2 last Friday and got me last Friday too. (R18) got me yesterday too." E17 stated, "Back about a month ago (R18) came up behind me and hit me on my back." E16 stated, "(R18)threw a walker at my back and on 8-09-13, (R18) came from behind and tried to hit me on my back." E16 stated, "And he tried to choke me." E16 stated that the incident had not been documented on an incident report because, "I knew that was just his behavior." E9 stated that some of R18's behaviors were because R18 wanted chocolate pudding stating, "I just walk R18 back to R18's room and give R18 what R18 wants." On 8-14-13 at 2:55 PM. E14 ( Assistant Director of Nurse's) stated that when R18 becomes agitated, threatens to hit or kick, or actually hits or kicks staff and residents, R18 is redirected to R18's room. E14 stated that R18, "gets better for awhile then gets aggressive. (R18) doesn't pick his people, it's just anyone who is near. (R18) will say, 'I need to hit you." R17's Nurse's Notes dated 8/12/13 at 5:50 p.m. document "it was brought to my attention a softball size lump had appeared on R17's left upper chest. It was not there during 2:30 p.m. rounds." The Nurse's Note at 7:15 p.m. documents "now bruised and appeared larger." R17's note at 7:15 p.m. documents "now bruised and appeared larger. send to emergency for evaluation, possible fractured rib." R17's Resident Transfer Form from the facility to the emergency room , dated 8/12/13 at 5:50 p.m., documents " injury of unknown origin, left upper chest, soft ball sized bump." R17's Preliminary Field Medical Report, dated 8/12/13, documents "hematoma above left nipple, bruise." R17's Emergency Transport Patient Care Report documents "large hematoma above left nipple, contusions and bruising all over body." The form documents chest, upper left arm and upper left leg as "soft tissue swelling and bruising." This form also documents under the Narrative section "(R17) was found laying in bed in the facility. "large [MEDICAL CONDITION] lump above left nipple up to shoulder about the size of a baseball. Patient (R17) also has bruising to his left upper arm and all across his chest. There is also bruising noted on legs. RN (Registered Nurse) stated being unsure of what happened to the patient but whatever occurred must have happened between 2 PM and 5 p.m. that day (8/12/13)." R17's Summary of Current hospitalization emergency room Note, dated 8/12/13, documents R17 was admitted from the facility with left chest hematoma. It also documents, "The emergency room staff contacted elder abuse hotline due to multiple ecchymotic(bruising) areas to skin and concern for abuse." Under the section of this form titled Assessment it documents "left chest hematoma, uncertain etiology, multiple bruises on body, social services following regarding potential elder abuse." R17's hospital record documents "5 inch diameter hematoma on left anterior chest. Ecchymosis (bruising) in left axillary region. Ecchymosis on right anterior chest wall. Multiple small [MEDICAL CONDITION] over legs." On 8/13/13 at 9:22 AM, Z2 (Admitting emergency room Physician) confirmed that the above-referenced note accurately represents R17's condition on admission to the emergency room . On 8/13/13 at 11:45 AM, R17 was unable to respond appropriately to questions and just repeated "yes." R17 had a softball size raised area on R17's left upper chest. R17 had dark purple bruising in the left axilla which extended down to the elbow. R17's entire left bicep area was bruised. R17 had scattered bruising all the way across the chest just below the nipple line. R17's left foot had purple bruising starting at the left great toe and extending up the length of the foot about 1 1/2-2 inches wide. R17 had a pea sized scabbed area on the left great toe and left knee. On 8/13/13 at 12:45 p.m. E13 (Nurse) stated that on 8/12/13 at 2:30 p.m. R17 was fine but when E15/CNA (Certified Nursing Assistant) got R17 up for dinner is when a red flat areas were discovered on R17's left chest, "don't know what it was, no one heard any noise or commotion from R17 and R18's room." E13 stated E2 (Director of Nursing) instructed E13 to chart the red area as an injury of unknown origin. E13 stated after dinner E13 reexamined R17 and found the red area to be bruised. E13 stated being "at loss as to what happened to R17." On 8/13/13 a signed statement by E15 CNA (Certified Nursing Assistant) documented on 8/12/13 at 5:30 