Every finding on record at Smith Village

Based on interview and record review, the facility failed to ensure an appropriate discharge for one resident reviewed for discharge practices by discharging the resident despite abnormal laboratory results indicative of dehydration. This deficient practice affected one (R1) of two residents reviewed for discharge. As a result, R1 was readmitted to the hospital within 48 hours of discharge with diagnoses of acute metabolic encephalopathy, likely secondary to a combination of dementia, dehydration, and urinary tract infection (UTI).Failure to ensure the resident was medically stable prior to discharge had the potential to result in worsening dehydration, delayed medical treatment, increased risk for hospitalization, and adverse health outcomes related to unresolved clinical conditions.R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. Her medical history includes fracture of left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white blood cell count, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hyperlipidemia and essential (Primary) hypertension.R1's laboratory results with a report date of 2/16/2026 13:37 showed the following abnormal results:BUN 26 mg/dLBlood Urea Nitrogen measures the amount of urea nitrogen (another protein-waste product) in your blood. The normal range is generally 7 to 223 mg/dL.Creatinine 2.1 mg/dLCreatinine is a waste product naturally produced by muscles and filtered out by healthy kidneys. Normal levels generally range from 0.4 to 1.6 mg/dL.EGFR (Non African American) 21mL/min.The Estimated Glomerular Filtration Rate measures how well your kidneys filter blood. A normal eGFR is 60 or above.V1, Director of Nursing (DON) presented a copy of R1's laboratory results with notation stating the results were sent to V9, R1's physician, on 2/17/2026 12:20 P.M. However, interview with V9 indicated that he was not made aware of the abnormal laboratory results. V1 is also unable to verify if the results were sent via fax or via telephone conversation or via text. On 5/16/2026 at 11:30 A.M., V9, R1's Physician, stated V9 was not aware that R1 ended up in the hospital after being discharged from the facility. V9 stated the abnormal laboratory results taken on 2/16/2026 were not relayed to him. V9 also stated that although he cannot keep residents in the facility for medical reasons once physical therapy says that R1 is ready for discharge, before discharging R1, V9 would have given R1 a bag of intravenous fluids, instructed R1 to increase fluids and then follow up with her primary care physician for follow up and monitoring because of R1's abnormal results which could indicate dehydration.On 5/15/2026 at 3:34 P.M., V10, receiving home health agency Director of Nursing, stated R1's start of care with the agency was 2/19/2026 and R1 went back to the hospital within 24 hours of start of care on 2/20/2026 with a diagnosis of acute metabolic encephalopathy most probably combination of dementia, dehydration and urinary tract infection. V10 also stated the abnormal laboratory results drawn on 2/16/2026 were not provided by the facility to their home health agency. V10 acknowledged receiving R1's Discharge Summary and that they expect to receive any laboratory results that would require monitoring and follow-up to be provided as well by the transferring facility. V10 also stated that R1's abnormal lab results do not surprise V10 because R1 already had a diagnosis of Acute Kidney Failure and will not impact R1's start of care. R1's Hospital records under assessment and plan dated 2/21/2026 documents under Assessment and Plan: Acute metabolic encepalopathy most probably combination of dementia and (sic) dehydration and UTI (Urinary Tract Infection).Facility policy titled Transfer and Discharge (including AMA) with date reviewed/revised 5/26 documents: It is the policy of the facility to permit each resident to remain in the facility and not transfer or discharge the resident from the facility, except in limited circumstances.

Based on interview and record review, the facility failed to notify the physician and residents' representatives when new treatments were initiated and failed to notify the physician of abnormal laboratory results for three (R1, R2 and R3) of three residents reviewed for notification of changes. This deficient practice had the potential to delay medical evaluation and treatment, limit resident and representative participation in care planning and informed decision-making, and place residents at risk for worsening conditions, avoidable hospitalization, and adverse health outcomes. R1 was admitted to the facility on [DATE] and discharged home on 2/18/2026. Her medical history includes fracture of left pubis, acute kidney failure, muscle wasting and atrophy, ataxic gait, type 2 diabetes mellitus, elevated white blood cell count, dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, hyperlipidemia and essential (Primary) hypertension. R1's Physician Order Sheet documents an order dated 2/11/2026 as follows: Ciprofloxacin HCl 500 MG Tablet 1 tablet by mouth twice daily for 7 days until finished (Dx: (Diagnosis) UTI (Urinary Tract Infection)) Review of R1's progress notes exclude any documentation that R1's family member was informed that antibiotics were started for R1. R1's laboratory results with a report date of 2/16/2026 13:37 showed the following abnormal results: BUN 26 mg/dLBlood Urea Nitrogen measures the amount of urea nitrogen (another protein-waste product) in your blood. The normal range is generally 7 to 223 mg/dL. Creatinine 2.1 mg/dLCreatinine is a waste product naturally produced by muscles and filtered out by healthy kidneys. Normal levels generally range from 0.4 to 1.6 mg/dL. EGFR (Non African American) 21mL/min.The Estimated Glomerular Filtration Rate measures how well your kidneys filter blood. A normal eGFR is 60 or above. V1, Director of Nursing (DON) presented a copy of R1's laboratory results with notation stating the results were sent to V9, R1's physician, on 2/17/2026 12:20 P.M. However, interview with V9 indicated that he was not made aware of the abnormal laboratory results. V1 is also unable to verify if the results were sent via fax or via telephone conversation or via text. On 5/16/2026 at 11:30 A.M., V9, R1's Physician, stated V9 was not aware that R1 ended up in the hospital after being discharged from the facility. V9 stated the abnormal laboratory results taken on 2/16/2026 were not relayed to him. V9 also stated that although he cannot keep residents in the facility for medical reasons once physical therapy says that R1 is ready for discharge, V9 would have given R1 a bag of intravenous fluids, instructed R1 to increase fluids and then follow up with her primary care physician for follow up and monitoring because of R1's abnormal results which could indicate dehydration. R2's Physician Order Sheet documents an order dated 2/13/2026 as follows:Ciprofloxacin HCl 500 MG Tablet 1 tablet by mouth twice daily for 7 days (Dx: (Diagnosis) UTI (Urinary Tract Infection)) Review of R2's progress notes exclude any documentation that R2's family member was informed that antibiotics were started for R2. R3's Physician Order Sheet documents an order dated 2/13/2026 as follows: Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously at bedtime for UTI for 7 Days Review of R3's progress notes exclude any documentation that R3's representative was informed that antibiotics were started for R3. On 5/15/2026 at 2:05 P.M., V1, Director of Nursing, stated family should be notified by phone or in person and documentation of family notification should be found on the progress notes. V1 stated he did not see documentation in R1 and R2's progress notes that their representatives were notified of starting antibiotics for R1 and R2. V1 presented the facility policy titled Notification of Changes with date reviewed/revised July 2025 which states: The facility must inform the resident, consult with the resident's physician and notify the resident's family member or legal representative when there is a change requiring such notification. The policy includes starting a new treatment as one of the circumstances requiring notification.

Based on interview and record review, the facility failed to follow their abuse protocol for one resident (R1) out of four residents reviewed for abuse. This failure resulted in an employee cashing several of R1's personal checks without his knowledge/permission. Findings Include:R1's 7/26/2025, 19:12 admission Details reads: Arrived by other. admission mode: wheelchair. Living situation prior to admission: Other residential facility / assisted living / group home. Mental Status: Alert & Oriented x3, communicated verbally, speech is clear, is able to understand and be understood when speaking.R1's 9/4/2025 18:26 Health Status Note Text reads: Resident actively transitioning. Family visiting through shift. Hospice RN made aware and was coming to facility. Resident resting in bed. Oncoming shift aware to monitor.R1's 9/4/2025 19:20 Health Status Note Text reads: Resident being unresponsive and pulseless. Daughter /POA present. Dr. made aware.During interview on 1/15/26 at 5:00pm V5 (Assistant Executive Director) stated she received a message on her voicemail from the daughter of R1. V5 stated the message was regarding R1's daughter wanting to know if a certain person, V1 (Certified Nurse Aide) worked at the facility. V5 stated she told the Administrator that R1's daughter had questions about an employee (V1). V5 stated she and the Administrator called R1's daughter and that was when she told them she was closing her dads bank estate and found several checks written to V1 and they were cashed in V1's name.Facility's abuse report reads on 10/1/25 the daughter of R1 left voicemail messages that there was suspicious activity on R1's account. On 10/2/25 called R1's daughter, she said that the name on the checks was one of the Certified Nurse Aides (name V1). We called V1 and took his statement over the phone, then suspended him pending a full investigation. After hours that day R1's daughter sent email along with copies of the cancelled checks that in fact have V1's name on them, Chicago Police Department called.On 1/21/26 at 4:50pm V6 (Executive Director/Administrator) stated she got a message to call R1's daughter. V6 stated R1's daughter asked if they had an employee called (V1's name), because she had seen several checks from her dad with V1's name on them. V6 stated she told R1's daughter they would investigate it and to email them proof of the checks she believed that V1 had cashed. V6 stated she called V1 to get his account on what happened. V1 denied knowing anything and denied seeing any checks. V6 stated she then told V1 he was suspended pending the investigation. V6 stated within a few hours R1's daughter sent them bank statements with copies of cashed checks from R1's account written to V1. V6 stated as soon as she received the copied bank statements sent to them, they contacted the police.On 1/15/26 at 4:45pm V4 (Director of Nursing) stated R1 used to reside on the Assisted Living Side then he was moved to their skilled side in August. V4 stated V1 had been regularly assigned to take care of R1 on the day shift. V4 stated after R1 had passed away his daughter contacted the facility and asked if they had an employee with the name of V1. V4 stated as soon the daughter alleged that V1 might have cashed her father's check he was immediately suspended and told he could not come back into the building until the investigation was completed. V4 stated once the daughter presented to them proof of the cashed checks, V1 was terminated. V4 stated he called V1 on the phone and told him they had to terminate him. V4 stated V1 apologized to them but did not say why he was apologizing just kept saying he was sorry.During interview on 1/15/26 at 5:30 pm, V2 (Human Resource Director) stated an employee cannot be terminated without her prior approval. V2 stated her job is to ensure that termination is legal. V2 stated R1's daughter presented copies of checks written to V1 from R1's bank account. V2 stated legally they had enough evidence to fire V1 for theft. V2 stated they are very strict and will terminate an employee for stealing, regardless of the value.During phone interview on1/15/26 at 5:45pm V1 (Certified Nurse Aide) stated he did take care of R1 while he was at the facility. V1 stated he stopped showing up to work because he thought some bull**** was going on. V1 stated he was never told that he was being terminated for stealing R1's checks or using R1's checks. V1 stated someone with his name cashed those checks, it was not him.R1's Check #7472 reads signed by V1 on 8/12/25 for rent in the amount of $940.00.R1's Check #7479 reads signed by V1 on 8/19/25 for rent in the amount of $940.00.R1's Check #7476 reads signed by V1 on 8/28/25 for rent in the amount of $760.00.R1's Check #7477 reads signed by V1 on 9/1/25 for rent in the amount of $760.00.R1's Check #7480 reads signed by V1 on 9/2/25 for rent in the amount of $640.00.R1's Check #7478 reads signed by V1 on 9/3/25 for rent in the amount of $840.00.R1's Check #7473 reads signed by V1 on 9/5/25 for rent in the amount of $940.00.R1's Check #7474 reads signed by V1 on 9/6/25 for rent in the amount of $760.00.R1's Check #7475 reads signed by V1 on 9/7/25 for rent in the amount of $840.00.V1's Employee Action Form dated 10/6/25 reads it was confirmed that several checks were written to V1 from R1's checking account and were subsequently mobile deposited into a personal account. Based on these findings, the facility has determined that a violation of policy has occurred.V1's Disciplinary Action Documentation dated 10/6/25 reads We are proceeding with immediate termination of employment.Facility's abuse policy reads this facility to provide for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview and record review the facility failed to perform hand hygiene before and after performing direct care to residents; failed to perform hand hygiene during dining; and failed to conduct proper respiratory etiquette during dining while feeding a resident. These failures affected three residents (R1, R5, and R27) in a total sample size of 36, and has the potential to affect all 23 residents that reside on the 3rd floor.Findings include: On 09/29/25 at 11:34am V7 (Certified Nursing Assistant/CNA) performed care (repositioning and fixing under pad) to R1 without performing hand hygiene or donning gloves. V7 then removed soiled napkin from R1's bed and exited the R1's room. V7 observed entering R5's room and placing soiled napkin from R1's room on R5's dresser. V7 observed donning gloves without performing hand hygiene and assisting R5 to the restroom. V7 then observed removing gloves, picking up soiled napkin and walking to dining area. V7 observed placing soiled napkin in a basket then placing ice in a cup from shared ice machine, without performing hand hygiene. On 09/29/25 at 12:03pm V8 (CNA) observed donning gloves without performing hand hygiene and enter R1's room to assist V7 (CNA) in pulling R1 up in bed. On 09/29/25 at 12:06pm V8 (CNA) stated I didn't sanitize my hands before putting the gloves on, but I should have. I was just trying to help out. On 09/29/25 at 12:07pm V7 (CNA) stated that she should have sanitized her hands and donned gloves before caring for R1, but she was moving too fast. V7 stated that she should sanitize her hands before entering and exiting a resident's room. V7 stated that she does not like to sanitize her hands before donning gloves because it makes her hands sticky. V7 stated that she should be sanitizing her hands between residents, but it is so busy and she moves fast. On 11/24/25 at 1:50pm V19 (Minimum Data Set (MDS) Coordinator) stated that hand hygiene is important because it prevents the spread of infection. V19 stated that hand hygiene should be done before entering a resident's room, before leaving a resident's room, and in between tasks. V19 stated that dirty linen should not be taken from one resident's room to another resident's room. V19 stated that the unit's ice machine is for all residents on the unit. V19 stated that if hand hygiene is not performed after care of a resident and the ice machine is then used, then the ice machine is considered contaminated. R1's medical diagnoses include but is not limited to hydronephrosis, bipolar disorder, pneumonia, major depressive disorder, anxiety disorder, peripheral vascular disease, muscle weakness. R1's Minimum Data Set (MDS) dated [DATE] has a Brief Interview for Mental Status (BIMS) score of 7, indicating R1's cognition is severely impaired. R5's medical diagnoses include but are not limited to bladder neck obstruction, urinary tract infection, type 2 diabetes mellitus, chronic kidney disease, major depressive disorder, generalized anxiety disorder. R5's MDS dated [DATE] has a BIMS score of 12, indicating R5's cognition is moderately impaired. Facility's policy titled Infection Control dated 02/2025 documents in part, Policy: All staff engaged in direct patient care shall be instructed in correct techniques and be familiar with our facility's established infection control policies and procedures.Purpose: The primary purpose for this policy is to prevent the spread of infections through identification of infectious agents requiring isolation.Policy Explanation and Compliance Guidelines:.5. Hand Hygiene Protocol: a. All staff shall wash their hands when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty. B. Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. C. For routine patient care, staff shall wash their hands with soap and water or a waterless alcohol agent before and after patient contact. D. Hands shall be washed in accordance with our facility's established hand washing procedure.7. Equipment Protocol:.C. Reusable items potentially contaminated with infectious materials shall be placed in impervious clear plastic bag labeled CONTAMINATED and placed in the soiled utility room for pickup and processing. D. Prior to returning soiled trays and carts for decontamination processing: i. Linen shall be removed and placed in designated linen bags. Facility's policy titled Hand Hygiene dated 02/2025 documents in part, Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility.Definitions: Hand hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of an antiseptic hand rub, also know as alcohol-based hand rub (ABHR).Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.3. Alcohol-based hand rub with 60-95% alcohol is the preferred method for cleaning hands in most clinical situations. Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. 6. Additional consideration: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perm hand hygiene prior to donning gloves, and immediately after removing gloves. On 9/29/2025 at 11:42 AM, this surveyor performs dining observation on R27's floor. On 9/29/2025 at 11:48 AM, R27 observed sitting at table in a high back wheelchair. V17 (Restorative Nurse) sat next to R27 and initiated R27's one to one (1:1) feeding of the mechanical soft lunch meal (turkey tetrazzini and vegetables). On 9/29/2025 at 12:12 PM, V17 asking R27 if R27 is finished with the turkey tetrazzini and vegetables (ate approximately 90 % during 1:1 feeding), and R27 stated yes. V17 removes R27's tray, leaving R27's table, and R27 remains at table in wheelchair. On 9/29/2025 at 12:19 PM, V9 (Server) delivers R27 an ice cream sandwich on a small plate. V7 (Certified Nursing Assistant, CNA) sits next to R27 at the dining room table to take over 1:1 feeding for R27. V7 observed coughing into V7's scrub shirt, turning V7's head and bringing the right neck of the scrub shirt up near V7's mouth with V7's right hand. V7 performed no hand hygiene and started feeding R27 the ice cream sandwich (taking spoon to ice cream sandwich and spooning small bites of the ice cream sandwich to feed to R27). V7 feed 2 bites of the ice cream sandwich to R27, then V7 sneezed into V7's right elbow (while sitting next to R27). V7 did not perform hand hygiene. V7 went back to feeding R27 with 3 more bites (on spoon) of the ice cream sandwich. With the last spoonful of ice cream sandwich for R27, V7 is brining the spoonful off the plate, and the ice cream sandwich fell off spoon onto the plate. With V7's bare left hand, V7 touches the ice cream sandwich piece to place it onto the spoon then feeds this ice cream sandwich bite to R27. R27's admission Record documents, in part, diagnoses of encephalopathy, type 2 diabetes mellitus, dementia, neurocognitive disorder with Lewy Bodies, cognitive communication deficit, chronic ischemic heart disease, Parkinsonism, muscle wasting, hypothyroidism, urinary tract infection, anxiety disorder, difficulty in walking, personal history of malignant neoplasm of skin and encounter for palliative care. R27's Minimum Data Set (MDS), dated [DATE], documents, in part, that R27's Staff Assessment for Mental Status indicates that R27 has problems with short and long term memory, and R27's Cognitive Skills for Daily Decision Making are severely impaired. R27's Functional Abilities for eating indicate that R27 is dependent where staff does all of the effort. R27's Order Summary Report showing active orders as of 11/25/2025 documents, in part, that R27's diet order is mechanical soft texture with regular/thin liquid consistency. R27's Care Plan dated 8/12/2024 documents, in part, a focus of R27 being at risk for weight loss, risk of dehydration, and risk for pressure ulcers with interventions of provide 1:1 feeding assistance and provide necessary assistance at meal time and between meals as needed. On 11/25/2025 at 10:29 AM, V19 (MDS Coordinator) stated that V19 is responsible for covering the nursing department for V2 (Director of Nursing, DON) who is currently on vacation. V19 that staff should step away from the resident if they have to cough or sneeze. V19 stated that the staff needs to perform cough etiquette and cover their mouth and lastly perform hand hygiene. V19 stated that hand hygiene is imperative after staff members cough, so they aren't spreading germs to the resident. V19 stated that cough etiquette entails covering the mouth or nose so that the staff member is not coughing or transmitting germs to someone else or someone else near to them. V19 stated that when a staff member is feeding a resident (1:1), the staff member should not touch the resident's food with the staff member's bare hands because the staff member's hands could have germs on them. V19 stated that staff must prevent the transfer of infection. Facility policy titled Respiratory Hygiene and Cough Etiquette dated November 2024 documents, in part, Policy: All staff will adhere to standard infection control precautions, including respiratory hygiene and cough etiquette, to prevent the spread of respiratory pathogens/infections. Definitions: 'Respiratory hygiene and cough etiquette' refers to a set of practices that staff, residents, and visitors can perform to prevent the spread of respiratory pathogens and infections. Policy Explanation and Compliance Guidelines: 1. The respiratory hygiene and cough etiquette strategy applies to any person with signs of respiratory illness including cough, congestion, rhinorrhea (runny nose), or increased production of respiratory secretions. 1. The elements of respiratory hygiene/cough etiquette include: . d. Hand hygiene (i.e. {that is} handwashing or use of alcohol-based hand rub) after contact with respiratory secretions or contaminated objects. e. Spatial separation (social distancing, maintain a separation of 3 – 6 ft {feet}) . 4. Spatial separation refers to social distancing, maintaining 3 ft – 6 ft, away from the person to reduce exposure. Facility policy titled Hand Hygiene dated February 2025 documents, in part, that for Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed when hands are visibly soiled or when exiting an isolation room, using the restroom, before and after eating and under other conditions listed in, but not limited to, the attached hand hygiene table which indicates after sneezing, coughing, and/or blowing or wiping nose.

