Every finding on record at Shelbyville Manor

Based on observation, interview, and record reviews, the facility failed to date stored foods when they were opened. This failure has the potential to affect all 80 residents in the facility.The LONG-TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID dated 8/2/26 documents 80 resident residing at the facility.During the brief walk through 8/2/26 it was observed the following food was opened and not dated: In the white freezer there was chocolate ice cream not dated. There were two gallon containers of chocolate milk that were opened and not dated. There was one gallon of 2% milk open and not dated. In the walk-in cooler there was a container of cheddar cheese opened and not dated.There was a container of boiled eggs that were opened and not dated in the walk-in cooler. There was a bag of crab Rangoon and some strawberry ice cream on the floor of the freezer.On 8/3/26 the ice cream and sherbet in the white freezer had not been dated. There was also a bag of blueberries in the freezer opened and not dated.On 8/3/26 at 11:00AM, V24 Dietary Manager verified nothing should be stored on the floor and all food should be dated when they are opened.

Based on observation, interview, and record review the facility failed to provide meals to meet the nutritional needs and preferences of three residents (R40, R54, R53) of three residents reviewed for dietary needs in a sample list of 44 residents.Findings Include:R40's Minimum Data Set, dated [DATE] documents R40 is cognitively intact. R40's Care Plan documents a problem initiated 7/13/26 (R40) has diagnosis of diabetes and is insulin dependent and an approach also dated 7/13/26 Encourage (R40) to stick to diabetic diet and to make proper choices of food.On 8/2/26 at the lunch meal R40 was observed to have a piece of chocolate cake served to R40 without being offered healthier choices. R40 stated R40 would like to be given a choice of something healthier but the staff tell R40 everyone here is on a regular diet. R40 then stated that R40 just eats what they give R40 and proceeded to eat the chocolate cake.On 8/3/26 at the lunch meal R40 was observed to be served peach dump cake for dessert. R40 was not offered healthy alternatives. R40 ate the cake. On 8/3/26 at the lunch meal all residents in the main dining room were getting ham salad, steamed broccoli and cauliflower, naan bread, pickled beets, and peach dump cake. No healthy alternatives were offered.R40's Nurse Practitioner note dated 7/15/26 at 6:36 PM documents R40's Renal Function: Blood glucose is significantly elevated at 440 milligrams per deciliter. This note also documents R40's Hemoglobin A1C has increased to 8.2 (previously 6.7), indication worsening diabetes control over past three weeks. Recommend intensification of the diabetic regimen as above continuing Trulicity, close glucose monitoring, diabetic diet, and repeat Hemoglobin A1C in three months.On 8/3/26 at 10:00AM, V24 Dietary Manager stated, We use a liberalized diet, so everybody just gets the same thing unless they ask for a substitute. The diet list provided by the Dietary Manager documents all residents' diets as regular.On 8/4/26 at 11:01AM, V26 Registered Dietitian stated We do utilize a liberalized diet based on a regular 1800 to 2000 calorie daily diet. For those residents who are diabetic we serve a tray with lower concentrated sweets and offer healthier, lower sugar desserts and beverages or smaller portions of the regular desserts. For residents with cardiac concerns, we discourage the use of table salt. 2. R54's Minimum Data Set (MDS) dated [DATE] documents R54 is cognitively intact. R54's current resident profile documents R54 has Type II Insulin Dependent Diabetes, Chronic Obstructive Heart Disease, and Hypertensive Heart Disease with Heart Failure. On 8/3/26 at lunch, R54 was served the same Peach Dump Cake as all residents were served. R54 stated I have to watch my salt, or I swell up and I can't breathe. I take insulin for my Diabetes too, so all these sweets aren't good for me. When you ask about getting something better for you all the staff just say, 'everybody gets the same thing.' Some staff will try to work with you but not most.3. R53's current Resident Profile documents, R53, has Metastatic Cancer affecting multiple sites. R53's Minimum Data Set (MDS) documents R53 is severely cognitively impaired. On 8/2/26 at 9:17 AM, V14 Power of Attorney for R53 reported being present in the facility daily from 7:00 AM to 8:30 PM. V14 POA stated that R53 recently returned from the hospital with orders for a cardiac diet. V14 reports the facility staff informed V14 that the facility does not provide specialized diets. To ensure compliance with the cardiac diet, the kitchen allows V14 POA to request and obtain specific food items for R53. V14 expressed concerns regarding other residents who may require specialized diets, including residents with diabetes, but who do not have an advocate to request appropriate foods. V14 POA reported that the facility provides texture modifications only and does not offer specialized diets, including diabetic diets. V14 stated that facility staff reported that specialized diets are not provided and that physicians will not prescribe them.The facility's policy Limited Concentrated Sweets/Diabetic Menu Preference Sheet revised October 2021 states It is the policy of the facility to provide the residents with a liberalized diet that has limited dietary modifications. A liberalized diet will improve dietary compliance, enhance caloric and nutrient intake, increase ability to maintain acceptable weight and nutritional status, and improve quality of life for the residents. However, we honor resident and Physician food preferences if they request a Limited Concentrated Sweets/ Diabetic Diet. Documentation and Care Planning by the food service supervisor should include the resident is requesting a Limited Concentrated Sweets/ Diabetic Diet. We continue to serve the residents a regular diet with altered texture if ordered, and follow information on the Limited Concentrated Sweets/ Diabetic Diet Menu Preference sheet.

Based on observation, interview and record review, the facility failed to implement post fall interventions for one resident (R3) of four residents reviewed for falls on the sample list of four residents. R3's fall resulted in spinal fractures and a right ankle fracture which required R3 to wear a back brace, compression wrap to the ankle and a surgical shoe for non-surgical intervention to treat severe pain. R3 sustained severe pain when interventions were not implemented.Findings include:R3's Current admission Diagnoses Sheet dated 4/28/26 upon return from the hospital post-fall 4/16/26 documents the following: Age-Related Osteoporosis with Current Pathological Fracture, Vertebra (e), Subsequent Encounter for Fracture with Routine Healing (Primary), Low Back Pain, Unspecified (Admission), Wedge Compression Fracture of Fourth Lumbar Vertebra, Subsequent Encounter for Fracture with Routine Healing, Long Term (current) use of Anticoagulants, Personal History of (healed) Osteoporosis Fracture, Chronic Atrial Fibrillation, Unspecified, Pain, Unspecified, and Essential (Primary) Hypertension.R3's Minimum Data Set (MDS) dated [DATE] documents R3's Brief Interview of Mental Status score of 13 out of a possible 15, indicating no cognitive impairment.R3's Progress Note dated 04/16/2026 at 09:03 AM documents R3 fell while walking to the bathroom in R3's room. R3 normally ambulates independently with R3's walker. Neuros WNL (Neurological assessment- within normal limits). Vital signs within normal limits (WNL). R3 stated R3 did hit R3's head when R3 fell. Room is clean and free of clutter. R3 was wearing non-skid socks at the time of fall. R3 stated R3 is not sure how R3 fell that it happened too fast. R3 was complaining of very severe back pain, which is not far from R3's baseline as R3 does complain of back pain on a day-to-day basis. R3 was sent out to a local hospital and later transferred to a distant hospital to be evaluated. V21 (R3's) Family Member/Power of Attorney (POA) and V3 Medical Director/Physician were notified.R3's Progress Note dated 04/28/2026 at 10:54AM (twelve days after admission to distant hospital) documents that report was received from the nurse at the distant hospital. R3 was admitted to the hospital on [DATE] after falling at Nursing Home. R3 was noted to have a broken back-had kyphoplasty (medical procedure of the spine) done on 4/27/26 with no complications. Follow up with V29 Orthopedic Physician, needed in two weeks, transport made aware. R3 has a TLSO (Thoracolumbar Sacral Orthosis) back brace to be in place when up. R3 is a two-assist pivot transfer, incontinent of bowel and bladder, and last bowel movement was 4/27/26. Incision to back covered with sterile dressing to be in place until 4/29/26, then leave adhesive strips in place and leave incision open to air. R3 to resume, Coumadin (oral blood thinner/anticoagulant medication) today. CT (Computed Tomography specialized X-ray) of right ankle after fall also showed a displaced fracture. Boot to be worn when walking. Chest Xray showed Pneumonia, and R3 has completed R3's five-day course of antibiotic medication treatment.R3's current Physician Order Sheet (POS) documents: Surgical Incision to back: monitor incision for signs and symptoms of infection. Adhesive bandage strips in place, leave incision open to air, leave adhesive strips in place until they fall off. This should be monitored every shift. R3's same POS documents: Right ankle/foot: Walking Boot (error in documentation as noted in interview below- this should read surgical shoe with ankle wrap) on at all times during transfers/ambulation related to ankle fracture. R3 should wear TLSO (Thoraco-Lumbo-Sacral Orthosis, back) brace when up.R3's same POS identified pain medication that the physician ordered on R3's readmission on [DATE] (R3's post-fall 4/16/26). The POS documents the following:1. Lidocaine adhesive patch medicated; 5 (five) percent; amt (amount): 1 (one); topical, Every 12 hours, 05:00 PM and 05:00 AM (routine).2. Gabapentin capsule; 100 mg (milligrams); amt (amount): 1 (one); orally, at bedtime 08:00 PM. (routine)3. Extra Strength Acetaminophen (acetaminophen) [OTC] (over the counter, no prescription needed) tablet; 500 mg; amt (amount): 1 (one); orally, Twice A Day - PRN (as needed).R3's same POS lists a more potent narcotic pain medication used to treat moderate to moderately severe pain, opioid controlled substance medication is documented as follows: Tramadol - Schedule IV (four) tablet; 50 mg; amt (amount): 1 (one) tablet; orally, Every 6 (six) Hours - PRN (as needed) [DX (Diagnosis): Low back pain, Unspecified-Lumbar Region].R3's corresponding Medication Administration Record (MAR) documents R3 received 17 doses of Tramadol between 5/1/26 - 5/5/26. The same MAR documents the letter P to indicate R3 had pain. The MAR does not document a pain scale measurement to quantify the level of pain being treated with the Tramadol. R3's Care Plan dated 3/20/26 (initial admission prior to fall 4/16/26) documents the following:Problem Start Date: On 03/20/2026, R3 has functional mobility related to medical status. Short Term Goal established stating that R3 will be able to ambulate, with assistance of one staff and walker during this quarter with a target date of 07/06/2026.R3's Care Plan dated 3/20/26 also documents R3 is to complete transfers using a four wheeled walker. It is documented that R1 ambulates independently in room using wheeled walker, with assistance of one when ambulating outside of room.R3's Care Plan dated 3/20/26 states R3 is at risk for falling related to recent (prior to fall, on first admission 3/20/26) Kyphoplasty (spinal procedure to heighten Osteoporotic compression fractures), weakness, pain, and Osteoporosis.This Care Plan also documents on 04/16/2026 (post-fall 4/16) R3 was educated to call before getting up.R3 is at risk for loss of voluntary range of motion to upper and lower extremities related to back pain, recent kyphoplasty, and osteoporosis. R3 will maintain voluntary range of motion of Upper/lower extremities as tolerated. Resident Care InformationPer the care plan, R3 should use a standard wheelchair, with specialty positioning- type cushion to prevent skeletal deformities, footrests, and TLSO brace should be worn when up.On 5/5/26 at 12:30 PM, R3 was partially reclined in a bedside recliner chair. R3's head was elevated approximately 45 degrees. R3 stated R3 can't put R3's brace on by R3's self. R3 stated R3's back is broken in several places. R3 came to the facility for therapy after R3 had surgery on R3's back. R3 had two breaks in R3's spine then. One is in the lower part of the neck, kind of between R3's shoulders. The other one fracture is lower. R3 stated R3 is almost [AGE] years old. R3 stated R3's bones break easily. R3 stated that when R3 fell at the foot of R3's bed, it was no one's fault but R3's own fault. Therapy had just told R3 the day before R3 fell, R3 was cleared to walk in R3's room on R3's own. R3 was going to the bathroom, when R3 lost R3's balance, and fell. R3 stated that R3 also hit R3's head and has a small fracture in R3's right ankle. R3 stated R3 is supposed to wear R3's brace anytime R3 is out of bed. R3 is not sure why the staff took the brace off. R3 stated R3 really wants R3's back to heal, so R3 can go back home. R3 was almost ready to go back home after therapy was completed. Then R3 fell and required more therapy. R3 stated it is not the facility's fault that R3 fell. R3 also reported that R3's knee is sore. R3 reported R3's right knee is bruised pretty good too. R3 reported R3 is supposed to wear a boot, they said in the hospital. R3 stated R3 doesn't know why they said boot, then put this shoe on R3. R3 stated R3 wears this shoe, but R3 really thinks R3 is supposed to have a boot. They had R3's ankle wrapped up good and R3's ankle pain seemed to be a lot less when R3 wore that. All the nurses don't put that on here at the facility per R3's report. R3 does have a bandage on R3's shin. R3 stated R3 banged that up and has a sore area. R3 pulled back the blanket covering R3's right lower leg. R3 remained seated but leaned forward to display R3's right shin bandage, right foot orthopedic shoe and R3's bare right ankle. R3 leaned forward and said Oh, oh, my back hurts so bad without my back brace on. R3 leaned back into the recliner chair, lowered R3's blanket off R3's chest and said I do not have my brace on. It is in the chair (straight back stationery). R3 stated R3 really needs R3's back brace. R3 reported having a lot less pain with the back brace on. R3 stated R3 is hoping it will promote R3's spine to heal, so R3 can go home. R3 didn't know anything more about the boot. R3 reported that the back brace and that wrap with that shoe or whatever they call it makes R3 feel a lot less pain. Sometimes the pain in R3's back is excruciating without the back brace on. R3 reported feeling so much better when R3 wears them. R3 reported feeling more secure, and R3's back is a lot less painful. R3 stated R3 is not sure why, V12 Certified Nursing Assistant (CNA) took the brace off. R3 reported that V12 transferred R3 to the chair, then left R3's room so fast, R3 did not have a chance to tell V12 to put R3's brace back on. R3 stated this has happened several times by a couple of different CNAs. R3 is only supposed to have R3's back brace off when R3 is lying in bed. R3 stated there is no pressure on R3's back when R3 is in bed. R3 stated R3 has a skinned area under the bandage wrap on R3's shin. R3 also stated, this bandage does nothing for my ankle. R3 does take medication for all R3's pain. R3 stated it helps to keep R3 somewhat more comfortable. It is the brace that gives R3 the support and gives R3 the most relief from R3's pain. R3 then asked this surveyor Would you talk to the nurse, let her know I need my back brace on. Also ask her to lower this (bandage) to my ankle look at my sore and knee.On 5/5/26 at 12:40 pm, V13 Registered Nurse (RN) entered R3's room and assessed R3's right kneecap bruising. V13 RN confirmed R3's kneecap was blue and purple and measured approximately, the size of a quarter. R3 stated to V13 that R3's kneecap was tender to the touch. R3 reported R3's low back was hurting terribly at that time. R3 stated that R3 needed R3's brace back on. (R3 pointed to a back brace in the chair approximately two feet from the recliner.) R3 repeated R3 cannot put the brace on by R3's self. V13 stated V13 will get R3 some pain medication and get the back brace back on. V13 RN stated to this surveyor that V13 is not sure if therapy took the brace off. V13 reported R3 had therapy this morning. R3 stated R3 did have it on when R3 did therapy today. A CNA took it off when the unidentified CNA transferred R3 to the recliner. R3 thought R3 was going to put it back on before the unidentified CNA left R3's room. R3 stated the CNA was busy, and left so fast, R3 did not have time to remind the CNA. This has happened several times. R3 stated R3 usually reminds staff to put the back brace back on. R3 wants to heal so, R3 doesn't have pain like this when R3 goes home. V13 RN then stated Absolutely, you (R3) are supposed to be wearing your brace. We (staff) want to make you (R3) stronger and hope those fractures get better so, your (R3) pain diminishes, and you can reach your desired goal to go home. I (V13) don't know about the boot. I'll check into that. V13 RN stated to R3, You absolutely need to wear your back brace when you are out of bed, even when you are seated in the recliner. This is a surgical shoe. I (V13) will find out about the wrap to your ankle. This is not a compression wrap, and it is too high up to be supporting your ankle. I'm (V13) not sure what's under there. I (V13) don't know anything about a tear in your (R3's) skin. I (V13) will check the treatment orders when I'm done passing medications. I (V13) will be back to assess the skin under the dressing on your shin. I (V13) will find out about the boot while I'm gone. V13 then searched in R3's closet and drawers and stated V13 did not see a boot. V13 then returned to V13's medication cart. V13 reviewed R3's computer record and said R3's physician orders, and care plan documented that R3 is always supposed to wear R3's back brace. It also says in the physician orders that R3 is supposed to have a boot. That makes sense, R3 has a right ankle fracture. V13 stated V13 will review all the orders and notes and get back to R3 and see where R3's boot is. It's obviously not in R3's closet. V13 stated V13 will make sure R3 has R3's back brace on, immediately. V13 saw R3's back brace in the chair across from R3's recliner. On 5/5/26 at 12:55 pm, V11 Director of Therapy/ Physical Therapy Assistant (PTA) stated V11 PTA completed R3's therapy this morning. V11 stated at that time R3's back brace and surgical shoe were on. When R3 had completed therapy, both R3's back brace and surgical shoe were on. V11 stated R3 is weight bearing as tolerated and R3's back brace is supposed to remain on, anytime R3 is out of bed. As far as the boot on R3's right foot, R3 was wearing a surgical shoe. V11 stated V11 can show in the notes from the hospital, R3 is to have the surgical shoe, on at all times, with ambulation and transfers. R3 had R3's surgical shoe on during therapy. R3 came back from the hospital with the surgical shoe, not a boot. The orthopedic surgeon is who ordered this. V11 stated V11 will get more information, to confirm orders. On 5/5/26 at 1:10 pm, V12 Certified Nursing Assistant (CNA) stated R3 came back from therapy today, and V12 transferred R3 to R3's recliner. V12 stated that V12 didn't know R3 had to wear R3's back brace all the time. V12 thought R3 would be more comfortable in the recliner with it off. V12 reported V12 removed the brace and pivot transferred R3 to the recliner. R3 seemed okay. As far as V12 knows, R3 doesn't have to wear the back brace all the time. V12 stated that no one has ever told V12 that the brace should be always worn when out of bed. V12 stated that V12 never looked at R3's care plan. V12 stated It's not like we have time to look at all the residents' care plans. As far as R3 wearing a boot, R3 wears an orthopedic shoe. V12 stated V12 has never seen a boot in R3's room, but V12 stated V12 will look for one. R3 is alert and oriented back to R3's usual self. When R3 came back from the hospital after R3's fall, R3 was very confused. V12 stated V12 worked the day R3 fell. When V12 found R3 on the floor at the end of R3's bed that day. R3 said R3 was going to the bathroom when R3 fell. V12 had taken R3 to the bathroom that morning between 6:15 am and 6:45 am because V12 got R3 up for breakfast. Breakfast is served at 7:00 am. Later that morning, when R3 fell R3 did not remember hitting R3's head. Since no one witnessed the fall, neuros (neurological assessment) were done anyway. The nurse did those, and V12 did vital signs (blood pressure, pulse, and respirations). R3 said R3's back was really hurting, but R3 did not mention R3's ankle. Though R3 had complained of back pain after back surgery when R3 first got admitted here on 3/20/26. You could tell by looking at R3's face the pain R3 had when R3 fell was worse. It brought tears to R3's eyes; R3 was hurting so much. V12 stated V12 stayed with R3 until the ambulance came.On 5/6/26 at 3:55 pm, V3 Medical Director stated R3's TLSO (back) brace should be worn, at all times, when R3 is out of bed. V3 confirmed that order includes when R3 is up in R3's recliner and during R3's therapy. V3 confirmed that also R3 required the compression wrap around R3's fractured right ankle and the surgical shoe R3 came from the hospital wearing. V3 also stated These, were ordered to keep R3 as comfortable as possible, until R3 has R3's orthopedic follow-up. Then, the plan may change, based on their findings.On 5/6/26 at 4:40 pm, V9 Licensed Practical Nurse (LPN) stated V9 entered the orders for R3's brace, and R3's ankle boot. V9 also did the assessment when R3 returned from the hospital. R3 did have a compression wrap around R3's ankle, but V9 didn't see an order for that on the discharge papers, received from the hospital. V9 stated that staff doesn't get all the paperwork like the staff used to. R3 had a surgical shoe on, but V9 thought that was considered a boot, when V9 wrote the order. V9 reported that V9 thought R3's TLSO brace was to be worn anytime R3 was out of bed. After V9 talked to the hospital nurse, V9 thought that nurse said the TLSO (back brace) was to be worn just as needed (PRN).