p.m. E15 went to get R17 up for dinner and noticed a large bump on R17's left chest. E15 asked R17 what happened and R17 stated "(R18) been hitting me." On 8/14/13 at 11:00 a.m. E16/CNA stated the following: Last Friday (8/9/13), between 9:45 a.m. and 10:00 a.m., E13 (Nurse) asked for help because R18 was in his room fighting with R17. E16 saw R18 hit R17. E13 (Nurse) directed E16 to get R17 up and out of his room because R18 was hitting R17 in his chest. E16 started getting R17 up and E13 had to hold R18 back so the staff could get R17 up. E13 also saw R18 hit R17. On 8/14/13 at 11:00 a.m. E9/LPN (Licensed Practical Nurse) stated the following: Last Friday (8/9/13) E13 (Nurse) had staff get R17 up and out of is room because R18 was hitting R17 in the chest. E9 saw R18 hit R17. E13 (Nurse) asked for help because R18 was fighting with R17 and E13 had to hold R18 so staff could get R17 up. On 8-13-13 at 11:10 AM, E1 stated that none of the incidents listed above in examples 1 and 2 were reported or investigated as abuse because the incidents were due to "behaviors". 3. A facility incident report dated 6/9/13 at 7:30 PM documents R33 was found on the floor unresponsive with a laceration to the left eye. R33 was sent to the hospital and found to have a Intercranial Hemorrhage. E1 did not sign the form until 6/10/13. IDPH was not notified until 6/10/13 at 9:43 a.m. O8-13-13 at 11:10 AM, E1 stated that this injury of unknown origin was not investigated as possible abuse. 4. R31's incident report dated 3/1/13 at 3:45 p.m. documents R31 was noted to have swelling and bruising to the 4th finger on the left hand which was later found to be fractured. The incident report under the section titled "describe exactly what you observed or heard" documented "unable to make statement clear, stated she sleeps and had nightmares and that is how it happened, no witnesses." R31's Physician order [REDACTED]. R31's history and physical documents R31 has [MEDICAL CONDITION], hallucinations, poor judgement, poor memory, verbal aggression and flight of ideas. An abuse investigation was not completed. E1 (Administrator) signed the incident form on 3/4/13. The incident form was faxed to IDPH 3/4/13, 3 days after the injury of unknown origin occurred. On 8/13/13 at 11:10 a.m. E1 (Administrator) stated E1 did not investigate this bruising and swelling as abuse because "you just have to know her (R31)." 5. A facility incident report dated 5/1/13 documents R32 punched R 34 in the head 3 times and then R32 pushed R34's wheelchair causing the wheelchair to propel. R32's history and physical documents R32 has a history of verbal and physical aggression and of making false accusations. R32 ' s care plan includes no documentation of review or new intervention after the 5-1-13 incident. An abuse investigation was not initiated. The incident form was not signed by E1 and IDPH was not notified until 5/2/13, 1 day later. On 8/13/13 at 11:10 a.m. E1 confirmed that the incident was not reported or investigated as abuse and stated "well, they are boyfriend and girlfriend." 6. A facility incident report dated 6/18/13 at 1:00 p.m. documents R38 grabbed R37's walker, R37 then struck R38 in the eye. R38 then threw water on R37. E1 ' s signature on the incident report form is dated 6/19/13. IDPH was notified of the incident via fax on 6/19/13 at 10:10 a.m. The care plan for R38 includes no documentation of review or new intervention after the 6-18-13 incident. On 8/13/13 at 11:10 a.m. E1 confirmed that the incident was not reported or investigated as abuse. On 08/14/13 at 1:00 PM an Immediate Jeopardy was identified to have begun on 12-03-12 when R18 was identified as having assualtive behaviors towards other residents. On 08/14/13 at 1:15PM E1/Administrator was notified of the Immediate Jeopardy. The surveyor confirmed through record review and interview that the facility took the following actions to remove the Immediate Jeopardy: 1) Amendment of the facility Abuse Policy to reflect throughout the policy that the facility Administrator will be notified immediately if there is a suspected case of abuse. This same policy also includes notification of state agency (IDPH) as soon as possible. 2) Education of staff on policy changes and expectations of all staff members with regard to notifying Administrator and IDPH of suspected abuse. 3 )R18 has been removed from the building and admitted for a psychiatric evaluation. A notice of immediate discharge has been given. 