Based on observation, interview and record review, the facility failed to ensure that kitchen staff perform proper hand hygiene; failed to label and date dry storage food and left-over prepared foods; and failed to discard foods past their discard date. These failures have the potential to affect 60 residents consuming oral diets from the facility kitchen.Findings include:On 9/29/2025 at 9:39 AM, this surveyor initiated the kitchen tour with V3 (Dietary Director). On 9/29/2025 at 9:45 AM, this surveyor viewed the dry storage room with shelving units containing stored food items in packages, containers and boxes. Orange colored labels with a date are noted attached to most dry food items. V3 stated that the orange sticker is the date of the delivery date of the food item, and V3 shows this surveyor the label machine hanging in the dry storage room with the orange stickers. On 9/29/2025 at 9:47 AM, on the shelving unit in the dry storage room, this surveyor observed 2 boxes of bananas. This surveyor is wearing surgical face mask and can smell the ripe bananas. When asked when the bananas were received, V3 is looking at all sides of one of the boxes of banana, and V3 said There's no date. They (kitchen staff) didn't put a date on it. V3 inspects the other banana box and states that there's no date of when the bananas were delivered, and it should be on the outside of the box. V3 stated, We need one on that box too. This surveyor observing the bananas exposed from the top of the box are yellow with black dots scattered on the bananas. On 9/29/2025 at 9:54 AM, V4 (Cook) joins the initial kitchen tour with this surveyor and V3. On 9/29/2025 at 9:55 AM, this surveyor, V3 and V4 walk into the walk-in cooler. This surveyor observes a clear plastic cover over the food tray cart with no label or date. V3 removes the plastic cover, and this surveyor observes a tray (1/2 full) of pre-cut salmon pieces. When asked when the salmon was prepared or cut, V3 stated I (V3) am not seeing a date on that one. Below the salmon tray, there is deep stainless-steel pan full of chicken meat in a liquid. There's a sticker label on the deep stainless-steel pan of chicken in liquid, with a prepared date of 9/21/25 and a discard by date of 9/24/25. Another food try cart (next to the other cart covered with plastic garbage, clear bag covering the cart, with no label or date. V3 removes this plastic cart cover, and on the top shelf, an opened package of sausage bratwurst (plastic wrapped) is observed with a white printed label with open date of 9/22/25 and a discard by date of 9/25/25. The two trays below the top tray are two trays of cod. One tray is plain cod pieces, and the other tray has cod pieces with a butter spread with dill. No label or date is noted on these two trays of cod. V4 stated that there are no dates on the cod and dill code trays. On 9/30/2025 at 9:45 AM, this surveyor performed follow up kitchen tour with V4 (Cook). This surveyor observed on the same shelves, the same 2 banana boxes with ripe bananas (yellow with large number of black spots on the bananas) noted from the 9/29/25 kitchen tour. V4 stated that the bananas are to be used. When asked for what? V4 stated, One case, I (V4) am going to get rid of and the other one use for smoothies in the Chef demo. V4 said that V4 determines the number of days that the food is good for by looking at the posted guidelines in the kitchen. V4 and this surveyor walk out of dry storage to the sign that is posted in the kitchen of the Storage Life of Food. V4 stated that it's for +3 days. When asked V4 about the process of when food is delivered from the vendor in reference to labeling and dating, V4 stated that food items are labeled with the label gun, pointing to the label machine by the shelving units in the dry storage room, and the label sticker is placed on the package or container with the date that the food item was received. A third box of bananas (green/yellow color) is observed on the nearby shelf in the dry storage room. V4 stated that that this specific box of bananas came in this morning. When asked where the date delivered is on this banana box, V4 moves the box examining all sides of the box and says the kitchen staff didn't date it with the label gun. When asked V4 to see a date/label on the 2 original boxes of bananas (noted on 9/29/2025). V4 said that V4 is going to bring these banana boxes out to the prep table to view them. V4 attempts to lift one box of bananas off the shelf is struggling to hold the box. V3 enters the dry storage room and takes the box of bananas from V4 and walks the box of bananas to the prep table in the kitchen. Upon opening one box of bananas, V3 removes a group of bananas bunched together that have the banana peels that have split open and throws them into the garbage. This surveyor views inside the open garbage can to see the banana peels split open, exposing the banana flesh inside and the banana peels filled with black spots. V3 confirmed again that the banana box was not labeled or dated. On 9/30/2025 at 10:27 AM, V4 stated that V4 is getting ready to prepare the puree sloppy joe sandwich over a bun and that V4 has 15 ounces of milk simmering on the stove to heat up for this puree preparation. Two mixing blenders are noted on the prep table, and V4 is walking around kitchen to obtain pans and utensils for the puree preparation process.On 9/30/2025 at 10:28:33 to 10:28:37 AM (less than 20 seconds), V4 washes V4's hands at the kitchen hand washing station and places gloves on. V4 next places 5 bread buns into the shallow pans, opening each of the five buns, so the five tops and five bottoms are open faced in the pans. V4 retrieves the heated milk and at the prep station, V4 is using a one-ounce ladle and spoons heated milk over the 10 open buns. V4 stated that the milk absorbs and softens the buns prior to the blending. V4 is observed touching the open-faced buns that are soaked with milk to ensure by touch that they are wet. V4 completed spooning all of the heated milk and stated that more milk is needed, but V4 will have to heat it up first. V4 removed V4's gloves. On 9/30/2025 at 10:34:40 to 10:34:45 AM (less than 20 seconds), V4 washes V4's hands at the kitchen hand washing station. V4 then talking to V21 (Registered Dietitian, RD) in the kitchen about heating more milk to continue the puree process.On 9/30/2025 at 10:36:53 to 10:37:05 AM (less than 20 seconds), V4 washes V4's hands and dons gloves. V4 observed at prep station, plugging up blenders in preparation for the puree process while waiting for clean blender container.On 9/30/2025 at 10:43 AM, V4 walks (while wearing gloves) to the stove on the opposite side of the prep table to check the milk heating on the stove. V4 then discards gloves and washes V4's hands from 10:43:57 to 10:44:05 AM (less than 20 seconds). V4 dons new gloves and begins to ladle more milk onto the open-faced buns in the pans to ensure that they are soaked wet. On 9/30/2025 at 10:46 AM, V4 wiped the prep table with the sanitization towel with V4's gloved hands and then removes gloves. V4 washed hands from 10:46:35 to 10:46:50 AM (less than 20 seconds). On 9/30/2025 at 10:52:02 to 10:52:15 AM (less than 20 seconds), V4 washed hands then dons gloves. V4 scoops the sloppy joe meat on the bottoms of the milk-soaked buns and places the milk-soaked bun tops on top of the sloppy joe meat to make the five sandwiches. V4 ladles the sloppy joe sandwiches in the blender to a smooth puree texture. V4 then pours and scoops the pureed sloppy joe sandwich mixture into a stainless-steel pan, places a cover on the pan, and places in the stand up, warming oven.On 9/30/2025 at 11:06 AM, V4 stated that when V4 enters the kitchen and in between tasks, V4 will wash V4's hands. V4 stated that the hand washing process is wetting hands, adding soap, rubbing together for 20 seconds, rinsing with water and dry with towel and turn off the water with the towel. V4 stated that the purpose of handwashing is to keep hands clean and helps prevent cross contamination. This surveyor informed V4 of the observations of V4 washing hands in kitchen several times for under 20 seconds. V4 questioned how surveyor tracked the seconds, and this surveyor showed V4 the stopwatch used by surveyor with the counting seconds that were clearly visible. On 9/30/2025 at 11:29 AM, temperatures of food items being obtained for lunch service with V4 and this surveyor reading 192 degrees Fahrenheit for the same pureed sloppy joe sandwiches in the pan. On 11/24/2025 at 10:32 AM, during a follow up visit to the kitchen, V4 (Cook) and surveyor performed a brief tour follow up tour of the dry storage room and viewed a box of bananas, yellow with slightly green color of banana peels, on the shelf with a label sticker indicating received on 11/24/25 and to discard on 11/27/25 (3 days).On 11/25/2025 at 10:48 AM, V22 (Assistant Dietary Director) stated that V3 (Dietary Director) cannot be reached via phone, and V22 is the assistant dietary director. V22 stated that hand washing must be done by kitchen staff every time they change a task, come from the bathroom, or touch door handles or knobs. V22 stated that the purpose of hand hygiene is cleanliness and won't cross contaminate or spread germs. V22 stated that the process of hand washing by kitchen staff is as follows: wet hands with water, apply soap and lather, wash hands for 20 seconds (sing a song for 20 seconds), rinse hands with water, dry with towel discard, and then turn off handle with towel. V22 stated that the purpose of washing hands for the entire 20 seconds is so kitchen staff will be washing away all the germs or anything that is on the kitchen staffs' hands. When asked if kitchen staff were to wash hands less than 20 seconds and then continues to perform a kitchen staff with preparing food, what could occur, and V22 stated that kitchen staff would carry germs to the next task they are doing in the kitchen. V22 stated that kitchen staff label fresh fruit items when the fruit is delivered (when it came into the facility kitchen), and a discard date is placed on the label. V22 stated that with the discard date is followed, and the discarded food item will be removed from production. V22 stated that the dating the in and out of a food item is an identifier that will ensure that no expired foods still remain stocked in the kitchen for potential use. This surveyor informed V22 that upon kitchen rounds on 11/24/2025, this surveyor viewed a box of bananas in the dry storage labeled with a received date of 11/24/2025 and a discard date of 11/27/2025 (3 days). V22 stated that if a box of bananas that are ripened and are opening are stocked in the kitchen past their discard date, bacteria can grow inside and outside (the bananas), and the smell of these bananas can attract fruit flies. V22 stated that when there are left-over prepared foods that are being stored, the kitchen staff must label and date these left-over prepared foods with a label containing the date and time that the food item was prepared, a discard date and time, and the initials of the kitchen staff member. V22 stated, All, absolutely all left-over prepared food items stored in the kitchen should have the identifying label of when the food was prepared and when it is to be discarded. V22 stated that if the left-over food item is stored in the cold storage past the discard date, we can't serve it, bacteria can grow and other nasty things. That can't happen and we cannot serve it to the elderly or anyone. Facility Cycle Menu, titled 2025 Spring, documents, in part, that the oral diet residents are being served from the Week 4 Menu Spread Sheet. Facility Menu Spread Sheet for Tuesdays on Week 4 (from Cycle Menu) documents, in part, that for the lunch meal for puree diet orders, the hot menu item is sloppy joe sandwich. Facility document titled with the facility's name was provided to the survey team by V1 (Administrator) on 9/29/2025 which documents, in part, that one skilled care resident (R7) is the only resident receiving tube feedings/nothing by mouth.On 11/25/2025 at 9:36 AM, V21 (Registered Dietitian, RD) confirmed that upon initiation of this survey on 9/29/2025, all skilled care residents residing in the facility were receiving oral diets except for R7.Daily Census, dated 9/29/2025, documents, in part, that the total census for skilled care residents is 61. Therefore, 60 residents were receiving oral diets.Facility kitchen policy titled Dry Storage Life of Foods dated January 2024 documents, in part, Use manufacturer's expiration date for product storage. If there is no expiration date on the package, add the time listed here to the date the food is received. The time listed is added to today's date. Expiration/use by dates are guidelines; discard products where the quality is deemed unacceptable. Facility kitchen policy titled Employee Health & Hygiene: 2.2 Hand Washing with creation date of 10/01/2022 and revision date of 10/01/2025 documents, in part, that kitchen staff are to wash their hands when anytime hands become soiled/contaminated, upon entering or returning to the kitchen or other food handling areas, immediately before engaging in food preparation including working with exposed food, clean equipment, utensils, and unwrapped single-service and single-use articles, when switched between working with raw food and working with ready-to-eat food; during food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks, and when changing gloves. Facility kitchen policy titled Food Handling Guidelines (HACCP, Hazard Analysis and Critical Control Points dated (revision) January 2025 documents, in part: Policies: Food is handled using a HACCP process in accordance with regulatory guidelines . Procedures: Contamination Precautions: Food shall be protected against cross-contamination by . appropriately separating raw (potentially hazardous) foods from ready-to-eat food products during storage, preparation . Hands should be scrubbed following appropriate hand washing techniques according to facility policy.

Based on observation, interview, and record review the facility failed to ensure two licensed personnel conducted a physical inventory of controlled substances at each change of shift. This failure has the potential to affect 7 residents prescribed controlled substances on the 3J medication cart and 5 residents prescribed controlled substances on the 2J medication cart.Findings include: On 09/30/2025 at 8:41AM accompanied by V14(LPN/Licensed Practical Nurse) reviewed the second-floor [NAME] medication cart's Controlled Substance Shift to Shift Count form for September 2025, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank for: September 17, 2025, 6:30am, - Nurse Off On 09/30/2025 at 9:36AM accompanied by V15(LPN/Licensed Practical Nurse) reviewed the third-floor medication cart's Controlled Substance Shift to Shift Count form for September 2025, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank for: September 23, 2024, 6:00AM - Nurse Off On 09/30/2025 at 08:41AM V14(LPN/Licensed Practical Nurse) stated every nurse is responsible for making sure the count of the narcotic medication is correct. V14 stated two nurses are to count the controlled substances in a medication cart and sign the on and off spaces on the controlled substances shift to shift count sheet. V14 stated the nurses are to notify the director of nursing of any missing nurses' initials. On 11/24/2025 at 2:15pm V20 (RN/Registered Nurse) stated the controlled substance shift to shift count sheets are used for the nurses to document that the total number of the narcotics in the medication cart is correct at the end of each nurse's shift. V20 stated when I come in for my shift, the outgoing nurse and I are counting the total number of all narcotics in the medication cart, making sure the counts are correct. Once we both agree that the narcotic count is correct, we both initial the form in the specific date and time slots. V20 stated we count to make sure there is no discrepancy for the narcotic count. If there is a discrepancy, the nurses are to notify the director of nursing.On 11/25/2025 at 1:18pm V19 (MDS Coordinator) stated the nurses are responsible for completing the controlled substance shift to shift count sheets. V19 stated the purpose of the controlled substance shift to shift count sheet is to verify that all narcotics in the medication cart are accounted for. V19 stated the nurses are to notify the DON (Director of Nursing) if the controlled substance shift to shift count sheet is not initialed and completed for each shift. On 11/24/2025 reviewed the facility's policy (with a reviewed date of July 2025) titled Controlled Substance Administration & Accountability which documents, in part, 9. Inventory Verification: b. Two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on interview and record review the facility failed to ensure that proper number of staff were used in transferring one of four residents (R1) to prevent accidental hazard in the sample who requires two persons assist in transfers from chair to bed or bed to chair. This failure affected R1 who was transferred from chair to bed by one staff instead of two. As a result, R1 sustained laceration of left lower leg, was sent to the hospital and the laceration required eighteen (18) sutures to be repaired. This has a potential to affect all 70-residents residing at the facility. Findings include: R1's medical record Admission Record showed that R1 was originally admitted to the facility on [DATE] and the latest admitted was 08/26/24 with a diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed hyperlipidemia, ataxic gait, muscle weakness(generalized), muscle wasting and atrophy, major depressive disorder, single episode unspecified, Unspecified Dementia unspecified severity without behavioral disturbance and anxiety. R1 was sent to the hospital on 10/02/2024 and was treated for diagnoses that includes laceration of lower leg initial encounter and cellulitis of left lower extremity. R1 was discharged from the facility on 10/11/2024. According to facility incident report, on 10/02/24 R1 was assisted from chair to the bed by V5 CNA (Certified Nurse's aide) not following the plan of care of using two persons assist and, in the process, R1 sustained skin tear (referring to laceration to left lateral lower leg that required 18 (eighteen) sutures from the local hospital. R1's medical record PT (Physical Therapy) Evaluation and Treatment notes with certification period 8/16/2024 to 10/14/2024 showed documentation that transfers from chair/bed-to chair transfer = dependent indicating that R1 is dependent on staff in performing this task, maximum of two person assist. R1 progress notes, V6 RN (Registered Nurse) describe the injury site as skin tear to LLE (Left Lower Extremity), hollow area noted adipose tissue exposed. On 02/06/2025 at 10:20am, V2 DON (Director of Nurse's) stated that the incident occurred during the evening shift and was reported 10/03/25. V2 stated that the CNA incorrectly transferred the resident (referring to R1). On 2/06/25 at 12:06pm, V8 CNA (Certified Nurse's aide) stated that she was usually assigned R1 in the morning shift when on duty. V8 stated that R1 needs two staff (persons) assistance when transferring from bed to wheelchair. V8 stated that the PT (Physical therapy) /OT (Occupational Therapy)/ Restorative department staffs are usually on the floor walking residents, and they will help with routine care of the residents as needed. In additional will bring R1 for meals and therapy. On 02/06/2025 at 12:09am, V9 (Restorative Nurse) stated that R1 is clinically compromised with ADL's (Activity of Daily Living) not wanting to get up. R1 had hip surgery and due to the surgery R1 was dependent on staff and not functionable. We educated the nursing staff including the CNAs that R1 was on hip precaution due to the hip surgery and R1 requires two persons assistant with transfers. All the residents have the green card or/and yellow card in their rooms that showed what kind of assistance needed and there is a 24-hour report on the computer that the CNAs can access to show the plan of care in assistant level. At 1:06pm V19 OT (Occupational Therapist) stated I worked with R1 and R1 needs two persons assist the day R1 was admitted to the day R1 was discharged . Staff must not transfer R1 by themselves, R1 becomes anxious, fearful due to fall history because R1 used to be very independent and now must depend on others. Multiple training was given to the family and staff before discharge from the (facility). V19 stated the PT/OT notes showed that R1 needs 2-person assistant with transfer and that for the incident on 10/02/2024, (V5) transferred R1 incorrectly by self and according to what was reported R1 got injured from (V5)'s action. At 1:16pm, V18 PT (Physical Therapist) stated that she is familiar with R1. V18 stated that R1 needs two (2) persons assistance with transfers. V18 stated that both herself and V19 do evaluation of the residents together to decide whether the resident needs a mechanical lift or sit to stand assistance. V18 stated that with R1, R1 needs 2 persons assistance with lateral transfer. V18 stated that R1 should not be transferred with a mechanical lift device because with any hip surgery and hemiarthroplasty that R1 had; it will force R1's hip to flexion greater that 90 degrees and this is contraindicated. The surveyor asks whether it is appropriate to transfer R1 with one person assist, V18 stated that transferring R1 alone is wrong. V18 stated that the staff must follow the green sheet in residents' room that showed the individual care needed which is updated as to resident needs. At 4:08pm, V5 CNA (Certified Nurse's Aide) stated that on that day (referring to 10/02/2024), I had given R1 a shower. Pulled R1 to the side of the bed for dinner. R1 tried to get out the wheelchair and R1 said I can do this, I (V5) put the gait belt around R1 and asked for R1 to reach for the bed side rails to turn into the bed easily and I picked up R1's legs and put it on the bed. That was when I noticed that R1 got a skin tear on the leg, I can't remember which leg. I left out of the room and called the nurse (referring to V6) who decided to send R1 to the hospital. When the surveyor asked V5 how many staff are needed and whether there is any transfer device used in transferring R1, V5 stated that in R1's case the needs were changing rapidly and by now I cannot remember what it was that day. V5 stated one person assistance means transfer must be done with one staff and use of gait belt, two persons assistance means two people with use of gait belt. The surveyor then asked if a resident is marked for two people assist and one staff did the transfer task, whether that is appropriate. V5 stated that will not be appropriate because the resident can fall, can have skin tear and staff can also injure self. On 2/10/2025 at 11:15am, V17 (Physician) stated that he cannot remember seeing the resident. V17 stated that the facility staff has reminded him of what happened with the incident (referring to 10/02/24 incident resulting in injury). V17 stated that skin tear can be managed with compression, dressing and we (referring to the facility) can keep the resident. If the resident must receive sutures, it is laceration, the resident must be sent out, it means they (facility) cannot take care of it there (facility). R1's Hospital report presented dated 10/2/2024 showed instructions documented that R1 was seen and evaluated after an injury that resulted in a laceration. In addition, R1 was treated for soft tissue infection. Facility Job Description for CNA (Certified Nursing Assistant) documented that the purpose of this position is to work under the direction of the charge nurse. Provides assists with all areas of ADL's. Assists in observing and reporting changes in resident's condition. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights. Ensures proper positioning of all residents while in bed or wheelchair, making sure that all mattresses and positioning device are in place, and carries out restorative programs. The facility job description for RN (Registered Nurse) documented that RN purpose is to be responsible for all nursing care administered to residents, including but not limited to overall supervision of the nursing assistants. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights.

Based on observation, interview, and record review the facility failed to ensure that the bed frame is locked to the size of the mattress for the safety of one resident (R1) reviewed for injury. As a result, R1's left lower leg made contact with the loose bed frame during transfer into bed causing a laceration. R1 was sent to the hospital and the laceration was repaired with 18 sutures. This has the potential to affect all 70 residents residing in the facility. Findings include: R1's medical record Admission Record showed that R1 was originally admitted to the facility on [DATE] and latest admitted was 08/26/24 with diagnosis list that includes but not limited to Unspecified intracapsular fracture of the left femur, subsequent encounter for closed fracture with routine healing, aftercare following joint replacement surgery, syncope and collapse, unspecified atrial fibrillation, mixed hyperlipidemia, ataxic gait, muscle weakness(generalized), muscle wasting and atrophy, major depressive disorder, single episode unspecified, Unspecified Dementia unspecified severity without behavioral disturbance and anxiety. R1 was sent to the hospital on 10/02/2024 and was treated for diagnoses that includes laceration of lower leg initial encounter and cellulitis of left lower extremity. R1 was discharged from the facility on 10/11/2024. According to facility incident report on 10/02/24, R1 was assisted from chair to the bed by V5 CNA (Certified Nurse's aide) not following the plan of care requiring use of two persons assist and, in the process, R1 sustain skin tear (referring to laceration to left lateral lower leg that required 18 (eighteen) sutures from the local hospital. On 02/10/25 at 4:29pm, V23 (Case Manager) was asked why V5 was written up for the incident on 10/02/2024? V23 stated that the write-up was for (V5) improperly transferring the resident (referring to R1). V23 stated that R1 was transferred with one-person assistance instead of 2-person assistance. V5 transferred R1 from wheelchair to bed and in the process R1 bumped the leg on the bedframe and caused the skin to open. Having 2-person would have made the transfer of R1 safe. After the facility administrative investigation of the cause of the skin tear (referring to the lower leg extremity laceration) we found out that the bed frame was larger than the bed mattress at the time of the transfer. The bed frame needed to be adjusted by pulling the lever (part of the bedframe) to adjust it, so it is stable. It was corrected after the incident. The surveyor asked who is responsible for making sure the bedframe is not larger than the mattress. V23 stated that the maintenance department are supposed to do that. On 2/11/25 at 9:02am, V25 Assistant Maintenance Manager EVS (Environment Services) stated that the bed frames maximum width is 42 inches, the facility standard mattress is 42, but the bedframe can be extended to about 80 inches. V25 stated that the bed frame can be adjusted down to 39 inches and if the mattress is narrower then it becomes a safety issue. The maintenance staff is responsible for making sure the bed frames are properly secured it's a safety issue. At 9:21am, V2 (DON) demonstrated on the bed frame with V25 and V26 present on how it was loose when the administration investigated the incident and what went wrong with the bed frame causing R1's injury laceration to lower left leg. V2 stated that the middle part of the bed frame was wider that the bed mattress causing R1's leg to make contact with the bed frame and resulted in the skin tear (Laceration). V2 stated that at the time of incident the bed frame was wider than the bed mattress and that's what caused the injury when the resident (R1) leg made contact (Bump) with the bed frame and that is what we reported (referring to IDPH (Illinois Department of Public Health)). On 2/11/25 at 9:22am, V26 EVSD (Environment Services Director) stated that we do not check on bed frames to check whether they are locked or loose. There is no reason for the bed frame to be out of place. V26 stated that all the facility beds should be at a 42 inches setting 100% of the time. The surveyor asked what measures have been put in place since the incident of 10/02/2024 to make sure this does not repeat itself. V2 who was present at the time stated that we (Facility) will have to put in a work order for the maintenance staff to come and check the bed frame. At 9:36am, the surveyor asked how they are monitoring the safety of the beds, V2 stated that a system must be put in place for checking the bed frames. As at 4:20pm on 2/11/25 the facility was unable to provide any work order or documentation that shows that a process has been put in place to ensure safety and prevention of such incident. The facility in-service instruction on Bed frame size, how and when to adjust the size, mattress sizes indicated that as a safety precaution the staff should make sure the bedframes are adjusted to match the mattress size correctly. Regular mattress size 42 inches wide, APM 42 inches wide, and Bariatric APM 48 inches wide. Bed frames can extend in length to 84 inches if needed. The facility policy on Safe and Home Environment with implementing date of 2/10/23 documented in part that in accordance with residents' rights, the facility will provide safe, clean, comfortable, and homelike environment which includes but not limited to ensuring that the resident can receive care and services safely and does not pose a safety risk. The facility Job description for job title Director of Facility management documented that the purpose of this position primary responsibilities includes but not limited to oversight of building and grounds maintenance, and to daily management of the facility operations and direct supervision of staff involved in these operations. Accountabilities and job duties listed includes but not limited to always understanding and adherence to resident rights, ensuring that the (facility) residents are always safe and secure. Listed primary job duties includes but not limited to ensures compliance with health safety and environment regulations. Making regular rounds.