Based on observation, interview and record review, the facility failed to maintain a safe environment, free of an accident hazard for one (R1) of four residents reviewed for falls on the sample list of four residents. R1's fall resulted in a hand laceration that required emergency medical treatment of 15 sutures to repair.Findings include:R1's most recent Diagnoses sheet documents the following: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Laceration of Superficial Palmar Arch of Right Hand, Initial Encounter.R1's most recent Minimum Data Set (MDS) documents the following: Brief Interview of Mental Status (BIMS) score of five out of a possible 15, indicating severe cognitive impairment.R1's same MDS documents R1 required partial/moderate staff assistance with the following: Sit to stand: The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. Toilet transfer: The ability to get on and off a toilet or commode.R1's same MDS documents: R1 had had two falls with no injury during the look back period of the assessment.R1's Care Plan dated 3/12/26 updated 3/29/26 post-fall documents the following:R1 requires use of a wheeled walker for mobility and assistance of one for safety.R1's same care plan documents: R1 is at risk of falling related to recentillness/hospitalization, new environment, history of falls, cognitive status, and impulsivity.R1 is non-compliant with transfer and ambulation program. R1 has a goal to have decreased risk for injury related to falls this quarter which was established on 03/29/2026 (post fall). Staff in-serviced to place R1's walker within reach.R1's Fall Event Progress Notes dated 3/29/2026 at 05:50 PM, documents the following: R1 was seen ambulating to restroom in R1's room without walker with pants lowered to knees/ankles. R1 had on slipper socks at time of incident. V7 Certified Nursing Assistant (CNA) began approaching R1 but could not reach R1 in time to prevent fall. R1 fell to R1's buttocks. R1 attempted to grab the bathroom door handle upon falling. Large laceration to inner right hand. Pressure applied. V3 Medical Director was notified. Orders received to send R1 to Hospital emergency room for evaluation. EMS (Emergency Medical Service/Ambulance) notified of incident, R1's condition and need for transfer to emergency room (ER) for evaluation. V28 (R1's) Family Member/Power of Attorney (POA), were notified of incident and R1's expected transfer to ER. Called report to Hospital Emergency Department to unidentified Registered Nurse (RN). R1 transported to Hospital ER via EMS.R1's Hospital emergency room Record dated 3/29/26 documents R1 had a fall at the facility resulting in R1's right hand laceration which required the following emergency medical treatment:Right hand X-Ray, Right hand15 suture laceration repair, a Tetanus-Diphth-Acell Pertussis 0.5 milliliter (ml) injection with Lidocaine HCI 10 ml.R1' s Progress Note dated 3/29/2026 at 09:33 PM documents the following: R1 returned to facility via family transport. Orders to start Doxycycline Hyclate (antibiotic). Sutures to right hand. Resident alert, no change in mental status, vital signs obtained and recorded. No complaint of pain at that time. Assisted with bedtime care and assisted to bed. Left upper extremity elevated on pillow (R1's right hand was injured, not her left). Dressing was Clean, Dry and Intact.The facility Illinois Department of Public Health Long-Term Care Facility & 11D - Serious Injury Incident and Communicable Disease Report documents the following: R1 whom is a [AGE] year old female who resides on the Memory Care Lane Fitness for the Mind unit, sustained a fall on 3/29/2026 around 5:00pm. R1 has a past medical history of NSTEMI (Heart Attack), Unspecified Dementia, Depression, and GERD. R1 has a BIMS score of five. On 3/29/26, R1 was ambulating to the restroom without R1's walker with R1's pants lowered to R1's knees. R1 began falling to R1's bottom and attempted to grab the side of the door to prevent the fall. When R1 grabbed the side of the door, R1's hand went down onto the metal where the lock was, and it cut R1's hand open. Medical Doctor and Power of Attorney (POA) were notified. R1 went to the ER for evaluation and received 15 sutures and an antibiotic. V1 Administrator/Licensed Practical Nurse (LPN) had V4 Maintenance Director inspect the door for splinters and sharp edges. As a precaution the door latch was filed down along with the edges of the door being sanded down. (During observation and interviews, as noted below, V4 Maintenance Director completed his precautionary intervention to R1's bedroom door. It was determined that R1 and R4's bathroom door not bedroom door, that caused the laceration).The note attached referred to above by V1 Administrator, documents the following: On the morning of 3/30/2026, it was reported to V4 Maintenance Director that a R1 had fallen in room. Upon being informed that the resident had received lacerations to the hand from attempting to grab the door edge to keep from falling. V4 inspected the door, door edge, and door handle for splinters and sharp edges. As a precaution the door latch was filed down along with the edges of the door being sanded as well.R4 (R1's previous roommate) still resides in the room R4 shared with R1. R4's current Diagnosis sheet documents R1's diagnoses include Unspecified Dementia, With Anxiety.R4's MDS dated [DATE] documents R4's BIMS score as three out of a possible 15, which indicates severe cognitive impairment.R4's Care Plan dated 2/27/26 documents R4 is at risk for falling related to the diagnosis of Dementia. R4 requires use of a wheeled walker for mobility.On 5/5/26 at 10:25 am, V4 Maintenance Director stated that V4 did not have a work order to replace or repair R1's bedroom door. V4 stated V4 heard about R1's door in a morning meeting. V4 stated V4 assessed R1's bedroom door and found no sharp areas on R1's bedroom door. V4 stated V4 filed down the bedroom door metal plate and door edges anyway as a precaution since R1's roommate R4 continues to reside in R1's previous room. (The bathroom door was not addressed.)On 5/6/26 between 10:00 am and 10:30 am, V4 Maintenance Director and this surveyor toured the Memory Care locked unit and observed all Memory Care unit multiple bedroom doors for any potential accident hazards. V4 confirmed several wooden bedroom doors had impairments that could result in splinters and could benefit from a sanding process to prevent any injury. There were no sharp metal components identified on the bedroom doors. R1 and R4's shared bedroom door (not bathroom doors identified below as the cause of R1's injury) was confirmed to have been sanded on the metal latch plate and outer edges of the wood door were smooth to the touch. The bathroom doors on the unit were not observed during this tour with V4.As V4 Maintenance Director left the Memory Care Unit, this surveyor was informed by V5 Memory Unit Director as follows: It was not (R1's) bedroom door (R1) got cut on. It was (R1's) bathroom door. V5 then walked into R1's (previous room-no longer resides in the facility) where R4 continues to reside. V5 identified the area of the door that R1 had cut R1's hand on. The doorknob lever metal cover measured approximately three and a half inches in circumference, was detached from the wood door and hanging over the approximately five-inch-long lever-type door handle. The detached metal cover exposed the inner metal components of the doorknob lever. The three and a half inches in circumference metal cover had sharp kitchen knife blade edges. V5 stated Maintenance is aware. I thought this had been fixed. It has not been fixed since (R1's) fall, I can see that. It is obviously not safe. On 5/6/26 at 10:45 am, V1 Administrator and V4 Maintenance Director were in the Administrator's office. V4 stated V4 had no idea it was R1's bathroom door that caused R1's laceration to R1's hand. V4 stated that this was miscommunication. V4 said V4 thought it was the bedroom door. V4 did not do any maintenance on the bathroom door. V4 also stated V4 would walk back down to the Memory Care unit and look at the bathroom door. V1 Administrator/Licensed Practical Nurse then stated We knew it was the bathroom door. I (V1) thought it was repaired. Yes, please go look at that door and get it repaired.On 5/6/26 at 10:50 am, V4 Maintenance Director walked back to Memory Care unit and confirmed that R1's bathroom door had a metal, circular plate that had slid down over the lever type door handle. V4 confirmed the metal ring, plate cover had sharp edges. V4 stated There was no work order turned in for this. I (V4) misunderstood when I (V4) was told to go look at the (R1's) door and repair it. I did not do any repairs to this (R1 and R4) bathroom door. I (V4) will have to replace the whole door handle. As you can see, it's all very sharp around the edges of this metal. The gears are exposed, which could lead to an additional injury for somebody else. I (V4) will get this fixed immediately.On 5/6/26 at 11:50 am, V7 Agency Certified Nursing Assistant (CNA) stated V7 was in R1's room taking care of R4 (R1's roommate). R1 came into the room and told V7 that R1 needed to urinate. R1 had on pants all day, that were too long and hanging past R1's feet. Night shift had R1 up (completed morning care) when V7 came in that morning. Staff had to pull up R1's pants several times that day. V7 told R1 to wait just a minute, to let V7 finish getting R4 (R1's) roommate into R4's night clothes. V7 did not actually see R1 fall. V7 stated V7 was kind of turned sideways. V7 looked back at R1 when R1 screamed out. R1 was mostly on the ground, kind of holding onto the bathroom door. V7 saw immediately that R1 cut R1's hand. V7 stated V7 is sure that the bathroom door handle cut R1's hand. The door handle has been broken for months. Every time V7 works on the Memory Care unit, V7 would have to slide that metal ring-thing up to the wood but it doesn't stay. It slides down every time you pull down the handle. It still was not fixed yesterday when V7 worked. When R1 cut R1's hand, V7 grabbed a towel and applied pressure to stop the bleeding. V16 Agency CNA and another agency CNA saw what was going on and went to get the nurse. V15 Licensed Practical Nurse/LPN called an ambulance and V7 stayed with R1 to comfort R1 and continued to apply pressure until the ambulance came. When R1 came back from the hospital R1's hand was wrapped up. V7 was told R1 had to get stitches. R1 continued to walk all over the place and never acted like she was hurting or anything. Since then, R1 got pneumonia and ended up in the hospital.On 5/6/26 at 10:40 am, V20 Licensed Practical Nurse (LPN) stated V7 took care of R1 after R1 fell. V20 wasn't there when R1 fell and cut R1's hand. Part of R1's bathroom door handle was loose for a while before R1 got hurt. V20 heard that is what caused R1's laceration. V20 stated V20 is not sure if anyone turned in a work order. V20 didn't know it was still broken. As far as R1, V20 stated that V20 knows that R1's hand remained wrapped most of the time. V20 did treatments when it was ordered. R1's hand did not seem to bother R1. R1 tried to use R1's right hand all the time. R1 did not appear to be in any pain related to that. Occasionally R1 would say it was tender.On 5/6/26 at 2:05 pm, V16 Agency Certified Nursing Assistant (CNA) confirmed V16 went to get the nurse when R1 fell and cut R1's hand on the bathroom door handle. V16 stated the bathroom door handle had not been right for a long time. The metal piece would just drop down onto the door handle.

Based on observation, interview and record review, the facility failed to provide appropriate treatments, services, non-pharmalogical interventions, and abuse risk assessments to maintain psychosocial well-being for residents diagnosed with dementia and severe cognitive impairment. This failure affects four residents (R2, R3, R4, R5) out of four reviewed for resident-to-resident incidents on the sample list of fourteen.Findings include:R2's Demographic Face Sheet dated 2/27/26 documents R2 was admitted to the facility 6/20/24 with medical diagnoses including Dementia. R2's Minimum Data Set, dated [DATE] documents R2 could not answer any questions during a Brief Interview for Mental Status and was assessed by staff as severely cognitively impaired.R3's Minimum Data Set, dated [DATE] documents R3 completed the Brief Interview for Mental Status with a score of 4 out of a possible 15, rating R3 as severely cognitively impaired.R4's Demographic Face Sheet dated 2/27/26 documents R4 was admitted to the facility 7/3/25 with medical diagnoses including Alzheimer's Disease, Restlessness and Agitation, and Dementia with Behavioral disturbance.R5's Demographic Face Sheet dated 2/27/26 documents R5 was admitted to the facility 6/28/26 with medical diagnoses including Dementia with Agitation.R2's Nursing Progress Note dated 2/6/26 documents another resident (R3) put her hand on the right side of the face of R2.R2's comprehensive medical record did not include a risk assessment to determine if R2 was at risk for abuse, either as a victim or perpetrator. R3's Nursing Progress Note dated 2/6/26 documents R3 put her hand on the right side of another resident's (R2's) face.R3's comprehensive medical record did not include a risk assessment to determine if R2 was at risk for abuse, either as a victim or perpetrator. On 2/25/26 at 1:35 PM, V11, Certified Nursing Assistant, stated she was the sole witness to the incident between R2 and R3. V11 stated R2 and R3 were talking, then R3 seemed to get mad and smacked R2. V11 confirmed observations that she was approximately six feet away from the dining room table where R2 and R3 were seated. V11 stated she did not hear a smack sound but appeared as though R3's finger, or fingernail, contacted R2 on the cheek under the eye.R4's Nursing Progress Note dated 12/19/25 documents R4 grabbed the buttocks of an unidentified Certified Nursing Assistant (CNA) and also was found in an unidentified female resident's leaning over the top of the female resident. This note describes the female resident as very scared, very upset, startled, and in tears. This note documents the facility staff removed R4 from the female resident's room. There was no documented staff intervention for R4 after grabbing the buttocks of the CNA.R4's Nursing Progress Note dated 12/25/25 documents R4 grabbed the buttocks, breasts, and attempted to kiss an unidentified CNA. This note documented the CNA wanted a different staff member to provide care for R4, and that R4 would be monitored for further behaviors. In a separate incident on this same date, R4 grabbed the buttock of an unidentified CNA today. There was no documented intervention for this episode.R4's Nursing Progress Note dated 12/26/25 documents R4 had been placed on an anti-psychotic medication Rexulti 0.5 milligrams daily and describes further and continued grabbing of female staff and exposing his genitals while walking in the public hallway. There were no documented interventions for R4's continued grabbing of staff or exposing his genitals.R4's Nursing Progress Note dated 12/27/25 documents R4 had grabbed the buttocks of an unidentified CNA. There was no documented intervention for this episode.R4's Nursing Progress Note dated 12/29/25 documents R4 was walking in the public hallway with only a shirt and an incontinent undergarment, attempted to grab the breasts of V39, Registered Nurse, who directed R4 to watch a movie in the dining room and have a snack. A second Nursing Progress Note of this same date documents R4 was in the dining room, waited for the staff to leave, then sneaks over to the women's table. The documented intervention for this behavior was to instruct R4 to go sit at another table. A third Nursing Progress Note of this same date documents R4 was in the public hallway following female residents to their rooms and standing in the doorways to watch the females. A fourth Nursing Progress Note of this same date documents R4 told an unidentified CNA he would love to see her boobs. The documented intervention for this instance was to tell R4 his behavior was inappropriate and ask R4 not to do that.R4's Nursing Progress Note date 12/31/25 documents R4 making attempts to go into female resident rooms. This same note further describes staff attempting to redirect R4 away from the female resident rooms and R4 hit the staff with his walker.R4's Nursing Progress Note dated 1/1/26 documents R4 in the public hallway without clothes and staff had to make several attempts to direct R4 to put his clothes on.R4's Nursing Progress Note dated 1/3/26 documents facility staff caught R4 coming out of a female resident's room and the female resident was asleep. The intervention for this episode was to monitor R4.R4's Nursing Progress Note dated 1/4/26 documents R4 was peeking out of the doorway of his room looking back and forth down the public hallway, completely naked and urinating into the public hallway. The responding staff noted R4 had also moved his bowels on the floor of his room. The documented intervention for this behavior was to assist R4 with cleaning care and put R4 back to bed. A second Nursing Progress Note of this same date documents R4 was making continued attempts to go into female resident's rooms and despite redirection from staff continued to watch female residents intently. This same second note documents R4 was observed scooting his dining room chair closer to a female resident's chair and attempting to touch her but staff were able to reach R4 prior to contact with the female resident.R4's Nursing Progress Noted dated 1/5/26 documents R4 reached under a blanket covering a female resident and grabbed her hand. This note documented R4, and the unidentified female resident were seated in separate chairs in the dementia unit day room when the observation was made. The documented staff intervention was to tell R4 to keep his hands to himself or he would have to go to his room. This same note documents R4's anti-psychotic medication Rexulti was doubled to 1 milligram daily.On 2/25/25 at 9:55 AM, R5 was noted to be seated in the dementia unit day room in a recliner with a blanket covering her. No other residents were noted to be seated in the day room covered by a blanket throughout the survey on 2/24/26, 2/25/26, 2/27/26, 3/3/26, 3/4/26, and 3/5/26.R4's Nursing Progress Note dated 1/6/26 documents R4 touched the buttocks of an unidentified staff member. The documented staff intervention was to tell R4 that was inappropriate and to not do it again.R4's Nursing Progress Note dated 1/11/26 documents R4 attempted to grab the buttocks of an unidentified CNA which was observed by another unidentified CNA and redirected R4.R4's Nursing Progress Note dated 1/12/26 documents R4 was walking naked in the public hallway towards staff who attempted to redirect R4 but R4 grabbed the buttocks of a CNA. After this incident, staff intervention was to assist R4 to re-dress and return to bed. A second Nursing Progress Note of this same date documents R4 continued to come out of his room naked and urinated on the floor in front of a CNA. The documented intervention was to assist R4 in cleaning and to go back to bed.R4's Nursing Progress Note dated 1/20/26 documents R4 received a visit from the facility Nurse Practitioner (V3) who acknowledged R4 had been prescribed a second anti-psychotic medication Seroquel 25 milligrams every evening. V3 wrote a new prescription to increase R4's second anti-psychotic Seroquel to 75 milligrams every evening. Additionally, this same note documents V3 prescribed an antacid Tagamet 200 milligrams daily. This same note documents V3 ordered for R4 to be referred to a geriatric psychiatric hospital for a possible admission, a referral which was undocumented in R4's medical record despite documentation that V1, Administrator, had been notified of the order for the referral.R4's Nursing Progress Note dated 1/22/26 documents R4 was in the dining room, waited until all staff were out of the dining room, moved close to an unidentified female resident who was resting at a different table, then when staff returned into the dining room R4 was observed rubbing the female resident's leg. The documented staff intervention for this behavior was to separate the residents and monitor R4's behavior.R4's Nursing Progress Note dated 1/24/26 documents R4 touched, and attempted to rub on, the upper thigh of a CNA as she was clearing breakfast dishes from the dining room table. The CNA informed R4 this was inappropriate and moved away from R4. The CNA informed the unidentified Licensed Practical Nurse in charge to monitor and document R4's behavior. A second note of this same date documents R4 grabbed the buttock of a CNA and was redirected. This second note documents R4 had another increase in his anti-psychotic medication Seroquel.R4's Nursing Progress Note dated 1/26/26 documents R4 had been making sexual comments to staff. This same note documents facility staff reminded R4 these comments are inappropriate and continue to monitor R4's behavior.R4's Nursing Progress Note dated 2/3/26 documents an allegation that R4 touched a female's breast and was redirected by an agency CNA. This same note documents R4 threw a pillow at the agency CNA.The facility's Resident-to-Resident Incident Investigation Report dated 2/3/26 documents the unidentified female resident allegedly touched on the breast by R4 was R5. On 2/24/26 at 1:25 PM, V17, Dementia Care Unit Director, stated the agency CNA who alleged R4 touched the breast of R5 was V19. V17 stated she had not witnessed any inappropriate behaviors from R4 but did have reports from other staff about R4 grabbing them. Throughout the survey from 2/24/26 through 3/5/26, V19 did not respond to multiple phone calls with messages left requesting an interview and to return the call, including a call directly to the agency managerial staff requesting to facilitate an interview with V19.R4's Nursing Progress Note dated 2/4/26 documents V1, Administrator, requested R4 be sent to the local emergency room for evaluation.R4's Nursing Progress Note dated 2/7/26 documents R4 was observed several times to put his hands down his pants and fondle himself.R4's Minimum Data Set, dated [DATE] documents a Brief Interview for Mental Status score of 10 out of a possible 15, rating R4 as moderately cognitively impaired. R5's Minimum Data Set, dated [DATE] documents R5 could not answer any of the questions for a brief interview and was assessed by staff as severely cognitively impaired.R4's Care Plan included a section for behavioral problems, physical in nature, directed at others and R4 was not able to differentiate between socially appropriate versus inappropriate behaviors. The care planned staff interventions listed in R4's care plan included to (1/21/26) administer anti-psychotic medication Seroquel 50 milligrams in the morning and 50 milligrams in the evening, another undocumented increase. Further staff interventions were documented as (1/21/26) review medications during behavior committee meeting, (1/21/26) monitor for behavior or mood changes in relation to medication changes, (1/21/26) if (R4) is disrobing redirect him to his room and assist with re-clothing as appropriate, (1/21/26) if (R4) is urinating walk with him to the bathroom or provide a urinal in a private location, (2/5/26) provide one-to-one supervision at all times, (12/19/26) if behavior occurs tell (R4) his comments and touch make you and others uncomfortable and re-focus to an activity of interest, (12/19/26) If observed approaching a female resident while appearing agitated or making any sexual comments, refocus his attention by asking him about being a painter at (industrial equipment company), talking to him about sports, or talking about his kids, (12/19/26) When not in his room, involve R4 in activities of interest and keep him engaged through interests such as talking about sports, spending time outdoors (weather permitting), physical activities like exercise, physical games, and Mindful Moments programming to stimulate his mind such as sorting objects by shape and color, organizing objects by category. There was no documented evidence that staff implemented any of the listed non-pharmacological interventions except for repeated verbal redirection, repeated monitoring, repeated reminding R4 his actions were inappropriate, and verbal direction to go watch a movie and have a snack on one occasion.On 2/24/26 at 11:35 AM, V4, Minimum Data Set/ Care Plan Coordinator, stated she had only witnessed R4's behaviors as yelling, screaming, and hitting at people.On 2/24/26 at 11:45 AM, V6, Registered Nurse, stated she had not witnessed R4's inappropriate behaviors but did have R4's behaviors reported to her from other staff members which she would document in R4's chart and notify the (former) Director of Nursing.On 2/24/26 at 11:50 AM, V7, Licensed Practical Nurse, stated she had not witnessed any of R4's inappropriate behaviors but did have CNAs report to her about R4's behaviors. V7 continued to state one incident that stands out in her memory was R4 waiting for all staff to leave the dining room and touching a female resident who was sitting with her eyes closed asleep. V7 stated she couldn't remember if the touch was on the female's arm or leg.On 2/24/26 at 12:00 PM, V8, V9, and V10, CNAs, all stated they had not witnessed any behaviors exhibited by R4 and had no problems providing R4 care.On 2/24/26 at 12:10 PM, V11, V12, and V13, CNAs, all stated they had not witnessed any inappropriate behaviors by R4.On 2/24/26 at 1:15 PM, V15, CNA, stated she had not witnessed any inappropriate behaviors from R4.On 2/24/26 at 1:20 PM, V16, CNA, stated R4 had made an attempt to reach under her shirt but she had not witnessed any inappropriate behaviors between R4 and other residents.On 2/24/26 at 1:30 pm, V18, Agency Registered Nurse, stated she had not witnessed inappropriate behaviors from any resident.On 2/24/26 at 1:35 PM, V20, CNA, stated he had witnessed R4 in the doorway of a female resident's room but was able to guide R4 away from the door.R4's Nursing Progress Note dated 2/21/26 documents R4 was sent to the local hospital for treatment of an infected chest port. R4's Nursing Progress Note dated 3/2/26 documents R4 had returned from the hospital after treatment for his infected chest port and had experienced a mild stroke during his hospital stay.On 3/3/26 at 9:40 AM, R4 stated he was well taken care of at the facility, received showers according to schedule, had plenty to eat, and had plenty of activities to engage in. R4 stated he did not have a girlfriend but there were many women who fit the bill for women he would like to have as a girlfriend. R4 stated he had to be careful or else he or the women might become attached. R4 denied touching any female residents or staff inappropriately on their buttocks or breasts. R4 concluded by stating he considered the residents and staff to be family and wouldn't want to make trouble for them.On 3/3/26 at 11:15 AM, V14, Licensed Practical Nurse, stated she had not witnessed any inappropriate behaviors from R4 and only had hearsay knowledge of the allegation made by the agency CNA (V19) that R4 had touched the breast of R5.On 3/3/26 at 12:55 PM, V40, Care Plan Coordinator in Training, stated she had worked in the facility as a Licensed Practical Nurse prior to the care plan position but had not witnessed any of R4's inappropriate behaviors nor had any staff reported directly to her about any inappropriate behaviors exhibited by R4.On 3/3/26 at 2:30 PM, V44, Social Services Designee, and V4, Minimum Data Set/ Care Plan Coordinator, stated and confirmed V44 had been in the training process for the documentation required to assess resident's social histories and behavioral risks. V4 stated she was not aware of any specific abuse or neglect risk assessment forms or documents utilized by the facility. V4 and V44 searched in the computer and stated there is a social history assessment completed for all residents which does include any history of abuse or sexual abuse. V4 stated the question was used to evaluate a resident's social history and not directed as a risk assessment. V4 stated the question also included Have you or a loved one ever experienced a car or plane crash, been in a war, been kidnapped, been in a natural disaster, had a life-threatening illness. V4 stated this document was used to determine if a resident had a prior history of a traumatic event and would require special services for trauma-informed care provisions, and not for a resident-to-resident or staff-to-resident abuse situation.The facility's Abuse Prevention policy dated 11/28/19 documents, Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being the victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as; entering other residents rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and / or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans, and reviewed as / when change occurs. These interactions will be communicated to the direct care staff.On 3/4/26 at 10:21 AM, V1, Administrator, confirmed the Social History Assessment was used to inform any trauma-related care and not for a risk of abuse. V1 stated the electronic record system used by the facility does not provide an actual abuse risk assessment. V1 stated interventions in a resident's care plan are expected to be implemented. V4, present during the interview with V1, stated the care plan changes must be communicated. V1 and V2, Director of Nursing, present during the interview with V1, concluded by stating the facility can not fix what already happened but they can fix it going forward.