4) Facility form to include a mechanism of staff reporting for the person suspecting abuse to fill out and give to the approprate person in charge at the time of the suspected abuse. Education of staff on this form was completed. 5) Establishment of an Abuse Prevention Compliance Committee who will meet after every suspected allegation of abuse and is responsible for gathering all information, interview, investigation and reporting of their findings to the Administrator. Effective 08/14/13. 6) New form for notification of IDPH. One form will be an initial report form that will be used to do the inital notification to the deparment while the other form is for notification of the final results of the investigation.. Effective 08/14/13. 7) Prescreening of all potential residents by the IDT (Interdisciplinary Team) prior to admission to determine the risk to abuse/be abused. 8) Immediate care planning of all residents with the potential to be abused. 9) Risk assessment for abuse is to be done on all current residents. An aggression and violence screening form will also be completed. Any deficits identified in these areas will be addressed on the residents care plan to maintain safety for all residents. Completion date 08/21/13. The Facility's investigation narrative documents the missing [MEDICATION NAME] investigation was initiated on 7/1/13. The investigation documents on 6/30/13 the narcotic count for [MEDICATION NAME] was incorrect and it was reported to E2 DON. On 8/21/13 E1 (Administrator) stated about 1 month ago [MEDICATION NAME] ([MEDICATION NAME]) came up missing from a medication cart. E1 stated around the same time there was a question about liquid [MEDICATION NAME] due to 2 different colored bottles. E1 stated at that time E1 decided to involve the state police and have the state police come into the facility to complete an investigation. E1 stated the State Police interviewed and investigated.. E1 stated the medication incident was not reported to the state agency. On 8/21/13 at 1:20 p.m. E2 DON (Director of Nursing) stated the suspected missing medications were not reported to the state agency.

Based on observation, interview, and record review the facility failed to re-assess and implement individualized interventions for two of seven residents (R13 and R18) requiring increased supervision in the sample of 17 and one resident requiring increased supervision on the supplemental sample (R23). This failure resulted in R18 being physically aggressive to staff and multiple residents including R17, who sustained a hematoma to the left chest and soft tissue swelling and bruising all over the body. The failure also resulted in R23 pushing R13 down and causing a pelvic fracture to R13. Findings include: 1. A physician's orders [REDACTED]. The POS documents that R18 has medications which include: Ativan 1 mg (Milligram) intramuscularly injection to be given every six hours as needed for 72 hours dated 8-08-13, Risperidone 2 mg three times daily, Lamictal 100 mg two times daily, Klonopin 1 mg three times daily. The POS also included an order for [REDACTED]. A Minimum Data Set (MDS) Assessment, dated 6-20-13, documents that R18 is moderately cognitively impaired, independently mobile, and displayed verbal behavioral symptoms directed toward others four to six days per week. The MDS documents that R18's behaviors, "Put others at significant risk for physical injury...Significantly disrupt care or living environment." Nurse's Notes, dated 9/2012 through 12/2012, document that the first incident of R18 becoming combative was 9-07-12. The Nurse's Notes document the first incident of R18, "trying to hit another resident," was 12-03-12. The remaining Nurse's Notes, dated 12/2012 to 8/2013, document multiple, frequent incidents of R18 hitting or attempting to hit facility staff and residents, entering resident rooms uninvited, throwing dishes, kicking, or attempting to hit others with R18's walker. A facility incident report, dated 12-19-12, documents that R18 was, "hitting and kicking staff with closed hand and other residents." The incident report also indicates that R18 was witnessed kicking E27 (Registered Nurse). The incident report documents that R18 was removed, "from hostile environment to prevent harm from self and others." A facility incident report, dated 3-18-13 documents that, "Another resident (R18) hit