Based on observation, interview and record review the facility failed to ensure foods were labeled, dated and maintained to prevent the spread of foodborne illness to all residents receiving oral nutrition. This failure has the potential to affect all residents. Findings include: On 9/15/2024 at 9:54am surveyor observed a 1.5 lb. container of uncovered beef patties (sliders) out of its original packaging and a roll of pepperoni wrapped in plastic with no received date or discard date. There was a bag of tilapia fish, not individually wrapped but open to air in its original container with no discard date. On 9/15/2024 at 9:57am V4 (Dietary Manager) stated no, they (beef patties-sliders) should not be in the freezer uncovered and all food items should be covered and have a received and discard date because you will not know when to discard the items. On 9/15/2024 at 10:02am surveyor observed two 5-gallon tubs of chocolate and pecan ice cream with the top not secured on the tubs in the dairy freezer. On 9/16/2024 at 10:17am surveyor observed (2) 1.5-gallon containers of Bread Battered Cod and Edamame Dumplings (1) with no lid (open to air) and not dated. On 9/16/2024 at 10:17am V4 (Dietary Manager) stated, yes, they (dumplings and bread battered cod) should be covered and dated to protect from cross contamination. Date Marking for Food Safety with a revised date of March 2022 documents, in part, the facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for food safety. 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible to cover, label and date marking the food at the time the food is opened or prepared. 6. The Executive Chef, or designee shall be responsible for checking the refrigerator daily for food items that are expiring and shall discard accordingly. Position Analysis for Dining Service Manager dated February 2020 documents, in part, Under the guidance of the Director of Dining Services, is responsible for overall service in the main dining room, health care, personal care, coffee shop, and special functions. These areas will be operated within established objectives, standards, policies, and procedures and 2. Assists in providing quality food. Undated job description titled Director of Dining Services, documents, in part, Oversee and participate in the preparation and service of food and beverage items in adherence to company food standards for preparation, presentation, sanitation and safety (meeting HACCP and OSHA guidelines) and portion control. Food Safety Policy with a revised date of 3/29/2023 documents, in part, It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. B. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms. 3. Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. C. Refrigerated storage - Practices to maintain safe refrigerated storage include: iv. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and v. Keeping foods covered or in tight containers.

Based on observation, interview, and record review the facility failed to ensure the garbage dumpster lids were closed. This failure has the potential to affect all residents residing in the facility. Findings include: On 9/16/2024 at 10:11am surveyor observed a blue garbage dumpster with both lids open. Surveyor observed V4 (Dining Service Manager) close both lids on the blue garbage dumpster. On 9/16/2024 at 10:11am V4 (Dining Service Manager) stated, no, the lids should not be open, but the CNAs use the dumpsters too. On 9/18/2024 at 12:30pm V8 (Environment Service Director) stated that the dumpster lids should be closed on the dumpsters. Policy titled Disposal of Garbage and Refuse with an implemented date of 2/10/2023, documents, in part, Garbage and refuse containers shall be covered when not in use and 7. Containers and dumpsters shall be kept covered when not being loaded. Undated job description titled EVS Director documents, in part, Plans, organizes and directs all functions of Environmental Services to provide for a safe, clean, functional and comfortable environment, adhering to regulatory requirements.

Based on observation, interview, and record review the facility failed to ensure a resident (R21) with a chronic wound was placed on Enhanced Barrier Precautions (EBP). This failure has the potential to affect all 27 residents on the second floor. Findings include: On 09/16/24 at 9:50 am, V1 (Administrator) presented a facility census of 27 residents on the second floor. R21's face sheet shows that R21's has diagnosis which include but not limited to unspecified malignant neoplasm of skin and other symptoms and signs involving the musculoskeletal system. R21's Brief Interview for Mental Status (BIMS) dated 06/24/24 shows that R21 has a BIMS score of 6 which indicates that R21 has some cognitive impairments. On 09/17/24 at 9:52 am, Surveyor observed R21 in bed resting with no EBP sign or Personal Protective Equipment (PPE) bin inside or near R21's room. On 09/17/24 at 9:54 am, V9 (Registered Nurse, RN, Wound Care Nurse) and V10 (Certified Nursing Assistant, CNA) were observed performing high-contact resident care activities (wound care to R21's left ischium stage 4 pressure ulcer chronic wound and ADL (Activities of Daily Living) care (providing hygiene and changing R21's incontinence pad that was saturated with stool) without wearing PPE (gown) in R21's room. On 09/17/24 at 10:00 am, V9 (Registered Nurse, RN, Wound Care Nurse) was asked regarding residents who require EBP and V9 stated that residents with indwelling catheters, ostomy, and wounds require EBP. When V9 was asked regarding R21 requiring EBP V9 stated, I (V9) don't know why he (R21) is not on EBP. You (referring to the surveyor) will have to ask V3 (Infection Preventionist). When V9 was asked regarding the importance of residents who require EBP due to having a chronic wound being placed on EBP and V9 stated, To avoid an infection. When V9 was asked regarding the proper PPE for residents who require EBP for high contact care such as wound care dressing changes and ADL care and V9 stated, A gown and gloves. 09/17/24 at 10:03 am, V10 was asked regarding residents who require EBP and V10 stated that V10 is made aware of residents who require EBP by checking the resident's room for a EBP sign placed on the resident's door and a PPE bin in the residents' room. V10 explained that if a resident does not have a EBP sign on the resident's door then V10 is not aware of the resident requiring EBP. On 09/17/24 at 10:13 am, V11 (Certified Nursing Assistant, CNA, Agency) was observed performing ADL care (dressing) with R21 without wearing proper EBP PPE (gown). On 09/17/24 at 10:14 am, V3 (Infection Preventionist, IP, Registered Nurse, RN) was asked regarding residents who require EBP and V3 stated, R21 does not require EBP. His (R21) wound is not chronic and does not have a history of MDRO (Multidrug-Resistant Organism). Only wounds that are chronic with MDRO require EBP. If his (R21) was a heavily draining wound without a bandage, then we would place him (R21) on EBP. Surveyor questioned V3 regarding wounds that are considered chronic wounds and V3 stated, I (V3) will have to look at his (R21) co-morbidities. On 09/17/24 at 10:20 am, V2 (Director of Nursing, DON) was asked regarding a resident with EBP and V2 stated that residents with lines, drains, catheters, PICC (Peripherally Inserted Central Catheter) lines, history of MDRO's and chronic wounds require EBP. When V2 was asked regarding the purpose of residents being placed on EBP and V2 stated, To protect the staff and residents from MDRO transmission. When V2 was asked regarding how staff are made aware of residents who require EBP and V2 stated that a EBP sign is placed on the resident's door and through the nurses 24-hour report. When V2 was asked regarding what could happen if a resident who requires EBP is not placed on EBP and V2 stated, There is a risk of the resident getting an infection. The facility undated document titled Enhanced Barrier Precautions Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high contact resident care activities Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs for assisting with toileting, device care or use: Central line, urinary catheter, feeding tube, tracheostomy. Wound care: Any skin opening requiring a dressing. The facility's document dated October 20, 2023, and titled Enhanced Barrier Precautions documents, in part: Policy: it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO's). Definitions: Enhanced barrier precautions refer to the use of gown and gloves for use during high contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisitions (e.g. (example), residents with wounds or indwelling medical devices). Policy explanation and compliance guidelines: 2. Initiation of enhanced barrier precaution b. Enhanced barrier precautions will be initiated for residents with any of the following i. Significant wounds e.g., chronic wounds or skin openings such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, chronic venous stasis ulcers, stomas) and/or and dwelling medical devices (e.g., central lines, midlines, hemodialysis catheters, urinary catheters, plural drain, feeding tubes etc.) Even if the resident is not known to be infected or colonized with MDRO. Not intended for minor skin tears or cuts. 4. High contact resident care activities include: a. Dressing. b. Bathing. c. Transferring. d. Providing hygiene. e. Changing linens. f. Changing briefs or assisting with toileting. g. Device care or use: centralized, urinary catheters, feeding tubes. h. Wound care: any skin openings requiring a dressing. 7. Enhanced barrier precautions should be used for the duration of the affected residents stay in the facility or until the wound heals or indwelling medical device is removed. R21's Physician Order Sheet (POS) shows that R21 has orders for Left Ischium: Cleanse with skin integrity, pat, dry, lightly pack with collagen, apply moisture barrier to the peri wound and cover with ABD (abdominal) pad. R21's POS dated 09/17/24 documents in part: Precautions: Enhanced Barrier Precautions. R21's care plan dated 09/17/24 documents, in part: Focus: Enhanced Barrier Precautions initiated due to resident having chronic wound.

Based on observation, interview, and record review the facility staff failed to complete the controlled substance shift to shift count form which is utilized to complete a shift-to-shift count for controlled substances. This failure has the potential to affect all 27 residents on the second floor and all 16 residents on the first floor. Findings include: On 09/17/2024 at 10:00AM with V13(RN/Registered Nurse) reviewed the second-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse On and/or Nurse Off initial boxes were left blank for: September 08, 2024, PM Shift, - Nurse Off September 09, 2024, AM Shift-Nurse On September 11, 2024, PM Shift-Nurse Off On 09/17/2024 at 10:15AM with V14(RN/Registered Nurse) reviewed the first-floor medication cart's Controlled Substance Shift to Shift Count form for September 2024, this form is used by the facility for shift change accountability for controlled substances. The Nurse Off initial box was left blank for: September 04, 2024, 6PM - Nurse Off On 09/17/2024 at 10:06AM V13(RN/Registered Nurse) stated the nurses have been having trouble with the controlled substance shift to shift count sheets and getting confused. V13 stated two nurses are to count the controlled substances and sign on and off on the controlled substances shift to shift count sheet. V13 stated the nurses coming in to work and the nurses leaving for the day are to count the tablets in the medication cards of controlled substances to make sure the count of tablets are correct. V13 stated when both nurses agree that the count is correct, then both nurses initial the controlled substance shift to shift count sheet indicating the count for the controlled substances is correct. On 09/17/2024 at 10:17AM V14(Registered Nurse) stated the nurse coming in to work signs the controlled substance shift to shift count sheet with the nurse leaving the shift for the day. V14 stated the two nurses are to count the controlled substances together. V14 stated after both nurses verify that the count of the controlled substances is correct, then both nurses initial the controlled substance shift to shift count sheet for the correct date and time. On 09/18/2024 at 11:10AM V2(Director of Nursing) stated the nurses are responsible for completing the controlled substance shift to shift count sheets. V2 stated the incoming nurse is to count the controlled substances with the outgoing nurse to make sure the count of the controlled substances is correct. V2 stated the purpose of the controlled substance shift to shift count sheet is to make sure all narcotics are accounted for. V2 stated the nurses are to notify me, the DON (Director of Nursing) if the controlled substances shift to shift count sheet is not initialed and completed for each shift. On 09/18/2024 reviewed the facility's policy (dated June 2018, with a revision date of August 2024) titled Controlled Substance Administration & Accountability which documents, in part, 9. Inventory Verification: b. Two licensed nurses account for all controlled substances and access keys at the end of each shift.

Based on observation, interview and record review, the facility failed to ensure that one resident's (R11) urinary catheter drainage bag was covered with a privacy cover. This failure affected one resident (R11) in a sample of 44 residents reviewed for dignity. Findings include: On 09/17/2024 at 08:49am while in the hallway upon entry into R11's room, a urinary catheter drainage bag was observed hanging off the right-side lower bed frame of R11's bed. R11 was observed lying in the bed. R11's urinary catheter drainage bag contained yellow urine and was not covered with a privacy bag. R11's bed is the only bed in the room and the uncovered urinary catheter drainage bag was visible to others walking past R11's room door when the door was open. On 09/17/2024 at 8:53am this observation was brought to the attention of V12(LPN/Licensed Practical Nurse). V12 stated the urinary catheter drainage bag should be covered with a privacy bag. On 09/17/2024 at 8:54am observed V12(LPN) placing R11's urinary catheter drainage bag into a blue privacy bag. On 09/18/2024 at 11:10am V2(DON/Director of Nursing) stated the resident's urinary catheter drainage bag should be in a privacy bag, this provides dignity for the resident. R11's diagnosis includes but are not limited to neuromuscular dysfunction of bladder, unspecified, retention of urine, unspecified, difficulty in walking, not elsewhere classified, and muscle weakness (generalized). R11's (08/12/2024) Resident Assessment Instrument documents, in part, Section C. Brief Interview for Mental Status (BIMS) score 15, indicating R11's cognition is intact. R11's (08/12/2024) Resident Assessment Instrument documents, in part, Section H. Bladder and Bowel H0100. Appliances A. Indwelling catheter. R11's Order Summary Report, with active orders as of 09/18/2024 documents, in part, Catheter change foley catheter- monthly with 16FR(French) foley with 10cc balloon inflation one time a day every 30 days. Catheter: change foley drainage bag -drainage bag and leg bag every 1 week one time a day every Wednesday night. Routine Foley Catheter Care every shift. Reviewed facility's policy titled Catheter Care with an implemented date of June 2015, revised date of March 30, 2023, which documents, in part, 2. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. Reviewed the facility's policy titled Facility Responsibilities Resident Rights with an implemented date of 2/10/23, which documents in part, 1. Resident Rights. a. The facility will treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality.

Based on observation, interview, and record review the facility failed to follow a resident's diet order for fluid restriction. This failure affected one resident (R37) out of 44 residents in the sample. Findings include: R37's face sheet shows that R37's has diagnosis which include but not limited to acute on chronic diastolic (congestive) heart failure, chronic kidney disease and organ limited amyloidosis. R37's Brief Interview for Mental Status (BIMS) dated 08/19/24 shows that R37 has a BIMS score of 10 which indicates that R37 has some cognitive impairments. On 09/16/24 at 12:30 pm, R37's was observed in the second-floor dining room during the lunch meal. Surveyor observed R37 drink a 7.5 oz (ounce) can of ginger ale soda and then a 6.0 oz cup of water. Surveyor observed R37's diet card orders next to R37's lunch meal with the following dietary order documented in part: Diet Order: Regular texture no added salt, fluids thin. Notes Fluid restriction: provide the following only: 6 oz (ounces) water, coffee, juice, or soda- one of these options only . Alerts: 1500 mL (milliliter) fluid restrictions. On 09/16/24 at 12:42 pm, Surveyor questioned V7 (Dietician) regarding R37's lunch meal diet card fluid restrictions orders and V7 stated that R37 should have either water or ginger ale but not both due to R37's fluid restriction. V7 then stated, I (V7) did not give him (R37) that (referring to R37's water and ginger ale). The servers provide the drinks before the meals are served. They (referring to the servers) need to read the ticket (referring to R37's diet card). When V7 was asked regarding what could happen if a resident's diet card for fluid restrictions are not followed and V7 stated, R37 has CHF (Congestive Heart Failure) and if he (R37) drinks too much fluid, he (R37) could have issues with his (R37's) heart. I (V7) will in-service the servers. R37's diet card dated Mon (Monday) Sep (September) 16/24 shows that R37 has a diet order Diet Order: Regular texture no added salt, fluids thin. Notes Fluid restriction: provide the following only: 6 oz (ounces) water, coffee, juice, or soda- one of these options only . Alerts: 1500 mL (milliliter) fluid restrictions. R37's Physician Order Sheet (POS) dated 09/16/24 documents, in part: Diet: Fluid Restriction: 1500 mL daily 1080 mL, Nursing 420 mL every shift. R37's care plan presented on 09/17/24 documents, in part: Interventions: Provide fluid restriction as ordered per MD (Medical Director) (1500 mL (milliliter) day) (Dietary 1080 mL Nursing 420 mL. The facility's policy dated March 2022 and titled Therapeutic Diet Orders documented in part: Policy: the facility provides all residents with foods in appropriate form and/or the appropriate nutritive content as prescribed by physician, and/or assessed by the interdisciplinary team to support the residents treatment/plan of care, in accordance with his/her goals and preferences.

Based on observation, interview and record review the facility failed to maintain temperature logs and provide thermometers for resident's personal refrigerators for two residents R1 and R29 to ensure the safety of the residents. This failure has the potential to affect all three residents (R1, R14 and R29) with personal refrigerators. Findings include: On 9/16/2024 at 10:50am surveyor observed R1's refrigerator with no log or thermometer. On 9/18/2024 at 10:37pm surveyors observed R1's refrigerator with no log or thermometer. On 9/18/2024 at 10:38am V20 (Certified Nursing Assistant) stated that the kitchen staff is responsible for labeling and checking the food in resident's personal refrigerators every day. On 9/18/2024 at 9:18am V2 (Director of Nursing) stated that the family is responsible for cleaning, unthawing and discarding food from the resident's personal refrigerator. Policy titled Use and Storage of Food Brought in by Family or Visitors with a revised date of 3/26/2023 documents, in part, It is the right of the residents of this facility to have food brought in by family or other visitors, however, the food must be handled in a way to ensure the safety of the resident. 45346 On 09/16/2024 at 10:53am observed a black and gray refrigerator sitting in R29's room. Surveyor observed no thermometer in the inside of the refrigerator and no refrigerator temperature log to record a daily temperature affixed to R29's personal refrigerator. Surveyor observed 6 cartons of a nutritional drink, 2 containers of Jello, applesauce, and 27 cans of soda in R29's personal refrigerator. On 09/17/2024 at 10:12 am V13(RN/Registered Nurse) stated I am not sure who is responsible for maintaining and taking the temperatures in the refrigerators for resident's who have personal refrigerators. On 09/17/2024 at 2:09pm V8 (Environment Service Director) stated I do not know who is monitoring the temperature daily in resident's personal refrigerators. On 09/18/2024 at 11:10 am V2(DON/Director of Nursing) stated the resident's personal refrigerators are maintained by the resident's family. V2 stated the facility does not have a policy regarding the care and maintenance of resident's personal refrigerators. V2 stated if the temperature in a resident's personal refrigerator is not within an acceptable range, the food in the resident's personal refrigerator will spoil and cause the resident to experience gastrointestinal upset or discomfort. R29's Brief Interview for Mental Status (BIMS) dated 07/25/2024 Section C C0500 documents that R29 has a BIMS score of 13 which indicates that R29 is cognitively intact.