Based on interviews and record review the facility failed to provide showers, twice a week, to a dependent resident. This failure affected one of three residents (R7) reviewed for showers on the sample list of 14. Findings include:R7's Current Diagnoses List documents R7 has diagnose of Chronic Kidney Disease, Diabetes, Chronic Pain, and Morbid Obesity,R7's Minimum Data Set, dated [DATE] documents the following: Brief Interview of Mental Status score of 14 out of a possible 15, indicating no cognitive impairment.R7's Care Plan dated 2/19/26 documents the following: Approach Start Date: 03/14/2025, Bathing Type: (R7) receives showers twice weekly. (R7) requests we (facility staff) make sure she is dry and pat skin folds dry.R7's February 2026 shower sheets document R7 received a shower on 2/3/26, 2/10/26, 2/18/26, and 2/21/26. There is no documentation that R7 declined a shower between 2/3/26 and 2/10/26 or between 2/10/26 and 2/18/26 which indicates R7 missed two showers.On 2/24/26 at 1:10 pm R7 stated the staff forget to give R7 a shower almost every week. They (staff) just forget, so I remind them. Sometimes they don't have time until later in the day. I still have to ask to get one shower per week sometimes. It is supposed to be routine. I am scheduled for two, on Wednesday and Saturday.On 2/25/26 at 2:00 pm V2, Director of Nursing (DON) stated R7 was scheduled to receive two showers a week and care planned to get two showers each week. V2, DON reviewed shower sheets and confirmed R7 missed two showers in February 2026.

Based on observation, interview, and record review, the facility failed to implement fall prevention interventions according to residents' care plans for fall risks. This failure affects two residents (R6 and R10) out of three reviewed for falls with injuries on the sample list of fourteen.Findings include:1. R10's Demographic Face Sheet dated 3/3/26 documents R10 was admitted to the facility 4/10/25 with medical diagnoses including Dementia with Behavior Disturbance, Neuralgia, Glaucoma, History of Transient Ischemic Attacks, Chronic Pain, Pseudobulbar Affect, rash, Insomnia, Depression, Migraines, and Vitamin Deficiency.R10's Physician Order Sheet dated 3/3/26 documents R10 receives multiple anti-hypertension, anti-depressant, anti-anxiety, and anti-convulsant medications.R10's Event charting with associated Nursing Progress Notes dated 4/19/25 document R10 slid out of her bed onto the floor.R10's Event charting with associated Nursing Progress Notes dated 6/6/25 documents R10 was self-propelling her wheelchair, got her feet tangled in the wheelchair foot pedals, fell out of the wheelchair and struck her head on the wall. The interdisciplinary team review of this fall documents a revised care plan intervention was implemented to remove the foot pedals from R10's wheelchair to allow R10 to self-propel her wheelchair.R10's Event charting with associated Nursing Progress Notes dated 1/1/26 documents R10 fell out of her wheelchair and landed on the foot pedals, also striking her head on a doorway. The interdisciplinary team review of this fall documents a revised care plan intervention was implemented to remove the foot pedals from R10's wheelchair and to place non-slip material in the seat of R10's wheelchair.R10's Care Plan Resident Care Information section documents R10 requires the use of medical equipment including a high-back reclining wheelchair with anti-tip bars, and bilateral foot pedals dated 9/15/25. R10's Care Plan Fall Risk section documents to remove the foot pedals from R10's wheelchair dated 1/2/26. There was no reference to the non-slip material to be placed in the seat of R10's wheelchair.On 3/3/26 at 11:10 AM, following a staff-assisted transfer utilizing a sit-to-stand mechanical lift, there was no non-slip material in the seat of R10's wheelchair, either directly underneath R10 nor under the padded seat cushion.On 3/3/26 at 11:20 AM, V4, Minimum Data Set/ Care Plan Coordinator, was walking through the facility's central rotunda carrying a piece of non-slip material. V4 stated the material was intended for R10's wheelchair seat. V4 stated she would need to review R10's care plan to see if the non-slip material was listed as an intervention. At 12:55 PM, V4 confirmed R10's Care Plan Resident Care section listed to have R10's foot pedals in place on her wheelchair, and the Fall Risk section listed to remove the foot pedals from R10's wheelchair. V4 stated R10 does self-propel her wheelchair and does need the foot pedals to be removed. V4 stated she was not present at the interdisciplinary team reviews for R10's falls but V4 had revised R10's care plan to include the non-slip material.On 3/4/26 at 10:50 AM, V4 confirmed the intervention for R10's foot pedals to be removed should have been revised in the resident care section of R10's Care Plan. V1, Administrator, stated the care plan interventions recommended by the interdisciplinary team are expected to be implemented into the care plan. V4 stated the care plan changes need to be communicated.2. R6's Demographic Face Sheet dated 2/27/26 documents R6 was admitted to the facility 12/1/25 with medical diagnoses including Encephalopathy, Dementia with Agitation and Psychotic Disturbance, Non-displaced Fracture of Medial Malleolus of Right Tibia (12/25/25), Parkinsonism, Seizures, Pain, Constipation, Anxiety, Disorientation, Rhabdomyolysis, Osteoporosis, Altered Mental Status, Hypertension, Magnesium Deficiency, and Vitamin Deficiency.R6's Physician Order Sheet dated 2/27/26 documents R6 receives anti-Parkinson's, anti-psychotic, and multiple anti-seizure medications.R6's Nursing Progress Notes dated 12/19/25 document R6 experienced a fall in her own room while attempting to ambulate across the hallway to another resident's room looking for a bathroom. This note describes R6 was not wearing non-skid socks as she was bare-footed.R6's Nursing Progress Note dated 12/25/25 documents R6 experienced a fall in her own room and was wearing non-skid slippers at that time.R6's Nursing Progress Note dated 2/10/26 documents R6 experienced a fall in her own room and was seated on the padded mat beside her bed with an orthopedic boot in place on R6's right foot.R6's Nursing Progress Note dated 2/15/26 documents R6 was found on the floor of her room with a bird seed bag in her hand and bird seed spilled on the floor. There was no documentation of R6's footwear or orthopedic boot for this fall.R6's Nursing Progress Note dated 2/16/26 documents R6 made two attempts to get out of her thickly padded rolling recliner and had to be reminded that she needs assistance to get up.On 2/27/26 at 10:20 AM, R6 was seated in her high-back wheelchair, her left foot dangling between the two-foot pedals, wearing regular dress socks.On 2/27/26 at 10:23 AM, V14, Licensed Practical Nurse, stated R6 does make attempts to stand up without assistance. V14 stated she had been administering anti-seizure and anti-anxiety medications to R6 as R6 appeared to be having mild seizures or was in a post-seizure refractory period. At 10:50 AM, V14 clarified R6 had made an attempt to get out of bed the prior week, and this same morning had attempted to stand up from the wheelchair. V14 stated R6 should be wearing gripper (non-slip) socks and instructed a passing Certified Nursing Assistant to place gripper socks on R6.On 2/27/26 at 1:45 PM, V2, Director of Nursing, stated she would need to find out about gripper socks for R6 but the reason R6 was not wearing gripper socks may be related to R6's use of an orthopedic boot on her right foot for two months, which was just recently discontinued (2/18/26), and R6 had recently began receiving hospice services.

Based on observation, interview and record review the facility failed to provide a physician ordered high protein supplement and failed to honor a resident's food preference. These failures affect one of three residents (R8) reviewed for dietary intake/meals on the sample list of 14.Findings include:R8's Current Diagnose List includes: Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Vitamin D Deficiency, Unspecified, Vitamin E Deficiency, Unspecified, and Ascorbic Acid Deficiency and Disorder of Teeth and Supporting Structures, Unspecified.R8's Dietary Physician Order dated February 04, 2026, documents R8 is to have a Regular HP (High Protein) supplement TID (three times a day) with meals. 07:30 AM, 12:00 PM, and 05:30 PM.R8's Minimum Data Set, dated [DATE] documents the following: R8's Brief Interview of Mental Status score as 11 out of a possible 15 indicating, moderate cognitive impairment.On 2/24/26 at 12:20 pm R8 was served Chicken Cordon Bleu as the entree for lunch. R8 was not served the High Protein milkshake supplement documented on R8's physician ordered/meal ticket. R8's same physician ordered/meal ticket documents R8 dislikes chicken.On 2/24/26 at 12:58 pm R8 stated he does not like chicken but the ham inside with the chicken made some difference, and he could not taste the chicken, only the ham. R8 stated I really like the milkshakes (High Protein) I get. I am not sure why some days, I get one at every meal and some days, I don't get any at all. It is written on my ticket. My guess is they must run short of them. They taste good so a lot of people probably get them to.On 2/24/26 at 1:03 pm V8, Certified Nursing Assistant (CNA) confirmed R8 did not receive R8's high protein milkshake and received chicken cordon bleu in error. It is on his ticket (physician order/meal ticket). We messed up.On 2/25/26 at 11:15 am (V25) Dietary Manager stated (R8) was not supposed to get chicken yesterday. I am not sure if chicken does not taste good to him, or if it causes gastric discomfort, either way it is noted on his diet order ticket, as a dislike. It should be honored. My (the facility) Dietary Aides are supposed to check the ticket against what goes on the trays. The CNA should be checking the diet order tickets as well. They serve the trays to the residents. As far as (R8's) high protein supplement, we add those supplements in the kitchen. I guess that was our error, we (kitchen staff) missed that. He is supposed to be getting that three times a day.On 2/25/26 at 11:35 am V2, Director of Nursing (DON) reviewed and confirmed R8's Physician order/ dietary ticket and confirmed R8 dislikes chicken and was to receive a high protein milkshake with his meal. V2 stated staff will be reeducated on paying attention to the meal tickets when serving resident meals.