R39 on the back of the neck for no reason... R39 was sitting in reclining wheel chair in dining room." The incident report documents that, "Staff (counseled) on keeping R18 away from the other resident (R39) as much as possible and monitor closely when they are in the same room." A second incident report for the same incident, dated 3-19-13, documents that R18 also was attempting to, "kick another staff and resident." The incident report documented E 28 (Certified Nurse Aide), "Was in the dining area and resident hit at me twice and tried to kick me..." A facility incident report, dated 8-12-13, documents that R18, "Entered another resident's room (R21) and struck R21 on the left forearm for an unknown reason. When asked why R18 did it, R18 said, 'I had to,' Neither resident was injured." The incident report indicates that the "recommended steps to prevent recurrence" included, "R18 had recent med increase. R18 is to be redirected when going down hall and kept from going into others rooms without permission. When R18 is having behaviors redirect to R18's room or the nearest quiet place. Resident on 30 minute checks." A facility incident report dated 8-13-13 documents that, "E14 (Assistant Director of Nurses) observed R18 running into another resident (R28) unintentionally with R18's walker pushing R28 up against the wall...(R18) also approached E14 in the medication room and struck E14 on the left wrist with R18's hand." A care plan dated 9-13-12 documents that R18, "...has a history of verbal and physical aggression...R18 does not like to be touched...hits staff, throws trays." R18's behavior care plan interventions include: "explain R18 cannot use physical aggression and the importance of not being verbally or physically aggressive to anyone." The care plan also includes the intervention of providing, "1 to 1" supervision for R18 "Daily and as needed." On 8-13-13 at 11:30 AM. R18 was in the hallway in front of the nurse's station. R18 was yelling unintelligibly while pushing R28 against the wall with a walker. E14 (Assistant Director of Nurses) approached R18 and loudly stated to R18, Don't do that." and led R18 down the hall towards R18's room. On 8-14-13 at 9:05 AM. R21 stated that on 8-12-13 R18 entered R21's room and hit R21 in the arm. R21 stated that R18 has hit R21 at least four to five times in the past. R21 stated, "(R18) just rams me with the walker hard enough that if I was using my cane I would have gone down." R21 stated that, "(R18) is far too dangerous." R21 stated that when R18 hit R21 on the arm facility staff removed R18 from R21's room while at the same time telling R18, "(R18) couldn't get any pudding or something." R21 stated, "I do everything to avoid (R18) but (R18) comes up behind me. (R18) lives right by me and (R18) will see me come out of my room then (R18) will come right out and come after me" R21 stated, "I'm [AGE] years old and I've never been bullied until now." On 8-14-13 at 11:00 AM. E9 (Registered Nurse), E16, and E17 (Certified Nurse Aides) were at the nurses station. E9 stated that R18's behaviors had increased recently but that R18's behaviors were actually just getting back to normal now that R18's medical problems were improving. E17 stated that R18 had hit E2 (Director of Nurses)and E17 on 8-09-13 and had hit E17 also on 8-13-13. E17 stated, "(R18) got E2 last Friday and got me last Friday too. (R18) got me yesterday too." E17 stated, "Back about a month ago (R18) came up behind me and hit me on my back." E16 stated, "(R18)threw a walker at my back and on 8-09-13, (R18) came from behind and tried to hit me on my back." E16 stated, "And he tried to choke me." E16 stated that the incident had not been documented on an incident report because, "I knew that was just his behavior." E9 stated that some of R18's behaviors were because R18 wanted chocolate pudding stating, "I just walk R18 back to R18's room and give R18 what R18 wants." On 8-14-13 at 2:55 PM. E14 ( Assistant Director of Nurse's) stated that when R18 becomes agitated, threatens to hit or kick, or actually hits or kicks staff and residents, R18 is redirected to R18's room. E14 stated that R18, "gets better for awhile then gets aggressive. (R18) doesn't pick his people, it's just anyone who is near. (R18) will say, 'I need to hit you." R17's Nurse's Notes dated 8/12/13 at 5:50 p.m. document "it was brought to my attention a softball size lump had appeared on