Based on interviews and record reviews, the facility failed to provide adequate supervision for 1 confused resident [R1] who is a high fall risk out of 3 [R1, R2, R3] residents reviewed for falls. This failure resulted in R1 being found on the bathroom floor bleeding to the back of the head. R1 was transferred to the hospital and R1 received laceration repair with staples. Findings Include: R1's clinical record indicates in part the following: R1 is a [AGE] year-old admitted to the facility on [DATE] with admitting medical diagnosis include but not limited to- right closed femur fracture, abnormal gait and mobility, weakness, cerebral infarction, aphasia following cerebral infarction, traumatic hemorrhage cerebral without the loss of consciousness, muscle wasting and atrophy, dementia with mood disturbance, mood affective disorder, fall on/from stairs, essential hypertension, and osteo-arthritis. R1's Minimum Data Set Brief Interview for Mental Status [BIMS] score [04] indicates R1 is severely cognitively impaired. R1's After Care Visit Summary form hospital emergency department dated 3/9/24, documents in part: -Diagnosis of injury to head, initial encounter -Laceration repair with staples R1's Care Plan documents in part-R1's fall risk behaviors are manifested by her attempts of self-toileting, and self-transfers from bed/wheelchair unassisted and poor safety awareness. R1's progress notes documented in part: V8 [Registered Nurse] Note: 2/14/24 at 5:41AM-R1 is requiring one on one assistance throughout the night to monitor for attempting to get out of bed. R1 is a high fall risk. PRN Xanax given and ineffective. V9 [Restorative Aide] Note: 02/14/2024 at 11:48 AM -R1 participated in transfer exercises today. Aide applied a gait belt prior to transfer exercises to ensure resident's safety. R1 stood three times with the assistance of two restorative aides. R1 needed extensive assistance to reach a standing position then was able to stand for 5-10 seconds before asking to sit down. V12 [Licensed Practical Nurse] Note: 2/21/24 at 4:08 PM-R1 alert requires redirection and 1:1 at times combative during patient care pain management effective at this time requires assist x 2 staff to complete ADL's and transfers. V10- [Social Service Director] Note: 02/23/2024 at 01:42 am- R1 scored a 5/15 BIMS which indicates that she is severely impaired for her cognition and needs consistent cueing and redirection during daily ADL care. R1 also needs close monitoring due to fall risk and poor safety awareness. V7 [Registered Nurse] Note: 3/9/24 at 10:07PM: 9PM V7 was called into R1's room because R1 was not in bed. R1 was found inside her bathroom with the door closed and the lights off. R1's head was underneath the bathroom sink and feet were up against the door. There was blood between R1's head and the toilet and on the right side of the sink. R1 was facing the toilet laying on her right side. There was blood on the back of R1's head. Upon further inspection, there was also blood on the opposite side of the wall to the bathroom and on the floor by R1's closet. R1 had about half inch laceration to the back of R1's head which had dried blood around it. There was only dried blood on the back of R1's head. On 4/6/24 at 9:55AM V3 [R1's Family Member] stated, Two years ago, R1 had a stroke that affected her mobility and speech. The end of January 2024, R1 fell at home in our basement, fractured her hip and had surgery for hip repair. R1 was admitted to the facility for rehab services at the beginning of February. R1 completed therapy, but now lives here. I can't take R1 home until she can walk without falling. I am not able to monitor R1 continuously at home, I felt her being here would be safer for R1. I come and visit with R1 every day, I arrive after breakfast, but stay until 7PM, which is her bedtime. On 3/9/24, not to soon after I left the facility I received a phone call, the nurse told me R1 got out of bed and looked outside her bedroom door in the hallway, then went into her bathroom, fell , and hit her head. R1 was bleeding from her head and was sent to the emergency room and received some stapes to the back of her head. R1 probably was at the door looking for assistance to go to the bathroom, but she is not able to communicate her needs since her stroke. She cannot talk but understands what you are saying to her and knows what she needs but has a hard time telling me or staff what she needs. R1 needs constant supervision since her stroke and last fall at home. R1 does not know how to use her call light, to call for assistance. I come every day to sit with my wife and monitor her closely and to give the staff a break. After R1 fell the last time, the facility placed a monitoring device in R1's room to help prevent another fall. I'll show you how it works. Surveyor observed V3 lay down on R1's bed and got up. Once V3 got out of the bed the speaker came on and said to please wait for assistance, and nursing staff came into the room. On 4/6/24 at 10:18 AM, V4 [Agency Certified Nurse Assistant] stated, I been working here through an agency for a month. I am familiar with R1. R1 is alert to self, however she needs constant supervision. When R1's family member is not here, I need to bring R1 out of her room into activities. R1 tries to stand up and walk all the time, even during activities. There are times when I try to hold onto R1 so she does not fall, R1 would try to hit me, so staff must be careful. When R1 is sleeping the staff take turns sitting in the chair outside her door to monitor R1 closely since her last fall. On 4/6/24 at 10:33 AM, V5 [Agency Licensed Practical Nurse] stated, I been working here for eight months through an agency. I am familiar with R1. She is alert to self, not able to communicate verbally her needs, but I try figure out what she needs. R1 does not have a communication board. Due to R1 not placing on her call light for assistance, and not able to verbalize her needs, the nursing staff provides close constant monitoring. R1 repetitively tries to stand up by scooting to the edge of her wheelchair and pulling on other furniture to try and stand up. I give frequent verbal ques not to stand and try to figure out what R1 needs or want. Some of R1's fall interventions are, R1 has the fall alert system in her room. It is a sensor that monitor's R1's movements when exiting the bed or chair. The alarm goes off on this phone the nurses carry and the tablets that the certified nursing assistance carry 30 to 65 seconds before the resident stands. This has been in place since her latest fall. Also, low bed, and floor mats on each side of her bed. On 4/6/24 at 1:01 PM V1 [Administrator] stated, R1's after care visit indicate there was a CT of the head without contrast. The hospital did not send any further paperwork in regard to the results of the CT scan of R1's head. On 4/6/24 at 1:18 PM, V1 stated, The Director of Nursing [V2] is out of town on vacation and is unavailable. However, I reached out to V2, and he said the hospital did not send the results and he [V2] did not contact the hospital for R1's CT scan of the head results. I called the hospital, and the medical record department is closed today. On 4/6/24 at 2:52 PM, V12 [Licensed Practical Nurse] stated, During R1's admission to the facility R1 was alert x3, verbal and able to express her needs, there were times R1 had periods of confusion. R1 was admitted to the Medicare unit for rehab services. The staff rotated and sat outside her door to always monitor R1 closely, because R1 would not use her call light for assistance. R1 did not fall on the Medicare unit, she fell on the long-term care unit. I have not worked with R1 since her move to the other unit. On 4/6/24 at 2:55PM, V6 [Certified Nurse Assistant] stated, I am familiar with R1. She is alert to self, confused and combative towards staff. R1 is a high fall risk. I have never seen R1 walk. R1 needs frequent reminders, she will scoot to the edge of the wheelchair and while in bed, she would move her legs while in bed trying to get out. On 3/9/24, I checked on R1 around 6PM, and R1 was dry. Around 8:40 PM, I was making rounds and I went into R1's room and noticed she was not in her bed and the bathroom door was closed. I went out to the nurse station and asked coworkers if anyone knew where R1 was at. Everyone said they did not know where R1 was at. I went back to R1's room and tried to open the bathroom door, but the door could not open. I pushed the door in a little more and saw R1 laying on the bathroom door, I yelled out R1 was on the floor. I asked R1 to slide her foot off the door, and she did. R1 was positioned under the sink, and blood was on the floor. V7 [Registered Nurse] came into the bathroom and assessed R1, and 911 was called. R1 is not able use her call light, needed two-person assist for transfers and toileting. Some fall interventions for R1 were low bed, call light in reach, floor mat on each side of the bed. After her last fall, now she has the fall monitoring censor in her room. The system detects R1 having movement from one position, the alarm will go off on my tablet and will talk out loud to R1 to remind her not to get up and help is on the way. On 4/6/24 at 3:10 PM, V7 [Registered Nurse] stated, R1 was admitted post fall surgery on her hip. R1 is alert x 1-2, at times she's very confused and combative. R1 has diagnosis of dementia. She cannot voice her needs, we must monitor R1 closely, she is high fall risk. On 3/9/24, when I started my shift, R1 was in her room with V3 [R1's Family Member]. Around 730PM, V3 left the facility, I remember seeing him leave. I was in the hallway passing medication. A few minutes later V3 called me on the phone and said that he left R1's bed up, it was not in the lowest position. I was in a room with another resident and forgot to go check on R1. I completed passing medications, I had already given R1 her medication earlier when V3 was here. Around 9pm, V6 asked me if I knew where R1 was at, because she was not in the room. V6 and I went back to R1's room, and V6 told me that R1 was on the bathroom floor. R1 was laying on the floor with her head under the sink and her feet were next to the door. The bathroom lights were off, and she was facing the toilet. There was blood on the floor, the blood was dry and there was a smear of blood on the bedroom wall across from hallway and some more blood near the hallway door at the bottom near the floor door of her closet. R1 could have fallen in the bedroom on the floor near the closet and again in the bathroom or crawled on the bathroom, I am not sure. During my assessment of R1, there was a nice size of a round dried spot of blood on the back of her head. The blood was dried in her hair, I could not see where the blood came from. The area looked like it was starting to scab over. I looked over all R1's extremities, and she was able to move them. The charge nurse came to see R1 and called 911, due to her head injury and R1 takes a blood thinner. R1 returned back to the facility with several staples. Now, R1 has the fall [NAME] monitoring system, and it has been helping us monitor R1 more closely. On 4/6/24 at 3:40 PM, V1 stated, In R1's conclusion of the fall, we looked at video tape and saw V3 left and closed the bedroom door. In two minutes, she poked her head out looking in the hallway. I think she fell soon as V3 left due to blood. V3 called back and said he left the bed up. I don't know if that was the cause of the fall. I don't think the fall could have been prevented because she fell within minutes of, V3 leaving. V3 told staff she was in bed when he left. Even if V7 went to check on R1, after V3 called her, I believe R1 had already fallen. R1 receives close monitoring and supervision, with the new fall system sensor, she has not fallen. On 4/7/24 at 10:12 AM, V11 [R1's Physician] stated, R1 is alert and very confused. R1 needs close supervision and monitoring. Prior to R1's fall I was receiving frequent phone calls regarding R1 being agitated. I started R1 on several medication with the consent of V3, and they seem to be helping R1. The facility staff does a great job monitoring R1, however no one can sit with R1 24 hours 7days per week. I don't think R1's fall was avoidable because she is impulsive. Since the fall and medications, R1 has been calmer, and less agitated. Policy documented in part: Fall Management dated 3/3/19. -The purpose for identification of fall risk factors and interventions that may be used to manage and decrease the number of falls, therefore preventing resident injury. -Upon admission, review hospital discharge records, transfer sheets, other data regarding the resident's history of, or risk factors related to falls. -Fall history in the past three months, ambulation, gait, and balance.

Based on observation, interview, and record review, the facility failed to supervise and prevent a demented and confused resident from eloping from the facility. This failure affects one of three residents (R1) reviewed for supervision in a total sample of three residents. Findings include: R1 is an [AGE] year-old female. R1's diagnoses are but not limited to muscle wasting with breakdown, abnormalities with walking and mobility, major depressive disorder, anxiety, high cholesterol, dementia, restlessness, agitation, and arthritis. R1's BIMS (Brief Interview for Mental Status) dated 09/27/2023, notes R1 is alert. R1's MDS (Minimum Data Set) dated 09/27/2023, notes R1 requires supervision with walking. R1's care plan notes R1 is alert with confusion and episodic anxiousness, and poor safety awareness noted daily. R1 is moderately impaired with her cognition and may benefit from cueing, redirection, and reassurance from staff. R1 does have some physical and verbal aggression. On 11/17/2023, R1 displayed wandering and had an elopement episode where she was found off unit in the courtyard unattended. She has also been more argumentative with staff, refusing care, and redirection from staff. Clinical note dated 11/17/2023, notes R1 combative with staff, agitated, resisting, and refusing care. V10 (Former Nurse) was assisting another resident in the bathroom. When the resident was done in the bathroom, the resident wanted to be put back to bed. V10 put the resident back to bed because the two other aides were assisting their residents. At the same time, the medication delivery guy and V10 got medication from him. At that time, V10 looked for R1 in the common area and R1 was no where to be found. V10 checked all the floors, independent living, and the assisted living lobby with security. Both security guys were notified. The nurse manager on duty was called several times to notify of the incident. But she was not able to be reached. Independent living security finally found her by the exit. When V10 and staff got there, R1 was found kneeling in the courtyard. She was brought back to the facility. She refused to be checked. She removed the blood pressure cuff and threw it away. 911 came and R1 was assisted to the hospital. V10 cannot be in two places at the same time. V10 cannot be helping a high fall risk resident in the bathroom and be watching eloped resident. Clinical note dated 11/17/2023, notes at 4:30 AM, during morning rounds, it was observed that R1 was not in her room. She was also not in the common area. The 2nd floor was searched. She was not found. A code purple was initiated. At 5:15 AM, R1 was not found. 911 was called for assistance with searching the parameters. At 5:28 PM, cameras showed her leaving the building at an unknown time. Writer walked to the courtyard to the closest exit she was seen leaving out of. At 5:30 AM, R1 was found in the bushes in the courtyard. Facility Daily Activity Report, dated November 17th, 2023, notes at 4:28 AM, notes skilled nursing 1J alarm was going off. V6 (Security Officer) responded and turned the alarm off. There was no sign of anyone outside of the door or inside. At 5:00 AM, skilled nursing department called the independent living desk stating R1 was missing. At 5:02 AM, a resident was missing from center. V6 reviewed the camera and found R1 in the garden area. On 02/08/2024, at 12:26 PM, R1 stated, I remember leaving the building. I don't know why I wanted to leave. Something went wrong. I am awake a lot. It is hard to sleep. I cannot always remember names. I have a hard time hearing. On 02/08/2024, at 12:26 PM, V2 (R1's Resident Companion) stated, She has dementia and is hard of hearing. I just try to make the best life that she can while she is here. I usually stay with her for four hours. Sometimes its longer and sometimes its shorter. Some nights are hard for her. She is up a lot. On 02/08/2024, at 12:40 PM, V3 (Registered Nurse) stated, The [NAME] stairwell and elevator require staff badges to open them. All the floors have dementia residents. It is not just this floor. Before anyone gets outside the building there should be security at the front. I have taken care of R1. She is confused, but pleasant. She will say when she feels confused. She is in a wheelchair. But she can walk with a walker with supervision by one person staff. If I see the resident, I will try to redirect the resident if he/she got on the stairs or the elevator. A lot of the residents on this floor require redirection. There are alarms on the floor. There are bed and chair alarms. Certain residents have this. The elevator and door need badges and frequent rounds. If the resident tries to open the door to the stairwell or get on the elevator there is a loud alarm. Staff run to the alarm go to the stairs. Checks are supposed to be done up and down the stairwell. If I cannot find the resident, I ask the aides to check their residents. Staff are supposed to round on the residents every 15 minutes. On 02/08/2024, at 1:37 PM, V4 (Agency Certified Nursing Assistant) stated, I aware of R1. I was working as an aide that night on the second floor of the facility. I was working the night shift. I was doing rounds when I was alerted that a patient was missing from the floor. I became aware of this when other people were looking for her. I found out about it from another aide and a nurse. I do not recall if I was her aide that shift. When I was working agency, that was my first time working there when an elopement had occurred. I have only been to the facility a couple of times. I was not trained at the facility on how to handle an elopement. I recall seeing R1. She got up a few times. The aide put her back to bed. The very last time I saw her, the aide had put her back to bed. I do not remember the name of the aide. I was agency and I did not have a badge. I will ask staff to let me back in. I do not recall hearing any alarms going off while making rounds and providing care to the residents. Once staff and I found out she was missing we were very diligent looking for her. If I heard the alarm, I would just keep searching resident rooms and keep an eye out to see if she showed up again. On 02/08/2024, at 1:53 PM, V6 (Security Officer) stated, I have been the security officer for about a year. That night I was at the independent living desk. A nurse or aide called me on the phone and stated that a resident was missing; R1. There are cameras on the assisted living, independent living, and skilled doors. Usually, I keep the camera on the parking lot. I reviewed the camera and saw that R1 had exited through the independent living entrance leading towards the courtyard. There are alerts that go on the screens. I did not see any alerts because I was doing rounds. I did hear an alarm before going off in that section. I looked but I did not see anyone. I assumed it was a worker that left because I did not see anyone. It was going off by the independent living restaurant. There was another guard at the independent living desk. It was V7 (Security Officer). I went back to the desk a few minutes later. I reviewed the camera footage and saw that R1 had eloped. The alarm is set off all the time. I try to check it all the time. When they called me, I was at the independent living desk. Right away, I called the nurse, and we went after her through the independent living courtyard door. She was in the bushes or shrubs. It was dark outside. It was around 5:00 AM. It looked like she was kneeling or sitting. She was upward. She was agitated. She was saying things like you call yourself a police officer. The nurse got the wheelchair and brought her back in the facility and alerted the family. I work for an outside company. There are fifteen points (scanning points) that I have to monitor. The stairwells are part of the scanning points. The assisted living and skilled have nurses and aides are supposed to monitor the residents. On 02/08/2024, at 2:09 PM, V7 (Security Officer) stated, I can recall the incident. I can recall, it must have been early morning. One of the nurses asked me if I saw anyone leaving out the entrance door. I said no. Someone told me that there is a resident missing. The Nigerian nurse. We looked down in the basement, all the floors, and independent living. We did not see anyone. In the meantime, I called V6, the lead guard with the computer information. He was aware that we had a missing resident in the facility. I asked V6 if he could get the cameras back to the time the resident went missing. V6 called me back. The pharmacy guy was in the building in the same area. V6 went back further in the footage and thought he saw someone leave out the exit door. I went back to the front desk, and he went out where the pharmacy guy was. The door alarm went off. The pharmacy guy would not go out that way. We realized that it must have been whoever went out that door. I have been at that facility going on two and half years. When I do rounds, we monitor the stairwells as well. I did not hear the alarm. I was a rover. I check all the physical handicap button when they go off for independent living. The rover gets the information back to the lead guard. My little camera only covers the outside facility and the streets. The main camera covers everything. But you cannot watch everything at the same time. I believe where I am, there should be a bigger camera for monitoring. There should be more visibility. If the nurse hears the alarm, they should be answering them and alerting us. We are the only guys at night. There is more help during the day. On 02/08/2024, at 2:38 PM, V8 (Director of Nursing) stated, It is a collaborative effort between the administrator and me. We talked to staff, reviewed cameras, and talked with the security guards. The error found was there was no follow through by the staff member. The staff member acknowledged that the alarm was going off. The alarm was going off in the stairwell. R1 went down the stairs. Staff did not look in the stair well or look upstairs or downstairs. The staff did not tell me why. The alarm was addressed. Pharmacy had arrived to deliver medication. Staff was not aware that the resident was missing from the common room. They initiated a search on the unit. One of our nurse managers, initiated her search as well. They notified security. When we were reviewing the videos, R1 missed the security guard by a split second. The security guard noticed the alarm was going off. He went out to check and did not see anyone. The nurse manager found R1. The resident was in the bushes off the courtyard. She was laying on the ground. I believe she fell outside or into the bushes. That part we could not see in the camera so we could not tell. Staff attempted to do an assessment on her after she was found but she refused. She must have been agitated. She can be difficult to redirect at times. The alarm system has always been there on the second floor. Anyone can get on the unit but must be badged to leave. It is in place if the door is opened. If a resident is attempting to elope, it alerts staff. It is loud when it goes off. It is hard to ignore it. It is there to keep the resident safe. If they hear the alarm going off, they are supposed to investigate to see who triggered it. The assumption was the pharmacy guy set it off because he went that way. R1 went down the stair well. R2 was coming up corridor but the pharmacy guy was already on the unit. In my opinion, the staff could have investigated the alarm better. On 02/08/2024, at 3:00 PM, V8 took surveyor the same way R1 took when R1 eloped from the facility. V8 pushed the door open on the second floor. This is where R1 resided. The alarm went off loudly and there was a blue flashing light. V8 took surveyor down the stairs to the door 1st floor stairwell door. V8 pushed the door open. The alarm sounded loudly, and a blue light flashed. Lastly, V8 took surveyor to the 1st floor door that led to the outside. V8 pushed the door. The alarm sounded loudly and there was a blue light flashing. R1 was able to get through three separate door alarms before R1 eloped from the facility. On 02/08/2024, at 3:07 PM, V1 (Administrator) stated, V8 told me that V5 (Registered Nurse) called him and told him what had occurred. V8 told me that R1 had eloped and that she was on the way to the hospital. A thorough investigation was completed. R1 was up and about. V9 (Former Certified Nursing Assistant) went to go change someone. R1 proceeded towards the door. At the same time the pharmacy came up and was trying to get V10's (Former Registered Nurse) attention. Then, R2 came out of her room. When staff went to investigate the alarm, it seemed as if R2 set the alarm off because she was standing in front of the door. The door was closed, and it was going off. V10 looked like he checked the pharmacy drugs. Shortly after staff noticed that R1 was not where she was supposed to be. They searched the unit first. Then, V10 went down to the first floor. He was searching for her. Security was doing his rounds and went out the door. He did not see anyone and shut the alarm off. He stated he presumed it was the pharmacy as well. Security should have come and reviewed if it was the pharmacy person. The security system was upgraded to the badge system because residents could learn the codes. The purpose for the alarm is to alert staff if someone is trying to leave the unit. I expect staff to go down the stairwell to see who went down the stairwell. V10 shut the alarm off and then was looking for R1 on the floor. The alarms are there to keep the residents safe. All my staff was in serviced on what to do about elopements before and after the incident occurred. On 02/09/2024, at 3:19 PM, V10 stated, I remember the facility was short staffed. There were high fall risks on the unit. I passed part of my medications. I returned to the nurse's station. The resident in question (R1) was being combative. There was no communication that she was trying to elope for the past two days. I found out from other staff about that. Nothing was done about it. I worked part time. This incident happened Tuesday. She was trying to get out bed and the bed alarm was going off. I asked the aide to bring her to the common room. She was sitting in the recliner. There was another high fall risk resident that pulled the call light. The aides were busy. I rushed down to the resident to make sure she did not fall. I helped that resident to the bathroom. I returned to the nurse's station to chart. The high fall risk resident pulled the call light again. I had to help the resident out of the bathroom and into bed. When I was coming back, I saw the medicine delivery guy. The door was beeping close to the elevator. His English was not very good. I assumed that he came through the door that was beeping. I used my badge to stop the beeping. I checked the stairs and there was no one there. R1 was not on the unit. I told the aide that we should look for the resident and stop what they were doing. We were checking on the floors and she was not there. I told security to check the stairs and they did not see anyone. Not long after that, the second security guy checked the camera again. He found out that R1 walked through the service door. Me and the security guy checked the ground floor. The wound nurse was at the facility at that time. She found R1 outside. When I got there, R1 was kneeling and was combative. R1 was saying, leave me alone I just want to leave. I put R1 in a wheelchair and took her to the floor. R1 was still being combative. I called 911 and she was transferred out. When the door is being opened, the alarm will go off. Without a badge, the door can be opened but it will be beeping. I was not sure if the medicine guy came through the stair's door or the elevator. I was in another resident's room providing care. I think R1 snuck down on the elevator. I do not know how she opened the door and left the floor. I worked with her before. This night it was one nurse and two aides for at least thirty residents. I did receive training on elopement, but it was long ago. On 2/09/2024, at 4:19 PM, V9 (Former Certified Nursing Assistant) stated, I came in on my shift from 10:30 PM to until 6:30 AM. Prior to me coming in, R1 was being noncompliant and giving the last shift a hard time. When I came in, she was sitting in a chair, by the television. She was sleeping. V10 stated he would watch her. She was fully clothed. She was handed off to me. The previous shift knew this patient was being non-compliant earlier. There was an aide sitting with her before I started my shift. There was one nurse and two aides. R1 should have been given a sitter. I had fifteen patients. I got an agency aide due to the staffing. Two months prior to this incident, I contacted my director of nurses and asked for more help. He hung up on me. They expect us to take care of all these patients with two aides and one nurse. The male nurse was supposed to be watching the resident. He told me to go do my rounds. Around 1:00 AM, R1 woke up. I took her back to her room and changed her. I brought her back up front. She would not sit down. I walked her up and down the halls. The nurse tried to give her some medication, but she refused. I was done with my rounds, and I started to chart. She fell asleep. I took my break, and the other aide watched her. When I was doing my rounds, somehow, she got out. When she did get out, I tried to call the nursing supervisor, but she was nowhere to be found. They started looking for her. R1 was found outside. It is hard for the nurses to watch these residents. I never heard an alarm going off because I was taking care of my patients. The facility let me go because she got out. They cannot expect us to do everything. I have heard that another resident got out. I do not know if it is true, but this is what I have heard. There are not enough cameras to protect these residents. I feel bad for R1, but I can only do so much. I alerted administration about staffing, but they hang up on me. If I had heard the alarm, I would have seen what was going on. If a sitter was put with this resident, this would not have happened. Facility final investigation dated 11/20/2023, notes the investigation notes that the alarms were fully functional. When the alarm was triggered, V10 responded and disarmed the alarm without investigating who set the alarm off. Facility procedure titled Code Purple: Resident Elopement, undated, notes to prevent elopement answer all alarms immediately. Do not assume someone else will answer it. This is an alert that something is wrong. When alarms go off check the entire stairwell. Facility procedure titled Elopement/Missing Resident, undated, notes should an employee hear the security alarm sounding, he/she should proceed to the security annunciator panel to locate the exit opened and immediately proceed through the same exit to determine who went through the exit.