Based on observation, interview and record review the facility failed to update one (R1) resident care plan with fall interventions, repeatedly failed to implement fall interventions and complete thorough fall investigations for two (R1, R2) residents out of three residents reviewed for accidents in a sample list of eight residents.Findings include: 1.R1's undated Face Sheet documents medical diagnoses as Dementia, Psychotic Disturbance, Diabetes Mellitus Type II, History of Urinary Tract Infection (UTI), Vitamin B deficiency, Pain and Vitamin D deficiency. R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's Fall Risk Evaluation dated 10/7/25 documents R1 as a high fall risk. R1's Nurse Progress Note dated 9/29/25 at 7:15 AM, documents R1 had an unwitnessed fall in her room just outside the bathroom. This same note documents R1 was ambulating from her bed to the bathroom, lost balance and fell to the floor R1's Care Plan intervention dated 9/29/25 following R1's fall on 9/29/25 was for R1 to use the alternate call system. R1's Nurse Progress Notes dated 10/4/25 at 8:45 AM, 10/7/25 at 3:42 PM and 10/9/25 at 9:15 PM documents R1 falling at the facility. On 11/15/25 at 12:50 PM, V5 Licensed Practical Nurse (LPN) stated R1 had Dementia and would not remember to use her call light or ask for help. V5 LPN stated R1's fall on 10/4 was witnessed 'but the staff had to help her down or she would have hit the ground'. V5 LPN stated a Certified Nurse Aide (CNA) was helping R1 when R1's legs 'went weak'. V5 LPN stated she did not remember which CNA it was. V5 LPN stated no one from management ever asked her to complete a witness statement or asked her any questions about the fall. On 11/15/25 at 2:25 PM, V4 Registered Nurse (RN) stated on 10/9/25 R1 had an unwitnessed fall in her room while attempting to walk to the bathroom. V4 stated she heard a loud noise and when she investigated, found R1 lying on the floor in her room. V4 RN stated she was not asked to complete a witness statement. V4 RN stated she was not asked any 'detailed' information about R1's fall. On 11/16/25 at 12:50 PM, unable to leave message for V20 LPN due to voicemail full. On 11/16/25 at 1:00 PM, V2 Director of Nurses (DON) stated the CNA who was involved in R1's fall on 10/4/25 was V11. V2 DON stated she found V11's name by searching through the Daily Staffing sheets for that day. V2 DON stated the facility does not document staff names in the resident's Electronic Medical Record (EMR) and does not ask staff for witness statements. V2 DON stated this should be a part of the fall investigation but the facility 'doesn't keep track of who was involved in resident's falls'. V2 DON stated there is no way to know other than re-interview the nurse who wrote the progress note or look at the daily staffing sheets. On 11/15/25 at 3:15 PM, V7 Care Plan Coordinator/Licensed Practical Nurse (LPN) stated the facility conducts a morning meeting Monday through Friday to discuss any resident changes/concerns/updates. V7 CPC stated over the weekend there is a nurse on call to handle any situations that arise. V7 CPC stated when a resident fall there should be a fall intervention to 'match' each fall. V7 CPC stated that intervention should be put into place immediately, reviewed in morning meeting and either placed on the resident care plan then or changed to a more appropriate intervention. V7 CPC stated R1 had multiple falls with interventions added into the care plan for 'most'. V7 CPC stated she could not find an intervention for R1's 9/16/25 or 10/7/25 fall. On 11/15/25 at 3:30 PM, V14 Assistant Director of Nurses (ADON)/Registered Nurse (RN) stated all fall investigations should include basic information of who the resident/staff were that were involved, how the fall happened, what time it happened, if there were injured, what were the surroundings like, what care plan interventions were put into place and any other pertinent information relating to the resident's fall. V14 ADON stated a new intervention is supposed to be entered into the resident's care plan directly after a fall. V14 ADON confirmed R1 did not have fall interventions for R1's 9/16/15 and 10/7/25 falls. V14 ADON stated the fall intervention is put into place to help reduce the risk of the resident from falling again the same way. V14 ADON stated if the interventions are not implemented then the resident could fall again and 'maybe get injured'. 2. R2's undated Face Sheet documents R2's medical diagnoses as Encephalopathy, Dementia, Anxiety, Muscle Wasting and Atrophy, Repeated Falls, Vitamin Deficiency, and difficulty in walking.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as severely cognitively impaired. This same MDS documents R2 requires maximum assistance from staff with oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R2's Care Plan intervention dated both 6/4/25 and 10/1/25 documents an intervention of 'alternative call light'. R2's Nurse Progress Note dated 10/13/25 at 6:24 AM documents R2 had an unwitnessed fall in her room. R2 was observed on the floor on her back between the bed and the wall. This same note documents R2 has been noted in her bed about 15 minutes before dayshift came on. On 11/15/25 at 1:05 PM, R2 was not in her room. V8 CNA stated 'alternate call light' means the resident should be visualized every 15 minutes. V8 CNA stated staff do not document this. V8 CNA stated there is no place in the CNA charting to document any resident's 15- minute checks. V8 Certified Nurse Aide (CNA) stated R2 was provided incontinence care at 11:30 AM, then R2 went to lunch. V8 CNA stated I guess (R2) is still up by the front nurses station. Lunch gets over at 12:30 PM so (R2) must be up there. The last time I saw (R2) was 11:30 AM. On 11/15/25 at 1:08 PM, V9 Certified Nurse Aide (CNA) stated the R2 normally eats lunch in the main dining room at 12:00 PM, then sits up front by the nurse's station. V9 CNA stated R2 'should be' monitored by the staff up front. V9 CNA stated she cannot verify that R2 has been monitored every 15 minutes. V9 CNA stated the last time she visualized R1 was before lunch. On 11/16/25 at 3:00 PM V12 Licensed Practical Nurse (LPN) stated R2 has an 'alternate call light' which means R2 should be visualized every 15 minutes. V12 LPN stated she arrived at 5:30 AM on 10/13/25. V12 LPN stated she was informed that R2 had fallen in her room 'around 6:20 AM'. V12 LPN stated she remembered the dayshift staff had not been on R2's hall yet that morning due to they (staff) started getting people up on another hall first. V12 LPN stated the last time R2 was visualized was on night shift prior to 5:30 AM. V12 LPN stated she talked to the staff that morning after R2 fell, and they confirmed R2 had not been visualized yet that morning. V12 LPN stated she wrote in the nurse progress note that R2 had been visualized 'about 15 minutes' prior to her fall but that was incorrect information. V12 LPN stated no one asked her about the fall details. V12 LPN stated If someone would have asked, I would have realized right then that (R2) had not been seen since around 5:15 AM. We (staff) are supposed to be checking on our people (residents). This is what happens when we don't. On 11/16/25 at 2:00 PM, V2 Director of Nurses (DON) stated the facility will use 'alternate call light' for a care plan intervention. V2 DON stated this means that a resident is supposed to be visualized every 15 minutes. V2 DON stated there is no documentation for any resident's 15-minute checks. V2 DON stated since the facility does not document the resident's 15-minute checks that would mean the facility cannot prove that any of those residents' interventions were in place prior to any fall. V2 DON stated the facility is going to 'look at this system' to see how that can be rectified. V2 DON stated she has witnessed the staff caring for residents who have an alternate call light system but cannot say that the 15-minute check was completed every time due to lack of documentation. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility does not keep separate files for fall investigations. V1 stated the only time a paper component would be available would be for a resident's fall that had to be reported to the State Agency. V1 Administrator stated whatever is in the Electronic Medical Record (EMR) is all that the facility would be able to provide. V1 Administrator stated the facility does not have a policy on staff documenting cares. V1 Administrator stated the expectation is for the staff to follow the care plan for each resident. The facility policy titled Call System (Alternate) revised April 2021 documents all residents that are unable to use a call light system will be provided with an alternate source of monitoring for needed assistance.

Based on observation, interview and record review the facility failed to ensure hot water heaters housed in resident closets are sanitary for six (R1, R4, R5, R6, R7, R8) residents out of six residents reviewed for Physical Environment in a sample list of eight residents. Findings include:R1's Minimum Data Set (MDS) dated [DATE] documents R1 as moderately cognitively impaired. This same MDS documents R1 requires supervision with eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers.R1's Electronic Medical Record (EMR) does not include V6 (R1's) Power of Attorney (POA) concern of R1's hot water heater in R1's closet having 'mold, lime build up and rust'. On 11/15/25 at 1:20 PM, R4 and R5's shared closet housed a ten-gallon hot water heater. This water heater had a bright green and white dry substance covering the front quarter of the water heater, approximately six inches off the closet floor underneath and approximately eight to ten inches of the pipes attached to the water heater leading to the wall. The closet floor close to the perimeter of the water heater had a brown substance appearing to be rust. The wall behind the water heater on both sides had approximately three inches of black dots, some faded and some had clear edges appearing to be black mold. On 11/16/25 from 11:15 AM-11:30 AM, V2 Director of Nurses (DON) toured rooms with hot water heaters in the closets. V2 DON stated there are five rooms with hot water heaters in their closets. V2 DON stated four of the five rooms are occupied with residents. R4 and R5's shared closet housed a water heater that showed bright green and white dry substance that appeared as lime build up, rust and black dots on the wall that appeared as black mold. R6 and R7's hot water heater located in their shared closet showed a large area of brown flaky substance on the floor that appeared as rust. R8's water heater located in the closet showed bright green and white dry substance appearing as lime build up on the floor, the water heater and the pipes attached to the water heater. On 11/15/25 at 10:10 AM, V6 (R1) family stated R1 had a hot water heater in her closet that sat directly beneath her clothes causing her clothes to be 'very warm'. V6 stated the front of R1's hot water heater is 'a lot of lime build up' and on the back wall behind the water heater is 'mold all over the wall'. V6 stated she reported this to V7 Care Plan Coordinator during R1's last care plan meeting. V6 stated the facility did not 'fix the problem'. V6 stated having a hot water heater causes R1's clothes to be very warm and having 'mold and lime buildup' would be a health risk for any resident.On 11/15/25 at 1:25 PM, R4 stated the water heater 'has been like that' since she admitted to the facility. R4 stated the water heater is on her roommate's (R5) side of the closet but R4 backs into 'that thing' every time she gets into her closet. On 11/15/25 at 1:30 PM, R5 stated her clothes hang directly over the water heater. R5 stated she had a long robe hanging up in her closet that rested on top the water heater. R5 stated she reached in for her robe. R5 stated her robe was so hot she thought it would 'catch fire'. R5 stated she reported this to the facility last week and V16 Maintenance Director told her it would get fixed. R5 stated With all of that mold, rust and lime build up I worry that we (R4, R5) will get sick. On 11/15/25 at 1:35 PM, V15 Custodian stated there are several rooms with water heaters located in the resident closets. V15 stated (R4, R5)'s water heater is in 'the worst shape'. V15 stated the facility is working on getting that one fixed first. On 11/15/25 at 1:40 PM, V16 Maintenance Director stated he has been working with 'corporate' to get the closet water heaters replaced. V16 stated he was aware of the 'mold, rust and lime build up on a few' of the closet water heaters. V16 stated resident clothes do hang over the water heaters but should not be touching them. V16 stated the water heaters will not get hot enough to be a fire hazard but the 'lime, rust and mold could make people sick'. V16 Maintenance Director stated the water heaters that could be a risk to the residents are being replaced first. On 11/16/25 at 11:10 AM, V7 CPC stated V6 (R1) Power of Attorney (POA) called V7 to inquire about a water heater in R1's room having 'mold, rust and a bunch of stuff' all over it. V7 CPC stated she reported this to V1 Administrator in the next day's morning meeting. V7 CPC stated I don't know whatever was done with that, but I reported it to (V1). That was (V1's) responsibility then, not mine. V7 CPC stated there was no progress note made about this concern. V7 CPC stated she did not remember what date V6 called her. On 11/16/25 at 2:30 PM, V1 Administrator stated the facility has 'several' hot water heaters that are located in closets in resident rooms on three different hallways. V1 stated she was 'just made aware' that three of those water heaters had 'mold, mildew and rust' on them that could cause a potential health risk to a resident. V1 Administrator stated the water heaters 'probably' don't get hot enough to cause a fire hazard but also should not have 'mold, mildew and rust' on them within the resident areas. V1 Administrator stated V16 Maintenance Director is working to get them replaced.

Based on Observation, Interview, and Record Review the facility failed to identify full body pillows and a concave mattress as restraints, failed to assess the resident for the use of the full body pillows and concave mattress, and failed to ensure that the body pillows and concave mattress did not pose a risk of injury from falls for one (R1) of eight residents reviewed for restraints on the sample list of eight. This failure resulted in R1 who is at high risk for falls and has cognitive impairment climbing out of bed and falling on multiple occasions while the full body pillows where in place. This failure ultimately resulted in R1 climbing out of bed and falling and sustaining a left pelvic fracture.Findings Include:On 10/21/2025 at 10: 55 AM, R1 was lying in bed on top of a concave mattress. Full-length body pillows were placed on top of the concave mattress and were positioned along both sides of R1's body underneath a fitted sheet. On 10/22/25 at 10:10 AM, R1 was lying in bed on top of a concave mattress. Full-length body pillows were placed on top of the concave mattress and were positioned along both sides of R1's body underneath a fitted sheet.R1's Progress Note dated 7/20/25 documents R1 has Increased restlessness and anxiety this noc (night). Res (Resident) has exited bed and ambulated into hall multiple times this noc. Bed in lowest position, call light is within reach but not activated. Floor mats in place next to bed and body pillows in place beside resident in bed. Res gait and balance unsteady, Res frequently asking questions like Where am I supposed to be? What am I supposed to do? Where are my morn (mom) and dad?. Each time resident easily redirected, toilet offered, fluids offered and accepted, then res assisted back to bed. Res denies pain or discomfort. Res has not been incontinent of B/B (bowel/bladder). PRN (as needed) Ativan administered earlier in shift and somewhat but temporarily effective. R1's Minimum Data Set assessment dated [DATE] documents R1 is cognitively impaired and has a history of falls. R1's Post Fall Interdisciplinary notes document R1 was found on the floor at the end of her bed on 8/18/25 and 9/26/25. R1's care plan documents a fall intervention for a concave mattress on 8/18/25. R1's medical record does not contain an assessment for the use of the concave mattress or full-length body pillows. R1's Post Fall Interdisciplinary Notes document on 10/10/25 at 9:35 PM, R1 was observed sitting at the foot of her bed; (on the floor) on her buttocks with legs outstretched in front of her after attempting to self-transfer. This note documents the full body pillows were in place. This note documents R1 was sent to the hospital on [DATE] after complaining of pain. This note documents R1 was found to have a Left Superior Pubic Rami Fracture (pelvic fracture). This note does not document an assessment or reassessment for the use for the concave mattress or the body pillows. On 10/21/2025 at 11:35 PM, V4 Certified Nursing Assistant (CNA) stated she takes care of R1. V4 stated the body pillows are used so R1 doesn't get out of bed. V4 stated R1 can put her legs over the body pillows if R1 is determined to get out of bed. V4 stated that R1 can ambulate with assistance and has had body pillows since V4 has been taking care of R1 since April 2025. On 10/21/2025 at 11:40 AM, V5 CNA stated she has taken care of R1 since April 2025. V5 stated R1 has always had body pillows in place while in bed and if R1 is not in bed, R1 is to be up at the nursing station for closer supervision. V5 stated, R1 transfers with one assist. V5 stated R1 requires frequent visual checks because R1 likes to get out of bed and ambulate throughout the day and night. V5 stated R1 falls frequently because she is unsteady and requires assistance with walking. V5 stated that body pillows are to be placed under the sheet to keep R1 from getting up and walking by herself. When asked about R1's care plan, V5 looked at R1's electronic health record and stated R1's care plan does not include the use of the body pillow. V5 also stated R1's record did not contain an assessment for the use of the body pillows on R1's bed. On 10/21/2025 at 11:17AM V7 Licensed Practical Nurse (LPN) stated, R1 likes to get up by herself and the body pillows that are on each side of the bed are to prevent falls. V7 stated there is no assessment for the body pillows in the chart or care plan but staff were told by the facility to keep the body pillows on while R1 was in bed.On 10/21/2025 at 12:30PM, V11 Registered Nurse stated, If (R1) is determined she will find a way out of her bed as she is a high-risk faller.On 10/21/2025 at 12:56 PM, V2 Director of Nursing stated the body pillows are used to prevent R1 from getting out of the bed. V2 stated a restraint assessment should have been completed for the use of the body pillows and reassessed after each fall. At that time, V2 looked at R1's electronic medical record and confirmed there were no restraint assessments in the medical record and no interventions on the care plan related to the use of the full-length body pillows. V2 stated that the fracture was related to the fall on 10/10/25 and the body pillows were in place on R1's bed before the fall. On 10/21/2025 at 12:45 PM, V8 (R1's Hospice Nurse Practitioner) stated using the full body pillows on top of a concave mattress puts R1 at a greater risk for injury as it creates an extra obstacle for R1 to get out of bed. V8 stated R1 is at greater risk for falls and injury due to cognitive impairment, ambulatory, and receiving pain medication. The Facility's Restraint Policy with a revision date of 11/2017 documents restraints will not be used to restrict a resident's freedom of movement. This policy documents using a concave mattress to prevent a resident from getting out of bed as an example of a physical restraint. This policy documents that an assessment will be completed prior to the use of the restraint, and a reassessment will be completed every 90 days. The facility will assess for restraints with each resident to attain or maintain his/her highest practicable well-being in the least restrictive environment while preventing injury.

Based on interview and record review the facility failed to protect from further abuse by staff following a staff to resident abuse allegation for 14 of 18 residents (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18) reviewed for abuse in the sample list of 18. R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to Certified Nursing Assistants (CNAs) that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 Licensed Practical Nurse (LPN) assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.V13's Timecard dated 7/13/25-7/26/25 documents V13 worked on the following dates: 7/18/25 from 5:31 AM until 2:05 PM. 7/19/25 from 5:32 AM until 10:11 PM. 7/20/25 from 5:30 AM until 10:34 PM. The CNA Daily Assignment Sheets dated 7/19/25 and 7/20/25 document V13 worked on the Independence Place unit. The facility's Resident Bed List Report dated 7/22/25 documents R6-R18 reside on the Independence Place unit. On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V6 CNA who said V7 CNA gave R5's shower that Friday, but V7 said V7 didn't give R5's shower. V1 stated 7/14/25 was R5's only documented shower, which was given by V21 CNA. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH. V1 stated no alleged perpetrator was identified. V1 confirmed V13 CNA, alleged perpetrator reported by R5, was not placed on suspension pending investigation of this allegation. On 7/22/25 at 3:19 PM V2 Director of Nursing confirmed the CNA Daily Assignment Sheets 7/19/25 and 7/20/25 accurately reflect the staff's hall assignments and V13 worked on the Independence Place unit. The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents if the alleged abuse involves an employee as the perpetrator, then the administrator shall immediately suspend the suspected employee without pay pending the investigation of the incident.

Based on interview and record review the facility failed to report allegations of staff to resident physical abuse to the state survey agency for two of 18 residents (R1, R5) reviewed for abuse in the sample list of 18.1.) R1's Minimum Data Set (MDS) dated [DATE] documents R1 has moderate cognitive impairment.R1's Nursing Note dated 7/21/2025 at 5:10 PM documents V16 (R1's Family) spoke to V9 Licensed Practical Nurse (LPN) about incident and R1 experienced pain during repositioning. V16 was dissatisfied with the incident and stated V16 just wanted R1 safe. R1's Nursing Note dated 7/21/2025 at 5:20 PM documents V1 was notified of the incident, and Certified Nursing Assistant (CNA) was sent home until further investigation. R1's Nursing Note dated 7/21/25 at 5:25 PM documents Nurse Practitioner was notified of incident and increased right hip pain, and orders received to send R1 to the emergency room for further evaluation and right hip x-ray.R1's emergency room Note dated 7/21/25 at 7:07 PM documents R1 had a fall on 6/26/25 that resulted in fracture of right distal femur involving the arthroplasty component, R1 was transferred to another hospital for surgical repair of the fracture and discharged on 6/30/25. R1 presented today for complaints of significant pain in groin area while CNA turned R1 side to side in the bed, and R1 reported they were handling (R1) very rough.On 7/22/25 at 11:11 AM V9 LPN stated last evening around 4:50 PM, V9 was called back from her break because V14 (R1's Family) had called the facility and spoke with V10 LPN. V16 (R1's Family) called the facility and spoke with V9, and V16 suspected abuse of R1. V9 stated R1 had a recent fall with hip fracture, so has the potential for pain. V9 stated R1 reported a Certified Nursing Assistant (CNA) had repositioned R1 in bed causing R1 hip pain, and R1 called V14 to report this incident. V9 stated V9 immediately reported R1's abuse allegation to V1 Administrator. V9 stated at first R1 was unclear if the abuse involved more than one staff person, so V9 took V8 CNA, who was assigned to R1's hall, into R1's room and confirmed with R1 that V8 was the CNA.On 7/22/25 at 11:30 AM V10 LPN stated V10 received the phone call from V14 shortly after 5:00 PM last evening. V10 stated V14 wanted to know what was going on and R1 had told him that people were being rough with R1. V10 stated V10 was not assigned to R1's hallway and went to get R1's nurse (V9) and also notified V2 Director of Nursing.The initial report of R1's abuse allegation submitted to IDPH on 7/22/25 at 10:25 AM, provided by V1, documents the following: On 7/21/25 V16 contacted V9 to report a staff member had hurt R1 during repositioning, and V16 felt this was abuse. R1 was unsure of the employee's name but indicated V8 CNA had repositioned R1. V8 was placed on suspension pending results of the investigation.On 7/22/25 at 11:03 AM V1 Administrator stated the initial report of R1's allegation was submitted to IDPH this morning due to not being able to interview R1 last night since R1 was at the hospital. V1 confirmed the report was submitted at 10:25 AM on 7/22/25. At 2:48 PM V1 stated V1 thought V1 had 24 hours to report abuse allegations to IDPH.2.) R5's Nursing Note dated 07/18/2025 at 6:37 PM documents R5 reported to CNAs that during his shower today a male CNA cleaned his perineal area a little hard and when R5 told the CNA it hurt, the CNA replied, it will heal. This note documents a CNA reported R5 was bleeding in scrotum area. R5's Nursing Note dated 07/18/2025 at 6:39 PM documents V10 LPN assessed R5's scrotum which had a 2 centimeter (cm) by 1 cm open area, like skin was ripped, and blood noted in brief. This note documents R5 reported that he did not have a shower today but had one a couple days ago. V10 looked at the shower schedule and R5's showers are scheduled for Mondays and Thursdays. V10 obtained orders to apply barrier cream and Vitamin A & D ointment until healed. R5's Nursing Note dated 7/18/25 at 7:01 PM documents V1 Administrator returned call to the facility and was notified of R5's reported incident. R5's Nursing Note dated 07/18/2025 at 7:02 PM documents POA (Power of Attorney) was called about open area to scrotum and that due to the circumstance of how resident told how area got there will be investigated by administrator.On 7/22/25 at 11:30 AM V10 LPN was asked to describe any abuse allegations in the facility. V10 stated on 7/18/25 around 5:30 PM R5 had a bleeding scrotal skin tear and R5 reported to the CNAs that V13 CNA had given R5's shower that day and washed R5 hard, R5 told V13 to stop, and V13 said it will heal. V10 stated R5 had a 2 cm skin tear to his scrotum and R5 told V10 that it happened a few days prior. V10 stated V10 reported R5's allegation to V1 Administrator and R5's family immediately.On 7/22/25 at 12:36 PM V11 CNA stated on 7/18/25 around 5:30 PM V11 overheard R5 tell V15 CNA that V13 CNA gave R5 a shower on first shift, and V13 rubbed R5's scrotal area hard. V11 stated per R5, R5 told V13 to stop and V13 said it would be ok, it would heal. V11 stated the underside of R5's scrotum was bleeding and V10 was notified. V11 stated V11 considered this to be an abuse allegation and V10 reported the incident to V1.On 7/22/25 at 2:33 PM V15 CNA stated on the evening of 7/18/25 R5 told V15 that unidentified male CNA was rough with R5 during R5's shower. V15 stated R5 said R5 told the CNA to be more gentle and the CNA replied that he was just trying to get R5 clean. V15 stated there was blood in R5's brief and V15 reported this to the nurse.On 7/22/25 at 2:48 PM V1 Administrator stated on the evening of 7/18/25 R5 reported to staff that during his shower V13 CNA scrubbed a little hard and that it hurt. V1 stated that was all that was reported to V1. V1 stated V1 looked at R5's shower documentation and V13 had not given R5 a shower. V1 stated V13 is the only male CNA that works on R5's hallway. V1 stated V1 spoke with V13 who denied giving R5 a shower. V1 stated V1 spoke with R5 about the incident and R5 did not know what V1 was talking about. V1 stated V1 did not consider this to be an abuse allegation, therefore it was not reported to IDPH.The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents alleged abuse should be immediately reported to the facility's administrator, and if the matter involves alleged abuse or results in serious bodily injury, the administrator, or designee, shall submit an initial notice to the Illinois Department of Public Health (IDPH) no more than two hours after the matter becomes known.