R17's left upper chest. It was not there during 2:30 p.m. rounds." The Nurse's Note at 7:15 p.m. documents "now bruised and appeared larger." R17's note at 7:15 p.m. documents "now bruised and appeared larger. send to emergency for evaluation, possible fractured rib." R17's Resident Transfer Form from the facility to the emergency room , dated 8/12/13 at 5:50 p.m., documents " injury of unknown origin, left upper chest, soft ball sized bump." R17's Preliminary Field Medical Report, dated 8/12/13, documents "hematoma above left nipple, bruise." R17's Emergency Transport Patient Care Report documents "large hematoma above left nipple, contusions and bruising all over body." The form documents chest, upper left arm and upper left leg as "soft tissue swelling and bruising." This form also documents under the Narrative section "(R17) was found laying in bed in the facility. "large edematous lump above left nipple up to shoulder about the size of a baseball. Patient (R17) also has bruising to his left upper arm and all across his chest. There is also bruising noted on legs. RN (Registered Nurse) stated being unsure of what happened to the patient but whatever occurred must have happened between 2 PM and 5 p.m. that day (8/12/13)." R17's Summary of Current hospitalization emergency room Note, dated 8/12/13, documents R17 was admitted from the facility with left chest hematoma. It also documents, "The emergency room staff contacted elder abuse hotline due to multiple ecchymotic(bruising) areas to skin and concern for abuse." Under the section of this form titled Assessment it documents "left chest hematoma, uncertain etiology, multiple bruises on body, social services following regarding potential elder abuse." R17's hospital record documents "5 inch diameter hematoma on left anterior chest. Ecchymosis (bruising) in left axillary region. Ecchymosis on right anterior chest wall. Multiple small lesions over legs." On 8/13/13 at 9:22 AM, Z2 (Admitting emergency room Physician) confirmed that the above-referenced note accurately represents R17's condition on admission to the emergency room . On 8/13/13 at 11:45 AM, R17 was unable to respond appropriately to questions and just repeated "yes." R17 had a softball size raised area on R17's left upper chest. R17 had dark purple bruising in the left axilla which extended down to the elbow. R17's entire left bicep area was bruised. R17 had scattered bruising all the way across the chest just below the nipple line. R17's left foot had purple bruising starting at the left great toe and extending up the length of the foot about 1 1/2-2 inches wide. R17 had a pea sized scabbed area on the left great toe and left knee. On 8/13/13 at 12:45 p.m. E13 (Nurse) stated that on 8/12/13 at 2:30 p.m. R17 was fine but when E15/CNA (Certified Nursing Assistant) got R17 up for dinner is when a red flat areas were discovered on R17's left chest, "don't know what it was, no one heard any noise or commotion from R17 and R18's room." E13 stated E2 (Director of Nursing) instructed E13 to chart the red area as an injury of unknown origin. E13 stated after dinner E13 reexamined R17 and found the red area to be bruised. E13 stated being "at loss as to what happened to R17." On 8/13/13 a signed statement by E15 CNA (Certified Nursing Assistant) documented on 8/12/13 at 5:30 p.m. E15 went to get R17 up for dinner and noticed a large bump on R17's left chest. E15 asked R17 what happened and R17 stated "(R18) been hitting me." Attempts to contact E15 were made without success. On 8/14/13 at 11:00 a.m. E16/CNA stated the following: Last Friday (8/9/13), between 9:45 a.m. and 10:00 a.m., E13 (Nurse) asked for help because R18 was in his room fighting with R17. E16 saw R18 hit R17. E13 (Nurse) directed E16 to get R17 up and out of his room because R18 was hitting R17 in his chest. E16 started getting R17 up and E13 had to hold R18 back so the staff could get R17 up. E13 also saw R18 hit R17. On 8/14/13 at 11:00 a.m. E9/LPN (Licensed Practical Nurse) stated the following: Last Friday (8/9/13) E13 (Nurse) had staff get R17 up and out of is room because R18 was hitting R17 in the chest. E9 saw R18 hit R17. E13 (Nurse) asked for help because R18 was fighting with R17 and E13 had to hold R18 so staff could get R17 up. 2. An accident/incident report dated 11-19-13 at 4:30 a.m., documents R23's nurse's notes dated 12-21-12 at 2:45 a.m., document R23 hit R40 in the mouth