Based on observation, interview and record review, the facility failed to ensure food items were properly labeled, dated, and stored; failed to ensure raw food and cooked/ready to eat foods stored properly on the same storage rack using top-to-bottom system per facility policy; and failed to ensure staff performed appropriate hand hygiene in between handling dirty plate ware and clean plate ware. This deficient practice has the potential to affect all 70 residents receiving food prepared in the facility's kitchen. Findings include: On [DATE] at 09:22 AM, V8 (Director of Dining Services) stated all food items stored in the refrigerator are labeled with an open/prepared date and a use by date. V8 stated the kitchen uses an orange sticker to label items which has the following information on it to be filled out: product name, today's date (prepared date), good thru date and staff initials. V8 stated the use by date lets staff know when the product needs to be used by and/or discarded. On [DATE] at 09:32 AM, observed in the walk-in refrigerator a container of green beans labeled with orange sticker indicating prepared date [DATE], and good thru date [DATE]. V8 stated the green beans should have been thrown out because it is past the use by date as marked on the label. V8 stated there is the potential to cause a food borne illness for the residents which is why the product should have been thrown out. On [DATE] at 9:40 AM, observed two cases of defrosted ground beef patties on the upper shelf in the walk-in refrigerator with a large container of salmon fillets on the lower shelf directly underneath the defrosted ground beef patties. V8 observed the location of the ground patties above the salmon and stated the ground patties should be stored on the lowest shelf, underneath the salmon because the cooking temperature of the fish is lower than the beef. On [DATE] at 9:44 AM, observed a portable open shelving rack containing various food items in the walk-in refrigerator. Raw fish was observed in a shelving slot stored over cooked prepared food and on the same portable shelving rack. Raw pork was observed in another shelving slot stored over cooked prepared food. V8 stated raw foods should never be stored above ready to eat prepared food or cooked left over foods because the potential for the dripping of the raw meat could cause cross contamination and food borne illness. On [DATE] at 9:55 AM, V8 stated that all items in the dry storage area should be labeled with a delivery date unless there is already an order label containing the delivery date on it. On [DATE] at 10:10 AM, observed in dry storage room [ROOM NUMBER]-plastic bottles (7 pounds, 6 ounces each) of Sliced Strawberry Topping, ,d+[DATE] gallon containers of mayonnaise, ,d+[DATE] gallons of Balsamic Vinaigrette, and ,d+[DATE] gallons of Home Ranch Dressing without any delivery dates or label indicating the delivery date. V8 stated the items should have been labeled with a delivery date so the staff would know how to rotate the food in storage using first in, first out. On [DATE] at 10:30 AM, observed in reach-in refrigerator near prep area ,d+[DATE] full container of Fat Free Sour Cream dated with an open date of [DATE] with manufacturers best by date printed on the container of [DATE]. Also, observed in reach-in refrigerator an opened glass jar of apricot preserves labeled with an open date ,d+[DATE] (year not specified) and good thru date ,d+[DATE] (year not specified) and container of opened applesauce labeled with open date [DATE] and good thru date [DATE]. V9 (Executive Chef) stated the items should not be used because they have expired and I'll throw it out right now. On [DATE] at 9:44 AM, V4 (Kitchen Server) stated that each of the nursing units contain a dishwasher which is used after every meal to wash all the utensils, plates, and glass ware for the residents to use for the next meal. On [DATE] at 9:46 AM, observed V4 rinse off resident dirty dishes and then stack the dirty dishes into a rack. At 9:47 AM, V4 placed the rack containing the dirty dishes into the dishwasher and turned dishwasher on. On [DATE] at 9:50 AM, without performing hand hygiene after handing the dirty dishes V4 removed a rack now containing clean dishes from dishwasher. On [DATE] at 9:51 AM, without performing hand hygiene observed V4 remove dishes one at a time from the rack and stack dishes in a pile on the counter. On [DATE] at 10:05 AM, in main kitchen observed V14 (Kitchen Utility Aide) feeding dirty pans into dishwasher, then performing hand hygiene and putting on new pair of gloves before pulling clean pans out of the dishwasher. V14 stated that he has to wash his hands and change gloves in between touching the dirty dishes and before getting the clean dishes from the dishwasher to prevent cross contamination. Facility policy titled Food and Supply Storage dated ,d+[DATE] documents in part, foods past the use by, sell by, best by or enjoy by date should be discarded, products are good through the close of business on the date noted on the label, refer to the Food Storage Chart to determine discard dated for food items, separate cooked and raw foods, store ready-to-eat and cooked food above raw food, if raw animal foods are stored on the same rack, store them in the following order from top of the rack to the bottom of the rack (fish, eggs, whole cut of beef or pork, ground meat and poultry. Facility policy titled Refrigerated Storage Life of Foods dated ,d+[DATE] documents in part unused portions of foods prepared on site use by 3 days, and fruit purees use by one month. Facility document titled Proper Refrigerator and Freezer Storage undated documents in part top-to-bottom storage of different foods in the same refrigerator and shows a picture diagram with cooked and ready-to-eat food stored at the top and raw products below cooked and ready-to-eat food in the following order from top to bottom: whole fish, raw shell eggs, whole meat, pork, ground meat, and poultry. Facility policy titled Hand Hygiene dated [DATE] documents in part all staff will perform proper hand hygiene procedures to prevent the spread of infection, and this applies to all staff working in all locations within the facility.

Based on observation, interview and record review, the facility failed to ensure dumpsters were covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 70 residents who reside in the facility. Findings include: On 10/17/23 at 10:16 AM, surveyor traveled outside facility to view dumpster area with V9 (Executive Chef). Observed both lids to dumpster wide open and garbage loose inside the dumpster. Also, observed smashed Brussel Sprouts, multiple plastic gloves, milk cartons and other garbage debris on the ground all around the dumpster. V9 stated the dumpster lids should be kept closed to keep animals out and that food and other garbage around the dumpster could attract unwanted visitors which could lead to an infestation. On 10/17/23 at 10:23 AM, V10 (Kitchen Utility Aide) viewed the dumpster and stated that the lids to the dumpster should be closed when not being used. V10 did not know why both lids were wide opened and stated they should be closed to prevent animals from getting inside. On 10/18/23 at 12:43 PM, V15 (Assistant Environmental Services Director) stated the dumpster lids should be kept closed when not in use to keep rodents, and other animals out and there should be no food or other debris on the ground around the dumpster as this could attract rats. V15 stated we don't want that. V15 stated the facility wants to try to eliminate the potential of rodents getting close to the doors to prevent them from getting inside the facility. Facility policy titled Disposal of Garbage and Refuse dated 02/10/23 documents in part, containers and dumpsters shall be kept covered when not being loaded, surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized.

Based on observations, interviews, and record reviews, the facility failed to maintain residents' dignity during meals (R8, R12, R42, R68) and while using a urinary catheter drainage bag (a device in which urine drains into) for one resident (R43) in a sample of 37 residents. Findings include: On 10/17/2023 at 12:07 PM, R12, R42, and R68 were sitting at the same table in the dining room for lunch services. R42 and R68 had their lunch plates and were eating. R12 did not have a lunch plate. R12 only had lemonade and a cup of tea. V4 (Server) was plating and serving lunch plates to other residents at different tables. When surveyor went to the counter where V4 was plating, surveyor did not observe R12's meal ticket on the counter. At 12:13 PM, R12 stated I hope they bring my lunch plate sooner than later. At this time, R42 completed their lunch meal. At 12:15 PM, V4 served R12's lunch plate. Facility's Resident Food Services policy, last revised 01/2022, documents in part: Meals are served in a manner that enhances each resident's dignity and in an environment that is home inspired. Traditional Dining Service: Serve residents seated at one table at the same time. On 10/17/2023 at 10:43 AM and 11:02 AM, R43 was lying in bed. Urinary catheter drainage bag was hanging from the right side of the bed in plain view from the hallway. It was not in a privacy bag. On 10/18/2023 at 9:38 AM, R43 was lying in bed. Urinary catheter drainage bag remained hanging from the right side of the bed in plain view from the hallway. During an interview with V2 (Director of Nursing) on 10/18/2023 at 11:46 AM, V2 stated residents' urinary catheter drainage bags should be placed in a privacy bag when visible to other residents and guests. Facility's Catheter Care policy, last revised 06/2022, documents in part: It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use. Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 46342 On 10/17/23 at 11:51 AM, observed V12 (Certified Nursing Assistant) sitting at head of a table in the 2nd unit dining room. On 10/17/23 at 11:54 AM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth and R42 accepted the food from the utensil. V12 then put R42's utensil down on the table and turned toward R68, away from R42. R42 made no attempt to feed herself. On 10/17/23 at 11:56 AM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. R68 made no attempt to feed self. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 0/17/23 at 11:57 AM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food from the utensil. V12 then put R42's utensil down on the table and picked up R42's water glass and brought it to R42's mouth. Afterwards, V12 turned back toward R68, away from R42. On 10/17/23 at 11:58 AM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. R68 made no attempt to feed herself. On 10/17/23 at 12:02 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. R42 made no attempt to feed herself. On 10/17/23 at 12:03 PM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 10/17/23 at 12:04 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. On 10/17/23 at 12:05 PM, observed V12 pick up R68's utensil, place utensil into R68's food and brought utensil to R68's mouth. Observed R68 accept the food. V12 then put R68's utensil down on the table and turned toward R42, away from R68. On 10/17/23 at 12:06 PM, observed V12 pick up R42's utensil, place utensil into R42's food and brought utensil to R42's mouth. Observed R42 accept the food. V12 then put R42's utensil down on the table and turned toward R68, away from R42. This process of V12 giving R42 and then R68 a bite of food back and forth continued until 12:25 PM. Surveyor did not observe R42 or R68 make any attempt to feed themselves during this time period. On 10/18/23 at 11:29 AM, V19 (Food Server) stated that the meal tickets are organized and distributed by room number, not by table in the unit dining room. On 10/18/23 at 12:26 PM, in the 2nd unit dining room observed V6 (Licensed Practical Nurse) standing over R8 while feeding R8 food. Did not observed R8 make any attempt to feed herself. On 10/18/23 at 12:28 PM, when V6 saw surveyor watching V6 standing while feeding R8, V6 quickly turned around and pulled a chair over from the wall to the table, sat down in the chair and continued to feed R8 again. On 10/18/23 at 3:35 PM, V16 (Registered Dietitian) stated the staff should be sitting down when feeding a resident, not standing. V16 stated it is a dignity and safety issue. The resident who is dependent on staff for feeding needs the staff members full attention. Staff should be feeding one resident at a time at eye level so that they can be monitored closely for choking or swallowing issues. V16 stated if a staff member is getting pulled away then they are not providing their full attention, and this would be doing a disservice to the resident. On 10/19/23 at 8:35 AM, V17 (Restorative Nurse) stated that residents who require feeding should be fed one at a time and staff should be sitting down next the resident, at eye level, not standing. V17 stated this is because of safety and dignity. V17 stated, I wouldn't want anybody standing over me when I was being fed and that this could be viewed as intimidating to a resident, which could make a resident fearful. R8's diagnosis included but not limited to Dementia, Dysphagia, Muscle Weakness. R8's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 3/15. R42's diagnosis included but not limited to Muscle Weakness, Dementia, Acute Respiratory Failure with Hypoxia, Muscle Wasting/Atrophy, Anxiety. R42's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 6/15. R68's diagnosis included but not limited to Malaise, Weakness, Muscle Wasting and Atrophy, Alzheimer's Disease. R68's MDS (Minimum Data Set) undated indicates severe cognitive impairment with BIMS (Brief Interview for Mental Status) 0/15. Facility policy titled Promoting/Maintaining Resident Dignity During Mealtimes dated 03/23/23 documents in part it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life. Guidelines include feed only one resident at a time and all staff will be seated, if possible, while feeding a resident. Facility policy titled Facility Responsibilities - Resident Rights dated 02/10/23 document in part the resident has the right to a dignified existence and the facility will treat each resident with respect and dignity, and care for each resident in a manner and environment that promotes maintenance or enhancement of his or her quality of life.

Based upon observation, interview and record review the facility failed to address R3's (4/18/23) injury of unknown origin, failed to obtain physician orders for weekly skin assessments, failed to conduct bi-weekly showers/skin assessments (as scheduled) for four of four residents (R1, R2, R3, R4) in the sample, failed to document (R1) skin integrity impairments, and failed to timely notify the physician of (R1's) change in skin condition. These failures resulted in (R1) sustaining a keratotic papule on the chest measuring 1.6 cm (centimeters) which required surgical intervention due to neoplasm of uncertain behavior vs. keratoacanthoma. Findings include: On 4/5/23, IDPH (Illinois Department of Public Health) received allegations that the facility is not doing proper skin checks on residents. A resident wound was present, and staff were unaware. R1's diagnoses include dementia and malignant melanoma of skin. R1's (undated) BIMS (Brief Interview Mental Status) determined a score of 6 (severe cognitive impairment). R1's (undated) functional assessment affirms (1 person) physical assist is required for dressing and personal hygiene. R1's care plan states (4/9/23) resident requires full hands-on assistance with ADL's (Activities of Daily Living). Monitor skin for redness/breakdown when changing and report to Nurse/Medical Doctor. Resident is at risk for alteration in skin integrity related to history of melanoma. Intervention: weekly skin assessment On 4/19/23 at 9:15am, surveyor inquired about concerns with R1's care at the facility V3 (Family) stated, They (staff) have to bathe her (R1) twice a week and dress her because she's incapable of doing it herself. I (V3) came to visit R1 and, she (R1) said can you take a look at this and showed me her chest. She (R1) said she told the Nurse, and the Nurse said it could be skin cancer. They (staff) called the wound care nurse to see if it (lesion) was annotated and it was not. She (R1) needed to see a doctor to get a biopsy. He (V12/Dermatologist) thought it was a squamous spot, were awaiting the test results. He (V12) said squamous cells can grow quickly but this (lesion) has probably been there for at least 2 weeks. It's just neglect, they (staff) had to have seen it (lesion). On 4/19/23 at 9:45am, surveyor inquired about R1's alleged skin integrity impairment. V5 (CNA/Certified Nursing Assistant) stated, When they found out about what she (R1) had on her skin, that was my first time working with her (R1). Surveyor inquired how V5 found out about R1's skin integrity impairment. V5 responded, When I walked in the room (after breakfast) I was about to change her (R1), the sister (V3) was in the room. That's when she (R1) was telling the sister (V3) look at this, I've been having this for a long time and affirmed the Nurse (V6) was made aware. On 4/19/23 at 9:52am, surveyor inquired about resident skin assessments. V6 (Registered Nurse) stated, Usually, the CNA's will hit the light (call light) in the shower. We (Nurses) check their (residents) skin for any redness, bruising, skin tears or any new changes. Surveyor inquired about R1's skin integrity impairment. V6 responded, She complained that she had something like a lesion on her chest. It (lesion) was something that was raised, irregular and different shades of dark colors. Surveyor inquired when R1's lesion was identified. V6 replied, I think 3 weeks ago already. The sister (V3) was upset, she (V3) wanted to talk to someone. I went to see if there was anything on her chart, it said that she (R1) has a history of melanoma, but I really couldn't find much, there was nothing under wounds. I looked at her admission assessment also since there was nothing there. She (V3) spoke to (V4/Director of Clinical Operations). We (V4 & V6) did a thorough skin assessment then called the attending and wound doctor. Surveyor inquired if V6 was aware of R1's lesion prior to (V3) requesting to speak with someone. V6 stated, Her (R1's) showers are in the evening so I never did a skin assessment on her (R1) before. Surveyor inquired about R1's current location. V6 responded, She's in the hospital. R1's (March/April 2023) progress notes include (4/5/23) resident skin assessment was completed (entered by V4) observed with dry, flaky skin all over, dry brown, irregular shaped moles on her arms, legs upper back, dry healing scabs to bilateral shins, some redness to buttocks, dry patch nickel size to back of head. To the left chest area, a quarter sized elevated lesion hard to touch middle noted with whiteness and brown, area surrounding noted with dry, scaly redness. Doctor made aware order for dermatology consult given [there were no prior skin integrity impairments documented]. R1's (4/6/23) skin/pressure ulcer assessment states resident was assessed today by wound care nurse. Resident was noted to have a dry patch in the back of her head. Dry skin and lesions throughout her face, back and upper anterior body. Left upper chest there is a raised lesion brown in color, quarter size, hard to touch, no redness, no temp, no complaint of pain to area. Right shin skin tear present dressing applied, scabs on bilateral shins, red spots on bilateral lower extremities. Left arm skin lesions present. Dryness under breasts. Dry scaly skin throughout the body. Floor Nurse gave her shower today. R1's (4/9/23) physician progress notes state patient was seen and examined. She is complaining of skin lesion/mass on her left chest. Skin: left chest skin mass. Skin mass on the left side of the chest most likely skin cancer. R1's (4/10/23) dermatology consult states patient seen for an evaluation of a skin lesion that has been present for at least 2 weeks and increasing in size. Pertinent history: melanoma unspecified, removed and squamous cell skin cancer. Additional visit reasons: evaluation for suspicious growths. An examination was performed including the chest and back. Diagnoses include neoplasm of uncertain behavior vs. keratoacanthoma 1.6 cm (centimeters). A biopsy by shave method to the level of the dermis was performed using a dermablade on the left lateral superior chest. Patient will be notified of biopsy result. The shower assignment sheet affirms R1's showers are scheduled Mondays and Thursdays (PM shift). On 4/19/23 at 10:33am, surveyor inquired about requirements for resident showers. V7 (CNA) stated, We got a shower list Monday through Saturday, they're scheduled 2 times (a week) on days or evening shift. We document the shower and have the Nurse sign off on the skin check. R1's (March 2023) skin monitoring: CNA shower reviews include the following: (3/6/23) Stated she personally bathed herself [R1 has dementia & requires assistance]. (3/9/23) Visual assessment excludes any abnormalities (bruising, skin tears, rashes, dryness, lesions, wound, blisters, scratches, abnormal color, abnormal skin). (3/27/23) Refused. (3/30/23) Visual assessment excludes any abnormalities. [3/2, 3/13, 3/16, 3/20, 3/23 assessments were not documented as scheduled]. R1's (4/6/23) skin monitoring: CNA shower review includes left chest lesion, right shin skin tear and dry skin from the neck down endorsed by the CNA and Nurse however dry skin lesions throughout the face, red spots on bilateral lower extremities and scabs on bilateral shins (documented 4/6/23 by the wound care nurse in the progress notes) were excluded. R1's Physician Orders were updated (4/20/23) with skin assessment twice weekly on shower days [2 weeks after R1's lesion was identified]. On 4/19/23 at approximately 12:15pm, surveyor relayed concerns with resident showers and/or skin assessments not documented twice a week. V1 (Administrator) affirmed the facility identified the concern and presented a (4/7/23) memo which states In doing bath sheet audits, it has been discovered that residents are not getting their baths as scheduled. In addition, it appears that Nurses are not doing body check each time a bath sheet has been filled out. This does not meet the standards for good care. R3's diagnoses include dementia, muscle wasting and atrophy. R3's care plan states resident is at risk for impaired skin related to impaired mobility, fragile skin, incontinence, and muscle wasting. Intervention: bi-weekly skin assessment on shower days to monitor for any alterations in skin integrity (goal date 7/15/23). R3's POS excludes bi-weekly skin assessments. The shower assignment sheet affirms R3's showers are scheduled every Wednesday and Saturday (AM shift). R3's (April 2023) Skin Monitoring: CNA shower sheets were documented (Monday) 4/3, (Thursday) 4/6, 4/12, 4/15, and 4/19 (not as scheduled). R3's (4/18/23) progress notes state resident noted with bruise to lateral side of right knee however cause of the bruise was excluded. On 4/19/23 at 11:10am, a large (dark purple) bruise was observed on R3's right (lateral) leg below the knee. On 4/20/23 at 10:31am, surveyor requested R3's (4/18/23) incident report. At 11:23am, V2 (Director of Nursing) stated, we don't have anything in particular for that bruise because we attributed that to her (R3) fall on March 23rd (4 weeks ago). Surveyor inquired how an old bruise appears. V2 responded, It's actually pink, yellow and green depending on what stage it is. Surveyor inquired how R3's (dark purple) bruise was therefore considered old. V2 replied, I'm not a wound doctor so I don't know. Surveyor inquired if R3 has weekly skin checks ordered. V2 stated, Your concern with the weekly skin checks is our concern as well, so we're currently doing house-wide assessments on everyone's skin. She (R3) has orders for skin protectors cause she's high skin risk so it's not like we don't have interventions in place for her (R3). Surveyor inquired again if R3's physician orders include skin checks. V2 responded, I think everyone should have twice a week skin checks during showers, it's not an order though. On 4/20/23 at 1:14pm, surveyor inquired about potential harm to a resident (with history of malignant melanoma) that develops a new lesion that is not addressed. V13 (Medical Director) stated, They do assessment of the patients there. I know what you are calling me about, it was addressed. Surveyor advised that R1's lesion was not addressed by the facility until (V3) reported it to staff. V13 responded, This lady (R1) complained and said look at what I have. I said this looks like cancer, we need to send you to a dermatologist and do a biopsy. I talked to the lady (R1) and said it's not an infection it looks like cancer. Surveyor inquired if R1's (1.6cm) lesion may have developed within less than a week because R1's (3/30/23) skin assessment excluded skin integrity impairment. V13 replied, No, it's like a week or more. Surveyor inquired about potential for harm to a resident with a large bruise (of unknown origin) that is not addressed. V13 stated, Bone fracture if somebody falls, and it's a bruise. They (staff) have to pay attention to that part. Anything is possible, it may be in a shower she (resident) was handled a little bit roughly, they are frail, they are old if you put the hand, they (residents) may have a bruise. If there's anything suspicious, they tell the nurse they have to do that. R2's diagnoses include weakness, chronic kidney disease, urinary incontinence, muscle wasting and atrophy. R2's care plan states resident is at risk for skin breakdown related to impaired mobility, fragile skin, incontinence, muscle wasting and atrophy. Intervention: bi-weekly skin assessment on shower days (goal date 5/6/23). R2's POS (Physician Order Sheets) exclude bi-weekly skin assessments. The shower assignment sheet affirms R2's showers are scheduled every Wednesday and Saturday (AM shift). R2's (April 2023) Skin Monitoring: CNA Shower sheets were documented 4/1, 4/5, 4/12, 4/15 and 4/19 however 4/8 was not documented. 4/1 & 4/15 showers were refused therefore skin assessments were not documented for over 1 week. R4's diagnoses include encephalopathy. R4's care plan states resident is at risk for skin breakdown related to impaired mobility, fragile skin, incontinence, muscle weakness and dementia. Interventions exclude skin assessment. R4's POS excludes skin checks. The shower assignment sheet affirms R4's showers are scheduled every Tuesday and Friday (PM shift). R4's (April 2023) Skin Monitoring: CNA shower sheets were documented 4/7 (refused). 4/11 and 4/14 (denied shower/bed bath) however 4/4 and 4/18 were not documented. The skin audits by Nursing Assistants policy (revised 3/31/23) states Nursing Assistants shall inspect all skin surfaces during bath/shower and report any concern to the resident's Nurse immediately after the task. Nursing assistants shall also report changes in skin condition that are noted during any care procedure. Notification shall be made to the Nurse verbally and in writing via shower sheet. The (2/10/23) abuse/neglect policy states the facility will identify events, occurrences, patterns and trends that may constitute neglect: failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. [Injuries of unknown origin is inclusive].