Based on observation, interview, and record review, the facility failed to prevent an incident of staff to resident physical and verbal abuse and failed to provide adequate supervision to prevent a resident-to-resident incident of physical abuse. This failure affects two residents (R76 and R62) out of four reviewed for abuse on the sample list of 35. This failure resulted in R62 suffering a high level of pain and a bump on the head. Findings include: 1. The facility's Initial Incident Report dated 3/21/25 documents an allegation reported from a family member (V23) that a Certified Nursing Assistant (V22) had used profanity towards a resident (R76) and then had put his hands on the shoulders of R76 to restrict and confine R76 to stay seated in the wheelchair. On 4/29/25 at 10:26 AM, R76, having severe cognitive impairment and Dementia, stated he had no recollection of the incident involving the allegations against V22. On 5/1/25 at 11:01 AM, V1, Administrator, confirmed there was an allegation against V22 reported by the family member of R2 alleging that V23 had used profanity and pushed R76 into his wheelchair. V1 further confirmed V22 had been terminated for his comments (profanity). V1 stated she had spoken with V22 who told her he did place his hands on R76's shoulders to guide him from getting up from the wheelchair but that V22 told her he did not put any pressure on R76's shoulders. On 5/1/25 at 1:50 PM, V23, Family Member of R2, stated R2 was admitted to the facility on [DATE]. V23 stated she had been at the facility with R2 less than one hour when she noticed R76 seated by the entrance door for the facility's Dementia unit. V23 stated R47 was standing next to R76 and R47 had his hand on R76's wheelchair armrest. V23 stated R76 leaned forward like he was going to try to see if the door would open, then V23 witnessed V22, Certified Nursing Assistant, come up behind R76's wheelchair and violently, aggressively, and quickly jerk R76's wheelchair backwards. V23 stated at that time, V22 said to R76, Where the f**k (expletive) do you think you're going? V23 stated that R76 never did try to stand up, just leaned forward as if to try to open the door. V23 stated she was surprised that when V22 jerked the wheelchair, that R76 did not fall out, and was surprised that R47 did not get knocked to the floor. V23 stated she had worked as a Certified Nursing Assistant off and on for about 30 years and had never witnessed anything like what V22 did. R2's Face Sheet dated 5/1/25 confirmed R2 was admitted to the facility 3/21/25. Through the survey period 4/29/25 through 5/2/25, V22 was not available for a requested interview. V22's Employee Disciplinary Action form dated 3/21/25 documents V22 was dismissed/ terminated from employment due to violating facility policy by being discourteous, rude, and harassing a customer. V22's Employee Disciplinary Action dated 1/21/25 documents V22 received a written warning for using profanity while working in the hallway in the presence of residents, as reported by a (unidentified) family member. V22's Employee disciplinary Action dated 10/17/24 documents V22 received a written warning for, as reported by a (unidentified) family member, being in the dementia unit office using his cell phone while leaving residents unsupervised, and this family member found his beloved resident to be incontinent of a large amount of urine and having soiled clothing. The facility's Abuse Prohibition and Reporting policy dated 11/28/19 documents the facility actively prohibits resident abuse including corporal punishment and protects residents from any kind of abuse such as verbal, physical, and corporal punishment. This policy defines verbal abuse as oral disparaging and derogatory remarks to a resident or their families within their hearing. This policy defines physical abuse as any infliction of injury on a resident by any means other than accidental, including attempting to control behavior by corporal punishment. 2. Throughout the survey period 4/29/25 through 5/2/25, R76 was observed being in a one-to-one supervision from facility staff. On 4/29/25 at 10:30 AM, V5, Certified Nursing Assistant, stated the reason why she was sitting in a one-to-one duty with R76 was because R76 had hit another resident (R62) with a plastic bubble wand. At this same date and time R76 stated he had no recollection of this incident. On 5/1/25 at 11:01 AM, V1, Administrator, confirmed there had been an incident when R76 hit R62 with a plastic bubble wand. The facility's Initial Incident Report dated 4/3/25 documents an allegation made by a facility Certified Nursing Assistant (V26) that R76 had entered the room of R62, both V26 and R62 told R76 to leave the room but R76 did not comply with the request and picked up an object, later determined to be a plastic bubble wand, and began to hit R62 in the head and face. On 5/1/25 at 3:40 PM, R62 stated she had no recollection of the incident. On 5/1/25 at 3:52 PM, V26, Certified Nursing Assistant, stated he was in a resident's room directly across the hall from R62's room when he saw R76 go into R62's room. V26 stated he had called out to R76 to not go into that room, but he could not leave the resident he was providing care to. V26 stated R76 did not comply with his request to not go into the room. V26 stated that R62 likewise told R76 to get out of her room, but again, R76 did not comply. V26 stated R76 then picked an object up from R62's dresser and began to hit R62 on the head and face with it, causing R62 to fall to the floor. V26 stated when he was able to get to R76, the object was a plastic bubble wand. V26 stated he asked a co-worker to report this incident to the nurse (V28) while he monitored R76. R76's Nurses Note dated 4/3/25 at 1:21 AM, documented by V28, Licensed Practical Nurse, documents R76 struck another resident (R62) in the head with a bubble wand causing injury to R62. R76's Nurses Notes document multiple weekly incidents of R76 being verbally and physically aggressive towards staff. R62's Nurses Note dated 4/3/25 at 12:15 AM, documented by V28, Licensed Practical Nurse, documents R62 was noted to have a bump on the side of her head measuring 3 centimeters long by 2 centimeters wide by 3 centimeters high and slight purple bruising on her left ear. This note further documents R62 was complaining of dizziness and a headache, with a pain rating of eight out of ten.

Based on record review and interview, the facility failed to provide a cognitive impaired resident, who required substantial to maximum staff assistance, with a safe transfer and toileting. This failure resulted in R57 sustaining two fractures on 3/12/25, that required emergency medical attention and surgical repair. The facility also failed to initiate targeted post-fall interventions to address the root cause of self-toileting. These failures affected one of three residents (R57) reviewed for falls on the sample list of 35. Findings include: R57's Minimum Data Set, dated [DATE] documents R57's Brief Interview for Mental Status score was 12 out of a possible 15, indicating moderate cognitive impairment. The same MDS inaccurately (according to V20, MDS/Care Plan Coordinator and V27, Nurse Practitioner below interviews) documents R57 had no falls prior to admission to the facility. R57's Face Sheet documents his admission date as 3/6/25. The same Face Sheet includes the following diagnoses: Dementia in Other Diseases, Classified Elsewhere, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Other Lack of Coordination, Difficulty in Walking, Not Elsewhere Classified, Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites. R57's admission assessment dated [DATE], documents: R57's Fall Risk Score of 16 (High Risk), using the following fall risk scale: Scoring: 0-5 Total Points equals Low Fall Risk, 6-13 Total Points equals Moderate Fall Risk, greater that 13 Total Points equals High Fall Risk. R57's Physical Therapy (PT) Evaluation and Plan of Treatment dated 3/6/25 documents R57's diagnoses as follows: Urinary Tract Infection, Site Not Specified, Difficulty in Walking, Not Elsewhere Classified, and Muscle Wasting and Atrophy, not elsewhere classified, Multiple Sites. The same PT evaluation document: R57 required substantial/maximal staff assistance with transfers. R57's Resident Care Information Certified Nursing Assistants Task sheet dated 3/10/25 directs staff to transfer R57 with one assist, front wheeled walker and to use a gait belt. R57's Safety - Fall Event report documents R57 fell on [DATE] at 1:00 pm. The same report documents: Staff report resident (R57) noted to be in (on the) floor. Upon arrival, resident noted to be laying on back in (sic) floor, in front of (the) doorway, with (his) head facing (the) doorway and (his) feet facing (the) window. W/C (wheelchair) noted to be parked at foot of bed, facing window. No O2 (oxygen) on. Resident states 'I was trying to go to the bathroom, and I tripped over my heel'. Environment free of clutter. Room well lit. Call light not activated. Non-skid shoes on. Resident c/o (complained of) pain 10/10 (on a scale of 0-10, 10 being the worst pain level on the scale) to left shoulder and left hip, unable to complete ROM (range of motion). Resident states he did not hit his head, neuros (neurological assessment) WNL (within normal limits). VS (vital signs) Temperature:97.6, Pulse:70, Respirations:18, Blood Pressure: 136/72, Oxygen Saturation (blood saturation level): 90% RA (room air), Oxygen placed on resident, at 2 L/min (two liters per minute) (via) NC (nasal cannula). Resident made comfortable on floor. MD (unidentified physician) notified, N.O. (new order). Send to ER (hospital emergency room) for eval (evaluation) and tx (treatment). The same Safety-Fall Event documents: On 3/12/2025 at 3:36 pm, received call from (local hospital) ER (emergency room), ER (unidentified) nurse states resident has a fractured left shoulder and a fractured left hip and will be transferred to a higher level of care hospital. ER nurse does not know which hospital resident is being sent to at this time but will contact facility as soon as information becomes available. DON/Administrator (V2, Director of Nursing/V1, Administrator) notified. R57's Regional Level 1 Trauma Center, Acute Care Surgery Service: Emergency Surgery. Trauma, Surgical Critical Care Hospital (hospital, long distance from the facility) record, documents the following: HOSPITAL COURSE: (R57's name and age) who presented on 3/12/2025 at 6:30 PM, as a transfer from (hospital, shorter distance from the facility) after he suffered a mechanical fall at his nursing home. He was found to have left humerus fracture and left femoral neck fracture. A (name brand indwelling urinary catheter) was inserted at the previous hospital prior to transfer. Orthopedic Surgery was consulted and planned for operative intervention the next day. The same hospital record documents: He (R57) underwent in-situ fixation (surgical repair) of left femoral neck fracture on 3/13/25 with (Orthopedic Surgeon). His humeral fracture is being managed non-operatively with a sling. He is weight-bearing as tolerated to the left lower extremity, and non-weight bearing to the left upper extremity. On 4/30/25 at 10:40 am V2, DON stated (R57) was not to ambulate unless he was working with therapy. V2, DON also stated V7, Certified Nursing Assistant (CNA) was the staff member that found R57 on the floor post fall. On 4/30/25 at 10:55 am V7, CNA walked down to the empty room on 400-hall that R57 resided in when he fell 3/12/25. V7, CNA confirmed V2, DON's observation and stated (R57's) head was close to the open door of his room. His feet were directed towards the window where his wheelchair was at. I did not pay attention to if his wheelchair was locked or unlocked. I was focused on the patient (R57). (R57) said he was going to the bathroom when he fell. The bathroom is pretty far from here, where he laid. (approximately 8 feet away). I don't know if he was incontinent at the time of his fall. He was not wet on the outside of his clothes. The last time I saw him, he was in the small dining room eating about a half hour before he fell. I did not take him to the bathroom before lunch. He always took himself. He was independent (per admission and therapy notes above R57 required substantial to maximum staff assistance with transfer) when I worked. He never asked for help. For the most part he was alert and oriented (diagnoses documented above as Dementia). I don't know if he had a history of falls, he had not been here very long (admitted six days prior to the fall). On 4/30/25 at 12:40 pm V2, Director of Nursing stated (R57) was moved to the room closer to the nursing station when he returned from the hospital post fall (3/12/25). That was the intervention to increase supervision. It makes sense that we should have identified why he was trying to self-transfer. He should have had assistance. He was going into bathroom. His intervention should have included increased toileting, in addition to increasing (R57's) supervision. On 5/1/25 at 3:30 pm V27, Nurse Practitioner stated I have known (R57) long before he was a resident in the facility. He had numerous falls when he was at home. He had a very unstable gait. He should have had assistance with ambulation, transfers and toileting. He was somewhat impulsive. I was not surprised when I heard he had the fall with the fractures. I did not realize staff were not providing him the assistance he needed. He was admitted to the facility and was receiving PT (Physical Therapy) for strengthening. Yes, he should have been toileted by staff. He was trying to toilet himself, from what I understand, that was the root cause of his fall. On 5/2/25 at 1:30 pm V20, Minimum Data Set (MDS)/Care Plan Coordinator, stated R57's MDS did not document that R57 had previous falls, because the facility did not have his history when he was admitted [DATE]. He is moderately impaired and did not remember falling prior to admission. Now we know his history. The fall here in the facility 3/12/25 with fractures, is listed (documented) on the MDS because his assessment goes until midnight on 3/12/25.

Based on interview and record review, the facility failed to transmit (submit) Minimum Data Set Resident Assessment Instruments to the Centers for Medicare and Medicaid within the required time frames. This failure affects five residents (R18, R49, R52, R54, and R58) out of five reviewed for Minimum Data Set transmission on the sample list of 35. Findings include: 1. R58's Minimum Data Set (MDS) dated with an Assessment Reference Date (ARD) of 2/21/25 was documented on the facility's CMS (Centers for Medicare and Medicaid) Submission Report dated 4/29/25, documenting R58's MDS was submitted on 4/29/25. 2. R52's MDS dated with an ARD of 2/4/25 was documented on the facility's CMS Submission Report dated 4/29/25, documenting R52's MDS was submitted on 4/29/25. 3. R49's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report dated 4/23/25, documenting R49's MDS was submitted 4/23/25. 4. R18's MDS dated with an ARD of 2/18/25 was documented on the facility's CMS Submission Report dated 4/29/25, documenting R18's MDS was submitted 4/29/25. 5. R54's MDS dated [DATE] was documented as In Process on 4/30/25, documenting this MDS was not yet completed or transmitted. On 4/30/25 at 3:15 PM, V20, Minimum Data Set Coordinator, confirmed she had just submitted (transmitted) MDSs for R58, R52, and R18 on 4/29/25. V20 further confirmed she had submitted R49's MDS on 4/23/25. V20 stated the MDS for R54 was not yet completely coded into a form to be able to be submitted to CMS. V20 then stated and confirmed that there is a timing process for the MDS in which was there is an allowance for 14 days after the ARD to do the actual assessment of the resident, another 7 days to have the MDS electronically coded in a form to be able to be transmitted, and another 7 days to transmit (submit) the MDS to CMS. V20 concluded by stating R58's MDS should have been transmitted by 3/21/25, R52's MDS should have been transmitted by 3/4/25, R49's and R18's MDS should have been transmitted by 3/18/25, and R54's MDS should have been transmitted by 4/8/25.

2. R12's Face Sheet dated 5/1/25 documents R12 was admitted to the facility 12/31/18. R12's original Interagency Certification of Screening Results (Level 1 PASRR) dated 12/27/18 documents no reasonable basis to suspect R12 had any mental illness or developmental disability diagnoses. R12's Face Sheet dated 5/1/25 documents R12 was diagnosed with Psychotic Disorder with Delusions (severe mental illness) on 5/28/19. There was no Level 2 PASRR in R12's comprehensive medical record. 3. R26's Face Sheet dated 5/1/25 documents R26 was admitted to the facility 11/14/19 under hospice services, and did not require a Level 1 PASRR. This same Face Sheet documents R26 was diagnosed with Bipolar Disorder (severe mental illness) on 7/6/20. R26's original Interagency Certification of Screening Results dated 12/30/20, after R26 no longer required hospice services, documents there was no reasonable basis to suspect R26 had a mental health or developmental disability diagnosis. There was no Level 2 PASRR in R26's comprehensive medical record. 4. R45's Face Sheet dated 5/1/25 documents R45 was admitted to the facility 9/13/21. R45's original Interagency Certification of Screening Results dated 9/13/21 documents no reasonable basis to suspect R45 had a mental illness or developmental disability diagnosis. R45's Face Sheet dated 5/1/25 documents R45 was diagnosed with Psychosis (severe mental illness) on 2/29/24. There was no Level 2 PASRR in R45's comprehensive medical record. On 4/30/25 at 10:45 AM, V19, Business Office Manager, stated the facility staff had received training from the (screening agency) back in 2023, when this new PASRR process started, who told the facility staff to do a PASRR on the new residents coming into the facility. V19 further stated the (screening agency) never said anything about doing a PASRR Level 2 on the people who were already in the building. On 5/1/25 at 11:01 AM, V1. Administrator stated she has become aware of the lack of obtaining Level 2 PASRR's and is understanding the Level 2 needs to be completed for residents with a mental health diagnosis. V1 further stated the facility will be doing the Level 2 PASRR going forward. Based on interview and record review the facility failed to obtain a Level 2 Pre-admission Screening and Record Review (PASRR) for four (R12, R26, R45, R68) residents out of six reviewed for PASRR in a sample list of 35. Findings include: 1. R68's undated Face Sheet documents R68 admitted to the facility on [DATE]. R68's Pre-admission Screening and Record Review (PASRR) dated 1/26/24 documents R68 did not require a Level 2 PASRR. R68's Face Sheet documents R68 was diagnosed with Schizoaffective Disorder, Bipolar type on 10/16/2024. The facility was unable to provide documentation of a Level 2 PASRR being completed after R68 was diagnosed with a new mental health disorder on 10/16/2024. On 4/30/25 at 3:00 PM V19 Business Office Manager (BOM) stated the facility did not complete a Level 2 PASRR for R68. V19 stated V19 was under the impression after admission a Level 2 PASRR would only be completed if the resident had a significant change. On 5/2/25 at 9:00 AM V1 Administrator stated the facility had only been completing the Level 2 PASRR's with a resident's significant change. V1 Administrator stated she was not aware that the facility needed to complete a Level 2 PASRR with any resident who is diagnosed with a Mental Illness after admission. V1 Administrator stated the facility will be obtaining this Level 2's from this point forward. The facility policy titled Pre admission Screening and Resident Review (PASRR) adopted 2/17/25 documents the facility will complete a Level I PASRR and a Level 2 PASRR if required. Residents with Mental Illness (MI) diagnoses or Psychotropic medications may have a determination indicating that a PASRR Level 2 is required. If this is indicated, the facility shall ensure that any recommendations identified on the Level 2 screen have been incorporated into the care plan. The facility shall resubmit a PASRR for any resident who has had a significant change in status, as identified through the Minimum Data Set (MDS) process, received an order for a first-time psychotropic medication, and/or receives a new MI diagnosis.