because R40 took R23's radio and ate R23's food. The accident report does not include interventions to prevent a recurrence of R23's behaviors. R23's POS dated 3-1-13, documents R23 had [DIAGNOSES REDACTED]. R13's current Physician order [REDACTED]. A facility report dated 3-26-13 at 9:43 a.m. and signed by E2 (Director of Nursing), documents on 3-25-13 at 5:45 p.m., R13 walked into R23's room. R23 became upset because R13 entered the room and R23 pushed R13 down to the floor. R13 was sent to the emergency room for complaints of right hip pain. The facility report documents R23 was ticketed for battery and given a notice to appear in court. R13's pelvis and right hip x-ray dated 3-25-13, documents R13 had two acute fractures of the pelvis. R13's accident/incident report dated 3-25-13 does not include new interventions to keep R13 from wandering into other resident rooms. R13's current care plan does not include interventions to address R13 wandering in and out of other resident rooms. On 8-13-13 at 1:30 p.m., E17 (Certified Nursing Aide/CNA) stated R13 is confused and has always propelled self in a wheelchair up and down the hallway and into other resident rooms. On 8-15-13 at 1:15 p.m., E26 (Social Rehabilitation Worker) stated no interventions have been implemented with the facility staff or on R13's care plan to address R13 wandering in and out of resident rooms. E26 states, "I was not even aware that R13 wanders in and out of resident rooms." On 8-13-13 at 2:40 p.m., E1 (Administrator) stated R13 likes to frequently wander into other resident rooms. R23's nurse's notes dated 1-8-13 at 8:00 a.m., document R23 was "yelling and telling people to get out of the room." R23's nurse's notes dated 3-25-13 at 5:45 p.m., document R23 "got mad" because R13 came into R23's room, and R23 pushed the resident (R13) down. The 3-25-13 nurse's notes document R23 feels no remorse and R23 stated, "No one should come into my room." R23's accident/incident report dated 3-25-13 does not include new interventions to prevent a recurrence of R23's behaviors towards other residents. On 8-14-13 at 9:15 a.m., E6 (CNA) stated R23 would curse and fight with staff and residents almost everyday. E6 stated the residents were scared of R23. On 8-14-13 at 10:30 a.m., E9 (Licensed Practical Nurse/LPN) stated R23 was physically and verbally abuse to residents and staff. R23 stated if other residents entered R23's room, R23 would push the residents out of the room and throw things at them. On 8-15-13 at 1:15 p.m., E26 (Social Rehabilitation Worker) stated R23's interventions to deal with behaviors were basically talking with R23 and telling R23 "you can't hurt people." E26 stated "I was unaware of (R23) ever hitting other residents." E26 stated no new interventions were implemented on R23's care plan regarding R23's verbal and physical behaviors towards R13 on 3-25-13 or towards R40 on 12-21-12. On 8-13-13 at 2:40 p.m., E1 (Administrator) stated R23 was known to not like other residents in R23's room or space.

Based on observation, record review and interview, the facility failed to effectively reposition and provide the necessary care/treatment to promote wound healing and prevent the development of pressure sores for two (R2, R1) of three residents reviewed with pressure sores, in a sample of three. This failure resulted in a deterioration of R2's coccyx/left buttock wound from 1.0cm (centimeters) by 1.0cm on July 18, 2011, to 6.0cm by 6.0cm on August 8, 2011. Findings include: 1. On 8/10/11, at 10:45 a.m., R2 was lying on his back in bed with foam boots on both feet. At 11:03 a.m., E4 (Wound Nurse) lifted R2's gown to expose the site of R2's feeding tube. The area around the feeding tube did not have a dressing and was very red with multiple pin-hole size open areas. Drainage and yellow crust was on the gown at the area of the feeding tube. E4 cleansed the area around the feeding tube and applied a clean dry dressing. E4 then removed R2's foam boots and indicated that R2 should not be wearing the foam boots while in bed. R2 had quarter size red areas on the right and left heel. R2's right foot had multiple areas of discoloration. The ball of R2's right foot had a black area, approximately the size of a nickle, and an oblong shaped red and brown colored area that extended towards the center of the foot. E4 indicated the area on the ball of R2's right foot appeared to have deteriorated from the