Based on observation, interview and record review, the facility failed to supervise three cognitively impaired residents (R11, R53, and R62) who are at high risk for falls and have a history of falls from having repeated falls and failed to implement fall prevention interventions as care planned for two residents (R11 and R53) in a total sample of 29 residents. As a result, R11 fell and sustained a 2-centimeter laceration to the left posterior head that required four staples and bruising to the right hand. Findings include: R11's Face Sheet documents an admitted [DATE] and diagnoses including but not limited to intracranial injury w/o (without) loss of consciousness, anxiety disorder, dementia, osteoarthritis, abnormalities of gait and mobility, muscle weakness and history of falling. R11's 11/14/22 BIMS (Brief Interview for Mental Status) determined a score of 3, indicating that R11's cognition is severely impaired. R11's 11/2/22 Admission Fall Risk Assessment documents, in part, Overall score of 10 or above represents HIGH RISK. Calculated overall score: 10. The facility fall report reviewed from July-December 2022 documents that R11 sustained a fall on 11/2/22 at 7:15 AM with no injury and on 11/11/22 at 7:15 pm with injury and sent to hospital. R11's 11/3/22 care plan documents, in part, Problems: (R11) is at risk for injury related to fall risk. (R11) is admitted to skilled rehab from independent living. She (R11) experienced a fall while a resident in independent living that resulted in a subdural hematoma. Falls in skilled rehab then listed on 11/2/22 and 11/11/22. Interventions include but are not limited to, Keep (R11) in public area as much as possible for increased supervision; Continue to increase frequent rounds and monitoring for the resident; Communication boards/signs in Italian placed in resident room. On 12/05/22 at 9:50 AM, V1 (Executive Director) provided the surveyor with the Initial and Final Facility Reported Incidents reports that were sent to the state agency for the alleged incident that occurred on 11/11/2022. The Final Investigation report documents, in part, She (R11) is one person assist with transfers, speaks Italian, and needs cueing and redirection. On the evening of November 11, 2022, around 7 pm, resident was toileted and assisted to bed and then at approximately 7:30 PM, the Nurse on duty reported she was making rounds and observed resident on floor next to her (R11) bed and soiled. The nurse assessed resident and then assisted resident to bathroom and incontinence care provided. During her assessment, the nurse used hand gestures to determine any signs of pain or discomfort. The resident pointed to the lateral side of her hand and expressed pain. The nurse continued to further assess resident and noted a small laceration to her head .Resident returned from ER (emergency room ) with results of no right-hand fracture, negative CT (Computed Tomography scan), and staples to the laceration sustained from her (R11) fall. On 12/07/22 at 1:53 PM, V23 (LPN/Licensed Practical Nurse) who was the nurse on duty on 11/11/22 stated that she (V23) was rounding on her (V23) residents at the start of her (V23) shift around 7pm when she (V23) found R11 on the floor next to her (R11) bed. V23 stated that during the initial assessment R11 was pointing to her right hand and had pain upon palpation so the physician was contacted for an x-ray order. Per V23, a CNA (Certified Nursing Assistant) noted blood in R11's hair so when V23 inspected it, a laceration was found to R11's scalp and the resident was sent to the hospital for evaluation. The surveyor inquired what fall precautions are in place for R11. V23 replied, We do pretty much a one to one with her. We keep her with a staff member. If the CNAs were busy, I would keep her with me. If they were available to take her, they would take her to keep her in close visuality to make sure nothing happens. V23 stated that this was an intervention that was in place from the first day that R11 came to the facility. The surveyor inquired where the assigned CNA was at the time of the fall. According to V23, she (V23) did observe a CNA in the break room when she (V23) arrived for her (V23) shift but did not know which CNA was assigned to which patients at the time and proceeded to obtain report from the previous nurse and do her (V23) rounds. On 12/07/22 at 3:05 PM, V25 (CNA) stated that on 11/11/22, I happened to be at the charting desk outside of (R11's) room when the day shift CNA (V18 Restorative Aide) was giving him (V22 Agency CNA) report, so I heard (V18) tell him (V22) that (R11) is one to one. According to V25, (V18) told V22 that R11's caregiver leaves at 4:30pm so after that she (R11) needs to be closely monitored and he (V22) responded, Oh ok. V25 added that she (V25) has taken care of R11 in the past and we wouldn't leave her (R11) alone in the room because R11 was a high fall risk and in report V25 was instructed to not leave R11 unsupervised. V25 also reported that on 11/11/22 when she (V25) returned from her (V25) scheduled break around 7-7:30 pm, she (V25) observed V22 sitting in the break room on his (V22) personal laptop. On 12/07/22 and 12/08/22, the surveyor attempted to contact V22 (Agency CNA) multiple times but was unsuccessful. On 12/07/22 at 2:07 PM, the surveyor walked with V14 (Restorative Nurse) to R11's room and inquired if there were any signs in Italian. V14 replied, No. There should be because I made them myself. V14 added that staff should have brought the signs with R11 when R11 was transferred from the first to the second floor. On 12/08/22 at 10:26 AM, V18 (Restorative Aide) stated, I remember giving him (V22) a walk-through of the whole set. I told him (V22) that he (V22) has to keep a close eye on (R11) because she's (R11) a busy body; she (R11) likes to move around a lot and that she's (R11) a one-to-one assist. The surveyor inquired what V18 meant by one-to-one assist. V18 replied, Like somebody has to sit with her (R11). So, if you're giving care to somebody else, you have to make sure somebody else is sitting with her (R11). V18 added, I told him that she (R11) has a caregiver and the caregiver leaves between 4 and 4:30 PM. He said, 'Ok.' On 12/08/22 at 10:47 AM, the surveyor inquired what is the risk to a resident who has an unwitnessed fall. V29 (R11's Primary Physician) replied that any injury can occur depending on how hard the resident fell . V29 listed, Fracture, head trauma, bruises, concussion, laceration, intracranial bleed .anything. R11's 11/11/2022 Emergency Department APP (Advanced Practice Physician) Note authored by V26 (PAC/Physician Assistant-Certified) and cosigned by V27 (DO/Doctor of Osteopathic Medicine) documents, in part, History of Present Illness: (R11) . presents to the ED (Emergency Department) with son from nursing home unwitnessed fall PTA (Prior to Arrival) .Physical exam: Skin: 2 cm (centimeter) linear laceration to left posterior head . dried blood noted. Musculoskeletal: TTP (Tenderness to Palpation)-scant edema (swelling) and ecchymosis (bruising) overlying posterior right 4th and 5th metacarpals (hand bones) . Laceration repair: skin closure: staples. Number of sutures: 4. R53's Face sheet documents an admitted [DATE]. R53's 10/14/22 BIMS, determined a score of 9, indicating R53's cognition is moderately impaired. R53's 09/02/22 Admission Fall Risk Assessment documents, in part, Overall score of 10 or above represents HIGH RISK. Calculated overall score: 14. R53's 9/14/22 care plan documents, in part, (R35) is at risk for falls related to: impaired mobility, muscle wasting cervical disc disorder, OA (osteoarthritis), lumbar spondylosis, SOB (shortness of breath), pain, muscle weakness, incontinence, difficulty walking, gait abnormalities, poor safety awareness, DM (diabetes mellitus), HTN (hypertension), NSTEMI (non-ST Elevation Myocardial Infarction), atrial flutter, CAD (Coronary Artery Disease), CKD (Chronic Kidney Disease), heart failure, hx (history) of falls, hx hip replacement. Interventions include but are not limited to: Keep call light within reach at all times and encourage (R53) to ask for assistance. The facility fall report reviewed from July-December 2022 documents that R53 had a fall on 9/4/22 at 10:20 PM with no injury; 10/9/22 at 2:15 AM with no injury; and 11/23/22 at 1:23 AM with min injury. Not sent to hospital. On 12/05/22 at 10:41 AM, R53 was observed sitting in a recliner next to the window in R53's room. R53's call light was noted on R53's bed, not within reach. At 10:43 AM, this observation was brought to the attention of V30 (Restorative CNA) who verified that the call light was on top of the bed and when the surveyor inquired if R53 was able to reach the call light from his (R53) position, V30 replied, No. I wouldn't have set it here. The surveyor inquired what the risk is of not having the call light within reach. V30 replied, He's (R53) not going to be able to call and he (R53) could get up and fall. The 3/3/22 Protocol for: Fall Prevention, Response and Management documents, in part, Policy: (Facility) is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. While preventing all falls is not possible, it is this community's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. All staff will be responsible in assisting with the implementation of the Facility's Fall Management Program to ensure the safety of all residents in the community .Standards and Practice Guidelines: . 3. An indicated score of high risk for falls, or history of falls will require the development of a care plan with interventions designed to reduce the risk and/or re-occurrences. 4. The admitting nurse and assigned CNA are responsible for initiating safety precautions at the time of admission. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. Standard fall/safety precautions for all residents: All staff will be oriented and trained on the Fall Prevention Program upon hire, annually and as needed. At the time of admission, and in accordance with the plan of care the resident will be oriented to use the call nurse device. The nurse call device will be placed within the resident's reach at all times .In addition to the use of Standard Fall Safety Precautions, the following interventions will be implemented for resident identified at risk: 1. The resident will be checked frequently or as according to the care plan, to assure they are in a safe position/environment. The frequency of safety monitoring will be determined by each resident's risk factors and plan of care. The September 2017 Call Lights: Accessibility and Timely Response Policy documents, in part, The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance .Policy Explanation and Compliance Guidelines: . 5. Staff will ensure the call light is within reach of resident and secured with each interaction in the residents' room or bathroom and as needed. 32338 On 12/5/22 and 12/6/22 during observation of residents on the nursing units, R62 was observed and interviewed. R62 could not respond to any questions regarding any of the fall incidents and could not use call lights to ask for staff assistance. R62's face sheet shows that R2 has multiple diagnoses which include but are not limited to Dementia, History of Falling, and Abnormalities of Gait and Mobility. R62's MDS (Minimum Data Set) dated 10/1/2020, section C states that R62 has a BIMS (Basic Interview for Mental Status) score of 5 out of 15 (severe mental impairment). R62's MDS dated [DATE], Section G (Functional Status) shows that R62 requires assistance to walk, to transfer from bed or from chair. R62's Fall Risk assessment dated [DATE] shows that R62 has a score of 18 (High Risk for Falls). On 12/06/22 at 2:10pm, V14 (Restorative Nurse) was interviewed regarding why R62 was not supervised closely and had 8 falls within 6 months. V14 stated that R62 was previously residing at the Assisted Living side of the facility and wanted to do things for herself. V14 later presented eight records of R62's falls within the past 6 months. The fall incident records are as follows: 8/1/22 at 1:30am - R62 fell in her room and was sent to the hospital and returned. 8/4/22 at 8:30am - R62 fell in the hallway with no injury. 8/31/22 at 8pm - R62 fell in the common area. 8/31/22 at 10:30pm - R62 fell in the common area. 10/1/22 at 2:40pm - R62 fell in his room with minimal injury. 10/27/22 at 8am - R62 fell in the common area. 11/4/22 at 12:30pm - R62 fell while trying to walk. 11/15/22 at 5:50pm - R62 fell in the Dining Room and was sent to the hospital and returned. R62's care plan initiated on 6/20/22 states that R62 is at risk for injuries related to falls related due to several medical diagnoses including but not limited to Dementia, Alzheimer's Disease, Muscle Weakness, history of falls, and Poor Safety Awareness. Facility's policy on Accidents and Supervision dated September 2015 with latest revision date of January 2022 states in part: Each resident will receive adequate supervision and assistive devices to prevent accidents.

Based on interviews and record review the Facility failed to follow their policy on transfers for R1, one of three residents reviewed for falls with serious injuries. Per Facility's policy, residents who are transferred by mechanical lifts are a 2 person assist. R1 was transferred by one person assist on 4/27/2022, sustaining a fall to the floor from the mechanical lift. This failure resulted in R1 being hospitalized on [DATE] after complaining for 5 days of pain in the lower back and a swollen left knee. R1 was hospitalized for 13 days from 5/2/22 - 5/15/2022 and underwent surgical procedures for the left hip and left knee. Findings Include: R1 is [AGE] years old and cognitively impaired. R1 was observed on 6/30/2022 at 11:39 am sitting in his wheelchair next to the nursing station. R1's clothing was clean and neat. Surveyor called R1 by name and said hello, R1 looked at surveyor and did not respond back. On 7/12/22 at 1:12 pm, R1 was in his wheelchair for lunch, he ate approximately 75% of his meal with assist from staff. Resident transfers with sit to stand and 2 person assist. R1's order is for weight bearing as tolerated, one person assist with ADLs. Records Review: R1's Brief Interview Mental Status (BIMS) dated 4/3/2022 scored R1 as 8 out of a score of 15. The Minimum Data Sets (MDS) dated [DATE] and 1/25/2022 scored R1 as a 3 for Extensive Assist with a 2 persons Transfer. R1's Medication Administration Record (MAR), noted R1 received controlled substance medications named [MEDICATION(S)] ([MEDICATION(S)]) and Tylenol for pain 2-3 times daily on 4/27/22 thru 5/2/2022. R1's pain was rated as 5 - 6 on a scale of 1-10 after administration of the narcotic medications. Hospital Note: dated 5/16/2022 at 4:14 pm, by V8 (Nurse Practitioner): Chief Complaint: Impairment of ADLs and mobility 2/2 ORIF left hip and hardware removal, with muscle weakness and difficulty with functional mobility. [AGE] year-old male with history of dementia, depression, heart failure with preserved ejection fraction, [CONDITION(S)], [CONDITION(S)], history of seizures, who presented to the ED (Emergency Department) with left knee pain. Patient had a CT (Computed Tomography) scan of his left knee which showed an acute versus chronic extra-articular distal femur fracture with mild shortening and flexion deformity. The patient underwent a left distal femur ORIF (Open Reduction and Internal Fixation) and hardware removal. Patient had a Left femur fracture repair and a Left total arthroplasty (Total Hip replacement) on 5/09/22. The patient was medically treated and stabilized. The patient was transferred back to Facility on 05/15/2022 for sub-acute rehab to optimize functional status. R1 underwent a surgical procedure on 5/9/2022 called an ORIF of the left hip and left leg. On 5/17/2022 at 2:24 pm, V10 (Wound Nurse) noted, R1 was hospitalized for 10 days and underwent surgical procedures for the left hip and left knee. Patient had a CT (Computed Tomography) scan of his left knee which showed an acute versus chronic extra - articular distal femur fracture with mild shortening and flexion deformity. Resident readmitted to facility with left hip and knee surgical incision. Left hip present with 96 clean, dry, intact, and well approximated staples. Medial left knee noted with 24 staples, clean, dry, intact and well approximated. Lateral left knee noted with 23 staples clean, dry, intact, and well approximated. Progress Notes: On 5/15/2022 at 11:18 PM by V3 (nurse), readmitted a 67yrs old male from Christ Medical Center, alert, oriented x3, s/p ORIF on 5/9/22, Left femur fracture repair, left total arthroplasty. Resident denied pain during admission assessment, oral cavity is pink and moist, trachea in midline, lung sounds bilaterally clear to auscultation, breath sound diminished. Left hip to left thigh with 96 staples, edges well approximated, left medial knee with 24 staples. Bowel sounds present in all four quadrants, no masses palpated, foley catheter fr14 in place with yellow urine draining per gravity, right buttock with stage 3 decubitus, 20cm x 12cm with black colored top, no drainages, [MEDICATION(S)] dressing, and barrier cream applied. Pedal pulses bilaterally present and 2+, no [CONDITION(S)] to lower extremities, abductor wedge in place, knee brace in place to left leg, v/s=98.7-73-18-120/70, spo2=97% room air; Physician notified of admission, orders verified, noted and carried out. Call light within reach, resident made comfortable in his bed, non- weight bearing to left lower extremity. R1's record dated 4/27/22 at 7:43 pm, V3 (nurse) - Resident was lowered to the floor in his room while on a sit-stand lift; his knees buckled prompting writer to lower him to the floor. R1 was assisted up to his bed via draw sheet and four staff lift. R1 complained of back pain during transfer, stated that staff was rough lifting him, he kept stating This is like Nazi [NAME] for Christ's sake. PRN pain med given by nurse on duty, no changes in his baseline ROM (range of motion), v/s=97.2-68-18-140/87. Physician and POA (Power of Attorney) made aware of resident having been lowered to the floor. On 4/28/2022 at 12:56 pm, V8 (Rehab Nurse) -Transfer method evaluation note: Resident was assisted with transferring via sit-to-stand today in the afternoon, Writer and aide assisted R1 with patient care and transferred resident using sit-to-stand, R1 was able to tolerate sit to stand with proper application of sling and lower leg safety belts, R1 was able to rise from sitting on the edge of bed and maintain standing position until lowered onto the toilet. After toileting resident was again raised from sitting position to standing position via sit to stand and placed into wheelchair, Resident noted to have poor posture when placed into wheelchair, Resident leaning to the left and forward, x-rays for lumbar spine and pelvis ordered to r/o scoliosis, resident will be provided with a (Left) side- board or position wedge (left) to help resident correct posture and positioning, any changes will be documented and reported to attending physician. On 4/28/2022 at 7:54 PM, V9 (nurse), Day 2 Note 3 of fall with no injury. Resident received in bed sleeping. Midwest X-ray tech arrived around 10:45 am. X-ray to lower back done this evening. Results pending. Resident compliant with incontinence care this morning and afternoon. +ROM. C/O lower back pain PRN [MEDICATION(S)] administered with effective results. VS:124/81, 74, 97.6, 18, 96%. On 4/29/2022 at 2:12 PM, V14 (nurse), Received resident this morning in bed asleep. Alert oriented x 2-3, forgetful. [MEDICATION(S)] given 2x and Tylenol this shift due to lower back pain and leg pain. Observed leaning to his left side while sitting on the w/c and recliner chair. Resident stated I have pain in my back. V/s: BP 157/95 Pulse 86 Temp: 97.6 V3 (nurse) noted on 5/02/2022 9:14 PM - Writer was called to resident's room, observed resident's left knee with swelling, resident c/o pain to back and left leg, v/s=98.5-71-18-135/82, spo2=94% room air. V11 (Physician) notified of resident's presentation and complain of pain, as well as refusing ADL care, new order issued to send to ER (emergency room ) for medical evaluation. (V12) POA informed of transfer to ER order, V12 requested that resident be sent to Christ Hospital ER, stating she does not like Little Company of [NAME]. Elite Ambulance called at this time, ETA 30-45MINS. Review of R1's hospital notes and wound notes on readmitted d 5/17/22 at 2:24 pm, R1 was hospitalized for 10 days and underwent surgical procedures for the left hip and left knee. Patient had a CT of his left knee which showed an acute versus chronic extra-articular distal femur fracture with mild shortening and flexion deformity. Resident readmitted to facility with left hip and knee surgical incision. Left hip present with 96 clean, dry, intact, and well approximated staples. Medial left knee noted with 24 staples, clean, dry, intact and well approximated. Lateral left knee noted with 23 staples clean, dry, intact, and well approximated. Review of R1's falls since admission to Long term care (LTC) facility from the Assisted Living side: R1 was admitted to (LTC) on 10/24/2021, R1 had 7 falls in 6 months. R1 fell on [DATE], 11/30/21, 12/11/21, 12/15/21 12/27/21, 01/01/22 and 4/27/2022. Review of R1's (MDS) Minimum Data Set: Quarterly 4/3/22 noted R1 with an 8/15 for Brief Interview Mental Status and a 3 for Extensive Assist with a 2 person transfer in a sit to stand mechanical transfer. Quarterly MDS dated [DATE] noted R1 as a 2 person assist with mechanical transfer and a 7/15 BIMS. Interviews: During a face-face interview on 6/30/22 at 11:12 am with V1 (Administrator) and V2 (Director of Nursing), V1 and V2 presented surveyor with in-services on transfers with mechanical lifts and a Disciplinary document for V3. Surveyor asked to speak with V3 and was told he no longer worked for the company. Surveyor requested to review R3's employee record and to obtain a contact phone number to reach (V3). V1 and V2 stated all staff know they should have used a Mechanical lift and our mechanical transfers are 2 persons assist, we asked that same question to all of them when we investigated the incident. V2 provided surveyor with V3's contact number. Surveyor asked V2 if R1 was a 2 persons transfer, V1 and V2 answered yes, R1 is an SSS code for (Sit to Stand) transfers. On 7/14/22 at 1:35 pm, via phone V4 (nurse), said R1 was already on the floor when I walked in. Surveyor asked V4 (nurse) to describe how she found R1. V4 stated His arms was hanging up in the sit to stand and his legs and butt was on the floor. Surveyor asked V4 if she helped lift R1 off the floor. V4 said I didn't help lift anyone because I had knee surgery. I was the one who suggested they use the blanket to transfer the resident off the floor and back to bed. Surveyor asked V4 if she thought to use a Mechanical Lift to get R1 off the floor. V4 stated We all know we should have used the Mechanical Lift, but we were just trying to get him up because he was screaming. On 7/14/22 at 1:44 pm via phone V3 (nurse) stated I took resident (R1) to the bathroom, it was around dinner time. I had 3 CNA (Certified Nursing Assistants) on duty, 2 was in the dining room and one (V5) was in the room across the hall giving care to another resident. I called V5 over to help me put R1 in the sit to stand because I knew she could not stay with me she was providing care to another resident. When we got R1 in the sit to stand, I told V5 she can go back to her patient that I can take it from here. I took the patient to the bathroom, he was using the toilet, I told him to pull the call light when he was finished. I went in to get the patient off the toilet and when I was cleaning him, he started having another bowel movement. When he finally finished moving his bowels, I pulled him out. When I got to the door he screamed. The sling straps were up to his chest, his legs and butt was on the floor and both knees were bending outwards. I called for help and staff came and we lifted R1 off the floor with a blanket and carried him to the bed. Surveyor asked V3 if he thought to use the Mechanical Lift to get R1 off the floor. V3 stated It never occurred to me to get the Mechanical lift, he was just screaming, I just wanted to get him off the floor. On 7/14/22 at 1:56 pm via phone V5 CNA (Certified Nursing Assistant) stated, I was taking care of another resident across the hall when V3 (nurse) called me to help put R1 in the sit to stand. I helped V3 and he told me to go ahead and get back to my resident he could handle it from here. I went back and shortly thereafter I heard a loud scream saying Help, Help. I went into the room and saw R1 hanging from the sit to stand with his legs and butt was on the floor. More help came and we used a blanket to lift him off the floor to bed. Surveyor asked V5 if she thought or was trained to use the Mechanical Lift to get R1 off the floor. V5 stated, it was a spare of the moment thing and we were trying to get him off the floor. 3 calls were made on 7/12/22 at 1:02 pm, 7/13/22 at 2:13 pm and 7/14/22 at 1:08 pm. to V11 (Physician). Voice mail messages were left, with no return calls from V11. Facility's Policy - Safe Resident Handling, Dated May 19, 2022: POLICY: To facilitate a safe work environment for staff and residents by implementing a Safe Resident Handling program. PURPOSE: To establish a framework for staff and resident safety during the handling and movement of residents. PROCEDURE: 1. Staff participating in resident handling and movement shall always practice safe resident handling techniques. a. Minimal lifting of residents shall be eliminated when feasible b. Practice proper body mechanics at all times c. Evaluate each situation carefully and plan to minimize risks as best possible prior to initiating task 4. Residents transfers will be designated into one of the following categories: a. I = Independent (resident can safely perform transfer with no assistance from staff). b. S = Supervision (resident can perform transfers with stand by assist, for verbal or tactile cueing, with or without use of assistive device such as walker or cane). c. 1 = 1-person transfer (minimal assistance from the caregiver and resident is able to stand for 4 seconds - Limited Assist). d. 2 = 2-person transfer (should only be used for behaviors or when resident is not medically appropriate for sit to stand or total lift - Extensive Assist). e. SSS = Sit to Stand with Standard Sling with 2 caregivers - Extensive Assist). f. TL = Total Lift Transfer) also known as Mechanical Lift (HL) - with 2 caregivers- Total Assist). 6. Requirement for resident use of mechanical lifts or transfers such as Mechanical Lift or Sit to Stand A. Sit to Stand - Able to follow directions - Able to hold on - Have good trunk control - Able to bear weight (both extremities, no restrictions) B. Mechanical Lift If the resident is unable to meet the above requirements, they must be transferred using a Mechanical Lift