3. R16's Minimum Data Set, dated [DATE] documents R16 has an Indwelling Urinary Catheter for the diagnoses of Obstructive Uropathy. R16's current Physician Order Sheet documents the following: (name brand indwelling urinary) catheter care Q (every) shift. R16's Urine Bacteria Culture laboratory report dated 01/17/25 that documents the following urinary tract infection: Klebsiella Pneumoniae (Multi-drug Resistant Organism) equal or greater than 100,000 colony forming units per milliliter and Methicillin Resistant Staphylococcus Aureus (Multi-drug Resistant Organism) equal or greater than 100,000 colony forming units per milliliter. On 5/2/25 at 11:20 am, V33, Certified Nursing Assistant (CNA), with V2, Director of Nursing (DON), entered R16's room. V2 was present to provide R16 assistance with positioning while V33, provided indwelling urinary catheter care. R16 had a bedside, indwelling urinary catheter drainage bag, that hung from R16's bed frame. R16 had cloudy, beige sediment adhering to the inside of the indwelling catheter tubing. R16 was assisted to a back lying position with R16's legs separated. R16's urinary catheter insertion site, at the tip of the penis and the extending catheter, approximately two inches down on the external indwelling catheter tube, was soiled with dried, crusted, yellow and light brown body fluid. V33, removed her gloves after positioning and washed her hands in the bathroom. V33 donned new gloves and cleaned R16's upper inner thighs and sides of R16's testicles using disposable wipes. V33 again washed her hands and donned new gloves. V33 then used disposable wipes, and swiped R16's penis repeatedly from the base up his penis shaft, up and over the opening at the catheter insertion site, cross contaminating tip of R16's penis and catheter. V33 then used a disposable wipe with one swipe, to clean the indwelling catheter external tube, from R16's insertion site down to the junction with the bedside drainage bag tubing. V33 removed her gloves, washed her hands, donned new gloves and assisted V2 in repositioning R16 to a side lying positron. V33 repeated hand hygiene and re-gloving appropriately and V33, cleaned feces off of R16's buttocks and buttocks crease. R16 was then repositioned by V2 and V33 to a back lying position. As V33 began to pull R16's blankets up over R16, V33 confirmed she had completed R16's indwelling urinary catheter and incontinence care. This surveyor then asked V33 if she could see the external indwelling urinary catheter remained soiled with the dried, crusted, yellow and light brown body fluid. V33 confirmed R16's catheter remained soiled. On 5/2/25 at 11:40 am V2, DON stated I saw (V33, CNA) cleansed (R16's) penis in the wrong direction (towards, instead of away from the meatus). I know you wrote it down. Yes, that is cross contamination. I think she (V33, CNA) was just nervous. Based on observation, interview and record review the facility failed to prevent cross contamination during indwelling urinary catheter care for two (R16, R65) residents, and incontinence care for one (R68) resident out of four reviewed for incontinence care in a sample list of 35. Findings include: 1. R65's Minimum Data Set (MDS) dated [DATE] documents R65 as cognitively intact. This same MDS documents R65 is dependent on staff for toileting, dressing, bathing, bed mobility, personal hygiene and transfers. R65's Physician Order Sheet (POS) dated May 2025 documents a physician order to provide urinary catheter care every shift. R65's Physician Order Sheet (POS) dated May 2025 documents a physician order starting 4/21/25 to insert a indwelling urinary catheter monthly and as needed. R65's face sheet documents a diagnosis of Neuromuscular Dysfunction of the Bladder on 4/17/2024. On 4/30/25 at 2:30 PM, V17 and V18, Certified Nurse Aides (CNAs) completed perineal and indwelling urinary catheter care for R65. R17 CNA did not change her gloves nor use hand hygiene after providing frontal perineal care before providing R65's rear perineal care. R65's indwelling catheter drainage bag cover fell to the floor as V17 and V18 were repositioning R65. V17 picked up R65's urinary drainage bag cover and placed it back over R65's urinary drainage bag. V17 and V18 did not apply barrier cream after providing perineal care for R65. On 4/30/25 at 2:50 PM, V17, Certified Nurse Aide (CNA), stated she should have changed her gloves and completed hand hygiene between cleansing R65's front and rear perineal areas. V17 stated barrier cream should have been applied. On 4/30/25 at 3:10 PM, V2, Director of Nurses (DON), stated the staff should change their gloves when moving from one area to another if the gloves become contaminated. V2 stated V17 should have changed her gloves, provided barrier cream and obtained a new drainage dignity cover. V2 stated the facility has 'tons of dignity bags' and it is encouraged to keep them off of the floor due to infection control purposes. V2 stated the facility does not have a policy for the dignity bags but it is the expectation that staff do not put contaminated products over a urinary drainage bag. The facility policy titled Catheter Care revised June 2005 documents staff should remove gloves and wash hands after providing catheter care. The facility policy titled Perineal Care revised November 2018 documents staff should apply skin care product after completion of perineal care. 2. R68's Minimum Data Set (MDS) dated [DATE] documents R68 as severely cognitively impaired. This same MDS documents R68 as being dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. R68's Care Plan intervention dated 4/3/24 instructs staff when (R68's) physical behaviors occurs, ensure safety and re-approach at a later time utilizing a different staff member. On 5/1/25 at 10:35 AM, V31 and V32, Certified Nurse Aides (CNAs), provided incontinence care for R68. R68 was incontinent of bladder and bowel. V32 cleansed urine and bowel movement from R68's buttocks, then applied a clean incontinence brief to R68 without changing gloves and/or using hand hygiene. On 5/1/25 at 10:50 AM, V32 Certified Nurse Aide (CNA), stated she should have removed her gloves after providing incontinence care and prior to applying a clean incontinence brief. On 5/1/25 at 11:15 AM, V2, Director of Nurses (DON), stated hand hygiene should be performed after providing incontinence care and applying a new brief.

Based on observation, interview and record review the facility failed to ensure the dignity of one resident (R68) out of one reviewed for dignity in a sample list of 35. Findings include: R68's undated Face Sheet documents R68's medical diagnoses as Alzheimer's Disease, Anxiety, Schizoaffective Disorder Bipolar Type, Difficulty in Walking, Abnormal Posture, Violent Behavior, Syncope and Collapse. R68's Minimum Data Set (MDS) dated [DATE] documents R68 as severely cognitively impaired. This same MDS documents R68 as being dependent on staff for eating, oral hygiene, toileting, bathing, dressing, personal hygiene, bed mobility and transfers. On 4/29/25 at 2:55 PM, V17 and V18, Certified Nurse Aides (CNAs) were assisting R68 from his room on 700-hall to the shower room on the 100-hall. R68 was reclined back in a mesh slatted shower recliner chair with his left shoulder, left trunk, left buttock and left thigh all visible. R68 was wearing only a thin bath blanket laid over the top of him. Another resident and staff members were sitting at the nurse's station at the same time V17 and V18 pushed R68 by to the shower room. On 4/29/25 at 2:57 PM V8, Licensed Practical Nurse (LPN), stated the staff will undress R68 in his room and then transport him to the shower room. V8 stated it is too much work for the staff to transfer R68 in the shower room. On 4/29/25 at 3:45 PM V9, R68's Power of Attorney (POA), stated R68 was a minister his entire life and would not appreciate being unclothed in public. V9 stated R68 has advanced Alzheimer's Disease and is not able to speak for himself but was very modest in his earlier years and would be very embarrassed by being exposed in public. On 4/30/25 at 11:00 AM, V1, Administrator, stated all residents should be covered appropriately when being transferred to the shower room. V1 stated the 100-hall shower room is large enough to accommodate the total body mechanical lift and the reclining shower chair. The facility policy titled Resident Rights revised 11/28/2017 documents the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance of enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based on interview and record review the facility failed to obtain a Level 2 Pre-admission Screening and Record Review (PASRR) for one resident (R46) out of six reviewed for PASRR's in a sample list of 35. Findings include: R46's undated Face Sheet documents R46 admitted to the facility on [DATE]. This same face sheet documents R46 was diagnosed with Major Depressive Disorder with recurrent Psychotic Symptoms on 2/5/2025. R46's Level 1 Preadmission Screen and Record Review (PASRR) dated 6/5/2020 documents R46 does have an Intellectual Disorder (ID). The facility is unable to provide documentation of a Level 2 PASRR being completed. On 5/2/25 at 9:00 AM V1 Administrator stated the facility had only been completing the Level 2 PASRR's with a significant change. V1 Administrator stated she was not aware that the facility needed to complete a Level 2 PASRR with anyone with an Intellectual Disability (ID). V1 Administrator stated the facility will be obtaining this Level 2's from this point forward. The facility policy titled Pre-admission Screening and Resident Review (PASRR) adopted 2/17/25 documents the facility will complete a Level 1 PASRR and a Level 2 PASRR if required. Residents with Mental Illness (MI) diagnoses or Psychotropic medications may have a determination indicating that a PASRR Level 2 is required. If this is indicated, the facility shall ensure that any recommendations identified on the Level 2 screen have been incorporated into the care plan. The facility shall resubmit a PASRR for any resident who has had a significant change in status, as identified through the Minimum Data Set (MDS) process, received an order for a first-time psychotropic medication, and/or receives a new MI diagnosis.

Based on interview and record review, the facility failed to safely transport R1 after a shower to prevent a traumatic fall. This failure resulted in R1 falling from a shower chair to the floor causing multiple back and neck fractures requiring emergency medical evaluation and treatment at two hospitals. R1 is one of three residents reviewed for accidents in the sample of three. Findings include: R1's medical diagnosis list (9/25/2024) documents R1's diagnoses include Spastic Paraplegia (inherited neurological disorder causing muscle weakness and difficulty or inability to walk), Abnormal Posture, Difficulty in Walking, and Muscle Wasting and Atrophy. R1's quarterly assessment (7/24/2024) documents R1 has upper and lower extremity impairment limiting range of motion, is completely dependent on staff for all activities of daily living and utilizes a wheelchair for locomotion. The same record documents R1 is dependent on staff assistance for mobility while using a wheelchair. The facility incident report (9/13/2024) documents on 9/13/2024 at 8:50AM, facility staff were moving R1 on a shower chair from a shower stall when a wheel on the chair became caught on the shower curb and R1 fell from the chair to the ground and expressed pain. The facility incident investigation (9/13/2024) documents R1 complained of neck, chest, abdomen, and knee pain after falling to the ground on 9/13/2024. R1's progress notes (9/13/2024) documents R1 stayed in bed during lunch and only ate about six bites due to experiencing chest and abdomen pain. The same record documents R1 was sent to the local hospital emergency department for evaluation. The hospital emergency department report (9/13/2024) documents R1 presented to the department due to a fall and head, neck, chest, and lower back pain. The same report documents R1 reported experiencing pain everywhere and was diagnosed with neck and back fractures requiring transfer to a regional trauma center for further evaluation. The trauma center report (9/13/2024) documents R1 was diagnosed with six back and neck fractures (thoracic vertebrae #11/#12, lumbar vertebrae #1/#2/#3, and cervical vertebrae #3) and received intravenous morphine (narcotic pain medication used to treat severe pain) while at the regional trauma center. The same reports documents R1 remained an inpatient at the trauma center from 9/13/2024-9/18/2024 when R1 transferred back to the nursing home facility with an order for analgesic pain medication and a rigid cervical immobilizer (a type of rigid neck brace used to limit movement after surgery or serious injury) to be worn at all times. On 9/27/2024 at 10:40AM, V4 (Certified Nurse Aide) reported giving a shower to R1 on 9/13/2024 and when V4 began pulling R1's shower chair forward out of the shower stall, a wheel on the chair got caught on the shower curb and R1 began falling forward. V4 reported then pushing back on R1 and the shower chair and both R1 and V4 fell to the ground followed by R1 stating ow that R1 was hurting. V4 reported R1 continued to express pain when staff transferred R1 from the floor to a chair. V4 reported R1 does not lean forward in the shower chair and does not have any behaviors during cares including bathing. R1's medication administration record (September 1-26, 2024) documents R1 had been prescribed acetaminophen (pain analgesic medication), 325 milligram tablets, two tablets by mouth as needed every six hours for pain starting on 12/11/2023. The same record documents R1 had received only a single dose of acetaminophen on 9/8/2024 during the month of September prior to the fall but had taken acetaminophen nearly every day (9/19/2024-one dose, 9/20/2024-three doses, 9/21/2024-two doses, 9/22/2024-one dose, 9/24/2024-two doses, 9/25/2024-two doses, 9/26/2024-two doses) for pain since readmitting to the facility on [DATE] from the hospital.

Failures at this level required more than one Deficient Practice Statement. A. Based on interview and record review the facility failed to identify a resident's need for increased supervision in order to reduce the resident's risk for falls and ensure safe resident transfers and mobility. This failure resulted in the resident falling on four separate occasions in less than two months' time which resulted in two pelvic fractures and one rib fracture. This failure affects one of three residents (R41) reviewed for falls on the sample list of 29. B. Based on record review and interview, the facility failed to provide adequate supervision for a resident (R27) during transport while at an outside facility appointment, resulting in R27 falling while self-toileting. R27 is one of three residents reviewed for falls in the sample list of 29. Findings include: a.) R41's Physician Order Sheet (POS) dated May 2022 documents R41 is diagnosed with Dementia with Behavior Disturbances, Difficulty in Walking, Muscle Wasting and Atrophy, Unsteadiness on Feet, Restless Leg Syndrome, and [CONDITION(S)]. R41's Minimum Data Sets (MDS) dated [DATE] and 4/26/22 document R41 is moderately cognitively impaired and requires supervision (1/25/22) and limited assistance (4/26/22) of one staff person for transfers and mobility. The same MDS documents R41 uses a walker for mobility. R41's Fall Risk Assessment Tool dated 1/25/22 documents R41 is a High Fall Risk and requires assistance or supervision for mobility, transfers, or ambulation, has altered awareness of her immediate physical environment, is impulsive, and has a lack of understanding of her physical and cognitive limitations. R41's Fall Risk Assessment Tool dated 4/26/22 documents R41 is a High Fall Risk and requires assistance or supervision for mobility, transfers, or ambulation, has an unsteady gait, has altered awareness of her immediate physical environment, is impulsive, and has a lack of understanding of her physical and cognitive limitations. R41's Event Report dated 3/17/22 documents R41 had a witnessed fall in the dining room when attempting to stand and move from the table without assistance. R41 hit her head on the drink cart and fell to the floor. R41 was sent to the emergency room and diagnosed with a pelvic fracture. R41's Pelvic Computed Tomography (CT) dated 3/17/22 documents R41 fell and was diagnosed with an Acute non-displaced Fracture of the left inferior pubic ramus. R41's Event Report dated 3/19/22 documents R41 had an unwitnessed fall in the day room when attempting to stand and walk to the bathroom without assistance. R41 complained of pain to her right arm and previously fractured pelvis after this fall but had no new injuries. R41's Event Report dated 4/8/22 documents R41 had an unwitnessed fall in a resident room when ambulating without assistance. R41 hit her head and fell to the floor. R41 was sent to the emergency room and diagnosed with a second pelvic fracture. R41's Pelvic Computed Tomography (CT) dated 4/8/22 documents R41 fell and was diagnosed with an acute non-displaced fracture of the left superior pubic ramus. R41's Event Report dated 5/9/22 documents R41 had an unwitnessed fall in her room when attempting to go to the bathroom without assistance. R41 hit her head and fell to the floor. R41 was sent to the emergency room and diagnosed with a posterior 12th rib fracture. R41's Abdominal/Pelvis Computed Tomography (CT) dated 5/9/22 documents R41 fell and was diagnosed with an acute posterior right 12th rib fracture. On 5/19/22 at 11:40 AM V25 Certified Nurse's Assistant (CNA) stated R41 is unsteady and impulsive. She requires limited assistance with a gait belt and walker for safe transfers and mobility. She can easily get her feet tangled up and fall if she doesn't have assistance. On 5/19/22 at 12:00 PM V10 Dementia Unit Coordinator stated R41 is impulsive and likes to be on the go all of the time. She often attempts to transfer without assistance and does not use her call light when needing help. V10 stated R41's need for physical assistance has increased in the last few months especially after the fall on 3/17/22 when she fractured her pelvis the first time. V10 confirmed the facility has implemented multiple fall interventions for R41 however R41 really needs more supervision. V10 confirmed if staff would have been able to more closely supervise R41, the falls and subsequent fractures on 4/8/22 and 5/9/22 might not have occurred. On 5/20/22 at 10:45 AM V9 Nurse Practitioner (NP) confirmed with R41's cognitive diagnosis of Dementia and subsequent cognitive and physical decline, she is at increased risk for falls and requires increased supervision and physical assistance in order to prevent falls and subsequent injuries. V9 NP confirmed R41's recent falls with fractures could have been avoided if staff were able to supervise her more closely and assist R41 with transfers and mobility. b.) R27's Face Sheet (current) includes the following diagnoses: Complete Traumatic Amputation at Knee level: left lower leg, Type I Diabetes Mellitus, Muscle Weakness and Atrophy, [CONDITION(S)] and Diarrhea. R27's Minimum Data Set (MDS) dated [DATE] documents R27 as being mildly cognitively impaired. This same MDS documents R27 as an extensive assist for transfers and toileting. R27's Nursing Notes dated 3/14/22 document that V17, Transport Driver notified the facility that R27 had fallen in the bathroom at the wound clinic prior to R27's appointment time. On 05/18/22 at 2:10 pm, V16 Transportation Coordinator stated V17, who is not a Certified Nursing Assistant (CNA), transported R27 to a wound appointment alone. V16 confirmed that a CNA did not accompany R27 on the transport for assistance with any personal needs such as toileting. V16 stated R27 was in a wheelchair and after getting to the wound clinic on 3/14/22, R27 had to use the restroom and fell while in the bathroom alone and yelled for help. On 5/19/22 at 12:10 pm, V17 stated R27 told V17 that R27 had diarrhea when they arrived at the entrance to the wound clinic (hospital). V17 stated there was a restroom right at the entrance and R27 went in alone as V17 is not a trained care giver. V17 stated V17 then heard R27 fall and yell and the nurses at the desk also heard R27 and they went in and found R27 on the floor. V17 stated V17 notified the facility and when V17 and R27 returned to the facility V17 told the nurse on R27's unit that R27 had diarrhea and the nurse stated Yeah (R27's) had it for a few days. On 5/19/22 at 1:00 pm V22 Licensed Practical Nurse and R27's Primary Nurse confirmed that R27 had been having diarrhea for a few days prior to R27's wound appointment on 3/14/22 and probably should have had a CNA accompany R27 to the appointment. V22 also confirmed that R27 tested positive for [CONDITION(S)] on 3/15/22. On 5/20/22 at 10:00 am, V1 Administrator stated the facility did not have a Fall Prevention Policy.