day before. On 8/10/11, at 11:20 a.m. E5 (Certified Nursing Assistant) and E4 (Wound Nurse) turned R2 to his right side. R2 was incontinent of stool and urine and had visible deep creasing in the skin of his back and buttocks. R2's coccyx had a large open and bleeding wound which extended toward the left, without a dressing. E4 applied the physician ordered dressing. On 8/10/11, at 12:40 p.m., E4 (Wound Nurse) placed a thin pillow under R2's right hip. R2 was not repositioned off of the wound on his coccyx and both heels remained on the mattress. R2 remained in that position until 2:55 p.m. On 8/11/11, at 11:24 a.m., R2 was positioned in bed with a thin pillow under his right arm and hip, not repositioned off of the coccyx wound. R2's feet were straight out, heels flat and foam boots were on both feet. A water gel pad was present, under R2's heels. On 8/11/11, at 12:05 p.m., R2 remained in the same position with the foam boots on both feet. E5 (Certified Nursing Assistant) stated R2 is usually positioned in this manner and indicated she had "forgotten" R2 should not have the foam boots on his feet while in bed. The physician's orders [REDACTED]. A physician's orders [REDACTED]. A telephone order, dated 8/05/11, indicates R2's coccyx wound is to cleansed with normal saline, apply Calcium Alginate, and covered with border foam dressing every day. A telephone order, dated 8/09/11, indicates R2 was started [MEDICATION NAME](antibiotic) 500mg (milligrams) twice per day for treatment of [REDACTED]. The Plan of Care (beginning date of 8/27/08) documents R2 has a history of skin breakdown on the heels dating back to 5/12/2009 and a history of skin breakdown on the coccyx dating back to 8/12/2009. The Plan of Care indicates R2 is to be turned and repositioned every two hours, only wear the foam boots while up in his wheelchair, and to utilize a water gel pad for his heels while in bed. A Minimum Data Set, dated dated [DATE], indicates R2 is at high risk for the development of pressure ulcers and is on a turning/repositioning program. Wound Surveillance Reports document that R2 wound on his coccyx deteriorated from 1.0cm by 1.0cm (Stage II) on 7/18/11 to 6.0cm by 6.0cm by 0.3cm (Stage II) on 8/01/11. On 8/10/11, at 11:20 a.m., E4 (Wound Nurse) stated she did not know why R2's feeding tube site and coccyx pressure sore did not have dressings on them and was unaware the dressings had been removed. On 8/10/11, at 12:15 a.m., E7 (Certified Nursing Assistant) stated she provided incontinence care to R2 at approximately 7:30 a.m. and noted R2's feeding tube site and coccyx did not have a dressing on at that time. E7 stated she informed the "wound nurse" that R2's dressings were missing and then recanted that statement, indicating she did not tell anyone R2's wounds were not dressed. On 8/11/11, at 12:07 p.m., E5 (Certified Nursing Assistant) stated R2 is typically positioned as he had been observed on 8/10/11 and 8/11/11 (on his back, with the thin pillow slightly under his hip, and not completely off of his coccyx). On 8/11/11, at 12:10 p.m., E4 (Wound Nurse) stated R2's coccyx wound has increase from a Stage II to a Stage III, as of 8/10/11. 2. A physician's orders [REDACTED]. The Admission Nursing Assessment, dated 7/11/11, documents R1 skins as being warm and without redness or skin breakdown. The Weekly Wound Documentation Form, indicates R1 developed a Stage II wound (size 9cm by 8 cm) on the left buttock/coccyx area on 7/18/11 and that staff are to reposition R1 "with rounds." The Wound Surveillance Report, dated 8/8/11, documents R1's wound had deteriorated to a Stage III (size 8cm by 8cm by 0.5cm). On 8-10-11, at 10:45 a.m., R1 was turned to right side in bed. At 11:20 a.m., E13 (Certified Nursing Assistant) and E14 (Certified Nursing Assistant) turned and repositioned R1 from the right side to the left side and placed a small flat pillow directly under the coccyx area where R1's pressure ulcer is located. R1 still appeared to be almost flat in the bed, with heels flat on the bed and head facing right. At 12:35 p.m., E6 (Certified Nursing Assistant) and E13 (Certified Nursing Assistant) removed the pillow from underneath R1 and turned R1 to the left side. E6 placed the small flat pillow directly under the coccyx where R1's pressure ulcer is located. R1's heels remained flat on the bed and R1 still appeared to be lying flat. R1 remained in this position until 2:15 p.m.