Based on record review and interview the facility failed to ensure a resident receives adequate supervision and assistive devices to prevent accidents in one (R1) of three (R1, R2 and R3) residents included in the sample by not using proper transfer assistive device and failing to use a two person assist in the use of transfer assistive device. This failure resulted in a serious injury to R1. Findings include: V3 (CNA) failed to use the proper transfer assistive device. V3 failed to use two persons for the transfer per facility policy. R1 is a [AGE] year-old female with a diagnosis including History of Falls, Muscle Weakness, Osteopenia and [CONDITION(S)] [CONDITION(S)]. R1 has a BIMs score of 11. R1 is presently on hospice care. R1 clinical notes dated 3/29/22 states including V6 (Nurse) notified by CNA that resident was assisted to bathroom via sit to stand. Resident was unable to tolerate sit to stand. Post transfer resident with C\O pain to left shoulder and left elbow. Unable to perform range of motion. Resident medicated for pain with Tylenol around 2PM. Left arm elevated on small pillow for comfort. Heat pack applied for pain relief. MD notified and ordered Xray to left shoulder and left elbow. R1 hospital record dated 3/30/22 shows x ray results of traumatic closed displaced fracture of left shoulder with anterior dislocation, initial encounter. On 04/22/22 at 11:35AM, V1 (Administrator) stated we did investigation into R1 incident with a dislocated shoulder. R1 recently had care plan changed to mechanical lift with two persons for any transfers including to the toilet room. V3 (CNA) failed to properly transfer R1 to the toilet room. V3 failed to view the care card located in R1s room before the transfer. V3 used a sit to stand instead of mechanical lift with two persons. During R's returning to bed her weight shift resulted in R1 fracturing and dislocating her left shoulder. During investigation of the incident V3 quit employment. On 04/22/22 at 11:43AM, V2 (DON) stated V3 (CNA) did not do a proper transfer. The CNA failed to look at the care card located in R1s room before taking her to the toilet. V3 used a sit to stand. R1 was complaining of shoulder pain. We ordered a x-Ray in house. We ordered pain medication. We updated our policy to say if in house x-Ray exceeds 5 hours we have to send to hospital for evaluation. We sent R1 out. The hospital found a fracture and dislocated left shoulder. We did an investigation and found that V3 transferred R1 by herself from bed to toilet room and back to bed with a sit to stand. When coming back from toilet room R1 let go of bars causing weight to shift and causing dislocation. We in-serviced V3 and staff on proper transfer. V3 quit before we could take any action with her. On 04/22/22 at 12:09PM, V4 (Physician) stated R1 is on hospice due to decline and family request. R1 was admitted to the hospital previous to incident for vaginal bleeding and possibility of cancer. R1 is [AGE] years old. The family decided not to have her treated. R1 was declining. R1 was injured due to CNA not using proper transfer. On 04/22/22 at 12:30PM, V5 (Restorative Nurse) stated the CNA who transferred R1 used the old method of sit to stand to transfer instead of mechanical lift to transfer. V3 failed to view the care card located in room before transferring R1. During return from toilet to bed she let go of the hand bar and her weight transferred causing the left shoulder injury. On 04/22/22 at 2PM, V6 (Nurse) stated V3 (CNA) reported to me that R1 was complaining of pain. I went to resident's room. Family members were there and told me that while V3 was transferring R1 with a sit to stand to transfer she complained of pain. R1 did not have the strength to hold on to the hand bar and her weight shifted. I gave her pain medication and notified the doctor. The Doctor ordered an X-ray. It was the end of my shift. I later found out she had an injury to her shoulder. V3 was supposed to use a mechanical lift with two staff to do the transfer. V3 (CNA) could not be contacted during investigation. V3 is no longer workin at facility. Facility interview document statement with V3 (CNA) dated 3/30/22 shows the following facts per interview of V3 of transfer incident by the Director of Nursing and Restorative Nurse. Managers Present during phone interview of document statement, V2 (DON) and V5 (Restorative Nurse). Did you transfer R1 prior to bathroom transfer? No, the first time transferring R1 was when I took her to the bathroom. Walk me through your transfer. CNA informed me the resident wanted to go to the washroom. I was monitoring the common area and I switched with V10. I asked V10 how to transfer her, he stated sit to stand. Resident was in the bed, and I wheeled her into the bathroom using sit to stand, I lowered her to the toilet. Did you transfer R1 alone? Yes. Was she holding on the sit to stand? She was holding onto the bar when I took her to the bathroom. I had her strapped in appropriately and her legs as well. Did she complain of pain at all? She complained of pain when she was holding onto the bars, coming out of the bathroom. She appeared tired when coming out of the bathroom because she let go of the bars. Her arms were tired of holding on, so I was trying to work quickly to get her back to bed. Did she bump her head? No, I have no recollection of that. When you don't know how to transfer a resident, what do you do? Look at the report sheet or ask someone that might know / is familiar with the floor. When you were orientating, how were you instructed to find out how a resident transfers? 24 hr. report, care cards and nurse. Did you have 24-hour sheet with you? No, I placed it on the desk. Are you familiar with the yellow cards in the room? Yes. Did you look at that before transferring the resident? No. Do you feel you need more education with transfer? Maybe just the different pads / slings. R1's current MDS Section G states R1 requires 2 person assist for transfer. R1 current care plan (SSL-ADL Functioning) states including R1 requires full hands on assistance with bed mobility, transfers (Hoyer lift w/2 person assist) and toileting. R1 Care Card dated by V1 as 3/18/22 which located in residents' room for staff reference, states including Hoyer transfer (2-person asst.) Restorative clinical note dated 3/9/22 12:30PM states restorative aid recognized that resident had more difficulty with standing/transferring while using sit to stand. Resident yellow card changed from sit to stand to Hoyer lift for transferring. 24-hour CNA report updated to Hoyer lift as transfer device. Physician, V4 stated he did not want to write orders for therapy at the time. Facility policy Titled Safe Transfers Effective Date: August 2002. states including: III. Procedure: 6. When using a mechanical lift for transfer such as Hoyer or Sit to Stand staff should use a two-person method. 7. Requirement for use of sit to stand i. Resident able to follow direction ii. Resident able to bear 30% of leg weight iii. Resident is able to hold on 8. If resident is unable to meet the above requirements, they must be transferred using a Hoyer lift.

Based on observation, interview and record review, the facility failed to supervise dementia residents identified as high risk for falls, failed to implement new interventions when the old interventions were not working and failed to ensure previous fall interventions are applied per care plan to minimize the risk of injury for 2 (R1, R2) of 3 residents reviewed for falls in the sample of 3 residents. These failures resulted in R1 sustaining a fractured left 5th finger, a laceration to the head and skin tears; and R2 sustaining a left [CONDITION(S)] from falling from the bed and requiring surgery that was not consented to due to advance age and poor cognition. The findings include: On 3/1/22 at 11:45 AM accompanied by V3 (Assistant Administrator), the 3rd floor was toured. Inside R1's and R2's room, there were no floor mats. V3 showed that R1 now has a bed alarm that is silent but alerts the nurse that R1 is out of bed. This intervention was not seen in the care plan. Both R1 and R2 were in the 3rd floor living room area being supervised. R1 was seated in a wheelchair on 6 inch thick seat cushion that was covered with a pillowcase; which can be slippery if not positioned correctly and R2 was dozing with her head down toward her chest seated in a regular wheelchair. R1 no longer had the finger splint on her pinky. Staff stated it was just removed per physician's order. On 3/1/22 at 12:30 PM with V5 (Restorative Licensed Practical Nurse/LPN), stated that fall interventions depend on the individual. Some of the interventions are education of the call light, lowest bed position, floor mats, toileting program, restorative exercises to build strength, keep in supervised areas, toilet after meals, wing-tipped mattresses, wedges and positioning pillows. V5 stated that floor mats are not good for ambulatory residents due to it being a tripping hazard. Asked about R2. V5 stated R2 is non-ambulatory, very anxious and moves herself from laying down to sitting up. V5 stated that R2 should of had floor mats in the room. As for the non-slip device, V5 stated that the skilled therapy department informed V5 that the non-slip device should be put under the seat cushion and not over the seat cushion. Asked V5 how is the non-slip device going to work to prevent R1 from sliding out of wheelchair? V5 stated he was surprised by what the skilled therapy department told him but V5 claims that R1's non-slip device should be under her seat cushion and not over the seat cushion. Asked V5 how is the non-slip device going to work to prevent R1 from sliding out of wheelchair? V5 stated he was surprised by what the skilled therapy department told him but V5 claims that R1's non-slip device would be under her cushion. V5 was asked about increased observation and purposeful rounding; and what the frequency was for observing and rounding? V5 stated that it's 30 minutes to an hour. Asked which is it, 30 minutes or one hour and V5 stated every hour is the frequency. On 3/1/22 at 1:15 PM in R1 and R2's room, R1 is asleep in the low bed and no non-slip device was seen on top of the seat cushion in her wheelchair. V4 (assigned Certified Nurse Aide/C.N.A.) was providing personal care to R2. At 1:20 PM, V4 leaves the room and fails to lower R2's bed; which is 36 inches from the floor and didn't apply floor mats. There were no floor mats in the room at all. V4 (assigned CNA) stated R1 is not on any toileting program because R1 can say when she wants to use the toilet. Later at 1:30 PM, R2 was still without floor mats and the bed was 36 inches from the floor. R1 is identified as high risk for falls per the Fall Risk assessments dated 2/2/22 and 12/28/21. The assessments document R1 to be alert, and oriented times three (person, place and time) with confusion. R1 has a brief interview mental score (BIMS) of 15 per the annual minimum data set (MDS) dated [DATE]. The psychiatric nurse practitioner evaluation done on 2/17/22 documents R1 to be severely impaired with her cognition. R1 does have a diagnosis of Dementia. R1 has had numerous falls, mostly unsupervised, while residing in this facility. R1's care plan documents three falls in 2022. The 1/30/22 fall was when R1 slid from her wheelchair on her way to the toilet, the 1/24/22 fall was when she tried to transfer self from toilet back into her wheelchair and sustained a left 5th finger fracture. The 1/12/22 fall had R1 on the floor parallel to the bed. In 2021, R1 had seven falls. The unsupervised falls were in R1's room on 2/10/21, 2/20/21 and 3/6/21; where R1 slid from the wheelchair and sustained a skin tear to left elbow and forearm. 5/5/21 and 5/10/21 falls occurred when R1 attempted to self transfer and fell . The 7/21/21 fall was when R1 tried to transfer self from bed to wheelchair to use the toilet. The 11/23/21 fall, R1 sustained a head laceration after attempting to go to the toilet and was sent to hospital and returned with surgical tape on the forehead laceration. R1's interventions are always the same and never change. R1's interventions have been to encourage R1 to use call light, educate R1 on bed positioning, supervise resident during use of toilet, frequent and purposeful rounding, increase observations, ensure wheelchair is locked, provide restorative services to maintain strength, use of a non-slip device and to initiate a toileting program to ensure staff are involved during toileting and to keep track of frequency of toilet breaks. The intervention for the 3/6/21 fall was the use of the non-slip device in the wheelchair which has not been seen in use. The toileting program was an intervention for the fall of 1/24/22. After R1's 1/30/22 fall, the facility's investigation documents assigned CNA stated that R1 will sit on toilet for 5 to 6 times in an hour and not void at all. In addition, R1 does not use the call light. Another CNA interviewed after the fall, stated that the cushion on wheelchair is large and that makes it difficult for the resident to reposition self and sit back further in wheelchair. R2 is high risk for falls per 1/17/22 and 1/30/22 fall assessments. R2 is severely impaired with her cognition (BIMS of 7) and requires extensive assistance from the staff for her activities of daily living per the quarterly MDS 1/4/22. R2's diagnosis includes Dementia. R2 has had 5 falls 1/30/22, 1/15/22, 1/12/22, 12/11/21 and 11/25/21 in 4 months' time. The 1/30/22 fall and the 12/11/21 fall were from the bed. The other falls were from the wheelchair due to sliding off cushion. The intervention was to apply a non-slip device to the wheelchair cushion to prevent sliding from wheelchair. This same intervention was added on 11/8/20, 4/4/21 and on 1/15/22. There was no mention of the non-slip device being in place for the 1/15/22, 1/12/22 and 11/25/21 falls, when R2 slid from her wheelchair. R2 did sustain a left [CONDITION(S)] from falling from the bed on 6/25/21 and the intervention was to lower the bed. R2's other interventions were frequent rounding, meeting resident's needs prior to leaving her, increased monitoring, place at nurses' station for more supervision and to provide activities. Floor mats were not seen as a current intervention. Although surgery was recommended for R2, V8 (R2's daughter) decided due to R2's advanced age and poor cognition status that surgery would not be performed for the distal left femoral fracture per June 26th, 27th and 28th of 2021 nurses notes. R2 had falls from the bed on 6/17/20, 6/3/20, 5/17/20, 5/6/20 and 5/5/20 but no injury prior to the 6/25/21 [CONDITION(S)] from a fall. The interventions were to re-educate the use of call light, frequent rounding, keep personal items close by and increased supervision for a severe cognitively impaired resident. On 3/2/22 at 10:53 AM in R1's room, V6 (assigned CNA) was supervising R1 on the toilet but V6 needed cued not take her eyes off R1 as R1 was hovering over the toilet wiping herself with her head downward. On the toilet room door frame was a blank Toileting Log. Asked V6 about the toileting log and V6 stated that the log has been there for a couple of weeks. After R1 was done with toilet use and assisted back to the main living area, V6 returned and filled out the log for that toilet break. The day shift for CNAs is 6:30 AM to 2:30 PM per V4 (Certified Nurse Aide); but there were no entries for earlier in the day. On 3/2/22 at 10:55 AM, V5 (Restorative Licensed Practical Nurse/LPN) stated the silent alarm pad was implemented 2 days ago for R1. As for the toileting log for R1, it was implemented after the 1/24/22 fall. V5 was only able to present 9 days of R1's toileting log instead of 37 days of toileting. V5 stated that one Certified Nurse Aide (CNA) told him she threw them out because she did not know what they were for. Asked the purpose of collecting the toilet log information? V5 stated not sure what he's going to do with the toilet log. At 11:11 AM, V4 (Certified Nurse Aide) stated he has seen the toileting log up in R1's toilet room but does not know what it is for because no one has informed him to use the log. On 3/2/22 at 2 PM, V1 (administrator) stated that the silent bed alarm took some time and effort to connect and set up due to the technology of it. V1 stated she understands that the Fall Prevention Program needs a major overhaul and more over-sight for V5. The facility's policy labeled FALL PREVENTION, RESPONSE AND MANAGEMENT documents it is the facility's commitment to minimize resident falls and/or injury so as to maximize each resident's physical, mental and psycho-social well-being. While preventing all resident falls is not possible, it is this community's policy to act in a proactive manner to identify and assess those residents at risk for falls, plan for preventive strategies and facilitate a safe environment. Residents at risk for falling will be assisted with toileting needs in accordance with voiding patterns identified during the assessment process and addressed on the plan of care. Residents requiring staff assistance will not be left alone during a bath, shower or toileting. The resident will be checked frequently or as according to the care plan, to assure they are in a safe position/environment. The frequency of safety monitoring will be determined by each resident's risk factors and plan of care. All assigned nursing personnel are responsible for ensuring ongoing precautions are put in place and consistently maintained. This was not followed.