Based on interview and record review the facility failed to follow Centers for Disease Control and Prevention (CDC) guidance and the Facility's policy to send home healthcare personnel (HCP) who developed symptoms consistent with Covid-19 while at work and prior to reporting to work. The facility also failed to follow CDC guidance to confirm negative rapid ([MEDICATION NAME]) Covid-19 test results for an employee with Covid-19 symptoms with a molecular (Reverse Transcriptase Polymerase Chain Reaction/RT-PCR) Covid-19 test. These failures resulted in HCP with Covid-19 symptoms providing direct care to residents which has the potential to affect all 52 residents in the facility. These failures resulted in an Immediate Jeopardy. Findings include: While the immediacy was removed on 10/23/20, the facility remained out of compliance at Severity Level 2. The facility is in the process of in-servicing all staff on the screening process for Covid-19, not working while symptomatic or sick, reporting signs and symptoms of Covid-19 that develop during an employees shift, using the rapid [MEDICATION NAME] testing and follow up PCR testing, and updating the Facility Assessment for the Covid-19 Plan. A CDC Symptoms of Coronavirus document dated 5/13/20 states, People with Covid-19 have had a wide range of symptoms reported-ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to [MEDICAL CONDITION]. People with these symptoms may have Covid-19: Fever or chills, Cough, Shortness of breath, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, Diarrhea. A CDC Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance dated 7/15/20 states to, Properly manage anyone with symptoms of Covid-19 or who has been advised to self-quarantine: HCP should return home. The Facility policy Covid-19-Screening, Prevention and Care dated 3/24/20 states, If a HCP develop symptoms while at work, they will immediately don a facemask, inform the Administrator/ designee and leave the campus. A CDC Interim Guidance for Rapid [MEDICATION NAME] Testing for [DIAGNOSES REDACTED]-CoV-2 (Covid-19) dated 9/2/20 documents that the rapid [MEDICATION NAME] test used for testing for Covid-19 is not as accurate as the RT-PCR Covid-19 test. This guidance further states that confirming a negative rapid [MEDICATION NAME] test with a RT-PCR test should be performed when there is a high prevalence of the disease in the community because that increases the probability of the rapid [MEDICATION NAME] test giving a false negative. A Facility Tracking sheet dated 10/15/20 documents that 36 residents in the facility have tested positive for Covid-19 between 9/3/20 and 10/12/20. A Facility Employee Covid Tracking Sheet (undated) documents that between 8/31/20 and 10/12/20 documents that 47 employees have tested positive for Covid-19. On 10/22/20 at 2:57p.m. and 4:14p.m. an email sent from V1 (Administrator) documents that from 8/31/20 to 10/22/20 the facility has actually had 47 residents and 48 staff members who have tested positive for Covid-19. On 10/16/20 at 9:30a.m. and 12:45p.m.; and on 10/19/20 at 3:21p.m. V2 (Director of Nurses) stated that there is a high Covid-19 positivity rate in the Facility's community. V2 also stated that the facility is having an outbreak of Covid-19 among its staff and residents which started 8/31/20 and is ongoing as of this date. V2 stated that staff are screened everyday at the beginning and half-way through their shifts to make sure they don't have symptoms of Covid-19 including a fever, cough, body aches, nasal congestion, headache, sore throat, shortness of breath, fatigue. V2 stated that if a staff member complains of Covid-like symptoms, they are given a rapid [MEDICATION NAME] test to see if it is positive for Covid-19. V2 stated if the test is negative, the facility will still send the employee home to quarantine for 10 days. On 10/20/20 at 3:50p.m. V13 (Certified Nurse Aide/CNA) stated she initially had symptoms of Covid-19 on 9/18/20. V13 stated that she was not scheduled to work until 9/19/20 but she went to the facility on [DATE] for a rapid [MEDICATION NAME] test which was negative. V13 stated that her symptoms included a sore throat and a cough. V13 stated that she has seasonal allergies [REDACTED]. V13 stated that since her symptoms were new, she thought she should be tested to be sure her symptoms weren't related to Covid-19 since the facility was having an outbreak at that time. V13 stated that the facility told her she was okay to work the next day on 9/19/20. V13 stated she did not have a RT-PCR test until 9/22/20 which came back as positive around 9/24/20. V13 stated she worked several times between 9/18/20 to 9/24/20. V13 stated that once she tested positive for Covid-19, she was sent home to quarantine from 9/24/20 to 10/2/20. V13 stated that although that was not the required 10 days of quarantine, the facility was basing her 10 days from her first date of symptoms on 9/18/20. A Facility Employee Covid Tracking Sheet (undated) documents V13 initially had symptoms on 9/18/20 and had a negative rapid [MEDICATION NAME] test 9/18/20. This sheet also documents V13's RT-PCR Covid test was positive on 9/24/20 at which time V13 was on quarantine from 9/24/20 to 10/2/20. A Facility rapid [MEDICATION NAME] test for Covid-19 dated 9/18/20 documents V13 was rapid tested as negative on that date. V13's Covid-19 screening form dated 9/20/20 documents V13's symptoms had worsened when she arrived for her shift on that date. This screening form documents that on 9/20/20 V13's symptoms included a sore throat, muscle/body aches, and a cough. A note written on the screening form stating that V13's rapid test was negative. A Covid-19 PCR Test Report dated 9/22/20 documents V13 tested positive for Covid-19 on that date but the test results were not reported to the facility until 9/24/20. A Facility Staffing Spreadsheet dated 9/2020 documents V13 worked on the 600 hall on 9/19/20, 9/20/20, 9/22/20, and 9/23/20. On 10/21/20 at 8:15a.m. V6 (CNA) stated that she initially had symptoms of Covid-19 on 9/22/20. V6 stated she started having symptoms of a sore throat during her shift on 9/22/20 while working on the 600 hall. V6 stated that since her sore throat symptom was new, she thought she should report it to the facility since the facility was having an outbreak of Covid-19. V6 stated that she was given a rapid test by V14 (Registered Nurse) which was negative. V6 stated that V14 told V6 that because the rapid test was negative, V6 could go back to work. V6 stated the facility performed a facility-wide RT-PCR test on 9/22/20 but she did not get her result back until 9/24/20 which was positive for Covid-19. V6 stated she worked the remainder of her shift 9/22/20 with symptoms and also worked the next day 9/23/20. A Facility rapid [MEDICATION NAME] test for Covid-19 dated 9/22/20 documents V6 was rapid tested as negative on that date. A Covid-19 PCR Test Report dated 9/22/20 documents V6 tested positive for Covid-19 on that date but the test results were not reported to the facility until 9/24/20. On 10/21/20 at 1:20p.m. V14 verified she performed V6's rapid [MEDICATION NAME] test on 9/22/20 after V6 complained of symptoms of congestion and a runny nose. V14 stated that V6 may have also had a sore throat. V14 stated that V6's symptoms were more like allergy symptoms since she did not have a fever. V14 verified that V6's rapid [MEDICATION NAME] test was negative and that V6 remained at the facility to finish her shift. A Facility Staffing Spreadsheet dated 9/2020 documents V6 worked on the 600 hall on 9/22/20 and 9/23/20. On 10/16/20 at 10:10a.m. V3 (CNA) stated that on 9/24/20, while she was working on the 600 hall at the facility, she wasn't feeling right and began experiencing body aches, a headache, and nasal congestion. V3 stated that, because her symptoms were new and the facility was having an outbreak of Covid-19, she decided to report her symptoms to the facility. V3 stated that when she reported her symptoms, the facility gave V3 a rapid [MEDICATION NAME] test which was negative. V3 stated that she was not sent home from work and she did not receive a RT-PCR test until the next week around 9/29/20 which came back as positive for Covid-19. V3 stated that she worked four times after reporting symptoms to the facility, on 9/24/20, 9/25/20, 9/29/20 and 9/30/20. A Facility rapid [MEDICATION NAME] test for Covid-19 dated 9/24/20 documents V3 was rapid tested as negative on that date. A Covid-19 PCR Test Report dated 9/29/20 documents V3 tested positive for Covid-19 on that date but the test results were not reported to the facility until 9/30/20. A Facility Staffing Spreadsheet dated 9/2020 documents V3 worked the first and second shift on the 600 hall on 9/24/20, the first and second shift on the 700 hall on 9/25/20, the first and second shift on the 500 and 700 halls on 9/29/20, and the first and second shift on the 700 hall on 9/30/20. On 10/21/20 at 2:06p.m. V15 stated that she has a chronic cough, however, on 10/3/20 while working at the facility, her cough seemed worse than usual and she also developed a stuffy nose. V15 stated that because the facility was experiencing a Covid-19 outbreak she decided to notify the facility concerning her symptoms. V15 stated that she notified V2 (Director of Nurses) who instructed another nurse to give V15 a rapid [MEDICATION NAME] test for Covid-19 which was negative. V15 stated that after her negative rapid test, she was instructed to continue working providing resident care. V15 stated she worked several days before the facility tested V15 using a RT-PCR test. A Facility rapid [MEDICATION NAME] test for Covid-19 dated 10/3/20 documents V15 was rapid tested as negative on that date. A Covid-19 PCR Test Report dated 10/6/20 documents V15 received a RT-PCR test on that date which was not reported to the facility until 10/8/20, five days after V15 reported her symptoms. A Facility Staffing Spreadsheet dated 10/2020 documents V15 worked at the facility on the 200 hall on 10/3/20, the 700 hall on 10/4/20, the 600 hall on 10/6/20, the 700 hall on 10/7/20, and both the 200 and the 100 halls on 10/8/20. On 10/20/20 at 2:03p.m. V16 (Local Health Department Administrator) stated that the Facility has had an outbreak of Covid-19 since the end of August 2020. V16 stated that he believes the outbreak has been exacerbated by the facility allowing staff to work when they have Covid-19 symptoms. V16 stated the Facility is relying heavily on their rapid [MEDICATION NAME] testing device to determine if staff are positive or negative for Covid-19, but not verifying the results with a RT-PCR test if the rapid test shows a negative result. V16 stated that no staff should be working in the Facility if they have symptoms and should be sent home from the facility to self-quarantine. On 10/22/20 at 10:00a.m. V1 (Administrator) and V2 verified the dates that V3, V13, V6, V15 had reported symptoms and were then given the rapid [MEDICATION NAME] test by the facility. V2 stated that V3, V13, V6, and V15 all had negative rapid [MEDICATION NAME] test results and were instructed to come to or stay at work instead of quarantining themselves at home. V2 stated she thought none of those staff members had Covid-like symptoms. V1 verified that V3 did not have a RT-PCR test following the rapid [MEDICATION NAME] test 9/24/20 until 9/29/20 which was reported to the facility on [DATE] as positive. V1 also verified V3 was not sent home to quarantine once she reported having symptoms of Covid-19 on 9/24/20 but instead worked at the facility on 9/24/20, 9/25/20, 9/29/20, and 9/30/20. V1 verified that V13 did not have a RT-PCR test following the rapid [MEDICATION NAME] test on 9/18/20 until 9/22/20 which was reported to the facility on [DATE] as positive. V1 verified V13 was not sent home to quarantine once she reported having symptoms of Covid-19 on 9/18/20 but instead V13 worked at the facility on 9/19/20, 9/20/20, 9/22/20, and 9/23/20. V1 verified V6 was not sent home to quarantine once she reported having symptoms of Covid-19 on 9/22/20 but instead V6 worked at the facility on 9/22/20 and 9/23/20 but also on 9/25/20. V1 stated that V6 was given a RT-PCR test on 9/22/20, the same day as her symptoms began, but the result was not reported to the facility until 9/24/20, which was positive. V1 stated that V6 was sent home from the facility at 8:28a.m. on 9/25/20 after the facility became aware of V6's positive test result. V1 verified that V15 did not have a RT-PCR following the rapid [MEDICATION NAME] test on 10/3/20 until 10/6/20 which was reported to the facility on [DATE]. V1 verified that V15 was not sent home to quarantine once she reported having symptoms of Covid-19 on 10/3/20 but instead V15 worked at the facility on 10/3/20, 10/4/20, and 10/6/20. A Resident Census and Condition of Residents form dated 10/16/20 and signed by V1 documents that at the time of the survey 52 residents resided in the facility. An Immediate Jeopardy was Identified on 10/22/20. The Immediate Jeopardy was identified to have begun on 9/19/20 when the facility allowed V13 to work providing direct resident care while having the symptoms of cough and sore throat which are consistent with Covid-19. The facility also failed to verify V13's negative rapid [MEDICATION NAME] test with a RT-PCR test. V13 was allowed to work while experiencing worsening symptoms to include muscle/ body aches as well as sore throat and cough on 9/20/20. Additionally, the facility allowed V6 to work while experiencing Covid-19 symptoms starting on 9/24/20, V3 to work while experiencing Covid-19 symptoms starting on 9/24/20, and V15 to work while experiencing Covid-19 symptoms starting on 10/3/20. V13, V3, V6, V15 all received a rapid [MEDICATION NAME] test while experiencing symptoms to detect the Covid-19 virus, but the facility did not follow up that rapid test with the more accurate RT-PCR test as described in CDC guidance for Rapid [MEDICATION NAME] testing, nor did the facility follow their policy and CDC guidance to send symptomatic employees home. On 10/22/20 at 10:05a.m. V1 was notified of the Immediate Jeopardy situation. On 10/27/20 at 9:00a.m. the surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. V1 and V2 verified initiating in-servicing to all staff for Covid-19 screening for visitors, vendors and employees with an extra emphasis on prohibition on working when symptomatic or sick with no staff allowed to work before receiving training. 2. V1 and V2 verified that all staff will be actively pre-screened by a nurse prior to their scheduled shift and if these employees report or exhibit any symptoms they will not be permitted to work per the CDC/State Agency Guidelines. Also, all symptomatic employees will be reported to V1 and V2. 3. V1 and V2 verified that all staff have been reminded to immediately report to a nurse upon the onset of any signs or symptoms that occur during their shift. V1 and V2 also verified those employees will be sent home. 4. V2 verified she received in-servicing from V1 on how to appropriately use the rapid [MEDICATION NAME] testing device, including when to follow-up with RT-PCR testing. 5. V1 and V2 verified that all screening forms are being reviewed with auditing of 20 employee screen forms weekly for one month for accuracy and to ensure staff are not working while symptomatic. 6. V2 verified she completed an audit on 10/22/20 to ensure that staff who were currently working were not symptomatic and that all staff have been tested in accordance with the facility testing plan. 7. V1 verified the Facility Assessment for the Covid-19 Plan has been updated to reflect the actions taken to remove the immediacy. These changes will also be added to the facility's quality assurance process and continue to be monitored.

Based on observation, interview and record review, the facility failed to ensure pressure relieving interventions were implemented to prevent pressure ulcers for three of eight residents (R22, R71, R276) reviewed for pressure ulcers in the sample of 41. This failure caused R22 to develop three Stage 2 Pressure Ulcers to the left upper buttock. Findings include: The facility's Pressure Injury Prevention and Treatment Protocol policy dated (MONTH) (YEAR) documents the objective and purpose is to ensure that measures are taken to prevent skin breakdown and to provide guidelines for treatment of [REDACTED]. This policy documents an individualized plan of care will be developed for the resident and all high and moderate risk residents may have the following and if so they will be addressed on the care plan- Special mattress and wheelchair cushions, passive range of motion, protein and/or nutritional supplements, turning and positioning schedule, skin checks and elbow/heel protectors/bridging of heels. This policy documents staff will be trained on pressure injury prevention and safety measures to be taken including proper positioning procedures. If residents are incontinent, perineal care will be given and the resident will be dried. When a resident is admitted to the facility or develops a pressure ulcer in the facility, the following will occur: Assess the pressure ulcer for location, size, wound bed, drainage, description. Determine the injury's current stage of development. For those residents that cannot reposition themselves, staff are responsible for assisting those residents. Special devices will be used to relieve pressure. All treatments and charting of pressure injuries will be done by licensed staff. This policy documents predisposing factors may include bedridden/decreased mobility, past [MEDICAL CONDITION], nutritionally depleted, contractures, obese, critically ill, incontinence, previous pressure injury, Diabetes, [MEDICAL CONDITIONS], and Chronic End Stage Renal, Liver or [MEDICAL CONDITION]. 1. R22's Face Sheet dated 6/3/19 documents R22's [DIAGNOSES REDACTED]. R22's Care Plans dated 5/6/19 document R22 is at risk for skin breakdown due to decreased mobility, incontinence, [MEDICAL CONDITION] and Diabetes. These Care Plans document R22 has a Stage II Pressure Ulcer below the right buttock fold. R22's Care Plans document interventions including a pressure relieving cushion to R22's wheelchair. R22's Admission Observation Report dated 6/3/19 documents R22 requires a mechanical lift with two staff assistance to transfer. R22's pressure sore risk assessment dated [DATE] documents R22 is at a high risk for pressure sores. On 06/04/19 11:32 AM, 06/04/19 01:42 PM, 06/05/19 11:05 AM, and 06/05/19 11:08 AM R22 was sitting up in R22's electric wheelchair in R22's room. At each of these times: R22's pressure relieving cushion was in the seat of R22's electric wheelchair and R22's mechanical lift sling was under R22 positioned between R22 and the pressure relieving cushion. On 06/05/19 11:08 AM V15 and V16, Certified Nursing Assistant (CNA's) provided cares for R22. R22 was in R22's electric wheelchair with the mechanical lift sling under R22. V15 and V16 provided perineal care to R22 and turned R22 to finish providing cares to R22. There were three pressure ulcers to R22's left upper buttock area that were not documented as current pressure ulcers in R22's medical record. On 6/5/19 at 11:34AM, V7, Wound Nurse, provided wound care to R22's Stage II Right Buttock. V7 confirmed there were three new Stage II Pressure Ulcers to the Left Upper Buttock. V7 stated, the three areas are new and all three are pressure ulcers, stage II. R22's Progress Notes dated 6/5/19 at 12:02pm document R22 noted to have Stage II Pressure ulcers to the left buttock measuring as follows: 1- 0.5cm (centimeters) by 0.3cm; 2- 1cm by 0.9cm; 3- 2cm by 0.3cm. 06/05/19 03:42 PM R22 observed sitting up in R22's electric wheelchair looking out the window in R22's room with a mechanical lift sling gathered up under R22 on top of R22's pressure relieving cushion. On 6/6/19 at 12:30pm, V2, Director of Nursing stated R22's mechanical lift sling should be removed after R22 has been transferred in to R22's electric wheelchair and should not be left under R22, so it does not interfere with the pressure relief the cushion is to be providing to prevent R22 from developing pressure ulcers. On 6/6/19 at 2:35pm R22 was up in R22's electric wheelchair in R22's room with a mechanical lift sling positioned between R22 and the pressure relieving cushion. The manufacturer's guidelines for the pressure relief cushion dated with the year of (YEAR) document DO NOT place anything between the user and the product as additional materials may reduce the effectiveness of the product and increase risk factors for skin breakdown and instability. 2. On 6/6/19 at 9:38 AM, R71 had a three centimeter by one centimeter pressure ulcer to the coccyx. R71's nursing notes documents that R71 was admitted to the facility on [DATE]. R71's Pressure Risk assessment dated [DATE] documents R71 as being a moderate risk for pressure ulcer. R71's medical record does not document passive range of motion or a nutritional supplement for R71. R71's care plan documents an intervention dated 4/24/19 to do skin checks every shift. R71's medical record does not document that skin checks were completed every shift. R71's care plan documents an intervention to turn and position R71 every two hours. R71's medical record does not include documentation that R71 was turned and positioned every two hours. On 6/06/19 at 9:55 AM, V2 Director of Nursing stated R71 did not have a pressure ulcer when R71 came into the facility. V2 stated R71 was admitted on [DATE] and was assessed as a moderate risk for pressure ulcer. V2 stated R71 was not provided with passive range of motion per facility policy. R71 stated a nutritional supplement was not started until 5/2/19. R71 stated there is no documentation in the medical record that skin checks were done every shift. V2 stated turning and positioning is on the care plan for every two hours. V2 stated there is not a flowsheet or a schedule which should be followed for turning and positioning. 3. On 6/6/19 at 1:35 PM, R276 had necrotic circular areas covering the right and left heel. R276 had a one by 0.5 centimeter darkened hard area to the right lateral malleolus and a 1.5 centimeter darkened hard area to the left plantar. R276's admission assessment dated [DATE] documents R276's heels as intact and not boggy. R276's pressure risk assessment form dated 5/2/19 documents R276 as a moderate risk for developing pressure ulcers. R276's medical record does not document that the facility provided passive range of motion to R276. R276's medical record does not documents that a nutritional supplement was initiated until 5/15/19. R276's Event Report dated 5/11/19 documents R276 developed a 7.5 centimeter by 6.5 centimeter fluid filled blister to the left heel. R276's Event Report dated 5/11/19 documents R276 developed a 4 centimeter by 7 centimeter fluid filled blister to the right heel. R276's nursing notes dated 5/15/19 documents R276 developed a stage two fluid filled blister to the right plantar on 5/15/19. This note documents R276's blister lines up with the wheel chair pedal where R276's foot rests. R276's medical record or care plan does not include pressure relieving interventions for R276's feet while sitting up in the wheel chair. R276's Event Report dated 5/24/19 documents R276 developed a stage two pressure ulcer measuring one by 0.5 centimeter to the left plantar (foot) on 5/24/19. R276's nursing notes dated 6/05/2019 at 7:03 AM written by V7 Registered Nurse/Wound nurse documents that there is a four by 2.5 centimeter unstageable pressure ulcer to the left heel, a four by three centimeter unstageable pressure ulcer to the right heel, a one by 0.5 centimeter pressure ulcer to the right lateral malleolus and a three by 1.5 centimeter pressure ulcer to the left plantar. On 6/6/19 at 10:19 AM, V2 Director of Nursing stated R276 was admitted on [DATE] and was assessed as being a moderate risk for pressure ulcers. V2 stated R276 did not receive passive range of motion per facility policy. V2 stated R276 did not receive a nutritional supplement until Liquid protein was started on 5/15/19. V2 stated R276 developed a left plantar unstageable pressure ulcer on 5/15/19 which lined up with the foot pedal in same location where resident rests his foot. V2 stated no intervention was put into place to prevent pressure from the foot pedal. V2 stated R276 then developed a right plantar blister on 5/23/19. V2 stated no interventions was put into to relieve pressure from the foot pedals.