Based on interviews and record review the facility failed to follow their fall policy to minimize resident's falls and or injuries, failed to provide adequate supervision and failed to implement specific interventions for (R39) 1 of 6 residents identified as a fall risk in the sample of 12. This failure resulted in R39 being found unconscious on the bathroom floor with a bleeding hematoma to the back of the head. 911 was called to the facility, Cardiopulmonary Resuscitation (CPR) was initiated; shortly after R39 went into full [CONDITION(S)]. (ALS) Advanced Life Support measures were initiated by the paramedics and R39 was transferred to the local emergency room where R39 was pronounced dead. Findings Include: During a review of R39's record on [DATE] at 11:00 am, it noted (R39) was a [AGE] year old with Diagnoses of Dementia, Difficulty in walking, [CONDITION(S)], [CONDITION(S)], Hypertension, Kidney Disease, Muscle Weakness, Repeated Falls and Urinary Tract Infection ([CONDITION(S)]). R39's MDS (Minimum Data Set) dated [DATE] noted R39 in Cognition as 4 out of 15 indicating cognitive impairment related to Dementia. R39 was a ,d+[DATE]=Extensive Assist with one person physical assist for Bed mobility, Transfer, Walk in the room, Locomotion on and off the unit, toileting and Personal Hygiene. The MDS noted R39 to have a history of multiple falls. R39's care plan indicated R39 had falls on the following dates: [DATE] - R39 was observed on the floor in the bathroom with a dash to the back of the head. 911 was called, resident sent to the hospital and died shortly after entering the emergency room . [DATE] - R39 was observed ambulating unattended to the bathroom by Dietary aide, Resident reported feeling weak and was lowered to the floor by Dietary aide. No injury. [DATE]- R39 was observed on the floor after nurse heard a loud thump from R39's room. Resident attempted to get up out of bed without assistance. No injury noted. [DATE] - R39 was observed in the bathroom laying on her right side. Resident had a right eyebrow laceration, resident sent out to the hospital. [DATE] - R39 was observed lying on right side in the common area. Resident was in front of recliner and walker off to the side. Resident was asked what happened and responded she wasn't sure. Resident has minor bruise on left hand, x-rays ordered. [DATE] - (R39) had repeated falls within a 4 hour period- Resident transferred to the hospital emergency room for evaluation. CT scan and EKG done in ER. Post care summary states Diagnosis: Traumatic Injury of Head and to F/U with family physician within 3 days. Staff instructed to make frequent rounds for safety. [DATE] - R39 was walking in the hallway and lost balance per maintenance. No injuries noted [DATE] - R39 was observed lying face down in the hallway on the floor. Previous year falls on [DATE] Resident had 2 falls on the same day, R39 was observed on the floor in the hallway and on the floor in front of room-mates cabinet. R39 sustained skin tears noted to the left arm. [DATE] - R39 had a fall and doesn't know how it occurred. No injuries noted. [DATE] - R39 was observed in the washroom on the floor and wasn't sure how she got on the floor. [DATE] - R39 was observed on the floor in the bathroom, she was upset with staff. No injuries noted. [DATE] - R39 was observed walking toward the door and falling. No injuries noted. The facility did not put any new interventions in place to prevent or minimize R39's falls and to avoid serious injuries. Fall Risk assessment were reviewed for each fall. R39 scored a 10 and 11 on assessments indicating a number greater than 10 = HIGH RISK. Review of R39's medication indicated R39 had an order for multiple anti-depressant medications that may cause drowsiness, dizziness, diarrhea, constipation or upset stomach. Medications as followed: [MEDICATION(S)] 40 mg. three times weekly at 9pm. Start date - ([DATE]) , [MEDICATION(S)] 15 mg. 1 tab at hour of sleep, (start date - [DATE]) [MEDICATION(S)] - 30 mg. capsule 1 capsule every morning (start date [DATE]). [MEDICATION(S)] 12.5 mg. tablet (1 tab), one time daily start date [DATE] and discontinued on [DATE]. R39's Incident Report: Dated [DATE] at 2:38 am -Resident was observed by (V16) assigned CNA (Certified Nursing Assistant) on the floor in her bathroom. V13 (Nurse) arrived, assessed R39 who appeared to be pale in the face with a tiny bit of blood present. V13 reported she was not able to obtain a blood pressure on R39 and that R39's oxygen level was at 74%. R39 begin to become unresponsive, V13 notified the physician and was instructed to send R39 out 911. The local Fire Department arrived at 2:45 am. Investigation Statements: V13 (Nurse), [DATE], no time noted - I saw resident in bed around 2:30 am. Resident was asleep at that time. Resident was awake at the beginning of my shift and watching television. Resident went to bed, took her medicine and no problems. V15 (CNA) heard when the resident fell , she was right outside of resident room. Resident got up on her own and went to the bathroom. V11 ( Executive Associate Director) - [DATE], no time noted - resident was observed on the floor in her bathroom, assessed by V13 to be pale color, decreased oxygenation level and undetectable blood pressure. R39 was transferred via 911 to the ER for a change in condition. Staff statement collaborate resident change in condition and listed chief complaint as [CONDITION(S)] that caused the fall. V16 (CNA) - [DATE], no time noted - I had just come out of a resident room and headed to another resident room when V15 called me. I heard a loud thump in the room around 2:00 am. I hadn't checked on R39 my entire shift. I didn't know resident could get up and walk around on her own. V13 (nurse) told me not to disturb resident sleeping. Resident's walker was with resident when she fell , it was on top of her on the floor. The resident was on her back. V15 (CNA) - [DATE], no time noted - I was in the hallway and heard a thump, I went in and saw R39 on the floor with her walker. Resident usually calls with call light in her hand she didn't use it. I didn't hear R39 get up. I got the nurse (V13) who was in another resident room, I don't recall the time. We picked up R39 and put her in the chair. Resident seemed out of it, we put her in the bed and put oxygen on her. When resident was assessed she had a cut on the back of her head and was bleeding. 911 came and the police. Review of Paramedic Run Sheet: Dispatched to the facility on [DATE] at 2:45 a.m., R39 was Unconscious/Breathing. Cardiopulmonary Resuscitation (CPR) was initiated by the local Fire Department at 3:00 a.m. Compressions were continuous, intermittent with bag valve mask. [DATE] at 3:07 a.m. - Local Fire Department witnessed R39 go into full [CONDITION(S)]. Patient was found lying in bed, Nursing home staff said patient had a hematoma on the back of her head. Upon moving patient into the ambulance crew noted patient to be apneic. Ambulance monitor not capturing rhythm, crew completed call with an E120 monitor and downloaded both into the report. Advanced Life Support (ALS) care and Cardiopulmonary Resuscitation (CPR) were initiated. Patient given 2 rounds of [MEDICATION(S)] in route with change in patient condition. Dispatch Time for Run Sheet: Dispatch Date/Time: [DATE] at 2:45 am, Unit in route: [DATE] at 2:47 am, Arrived at Scene [DATE] at 2:52 am, Arrived to Patient: [DATE] at 2:57 am, Left Scene [DATE] at 3:16 am, Patient at Destination: [DATE] at 3:21 am, Patient transfer of care: [DATE] at 3:24 am to hospital without further incident. Care released to emergency room nurse on staff. emergency room - Hospital Record: [DATE] at 3:51 am - Patient (R39) is a [AGE] year old with a history of Hypertension, Chronic Kidney Disease and Dementia who presents to the Emergency Department (ED) from the nursing home with [CONDITION(S)]. Per local Fire Department, the patient was found unresponsive with agonal respirations and shortly thereafter went into [CONDITION(S)]. CPR and ACLS initiated and the patient was intubated prior to arrival. Death Certificate - Review of R39's death certificate noted cause of death as Coronary Artery Disease, due to or as a consequence of. The death certificate is documented with time of death as 0341 pm. The hospital records noted the time of death in the emergency room as 0341 am. Interviews: During a phone interview on [DATE] from 1:47 pm - 2:04 pm, V13 (Nurse) was asked what happened on [DATE] when R39 was found on the floor unconscious. V13 stated I started my shift at 6pm, R39 was up sitting in the dining room watching television. R39 got up and went to bed. Surveyor asked V13 did R39 walk to the bedroom by herself. V13 stated yes R13 always walks with her walker around the unit and goes to the bathroom by herself. V13 stated I saw R39 in bed around 2:30 am, R39 was asleep at that time. I was called to the room, when I arrived R39 was lying flat on her back on the bathroom floor. There was some blood on the floor. I asked R39 did she hit her head and she said yes. I told V15 and V16 (Certified Nursing Assistants) to help me sit R39 up against the entry way. I told one of them to get a wheelchair and we lifted R39 up off the floor to the wheelchair and then put R39 in bed so I could assess her. During a phone interview on [DATE] from 2:06 pm - 2:13 pm, surveyor asked V15 (CNA) what happened the night R39 was found in the bathroom on the floor. V15 stated I was in the hallway when I heard a loud thump, I went into R39's room and I saw R39 on the floor in the bathroom with the walker on top of her. V15 was asked if R39 was responsive. V15 stated No, she was unresponsive until we placed her in bed. V15 was asked if there was blood on the floor and if R39 had an injury. V15 stated Yes, there was blood on the floor and R39 had a gash in the back of her head, I told V13 about the gash in the back of R39's head. I was not the assigned CNA, V16 was her aide. I called out to V16 who got V13 out of another resident's room. When V13 and V16 came into the bathroom, we picked R39 up off the floor, placed her in a wheelchair and transferred her to the bed. During a phone interview on [DATE] at 11:56 am with V16 (CNA), surveyor asked V16 what happened on [DATE] when R39 was found on the floor in the bathroom. V16 stated I had just come out of another resident room when I heard a thump around 2:00 am. I hadn't checked on R39 during my whole shift because V13 told me not to disturb the resident when sleeping. Surveyor asked V16 if she saw or looked in on R39 at any time prior to R39's fall incident. V16 said No I did not. I did not know R39 could get up and walk around by herself. Surveyor asked V16 how often should they round on residents. V16 stated every 2 hours but I was told not to disturb R39 because she can become agitated, I went into the bathroom, I saw R39 lying on her back on the floor with the walker on top of her. Myself, V16 (CNA) and V13 (Nurse) picked R39 up off the floor and placed her in the wheelchair. R39's head went forward and V13 said let's get her to the bed, so we transferred R39 to bed, V13 left the room, I guess to call 911. V13 told myself and V15 to put R39 up against the entrance of the bathroom and get a wheelchair. R39's head went forward; I called her name, but she didn't answer. V13 said let's get her in the bed. We applied oxygen, V13 ran to the nursing station, I guess she went to call 911. (R39) started having secretions come out of her mouth. V13 kept saying R39 was a Do Not Resuscitate (DNR). V16 was asked how long has she been employed by the facility? V16 replied [AGE] years, I work seasonal every other week. V16 was asked if she saw blood on the floor, V16 said yes. Surveyor asked V16 if R39 had a gash in the back of her head. V16 said yes. Surveyor asked V16 if they were supposed to pick R39 up off the floor knowing she hit her head and was bleeding. V16 said no, but V13 (nurse) told us to help get R39 off the floor into a wheelchair and put R39 in bed so she could assess her. On [DATE] at 11:02 am, surveyor called (V18) Physician and (V19) Alternate Physician, left voicemail to call regarding an investigation of R39's record. Surveyor did not receive a call back from the physician or the physician office. Facility's Policy - Fall Prevention, Response and Management (Revision date - [DATE]) - Although not all falls are preventable, staff can manage some contributing factors related to falls. Purpose: To describe the process for identification of fall risk and interventions that may be used to manage and decrease the number of falls, therefore preventing resident injury. C. Upon admission, quarterly and annually the resident will be assessed for fall risks using the Fall Risk Assessment Tool. This tool will be used to evaluate eight clinical parameter including: (Overall Score of 10 or above represent HIGH RISK). a. Level of Consciousness/Mental Status b .Fall History in past 3 months c .Ambulation/Elimination Status d. Vision e. Gait/Balance f. Systolic Blood Pressure Changes g. Medications h. Predisposing Medical Conditions D. Nurse on Duty/Restorative Nurse to implement Fall Interventions as needed. f. Do not leave resident unattended in bathroom g. Safety rounds/checks j. Resident assisted to the bathroom as needed

Based on observation, interview and record review the facility failed to provide safe transfer for 2 of 3 residents (R1 and R6) reviewed for transfer. This failure affected R1 and R6 and has the potential to affect all 44 residents residing at the facility. R1 and R6 were transferred during care without staff assistance or use of transfer device. This failure resulted in R1 sustaining a mild impaction [MEDICAL CONDITION] right radius. Findings include: On 1/5/21, R1's medical record face sheet showed that R1 was originally admitted [DATE] to assisted living section of the facility with [DIAGNOSES REDACTED]. On 1/5/21 at 9:26am, R1 was noted in her room sitting in a wheel chair, R1 was unable to remember how she got the bruises on 9/23/20 and the reported incident of 9/27/20. Review of R1's clinical notes report showed that R1 was noted with bruises to the right wrist during shower on 9/23/20. On 9/26/20 swelling was noted and X-ray was done. Result showed there was a mild impaction fracture distal right radius. According to the initial facility report sent to the regional office on 9/27/20, under the Description/ Summary of Incident documented that resident was observed with redness to right wrist during shower on 9/23/20, X-ray was ordered by MD (Medical Doctor), and received result today indicating a mild fracture distal right radius. The final report dated 10/1/20 under Resolution of Incident documented that Resident was transferred during shower improperly resulting in mild impaction Fracture to distal right radius. Resident received an X-ray and had an appointment with Ortho. New orders to follow up with OT (Occupational Therapy). Staff to receive education. Resident has [MEDICAL CONDITION] also [MEDICAL CONDITION]. R1's facility tool used in assessing residents MDS (minimum Data Set) dated 5/04/20 section G ADL (Activities of Daily Living) assistance coded R1 under transfer as 3/3 which indicated that R1 needs extensive assistance and two person assistance. R1's facility tool used in assessing residents MDS (minimum Data Set) dated 9/29/20 with completed date of 11/03/20 section G ADL (Activities of Daily Living) assistance coded R1 under transfer as 3/2 which indicated that R1 needs extensive assistance and two person assistance. On 1/5/21 at 10:03am, interview conducted with V7 LPN (Licensed Practical Nurse) wound care nurse who completed the final incident report sent to the regional office. V7 explained that she is the wound care nurse and any skin issues are reported to her for follow up. V7 explained that in her talking with V6 CNA (Certified Nurse's Aide), V6 admitted that she transferred R1 during shower without use of appropriate transfer device. On 1/5/21 at 11:53am, interview was conducted with V8 (Restorative Nurse/Assisted living Coordinator). V8 stated R1 is non mobile requires assistance for feeding, dressing, bathing and transfer.V8 stated R1 needs use of gait belt and two person assistance with transfer. V8 explained that V6 CNA (Certified Nurse's Aide) did not use the appropriate transfer method in transferring R1. V8 explained that V6 held R1's hand and turned pivoting R1 into wheel chair without use of gait belt. The surveyor asked V8 whether V6 used the appropriate transfer method in transferring R1. V8 replied, No she did not follow the recommended transfer use of gait belt. Review of R1's medical record did not show that R1 had a fall on 9/23/20. On 1/5/21 at 1:09pm, R6 was noted in the washroom on the toilet sit with the door opened and the main entrance door to the room also opened. V12 CNA (Certified Nurse's Aide) was noted standing by the door donning gloves on both hands. At 1:13pm, V12 assisted R6 from the toilet sit into the wheel chair without use of assistive device for transfer. Assistive device noted hanging on the back of the washroom door. When the surveyor asked V12 about the appropriate transfer plan of care for R6, V12 replied That I don't know. The surveyor then asked V12 about the facility documentation tool for the CNA. V12 stated I don't know whether it is in there. V12 searched on the tablet and was unable to find it. The surveyor asked what other way can V6 know about the plan of care for transfer. V6 replied, a yellow card is attached to the cupboard (referring to the credenza). Both V6 and the surveyor read the instruction on manual transfer for R6. The instructions read one person assist with instruction to always use gait belt. The surveyor asked V12 whether the instruction was followed when transferring R6. V12 replied, I did not use the gait belt, I thought (R6) was fine. R6's facility tool used in assessing residents MDS (minimum Data Set) section G ADL (Activities of Daily Living) assistance coded R6 under transfer as 3/3 which indicated that R6 needs extensive assistance and two person assistance. On 1/5/21 at 2:44pm, interview conducted with V6 CNA, V6 explained that she gave R1 a shower on 9/23/20 and after getting R1 to bed she noticed the bruising on R1's wrist. V6 stated and informed the nurse about it. When the surveyor asked V6 about the transfer device used, V6 replied that she did not use any transfer device, but another staff helped in the transfer. When the surveyor asked about the name of the staff that assisted V6, V6 replied that she has forgotten the name of the staff who assisted her in transferring R1 into wheel chair. V6 stated, She transferred R1 into the shower chair and back into the bed by holding her hands, putting a hand under R1's arm pit. V6 told the surveyor that she did not know why the facility is saying she is the cause of R1's fracture stating R1 did not fall. V6 stated the facility just changed the type of transfer device for R1 and did an in-service on it including use of gait belt with transfer. On 1/7/21 at 11:48am, interview conducted with V15 (Physician). The surveyor asked V15 what is the risk that can be expected if the required transfer device is not used when transferring a resident. V16 stated, A fall can occur and with fall injury like fracture can occur. When the surveyor asked V16 of notification, V16 stated the only way the facility will have X-ray ordered is if he was notified. V16 stated he was notified of the incident. At 12:32pm, when the surveyor asked about using the appropriate recommended device for transfer, V16 stated, That's what we want done if the resident needs use of (transfer device) that's what should be used to avoid injury. The facility Gait Belt Use policy with revision date August 15th, 2015 pointed out that all CNA (Certified Nurse's Aide) shall carry a gait belt as part of their uniform for purpose of safely assisting residents that cannot independently ambulate or transfer. Purpose of the policy documented that it is the policy of this facility to use gait belt (transfer device) with residents that cannot independently ambulate or transfer for purpose of safety. The facility policy on Safe Transfer with revision date October 16, 2018 documented that it is the facility policy to ensure resident transfers are done in a safe manner. Purpose to provide guidance to staff and a standard protocol for resident transfers in order to provide safest transfer possible. And procedure includes but not limited to identifying the resident transfer method via resident summary located in room or on touch screen. When assisting the resident to transfer to wheel chair gait belt to be applied and use pivoting technique. This guidelines was not followed.

Based on interview and record review, the facility failed to implement fall prevention monitoring and interventions to prevent one resident (R11) of 10 residents reviewed for falls in a sample of 16 residents. This failure resulted in a subsequent fall of R11 with a laceration on the scalp requiring staples and cerebral hemorrhage (Intraventricular Hemorrhage). Findings include: Admit/Transfer/Discharge logs and census activity indicate that R11 was initially admitted to the facility (Assisted Living) and had a fall on 10/13/2016 with a fracture of left Humerus and was transferred to skilled memory support nursing unit on October 14th 2016. In skilled unit, R11 had falls on 10/21/2016, 10/25/2016 and 04/12/2017. With the fall on 04/12/2017 R11 had laceration on the scalp with severe bleeding repaired with staples and intraventricular hemorrhage. R11's Physician order [REDACTED]. R11 was on medications such as anticoagulants, Diuretics, pain relievers and medications that cause hypotension. R11's initial fall risk assessment in the skilled memory support unit dated 10/14/2016 indicates R11 has intermittent confusion, has history of falls in past 3 months, is chair bound and needs assistance with elimination, have problems while standing, on medications that cause hypotensive effect and dizziness, R11scored high risk for falls but the column for calculated overall score and interventions were left blank. R11's fall risk assessment dated [DATE] indicates that R11had a score of 14- high risk for falls. Interventions: Resident has poor safety awareness due to cognitive communication deficit. Use fall/safety precautions to alert staff of postural changes. Resident does not comprehend use of call light. Staff will frequently check on resident when in room, if noted awake escort resident to common areas for supervision. R11's fall report indicates R11 had a fall in resident's room on 10/21/2017 at 05:30am, R11 was noticed to be on her knees by the bed with upper body on the bed. The root cause of the fall is due to resident action or internal risk factors. Resident status prior to fall: The number of staff in assistance- None. R11's fall report reads: On 10/25/2016 resident (R11) had a fall in the dining room at 3:56pm, R11 was watching a movie in her wheel chair with alarm in place and was observed laying on her right side on floor of dining room a few minutes later and the environment was quiet with no one around. The root cause of the fall is due to resident action or internal risk factors. Fall occurrence specific follow up and resident status prior to fall: The number of staff in assistance - None. RECOMMENDATIONS: When moving residents from an area, make sure you don't leave anyone behind. Everyone should be watching residents, even nurses. R11's fall report reads that on 04/12/2017 R11 had a fall in the dining room at 2:00pm; R11was found lying on the floor, holding back of her head with blood coming from her head, complained of dizziness. Nurse heard a loud bang and saw resident lying on the floor. 911 was called and R11 was transferred to local community hospital for head injury. Clinical Notes Report dated 04/12/2017 by the nurse reads: Resident was in the dining room sitting in a regular chair. I heard the chair alarm, when I look through the window from the sitting area I saw the resident losing her balance and going backward. I ran toward her, but she already hit the floor, and hit her head. Resident verbalized she was dizzy and was bleeding from the head. - No staff was watching when R11 was left behind in the dining room. Nurse's notes dated 04/13/2017 reads that R11 was admitted in the Intensive Care Unit (ICU) with intracranial hemorrhage and six staples to the head. Hospital records from the community hospital's emergency room physician documentation read the following: Two centimeters laceration on right occipital scalp with mild surrounding contusion. Laceration of the scalp was repaired with staples and Vitamin k was given to stop bleeding. Radiologic studies of the head on 04/12/2017 and 04/13/2017 indicated small intraventricular hemorrhage layering in the occipital horn of the right lateral ventricle. R11's nursing care plan reads R1 is at risk for injury related to fall risk. Goals: R11 will have measures in place to decrease incidents of injuries related to falls. Interventions include in part: Assist R11 with toileting, activities of daily living and ambulation as needed. Monitor altered cognition (Dementia) for progression, decline in safety awareness. Assess R11 on-going for fall risk. Keep R11 in public areas as much as possible for increased supervision. Staff will escort R11 to common area if noted awake in room for supervision. Resident should not be left in the dining room. Resident should be monitored at all times. R11 is also care planned for dementia with interventions of providing Person-directed interventions, validation and redirection. On 10/12/2017 at 3:45pm, Z2 (Primary Care Physician) stated Because the CT(Computer Tomography) Scan (Special X-ray) showed cerebral hemorrhage, anticoagulant was kept on hold and Vitamin K was given.When a resident is at high risk for falls, the resident should not be kept on anticoagulants or it depends on the clinical condition of the resident and judgment of the cardiologist. Or the staff should have closer supervision of the resident to avoid falls. On 10/13/2017 at 11:30am, E4 (Restorative Director) stated in part After the fall on October 25th 2016in the dining room, the fall prevention interventions in place were to make sure that She (R1) was not left alone in the dining room and to monitor her closely in the dining room. But the numbers of falls were increasing in number, she (R11) was not able to be redirected, if the staff had monitored her closely, we could have avoided the fall and injury on April 12th 2017. On 10/13/2017 at 12:30pm, E2 (DON) stated In general, on a given day at the lunch time, there is at least staff which includes 4-5 CNA's (Certified Nursing Assistant), one nurse, one life enrichment aide and two additional aides for feeding. The fall on 04/12/2017 happened after lunch. I'm not sure why she (R11) was still in the dining room alone. The staff that I mentioned above is responsible to transfer residents out from the dining room into the common area. The fall was witnessed by the nurses from the window; the nurse was not in the dining room. If they were in the room, they could have avoided that fall. On 10/16/17 at 12:25pm, Z3 (Cardiology physician) stated, For this resident (R11), I wrote my last note in January 2017 for medical attending to follow up with controlling the anticoagulant medication. I didn't follow her after that. I was not aware of the fall in April 2017. Facility's job description for Restorative Aide- Certified Nurse Assistant reads in part: Provides a neat and safe orderly department and environment for the residents. The facility policy titled Fall prevention, Response and Management reads in part: The facility is committed to minimizing resident falls and/or injury so as to maximize each resident's physical, mental and psychosocial well-being. All staff will be responsible in assisting with the implementation of the facility's fall management program to ensure the safety of all residents in the community. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices as necessary. This policy was not followed.