Based on observation, record review and interview the facility staff failed to ensure that the mechanical lift sling was properly secured prior to lifting one (R1) of three residents reviewed, on the sample of three, who require transfers with a mechanical lift. R1 fell out of the sling during a transfer and sustained a Skull Fracture and Acute Intracranial Hemorrhage. The findings include: On 8/24/12 a facsimile was received by the Department from the facility reporting an injury to R1 which occurred on 8/23/12 at 4:30 pm. The report documented that R1 had slid out of the mechanical lift and was transferred to the Hospital with admitting [DIAGNOSES REDACTED]. The report indicated an internal investigation was being conducted and information would be sent upon completion. The final investigation report dated 8/27/12 was provided by Administrator E1 on 8/27/12. The report stated "Shelbyville Manor has completed a thorough investigation of the fall involving (R1). The mechanical lift has been completely inspected and it has been determined that the lift did not malfunction. The sling utilized during the transfer has been inspected and no defects have been found with the sling". The report concluded "the left leg strap was not secured properly to the lift device which resulted in (R1's) right leg falling from the sling. (R1's) buttocks then slid through the sling between the torso and leg area of the sling. It has been determined that CNA (Certified Nurse Aid E5) was responsible for securing the left leg strap to the lift. (E5) was terminated 8/24/12." E5's signed statement dated 8/24/12 documented "..We hooked the straps to the lift. I proceeded to push the button to lift him off the bed. When he was lifted up I started to pull the lift back. I grabbed a hold of the sling to help position him into the chair and his leg fell out...I tried to prevent him from falling but I could not hold him up until (E4) could get over there to help me and I lowered him to the floor." CNA, E4's signed statement dated 8/24/12 documented "..(E5) started lifting him up and once all his body weight was off the bed I went around to position his chair. As I was walking (E5) was manipulating (R1) off the bed. I was standing beside the chair and (E5) was handling the lift. (R1's) leg fell ..before I could get over there (R1) fell and struck his head on the chair and the floor. I left the room to locate the DON (Director of Nursing)." R1's August 2012 physician's orders [REDACTED]. R1's quarterly Minimum Data Set ((MDS) dated [DATE] identified R1 with severe cognitive impairment, total dependence in bed mobility, and transfer with assist of 2 staff. The assessment lists R1 being totally dependent with personal hygiene and had an indwelling catheter. R1 also had functional limitations in Range of Motion (ROM) for both upper and lower extremities and had unsteady balance. R1's height and weight was 65 inches, 187 pounds. R1's Care Plan dated 7/12/12 documented R1 was at increased risk for falls related to [DIAGNOSES REDACTED]. The care plan states "Resident is immobile, he transfers via mechanical lift. He is dependent on staff for all ADL's (Activities of Daily Living), including propelling his gerichair. He is up to a (geriatric chair) for proper positioning. He does not attempt to self transfer." On 8/27/12 at 1:30 pm, Administrator E1 stated that R1 was still in the hospital in stable condition, was receiving IV (intravenous) antibiotics, and anti-inflammatory medication. E1 stated R1 had a Subdural Hematoma and Temporal Lobe Fracture. E1 stated that two Certified Nurse Aides (CNAs) E4 and E5 were transferring R1 from the bed to a chair and R1 fell from the lift because, E5 did not secure the left leg strap of the (mechanical lift) sling. E1 stated E5 was operating the lift and had raised (R1) up and had started moving R1 away from the bed when R1's right leg fell out because the loop was not secure and R1 came out of the lift, hitting his head on a chair and on the floor. E2 (Director of Nursing) was present during the conversation (8-27-12 1:30 p.m.) and showed the surveyor the orange sling that was involved in R1's fall. The sling was a nylon mesh construction and each side of the lift sling had three sets of color coded nylon loop straps. There were straps on each side at the shoulders, mid body and leg. The straps are used to connect the sling to the hooks on each side of the spreader bar of the lift. Once the appropriate corresponding color loop (red, green or yellow)is put over the U shaped hook a locking pin comes down to close the opening to keep the loop from coming loose when there is weight in the sling. E2 brought the lift into the room and demonstrated how the sling loops are placed over the hook and a metal clip closed over the opening when weight was put on the sling. E2 provided a list of fourteen residents (including R1) who currently require use of the Mechanical Lift. E1 stated on 8/27/12 at 2:00 PM they tried to figure out what happened and reenacted the incident with both CNA's using the lift and sling and with Physical Therapy and Support Services staff and they could not find any mechanical problems with the lift, or sling that would allow the loop to come off the hook. Director of Nursing E2 stated at 1:35 pm on 8-27-12 that she went down to R1's room immediately after she was notified of R1's fall. E2 stated when she arrived R1 was laying on the floor beside the bed, his lower back was across the leg of the lift, his head was forward and his airway was compromised so they stabilized his head and they removed the lift legs out from under him and he started breathing better. E2 stated on 8/27/12 at 2:00 pm that E3 (Nurse) was the first nurse to respond to R1's room. Nurse E3 stated on 8/27/12 at 2:15 pm that she was notified by a CNA ( 8/23/12) that R1 had fallen and she went running back there with E2 behind her. E3 stated R1 was still hooked up to the lift with his back and legs across the metal legs of the lift. E3 stated his head was bleeding, he wasn't talking and appeared unconscious, his pupils were pinpoint. E3 stated E2 thought his airway wasn't open, so E3 applied a towel to the back of R1's head to stabilize him and he started breathing better and became more aware. They removed the lift legs from beneath him. E3 stated she stayed with R1 until the ambulance arrived. R1's Nurse's notes dated 08/23/12 4:30 pm documents the ambulance arrived and transported R1 to the hospital. The hospital Radiology Report dated 8/23/12 of the CT (Computerized Tomography) of the Brain documented " Acute intracranial hemorrhage is seen within both hemispheres...predominately subarachnoid in nature..Right calvarial fracture is seen extending from the right parietal calvarium down into the right temporal lobe. There is soft tissue within the auditory canal." The hospital Acute History and Physical report dated 8/26/12 documented R1 " sustained laceration to right side of his head. The CT did reveal a fracture in the right parietal area extending into the right temporal area. He has a subarachnoid bleed and probably a small subdural bleed, bleeding noted in the right ear. Soft tissue swelling around right ear noted on CT scan." E4 confirmed during a telephone interview on 8/27/12 at 4:30 pm that she and E5 had placed the lift sling underneath R1 (on 8/23/12) while he was in bed and they had attached the straps of the sling to the lift bar. E4 was on the right side of the bed and E5 was on the left side of the bed. E4 stated they used red loops for the shoulder and green loops for the middle and lower leg straps. E4 stated the leg straps were crossed between his legs and were threaded through each other. E4 hooked the sling straps on her side to the lift hooks and E5 attached the straps on her side. E4 stated E5 was operating the lift and raised R1 up over the bed. E4 stated as E5 was pulling R1 in the lift away from the bed, one of R1's legs came down and he slipped out of the sling. R1's head hit the bedside chair and then the floor. E4 stated it happened so fast they were not able to stop him. E5 confirmed during a telephone interview on 8/27/12 at 4:45 pm that she and E4 had put the sling under R1 and they had each hooked all three straps on each side to the lift hooks. E5 stated she pushed the button control and lifted R1 up with the machine off the bed and E5 started to come around the other side of the bed with the chair. E5 stated she was getting ready to spread the legs of the lift when when R1's leg started to fall and he started coming out of the sling. E5 stated she tried to stop him from falling but she couldn't hold him up. E5 stated she has previously transferred R1 a couple times before with the lift with and had no problems. E5 said she had watched the training (mechanical lift) video during orientation and had a week on on the job training which included use of the lift when she started work. The undated facility training information from the manufacturer of the mechanical lift included "Sling Warnings" which included "Improper Sling Size, improper sling attachment or improper sling and lift inspection can cause death or serious injury...Ensure all sling straps are properly attached to lift spreader bar. Visually check nuts and bolts on spreader bar and lift..Lift resident 1-2 inches over bed or chair to ensure sling is holding resident securely and properly before further lifting." Physical Therapy Program Director E8 stated on 8/28/12 at 1:45 pm she felt the size of the sling used was appropriate for R1's size, weight and body structure. E8 stated as long as the sling loops were placed correctly on the hooks, they shouldn't come off. .

A. Based on observation, interview, and record review the facility failed to develop and implement an individualized toileting program after multiple falls where resident attempted to take self to toilet in order to reduce opportunities for further falls for one of eight residents (R10) reviewed for falls/fractures in the sample of 15. R10 sustained two fractured hips. The facility failed to protect during transport, the flaccid arm of one of eight residents (R8) reviewed for falls/fractures in the sample of 15. R8 sustained a fractured left hand. Findings include: 1. The physician's orders [REDACTED]. The Care Plan dated 10/15/10 through 7/12/11 indicates "...(R10) is at risk for falling based on decreased strength and endurance, the use of anti-hypertensives, analgesics, diuretics, and antipsychotics and resident requires staff assistance to utilize toilet. Res has a history of falls..." Nursing notes for the month of December of 2010 document multiple unwitnessed falls for R10. Incidents include: 12/3/2010 "Resident observed sitting on floor next to bed...Assisted up per 2 staff...Reminders to call for assistance..." Nurse notes dated 12/7/2010 states, "...Resident was found on floor next to bed..." 12/8/2010 note states, "...IDT (Interdisciplinary Team) met regarding resident's fall on 12/7. Resident was attempting to get up and does not know why..." 12/8/2010 reads as follows:"...Called to res (resident's) room per CNA (Certified Nursing Assistant). Res sitting on floor facing her bed with her back against room mates bed. Noted 8 cm (centimeter) abrasion to mid spine...Stated she was trying to get into bed... 12/11/10 note reads, "...Resident c/o (complains of) pain right wrist. Noted edema to wrist et (and) hand...Res thinks she hurt it when she fell the other day...Orders received for x-ray et immobilizer..." Nurses notes dated 1/2/2011 read as follows: "...Called to res room per CNA. Res noted sitting on her buttocks on the floor in her bathroom. Res. was positioned with her left side near the toilet and had her back leaning against the bathroom wall. Stated she had to go to the bathroom "bad"...Stated she was trying to hurry to avoid an accident and she lost her balance. CNA stated the call light was not on when she entered the room..." Nurses notes dated 1/3/2011 states: "...IDT team met regarding resident's fall on 1/2/11...Res having urgency (urinary urgency) as root cause analysis...Toileting program to be initiated..." E1 Administrator and E2 Director of Nurses stated on 7/14/2011 at 1:00 PM that R10 was not assessed for a toileting program after the fall on 1/2/2011. E1 stated the tool that is used to determine the need for a toileting program is called the "Cactus" tool. E1 stated that assessment tool had not been done for R10 since her admission in October of 2010. E1 stated that the "Bladder Retraining Record" that shows R10 was toileted every two hours subsequent to January of 2011 was not based on an assessment. E1 stated that after the "Cactus" assessment has been done the nurse completing the assessment would circle the times on the "Bladder Retraining Record" that R10 should be toileted. This would give nursing staff direction on when (how often) to toilet R10. The "Bladder Retraining Record" from 2/24/2011 through 3/2/2011 does not indicate the times R10 is to be toileted. Nurses notes dated 1/11/2011 state, "...Pt. states that she removed her alarm so she could use the commode. Pt (patient) stated that she attempted to get out of bed and fell on the floor to her left hip and hit her head on the wheelchair...Ambulance called to transport pt to (hospital)...This nurse called (the hospital) to inquire on status of pt and was informed that pt has Lt (left) hip fx (fracture) and is being transferred to (another area hospital)..." Nurses notes dated 3/1/2011 state, "...Pt. observed on floor beside the bed lying on Lt (left) side. Hematoma noted to Rt. side of head and c/o (complained of) pain in head...Ambulance called for transport...Writer called (hospital) to inquire on pt. status and ER nurse reported that pt. has a right hip fracture... Notes dated 3/2/2011 state, "...IDT team met regarding resident's fall on 3/1/11. Resident was on floor next to her bed and states she was trying to go to the commode...Root cause analysis reveals that res was attempting self transfer and fell to floor..." 2. The July 2011 physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] indicates R8 has Range of Motion impairment on both sides upper and lower extremities. The MDS indicates the impairment interferes with daily function and places the resident at risk for injury. The MDS indicates R8 is extensive to total care for all activities of daily living. Z1 family member stated on 7/12/2011 at 3:00 PM that facility staff had broken her father's hand while transferring him. A facility investigation report dated 8/18/11 states, "...Area to left hand 2nd finger assessed and appears to be purplish in color and approximately 7 x 3 cm (centimeters). Area was first noted on 8/18/2010 at 10:06 AM...Resident stated that he bumped it on the door frame when they pushed him from his room..." E13, CNA stated on 7/13/2011 at 9:50 AM, "...He will usually hold his flaccid hand with his other hand but not always. Sometimes he will let it go...I went right in (after the injury was discovered) and looked at his hand. The injury was very noticeable. I asked him how it happened and he said he hit it on the door..." E14 , CNA (Certified Nursing Assistant) stated on 7/13/11 at 10:25 AM that R8 will sometimes let go of his hand and it will go outside the frame of the wheelchair. E14 stated, "...I remember when (R8) got his finger broke. I was taking care of him that day. It was his left hand. He cannot control his left arm. We have to move the arm anytime we do anything with him. He leans to the left sometimes and to the right sometimes. If he does not hold on to his left hand - it can fall - I have seen it fall (outside of the wheelchair). Sometimes he will let go of his arm. It is possible he let go of his arm and it fell and we didn't notice..." B. Based on observation and interview the facility failed to maintain hot water accessible to the residents on the Dementia special care unit (Garden Court) at safe levels so as to prevent potential burns. This has the potential to affect 17 of 17 residents of the specialized unit (R1, R2, R3, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32). R1, R2, and R3 are 3 of 15 sampled residents. R19 through R32 in the supplemental sample. Findings include: On 7-12-11 at 2:15 p.m. hot water was permitted to run at the lavatory in R1's bathroom and felt extremely hot to the touch. Hot water was tested with a digital thermometer at this time at the lavatory and shower in the bathroom which registered a maximum of 116 degrees Fahrenheit. R1's hot water was tested again at 2:30 p.m. and registered a maximum of 117 degrees Fahrenheit. Hot water was tested in R2 and R3's bathroom lavatories on 7-12-11 at 2:20 p.m. and registered a maximum of 116 degrees Fahrenheit. Hot water was tested at sink in the special care unit dining/activity room at 2:25 p.m. on 7-12-11 and was found to be extremely hot to the touch. The hot water registered at 116 degrees Fahrenheit at this location. There are independently ambulatory cognitively impaired residents on the unit who could gain unrestricted access to hot water on the unit. Hot water was tested in the special care unit central shower on 7-12-11 at 2:30 p.m. which felt extremely hot and registered at 116 degrees Fahrenheit. Certified Nurse Aide, E8 stated on 7-12-11 at 2:30 p.m. that there have been no incidents involving excessively hot water or complaints about excessively hot water from residents. E8 stated that no residents on the unit are permitted to bathe without staff being present. Maintenance Director, E9 stated on 7-13-11 at 8:55 a.m. that hot water temperatures are checked once weekly and had last been checked 4 days earlier without any detected problem. E7, special care unit Director indicated on 7-12-11 at 10:15 a.m. that R1, R2, R3, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, and R32 reside on the closed unit and are cognitively impaired, each with [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to prevent a non-certified staff person from doing direct resident care in violation of facility policy. The staff member was not paying attention to a resident (R2) during assisted ambulation and the resident tripped and fell . R2 sustained a laceration of the head, an abrasion of the head, and abrasions of both the upper and lower extremities. Consequently R2 was sent to the hospital by ambulance and assessed and treated by an emergency room physician. R2 is one of three residents sampled for falls/injuries. Findings include: The January 2011 physician's orders [REDACTED]. The Minimum (MDS) data set [DATE] shows R2 has range of motion limits of the arm, hand, and leg and needs assistance to ambulate. The facility incident reports documents R2 had ten falls between July of 2010 and December of 2010. A facility incident report dated 8/6/2010 2:55 PM, states, "...Writer called to DR (dining room) per staff. Resident observed laying on floor. Blood observed on floor from a 1 and 1/4 inch laceration to the occipital region of her head...Call made to MD (Medical Doctor), orders to send to ER (emergency room )..." The emergency room report dated 8/6/10 reads, "...Patient arrived from the local nursing home due to a fall...Patient c/o (complaining of) right sided headache and general body aches. Laceration to right side of head with an abrasion to the right forehead, right elbow and right knee..." E5, Certified Nursing Assistant (CNA) and a witness to the fall stated per telephone on 1/26/2011 at 11:30 AM that E7, Nursing Assistant (NA) was not paying attention. E5 stated, "...A new girl (E7) was walking her (R2) into the dining room. The employee, (E7) had no shoes on, she was only wearing socks. (E7) was walking (R2) across the dining room and she was talking and not watching (R2). She (R2) stumbled and fell . She (R2) hit her head..." E5 goes on to say you have to be careful when you ambulate R2 because she routinely stumbles. She feels the injury to R2 could have been prevented if E7 would have been watching what she was doing. The job description for "Resident Assistant" reads, "...To assist facility staff, in a team approach, in providing non-direct care and activities to residents..." A sample of duties are listed such as "make and clean beds", "pass and prepare trays for residents in dining room", "stock linen carts", etc. There are no direct care duties listed in the job description. The job description was signed by E7. E1, Administrator stated on 1/26/2011 at 1:00 PM that E7 was a nursing assistant and that the term "nursing assistant" is interchangable with the term "resident assistant." She stated E7 was enrolled in a certified nursing assistant class but had not completed the class and was not certified. E1 stated E7 should not have been ambulating R2 because facility policy prohibits nursing assistants from giving direct resident care.